FORENSIC

MEDICINE
SL. NO CHAPTERS PG. NO
1. ALCOHOL 1
2. ARTIFICIAL INSEMINATION 24
3. ASPHYXIA 28
4. ASPHYXIANTS 52
5. BLOOD 61
6. CARDIAC POISONS 75
7. CORROSIVE POIONS 81
8. DELIRIANT POISONS 93
9. DELIVERY 107
10. FIREARMS 110
11. FORENSIC PSYCHIATRY 142
12. GENERAL PRINCIPLES OF TOXICOLOGY 163
13. IDENTIFICATION 194
14. IMPOTENCE 237
15. INFANTICIDE 239
16. INSECTICIDES 262
17. IRRITANTS 273
18. LEGAL PROCEDURE 300
19. MECHANICAL INJURIES 329
20. MEDICAL ETHICS 346
21. MEDICO-LEGAL AUTOPSY 385
22. MEDICO-LEGAL ASPECTS OF INJURIES 408
23. PREGNANCY 424
24. REGIONAL INJURIES 427
25. SEX RELATED CRIMES 449
26. SOMNIFEROUS POISONS 477
27. SPINAL POISONS 486
28. SUBSTANCE ABUSE OR DRUG ABUSE 488
29. THANATOLOGY 490
30. TRANSPORTATION ACCIDENTS 529
31. VIRGINITY 544
32.
 ALCOHOL
“The injurious effects of alcohol must not be construed as the result of the use of a
bad thing; it is actually the result of abuse of a good thing” – Abraham Lincoln

 Alcohol has had an important role in societies throughout history. Its use has ranged
from social to religious to medical. In the middle ages alchemists believed that alcohol
was a remedy for practically all diseases. In fact, a French professor in the thirteenth
century dubbed alcohol "aqua vitae," meaning "water of life". It is now recognized that
the therapeutic value of ethanol is extremely limited and that chronic consumption of
excessive amounts is a major source of social and medical problems.
 Alcohol along with ether, chloroform, nitrous oxide etc belongs to inebriant poisons.
Inebriants are a group of poisons which are characterized by two sets of symptoms,
excitement and narcosis. It is very important to recognize the state of ‘drunkenness’ as
the person in this state is not only dangerous to himself but to others too. While
examining a person for the certification of drunkenness it is also important to rule out a
number of conditions which mimic the state of drunkenness. Commonly the term
alcohol is synonymously used with 'Ethyl Alcohol'.

DESCRIPTION OF TERMINOLOGIES
Social drinker - drinks occasionally or regularly in moderation.

Heavy drinker - drinks regularly and heavily.

Binge drinker - drinks irregularly and heavily.

Alcohol abuser ("problem drinker"): This is an alcoholic related disability which still has
not advanced to the stage of alcohol dependence.

Alcohol dependence - This is a state where there is a plethora of symptoms of physical

or mental disturbance on depriving the person of alcohol.

Rectified spirit - 95% ethanol.

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Absolute alcohol - 99% ethanol

Methylated spirit - 90-95% ethanol

+
5-10% methanol
Proof spirit:
 The ethanol content of alcoholic beverages is expressed by volume percent or by
proof.
 The derivation term “proof” comes from the olden days when the British Navy sailors
used to suspect that their ration of “rum” (gorg) was diluted. They used to confirm the
proof of its purity by pouring this rum over the black gunpowder and igniting by match
stick. If the gunpowder ignited by match stick, it is the proof that the ration of “rum” was
up to standard.
 Proof spirits (100 proof) are those with weights of 12/13 the weights of an equal volume
of distilled water at 11°C (51°F). Thus, proof spirits are 48.24% ethanol by weight or
57.06% by volume (UK Customs & Excise Act 1952).
OR
A proof spirit (100 proof) is one containing 50% ethanol by volume. Therefore the proof
of an alcoholic beverage is twice its percentage of alcohol; e.g.,40% alcohol is 80
proof(US).
 Most of the drinks that are available in the market are under-proof i.e. below 100 proof.
 In Jamaica the over-proof drinks are very popular i.e., above 100 proof.

Standard Drink: For a typical 70 kg person, a “standard drink” containing 15 gram of

ethanol is defined as 1 oz (30ml) of 100 proof liquor or about a 4 oz (120 ml) glass of wine
(12% ethanol), or about a 10 oz bottle of beer (5% ethanol), raises blood ethanol level by
36 mg/dL (7.8 mmol/L).

DRUNKENNESS

DEFINITION
‘British Medical Association’ (1927) defined the word ‘Drunk’ to mean “that the person
concerned was so much under the influence of alcohol as to have lost control of his mental
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faculties to such an extent as to render him unable to execute safely the occupation in
which he was engaged at the material time”.
MEDICO-LEGAL IMPORTANCE OF DRUNKENNESS

1. Drunkenness and medical practice:

If a medical professional treats his patient under the influence of alcohol, he can be
held guilty of infamous conduct. He can also be charged with 'rash and negligent act'
[Section 304(A) IPC], showing utter disrespect to the life of the patient.
2. Drunkenness and driving:
 In India statutory limit of blood alcohol is 30 mg% (An increased reaction time,
diminished fine motor control, impulsivity, and impaired judgment become evident
when the concentration of ethanol in the blood is 20 to 30 mg/dl).
 Drunken driving is an offence in India, punishable under section 185 of the Indian
Motor Vehicle Act 1988 (1994). Punishment for drunken driving is in the form of a
fine which can extend up to Rs. 2000/-, or imprisonment which extend up to 6
months or Imposition of both. For a second offence committed within 3 years of the
previous one, the punishment is enhanced to Rs. 3000/-, or 2 years, or both.
 Indian Motor Vehicle act 1988 (1994), section 203 & 204 gives provisions for the
medical examination and for the laboratory tests on a driver accused to be under
the influence of alcohol.
 Alcohol intoxication affects driving in the following manner:
A. Delay in the reaction time- the drunken driver takes at least 15 to 20% more time
than a normal person to react to a given situation, like immediate application of
brakes, changing the gears etc.
B. False and unjustified increase in confidence – the drunken driver takes
unjustified risks, skips over the traffic lights, over takes the vehicles in a
dangerous manner etc.
C. Impairs concentration and affects the judgment – the drunken driver is unable to
appreciate instantly the dangers of a given situation and to react it.
D. Affects vision – the drunken driver can not tolerate the brightly lit lights coming
from the opposite direction as his pupils are dilated. The peripheral vision is

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 reduced (tunnel vision). Therefore he can not visualize the vehicles coming from
the sides, thus lowering his ability to control the vehicle.
E. Affects muscular incoordination: drunken state produces muscular coordination
thereby risking his life and that of others.
3. Drunkenness and criminal responsibility:
A. He cannot be held liable for his criminal deeds if it can be proved that he was
incapable of forming the intention (mens rea), that he was not, able to appreciate
the nature and the consequences of his act provided the drink was given to him
under force, against his will, without his consent, by fraudulent method etc (Section
85 of IPC).
B. If he has consumed alcohol after knowing its intoxicating effects, he may be
punished as if he had the intention to commit the crime (Section 86 of IPC).
4. Drunkenness and will:
Any will executed in a drunken state becomes invalid.

5. Drunkenness and contract:

Any contract executed in a drunken state becomes invalid; if it is proved that the person
was drunk to such a degree that he was not able to understand the terms of contract or
its natural consequences on his interests.
6. Drunkenness and sudden death:
There are increase chances of sudden death due to cardiac causes in a drunkard
person because of its tendency to release catecholamine. Catecholamine in
combination with alcohol produces cardiac arrhythmias and death.
7. Hooch tragedy:
 Every year lot of precious life’s lost to the menace of hooch. There are so many
recent instances of deaths due to consumption of hooch in the states of Gujarat,
Andhra Pradesh, and Karnataka; not even sparing the nation’s capital New-Delhi.
 Hooch is a colloquial nickname for an illegally distilled corn or grain-based alcoholic
beverage, also known as moonshine or creek water. Hooch production usually
begins under cover of darkness, as the distiller creates a mash of corn, sugar, water
and active yeast in a large copper pot. The interaction between the yeast and the
sugars converts a portion of the mash to ethanol, the basic form of alcohol present
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 in all consumable alcoholic beverages. The very first run of hooch when evaporated
often contains dangerous high levels of methanol, a toxic form of alcohol also
known as wood alcohol. In order to prevent accidental poisoning, the moon-shiner
will usually discard the first and last batches of hooch during an average night's
production.
MEDICAL EXAMINATION IN DRUNKENNESS
 Except the smell of alcohol in the breath, there is no single sign or symptom which is
pathognomonic of drunkenness.
 Consent for examination: Any subject could be physically examined only with his
consent which may be informed. It is likely that some person might refuse medical
examination. To tackle such an eventuality section 53 Cr. P. C enables the doctor to
use force as is reasonably necessary to restrain the accused for examination.
 Eye Signs: Alcohol intoxication may result in pupillary abnormalities (dilated in early
stages and constricted in late stages), abnormal reaction to the light and nystagmus.
 Muscular coordination tests: This is assessed by finger nose test (asking him to touch
nose with his index finger), picking up a coin from floor, buttoning and unbuttoning
clothes, checking his ability to stand when his heels together and toes apart with eyes
closed and open (Rhomberg`s sign). Muscular coordination is usually affected in
alcohol intoxication.
 CNS and other system examination to exclude conditions simulating drunkenness:
Severe head injuries, metabolic disorders, disseminated sclerosis, Parkinsonism,
Epilepsy, effect of drugs like insulin & barbiturates, Carbon monoxide poisoning etc.
 Opinion: Depending upon the findings whether positive or negative, the medical officer
opines that the person has,
 Not consumed alcohol.
 Has consumed alcohol but not under the influence of it (If there is undoubted smell
of alcohol in the breath, with some eye signs but with normal muscular coordination,
the person may be adjudged to have ‘consumed alcohol but not under the influence
of it’).
 Has consumed alcohol and is under the influence of it (If there is undoubted smell of
alcohol in the breath, with eye signs and defective muscular coordination, the

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 person may be adjudged to have ‘consumed alcohol and is under the influence of
it’).

TYPES OF BEVERAGES
 Beer 4-8%
 Wine 10-12%
 Whisky, scotch, rum, gin 40-45%

ABSORPTION OF ALCOHOL
Site of absorption:
 20% of alcohol is absorbed in the stomach.
 80% absorbed in the upper small intestine.

Factors that enhance absorption:

 Rapid gastric emptying.
 Ethanol intake without food.
 The absence of congeners (Congeners contribute to the special characteristics of taste,
flavor, aroma, and color of a beverage).
 Dilution of ethanol (Maximum absorption occurs at a concentration of 20%).
 Presence of carbonated drinks (Bubbles in the carbonated drinks provide extra surface
area for the absorption).
 Gastrectomy or Gastro-jejunostomy cases (dumping syndrome).

Factors that delay absorption:

 High concentration of ethanol (by causing pylorospasm)
 Presence of food.
 Coexistence of GI disease.
 Co-ingestion of drugs.
 Time taken to ingest the drink.

DISTRIBUTION OF ETHANOL
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 Alcohol gets distributed in the blood and water of the body.
 Tissues rich in water (muscle) take up more alcohol than those rich in fat.
 Alcohol is water-soluble and not fat-soluble.

 Average ratios for specimen – to - blood ethanol concentration

Specimen Ratio
Urine 1.3
Vitreous humor 1.2
Saliva 1.1
Spinal fluid 1.1
Bile 1.0
Brain 0.8
Kidney 0.7
Liver 0.6

METABOLISM OF ETHANOL
 90% metabolized.
 Alcohol Can get metabolized in the following ways:
1. Alcohol dehydrogenase pathway (ADH pathway).
2. Microsomal ethanol oxidizing system (MEOS).
3. Peroxidase - catalase system (associated with hepatic peroxisomes).
1. ALCOHOL DEHYDROGENASE PATHWAY
 Alcohol Dehydrogease (ADH) enzyme is located in the gastric mucosa, brain and in
the liver
 ADH enzyme in the gastric mucosa oxidizes a small proportion of the ingested
ethanol, thus reducing the amount available for absorption. This effect is more
pronounced in men than in women.
 ADH pathway in the liver is located in the cytosol of the hepatocytes.

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  ADH system is the main pathway for ethanol metabolism in the body and is also the
rate limiting step.

Ethanol Acetaldehyde Acetic acid Acetyl coenzyme A

Alcohol Aldehyde Thiokinase
Dehydrogenase Dehydrogenase

 Acetyl coenzyme A enters the Krebs cycle and is metabolized to carbon dioxide and
water. The entry of acetyl coenzyme A into the Krebs cycle is dependent on
thiamine stores.
2. Microsomal Ethanol Oxidizing System (MEOS):
 The MEOS system is located on the endoplasmic reticulum
 The MEOS system is responsible for very little ethanol metabolism in the novice or
unlimited drinker, but becomes more important as the ethanol rises or as ethanol
use becomes chronic.

EXCRETION OF ETHANOL
 Ethanol is primarily (>90%) eliminated by the liver
 5 -10% excreted unchanged by the kidneys, lungs, and sweat
 The excretion of ethanol by the lungs is first order and obeys Henry's law, in which the
ratio between the concentration of ethanol in the alveolar air and the blood is constant
i.e. 1:2100 (that there will be 2100 parts in the blood for every part in the breath) This
fixed relationship between the alveolar air and the blood forms the basis for the
sampling of subject’s breath to reliably estimate their blood ethanol concentration.
 In adults, the average rate of ethanol metabolism is 100 – 125 mg/kg/hr in occasional
drinkers and up to 175 mg/kg/hr in habitual drinkers. As a result, the average adult
metabolizes 7-10 g/hr and the blood ethanol level falls 15-20 mg/dl/hr

MECHANISM OF ACTION & EFFECTS OF ALCOHOL

 Like general anesthetics, alcohol dissolves in the lipid layer of membranes, causing an
increase in the fluidity of the membranes. This change in fluidity may, in turn, modify
the actions of specific receptors or ion channels, resulting in the many behavioral
effects of ethanol. Specific receptors that have been associated with the effects of
alcohol include gamma aminobutyric acid (GABA) and N-methyl-D-aspartate (NMDA).

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 The inhibitory effects of ethanol may result from an enhancement of GABA-A receptor
function, increasing the effects of this inhibitory receptor, and a blockade of NMDA
receptor function, interfering with the effects of this excitatory receptor.
 Alcohol is CNS depressant, produces following effects,
 Frontal lobe -Mood changes, disinhibition, talkativeness.
 Occipital lobe- visual disturbances.
 Cerebellum - muscular co-ordination and slurring speech.

CLINICAL FEATURES OF ACUTE ALCOHOL INTOXICATION

Stage of
Intoxication Characteristics Mnemonic

Blood alcohol: 0-50 mg/dl

Stage 1:Sobriety Decent
Normal behavior

Blood alcohol: 50-100 mg/dl

Stage 2:Euphoria Delighted
Increase in self-confidence, sociability, euphoria and
lack of inhibitions

Blood alcohol: 100-150 mg/dl

Stage 3:Excitement Delirious
Reaction time increased, in-coordination, emotional
instability

Blood alcohol: 150-200 mg/dl

Stage 4: Confusion Confusion, vertigo, in-coordination, staggering Dazed
gate/drunken gate, slurred speech

Blood alcohol: 200-300 mg/dl

Stage 5: Stupor Dejected
Diminished response, inertial, unconsciousness

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 pursues

Blood alcohol: 300-500 mg/dl

Stage 6: Coma Dead
Deep unconsciousness, reflexes abolished,
drunk
hypothermic, labored breathing

Blood alcohol: 500 mg/dl

Stage 7: Death Dead
Death secondary to respiratory failure

 MCEWAN'S SIGN
If the person intoxicated with alcohol is comatose, to differentiate this person with that
of other comatose conditions, McEwan's Sign should be observed. In such a situation,
a painful stimulus is given by pinching the sides of the neck or by applying pressure
over the sternum with the knuckles. Will cause constricted pupil to dilate and remains
dilated as long as the painful stimulus continues. When the painful stimulus removed,
the dilated pupils slowly come back to their original contracted state.
 Medico-legally, stages 3 and 4 of alcoholic intoxication (stages of excitement and
confusion) are the most important, since most of the offences associated with drinking
are committed during these two stages.
 PATHOLOGICAL INTOXICATION (POTO A MANIA)
 "Pathological intoxication," is a temporary psychotic reaction, often manifested by
violence, which is triggered by consumption of alcohol by a person with a pre-
disposing mental or physical condition, e.g., temporal lobe epilepsy, encephalitis,
epilepsy, head injury or a metabolic disturbance.
 This is attributed to the gain of function polymorphism of enzyme alcohol
dehydrogenase, which increases the rate at which acetaldehyde is produced. This
is encountered in 90% of Asians.
 When these individuals drink alcohol, they develop high blood acetaldehyde
concentrations. In affected individuals the accumulation of acetaldehyde with even

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 modest ethanol consumption leads to a severe flushing reaction. This is similar to
that seen with the combination of disulfiram and ethanol.
 The defense only applies if the defendant had no reason to know that he was
susceptible to such a reaction.

DIFFERENTIAL DIAGNOSIS OF ACUTE ALCOHOLIC INTOXICATION

Acute alcoholic intoxication can mimic several conditions which can lead to errors in
diagnosis. They include,
1. Barbiturate over dosage.
2. Carbon monoxide poisoning.
3. Hypoglycemia.
4. Head injury.
5. Parkinsonism.
FATAL DOSE OF ETHANOL
 One pint (550 ml) of a strong distilled spirit such as whiskey taken in a short span of
time can be lethal.
 The usual fatal dose corresponds to approximately 6 gram of ethanol / kilogram of body
weight (adult); 3 gram / kilogram of body weight (child).
 In terms of blood alcohol, a level in excess of 400 to 500 milligrams / 100 mL is usually
considered as lethal.
MANAGEMENT OF ACUTE ALCOHOL INTOXICATION
 The first priority is to be certain that the vital signs are relatively stable without evidence
of respiratory depression, cardiac arrhythmia etc. Life-threatening problems require
appropriate emergency care and hospitalization.
 Gastric lavage is usually not indicated as it retrieves only a small amount of alcohol
from the gut. However if necessitated it may be performed with plain warm water.
 Respiration is safeguard by clearing the passage. If needed be, analeptic like
Nikethamide is given. If analeptic does not work, 50-100ml of 50 % dextrose may be
given by slow I.V. infusion, along with 15 unit’s insulin subcutaneously.
 Thiamine 100mg I.V. infusion.
 Intravenous fluids as indicated.

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 A variety of drugs have been tried to hasten the elimination of ethanol or reverse its
intoxication effects. Recently, flumazenil (3 mg I.V.) has been shown to be effective (in
experimental studies) in reversing the respiratory depression.

ALCOHOL WITHDRAWAL
Sudden cessation of alcohol intake in a chronic alcoholic can provoke a withdrawal
reaction which may manifest as one of the following:

ALCOHOL WITHDRAWAL FEATURES

 Mild or minor alcohol withdrawal usually occurs within 24 hours of the last drink and
is characterized by tremulousness (shakes), insomnia, anxiety, hyper-reflexia,
diaphoresis (excess sweating), minor autonomic hyperactivity, and GI upset.

 Moderate or intermediate alcohol withdrawal usually occurs 24-36 hours after the
cessation of alcohol intake. This is an intermediate stage along the continuum. Its
manifestations include intense anxiety, tremors and insomnia. Patients maintain a clear
sensorium even during hallucinations.
 Severe or major alcohol withdrawal usually occurs more than 48 hours after a
cessation or decrease in alcohol consumption. It is characterized by profound alteration
of sensorium including disorientation, agitation, and hallucinations; along with severe
autonomic hyperactivity including tremulousness (shakes), tachycardia, tachypnea,
hyperthermia, and diaphoresis (excess sweating).
 ALCOHOLIC HALLUCINOSIS
 Usually occurs 24 to 36 hours after the last drink and may last for about 24 hours.
 Symptoms consists of persecutory, auditory, or (most commonly) visual and tactile
hallucinations; however, the patient's sensorium is otherwise clear. The patient can
be seen pulling at imaginary objects, clothing, and sheets, for example.
 RUM FITS
 Usually occurs 7 to 48 hours after the last drink.

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  Seizures are usually brief, generalized, tonic-clonic in nature without an aura. They
occur in a cluster of 1-3 seizures with a short postictal period. Partial seizures are
not uncommon. In half of the patients, the seizures progress to Delirium tremens.

 DELIRIUM TREMENS (DTS)

 Delirium tremens (colloquially, the DTs) is an acute episode of delirium that is

usually caused by withdrawal from alcohol.
 Usually occurs 3 to 5 days after the last drink (up to 14 days).
 Withdrawal from sedative-hypnotics other than alcohol, such as benzodiazepines or
barbiturates can also result in seizures, delirium tremens and death if not properly
managed.
 When caused by alcohol, it occurs only in individuals with a history of chronic
alcohol consumption.
 Fifty percent of alcoholics will develop severe withdrawal symptoms (seizures) and
of these only five percent of cases of acute ethanol withdrawal progress to delirium
tremens.
 Unlike the withdrawal syndrome associated with opiate dependence, delirium
tremens (and alcohol withdrawal in general) can be fatal. Mortality can be up to 35%
if untreated; if treated early, death rates range from 5-15%.
 Clinical features:
 The main symptoms are confusion, diarrhea, disorientation and agitation
and other signs of severe autonomic instability (fever, tachycardia,
hypertension).
 There may be hallucinations, or illusions related to the environment, e.g.,
patterns on the wallpaper that the patient perceives as giant spiders
attacking him or her.
 Unlike hallucinations associated with schizophrenia, delirium tremens
hallucinations are primarily visual, but are also associated with tactile
hallucinations such as sensations of something crawling on the subject -
a phenomenon known as formication.
 Delirium tremens can sometimes be associated with severe,
uncontrollable tremors of the extremities and secondary symptoms such
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13
 as anxiety, panic attacks and paranoia. Confusion is often noticeable to
onlookers as individuals will have trouble constructing simple sentences
or making basic calculations logic. In many cases, people who rarely
speak out of turn will have an increased tendency for gaffes even though
they are sober.
 Delirium tremens due to alcohol withdrawal can be treated with benzodiazepines.
Typically the patient is kept sedated with benzodiazepines, such as diazepam
(Valium), lorazepam (Ativan) etc. The de-addiction and psychiatric evaluation plays
a vital role in the management strategy.
 Medico-legal importance of this psychological disorder occurring in chronic
alcoholics is that they develop suicidal as well as homicidal tendencies.
 ALCOHOLIC KETOACIDOSIS (AKA)
 In 1940, Dillon and colleagues first described alcoholic ketoacidosis (AKA) as a
distinct syndrome.
 Alcoholic ketoacidosis follows withdrawal from alcohol and develops in chronic
alcoholics with a recent history of heavy episodes.
 Usually occurs 24 to 72 hours after the last drink.
 Alcoholic Ketoacidosis is characterized by metabolic acidosis with an elevated
anion gap, elevated serum ketone levels, and a normal or low glucose
concentration. The disorder typically occurs in people who chronically abuse alcohol
and have a recent history of binge drinking, little or no food intake, and persistent
vomiting.
 The following are the 3 main predisposing events:
 Delay and decrease in insulin and excess in glucagon secretion induced by
starvation.
 Elevated ratio of the reduced form of nicotinamide adenine dinucleotide
(NADH) to nicotinamide adenine dinucleotide (NAD) secondary to alcohol
metabolism
 Volume depletion resulting from vomiting and poor oral intake of fluids

These inciting events result in the rapid accumulation of the metabolic acids
hydroxybutyric acid and acetoacetic acid.
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MANAGEMENT OF ALCOHOL WITHDRAWAL
 Most alcohol-withdrawal seizures are self-terminating; however, if prolonged, they are
usually quickly terminated with benzodiazepines (e.g., diazepam, lorazepam).
Lorazepam is preferred because it has a long redistribution time that enables it to have
prolonged effectiveness, protecting the patient from recurrent seizures. Lorazepam is
less dependent than other benzodiazepines on hepatic metabolism, which may be
impaired in chronic alcoholics.
 If bedside glucose testing reveals hypoglycemia, glucose given as dextrose 5% and
thiamine 100 mg IV are indicated.

ALCOHOLISM (CHRONIC ALCOHOL ABUSE)

DEFINITION
Alcoholism has traditionally been defined as a chronic, progressive disease characterized
by tolerance and physical dependence to ethanol and pathologic organ changes.
Or
People who continue to drink alcohol inspite of adverse medical or social consequences
related directly to their alcohol consumption suffer from alcoholism.
COMPLICATIONS OF CHRONIC ETHANOL ABUSE
Complications of chronic ethanol abuse include:
1. CNS (Neuropsychiatric) complications.
2. Cardiovascular complications (Cardiomyopathy, Hypertension, Holiday Heart
Syndrome).
 Holiday Heart Syndrome
 The term was coined by Ettinger et al. in 1978.
 It was defined as an acute cardiac rhythm and/or conduction disturbance, most
commonly supraventricular tachyarrhythmia, associated with heavy ethanol
consumption in a person without other clinical evidence of heart disease.
 Typically, this resolved rapidly with spontaneous recovery during subsequent
abstinence from alcohol use.
 Several mechanisms are theorized to be responsible for the arrhythmogenicity of
alcohol. These include an increased secretion of epinephrine and nor-

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 epinephrine, increased sympathetic output, a rise in the level of plasma free fatty
acids, and an indirect effect through acetaldehyde, the primary metabolite of
alcohol, or fatty acid ethyl esters, a cardiac alcohol metabolite.
3. Endocrine complications (Hypokalemia, Malnutrition, Hyperurecemia etc.).
4. Gastrointestinal complications (Gastritis, oesophageal varices, pancreatitis etc.).
5. Hepatic complications (Fatty liver, Cirrhosis etc.).
6. Genitourinary complications (Impotence, infertility)
7. Ophthalmic complications (Ophthalomplegia, Tobacco-alcohol amblyopia).
8. Social complications (Accidents, Marital disharmony, Financial difficulties etc.)

CNS (NEUROPSYCHIATRIC) COMPLICATIONS

CNS complications of chronic alcohol use includes,

1. Wernicke's Encephalopathy.
2. Korsakoff’s Psychosis or Korsakoff’s Syndrome.
3. Marchiafava Bignami Disease.

1. WERNICKE'S ENCEPHALOPATHY
 Wernicke’s Encephalopathy is a syndrome characterised by ataxia,
ophthalmoplegia, confusion, and impairment of short-term memory.
 It is named after 19th century Polish neurologist Carl Wernicke.
 The classic triad of the syndrome is encephalopathy (brain damage),
ophthalmoplegia (eye paralysis), and ataxia (loss of coordination).
 It is caused by lesions in the medial thalamic nuclei, mammillary bodies,
periaqueductal and periventricular brainstem nuclei, cranial nerve nuclei III, IV, VI
and VIII, the thalamus, dorsal nucleus of the vagus nerve and superior cerebellar
vermis, often resulting from inadequate intake or absorption of thiamine (Vitamin
B1).
 Its most common cause is prolonged alcohol consumption resulting in thiamine
deficiency. Alcoholics are therefore particularly at risk, but it may also occur with
thiamine deficiency states arising from other causes, particularly in patients with
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 gastric disorders such as carcinoma, chronic gastritis, and repetitive vomiting,
particularly after bariatric surgery.
 Untreated, it may progress to Korsakoff's psychosis, coma and death.
 Treatment begins with intravenous or intramuscular injection of thiamine, followed by
assessment of central nervous system and metabolic conditions.

2. KORSAKOFF’S PSYCHOSIS
 Korsakoff’s psychosis or syndrome is an irreversible disorder of learning and
processing of new information, characterized by a deficit in short-term memory and
confabulation due to combined effects of alcohol toxicity and metabolic derangement of
thiamine deficiency.
 The syndrome is named after Sergei Korsakoff, the Neuropsychiatrist.
 Clinical features of Korsakoff's syndrome include:
 Anterograde Amnesia
 Retrograde Amnesia
 Severe memory loss
 Confabulation, that is, invented memories which are then taken as true
due to gaps in memory sometimes associated with blackouts
 Lack of insight
 Apathy - the patients lose interest in things quickly and generally appear
indifferent to change.
 Paralysis of muscles controlling the eye
 These symptoms are caused by a deficiency of thiamine (vitamin B1), which is
thought to cause damage to the medial thalamus and possibly to the mammillary
bodies of the hypothalamus as well as generalized cerebral atrophy.
 Associated with chronic alcoholism, and severe malnutrition. Alcoholism is often an
indicator of poor nutrition, which in addition to inflammation of the stomach lining
causes thiamine deficiency.
 Treatment involves the replacement or supplementation of thiamine by intravenous
(IV) or intramuscular (IM) injection, together with proper nutrition and hydration.
However, the amnesia and brain damage caused by the disease does not always
respond to thiamine replacement therapy.

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3. MARCHIAFAVA BIGNAMI DISEASE
 In 1903 Marchiafava and Bignami, 2 Italian pathologists, described 3 men with
alcoholism who died after having seizures and coma. They named this disease after
their name.
 Marchiafava Bignami disease is a demyelinating disorder of white matter of the
brain, commonly affecting the corpus callosum. It is seen in chronic heavy alcohol
drinkers.
 It is a radiological diagnosis as clinical features are variable and non-specific. It may
progress to dementia.
 Alcoholism remains the greatest risk factor, although rare cases have occurred in
individuals who did not drink alcohol.
 Clinical features include disorientation, epilepsy, ataxia, dysarthria, hallucination.

MANAGEMENT OF CHRONIC ETHANOL ABUSE

Drugs used in the treatment of chronic alcohol abuse are:
A). Deterrent agent or Antabuse therapy – Disulfiram (tetraethyl thiuram disulfide).
B). Anti-craving agents – Acamprosate, Naltrexone, Fluoxetine.

DISULFIRAM
 Disulfiram (tetraethyl thiuram disulfide), a widely used antioxidant in the rubber
industry, causes extreme discomfort to patients who drink alcoholic beverages.
 Disulfiram acts by inhibiting aldehyde dehydrogenase. Thus alcohol is metabolized as
usual, but acetaldehyde accumulates.
 When alcohol is ingested by a person who is on disulfiram, alcohol derived
acetaldehyde cannot be oxidized to acetate and this leads to an accumulation of
acetaldehyde in blood. This causes the important disulfiram –ethanol reaction
characterized by flushing, tachycardia, hypotension, tachypnoea, palpitations,
headache, sweating, nausea, vomiting, giddiness and a sense of impeding doom
associated with severe anxiety. These untoward symptoms deter the patient from
taking alcohol.

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 Disulfiram’s site of action leading to
inactivation of aldehyde dehydrogenase

Ethanol Acetaldehyde Acetic acid

Alcohol Aldehyde
Dehydrogenase Dehydrogenase

 The duration of disulfiram inhibition of aldehyde dehydrogenase is partially dependent

upon the dose ingested. A 500 mg dose inhibits aldehyde dehydrogenase up to 3-4
days, a 1000 mg dose up to 5-6 days, and a 1500 mg dose up to 7-8 days. Thus
patients remain vulnerable for a disulfiram –ethanol reaction for up to 1 week following
cessation of oral disulfiram therapy.
 Several other drugs, e.g. metronidazole, cephalosporins, sulfonylurea hypoglycemic
drugs and chloramphenicol, have disulfiram like effects on ethanol metabolism.
Patients should be warned to avoid drinking ethanol while taking these drugs.

ALCOHOL HANGOVER (VEISALGIA)

 The “hangover” syndrome is attributed to congeners, substances that appear normally
in alcoholic beverages in addition to ethanol and water.
 Congeners contribute to the taste, flavor, aroma and color of a beverage.
 Some of the congeners include fusel oil (a mixture of amyl, butyl, and propyl alcohol),
aldehydes, esters etc.
 Due to the reversible, toxic effects of ethanol on the brain, gastro-intestinal tract and
liver & congeners
 Clinical features are malaise, headache, tremor and nausea.
 Self-limiting and respond to antacids and simple analgesics.

BREATHALYZER (ALCOMETER; INTOXIMETER; DRUNKOMETER)

 Breathalyzer is special equipment carried by the traffic police to detect the alcohol in
the breath of a suspect driver. It serves as an “on the spot test”.
 Indian Motor Vehicle act 1988 (1994), section 203 gives legal sanctity to the estimation
of blood alcohol concentration based on breath.
 Breathalyzer (a combination of breath and analyzer) is a device for estimating blood
alcohol content (BAC) from a breath sample.

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 The excretion of ethanol by the lungs is first order and obeys Henry's law, in which the
ratio between the concentration of ethanol in the alveolar air and the blood is constant
i.e. 1:2100 (that there will be 2100 parts in the blood for every part in the breath) This
fixed relationship between the alveolar air and the blood forms the basis for the
sampling of subject’s breath to reliably estimate their blood ethanol concentration.
 The first practical roadside breath testing device intended for use by the police was the
drunkometer. The drunkometer was developed by Professor Harger in 1938. The
Professor Harger’s drunkometer collected a motorist's breath sample directly into a
balloon inside the machine. The breath sample was then pumped through an acidified
potassium permanganate solution. If there was alcohol in the breath sample, the
solution changed colour. The greater the colour change, the more alcohol there was
present in the breath.
 In 1954, Borkenstein invented breathalyzer, which used chemical oxidation and
photometry to determine alcohol concentration.
 Now, the older techniques are superseded by more sophisticated versions based on
fuel-cell sensing, electrochemical oxidation, infrared photometry, and microprocessors
which accurately predict the blood alcohol concentration alcohol concentration.
 One major problem with older breathalyzers is non-specificity: the machines not only
identify the ethyl alcohol (or ethanol) found in alcoholic beverages, but also other
substances similar in molecular structure or reactivity.

WIDMARK'S FORMULA
 During the early part of this century, E.M.P. Widmark, a Swedish physician, did much of
the foundational research regarding alcohol pharmacokinetics in the human body. He
developed formulae for calculating the total amount of alcohol in grams in the body of
an individual to cause a specific alcohol concentration within a specific time,
considering size (weight) and sex of the subject, the type of alcoholic liquor consumed,
and assuming equilibration of alcohol throughout the water compartment
 The Widmark formula is A = P x C x R
A = Total amount of alcohol in grams in the body at a given time to cause the particular
blood alcohol concentration.

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 P = The weight of the person in kilograms.
C = The blood alcohol concentration in grams/1000 gram blood. It is determined by
recalculating the BAC (gram/100gram, and then multiplying it by 10.
R = The Widmark or distribution factor. It varies between 0.5 and 0.9, but usually 0.88
for men and 0.55 for women.
 Conversely this formula is used to calculate the volume of alcoholic beverage
consumed if the blood or breath alcohol concentration is known. However the accuracy
depends upon factors like subject’s normal pattern of absorption, distribution,
elimination and accuracy for strength of alcoholic beverages.

METHYL ALCOHOL
 The term toxic alcohol commonly refers to ethylene glycol, methyl alcohol and
isopropanol. Other less common toxic alcohols include diethylene glycol, benzyl
alcohol, and the glycol ethers (butoxyethanol, methoxyethanol).
 Methanol is used as antifreeze in window washer fluid, as anti-icing agent in fuel, in
varnish removers and paints.
 It is used in the manufacture of acetic acid, formaldehyde, methyl derivatives and
inorganic acids.

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 Poisonings occur from accidental ingestion of methanol containing products or when it
is used by alcoholics as an ethanol substitute. Methanol toxicity remains a common
problem in many parts of the developing world, especially among members of lower
socioeconomic classes (‘hooch tragedy’).

MECHANISM OF ACTION
 Methanol has a relatively low toxicity. The adverse effects are thought to be from the
accumulation of formic acid, a metabolite of methanol metabolism.
 Upon ingestion, methanol is quickly absorbed in the gastrointestinal tract and
metabolized in the liver.

Methanol Formaldehyde Formic acid CO2 + H2O

Alcohol Aldehyde Folate
Dehydrogenase Dehydrogenase

CLINICAL FEATURES OF METHANOL POISONING

The signs and symptoms of methanol poisoning can be discussed under the system it
affects:
 Cardiovascular – tachycardia, hypotension.
 Central nervous – CNS depression, convulsions, dizziness, headache, hypothermia,
inebriation.
 Gastrointestinal – abdominal pain, anorexia, gastritis, nausea, vomiting, pancreatitis.

 Ophthalmic
 Snow fields, blurred vision, hyperemic discs, dilation of pupils, papilledema, and
blindness.
 Visual symptoms, if they develop, usually develop within 24 hours after methanol
exposure. This is the result formic acid mediated retinal toxicity. If formate
production persists, the toxin may result in permanent visual loss.
 Pulmonary – respiratory depression.

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 Metabolic – an anion gap metabolic acidosis is another common feature of methanol
toxicity. This is caused by formic acid, but may be exacerbated by the increase in
lactate production from formate’s inhibition of the cytochrome oxidase chain.

MANAGEMENT OF METHANOL POISONING

 Respiratory support.
 Thorough gastric lavage after airway has been protected by endotracheal intubations.
 Antidotes for methanol : Ethanol & Fomepizole
 10% of ethanol is often used intravenously as a treatment for methanol poisoning.
Although ADH metabolizes all alcohols, enzyme binding affinity varies. The affinity
of ADH for ethanol is 4 times greater than its affinity for methanol, thus, saturation of
the enzyme with ethanol reduces formate production.
 Fomepizole (4 methyl pyrazole) is used in western countries instead of ethanol. It is
used intravenously. Fomepizole has the advantage of being a very potent inhibitor
of alcohol dehydrogenase without producing CNS depression.
 Sodium bicarbonate infusion can help correct a profound metabolic acidosis (used
when pH is less than 7.2).
 Methanol concentrations more than 25 mg/dL are considered indication for
hemodialysis. Hemodialysis removes methanol and their toxic metabolites.
 Symptomatic treatment.

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 ARTIFICIAL INSEMINATION..

Definition:
It is the method to bring about pregnancy by deposition of semen into the vagina, cervical
canal or uterine cavity with the help of instruments.

Types of insemination:
 Artificial Insemination Homologous (AIH): When the semen of the husband of the
woman is inseminated.
 Artificial Insemination Donor (AID): When the semen of some other person is
introduced into the woman’s vagina
 Artificial Insemination Homologous Donor (AIHD): When the semen of both the
husband and the donor is pooled and introduced into the woman.

Indications for Artificial Insemination:

1. When the husband is impotent but fertile (AIH).
2. When the husband is unable, to deposit the semen in vagina due to presence of
Hypospadias or Epispadias, etc,
3. When the husband is sterile (AID).
4. When there is Rh-blood group incompatibility between the husband & wife.
5. When the husband is suffering from hereditary diseases, genetic defects, carrying a high
risk of infant mortality.

Precautions to be taken by the doctor:

 In case of AIH no precaution need to be taken by the doctor.
 But the precautions are necessary in AID and AIHD, they are as follows:
 The knowledge and full consent of both the spouses is essential
 Donor should never know to whom his semen is donated.
 The identity of the donor and the recipient should be secret
 Donor should be healthy physically and should not suffer from any hereditary
diseases
 He should be married and should be having children of his own.
 It is desirable that the donor should match the husbands profile and personality to the
closest possible.

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  The consent of the donor’s wife is equally important before using the donor’s semen
for insemination.
 Doctor shall preserve the secrecy of the procedure, details about the donor and the
recipient.

Legal implications of Artificial Insemination:

 Birth of a child following AIH, will not constitute proper evidence of consummation of
marriage in a couple.
 In case of AID, the position is radically different and the following legal issues may arise:
1. Legitimacy: A child born by AIH is always legitimate but in case of AID, as husband
is not the actual father, the child will be considered as illegitimate and cannot inherit
the father’s property directly. It can be made legitimate by the method of adoption.
But if parents do not declare artificial insemination and do not adopt the child, then
child for all practical purposes remains to be legitimate.
2. Nullity of marriage and divorce: As impotence is a ground for marriage but not
sterility, mere artificial insemination cannot be a ground for divorce. But If AIH is
done because the husband is impotent and has consented for it, nullity of marriage or
divorce can be granted to the wife.
3. Inheritance of property: Since the child is illegitimate if born out of AID, it cannot
inherit the property of his father. It can be made legitimate by the method of adoption
and after that the child has all rights to inherit the property.
4. Consummation of marriage: Conception of the wife by AI (AIH or AID) does not
amount to consummation of marriage, if there is no successful sexual act due to the
impotency of husband. The decree of nullity may still be granted in favor of the wife
on the ground of impotency of the husband or his willful refusal to consummate the
marriage.
5. Ground for divorce and judicial separation: Mere AI is not a ground for nullity of
marriage and divorce since sterility is not a ground, however if AI is due to impotence
of husband, it becomes the ground. AID without husbands consent can be a ground
for divorce and judicial separation.
6. Insemination after the death of the husband: This is seen when semen of the
husband is cryo-preserved by various methods and the women is inseminated after
death of the husband. Such Posthumous child is said to be legitimate because the
semen is of husband, although the complexity arises since conception is not during
the continuance of marriage.
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 7. Charge of Adultery: AID does not amount to adultery, even if it was done without
the consent of husband. For adultery to be committed both parties should be
physically present and engage in sexual act and sexual union involving some degree
of penetration of the female organ by the male organ should take place. AI is not
equivalent to sexual intercourse.

SURROGACY
Definition:
Surrogacy is a method or agreement whereby a woman agrees to carry a pregnancy for
another person or persons, who will become the newborn child's parent(s) after birth.

 In Latin “Surrogatus” means a substitute i.e. a person appointed to act in the place of
another.
 To give a womb for rent (rent a womb) means to nurture the fertilized egg of another
couple in your womb and give birth to the child with a specific intention, the intention
here being either money, or service, or because of altruistic reasons.

Indications:
1. When either pregnancy is medically impossible.
2. When pregnancy risks present an unacceptable danger to the mother's health or is a
same sex couple's preferred method of having children.

Types of Surrogacy:
A. On the basis of Selection of Surrogate Mother:
a. Altruistic surrogacy: Where the surrogate mother receives no financial rewards
for her pregnancy or the relinquishment of the child to the genetic parents except
necessary medical expenses. This usually happens when the surrogate mother is a
relative
b. Commercial surrogacy: Where the surrogate mother is paid over and above the
necessary medical expenses. This usually happens when the surrogate mother is
not related to the mother.

B. On the basis of Embryos:

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 a. Traditional Surrogacy: In this method, the surrogate mother carries the child for
the full term and delivers it for the couple through artificial insemination. The
surrogate mother is the biological mother of the child.
b. Gestational Surrogacy: In this, the eggs of the mother are fertilized with
father’s/donor’s sperm and then the embryo is placed into the uterus of the
surrogate. In this case the biological mother will be the one whose eggs are used
and surrogate mother is called the birth mother.

Surrogacy (Regulation) Bill, 2016:

1. It bans all forms of commercial surrogacy in India.
2. Altruistic surrogacy is permitted on the fulfilment of certain conditions.
3. Only childless couples who have been married for at least five years, provided that at
least one of them is proven to have fertility related issues.
4. Married couples who have biological or adopted children, single people, live-in
partners, homosexual persons would not be eligible to opt for surrogacy.
5. Foreign nationals won’t be allowed to commission surrogacy in India.
6. Childless or unmarried women would not be allowed to be surrogate mothers.
7. Surrogate mothers may only be close relatives, and they would be permitted only once
to be a surrogate.
8. The rights of both the surrogate mother and children are protected as per the Bill.

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 ASPHYXIA
Asphyxia is defined as “the physiologic and chemical state in a living organism in which
acute lack of oxygen available for the cell metabolism is associated with inability to
eliminate excess of carbon dioxide”.
 Asphyxia term is a misnomer; it implies “absence of pulse” or “pulselessness”.
 Terms such as 'anoxia' or 'hypoxia' are synonymously used with Asphyxia although
technically they are different.
 Hypoxia refers to low oxygen content in the blood.
 Anoxia refers to a total lack of oxygen in the blood.

BARCROFT’S (GORDON’S) CLASSIFICATION OF ANOXIA

Barcroft classified anoxia into following categories,

1. Anoxic anoxia, i.e. prevention of oxygen from reaching the lungs.
e.g.: Hanging, Strangulation, Smothering etc.

2. Anemic anoxia, i.e. inability of blood to carry sufficient oxygen due to low
hemoglobin concentration.
e.g.: Haemorrhage, Carbon monoxide poisoning, Chlorates etc.

3. Stagnant anoxia, i.e. impaired blood flow resulting in lack of oxygenated

blood flow to the tissues.
e.g.: Congestive cardiac failure, Traumatic shock etc.

4. Histotoxic anoxia, i.e. adequate amount of oxygen is available in the blood

stream, but it cannot be utilized by the tissues.
e.g.: Cyanide poisoning, Chloroform and Halothane poisoning.

 Histotoxic anoxia is further subdivided into extracellular (tissue oxygen enzyme

system is poisoned), pericellular (decrease cell permeability results in the inability of
oxygen to gain entry into cell) and substrate types (there is inadequate food for
efficient metabolism by the cell).

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 VICIOUS CYCLE OF ASPHYXIA

Asphyxia

Deficient oxygenation in lungs Decreased O2 tension

Reduced pulmonary flow

Capillary dilatation

Decreased venous return to heart

Capillary stasis

Stasis of blood in organs

Capillary engorgement

Asphyxial signs:
Classical signs of asphyxia are,
 Cyanosis:
It is the blue coloration of the skin and mucus membrane resulting from excess of de-
oxygenated hemoglobin in the venous blood. This is seen when reduced hemoglobin
or de oxygenated hemoglobin exceeds 5gm%.
 Petechial hemorrhages:
Small pin head sized collections of blood, venular in origin and are caused by acute
rise in venous pressure leading to rupture of thin walled venules. These are seen
commonly in the lax tissues like face, conjunctiva, sclera, and in unsupported serous
membranes like pleura and epicardium. Tardieu`s spots are petechial hemorrhages in
the thorax often restricted to visceral pleura, especially in the interlobar fissure and
hilum.

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 Fluidity of blood:
This is due to the excessive release of fibrinolysins from the endothelial surface of the
blood vessels.
 Congestion of the face:
This results from venous congestion.
 Engorgement of the chambers of the right side of the heart and great veins due to
generalized rise in venous pressure.

CLASSIFICATION OF ASPHYXIAL DEATHS

Asphyxial deaths can be categorized into following,
1) Mechanical asphyxia, flow of air into the lungs is mechanically interfered.
2) Non Mechanical asphyxia, insufficient oxygen in the atmosphere or exclusion
of oxygen by its depletion and replacement by another gas or by chemical
interference with its uptake and utilization by the body.
e.g.: Carbon monoxide poisoning, Cyanide poisoning etc.

Classification of Mechanical asphyxia:

A. Pressure on the exterior of the neck.

e.g.: Hanging, Strangulation, and Mugging

B. Obstruction of external respiratory orifices.

e.g.: Smothering

C. Obstruction of airways from the interior. SUFFOCATION

e.g.: Gagging, Choking etc.

D. Restriction of the respiratory movements.

e.g.: Traumatic asphyxia.

E. Prevention of gas exchange in the lungs by fluids.

e.g.: Drowning.

SUFFOCATION:

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Suffocation is a violent mechanical asphyxial death resulting from the mechanical
obstruction to the entry of air into the lungs by obstruction of the external respiratory
orifices, excluding drowning deaths and deaths arising due to pressure over the neck
structures.
E.g.: smothering, gagging, choking, and traumatic asphyxia

SMOTHERING:

Definition:
Smothering is a violent mechanical asphyxial death resulting from closure of the mouth
and nostrils by means of a hand, plastic bags, or soft pillows.

Medico-legal significance:
A. Suicide:
Suicide by smothering can be effected by tying a polythene bag over the head and
face.
B. Accident:
Accidental smothering usually seen in infants may be suffocated merely by the weight
of the bed clothes. It is also reported while an infant is being breastfed by the mother or
the mother accidentally rolling on the child in sleep.
C. Homicide:
To accomplish homicidal smothering, there need to be a considerable physical
disparity between the assailant and victim, or the victim is debilitated by drugs or injury.

Post mortem findings in deaths due to smothering:

1) Injuries may be completely absent if a soft material like a pillow is used.
2) Bruising around the mouth, nostrils and face
3) Abrasions due to fingernail scratches if the hands are used to smother, contusions and
lacerations over the inner aspects of the lip from pressure against teeth.
4) Internal organs may show asphyxial signs.

GAGGING:
Definition: Gagging is an asphyxial death resulting from stuffing pad or any piece of cloth
into the mouth.

Medico-legal significance:

These cases are commonly seen in sexual crimes and robbery to prevent the victim from
shouting, which results in asphyxial deaths.

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Post mortem findings in deaths due to gagging:
1. Injuries to the lips, gums, and tongue in the form of contusions or tears of the buccal
mucosa.
2. Loosening of the teeth can be seen resulting from resistance offered to prevent forceful
stuffing of the oral cavity.

TRAUMATIC ASPHYXIA (CRUSH ASPHYXIA/ COMPRESSION ASPHYXIA):

Definition:
Traumatic asphyxia is a form of suffocation caused by mechanical fixation of chest wall
movements.

Medico-legal significance:
These deaths are almost always accidental and occur in situations, such as earth quakes
leading to pinning of the victim beneath, or below an overturned car, or in crowds or mob
panics.

Sequence of events leading to traumatic asphyxia:

Compression of chest

Obstruction to venous return

Displacement of blood from the superior vena cava

Into subclavian veins, and veins of the head & neck

Sudden rise of intracapillary pressure

Rupture of capillaries

Petechial haemorrhages over the face, neck & shoulders

Post mortem findings in deaths due to traumatic asphyxia:

1. Severe congestion and cyanosis above the level of compression frequently with a
sharp line of demarcation.
2. Upper limbs are spared from congestion because of valves in the subclavian veins
which prevents back flow.

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3. Bleeding from the mouth & nostrils.
4. Petechial haemorrhages are prominent above the point of compression.
5. Fracture of ribs and sternum (buckled sternum).
6. Laceration of lungs and heart.

CHOKING:
Definition:

Choking is a form of asphyxial death resulting from the obstruction of the airway internally.
Medico-legal significance:
It is commonly accidental in nature, seen in very young, elderly, psychiatric and intoxicated
patients when the ability to chew or swallow is impaired.

Causes of Choking:
 Inhalation of foreign body into the glottis such as bolus of meat, nuts, coins, or artificial
dentures.
 Inhalation of vomited material in an unconscious, during anaesthesia or epileptic fits.
 "Cafe coronary", it is a form of choking seen in healthy and grossly intoxicated
person, who dies suddenly and unexpectedly during a meal with no signs of respiratory
distress or any of the classical signs of asphyxia. Initially the death looks like heart
disease that of coronary occlusion, but at autopsy a bolus of food seen lodged in the
pharynx or larynx.

Cause of death:

 In the case of Café coronary, the protective cough reflex which enables the coughing
out the foreign contents is depressed, leading to impaction of this material in the
laryngeal and pharyngeal mucosa, leading to stimulation of vagus nerve leading to
bradycardia.
 Asphyxia is another cause leading to death in choking.

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Post mortem findings in deaths due to choking:
1. If the object causing choking is present in the airway, the bolus may be smeared with a
mucus layer as a result of the tissue reaction, and inflammatory reaction of the tissue
can be seen due to local reaction.
2. Petechiae may be present if significant retching has occurred.
3. A complete autopsy and toxicological examination are necessary to confirm the event
leading to death.

BURKING:
This is the combination of smothering and traumatic asphyxiation, named after Burke &
Hare who used to kill their victims by this method, for the purpose of selling them to
anatomical schools.

HANGING:

Definition:
Hanging is a type of violent mechanical asphyxia where constriction is present around the
neck, the constrictor force being provided by the weight of the body.

Medico-legal significance:
A. Hanging is usually presumptive of Suicide.
B. Homicidal hanging is rare because it is very difficult to accomplish.
C. Accidental hangings are common in children, wherein they may accidentally get
entangled in ropes during play.
D. A person may be murdered, and the cadaver later suspended (Post-mortem hanging),
so as to make it simulate suicide and thus mislead criminal investigation.
E. Judicial hanging:
It is a form judicial execution in many countries like India. Person is hanged after
covering his face, and using a platform having trap door. When the trap door made to
open, prisoner falls to a specific distance determined by his weight. There occurs the
immediate death although the heart might beat for 5-15 minutes.

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Classification of hanging:

I. Based on the degree of suspension.

1. Complete hanging, wherein the body is completely suspended without any part of
the body touching the ground or any other objects on the ground. The constricting
force here is the weight of entire body.

2. Incomplete or Partial hanging, wherein some part of the body touching the
ground or any other objects on the ground.
e.g.: hanging in a sitting, kneeling or even lying position.

II. Based on the position of the knot.

1. Typical hanging, Wherein the point of suspension (knot) is placed at the nape of
neck at the back (occiput).

2. Atypical hanging, Wherein the point of suspension (knot) is placed anywhere

other than at the nape of neck at the back (occiput).

CAUSE OF DEATH IN CASE OF PRESSURE OVER THE NECK STRUCTURES:

Death due to pressure over neck structures (Hanging, ligature strangulation, throttling &
Mugging) can be caused by the following mechanisms, based on the structures which are
affected due to compression of the neck.

They are,
 Jugular veins.
 Carotid artery.
 Trachea.
 Vertebral arteries.
 Vagal stimulation.
 Spinal cord.

1. Occlusion of External Jugular Vein, results in stoppage of jugular venous cerebral

circulation leading to cerebral congestion, which requires a pressure of 2 kilo weight.
The victim looses consciousness and dies eventually if the occlusion is not relieved.
2. Occlusion of Carotid artery, results in cerebral anoxia, which requires a pressure of
five kilo weight.

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3. Occlusion of the airway, result from tongue being pushed backwards against
posterior pharyngeal wall resulting in hypoxia and asphyxiation. It requires a pressure
of 15 kilo weight.
4. Occlusion of vertebral artery, results in cerebral anoxia, which requires a pressure of
25 kilo weight.
5. Vagal stimulation caused by pressure over the carotid sheath and carotid body can
results in bradycardia leading to sudden cardiac arrest.
6. In judicial hangings, there will be transaction of spinal cord due to sudden long drop.

Post mortem findings in deaths due to hanging:

The findings can be studied under external and internal features.

EXTERNAL FEATURES
The salient external features are discussed under three categories
 Ligature mark.
 Findings above the ligature mark.
 Findings below the ligature mark.

Ligature mark:

1. The ligature mark is a pressure (patterned) abrasion.

2. In hanging, the ligature mark is,
 usually situated above the thyroid prominence.
 runs obliquely upwards and backwards ( inverted V shaped)
 may encircle the neck completely ( running noose) or partially (fixed noose)
 may reproduce the pattern (patterned abrasion) of the ligature material
 it appears reddish brown, grooved, dry, hard and parchmentized.
 deepest furrow of the mark is opposite the point of suspension, referred as the bight
area.
 soft and broad ligature material (saree, dupatta) may not leave any recognizable
marks or faint mark, whereas if the ligature material is tough and narrow (nylon or
coir rope) the mark is deep and prominent.
 at times there could be fingernails scratches in relation to the ligature mark, due to
an effort to release the ligature by reflex instinct to save their life.

Findings above the ligature mark:

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1. Dribbling of saliva:
This is seen at the angle of the mouth, opposite to the side of the knot, due to the
compression of the parotid and submandibular salivary glands. This is considered as a
definite sign of ante mortem hanging as salivation is considered as a vital process.
It is commonly seen at the scene of suspension or dried salivary stains may dribble
over to the face, neck, and chest and sometimes over the clothes worn by the victim.

2. Le facie sympathique:
Le facie sympathique is considered as an important ante-mortem phenomenon where
in the compression of the cervical sympathetic ganglia at the bight area (area opposite
to the knot) will cause the eye on that side to remain open and the pupil dilated.
3. Other findings:
 The tongue is usually swollen, blue and protruded in between the teeth (because it
is pressed upwards at its base by the ligature), with teeth bite marks.
 Petechial haemorrhages over the conjunctiva.
 Face is congested except in deaths due to vagal stimulation wherein it is pale.

Findings below the ligature mark:

1. Rigor mortis sets in early due to the exhaustion of ATP from the muscles due to violent
struggle prior to death.
2. The post-mortem lividity is limited to the hands, forearms, and the region surrounding
the genitalia over the limbs (glove and stocking type of distribution) if the body is
suspended in an upright position for long, because these form the dependent portion of
the body.
3. Cyanosis is noted over the lips, fingertips, nail beds, and tip of the nose.

INTERNAL FEATURES

 Examination of the neck structures in a bloodless and layered neck dissection (flap
dissection) may show bruising into the soft tissue, and damage to the thyroid and
cricoid cartilages.
 Dissection of the carotid arteries may show tears in the intimal layers with contused
margins.
 Fracture of the hyoid bone is seen in elderly persons after complete ossification. It is an
outward compression fracture.
 Fractures of the vertebrae (2nd, 3rd, 4th) do not occur unless there is a significant drop,
such as in a judicial hanging.
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BLOODLESS & FLAP DISSECTION or LAYERED NECK DISSECTION OF NECK

Indication:
Bloodless and flap dissection of neck is employed in deaths due to pressure over the neck
structures, e.g.:
 Hanging.
 Ligature strangulation.
 Throttling.
 Mugging.
 Bansdola.

Purpose:
 To avoid artefacts arising from seepage of blood from the neck veins.
 To more adequately document injuries (or absence of injuries) in deaths due to
pressure over the neck structures.

Procedure:
The dissection is performed by a step-by-step layer wise reflection of tissues after the
thoraco-abdominal organs and the brain have been removed. This allows the blood in the
neck drain away, providing for a cleaner dissection field. This is achieved by putting a
incision from sternal notch to pubic symphysis keeping neck intact. The organs of chest
and abdominal cavity dissected. Then the cranial cavity is opened and brain dissected.
This makes the neck bloodless. Over neck, incision is placed from symphysis mentis to
sternal notch. Structures of the neck are examined carefully avoiding artefacts layer by
layer (flap), i.e.
1) Skin is examined for any injuries.
2) Subcutaneous tissue for features of compression.
3) Cervical strap are reflected in the fascial plane, starting with the sterno-
cleidomastoid muscles and then reflecting deeper muscle layers (sternohyoid,
srenothyroid, thyrohyoid, omohyoid) – they are examined for blood extravasation.
4) Vessels of the neck ( carotid artery and jugular vein) are examined for any tear.
5) Thyroid gland is examined for any contusions.
6) Tracheal rings are examined for any fractures.
7) Hyoid bone, thyroid cartilage and cricoid cartilage examined for any fractures and
contusions.

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STRANGULATION:
Definition
Strangulation is a type of violent mechanical asphyxia where there is constriction around
the neck, the constrictor force being other than the weight of the body.
The different types of strangulations are,
1) Application of ligature (Ligature strangulation).
2) Application of human hands (Manual strangulation).
3) Others- Mugging, Bansdola, Garroting etc.

LIGATURE STRANGULATION:
Definition:
Ligature strangulation is a type of violent mechanical asphyxia where there is constriction
around the neck, applied by a constricting band that is tightened by a force other than the
weight of the body.

Medico-legal significance:
1. Strangulation is invariably homicidal in nature unless proved otherwise.
2. Children may accidentally entangled in ropes during play. Umbilical cord inside the
uterus may also accidentally strangulate the fetus.
3. Suicides by ligature can occur if the ligature is twisted in such a manner (multiple
rounds) that the pressure on the neck is maintained even after loss of consciousness.

Post mortem findings in Deaths due to Ligature Strangulation:

The findings can be studied under external and internal features.

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EXTERNAL FEATURES
The salient external features are discussed under two categories
 Ligature mark
 Other findings
Ligature mark:
1. The ligature mark is a pressure abrasion.
2. In ligature strangulation, the ligature mark is
 more evident as the force applied is much more than is required to constrict the
neck structures.
 usually situated at or below the thyroid prominence.
 runs transversely or horizontally.
 encircle the neck completely.
 may reproduce the pattern of the ligature material.
 it appears reddish brown, grooved, dry, hard and parchmentized.
 soft and broad ligature material (saree, dupatta) may not leave any
recognizable marks, whereas if the ligature material is tough and narrow the mark is
deep and prominent.
Other external findings
 There is usually gross congestion, cyanosis and petechiae on the face.
 There could be bleeding from the nostrils, scratches and contusions over the face,
arms and other parts of the body originating during struggle and resistance offered
by the victim in an attempt to save himself.

INTERNAL FINDINGS
1. Contusion of the soft tissues of the neck and the muscles is more common in
strangulation than hanging, due to the excessive pressure exerted and the effort of
struggle by the victim.
2. Thyroid cartilage and cricoid cartilage may at times get fractured and contused.
3. Injuries to blood vessels and hyoid bone (level of ligature is below the anatomical
location of the bone) are rare in ligature strangulation.

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MANUAL STRANGULATION (THROTTLING):
Definition:
Manual strangulation is a type of violent mechanical asphyxia brought about by
constricting the nec by the hand.
Medico-legal significance:
1) Throttling is invariably homicidal in nature.
2) Suicidal and accidental throttling is impossible.
Post mortem findings in deaths due to throttling:
The findings can be studied under external and internal features.
EXTERNAL FEATURES
 Neck findings.
 Other findings.

Neck findings:
 Disc-like finger-tip bruises over the front and sides of the neck.
 Crescentric finger-nail scratch marks (semi lunar) are seen when the victim trying to
remove the assailant’s hands from the neck
Other findings:
Contusions over the face, arms and other parts of the body originating during struggle and
resistance offered by the victim in an attempt to save himself.

INTERNAL FEATURES
1. The neck is dissected in a bloodless field after the great vessels of the thorax have
been emptied, so that post-mortem artifacts are not misinterpreted.
2. Dissection of the neck structures reveals hemorrhage under the skin and bruising of
the strap muscles
3. The damage to the neck structures, particularly the superior horns of the thyroid
cartilage, and the greater horns of the hyoid bone (inward compression fracture) are
seen in throttling.

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DIFFERENCES BETWEEN HANGING & LIGATURE STRANGULATION:

Findings Hanging Strangulation

at or above the level of thyroid above the level of thyroid
1. Ligature mark
cartilage cartilage
2. Direction oblique upwards transverse backwards

3. Salivary dribbling Present absent

4. Asphyxial
mild severe
features
5. Neck structures mild contusions severe contusions
fracture uncommon (outward fracture common (inward
6. Hyoid bone
compression fracture) compression fracture)
fracture is more common
7. Thyroid cartilage fracture is less common

8. Carotid arteries intimal tear is common uncommon

BANSDOLA:

It is a form of strangulation where the two sticks were placed across the victim’s neck, and
the neck is constricted.
MUGGING:
The term mugging means constriction of the neck by holding it in the bend of the elbow.
GARROTING:
When the assailant throws a ligature around the neck from behind and tightens with a
lever, causing sudden death, it is called Garroting. This is the mode of execution in Spain,
wherein a twisting device (Spanish Windlass) is used to constrict the neck.
LYNCHING:
To hang (or to kill by any other means) a person by mob action for an alleged offence
without a legal trial.

AUTOEROTIC ASPHYXIA (SEXUAL ASPHYXIA):

Sexual asphyxia is fatal condition resulting from self induced hypoxia during the course of
solitary erotic act.

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Mechanism of sexual gratification during asphyxia:
Suffocation (covering face by plastic bags), ligature strangulation), inhalation
anesthetics agents, or partial drowning

Partial cerebral hypoxia

Sexual arousal & orgasm

Different methods used for attaining hypoxia:

1. Suffocation using plastic bags over the base.
2. Ligature strangulation.
3. Inhalation of anaesthetic agents, petroleum products(glue sniffing).
4. Ligature strangulation.
5. Partial drowning.
Medico-legal significance:
Exclusively seen in males and death is accidental in nature not suicidal. Autoerotic
asphyxial deaths are accidental in nature because of the failure of safety precautions
which are employed by the victim to control hypoxia. The common causes are failure of
slipknot to loosen. Plastic bags covering the face may cause suffocation.

Indicators of deaths due to autoerotic sexual asphyxia:

1. Evidence of asphyxia produced by strangulation by ligature and presence of
protective means such as padding about the neck; indicate that the death was not
obviously intended.
2. Evidence of self-rescue mechanism
3. Presence of coexisting paraphilias e.g.: Cross dressing or Transvestism.
4. Evidence of solo sexual activity.
5. Evidence of sexual fantasy aids or pornography.
6. Evidence of prior autoerotic practice e.g.: healed injuries over the neck.

DROWNING
Definition:Drowning is a form of asphyxial death due to the submersion of the nostrils and
mouth in a liquid medium. The liquid is most commonly water but drowning can occur in
any liquid e.g. beer, wine, oil etc.

Classification:

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I. Typical or wet drowning, where in water enters the lungs leading to water logging of
lungs. It may be:
A. Fresh water drowning.
B. Salt water drowning.

II. Atypical or dry drowning, where in death occurs without water being entering the
lung. It may be due to,
A. Laryngeal spasm, in these cases sudden inhalation of water will result in reflex
spasm of the larynx, early unconsciousness and a rapid asphyxia leading to
sudden death without any asphyxial signs.

B. Immersion syndrome or Hydrocution, sudden contact of cold water over epigastric

region or tympanic membrane can cause death due to vagal stimulation causing
bradycardia leading to sudden cardiac arrest.

III. Secondary drowning (Post-immersion Syndrome or near drowning), is a term

used when a previously submerged victim ‘survives’ for atleast 24 hours after being
rescued. The individual may or may not be conscious. These individuals may develop
pulmonary edema, hemoglobinuria, cardiac arrhythmias, pneumonitis, fever, sepsis, as
well as symptoms related to cerebral hypoxia (convulsions, amnesia, confusion, coma). A
major cause of death within the first 24 hours is the sudden development of cerebral
edema.

PATHOPHYSIOLOGY OF WET DROWNING (FRESH & SALT WATER):

Fresh water:
Drowning in fresh water

Struggle to respire and save the life

Fresh water enters the alveoli

Alveolar lining membrane acts as a semi permeable membrane

Fresh water present in the alveoli is hypotonic in relation to blood

Water passes from the alveoli into the pulmonary capillaries

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 Increase in blood volume

Haemodilution

Swelling of RBC’s

Rupture of RBC’s

Increase in potassium, which is a cardio toxic

Ventricular fibrillation along with circulatory overload

Myocardial failure

Cerebral anoxia

Death within 4 to 5 minutes

Salt water:

Drowning in salt water

Struggle to respire and save the life

Salt water enters the alveoli

Alveolar lining membrane acts as a semi permeable membrane

Salt water present in the alveoli is hypertonic in relation to blood

Water passes from the blood to the alveoli

Hemoconcentration in the pulmonary circulation & massive pulmonary oedema

Haemoconcentration leads to crenation of RBC`s

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 Myocardial anoxia

Death within 8 to 12 minutes

Postmortem findings in drowning deaths

There are no pathological findings pathognomonic of drowning.

The autopsy as to establish that the victim was alive on entering the water
EXTERNAL
 The skin appears like Goose-skin, or cutis anserine, which is pimpling of the skin due
to the contraction of the erector pilorum muscles, which are stimulated from contact
with water. It is well appreciated on the extremeties.
 The skin of the hands and feet will appear shriveled and pale (washerwoman's hands
or Soddening) after being submerged in water for greater than 1 to 2 hours. This
change occurs regardless of whether the individual was alive or dead prior to the
submersion. Shriveling of the skin can also occur if the hands or feet are kept moist by
wet clothing or surrounding environmental matter (such as wet dirt or mud), and is,
therefore, not specific for drowning.
 Froth:
 Characteristic finding in drowning
 Mouth, nostrils & airways
 Produced by churning of air, water, mucus ( secreted by irritation of bronchial
mucosa), and surfactant during respiratory struggle
 Copious in quantity, white (sometimes blood tinged) and tenacious
 Resembles that of shaving lather
 It recurs if wiped off from the nose and mouth, especially if the chest is pressed.
 Fine bubbles of the froth does not readily collapse on touching with tip of scalpel
(because of surfactant coat)
 Postmortem staining confined to head, neck & front of chest, and both limbs due to the
postures of the body maintained after death in water.
 Rigor mortis may set in early due to the early depletion of the ATP due to violent
struggle occurring to save life.
 Cadaveric spasm and Foreign material in the hands:
Victims struggling in water may clutch at objects which are found grasped in the hand
after death. E.g.: weeds, plant, sand etc.

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INTERNAL
 The lungs
 Voluminous, bulky, edematous,
 Have a ballooned appearance with rib markings.
 Pit on pressure.
 Cut section of the lung show oozing out of large quantity of frothy fluid indicating
active inspiration of air and water
 Algae, weeds, mud, Sand and debris in the distal airways

 Paltauff’s Hemorrhages:
These are large hemorrhages found immediately beneath the pleura, commonly of
interlobar surface and anterior side of lower lobes.

 Emphysema Aquosum:
This is term used to describe lung picture seen when the person was alive at the time
of drowning i.e. pathognomic froth in the nostrils, mouth, airways, and increase in
weight of the lung.
 Edema Aquosum:
This is the term used to describe the lung picture wherein there is passive flooding of
airways in a case of drowning of unconscious victim i.e. the weight of the lung will be
increased but there is no pathognomic froth.
 The presence of large quantities of water and debris in the stomach is strongly
suggestive of the body immersed during life.
 Middle ear and mastoid air cell hemorrhage, blue-purple discoloration of the bone of
the roof of the mastoid air cells resulting from the pressure exerted by the surrounding
water.
DROWNING TESTS:

1. GETTLER CHLORIDE TEST

Principle:
When analyzing the chloride concentration of blood from the right and left chambers of
the heart, Gettler found a difference of more than 25% to be indicative of drowning. It
also helps to differentiate salt water drowning from that of fresh water. Normally
chloride content of the left & right sides of the heart is the same i.e. 600 mg%.

Inference:

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  If the death occurred in saltwater, the blood chloride concentration was greater in
the left heart chambers when compared to the right, due to hemoconcentration.
 If the death occurred in freshwater, the blood chloride concentration was greater in
the right heart chambers when compared to the left, due to hemodilution.

2. OTHER TESTS
A. Plasma Specific Gravity:
Left atrial blood, diluted by water from the lungs, has a lower specific gravity than
the right atrium in fresh water drownings.
B. Plasma Magnesium Level:
High levels of plasma magnesium in left heart blood, which contrasted with right
heart blood is considered to reflect absorption of that ion from the drowning medium
particularly salt water.
C. Blood Strontium Level:
Strontium is a trace metal that is found in relative abundance in the crust of the
earth. On this basis, strontium is widespread in sea-water and, to a lesser extent in
fresh water. Since strontium has a low concentration in the plasma, the addition of
minute amounts of strontium into the blood drowning may lead to relatively large
increases in the strontium concentration in the blood. The salt water drownings
have higher strontium levels than fresh water drownings. Therefore, strontium
analysis may be useful for the diagnosis of drowning particularly in the salt water
environment.
D. Diatoms Test.

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DIATOMS TEST:
Introduction:
 Diatoms are microscopic, unicellular algae, reportedly present in all types of water, in
moist soil, and in the atmosphere.
 They contain a siliceous outer box-like skeleton called a frustule, which is chemically
inert and resistant to strong acids and heat.
 Diatom analysis should be done on a closed organ system (such as the femoral bone
marrow), in a non-decomposed body, taking care to avoid contamination by
environmental factors which may contain diatoms.

Principle:
 When the living person drowned in water containing diatoms, they get penetrated
through the alveolar wall and through circulation reach distant organs such as brain,
kidneys, liver and bone marrow. Demonstration of these diatoms helps in indicating
that the person was alive at the time of being drowned.
 The tissue collected is digested with acid, or more recently with detergents or
enzymes, and the resultant centrifuged sediment is examined microscopically.
 A negative result for diatoms does not rule drowning as the cause of death.

Procedure:
Test

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 5 grams of femoral bone marrow (it is an closed organ system; distant organ, well
encapsulated thereby avoids contamination)

5 times the volume of concentrated Nitric acid

Kept at room temperature for 24 to 48 hrs

.
Acid digest all organic matter leaving behind acid resistant diatoms if present

The contents are centrifuged and supernatant fluid is discarded

The deposit is centrifuged again with adequate amount of distilled water 2-3 times to wash
off all the acid

The deposit is then examined using phase contrast microscope

Control
2 liters of water from alleged site of drowning

15 ml of iodine solution is added to decontaminate the water

Allowed to settle for 24 hrs

The bulk of the water is poured off

Remaining water is centrifuged to recover diatoms

This is examined using phase contrast microscope

Inference:
If the diatom in the water matches (control sample) with that of diatoms in the bone
marrow (test sample), indicates drowning.

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Limitations:
The test is limited by the possibility of contamination if the person drowned in a pond
which has been the source of drinking water or entry of diatoms through sea food.

INCOMPLETE LIST OF QUESTIONS FROM ASPHYXIAL DEATHS

1. Define asphyxia. Enumerate the classical signs of asphyxia.
2. Classify anoxia as per Barcroft (Gordon).
3. Outline the vicious cycle of asphyxia.
4. Classify asphyxial deaths (mainly the mechanical asphyxia).
5. Enumerate the deaths due to suffocation.
6. Discuss the death due to smothering (definition, medico-legal significance and
postmortem findings).
7. Discuss the deaths due to traumatic asphyxia (definition, medico-legal significance and
postmortem findings).
8. Discuss the deaths due to Cafe coronary (definition, medico-legal significance and
postmortem findings).
9. Define and classify hanging.
10. Write briefly on judicial hanging.
11. Discuss the external and internal postmortem features of deaths due to hanging.
12. Enumerate the causes of death in case of pressure over the neck structures (hanging,
strangulation etc.).
13. Write briefly on bloodless & flap dissection or layered neck dissection of neck.
14. Define ligature strangulation. Discuss the external and internal postmortem features of
deaths due to ligature strangulation.
15. Define throttling. Discuss the external and internal postmortem features of deaths due
to throttling.
16. Enumerate the differences between hanging and ligature strangulation.
17. Write briefly on autoerotic asphyxia (sexual asphyxia).
18. Define and classify drowning. Write briefly on near drowning.
19. Discuss the pathophysiology of wet drowning (Fresh & Salt water).
20. Discuss the external and internal postmortem features of deaths due to wet drowning.
Gettler Chloride Test.
21. Write briefly on diatom test.
22. Explain the following terms: a). Burking b). Garroting c). Gagging d). Mugging
e). Bansdola f). Lynching.

Dr. Francis N.P. Monteiro, Professor of Forensic Medicine & Toxicology 24

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51
 ASPHYXIANTS ]]]]}}}

As the name indicates, these are poisons which mainly act on the respiratory system. They
include Carbon Monoxide, Cyanide, Hydrogen Sulphide and War gases.
odourless
CARBON MONOXIDE (CO)
 Carbon monoxide is a colourless and gas.
 It does not cause much irritation of the air passages, and so its presence goes
unnoticed.
 It is produced wherever there is incomplete combustion of carbon and carbon
containing material.
 The common source of the gas are burning oil lamps, fires, Bunsen burners, coal gas,
gas supplied for domestic use, diesel and petrol engine exhaust fumes, all of which
contain carbon monoxide in varying proportions.
 Domestic gas contains 7 to 15% of the gas and car exhaust fumes 4 to 7%.

Medico-legal Significance:

 Poisoning is generally accidental or suicidal.

 Suicide has often been committed by inhaling the exhaust fumes of a running car
engine, particularly in an enclosed space such as a garage. New methods of
committing suicide by carbon monoxide poisoning include burning charcoal or other
fossil fuels within a confined space, such as a small room, tent, or car. Such incidents
have occurred mostly in connection with group suicide pacts in both Japan and Hong
Kong.
 Sometime the driver in the air condition car may go in to a state of Carbon monoxide
automatism due to leakage of the exhaust containing Co in to the car and may cause
an accident.

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52
 CO poisoning can also occur in scuba diving due to faulty or badly sited diving air
compressors.
 Symptoms of carbon monoxide poisoning include restlessness, depression, dementia,
emotional disturbances, and hallucinations. Many of the phenomena generally
associated with haunted houses, including strange visions and sounds, feelings of
dread, illness, and the sudden, apparently inexplicable death of all the occupants, can
be readily attributed to carbon monoxide poisoning. An examination of their furnace
found it to be severely damaged, resulting in incomplete combustion and forcing most
of the fumes (including carbon monoxide) into the house rather than up the chimney.

Mechanism of action:

 Haemoglobin has a great affinity for carbon monoxide, an affinity 300 times more than
that of oxygen.

 Carbon monoxide combines with haemoglobin to form carboxyhaemoglobin (COHb),

which is cherry red in colour.
Co + Hb COHb
 Carboxy haemoglobin is more stable than oxy-haemoglobin.
 Dissociation of carbon monoxide from haemoglobin is a rather slow process. As a
result of this union between carbon monoxide and haemoglobin, the latter is prevented
from functioning effectively as an oxygen carrier and therefore the effects of carbon
monoxide poisoning are essentially those of asphyxia.
 Although the blood is rich in oxygen, the body is not able to utilize it, and the person
dies a chemical asphyxial death.

Clinical Features of Carbon Monoxide poisoning:

The nature of the signs and symptoms and the quickness with which they manifest depend
on the concentration of the gas in the blood.
 When the concentration of the gas in the blood is about 20% the victim suffers from
headache. Feeling of tiredness and rapid pulse.
 As the concentration reaches 30%:
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  Nausea, vomiting and giddiness. Throbbing headache and buzzing in the ears.

 Breathlessness, muscular weakness, and ataxia and in-co-ordination.

 Judgment becomes impaired, and not able to realise the danger he is exposed to.
Because of loss of muscular power, he is neither able to help himself out nor call for
help.

 When the concentration reaches 40% there is fainting and vision becomes dim.
Respiratory rate increases.

 As the concentration reaches 50 %, face becomes flushed, mentally confused and

breathlessness increases.

 When the concentration reaches 60 % there convulsions, drowsiness and later

unconsciousness.

 Death results from asphyxia once the concentration reaches 65 to 75%.

 During the stage of coma, bullous lesions commonly develop in the skin on the
pressure areas (as in the case of the barbiturate coma). Cardiac arrhythmia is
sometimes seen in severe carbon monoxide toxicity.

Differential Diagnosis of Carbon Monoxide poisoning:

 Alcoholic Intoxication
 Epilepsy
 Cerebrovascular accidents.

Management:

 The first step is to remove the victim from the vitiated atmosphere to fresh air.

 Inhalation of 95% oxygen mixed 5% carbon monoxide (carbogen) is started

immediately. Oxygen helps to eliminate carbon monoxide and carbon dioxide helps
stimulate the respiratory centre.

 Administration of hyperbaric (greater than atmospheric pressure) oxygen is also

recommended. It is given at a pressure of 2.5 to 3 atmospheres. The principle

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54
 underlying this is that it increases the rate of dissociation of circulating carboxy-
haemoglobin and also by compensating for the lack of oxygen.

 Artificial respiration may be necessary.

 Body warmth is maintained.

 Blood transfusion.
 Mannitol in case of cerebral oedema.

Investigations:

 Blood Carboxy-Hemoglobin levels - Carboxyhemoglobin levels in an average person

are less than 5%, whereas cigarette smokers (two packs/day) may have levels up to
15%. In deaths due to carbon monoxide usually the Carboxyhemoglobin level exceeds
50% .

 A simple test can be done to know whether carbon monoxide poisoning is there in line
as well as in dead persons 1 ml of blood thus extracted to be diluted will 10 ml of water
in a test tube and add to it 1 ml of 5% solution of sodium hydroxide. If carboxy
haemoglobin is present below 20% it will change its colour to show yellow. It will
change its colour to pink when it is above 20%. In case of 40 to 50%.
 Kunkel’s test – diluted blood + tannic acid gives pink white precipitate.
 Spectroscopy – Two bands between the Frauenhofer lines D and E.

Post mortem findings:

 Cherry red post mortem lividity.
 Cherry red internal organs.
 Pulmonary oedema and serous effusions.
 Demyelination of the cerebral cortex.
 Myocardial degeneration.

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CYANIDE
 It can occur in gaseous state called hydrogen cyanide and in liquid form called
hydrocyanic acid and in solids as salts of crystalline powder.

 Sodium and potassium cyanide are its salts and are white powders.

 It is produced on burning of plastics, silk or wool.

 It occurs in nature in the leaves, barks and seeds of cherry, peaches, bitter almond,
apple, pear etc.,

 Hydrocyanic acid also called prussic acid or cyanogens, is a clear, colourless liquid
with an odour of bitter almonds (All persons cannot smell the gas, and the ability to
detect the same is sex linked recessive trait).

 Cyanides are used in fumigation, in plague eradication, in electroplating and

photography.

Medico-legal significance of Cyanide:

 Hydrogen cyanide gas was the agent used during the Nazi regime in Germany for
mass murder in some gas chambers during the Holocaust.
 Poisoning may occur accidentally in those engaged in electroplating and photography.
 Hydrocyanic acid is an ideal suicidal poison because it is neither prohibitively costly
nor difficult to procure.
 It can be easily swallowed, it is not of very unpleasant taste, has a small lethal dose
and it is capable of painless and quick lethal action. It is because of this Members of
the Liberation Tigers of Tamil Eelam (LTTE) use capsules made out of cyanide
compounds for suicide, where each member of the militia wears a capsule round their
neck, which is used to commit suicide when they are about to be captured by the
security forces.
 It was also used in US execution chambers, where it was generated by reaction
between potassium cyanide dropped into a compartment containing sulfuric acid
directly below the chair in the chamber.

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56
 Mechanism of action:
Cyanide inhibits the enzyme Cytochrome oxidase. Cytochrome oxidase is the enzyme
which is needed for the dissociation of oxygen bound in the haemoglobin as
oxyhaemoglobin. If the release does not take place, the cells and the tissues will be
deprived of oxygen. Thus it causes histotoxic anoxia.

Clinical Features:

 If inhaled, it is practically instantaneous in action and death results almost at once.

 If the person has swallowed the salts of cyanide, the salt has to be acted upon by the
hydrochloric acid in the stomach before hydrocyanic acid is liberated and then
absorbed in to the system.

 Consequently, those suffer from achlorohydria do not quickly manifest the effects of
poisoning e.g.patients suffering from pernicious anaemia.

 There is headache, giddiness and vomiting. The pupils are dilated. The breath smells
of bitter almonds. Froth collects at the mouth. There is rapid loss of consciousness.
Respiration is rapid and feeble. There is loss of muscular power.

Treatment:
 Antidotal therapy comprises of three steps. The drugs that are used are amyl nitrate,
sodium nitrite and sodium thiosulphate (Eli Lilly Kit). The main aim of the treatment is
to reverse the cytochrome – cyanide combination.
 The first step consists of administration of amyl nitrite as first aid measure. Amyl
nitrite which comes in the plastic ampoules are broken and held over the nose of the
victim to breath in or broken into a handkerchief and the person is made to inhale the
contents for about 30 seconds.
 The second step consist of giving sodium nitrite slow intravenously. This converts
haemoglobin in to methaemoglobin. Cyanide has more affinity to methaemoglobin

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57
 than oxyhaemoglobin. It combines with methaemoglobin to form
cyanmethaemoglobin, which is a non toxic compound.
 Third step involves administration of sodium thiosulphate slow intravenously. This
converts cyanide in to non toxic sodium thiocyanate, which is excreted in the urine.
 In some countries cyanide poisoning is treated by giving hydroxycobalamin (a form of
vitamin B12) which binds with cyanide to form the harmless cyanocobalamin.
Cyanocobalamin is eliminated through the urine.
 Decontamination to be done with soap water and assist ventilation with 100%
oxygen.

Post mortem findings:

 Characteristic bitter almond smell (not all can appreciate)
 Pink coloured post mortem lividity
 Bright red coloured blood

 Venous blood looking arterial (even venous blood contains as much oxygen as
arterial)
 All organs pinkish

WAR GASES
The term 'war gas' is not quite appropriate in the sense that the substances employed are
strictly not used in times of war but are used against the civilian population as well (for
example, to disperse unruly mobs), and they are not all gases, some being liquids and
some solids. But the term continues to be used by tradition. War gases may be classified
into:
1. Pulmonary agents or Choking gases
2. Vesicants or Blister gases
3. Lachrymators or Tear gases
4. Sternutators or Nasal irritants

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58
PULMONARY AGENTS
Pulmonary agents include ammonia, sulfur dioxide, nitrous oxide, chlorine, chloropicrin
and phosgene.

 They produce lachrymation, coughing, breathlessness, and headache, pain in the

chest, nausea, vomiting and cyanosis.

 Death results from asphyxia.

Treatment:

 Consists in removing the victim from vitiated atmosphere and

 Administration of oxygen inhalation and artificial respiration.

Autopsy findings:
Are those of asphyxia.

'VESICANTS' OR 'BLISTERING GASES'

 These are so called because they cause blisters on the skin. They include lewisite and
sulfur mustard gas.

 They have an odor of garlic, horseradish, or mustard.

 If inhaled they cause pneumonitis within 1 to 3 days.

 They cause skin erythema and blistering.

Treatment:

 Consists in removing the soiled clothing immediately.

 The body is washed with soap and water.

 Silver sulfadiazine may be applied to the skin.

 B.A.L. is a good antidote for lewisite poisoning.

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59
'LACHRYMATORS' OR 'TEAR GAS'
These include brom-benzyl-cyanide, chlor-aceto-phenone and ethyl-iodo-acetate. As the
terms suggest.
 These cause intense irritation of the eyes and profuse lachrymation, which results in
temporary blindness.
 There is also some irritation of the air passages. They are generally non-fatal.
Treatment:
 Consists of washing the irritating eyes with normal saline.
 Weak sodium bicarbonate solution is applied to the affected parts of the skin.

'NASAL IRRITANT' OR 'STERNUTATOR'

This is Diphenylamine chlorarsine, also called Adamsite
 Has a specific action on the vomiting centre and causes nausea and vomiting, hence
the name.
 It also causes sneezing (sternuation - to sneeze), headache and pain in the chest. It is
generally non-fatal.
Treatment:
Is mainly symptomatic. The victim is removed to fresh air and oxygen inhalation
administered.

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 BLOOD
Good blood cannot lie, they say. Nor can bad. As the distinguished forensic expert
Alixtair R. Brownlie (Solicitor Supreme Courts, Edinburgh. Scotland) put it to Britain's
Forensic Science Society: "Since Cain slew Abel, spilt blood had borne its mute
testimony in crimes of violence. Stains of blood and body fluids still play an important
part in crime detection, a lesser but increasing part in the proof of guilt…” And not only
the nature and grouping of stains, but their position at the scene of the crime can be
revolving and is now recognized as a vital piece of evidence in itself.

Blood is not the only body product, which can be of use to the forensic blood grouper.
The word serology comes from the ancient Sanskrit Sara, meaning, "to flow". Today it
is known that every fluid, which flows in the human body, can be identified: sometimes
to prove the guilt of a suspected person, but also very often to protect the innocent.

Medico-legal significance of blood stains:

1. Paternity/Maternity disputes
2. Nullity of marriage
3. Divorce
4. Workemen’s compensation issues resulting from occupational hazards
5. Civil negligence issues arising from blood transfusion
6. identification of victim
7. Identification of assailant
8. Indicates corpus delecti
9. Age of incident based on age of stain
10. Reconstruction of scene of crime
11. Link between criminal & victim, scene of crime, weapon

Steps in investigation of a blood stain:

1. Whether the stain is due to blood or some other material?
2. If it is due to blood, whether it is of human origin or animal origin?
3. If it is of human blood, what is source of bleedings?
4. Relative position of the victim based on pattern of the blood
5. Age of the blood stains:

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61
6. What is the sex of the person based on blood stain?
7. What is the blood group?
8. Whether it is arterial or venous in origin?
9. Whether the blood stain is derived from a living person or dead one (ante-mortem
or post-mortem)?

1) Whether the stain is due to blood or some other material?

 Investigators often find blood stains during their examination of a crime scene.
Different stains such as rust stain, vegetable stains (Jamuns, malburry, currants,
and tomato).and Synthetic dyes can resemble the blood stain. They may soil
clothing and take on the appearance of bloodstains.
 The tests done are grouped into 2 categories, namely
1. Presumptive/ Screening tests
2. Confirmatory tests
 Presumptive/ Screening/Colour tests include,
1. Benzedine test (Adler's Test):
2. Phenophthalein test (Kastle Meyer test):
3. Ortho-tolidine test (Kohn and O’Kelly test):
4. Leucomalachite Green Test
5. Luminol test
 Confirmatory tests include,
1. Microscopic Examination
2. Teichmann’s or Hemin Crystal Test Crystal Tests
3. Takayama Test or Hemochromogen Test
4. Spectroscopic Examination
5. Chromatography

 Principle of Presumptive / Screening / Colour Tests

 The general principle is that if the test is negative, blood is absent, but that if
the test is positive, blood is probably, not definitely present. For this reason the
tests are often described as "presumptive" tests.
 These methods depend on the fact that the haem group of haemoglobin
possesses a peroxidase-like activity which catalyses the breakdown of
hydrogen peroxide. The oxidizing species formed in this reaction can then react

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62
 with a variety of substrates to produce a visible colour change. Among
substrates in common use are benzidine, ortho-tolidine, leucomalachite green,
phenolphthalein. The reaction with 3-aminophthalhydrazide (luminol) to form a
luminescent rather than a colored product is also a catalytic test.

BENZEDINE TEST (ADLER'S TEST)

Procedure:
 Diluted stain extract in test tube + few drops of Benzidine reagent ( Benzidine +
Absolute ethanol + glacial acetic acid) + few drops of H2O2  Blue Colour
indicates Positive test within 30 seconds.
 Similarly the stain is moistened with Normal Saline and a blotter is pressed
over the area + Benzidine Solution + H2O2  Blue Colour indicates Positive
test.
Inference:
 Color change prior to the addition of H2O2 indicates false positive.
 The major sources of "false positives" were chemical oxidants or catalysts; and
(3) vegetable or fruit peroxidases. Chemical oxidant interference is readily
dispensed with by adding the reagent and the peroxide in successive steps; if
color develops upon the addition of re- agent alone, the presence of a chemical
oxidant is indicated. Plant peroxidases are heat- labile, and can be deactivated
by exposure to temperatures of 100 degree centigrade for a period of 7
minutes.
 Sensitivity of Benzidine screening test is 1: 500,000

PHENOLPHTHALEIN TEST (KASTLE – MEYER TEST)

Procedure:
Diluted stain extracts in test tube + phenolphthalein reagent (phenolphthalein reagent
preparation involves reducing the phenolphthalein over zinc in potassium hydroxide
which renders the reagent colorless) + few drops of H2O2  pink color indicates
positive test.
Inference:
 False positives are indicated by development of color other than characteristic
pink.
 The sensitivity of phenolphthalein test is 1:5000000.

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ORTHO-TOLIDINE TEST (KOHN AND O’KELLY TEST)
 Equal volume of Working Solution (4% Orthotolidine in Ethyl Alcohol + Glacial
Acetic Acid + Distilled Water in equal amounts) and H2O2 are mixed. Then few
drops of this mixture is added to the stain extract in a test tube  Blue or Green
Colour indicates positive test
 The sensitivity for the Ortho-tolidine test is similar to those of Benzidine.

LUMINOL TEST
 Luminol (3-aminophthalhydrazide) is a well known chemi-luminescent compound
and is used as a presumptive, catalytic test for the presence of blood utilizing the
peroxidase like activity of heme for the production of light (Blue white or yellow
green glow against dark back ground) as an end product rather than a true color
reaction.
 Luminol's major application is in areas where blood may be present but is difficult
to see, such as outdoors among vegetation, or where attempts have been made to
clean up blood and traces are still present. A positive reaction can also sometimes
be given by bloodstained clothing which has been washed.
 The sensitivity of the luminol test is 1:5000000

MICROSCOPIC EXAMINATION OF BLOOD

 All mammalian R.B.C’s including that of human are circular, biconcave, disc
shaped and non-nucleated.
 The only exception in mammals is R.B.C’s of Camel which are oval, biconvex and
non-nucleated.
 The average R.B.C diameter is 7 micron (equivalent to size of an lymphocyte)
 Amphibian and Reptile R.B.C’s are oval, biconvex and nucleated.

TEICHMANN'S TEST (HEMIN CRYSTAL TEST)

Principle:
Heating of blood stain in the presence of glacial acetic acid and sodium chloride
(halide) results in formation of hemin or hematin chloride due to the combining of
heme part of hemoglobin and chloride.

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Procedure: Crystals of NaCl + 2 to 3 drops of Glacial Acetic Acid is placed on the
stain on a glass slide. Cover slip applied + Evaporated by heating over small flame.
Examined under microscope.
Inference:
Faint yellowish-red to brownish black rhombic (diamond-shaped) crystals of hemin or
hematin chloride arranged single or in clusters are seen if blood is present.

TAKAYAMA REAGENT TEST (HAEMOCHROMOGEN TEST)

Principle:
If heme is gently heated with pyridine under alkaline conditions in the presence of a
reducing sugar as glucose, crystals of pyridine ferroprotoporphyrin or
hemochromogen are formed.

Procedure:
2 to 3 drops of Takayama reagent (distilled water + saturated glucose solution +
sodium hydroxide + pyridine in a ratio of 2:1:1:1 by volume) is placed on the stain on a
glass slide. Cover slip applied + Evaporated by heating over small flame. Examined
under microscope.

Inference:
Pinkish feathery crystals of pyridine ferroprotoporphyrin or hemochromogen are
formed which are arranged in clusters, sheaves etc., if blood is present.

SPECTROSCOPIC EXAMINATION OF BLOOD

Principle:
 The hemoglobin and derivatives present in the blood has the property of absorbing
some of the rays from the spectrum of light producing characteristic dark
absorption bands which vary with the type of the blood pigment present. The
sensitivity of this method is 1:5000.

Spectroscopic picture:
1. Oxyhemoglobin:
If the blood sample contains Oxyhemoglobin, two dark absorption bands will be
seen between the D and E lines of the spectrum. The band nearer the D line being
the narrower.

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2. Reduced Hemoglobin:
If the blood sample contains Reduced hemoglobin, a single broad band will be
seen between D and E lines of the spectrum.

3. Carboxyhemoglobin:
If the blood sample contains Carboxyhemoglobin, two dark absorption bands
similar to the oxyhemoglobin will be seen between the D and E lines of the
spectrum.
*It can be differentiated from Oxyhemoglobin by adding reducing agent like
ammonium sulfide; the Carboxy hemoglobin remains unaffected, whereas
Oxyhemoglobin gets reduced forming bands characteristioc of reduced
hemoglobin.

4. Methemoglobin:
If the blood sample contains Methemoglobin, in addition to two dark absorption
bands between the D and E lines, there will be a single band between C and D
lines and another between E and F lines of the spectrum.

5. Sulphmethemoglobin:
If the blood sample contains Sulphmethemoglobin, in addition to two dark
absorption bands between the D and E lines, there will be a single band between
C and D lines of the spectrum.

CHROMATOGRAPHY
High performance liquid chromatography (HPLC) can be used to confirm the identity
of blood using the absorbance of haemoglobin for detection. This method can also be
used to identify the species of origin from variations in the globin chains, to distinguish
foetal haemoglobin from adult haemoglobin, and to give an estimate of the age of a
bloodstain.

2) If it is due to blood, whether it is of human origin or animal origin?

 Once a stain has been confirmed as blood it has to be determined whether it is

human or animal because of the following reasons:
 Defense pleads that the stain is that of an animal.
 In hunting violations wherein it becomes necessary to determine whether the
stain belongs to an endangered animal species such as peacock, lion, tiger,
black buck etc.
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 The tests done are grouped into 2 categories, namely
1. Immunological Methods.
2. Enzymological Methods.

 Immunological methods include,

1. Preciptin test.
2. Antiglobulin consumption test.
3. Gel Diffusion.
4. Double Diffusion in Agar Gel.
5. Precipitation Electrophoresis.
 Enzymological (Isoenzyme) methods are more specific and less sensitive than
Immunological methods, which include,
1. Peroxidase.
2. Lactate Dehydrogenase.
3. Malate Dehydrogenase.
4. Esterases.

PRECIPITIN TEST / RING TEST

Principle:

Once a stain has been confirmed as blood it has to be determined whether it is human
or animal. The precipitin test is used for this purpose. Blood of every animal species
contains different proteins, and blood from one species will not accept proteins from a
different species. Blood develops antibodies as a protective measure against disease
and foreign matter to render them harmless. The serum containing antibodies
produced by this reaction provides immunity from disease.

This principle is used to test whether blood-stains are human or not. Serum for the
precipitin test is obtained from rabbits which have produced antibodies to destroy a
small quantity of human blood injected into them. A drop of this anti-human serum is
added to suspect blood, which will precipitate its protein if it is of human origin.
Antiserums are commercially available for several species including humans, dog, cat,
deer and many endanger species of animal (animal poaching cases).

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Types:
1) Tube
2) Slide
3) Gel electrophoresis
4) Gel diffusion
5) Latex particle method

Procedure:

The stain in dispute is diluted with physiological saline (9 gms of NaCl + 1000ml of
distilled water)

2 drops of Antihuman antiserum is placed at the bottom of the pipette and a layer is
prepared

1 drop of stain diluted with physiological solution now placed carefully over the layer of
antiserum

Carefully observe the interface between the antisera and blood stain

If it belongs to the human, a precipitate will appear at the junctions of two liquids

3) If it is of human blood, what is source of bleedings?

A. Foetal blood v/s adult blood
 By electrophoresis – determination of foetal haemoglobin (HbF)

B. Stain of blood resulting from pregnancy or abortion

 Pregnancy – raises the level of HCG, and presence of alkaline
phosphatase.
 Abortion – dark clotted blood, endometrial placental and fetal remnants.

C. Menstrual blood
 Dark, does not clot because of the presence of fibrinolysins and acidic in
reaction.
 One of the oldest methods of identifying menstrual blood is based on the
fact that it contains endometrial and vaginal epithelial cells, which may be
identified microscopically.

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  Presence of LDH4, LDH5, FDP (Fibrinogen degradation product) and MMP
(Metalo Myeloprotease) in menstrual blood.
D. Epistaxis
 Presence of nasal epithelial cells.
 Presence of mucus.
 Presence of nasal hairs.
E. Haemoptysis
 bright red frothy and alkaline in reaction.
F. Haematemesis
 altered blood (chocolate brown colored) and acidic in reaction due to the
presence of gastric contents.

4) Relative position of the victim based on pattern of the blood

 The shape and pattern of blood drops can reveal important information about
the nature of the wound from which the blood came. Was the bleeding person
standing still or walking? What distance did the blood drop fall? Did the blood
spatter in all directions?
 Fall from a height upto 50 cms → rounded appearance.
 50-150 cms → projections at the edges.
 >150 cms → projections become wider.
 From an angle → appear like a sphere indicating the direction.

5) Age of the blood stains:

 Age of the blood stain can be ascertained by naked eye examination,
calorimetric methods, immuno-electrophoresis and high performance liquid
chromatography (HPLC).
 Naked eye examination reveals the following:
 Bright red liquid stain – Fresh
 Reddish brown – <24 hours
 Few days – Brown
 Few weeks – Black

6) What is the sex of the person based on blood stain?

 The sex can be ascertained from the presence of sex chromatins (Barr bodies
and Davidson bodies) using Leishman stain.
 Barr & Bertram demonstrated

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  Davidson & Smith described the presence of drumstick appendage in the white
blood cells of the females. They observed that 6 nuclear appendages were
present in 300 neutrophils examined in cases of females (chromatin positive)
but in males no drumstick appendages were found even in 500 neutrophils
examined (chromatin negative).
7) What is the blood group?
 Blood typing can be used as an initial test to exclude some suspected sources
of a bloodstain. For example, if a blood stain at the crime scene contains Type
A blood, but the key suspect has Type O blood, the suspect could be excluded
as a source of the blood stain – meaning he or she definitely did not leave the
blood stain. However, blood type alone usually cannot positively identify a
suspect because many people share the same blood type.
 Different blood group systems:
 Based on red cell antigens
 ABO system
 Rhesus (Rh) system
 MNSs system
 P System
 Lutheran (Lu) System
 Kell system
 Lewis system
 Duffy system
 Kidd (Jk) system
 Fisher system
 Based on serum proteins
 Haemoglobin – Hb A, Hb F, Hb S, Hb C
 Heptoglobin
 Based on red cell enzymes
 Adenylate kinase system
 Esterase D system
 Based on white cell antigens
 HLA
 Blood groups based on ABO system, can be grouped into 4 types
 Group A – antigen A, Antibody B
 Group B – Antigen B, Antibody A
 Group AB – Antigen A & B, No antibody
 Group O – No antigens, Antibody A & B
 Blood grouping can be done by following methods:
1. Tube method
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 2. Tile method
3. Absorption – inhibition method
4. Absorption – elusion method
 Universal Donors:
Group O blood has neither A nor B antigens. In the past, type O blood was
given to anyone. Donors of blood group O were, in years past, referred to as
'universal donors.' Today, because of a better understanding of the complex
issues regarding immune reaction related to incompatible donor blood cells,
type O blood is no longer automatically seen as being suitable in most every
case. Group AB blood has neither anti A nor anti B antibodies, so any blood
can be transfused into it. Hence, persons with blood group AB have often been
seen as 'universal recipients’.
 Bombay Blood group:

 hh is a rare blood group also called Bombay Blood group. Individuals with
the rare Bombay phenotype (hh) do not express H antigen (also called
"substance H") (the antigen which is present in blood group O). As a result,
they cannot make A antigen (also called "substance A") or B antigen (also
called "substance B") on their red blood cells. As a result, people who have
Bombay phenotype can donate to any member of the ABO blood group
system (unless some other blood factor gene, such as Rhesus, is
incompatible), but they cannot receive any member of the ABO blood group
system's blood (which always contains one or more of A and B and H
antigens), but only from other people who have Bombay phenotype.
 This blood phenotype was first discovered in Bombay, now known as
Mumbai, in India, by Dr. Y.M. Bhende.
8) Whether it is arterial or venous in origin?
 Arterial → bright red in colour, jet like ejection.
 Venous → dark in colour, bleeds passively.
9) Whether the blood stain is derived from a living person or dead one (ante-
mortem or post-mortem)?

 Ante-mortem - coagulates, taken en-masse (in scales), leaves a network of

fibrin on removal over the material on which it is deposited.
 Post-mortem - It solidifies without coagulation. It cannot be removed en-
masse (breaks off into powder), does not leave any fibrin network.

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DNA FINGERPRINTING

 What is DNA?
 DNA or Deoxy ribo nucleic acid exists in the form of twisted double helix and
governs various inheritance traits of humans as well as animals.
 The human being originates in the union of ovum and spermatozoa which is
responsible for carrying the traits from their parents to the offspring.
 The bearers of the heriditory trait “genes” are located in the chromosome
present in the cell nucleus.
 DNA is the chemical structure that forms chromosome.
 DNA exists in all cells that contain nuclei. DNA is not present in red blood cells
because these cells have no nuclei; other cells present in blood contain DNA,
however, DNA is present in blood, seminal fluid, tissues, bone marrow, hair
roots, saliva, urine, and tooth pulp.
 DNA or Deoxy ribo nucleic acid consists of a PENTOSE SUGAR, a
PHOSPHATE and combination of four bases i.e. 2 Pyramidine
(Cytosine,Thymine) and 2 purines (Adenine, Guanine).
 The sugar and phosphate components are constant.
 What makes it individualistic is purine and the pyramidine bases.
 Adenine (A) will only bond with Thymine (T) and Guanine (G) will only bond
with cytosine (C).
 The two bases of each pair being linked by a hydrogen bond and two strands
are wound around each around in the form of double helix.

 What is DNA finger printing?

 DNA finger printing is developed by Dr. Alec Jeffreys.
 It is a technique involving chemically dividing the DNA into fragments which
form a unique pattern then matching that identity profile with the pattern
obtained from suspects blood specimen.
 In India D.N.A. Fingerprinting is done at CDFD or Centre for DNA
Fingerprinting and Diagnostics, Hyderabad.
 CODIS is the acronym for the Combined DNA Index System, an FBI-sponsored
initiative, consisting of database made up of the DNA samples collected from
persons convicted of crimes such as assaults, sexual assaults, and homicides.

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  Medico-legal importance of DNA finger printing:
1) Unlike a conventional finger print the DNA finger print is seen for every cell,
tissue and organ of a person and it can not be altered by any means
2) Sexual crimes: Samples such as hair roots, blood, buccal smear, vaginal swab
can be compared with that of the suspect.
3) Identification: Helps in the identification of mutilated bodies, mass disaster
victims by comparing DNA specimen of the victim with that of the relatives.
4) Paternity disputes: In the child/mother/alleged father’s DNA are printed and
matched.
5) Murder cases: DNA specimen from the crime scene helps in the tracing of
accused.

 Methodology:
A. Restriction fragment length polymorphism (RFLP)
This technology is based on the fact that certain regions of DNA consist of
repeated sequences of units that are referred to as variable numbers of tandem
repeats or VNTR's. These are regions of DNA of no known function. The exact
number of these consecutively repeated sequences varies from individual to
individual; therefore, the length of the VNTR region varies. It is this reason that
VNTR’s can be used as markers for human identification.
B. Polymerase chain reaction (PCR)
 Polymerase chain reaction is a technology that copies short segments of
DNA millions of times in a process that resembles the way DNA duplicates
itself naturally in the body. (Some have described this process as the
equivalent of a biological Xerox machine.)
 PCR is a powerful technology because it can be applied to any tissue
specimen, no matter how small, degraded or old, and produces billions of
copies within a few hours (e.g., a single hair with its root, dried saliva on the
back of a letter or postage stamp, dandruff, etc.
C. Short Tandem Repeats (STR)
A refinement of PCR technology is a process called short tandem repeats
(STR) that combines PCR with RFLP and is used on larger segments of DNA.

 Samples needed for DNA typing:

1. Blood

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  5 ml of blood preserved in EDTA or frozen solid in a deep freeze
 Blood stains should be sent intact, kept as cool as possible during transit
2. Seminal & vaginal fluids
 Swabs from vagina, rectum, mouth etc should be air dried and stored in
deep freeze
 Liquid semen deep frozen
 Seminal stains should be sent intact, kept as cool as possible during transit
3. Hairs
 10-20 hairs with intact root
 Kept as cool as possible during transit
4. Autopsy samples
 Spleen is the best organ for DNA recovery.
 Others include liver, muscle, kidney, brain, and bone marrow
 The organs should be deep frozen

INCOMPLETE LIST OF QUESTIONS FROM BLOOD & DNA TYPING

1. Write briefly on presumptive tests for blood stains (Benzedine test, Phenophthalein
test, Luminol test).
2. Explain confirmatory tests for blood stains (Hemin Crystal Test, Takayama Test
Spectroscopic Examination).
3. Write a short note on spectroscopic examination of blood.
4. Write briefly on Precipitin Test / Ring Test.
5. Enumerate paternity exclusion chances with different blood group systems.
6. Add a note on ABO system.
7. Write briefly on Bombay Blood group.
8. What is DNA finger printing? Explain its methodology, medico-legal significance
and the specimens required for DNA typing.

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 CARDIAC POISONS

The plants that have the active principles in the form of glycosides ('Glycosides' are
substances found in plant containing a sugar and a non sugar component in them. In them
non sugar component is poisonous.), which are cardio toxic in nature, are the common
oleanders (Nerium odourum, Cerbera thevetia), Monk’s hood (Aconite), Foxglove
(Digitalis) and Tobacco (Nicotiana tobaccum). Though the manifestations are attributable
to the other systems, the main action is on the heart.

ACONITE (ACONITUM NAPELLUS; MONK’S HOOD)

 Acontium napellus, also called aconite is a plant, which grows in the Himalayan ranges.
 The dry root is conical in shape, dark-brown in colour and is shriveled and wrinkled.
 It is called as Monk's Hood because of its blue helmet shaped flowers resembling
monks cap.
 The Active principles are 'aconitine', 'mesoaconitine', and pseudo aconitine.
 Aconitine is one of the most potent poisons, which on gaining entry in to the body
produces severe cardiac arrhythmias.

MEDICO-LEGAL SIGNIFICANCE
1. Death due aconite poisoning is usually accidental.
2. It can be mistakenly consumed because of its similarity with horse-radish (Aconite
when cut, shows whitish surface which slowly reddens but horse radish remains white).
3. It may be used as a cattle, arrow or spear poison.
4. Aconite has many of the characteristics of an ideal homicidal poison, like
 Easy availability
 Sweet taste (hence the name Mita Bhish)
 Ease with which it can be mixed with the food.
 Prompt and definite action
 Manifestations resembling cardiac disease.

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CLINICAL FEATURES OF ACONITE POISONING
 When ingested, it causes a burning sensation, tingling and then numbness of the lips,
mouth and tongue. There is a feeling of constriction in the throat and dysphagia
followed by pain in the stomach.
 The heart becomes slow, feeble and irregular due to stimulation of the vagus and leads
to partial heart block, pulse becomes slow. The blood pressure falls.
 One of the characteristic finding is the alternate contraction and dilatation of the pupils
which ends with dilatation, a condition called ‘Hippus’.
MANAGEMENT OF ACONITE POISONING
A. The stomach is washed out with a solution of potassium permanganate or tannic acid.
B. Anti-arrhythmic drugs are used to stabilize.
POSTMORTEM FINDINGS OF ACONITE POISONING
These are similar to that of asphyxia. Aconite deteriorates rapidly after death, so prompt
chemical analysis is indicated

NERIUM ODORUM (WHITE OLEANDER; PINK OLEANDER)

 Grown commonly as an ornamental plant in the gardens, white oleander which also
come with pink flowers,
 The active principles are neriin, oleandrin, folinerin etc which are glycosides, and
powerful cardiac poisons.
MEDICO-LEGAL SIGNIFICANCE
1. Poisoning is generally suicidal.
2. Children swallow the seeds out of curiosity and accidentally get poisoned.
3. This plant oozes latex from any part on being injured. The latex is an irritant. The twigs
of the plant are dipped in the latex and introduced in to the vagina to procure abortion,
illegally.
4. It is also used as a ' cattle poison'.

CLINICAL FEATURES OF PINK OLEANDER POISONING

 Ventricular tachycardia, fibrillation, A V block.
 Nausea, vomiting.

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MANAGEMENT OF PINK OLEANDER POISONING

A. The stomach is washed out with potassium permanganate solution.

B. Rest of the treatment is only symptomatic.

C. Injections of atropine sulphate and adrenaline are helpful.

POSTMORTEM FINDINGS OF PINK OLEANDER POISONING

 Petechial haemorrhages on the heart are a characteristic feature, otherwise nothing

specific.

 It resists putrefaction and even burning, hence can be detected long after death.

CERBERA THEVETIA (YELLOW OLEANDER)

 This plant is also grown for the ornamental purpose in the gardens.
 It has yellow coloured bell shaped flowers.
 It has green, globular fruits about 5 cms in diameter and containing a single nut, which
is brown in colour and triangular in shape. Each nut contains two seeds.
 The Active principles are 'thevetin', 'thevetoxin' and 'cerberin' (strychnine like spinal
cord action), which are glycosides, and powerful cardiac poisons.
MEDICO-LEGAL SIGNIFICANCE
1. Poisoning is generally suicidal.
2. Children swallow the seeds out of curiosity and accidentally get poisoned.
3. This plant oozes latex from any part on being injured. The latex is an irritant. The twigs
of the plant are dipped in the latex and introduced in to the vagina to procure abortion,
illegally.
4. It is also used as a ' cattle poison'.
CLINICAL FEATURES OF YELLOW OLEANDER POISONING
 There is burning pain in the mouth, dryness of the throat and tingling and numbness of
the tongue followed by nausea and vomiting.
 Ventricular tachycardia, fibrillation, conduction blocks etc.

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MANAGEMENT OF YELLOW OLEANDER POISONING

A. The stomach is washed out with potassium permanganate solution.

B. Rest of the treatment is only symptomatic.

C. Injections of atropine sulphate and adrenaline are helpful.

POSTMORTEM FINDINGS OF YELLOW OLEANDER POISONING

Petechial haemorrhages on the heart are a characteristic feature, otherwise nothing

specific.

CERBERA ODOLLUM (DABUR; DHAKUR)

 This plant or shrub, belonging to the family of oleander, grows over the south coastal
parts of India (Kerala) and is known as ‘suicide tree’.

 The flowers are white like those of jasmine.

 The fruits resemble unripe mangoes having a single seed.

 The Kernal of the fruit contains toxic glycosides such as cerberin, cerberoside, odollin,
odollotoxin.
 The toxin blocks calcium channel of heart causing various types of arrythmias and
heart block.

MEDICO-LEGAL SIGNIFICANCE
1. Poisoning is mostly suicidal or accidental.

2. This tree is known as suicide tree. It is mixed with jaggery or sugar and consumed to
commit suicide

CLINICAL FEATURES OF CERBERA ODOLLUM POISONING

 Nausea, vomiting, abdominal pain, diarrhoea.
 Bradycardia, general weakness, irregular respiration and death due to cardiac failure.

MANAGEMENT OF CERBERA ODOLLUM POISONING

A. The stomach is washed out with potassium permanganate solution.
B. Injections of atropine sulphate and adrenaline are helpful.
C. Rest of the treatment is only symptomatic.

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DIGITALIS PURPURA (DIGITALIS; FOXGLOVE)
The Active principles are glycosides – Digitoxin, Digoxin, Gitoxin, which are used for the
therapeutic purpose to energize the failing heart.

MEDICO-LEGAL SIGNIFICANCE
Most of the cases of poisoning are accidental arising out of therapeutic overdose.

CLINICAL FEATURES OF DIGITALIS POISONING

 It causes nausea and vomiting.
 Mental confusion and visual disturbances.
 Cardiac arrhythmias, conduction defects leading to death, from cardiac vascular
collapse.
MANAGEMENT OF DIGITALIS POISONING
A. The stomach is washed out with a solution of potassium permanganate or tannic acid.
B. Anti-arrhythmic drugs are used to stabilize.

NICOTIANA TABACUM (TAMBAKU)

 Nicotine is the oldest insecticide known.
 The Active principles are alkaloids - nicotine and anabasine.
 Alkaloid is substances which like an alkali forms a salt when combined with an acid, but
truly is not an alkali (does not change litmus color).
 Average cigarette contains 10 to 20 mg of nicotine but no anabasine.

MEDICO-LEGAL SIGNIFICANCE
1. It can be used for the purpose of malingering – Tobacco leaves are soaked in water
and placed in axilla which raises the body temperature, which can be used as a reason
for avoiding duty.
2. Chewing tobacco may predispose to oral cancer.
3. It is a habit forming substance.
MECHANISM OF ACTION OF NICOTINE
 Nicotine binds to nicotine receptors which are present throughout the body particularly
in the central nervous system.

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 This first stimulates and later depresses all the autonomic ganglia throughout the body.

CLINICAL FEATURES OF NICOTINE POISONING

ACUTE POISONING:
 Leads to gastrointestinal symptoms such as nausea and vomiting.

 CNS symptoms of vertigo, headache, sweating, confusion and convulsions.

 Hypotension, Tachycardia followed by bradycardia and finally cardio vascular collapse.

CHRONIC POISONING:
 Bronchitis

 Laryngitis

 Pharyngitis

 Tobacco Amblyopia: In the habitual smoker, there may be amblyopia, narrowing of the
field of vision and blurring.

 Tobacco Heart: a condition characterized by irregularity, extrasystole and occasional

attacks of pain suggesting angina pectoris.
MANAGEMENT OF NICOTINE POISONING
A. Cardiac monitoring. Atropine helps to control bradycardia and hypotension.
B. Diazepam to control convulsion.
C. Supportive.

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 CORROSIVE POISONS

GENERAL PROPERTIES OF CORROSIVES

 Corrosives are contact poisons.
 Causes only local action but no remote effects on the system.
 In concentrated form, they cause corrosion and destruction of the tissue.
 Extracts the water from the tissues.
 Conversion of Hemoglobin to Hematin.
 Fixes, destroys and erodes the tissues.
 Causes coagulation necrosis by precipitation of proteins.

CLASSIFICATION OF CORROSIVES
Corrosives are classified into three groups:
A. Acids:
1. Inorganic or Mineral Acids:
E.g.: Sulphuric acid
Nitric acid
Hydrochloric acid
2. Organic Acids:
E.g.: Acetic acid
Carbolic acid
Oxalic acid
Salicylic acid
B. Alkalies: E.g.: Hydrates and carbonates of sodium, potassium and ammonia
C. Metallic Salts: E.g.: Zinc Chloride, Potassium cyanide

GENERAL PRINCIPLES OF TREATMENT

 Stomach wash should not be given as there are chances of perforation of stomach
except in the case of Carbolic acid wherein a softer Levin tube can be used for
stomach wash because the carbolic acid hardens the mucosa thereby decreasing
the chances of perforation . The tube should be passed softly and with due care
avoiding the risk of perforation of stomach and oesophagus

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 Emesis is to be avoided as there is risk of perforation of already thinned out
stomach and oesophagus

 Acids should be immediately diluted and neutralized by drinking plenty of water

containing a tablespoonful of calcium oxide, magnesium oxide or aluminium
hydroxide gel. If these are not available then demulcents like vegetable oil, soap
solution, milk, limewater or white of an egg should be followed by barley water and
olive oil.

 Morphine 15 mg i. m or i. v should be given for pain.

 Tracheostomy can be performed if oedema of glottis is present.

 In case of skin burns, wash with large quantities of water or apply paste of sodium
bicarbonate.

 Eye burns are treated symptomatically after irrigating with water for 10-15 minutes.

 Use of strong alkalis such as carbonates and bicarbonates of sodium and potassium
should be avoided as they produce CO2 and can cause distension and perforation.

SULPHURIC ACID – H2SO4 (OIL OF VITRIOLE)

PROPERTIES
 Pure sulphuric acid is colourless with no fumes and it chars, and blackens the skin
 Commercial sulphuric acid is dark or brown in colour due to the addition of
impurities like lead sulphate, arsenic or nitric acid

 Sulphuric acid is chiefly used for preparing chlorine, for dissolving metal, for
cleansing drains, for medicinal purposes, and to remove fur from kettles.

CLINICAL FEATURES OF SULPHURIC ACID POISONING

 Intense burning pain in mouth, throat, esophagus and up to the stomach Dribbling of
acid mixed with saliva on the angles of mouth and chin causing corrosion and
brownish discolouration of skin over angles of mouth, chin and over the chest

 Oral cavity: Mucosa of mouth and lips are softened, excoriated, corrugated and
covered with dirty white necrotic membrane that assumes brownish black
discolouration. The oral cavity is full of secretions consisting of saliva, blood,
mucous making speech and swallowing difficult and may even result in death from
asphyxia
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 Tongue is swollen, excoriated and discoloured with white coating that becomes dark
later on. It may get disorganized in to a shapeless, pulpy mass

 Teeth are dead chalky white deprived of polish or shining

 Lips are swollen, excoriated with brown or black streaks resulting from the action of
acid running from the angle of mouth to the chin and chest

 Frothy eructation, retching and vomiting; vomited matter is acid, contains blood,
mucous and shreds of mucous membrane

 Intense thirst and an attempt to drink water brings vomiting that leads to
dehydration. Along with vomiting, there is extreme dysphagia

 Voice is hoarse and husky and speech is painful and difficult due to the inflam-
mation of epiglottis, uvula etc.

 Complications in the form of mediastinitis or peritonitis from perforation of

oesophagus or stomach and stricture of oesophagus may develop within a few
weeks.

POSTMORTEM FINDINGS OF SULPHURIC ACID POISONING

Postmortem findings can be divided into:
A). External findings

B). Internal findings

A. External findings:
 Evidence of acid corrosion and chemical burns with brownish black parchment like
and corroded spots are seen over chin, cheek, neck and chest resulting from
trickling of the acid
 Excoriation of lips, corrosion of mucosa of mouth and tongue, chalky white teeth are
characteristic
 Mucous membrane of mouth, tongue and lips shows brown or brownish black
corroded spots with necrosis that are grayish white initially that changes to brownish
black and leathery later on.
B. Internal findings:
 Mucous membrane of esophagus is inflamed, swollen by oedema and severe
interstitial hemorrhage is present even when corrosion is absent. Mucous

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 membrane of stomach is inflamed, oedematous, blackened Peritoneal cavity is filled
with black acidic liquid containing mostly altered blood from escape of the acidic
stomach contents into peritoneal cavity following perforation of stomach
 Greater part of the stomach is converted in to soft, boggy, black mass that readily
disintegrates on touching (wet blotting paper consistency).
 As a result of perforation of oesophagus or stomach, the thoracic and abdominal
viscera is blackened and corroded by acid with features of chemical peritonitis.
MEDICO-LEGAL SIGNIFICANCE
1. Accidental poisoning occurs when consumed by mistake
2. Mostly it is employed for suicidal purposes due to its easy availability
3. It is not used for homicidal purposes
4. Employed for the purposes of vitriolage causing grievous hurt (Section 320 IPC)
5. Sometimes sulphuric acid is used in an attempt to dissolve a dead victim of murder
(The infamous acid bath murder)

VITRIOLAGE OR VITRIOL THROWING

Vitriolage is throwing of strong sulphuric acid, concentrated mineral acid, corrosive
alkalis, carbolic acid, or the juice of marking nut over the face or body of the victim for
the purpose of disfiguring the face, destroying the vision for causing injury on the body
or even destroying the clothing of the victim. Malicious persons do this when they have
a hatred or enemity to the victim. Some people use old electric bulb filled with acid to
carry out their motive.
 Effects produced are
 There is severe burning pain and corrosion of the tissues with formation of
brownish black burned areas that later on leave a permanent scar
 Blindness may result if eyes are involved
 Extensive disfiguring injuries are caused on the face
 Death may occur from shock, toxemia or infection from severe chemical burns
inflicted on the skin.
MEDICO-LEGAL SIGNIFICANCE
1. Blindness amounts to grievous injury
2. Scar tissue formation leading to permanent disfiguration of head or face also
amounts to grievous injury

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3. Contractures on the joints leading to defective mobility constitute grievous injury
4. Vitriol age amounts to dangerous injury either due to severe extensive burn or
subsequent infection.

NITRIC ACID-HNO3 (AQUA FORTIS)

PROPERTIES

 Pure nitric acid is colorless, clear liquid gives fumes when exposed to air.

 It has a peculiar choking odor.

 A powerful oxidizing agent dissolves all metals except gold and platinum.

 It destroys organic matters with formation of xanthoproteic acid that imparts deep
yellow color to the affected tissues.

CLINICAL FEATURES OF NITRIC ACID POISONING

 The signs and symptoms produced by ingestion of concentrated nitric acid are
similar to those of sulphuric acid.

 Lips, tongue and mucous membrane of mouth are soft. Initially it is white then yellow
due to formation of xanthoproteic acid.

 Teeth and clothes are yellow stained.

 Abdomen is more distended and tender due to formation of large quantities of gas
by direct action of acids on the organic matter of stomach.

 Violent vomiting occurs and the vomitus is yellowish brown containing altered blood.

 As nitric acid like hydrochloric acid but unlike sulphuric acid is volatile and gives
fumes at room temperatures, the effects produced by the inhalation of fumes are:

 Irritation of the eyes with lachrymation and sneezing Photophobia

 Burning in the throat
 Feeling of constriction in the chest

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  Dyspnoea: death may occur immediately from suffocation due to oedema of
glottis or later on from pulmonary oedema or bronchopneumonia.
POSTMORTEM FINDINGS OF NITRIC ACID POISONING
 Postmortem appearances are similar to those of sulphuric acid but tissues are
stained yellow

 If the death is from inhalation of fumes then the respiratory passages are congested;
lungs are congested and oedematous and the lining membrane of right auricle may
show inflammatory changes.

MEDICO-LEGAL SIGNIFICANCE

1. Poisoning is mostly accidental or suicidal, rarely it is homicidal.

2. It can be used for the purpose of vitriolage.

HYDROCHLORIC ACID – HCL (MURIATIC ACID)

PROPERTIES

 Pure hydrochloric acid is colourless and fuming liquid with strong pungent irritating
odour. The strong solution gives fumes even at ordinary temperature and air.

 It is used for preparing chlorine, for dissolving metal, for cleaning drains, to remove
furfrom kettles and as medicine.
 Muriatic acid is the solution of hydrochloric acid gas in water having yellow colour
and fumes strongly in damp air. It is used commercially and is less destructive than
sulphuric and nitric acids.
CLINICAL FEATURES OF HYDROCHLORIC ACID POISONING
 Hydrochloric acid is less active than the other two acids hence symptoms are much
milder
 It does not corrode or damage the skin
 It readily destroys the mucous membrane
 Mucous membrane is gray or gray white
 Inhalation of fumes causes:
 irritation of the air passages

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  spasm of glottis
 symptoms of suffocation

POSTMORTEM FINDINGS OF NITRIC ACID POISONING

 Findings are same as that of sulphuric acid poisoning but there is less tendency to
charring and tissue destruction

 Oral cavity and oesophageal mucous membrane is ashy grey in colour but may get
blackened, swollen and hardened if the acid is concentrated

 Stomach contains brownish acidic fluid and mucosa is corroded and grayish white in
colour.

MEDICO-LEGAL SIGNIFICANCE

1. Suicidal poisoning is common

2. There are a few cases of accidental poisoning

3. It is very rarely homicidal

4. It is used for erasing writing; attempts for forgery may be there.

CARBOLIC ACID (PHENOL)

PROPERTIES
 This is hydroxy benzene obtained from coal tar oil by fractional distillation.
 Pure carbolic acid has colourless, prismatic needle shaped crystals with burning
sweetish taste. It turns pink and liquefies when exposed to air.
 Commercial carbolic acid is dark brown liquid containing several impurities chiefly
cresol.
 Carbolic acid and its derivatives are commonly used as disinfectants, antiseptics,
germicides
MECHANISM OF ACTION
 Carbolic acid acts locally as a corrosive and systemically as narcotic, induces sleep
and drowsiness
 Carbolic acid has a great penetrating power as it coagulates protein

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 When applied to the skin, it produces burning sensation, numbness, and
anaesthesia due to its action on the nerve endings.
CLINICAL FEATURES OF CARBOLIC ACID POISONING
 Burning sensation in the mouth and throat
 Mucous membrane of the mouth and lips is hard and white

 Rapid absorption of acid into the blood stream is soon followed by giddiness
insensibility and coma

 Pupils are constricted

 Smell of carbolic acid is present in the breath

 Carboluria:

Phenol is a nephrotoxic or renal poison. After absorption, phenol is converted into

hydroquinol and pyrocatechol, which are excreted in the urine, rendering it a dark or
olive green on exposure to air due to oxidation of pyrocatechol and hydroquinone in
air. The urine is scanty and contains albumen and blood casts because of severe
irritation of the kidneys. All these urinary findings are grouped together under the
term 'carboluria'.

 Chronic poisoning may result in pigmentation of the skin and sclera (ochronosis).

POSTMORTEM FINDINGS OF CARBOLIC ACID POISONING

External findings

 Dark brown excoriations may be seen at the angle of mouth and chin

 Tongue is white or swollen

 Smell of phenol comes from the mouth

 Mucous membrane of mouth is corrugated, sodden and white or ash gray small
submucosal haemorrhages may be seen.
Internal findings
 Oesophageal mucosa is tough, white gray
 Stomach mucosal folds will have a leathery feel (

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 The stomach may contain reddish fluid mixed with mucus and shreds of epithelium
emitting odour of phenol
 Liver and spleen are in the form of white, hardened patch when in contact with
stomach
 Kidney is inflamed and shows haemorrhagic spots
MEDICO-LEGAL SIGNIFICANCE
1. Used for suicidal purposes
2. Accidental poisoning results from its medicinal use and when it is introduced into
vagina for abortion.

3. Contact of phenol preparations on wounds, ulcers, abraded skin, can also result in
accidental poisoning

4. Due to its peculiar phenolic odour and taste, it is rarely used for homicidal purposes.

OXALIC ACID (ACID OF SUGAR AND SALT OF SORREL)

PROPERTIES

 Oxalic acid is colourless, transparent and prismatic crystals

 It is prepared from sugar by oxidation with nitric acid or by heating sodium or

potassium formate.

 Oxalic acid is a common household remedy used for removing stains of ink and
marks from clothing.

MECHANISM OF ACTION
Oxalic acid has local as well as remote or systemic action.
Local Action
 In solid or concentrated form or in large quantities, it acts as a corrosive
 In weaker solutions, it acts as an irritant and this is more evident in the nervous
system
 When applied to the wound, it acts as a poison.

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Remote Action
 After absorption from the gut it combines with serum calcium and produces
symptoms of hypocalcaemia.
 Large doses' cause rapid death from shock.
 Causes tubular necrosis, uremia and death 2-14 days.
CLINICAL FEATURES OF OXALIC ACID POISONING
 Burning pain in the mouth and the throat
 Persistent vomiting of coffee ground colored fluid
 Muscular tremors, tetany (carpopedal spasm, tonic spasm of the limbs), convulsions
 Ventricular fibrillations preceding to death
 Oxaluria- Presence of calcium oxalate crystals, oliguria, haematuria in the urine is
termed as oxaluria. These calcium oxalate crystals have the shape of an envelope
when seen under a microscope.
MANAGEMENT OF OXALIC ACID POISONING
A. Antidote is calcium lactate or gluconate, it converts oxalate to calcium oxalate that is
insoluble; 10 ml of 10% calcium gluconate is administered intravenously at regular
intervals.
B. Parathyroid extract 100 units I.M. is given in severe cases.

POSTMORTEM FINDINGS OF OXALIC ACID POISONING

 Strong solution may cause white as if bleached appearance of mucous membrane

of mouth, tongue and lips. It may be red due to irritation

 Outer coat of stomach is inflamed and reddened with patchy softening, perforation is
rare. The contents of the stomach are brownish due to acid haematin. At times the
whole stomach is corroded and perforated.

 Kidneys are swollen and congested, tubules show oxalate crystals

 All other organs are congested.

MEDICO-LEGAL SIGNIFICANCE

Accidental poisoning commonly as it is mistaken for magnesium sulphate.

CORROSIVE ALKALIES

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The strong solutions of alkalis act as corrosives but in dilute form, they act as irritants.
Concentrated corrosive alkalis are more dangerous than acids. The chief alkaline
corrosives are the following:
1. Potassium hydroxide (Caustic potash): 5 gm
2. Sodium hydroxide: 5 gm
3. Potassium carbonate (Caustic soda): 18 gm
4. Sodium carbonate (Washing soda): 30 gm
5. Ammonia: 30 gm; gaseous ammonia dissolved in water forms strong solution of
ammonia that is strongly alkaline, pungent liquid
6. Ammonium carbonate.
CLINICAL FEATURES

 Charring is not present

 Vomited matter is alkaline

 Purging is frequent; mucous and blood is present in the stools

 When a strong solution of alkali is ingested, the mucosa of mouth and lips is
discolored and blister formation is there.

 Following symptoms are produced, when the ammonia vapors are inhaled:
Congestion and watering of the eyes

 Sneezing, coughing and choking

 Sudden collapse and death may occur - Death is due to suffocation and
oedema of glottis.
POSTMORTEM FINDINGS
The findings are similar to corrosive acids.
MANAGEMENT

A. Neutralize the poison by giving vegetable acids and water

B. Demulcents are given

C. Stomach can be washed carefully

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MEDICO-LEGAL SIGNIFICANCE
1. Accidental poisoning is common as it is mistaken for medicines
2. Homicidal poisoning is rare
3. Poisoning by inhalation of ammonia vapor is common
4. Sometimes caustic soda is thrown over the face and body producing chemical burns

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 . DELIRIANT POISONS .

Deliriant are poisons that cause an acute disturbance of consciousness. The important
plants that are included in this category are Datura, Atropa balladona, Cannabis and
Cocaine yielding plant. The active principles present in these plants bring about an altered
sense, which could be stupefying in nature or pleasant hallucinations or even terrifying
experience. These are the drugs when used for some time become addictive in nature.

DATURA FASTUOSA

 Datura is a plant that grows all over India, known by common names like Jimson weed,
thorn apple etc.
 It exists in two varieties:
 Datura Alba – plant having white flowers
 Datura Niger- plant having black or deep purple flowers.
 The fruits are spherical with sharp spines (Thorn apple) and contain yellowish brown
seeds. The seeds of Datura seeds may be mistaken for capsicum seeds.
 The differentiating points between chilli and Datura seeds are,

Features Chilli Seeds Datura Seeds

1. Size Smaller in size Larger in size
2. Shape Round Kidney shaped
3. Surface Smooth Finely pitted or reticulated
4. Color Yellowish Brownish
5. Smell Pungent Odorless
6. Taste Pungent Bitter
7. Convex Border Single-edged Double-edged
8. On section The embryo curved outwards The embryo curved inwards

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 This plant contains active principles that are alkaloids, which include
1. Hyoscine.
2. Hyoscyamine.
3. Traces of atropine (Levo-atropine).

Medico-legal significance of Datura:

A. Suicide:
Due to easy availability, in rural areas this is used for committing suicide.

B. Accident:
Accidental poisoning can result in following circumstances,
 Children can eat raw Datura fruits because of their attractive nature

 Seeds may be mistaken for capsicum seeds

 Medicinal use by village healers (asthma, rheumatism, fever)

C. Stupefaction:
Datura can be used for criminal purposes as stupefying agent.
It means rendering a person unconscious or semi-conscious, to make him incapable of
offering resistance in the way of committing a crime, mainly like child lifting, robbery,
rape or theft. The seeds are powdered and then mixed with food or by putting them in
the paan and offered to the fellow passengers in the bus or train. The unsuspecting
fellow passenger after eating the food or paan that has Datura seeds, become queer in
his behaviour and is stupefied thus becoming vulnerable for robbery. Therefore it is
also called as Road Poison Or Railway Poison.

D. Homicide:
Datura is sometimes used for homicidal purposes.
E. Datura seeds resist putrefaction for a long time. It can be chemically detected even
after a long time

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Clinical features of Datura poisoning:
 All the signs and symptoms can be summed up in the form of following ‘D’s:
 Dilated pupils
 Diplopia
 Dryness of mouth
 Dysphagia
 Difficulty in deglutition
 Dry hot skin
 Drunken gait
 Delirium
 Drowsiness
 The signs and symptoms can also be remembered in the form following similes given
by Morton Still:
“Blind as a bat (dilated and fixed pupils make the person literally blind in the presence
of light)
Red as a beet (cutaneous vasodilatation over the face causes flushing of the face with
blood, making it appear red as a beet)
Hot as a Hare (Peripheral vasodilatation coupled with loss of sweat production and
stimulation of the heat-regulating center situated at the floor of the third ventricle, raises
the body temperature)
Dry as a bone (All the secretion of the body goes dry)
Mad as a wet hen (Delirium - His speech becomes incoherent and he starts muttering
in a state of delirium, hallucination, delusion, restlessness).”

Management of Datura poisoning:

1. A thorough gastric lavage removes the remnants of the crushed seeds.

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2. Neostygmine or Physostigmine is the physiological antidote of choice.
3. Sponging to relieve high temperature.

Post-mortem findings:

 Postmortem findings are not characteristic but signs of asphyxia are evident.

 Seeds or their fragments may be found in the stomach or intestine.

CANNABIS INDICA OR CANNABIS SATIVA

 The plant Cannabis indica or sativa grows all over India but its cultivation is restricted
due to the monopoly of the state government.
 Known as Indian hemp in common language
 The other names used for cannabis are Marihuana, Marijuana, Pot, Grass, Tea, Mary
Jane, etc,

 The plant yields sticky amorphous resin, which contains the active principle Delta 9
Tetrahydrocannabinol (THC).

Different preparations of Cannabis:

1. Bhang (Siddhi, Patti or Sabji):

It is prepared from dried leaves and flowering or fruiting shoots. It is used as an infusion
in the form of beverage. It is prepared by rubbing on a stone and black pepper, dried
leaves and sugar is added to form pill or bolus. Water is added and it is drunk after it is
strained through the muslin cloth. People of Northern India consume this drink at
festivals like Holi. It is the mildest form containing about 15% of the active principle.
Bhang is usually intoxicated to produce cheerful mood for dancing and singing.
2. Majun:
It is sweet meat confectionery prepared from bhang after treating with sugar, milk and
butter.
3. Ganja:
It is prepared from the flowering tops of female plant. They are shade dried. It has rusty
green color. This dried mass is mixed with tobacco and smoked. This preparation
contains about 15% of the active principle. Sadhus, faqirs and poor laborers, cut leaves
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 and flowering tops of cannabis plant and roll them in to cigarettes and then smoke
them. These cigarettes are called 'reefers' or 'pot'.
4. Charas or Hashish:
Hashish, named after the Persian founder of the Assassins of the 11th century (Ḥasan-
e Ṣabbaḥ). This is prepared from the exudates that ooze from the injured stem and the
twigs. The latex, which is white in color initially, turns brown on exposure to air. Charas
contain the highest amount of the active principle ‘Delta 9 Tetrahydrocannabinol’ (25-
40%). It is smoked in pipes.
Medico-legal significance of Cannabis:

A. Poisoning by bhang is mostly accidental.

B. Majun and Charas are used as stupefying poisons.

C. Cannabis can be used for homicidal purposes (To steady nerves before committing
crime).
D. Run amok:
This is a frenzied state characterized by homicidal tendency resulting in killing of
people without any motive and reason. These murders are purposeless, and
motiveless. The accused may commit suicide or surrender before the police after the
offence. The victims of the assailant who runs amok are usually the kith and kin of the
family. There is no knowledge regarding the act what he was doing at the material time.
He does not even recollect the incident after he recovers. This state is considered as
due to structural brain damage and the perpetrator of the crime is absolved from the
criminal responsibility (Mc Naughtons Rule / Section 84 of Indian Penal Code).

E. Cannabis and the law:

Cannabis is a banned drug. Cultivation, storage, transportation and consumption of this

are punishable as per law.

F. Cannabis and driving:

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 While driving intake of Cannabis affects motor and coordination skills along with the
vision, perception of time and space resulting in increased vulnerability for vehicular
accidents.

Clinical features of acute cannabis poisoning:

 They appear soon after smoking ganja or Charas and after half an hour after
swallowing bhang.
 There are two stages:
1. Stage of inebriation.
2. Stage of narcosis.

Stage of inebriation:
 Person becomes dreamy or semiconscious.
 There are realistic visions of erotic nature (beautiful women dancing before him)
 Judgment in relation to time and space is lost and sensation of pain is lessened.
 Hampers the psychomotor activity (physical coordination, quick reaction time and visual
perception) needed for driving and operating machinery.

Stage of narcosis:
 Giddiness and ataxia.
 Speech may be confused and rambling.
 Tingling and numbness of skin occurs and in severe cases general anesthesia and
muscular weakness develops.
 The victim becomes drowsy and passes into deep sleep
 In extreme rare cases death is due to respiratory failure.

Clinical features of chronic cannabis poisoning:

Chronic cannabis poisoning is characterized by ‘Running Amok’. This is a frenzied state
characterized by homicidal tendency resulting in killing of people without any motive and
reason. These murders are purposeless, and motiveless. The accused may commit

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suicide or surrender before the police after the offence. The victims of the assailant who
runs amok are usually the kith and kin of the family. There is no knowledge regarding the
act what he was doing at the material time. He does not even recollect the incident after he
recovers. This state is considered as due to structural brain damage and the perpetrator of
the crime is absolved from the criminal responsibility (Mc Naughtons Rule / Section 84 of
Indian Penal Code).

Management of cannabis poisoning:

1. Gradual de addiction
2. Psychiatric counseling
3. Symptomatic treatment.

Post-mortem findings of Cannabis poisoning:

 Postmortem findings are not characteristic but signs of asphyxia are evident.
 It is necessary to preserve urine for chemical analysis.
COCAINE

 Cocaine is also commonly known by the names of Coke, Snow, White lady and
Cadillac etc.

 It is an alkaloid derived from the leaves of the tropical shrub coca-tree, Erythroxylon
coca

 The leaves of coca plant (Erythroxylon coca) contain about 0.5-1% cocaine.

 Cocaine acts as a good surface anesthetic and it was introduced as first local
anesthetic for use in ocular anesthesia.

Routes of Administration:
 Orally, it is rapidly destroyed.
 Snuffing via nasal and oral mucous membranes when it is rapidly absorbed and causes
cerebral stimulation followed by depression.
 Inhalation of freebase cocaine produces almost immediate absorption and a rapid
onset of effects.
 Injection.

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Different forms of Cocaine used for abuse:
1. Crack:
Crude form of free base cocaine may be obtained by heating the cocaine with sodium
bicarbonate to yield 'crack', a hard white mass that is free base plus impurities but
without hydrochloride moiety. When smoked, this material gives off a cracking sound,
hence the name.

2. Speedball:
Sometimes cocaine abusers simultaneously inject intravenously a mixture of an opiate,
such as heroin called speedball. This mixture is especially euphorogenic.

Medico-legal significance of Cocaine:

1. Accidental cases occur in the people who are addicted to cocaine, or in first time users
due to injection of a large amount of Cocaine.

2. Chronic users may develop metal derangements who may get involved in crimes.

3. Cocaine induces states of paranoid and aggressive behavior.

Mechanism of action of Cocaine:

 Cocaine acts as a CNS stimulant and local anesthetic with potent vasoconstrictor
properties.

 It stimulates the vagal centre, vasomotor centre, vomiting centre and temperature
regulating centre.

 It blocks uptake of nor-adrenaline and adrenaline into adrenergic nerve endings

producing sympatho-mimetic effects.

Use of Cocaine in conjunction with alcohol:

 Alcohol is most commonly used along with cocaine as it modulates both the 'cocaine
high' and 'dysphoria' associated with abrupt disappearance of cocaine's effects.
 The concurrent use of cocaine and alcohol may result in the accumulation of a distinct
metabolite, Cocaethylene (Cocaethylene is an active metabolite and produces changes
in the cardiovascular functions as that produced by cocaine alone. It produces long

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 lasting effects than cocaine itself and also accounts for the enhancement of subjective
effects as well as toxic symptoms when the two are used simultaneously).

Clinical features of acute Cocaine poisoning:

 Cocaine users develop the signs and symptoms of intoxication during the course of
single binge and a hyper-adrenergic state is produced.
 There are two stages:
1. Stage of euphoria.
2. Stage of depression.

Stage of euphoria:
This stage is accompanied with increased suspiciousness, hypervigilance, anxiety,
hyperactivity and talkativeness.

Stage of depression:
 Loss of reflexes and paralysis of muscles.
 Coma and tonic-clonic seizures.
 Circulatory and respiratory failure.
 Sudden death may follow I.V. injection, smoking and snorting results in cardiac
arrhythmias and cardiopulmonary arrest.
Clinical features of chronic Cocaine poisoning (Cocainism):

Cocaine is usually abused by upper classes of society to enhance self-image or improve

professional performance. Chronic abuse is characterized by following:

 Euphoria (rush) followed about an hour or so later by rebound depression (crash). To

avoid unpleasant effects of rebound depression, the person feels compelled to take the
drug again

 It can also induce a toxic delirium and a more persistent toxic psychotic disorder
characterized by suspiciousness, paranoia, visual and tactile hallucinations such as
hallucinations of bugs (cocaine bugs) and worms crawling under the skin (Formication /
Magnan's symptoms), and loss of insight. Magnan’s symptoms may even result in
injuring himself so as to remove these imaginary bugs.

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 Chronic intake of cocaine in males causes impotence and gynaecomastia and in
females menstrual disorders including amenorrhea, galactorrhoea and infertility

 In pregnant woman with cocaine abuse there is incidence of abortion, abruptio

placentae and cerebrovascular diseases in mother. In the foetus also there is incidence
of congenital malformations. The smoking of 'crack' results in production of 'crack
babies' (the baby shows congenital anomalies, low birth weight, undernourished and
shows muscle twitching).

 Rarely, ulceration and perforation of the nasal septum occurs in chronic 'snorters'.

Management of Cocaine poisoning:

1. Treatment of chronic cocaine abuse requires combined efforts of primary care

physicians, psychiatrists and psychosocial workers.

2. To control seizures, intravenous Diazepam 0.5 mg/kg may be given.

3. Propranolol 0.5-1 mg I. V. for ventricular arrhythmias.

4. To treat psychosis, haloperidol should be given.

Post-mortem findings of Cocaine poisoning:

 There are no specific autopsy features.
 Formation of foreign body granulomas in the lungs when cocaine mixed with talc or
starch is used intravenously. This is due to filtering out of the undissolved components
in the pulmonary capillary bed.
 Samples to be preserved:
 Swab from each nostril using a plain cotton swab along with another swab used as
control
 Routine viscera and blood sample for cocaine levels

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  Sample of urine as cocaine metabolites can be detected for varying lengths of time
in urine depending on the dose of cocaine and sensitivity of the assay. The
metabolite is generally detectable in the urine for 24-72 hours after brief periods of
use
 Injection prick site along with control sites.

BODY-STUFFERS & BODY PACKERS

 Body-Stuffers:
The body-stuffers, also known as mini-packers, are generally small scale traffickers or
users who, when they come into contact with police or customs officials, immediately
swallow the drug in secretly prepared wrappings in order to avoid arrest.
 Body packers:
 Body packers are people who illegally carry drugs, mostly cocaine and heroin,
concealed within their bodies. The packets can be made of various materials, but
most often are condoms, which are easily available on the market. The packets are
inserted in the mouth, rectum or vagina in order to get across borders without being
detected.
 After the body packer swallows these packets, Constipating agents, such as
diphenoxylate or loperamide, are frequently used. Transit times may be as brief as
one or two days or as long as two to three weeks. After entering the country of
destination, body packers use laxatives, cathartics, or enemas to help pass their
cargo rectally.
 Body packers usually present to health care providers for one of three reasons:
drug-induced toxic effects, intestinal obstruction, or medical assessment after
detention or arrest. These people develop life threatening cocaine toxicity from
leakage of the contents of these packages into their bowels.
 Body packing should be suspected in anyone with signs of drug-induced toxic
effects after a recent arrival on an international flight or when there is no history of
recreational drug use.
 Body Packers versus Body Stuffers

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 Body Packers Body Stuffers
1. Background Hired specifically to User or seller, on verge of arrest,
smuggle drugs, e.g., swallows the evidence.
Heroin or cocaine

2. Wrapping Carefully wrapped (latex, May not be carefully wrapped or

sometimes condoms, with in aluminum foil; may be in an
or without covering of open porous container such as a
aluminum foil ) sandwich bag, glass , or plastic “
crack vials”; sometimes
swallowed
3. Detection Most escape detection -
4. Toxicity Few toxic effects Initially asymptomatic; later may
be seizures, comatose, or dead in
a jail cell
5. Radiograph Carefully wrapped package Not always useful; number of
with air or liquid trapped in ingested containers small; little
packaging material ( liquid or air in packaging material
useful in 75% - 80% of
cases)
6. History Inaccurate Inaccurate
7. Coingestants Usually not; most are not Present (Users, street sellers)
drug abusers , transport
one drug
8. Treatment Gastric emptying, activated Gastric emptying, hazardous;
charcoal, whole-bowel careful induction of emesis;
irrigation activated charcoal with whole
bowel irrigation
9. Surgery If severely symptomatic If severely symptomatic risk of
obstruction is less
10. Endoscope Encourage gastrointestinal Empty bags will pass through on
transit normal gastrointestinal transit

BARBITURATES
 Barbiturates are sedatives and hypnotics.
 Depending on the action, barbiturates are classified in to 4 groups.

Action Example Effect

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 1. Long acting Phenobarbitone 1 to 8-12 hrs
2. Intermediate acting Amylobarbitone ½ to 4-8 hrs
3. Short acting Cyclobarbitone ¼ to 2-4 hrs
4. Ultra short acting Thiopental sodium Instantaneous

Medico-legal significance of Barbiturates:

1. Barbiturates are commonly used for suicide due to their easy availability.
2. Automatism:
Automatism is performance of an act of which one is not aware and over which he has
no conscious control. Barbiturates have no analgesic property. This is an important
point to note because a regular user of barbiturate, by experience would know that an
increase in dose would result in sound sleep. Suppose this person has sleeplessness
due to some painful condition he is suffering from, he takes one extra dose of
barbiturate to get a good sleep. But, as the drug has no analgesic property, it does not
reduce his pain. The patient may believe that the dose taken was not adequate and
may take one more dose. The pain does not allow him to sleep and the barbiturate
does not allow him to be awake. The patient enters in to a state of confusion. In this
confusional state he may accidentally overdose himself, a condition called ‘Barbiturate
automatism’.

3. Rarely used for homicidal purposes

Clinical features of Barbiturate poisoning:

 Central nervous system features:
 Drowsiness
 Transient period of confusion, excitement, delirium and hallucinations.
 Ataxia, vertigo and slurring of speech.

 Respiratory system features:

 Respiration becomes periodic and shallow (Cheyne Stoke breathing).

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  If coma continues then infection, pneumonia and pulmonary edema may develop

 Cardiovascular system:

 Fall in cardiac output

 Hypotension

 Dermatological symptoms:

If the patient is in a state of deep coma for a prolonged period, he may develop blisters
in the frictional areas of the body. These blisters are called barbiturate blisters. These
bullous lesions occur where the skin surface rubs the other part of the skin such as
inner aspects of thigh and pressure bearing areas like hands and feet. Initially there are
slightly raised areas of erythema and later on bullous eruptions are formed. The blister
contains serous fluid, the rupture of which leaves a red raw surface that may be
mistaken for burns. It is suggested that bullous formation is either due to toxic effects of
the drug or patient is unduly sensitive to the drug itself.

Management of Barbiturate poisoning:

1. A very thorough gastric lavage is necessary as the tablets are found in lumps.
2. Forced alkaline diuresis is useful. This is achieved by giving i.v Chlorothiazide in 500 ml
of Mannitol.
3. Dialysis is useful.
4. If facilities are available total exchange transfusion is most beneficial.

Post mortem findings:

 Bluish lividity.
 Remnants of coloured capsules in the stomach.
 Gastric erosions.
 Blackish lungs
 Barbiturate blisters.

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 DELIVERY…..

Definition:
It is the expulsion of the product of conception at birth.
 Examination of a lady may be required to determine whether she has delivered or how
much time has passed since her delivery in cases where the question is raised on:
 Abortion
 Infanticide
 Concealment of birth
 Feigned delivery
 Contested legitimacy
 Nullity of marriage
 Disputed chastity

Signs of recent delivery in a living woman:

The signs will be marked when the delivery is recent. They are as follows:
 For first two days after delivery the woman will look pale and exhausted having a
languished look with sunken eyes.
 Peculiar puerperal odor that can be easily smelt around the patient
 Breasts become enlarged tense, full, tender with turgid knotty nipples, and well
demonstrable Montgomery’s tubercles
 Presence of colostrum in milk
 Abdominal wall is loose, lax and flabby. There is evidence of linea nigra and linea
albicantes
 Vaginal discharge – lochia, is basically due to the uterus undergoing involution and partly
from the vagina having a peculiar sour and puerperal smell.
 In the first 4 –5 days, the lochia is bright red in colour – Lochia rubra, consisting of pure
blood mixed with large clots and fragments of decidual remnants.
 In the next four days, the lochia becomes serous and paler in colour, it is known as –
lochia serosa
 Usually after 9 – 10 days after delivery, the color of the discharge becomes yellowish-
white – lochia alba. Gradually the quantity of the discharge diminishes, until it disappears
altogether by 14 days.

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  The vulva will be swollen, tender and at times bruised or lacerated. There may be signs of
episiotomy.
 The vagina will be relaxed, dilated and capacious with its walls smoothened, rugosity of
its wall being not well marked. It may show recent tears.

Signs of recent delivery in the dead:

All the local signs described in the living would be evident. In addition the following signs
help:
 Soon after delivery at full term, uterus is approximately 30 cms long, walls 5 –6 cms
thick, weighing approximately 850 gms
 By second day, the involuting uterus diminishes to 18 cms in length and 10 cms in
breadth, weighing 550 gms.
 By the end of the week, the size is reduced to 12-14 cms in length, 6 cms in width and 350
gms in weight.
 The ovaries remain congested for few days after delivery.

PRECIPITATE LABOR:
 It is defined as expulsion of the fetus within less than 3 h of commencement of regular
contractions.
 Precipitate delivery refers to childbirth after an unusually rapid labor (combined 1st stage
and second stage duration is under two hours) and culminates in the rapid, spontaneous
expulsion of the infant.
Causes:
 A multipara with relaxed pelvic or perineal floor muscles may have an extremely short
period of expulsion.
 A multipara with unusually strong, forceful contractions. Two to three powerful
contractions may cause the baby to appear with considerable rapidity.
 History of previous precipitate labour
 A very smooth birth canal
 A baby who is smaller than the average size
 When prostaglandin is used to induce labour

Complications:
1. Maternal:
 Precipitate delivery may cause lacerations of the cervix, vagina, and/or perineum.

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  Rapid descent and delivery of an infant does not allow maternal tissues adequate time
to stretch and accommodate the passage of the infant. There may
be hemorrhage originating from lacerations and/or hematomas of the cervix, vagina,
or perineum. There may also be haemorrhage from the uterus.
2. Neonatal:
 Precipitate delivery may cause intracranial hemorrhage resulting from a sudden
change in pressure on the fetal head during rapid expulsion.
 It may cause aspiration of amniotic fluid, if unattended at or immediately following
delivery.
 There may be infection as a result of unsterile delivery.

Medico-legal Implications:
1. Infanticide:
Defence of Precipitate Labor sometimes is raised in cases of infanticide.
2. False Allegations:
 In case of Precipitate labor mother may be accused of Infanticide.
 The umbilical cord usually gets ruptured by child falling from the materal parts and
ruptured parts will be having ragged ends.
 The head injury caused by Precipitate Labor will be caused by sudden dropping of
new born infant from pelvis on the floor due to the sudden Precipitate labor.
 The Bruises will be on the vertex, the point coming in contact with the floor.
 Lacerations on the scalp usually absent.
 The fissured fracture usually involves parietal bone.

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 FIREARMS
For millennia man has been fascinated with the idea of launching a projectile at
animals--or men of opposing points of view--and has developed more efficient ways of
doing so. The invention of gunpowder led to the development of firearms. Gunpowder
first appeared in use in China over a thousand years ago, but was used primarily in
firecrackers and only sparingly in weapons for military use.

Machine guns were refined in World Wars I and II. Modern assault weapons used by
armies around the world utilize a mechanism in which the expanding gasses of the
gunpowder provide the force for cycling the mechanism to shoot multiple rounds--up
to 600 rounds per minute.

Definition: Firearm is an instrument or device, designed to propel a projectile by the

expansive forces of gases by the burning of an explosive substance (gun powder).

Classification of Firearms or Types of Firearms:

Based on the interior of barrel the firearms are classified into,

I. Smooth Bore Weapon or Shot guns.
II. Rifled Weapons.
I. Smooth Bore Weapon or Shot guns:
These are called smooth bore weapons because of the smooth interior
the barrel. They are used to fire multiple projectiles, or lead shots.
Shot guns are further classified into,
1. Based on the number of barrels,
A. Single barreled shot guns.
B. Double barreled shot guns.
2. Based on the choke,
A. Full choked shot guns.
B. Three-fourth choked shot guns.
C. Half choked shot guns.
D. Quarter choked shot guns.
E. Improved cylinder shot guns.
F. True cylinder shot guns.

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II. Rifled Weapons:
These are called so because of the presence of rifling on the inner surface of
the barrel and they are used to fire a single missile or bullet at a time.

Rifled weapons are further classified based on velocity into,

A. High velocity guns: e.g: Machine guns.
B. Low velocity guns. e.g: Pistol, Revolver.

BALLISTICS

Explanation:
The term ballistics refers to the science of the travel of a projectile in flight. The flight
path of a bullet includes: travel down the barrel (within the gun or Proximal/Internal
ballistics), path through the air (from gun to target or Intermediate/External ballistics),
and path through a target (hitting the target or Terminal/Wound ballistics).

IMPORTANT TERMINOLOGIES IN FIREARMS:

Barrel: The metal tube through which the bullet is fired.

Breech: The back end of the barrel.
Butt: The portion of the gun which is held or shouldered.
Chamber: The portion of the "action" that holds the cartridge ready for firing.
Hammer: A metal rod or plate that strikes the cartridge primer to detonate the powder.
Magazine: This is a device for storing cartridges in a repeating firearm for loading into
the chamber. Also referred to as a "clip"
Magnum: An improved version of a standard cartridge which uses the same caliber
and bullet, but has more powder, giving the fired bullet more energy. Magnum shotgun
loads, however, refer to an increased amount of shot pellets in the shell.
Muzzle: The end of the barrel out of which the bullet comes.
Pistol: Synonym for a handgun that does not have a revolving cylinder. The handle,
or butt, is more important here because it contains the magazine holding the
cartridges. Ejected cases will virtually always be left behind at the scene, but must be
searched for diligently.
Revolver: The revolver is the common type of handgun, which has a revolving
cylinder that contains five or six chambers, each of which holds one cartridge. The

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cylinder is rotated mechanically so as to align each chamber successively with the
barrel and firing pin. This must be a conscious act, so that no empty cartridge cases
will be found at a crime scene unless the assailant stopped to reload.
Silencer: A device that fits over the muzzle of the barrel to muffle the sound of a
gunshot. Most work by baffling the escape of gases.
Assault Rifle: The term “assault rifle” refers to a rifle that is auto-loading, has a large
capacity (20 round or more) detachable magazine, is capable of full-automatic fire,
and fires an intermediate rifle cartridge. E.g.: AKS-47, MAK-90, and Colt AR-15
Sporter.
Machine Guns: A machine gun is a weapon that is capable of full-automatic firing and
that fires rifle ammunition. It is generally crew operated, but some forms may be fired
by single individual. Most machine guns have the ammunition fed by belts, although
some use magazines.

TERMINOLOGIES RELATED TO THE RIFLED FIREARMS:

RIFLING
Explanation:
The Rifling is characteristic of rifled weapons, wherein the inner surface of the barrel
of the rifled firearm is made up of lands and grooves. The grooves which are spiral are
cut longitudinally over the inner surface of the barrel, leaving elevated portions
between them called lands. Rifling is done by instrument known as Lapper or Broach.

Land

Groove

Rifling defers in,

 Direction (clockwise and anti-clockwise).
 Depth.
 Width.
 Number.

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Purpose of Rifling:

1. Lands bite into the bullet as it is propelled through the barrel, and because the
rifling is spiral, it imparts to the bullet a spin or rotation, whereby it acquires
gyroscopic steadiness, which helps to keep its nose forward during its flight, and
prevent it from wobbling.
2. Spinning helps to maintain a straight trajectory and accuracy.
3. Spinning gives the bullet greater power of penetration.
4. Spinning helps in the increase of the lethal range.

Medico-legal Importance of Rifling:

A. As the bullet is propelled through the barrel, because it is in between the lands, the
surface of the bullet becomes marked with grooves corresponding in number, size
and direction, with the lands in the barrel. These indentations, called rifling marks,
which are transferred from the barrel, are peculiar to that weapon which helps in
the identification of the offending weapon.
B. Class Characteristics: When a bullet is fired down a rifled barrel, the rifling
imparts a number of markings to the bullet that are called as "class
characteristics". Class refers to the type of caliber and rifling. These markings may
indicate the make and the model of the gun from which the bullet has been fired.
These are specific for the particular firearm.
C. Individual Characteristics: These individual characteristics are based upon burrs
or imperfections in the barrel, particularly the muzzle, that impart specific markings,
or striae, to fired bullets. If such markings are present, they may lead to a
"determinative".

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CALIBER
Explanation:
The caliber is the inner diameter of the barrel of the rifled firearm. It is measured as
the distance between the two diametrically opposite lands in case of even number of
lands and in the case of odd number of lands it is the distance from a land to the
diametrically opposite line which joins the inner edge of two adjacent lands. It is
usually mentioned in terms of fractions of an inch. These measurements represent the
diameter of the barrel before the rifling grooves were cut.

Land Caliber

Groove

Caliber refers to the diameter of the bore of the barrel, given in decimal fractions of an
inch or, in metric systems, in millimeters. E.g.: 0.303 & 0.22 rifle, meaning that the
caliber is 0.303 of an inch and 0.22 of an inch respectively.

TERMINOLOGIES RELATED TO THE SMOOTH BORE FIREARMS:

BORE
Explanation:
Bore of a smooth bore weapon is the number of lead balls of equal size, equal weight
and shape which can be made out of 1 pound or 454 grams of lead, each fitting
exactly into the barrel. It is expressed in terms of gauge or inches or mms.

E.g.: 12 bore shot gun is one, whose diameter of the interior of the barrel is equivalent
to the diameter of a lead ball of such a size that 12 such balls can be made out of 1
pound of lead. Therefore greater the number of lead balls smaller is the inner diameter
of the barrel.

CHOKING

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Explanation: Choking means narrowing or constriction of the terminal few
centimeters of the barrel near the muzzle end of the shot guns. A special device is
developed to introduce into the muzzle to adjust this choke known as "poly choke".

Breech End Muzzle End

Purpose of Choking:

1. To prevent dispersion of pellets over a longer distance.

2. Enhances the explosive force.
3. Increases the lethal range of the shot gun.
4. Increases the velocity.

Classification of Choking:

Choking in the short guns is classified based on the degree of constriction:

1. Full choke: 40 thousandth part of an inch

2. Three fourth choke: 30 thousandth part of an inch
3. Half choke: 20 thousandth part of an inch
4. Quarter choke: 10 thousandth part of an inch
5. Improved cylinder: 3-5 thousandth part of an inch
6. True cylinder: No choke

Approximate
Constriction in
Choke Type Degree of Constriction spread at 40
mm
yards

Full choke 40 thousandth part of an inch 1 mm 41''

¾ choke 30 thousandth part of an inch 0.75 mm 43''
½ choke 20 thousandth part of an inch 0.50 mm 46''
¼ choke 10 thousandth part of an inch 0.25 mm 49''

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 Improved
3-5 thousandth part of an inch 0.075-0.125 mm 52''
Cylinder
True Cylinder None 0 59''

Medico-legal Importance of Choking:

If the degree of choking is known, based on the dispersion of the pellets, the range
(distance between the assailant and the victim) of firing can be calculated which will
help in the reconstruction of events leading to death.

Range of fire:
Spread in inches = Distance in yards for a half choke weapon
Spread in inches = Distance in yards x 3/4 for a full choke weapon
Spread in inches = Distance in yards x 3/2 for a true cylinder weapon
*1 yard = 3 feet.

AMMUNITION OF FIREARM:
Both rifled and smooth bore weapons employ cartridges, but of different types. A
cartridge is made up of the following components:
1. Cartridge case.
2. Detonator or Primer.
3. Gun powder or propellant charge.
4. Projectle (Bullet/Pellet) and
5. Wads (in shotguns only).

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 Bullet
Cannelure

Cartridge Case

Gun Powder

Flash Hole
Anvil
Percussion Cup Primer
RIFLED FIREARM CARTRIDGE (LONGITUDINAL SECTION)

Top Wad

Pellets
Cartridge Case

Felt Wad Cardboard Wad

Gun Powder

Flash Hole
Anvil
Primer
Percussion Cup
SHOTGUN FIREARM CARTRIDGE (LONGITUDINAL SECTION)

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CARTRIDGE CASE
 The outer shell of cartridge is called the cartridge case, which keeps all the
components in place and also provides a water proof cover.
 Remaining of the cartridge after its use is known as 'used cartridge' or 'spent
cartridge'.
 In rifled firearms, it is made of alloy of copper and zinc.
 In smooth bore firearm, it is made of a Cardboard and the base is made of brass.
 Bottom of the cartridge is called its 'base'.
 Base contains percussion cap.

DETONATOR or PRIMER
 It is located at the base of the cartridge.
 The principal ingredients of the primer are lead styphnate, barium nitrate and
antimony sulphide.
 Cartridges are classified as centerfire or rimfire, depending on the location of the
primer.
 In "centerfire cartridges", the primer is located in the center of the base of the
cartridge case.
 In "rimfire cartridges", the primer component is spun into the rim of the base of
the cartridge case.

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 Gun Powder

Primer

GUNPOWDER or PROPELLANT
 It may be 'black powder' or 'smokeless powder' or 'semi-smokeless powder.
 Black powder which is in the form of granules composed of potassium nitrate
(75%), charcoal (15%) & sulphur (10%) – Charcoal acts as the fuel, the potassium
nitrate the oxygen supplier or oxidizer while the sulphur makes it ignitable and
produces enough pressure for the propulsion.
 Smokeless powder (may be in the form of disk, flake, or cylinder) consist either of
single or double or triple base:
 Single base smokeless powder consists of nitrocellulose.
 Double base smokeless powder consists of nitrocellulose and nitroglycerine.
 Triple base smokeless powder consists of nitrocellulose, nitroglycerine and
nitro-guanidine.
 Semi-smokeless powder consists of combination of smokeless powder (20%) &
black powder (80%).
 Smokeless powder is called so because it is capable of getting burnt completely
without producing as much smoke as black powder.
 Smokeless powder is more effective than black powder, and is able to impact
greater velocity to the bullet.

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 One gram of black powder produces 3000-4500 cc of gas, while one gram of
smokeless powder produces 12000-13000 cc of gas.

PROJECTILE
 Bullet is the projectile in the rifled firarms.
 Pellets or lead shots are the projectile in smooth bore firearm.
 Bullet is held in the cartridge case by a groove called 'cannelure'.
 The best bullet composition is lead (Pb) which is of high density (sectional density)
and is cheap to obtain. Its disadvantages are a tendency to soften at higher
velocities, causing it to smear the barrel and decrease accuracy, and also its
tendency to melt completely at higher velocity. Alloying the lead (Pb) with a small
amount of antimony (Sb) helps, but the real answer is to interface the lead bullet
with the barrel through another metal soft enough to seal the bullet in the barrel but
of high melting point. Copper (Cu) works best as this "jacket" material for lead.
Jacketing is used to prevent fragmenting or melting of lead.
 Bullets are shaped or composed differently for a variety of purposes:
 "round-nose" - The end of the bullet is blunted.
 "hollow-point" - There is a hole in the bullet that creates expansion when a
target is struck, creating more damage.
 "jacketed" - The soft lead is surrounded by another metal, usually copper, that
allows the bullet to penetrate a target more easily and avoid soft lead from
being damaged during firing.
 "wadcutter" - The front of the bullet is flattened.
 "semi-wadcutter" - Intermediate between round-nose and wadcutter.
 "semi-wadcutter" - Features of both hollowpoint and wadcutter.

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 Three general types of lead shots or pellets have been made: drop or soft shot,
which is essentially pure lead; chilled or hard shot, which is lead hardened by the
addition of antimony; plated shot, which is lead coated by copper or nickel to
minimize distortion on firing, and fourth category of shots made of steel, bismuth,
and tungsten.

WADS
 Between the pellets and gun powder; and over the pellets, shotgun cartridges are
provided with a circular disc shaped structures made up of compressed paper
termed as wad.
 The wad separating the wads (paper wads), between pellets and gun powder is
known as 'felt wad', which is impregnated with grease.

Purpose of wads:
 Prevents the mixing of pellets and gun powder.
 Holds the pellets and gun powder tightly so that they may not fall down.
 Felt wad acts as a piston and seals the propellant compartment thus preventing
the expanding gases from escaping, thereby maintaining the force to propel the
pellets along the bore and through air.
 Since the thick felt wad is impregnated with grease, it helps in lubricating the barrel
thus facilitating propulsion of projectile.

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Medico-legal importance of firearm ammunition:
CARTRIDGE CASE
 When the gun is fired, it leaves several marks on the cartridge case (used or spent
cartridge case). These marks are of special value in the identification of the gun
used in the crime.
 The firing pin marks on the percussion cap are peculiar to the gun used in the
crime.

DETONATOR or PRIMER
Primer components (barium, antimony, and lead) can be detected (Harrison & Gilroy
test) on the hands of individual who fired firearm. These metals, which originate from
the primer of a cartridge on discharge of a weapon, are deposited on the back of the
firing hand, which will help in nabbing the assailant.

GUNPOWDER or PROPELLANT
When a weapon is fired, gun powder residues (nitrates & nitrites) escaping from the
breech (back portion of the firearm) will contaminate the hands that hold the weapon,
demonstration (Dermal Nitrate Test) of which helps in the nabbing of the assailant.

BULLET
 As the bullet is propelled through the barrel, because it is in between the lands, the
surface of the bullet becomes marked with grooves corresponding in number, size
and direction, with the lands in the barrel. These indentations, called rifling marks,
which are transferred from the barrel, are peculiar to that weapon which helps in
the identification of the offending weapon.
 Each bullet keeps a diary in its own way of where it has been and what it has
done. The bullet base will contain irregular dimples marking the pressure delivered
there in its acceleration. The bullet sides will bear the markings of the barrel
interior rifling. These spiral lines, or striae, contain the micrscopic imperfections of
the gun from which it was fired and can be as specific as a fingerprint. The bullet
nose carries information about the target, and recognizing these may give a clue to
the injury rendered.

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 If a bullet is recovered from the scene or from the body (crime bullet), it may be
compared to bullets obtained by test-firing the suspected weapon (test bullet).
Test firing is done using similar ammunition. Bullets are marked on the nose at the
12 o'clock barrel position (called "index", "witness", or "reference" marks).
Consecutive test bullets are then fired into a water tank, recovered, and juxtaposed
with a comparison microscope to compare test bullets with the recovered
evidence. Index marks help to align test bullets to determine reproducibility of
markings. Photographs should be taken (a ruler or coin can be used to give scale
and alignment).

WORKING OF THE FIREARM WEAPONS:

Rifled Firearm:

Trigger pressed

Firing pin strikes the center of the primer cup

Compresses the primer composition between the cup and anvil

Primer composition explodes

Vents in the anvil allow the flame to pass through the flash holes

Ignites the gun powder

Burning of gun powder causes accumulation of gases

Builds up the pressure

Expansion of the cartridge case thereby releasing the bullet from the grip of
'cannelure'

Propulsion of the bullet out of the muzzle, under tremendous velocity

Smooth bore Firearm:

Trigger pressed

Firing pin strikes the center of the primer cup

Compresses the primer composition between the cup and anvil

Primer composition explodes

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 Vents in the anvil allow the flame to pass through the flash holes

Ignites the gun powder

Burning of gun powder causes accumulation of gases

Builds up the pressure

Propulsion of the pellets out of the muzzle, under tremendous velocity

INJURIES PRODUCED BY RIFLED FIREARM:

Based on the distance between the muzzle end of the barrel and the body(target) the
rifled firearm injuries are studied under following headings,
1. Contact shot: muzzle end is in contact with the body.
2. Close shot: body is within the distance traveled by the flame (15-20 cms).
3. Near shot: body is within the distance traveled by smoke and unburnt
particles of the gun powder (30-60 cms).
4. Distant shot: body is within the distance traveled by the bullet (100-200
meters).

Bullet
Flame Smoke
Rifled Firearm Unburnt Gunpowder particles

CONTACT SHOT: muzzle end is in contact with the body.

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 Penetrating Lacerated Entry

Grease Collar

Burning
+
Blackening Abrasion Collar
+
CO

Contusion Collar

 Size of entry wound (lacerated wound) is large, can be triangular, stellate, cruciate
or elliptical in shape.
 Contact shot over the forehead/ mastoid region of head, entry wound will be large,
irregular, stellate shaped with everted margins because of expansion of gases
between the skull and scalp resulting in splitting of skin due to the back pressure of
gases.
 No evidence of burning, singeing, blackening and tattooing around the entry
wound.
 Muzzles imprint abrasion around the wound of entry.
 Grease collar surrounded by an abrasion collar around the entry wound.
 Carbon monoxide is found in tissues along the track (cherry red discoloration).
 Track of the wound will show the evidence of burning, blackening, and tattooing.
 Grease Collar: Lubricant and debris on bullet surface wiped off onto the wound
edge.
 Abrasion Collar (Marginal abrasion): When spinning bullet strikes the body,
skin gets stretched leading to ring of abrasion.
 Blackening (Smudging): Superficial deposit of smoke on skin which can be
easily wiped out with a wet sponge.
 Singeing: Flame from muzzle causes burning of hairs.
 Tattooing (Stippling/Peppering): Small discrete black specks resulting from
the deposition of hot grains of gun powder on the skin.

CLOSE SHOT: body is within the distance traveled by the flame (15 cms).

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 Penetrating Lacerated Entry

Grease Collar

Abrasion Collar
Contusion Collar

Tattooing
+
Blackening
+
Singeing
+
Burning

 Entry wound is small, circular (when fired at right angle) or oval (when fired at an
angle) with inverted, contused margin.
 Grease collar surrounded by an abrasion collar around the entry wound.
 Burning, singeing, blackening and tattooing over the skin around the entry wound.

NEAR SHOT: body is within the distance traveled by smoke and unburnt particle
of the gun powder (30-60 cms).

Penetrating Lacerated Entry

Grease Collar

Abrasion
Collar

Contusion
Collar

Tattooing
+
Blackening

 Entry wound is small, circular (when fired at right angle) or oval (when fired at an
angle) with inverted, contused margin.
 Grease collar surrounded by an abrasion collar around the entry wound.
 Blackening and tattooing over the skin around the entry wound.
DISTANT SHOT: body is within the distance traveled by the bullet (100-200 meters).

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 Penetrating Lacerated Entry

Grease Collar

Abrasion Collar

Contusion Collar

 Entry wound is small, circular (when fired at right angle) or oval (when fired at an
angle) with inverted, contused margin.
 Grease collar surrounded by an abrasion collar around the entry wound.

RIFLED FIREARM INJURY OVER THE SKULL:

An entrance wound into skull bone typically produces beveling, or coning, of the bone
at the surface away from the weapon on the inner table. In thin areas such as the
temple, this may not be observed. Sternum, iliac crest, scapula, or rib may show
similar features. These observations may permit determination of the direction of fire.

PECULIARITY or ATYPICAL NATURE OF RIFLED FIREARM INJURY:

 Tangential entrance wounds into bone may produce "keyhole" defects with
entrance and exit side-by-side, so that the arrangement of beveling can be used to
determine the direction of fire
 "Shoring" of entrance wounds can occur when firm material is pressed against
the skin, such as when a victim is shot through a wooden, glass, or metal door
while pressing against it to prevent entry of an assailant.
 If the exit wound is "shored" or abutted by a firm support such as clothing,
furniture, or building materials, then the exit wound may take on appearances of an
entrance wound, such as a circular defect with an abraded margin.

DIFFERENCE BETWEEN ENTRY & EXIT WOUND OF A RIFLED FIREARM:

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Feature Entry wound Exit wound

Usually small except in

1. Size Bigger than entry wound
contact wounds
2. Margins Inverted Everted
3. Grease collar Present Absent
4. Abrasion collar Present Absent
5. Blackening Present Absent
6. Burning Present Absent
7. Singeing Present Absent
8. Tattooing Present Absent
9. Clothe fibres Present Absent
10. CO High quantity Very low or nil
11. Bleeding Less More
12. Tissue protrusion Absent Present
INJURIES PRODUCED BY SMOOTH BORE / SHOT GUN FIREARM:

Based on the distance between the muzzle end of the barrel and the body (target), the
smooth bore firearm injuries are studied under following headings,
1. Contact shot: muzzle end is in contact with the body.
2. Close shot: body is within the distance traveled by the flame (20-30 cms).
3. Near shot: body is within the distance traveled by smoke and unburnt particles
of the gun powder (60-90 cms).
4. Distant shot: body is within the distance traveled by the pellets (20-30 meters).

Pellets
Shot Gun Flame Smoke Unburnt Gun Powder
Particles
CONTACT SHOT: muzzle end is in contact with the body.

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 Large Penetrating
Lacerated Entry

Blackening

Tattooing

 Neat, circular entry wound, with a diameter equivalent to approximately the size of
the muzzle.
 Imprint abrasion by muzzle end if the contact is firm.
 Wound edges are scorched by flame.
 Blackening of skin around the entry wound due to the escape of gases.
 Tattooing by unburnt gun powder.
 Shot passes into the body as a solid mass.
 Injured tissues are cherry red in color due to the presence of carbon monoxide in
the discharged gases.

CLOSE SHOT: body is within the distance traveled by the flame (30 cms).

Large Penetrating
Lacerated Entry

Blackening

Tattooing

 Neat, circular entry wound similar to the contact shot but without evidence of
muzzle imprint.
 Wound edges are scorched by flame.
 Blackening of skin surrounding the entry wound.
 Tattooing by unburnt gun powder.
 Shot passes into the body as a solid mass.
NEAR SHOT: body is within the distance traveled by smoke and unburnt particle
of the gun powder (60-90 cms).

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 Large Penetrating
Lacerated Entry with
Scalloping Edges
(Rat Hole Appearance)

Tattooing
Blackening

 Large, irregular lacerated entry wound with scalloping edges known as COOKIE
CUTTER ETCHING or RAT HOLE APPEARANCE.
 Blackening of skin surrounding the entry wound.
 Tattooing by unburnt gun powder.

DISTANT SHOT: body is within the distance traveled by the pellets (20-30 meters).

Main Penetrating
Lacerated Entry
Blackening
Tattooing

Satellite Pellet
Holes

Uniform
Distribution of
Pellet Holes

 The shot spreads progressively with the formation, at a distance of 2 to 3 meters,

of satellite pellet holes around a central wound.
 At longer ranges (20-30 meters) there is uniform distribution of the shot.

MANNER OF DEATH:
 The manner of death from firearms injuries can be classified as homicide, suicide,
accident, or undetermined.

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 There is no single characteristic appearance of a gunshot wound that defines the
manner of death. Such a determination requires analysis of multiple pieces of
evidence, including the scene investigation, the examination of the body, ballistics
evidence, analysis for gunshot residue, and interviews of persons involved with the
decedent and the scene of death.
 In many cases, the distinction between death from homicide and suicide must be
determined. The presence of multiple entrance wounds may not exclude suicide.
 Common sites of suicidal gunshot injuries are temple, mouth, forehead, under
chin, back of head, chest, and abdomen.

MECHANISM OF WOUNDING BY GUNSHOTS:

Mechanism of wounding by gunshots includes:

1. Penetration: The tissue through which the projectile passes, and which it disrupts
or destroys.
2. Permanent cavity theory: A projectile crushes the tissues it strikes, thereby
creating a permanent wound channel. The crushing of the tissues is facilitated by
the fragmentation of projectiles.
3. Temporary cavity theory: A spinning bullet when strikes, it causes radial
stretching of the projectile path causing cavity which collapses after the bullet has
passed through the tissue. The temporary cavitations has devastating effect on the
less elastic tissue (brain, liver and spleen),fluid filled organs(heart, bladder and
gastrointestinal tract) and dense tissues(bones)
4. Fragmentation: Projectile pieces or secondary fragments of bone which are
impelled outward from the permanent cavity and may sever muscle tissues, blood
vessels, etc., apart from the permanent cavity. Fragmentation is not necessarily
present in every projectile wound. It may, or may not, occur and can be considered
a secondary effect.
5. Shockwaves theory: shockwaves generated from the projectile at the speed of
sound, may cause the rupture of gas-filled organs such as the bowel.

INVESTIGATIONS IN GUNSHOT DEATHS:

Scene of Crime:

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1. Handling the body as little as possible thus avoiding artifacts and loss of trace
evidence.
2. Hands should be covered with the paper bags so as to preserve trace evidence
3. Transporting the body in clear plastic sheeting or a body bag to preserve trace
evidence and avoid contamination.

Autopsy Protocol:
1. X-ray prior to removing clothing.
2. Recovering primer residues from hands by acid (5% nitric acid) moistened
swab or adhesive tape.
3. Examining the hands for trace evidence, soot and propellant grains, and
blood spatter.
4. Examining the clothing.
5. Examining the body, and correlating the wounds with that of the defect
in the clothing.
6. Cleaning the body, photographs and describing the wounds.
8. Tracing the wound tracks and recovering the projectiles.

X-RAY IN GUNSHOT WOUNDS:

In gunshot wound cases x-rays should always be performed, to answer the following
questions:

1. Is the projectile present?

2. If present, where is the projectile located?
3. If the projectile exited, are projectile fragments present and where are they
located?
4. What type of ammunition or weapon was used?
5. What was the path of the projectile?
6. To ascertain presence of Air Embolism/ Bullet Embolism or any injury to the
vital organ leading to death.

COLLECTION, PRESERVATION & DISPATCH OF EVIDENTIARY MATERIAL IN

GUNSHOT WOUNDS
1. Histology section of Entrance and Exit wounds:

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  Helpful in confirming entry & exit wounds.
 The alizarin red S stain can be utilized in microscopic tissue sections to
determine the presence of barium as part of GSR
 The carbon monoxide concentration decreases along the track (maximum at
entry, minimum or zero at exit).

3. Projectile (bullet/pellets):
 Bullets and pellets should be recovered with the help of gloved hands or rubber
tipped forceps.
 Recovered bullets must not be cleaned or washed.
 It should be air dried and preserved.
 Projectiles are marked for future identification by inscribing ones initial on its
base with a sharp pointed instrument.
 Projectiles are wrapped in absorbent cotton and placed in a empty match box.
 The match box containing the projectile should be sealed and sent to ballistic
expert.

4. Gunshot residues:
 These include particles of projectile, jacket, gun powder particles, soot and
primer particles.
 These can be recovered from the firearm(muzzle end, space between chamber
& barrel, trigger) or body(clothings, back of hand and palms and near wound of
entry)
 Site of deposition of gunshot residues over hands of accused or person
commiting suicide - The hand holding the muzzle may show soot deposition on
the radial margin of the forefinger and the adjacent surface of the thumb and
the radial half of the palm due to muzzle blast.
 The residues are collected, by using four cotton swabs moistened with 5% nitric
acid or hydrochloric acid are used to swab the palms and backs of the hand (as
depicted in the diagram). A fifth swab is moistened with the acid acts as a
control.

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DETECTION OF GUNSHOT RESIDUES (GSR):
Following tests are done to detect the gunshot residues,

1. Paraffin Test or Dermal Nitrate Test.

2. Harrison and Gilroy Test.
3. Neutron activation Analysis:
Neutron activation analysis (NAA) for antimony and barium has been described as
the most effective technique for the detection of gunshot residues on the hands of
a suspect.
4. Flameless Atomic Absorption Spectroscopy (FAAS):
FAAS will detect antimony, barium, and lead from the primer as well as copper
vaporized from either the cartridge case or the bullet jacketing.
5. Trace Metal Detection Technique (TMDT);
These tests depend on the detection of trace metal left on the hand as a result of
handling a gun. The metal forms characteristic color complexes with a reagent
sprayed on the hand. The reagents used are 8-hydroxyquinoline or 2-nitroso-1-
naphthol.
6. Scanning Electron Microscope Energy Dispersive X-ray Spectrometry (SEM-EDX):
This method employs SEM-EDX capability. Gun shot residue particles are
removed from the hand using adhesive lifts. The material removed is scanned with
the Scanning Electron Microscope for gunshot residue particle.
7. Proton-Induced X-Ray Emission (PIXE) Analysis:
Detection of bullet lead has also been carried out with proton-induced X-ray
emission (PIXE) analysis, even in a victim buried for several years.

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PARAFFIN TEST or DERMAL NITRATE TEST or DIPHENYLAMINE TEST

Principle:

When a weapon is fired, gun powder residues escaping from the breech (back portion
of the firearm) will contaminate the hands that hold the weapon. Suspected persons
hands are examined for presence of nitrates and nitrites that originate from gun
powder and may be deposited over skin after firing a weapon.

Procedure:
Hands are coated with a layer of paraffin heated to 65 degree centigrade

Paraffin penetrates ridges and furrows of skin of hand and fingers

Takes off any gun powder residues if present and solidifies

After cooling of paraffin the cast is removed

Cast is treated with an acid solution of Diphenylamine or Lunge's reagent

Positive test (Presence of nitrates and nitrites of gun powder) is indicated by the blue
flecks in the paraffin cast

Drawbacks:

Paraffin test is a non specific test, because it also gives falls positive results in
individuals who have not fired weapon, because of the widespread distribution of
nitrates and nitrites in the environment.

HARRISON & GILROY TEST

Principle:
Harrison and Gilroy test is a qualitative calorimetric test to detect the presence of
barium, antimony, and lead on the hands of individual, who fired a firearm. These
metals, which originate from the primer of a cartridge on discharge of a weapon, are
deposited on the back of the firing hand.

Procedure:

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 Swabs are taken from the back of the firing hand using 10% Hydrochloric acid or 5%
Nitric acid

Swabs are treated with two reagents i.e.

Triphenyl-methyl-arsonium iodide for the detection of antimony
&
Sodium rhodizonate for the detection of barium and lead

Colored spots are produced in areas of swab, contaminated with primer residues
(barium, antimony, and lead).
Drawbacks:

Although it is rapid and specific method, the poor sensitivity has limited its utility.

BULLET CYTOLOGY
The presence of particles embedded in or adhering to the surface of bullets may give
the forensic scientist an indication of which material the bullet has passed through.
This has been reported using scanning electron microscopy, and recently Cytology
has been proposed in the search for tissue fragments.

DNA TYPING OF TISSUES ON BULLET

A bullet found at a scene may be linked to the specific individual through whom the
bullet had passed by examining tissue deposited on the bullet. This DNA fingerprint
from the deposited tissues on the bullet can then be compared to the DNA fingerprint
of the individual through which the bullet thought to have passed.
SEQUENCE OF FIRE
In some situations, pathologic findings may help to establish in what sequence the
bullets were fired that caused the injuries. For example, multiple gunshot wounds to
the head may produce fracture lines, and a subsequent fracture line will not cross a
pre-existing fracture line.
MISCELLANEOUS WEAPONS, AMMUNITION & WOUND BALLISTICS
Paradox Gun: This is double barreled weapon, having one barrel rifled and other
barrel smooth bored.
Stud Gun: Stud guns are industrial tools that use special blank cartridges to fire metal
nails or studs into wood, concrete, or steel. Stud guns known to have caused
accidental deaths at industrial sites after the nails or studs have either perforated walls
or ricocheted off a hard surface, striking and killing workers.

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Captive Bolt Pistols: Captive bolt pistols are used in cattle slaughtering. In these
devices, discharge of a blank cartridge drives a captive bolt, 7-12 cm long, out the
muzzle of the device.
Bang Sticks or Fish Popper: A bang stick is a device used by fisherman to kill
sharks, large fish or alligators.
Taser Gun: The taser gun is a device that uses electric current to immobilize victims
without killing them.
Ricochet Bullet: Ricochet bullet is the bullet which deviates in its course after hitting
an intervening object and hits an unintended object. Since the bullet hits an
unintended object it gets deformed thereby producing a keyhole entry wound. The
death is accidental in manner. In internal ricocheting – the bullet hits a bone and
breaks it into multiple splinters and deviates in its course.
Tandem Bullets or Piggy Back bullet: Word tandem mean one after another.
Reasons: Due to the defect in firing mechanism or obstruction to the interior of the
barrel, the bullet does not propelled out after firing. When the next bullet is fired, both
bullets come out one after another resulting in two entry or exit wounds. It can be
opined based on the indentation on the base of the first bullet caused by the second
bullet due to the impact.
Tandem Cartridge: A cartridge having two bullets.

Dum-Dum Bullet: These bullets have a tip which is sawn off or cut off. As a result,
they expand or mushroom on firing and imparts all kinetic energy to the target causing
maximum destruction.

Blank Cartridge: It is a cartridge which does not contain bullet or pellets inside. It
simply detonates on firing. It is mainly used in riot control and on stage shows. It does
not produce injuries but if shot in a very close range, the wad may produce laceration
on the body. The famous actor Brandon Lee (Bruce Lee's son) sustained fatal injuries
from blank cartridge while shooting for the movie "The Crow".
Frangible Bullet: They are made up of iron that fragments on impact and
disintegrates. These are commonly used in firing range during training.

Crime Bullet: This is the bullet recovered from the body of the victim, which is kept as
evidence.

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Test Bullet: This is the bullet that is fired from the same weapon that has been used
for committing crime for comparison with the crime bullet.
Explosive bullet: These are filled with explosive charge and explode on hitting,
causing maximum damage. These bullets apart from causing extensive damage in the
victim, pose consider potential danger to treating surgeon and doctor conducting the
autopsy if the victim succumbs. Exploding bullet was used in the assassination
attempt of former President of U.S.A Ronald Reagan.
Incendiary Bullet: Incendiary bullets, intended to ignite flammable materials such as
gasoline, contain a charge of chemical incendiary agent such as phosphorous.

Armor-piercing bullets: Armor-piercing bullets are designed to penetrate soft body

armor (such as bulletproof vests worn by law enforcement officers). Though they
penetrate such armor, they produce no more wounding than ordinary bullets of similar
size. Some have Teflon coatings to minimize barrel wear with firing. They may
demonstrate less deformation when recovered. They are illegal to possess and use.
Rubber and Plastic Bullets: Rubber and plastic missiles have been used extensively
in riot control. They are intended to incapacitate by inflicting painful and superficial
injuries without killing or serious injury.
Bird-shot Ammunition: These are small pellets of average diameter 4 mm used for
hunting small birds.
Buck-shot Ammunition: These are slightly larger pellets of average 8 mm used for
hunting animals.
Billiard Ball Effect: This is extensive dispersion of lead shot because of the pellets
striking against each other in flight. It gives erroneous impression about the range of
the fire.
Balling or Welding of Shot: The lead shots are bunched together for a longer
distance than usual by pouring wax or glue into the projectile compartment.
Chilled Shot: These are the lead shots or pellets hardened or alloyed by tin or
antimony (98% lead+2% antimony or tin).

Kronlein Shot: In contact gunshot injuries over the skull, if the cavitation is severe,
the skull may burst leading to throwing of the large portion of the brain out of the skull.
This is known as Kronlein Shot.

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Back-spatter: Back-spatter is the ejection of blood and tissues from a gunshot wound
of entrance, which will be smeared on the barrel and hands of the shooter. It is
common in contact shot which will help recovering the offending weapon and the
shooter.
Bullet Embolism: Bullet may enter blood vessels and thus enter circulation and may
lodge at different places causing bullet embolism. The common area from which bullet
can enter circulation are heart and aorta.
Souvenir Bullet: They are the bullets that are retained inside the body without
producing any harmful effect and they are not even removed during surgical
operation.
Rayalseema Phenomenon: This is seen in Rayalseema belt of Andhra Pradesh,
where in to mislead the investigation the stab wounds are stuffed with bullets.
Kennedy Phenomenon: It is an artifact produced due to surgical alteration or
suturing of gunshot wounds, the evaluation of such wounds becomes difficult on
autopsy.
Multiple entry and exit by one bullet:
One bullet can make multiple entry and exit wounds.
E.g.: bullet entering the arm from one side and comes out from the other side and re-
enter the chest and while coming out may enter another arm.

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Single entrance and multiple exit wounds:
This can occur in Tandem bullets. This is also seen in fragmentation of the bullet
inside the body resulting in multiple exits.

Entrance Wound but no Bullet or Exit Wound:

It could be due to following reasons,
 Bullet entered in the stomach and got vomited out.
 It has been coughed out of the trachea.
 Bullet passed out in the faeces after entering the gastrointestinal tract.
 Bullet comes out through the same wound.

INCOMPLETE LIST OF QUESTIONS FROM FIREARMS

1. Define and classify firearms.
2. Write briefly on the following:
a. Rifling.
b. Caliber.
c. Bore.
d. Choking.
3. Draw a neat labeled diagram of the following:
a. Rifled firearm ammunition.
b. Shotgun firearm ammunition.
4. Write shorts on the following:
a. Primer.
b. Black powder.
c. Smokeless powder.
5. Explain the Injuries produced by rifled firearm at following ranges:
a. Contact shot.
b. Close shot.
c. Near shot.
d. Distant shot.
6. Enumerate difference between entry & exit wound of a rifled firearm.
7. Explain the injuries produced by shot gun at following ranges:
a. Contact shot.
b. Close shot.
c. Near shot.
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 d. Distant shot.
8. Enumerate the mechanisms of wounding by gunshots.
9. Discuss the autopsy protocol in firearm deaths.
10. What is the rationale for X-ray in gunshot wounds?
11. Write briefly on collection, preservation & dispatch of evidentiary material in
gunshot wounds.
12. Enumerate the various tests done to detect the gunshot residues.
13. Write briefly on the following:
a. Paraffin or Dermal nitrate test.
b. Ricochet bullet.
c. Tandem bullets.
d. Dum-dum bullet.
e. Blank cartridge.
f. Explosive bullet.
g. Souvenir bullet.
h. Rayalseema phenomenon.
i. Kennedy phenomenon.
14. Explain the reasons for the following:
a. Multiple entry and exit by one bullet.
b. Single entrance and multiple exit wounds.
c. Entrance wound but no bullet or exit wound.

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141
 . FORENSIC PSYCHIATRY
Introduction:
 Psychiatry deals with the study, diagnosis and treatment of Mental illness.
 Forensic Psychiatry deals with application of psychiatry in the administration of
justice.
 Psychology is the study of the mind and behavior.
 Forensic psychology is the intersection between Psychology and the legal system.
It is a division of applied psychology concerned with the collection, examination and
presentation of psychological evidence for judicial purposes.
 Mentally ill person means a person who is in need of treatment by reason of any
mental disorder other than mental retardation.
 ‘Insanity’, solely a legal and sociological concept, has no technical meaning in law
or in medicine and does not connote any definite medical entity. Insanity is seen to
be a social inadequacy and medically, it takes the form of a mental disease.
 ‘Unsoundness of mind’ and is used as a synonym with other terms such as
insanity, lunacy, madness or mental derangement or disordered state of mind, due
to which an individual loses the power of regulating his actions and conduct
according to the rules of the society to which he belongs.
Forensic significance of ‘unsoundness of mind’:
A medical officer may ask to give his opinion on the state of mind of the accused in the
following circumstances:
In relation to criminal cases
 When a defense is attempted on the ground that a criminal act has been committed
by a person in a state of mental unsoundness.
 Inability to plead defense during trial on the ground of insanity.
 To defer the execution of the punishment till the convict is mentally sound.
 When a woman of unsound mind is raped.

In relation to civil cases

 Testamentary capacity to make a valid will.
 Nullity of marriage or divorce cases.

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 Validity to act as a witness.
 Appointment of a caretaker of a mentally unsound person who is unable to look after
his property.

MIND IN PSYCHOLOGY
Mind in western psychology has been conceived in terms of mental process (specially
the conscious mental processes). Feldman (1998) talked of the following three kinds of
mental processes.
1. Cognitive mental processes: Cognition means knowledge, so all such mental
processes which provide us knowledge of stimuli, situations and ideas come under
this category. Sensation is the elementary and basic cognitive process which
provides us simply an awareness of present stimulus in form of shape or size and
basic identity. More complex are attention and perception. Similarly learning,
remembering, imagination and thinking etc. are higher order cognitive processes in
which we develop skills and knowledge regarding difficult situations and ideas.
2. Affective mental processes: Affection refers to feeling and emotions. Not only
have we acquired knowledge through mental processes rather we also have the
experience of pleasure and pain and of emotions like love, anger, hatred, jealousy
etc. Some of these affective processes are of positive nature like pleasure, delight,
love etc; and some others have negative nature like anxiety, jealousy, hatred,
displeasure etc. For happy life we need having positive feelings and emotions. This
is possible when we have positive cognitions and attitude.
3. Conative Mental processes: Conations refer to action tendencies. So all desires
and motivations constitute the conative mental processes. They are like mental
forces which impel the individual to perform certain actions.

DISORDERS OF COGNITION
DELUSIONS:
Definition:
A delusion is an unshakable belief in something untrue. These irrational beliefs defy
normal reasoning, and remain firm even when overwhelming proof is presented to
dispute them.

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 Psychiatrist and philosopher Karl Jaspers was the first to define the three main
criteria for a belief to be considered delusional in his book General Psychopathology.
 These criteria are:
 certainty (held with absolute conviction)
 incorrigibility (not changeable by compelling counterargument
or proof to the contrary)
 impossibility or falsity of content (implausible, bizarre or
patently untrue)

Etiology:
Delusions may be present in any of the following mental disorders: Psychotic disorders
including schizophrenia, bipolar disorder, and major depressive disorder with psychotic
features, delirium, and dementia.

Types of Delusions:
According to the nature of belief, delusions may be of various types:
1. Persecutory delusions: These are the most common type of delusions and involve
the theme of being followed, harassed, cheated, poisoned or drugged, conspired
against, spied on, attacked, or obstructed in the pursuit of goals. Sometimes the
delusion is isolated and fragmented (such as the false belief that co-workers are
harassing). A person with a set of persecutory delusions may be believe, for
example, that he or she is being followed by government organizations because the
"persecuted" person has been falsely identified as a spy.
2. Grandiose delusions: An individual exaggerates his or her sense of self-
importance and is convinced that he or she has special powers, talents, or abilities.
Sometimes, the individual may actually believe that he or she is a famous person
(for example, a rock star or Christ). More commonly, a person with this delusion
believes he or she has accomplished some great achievement for which they have
not received sufficient recognition.
3. Delusional jealousy (or delusion of infidelity or Othello syndrome): A person
with this delusion falsely believes that his or her spouse or lover is having an affair.
This delusion stems from pathological jealousy and the person often gathers
"evidence" and confronts the spouse about the nonexistent affair.

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4. Erotomanic delusions (De Clerambault syndrome/ Psychose Passionelle):
Delusional belief, more common in women than in men that someone is deeply in
love with them. The object of their affection is typically of a higher social status,
sometimes a celebrity. This type of delusional disorder may lead to stalking or other
potentially dangerous behavior.
5. Delusions of reference: These are the belief that the everyday actions of others
are premeditated and make special reference to the patient. Commonly patients
complain about being talked about on television or the radio. Patients may believe
that music played or words spoken on television have been specifically chosen to
identify or annoy them. People crossing the street or coughing may be interpreted as
purposeful actions, performed to indicate something to or about the patient.
6. Delusions of influence: This is a false belief that another person, group of people,
or external force controls one's thoughts, feelings, impulses, or behavior. A person
may describe, for instance, the experience that aliens actually make him or her
move in certain ways and that the person affected has no control over the bodily
movements.
7. Nihilistic delusions: These are the beliefs that part of the individual or the external
world does not exist, or that the individual is dead. Financially comfortable
individuals may believe they are destitute, in spite bank statements to the contrary.
Patients who believe they have no head or are dead, are unable to explain how that
could be possible, but still hold the belief.
8. Delusion of guilt or sin (or delusion of self-accusation): This is a false feeling of
remorse or guilt of delusional intensity. A person may, for example, believe that he
or she has committed some horrible crime and should be punished severely.
Another example is a person who is convinced that he or she is responsible for
some disaster (such as fire, flood, or earthquake) with which there can be no
possible connection.

Forensic significance of delusions:

 Individuals with persecutory delusions may carry out violent actions. Culpability may
be determined on the basis that if the person felt threatened because of a delusional
belief and reacted in self defense, his degree of blame considered to be low. But if

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 he was equally deluded and carefully plotted revenge, this might be seen as
culpable.
 Severe assault and even murder may be committed under jealousy delusions. The
doctor has a duty to warn and protect the partner if the danger seems substantial.
 Erotomanic delusional disorder may lead to stalking or other potentially dangerous
behavior. Any professional person dealing with these individual must be vigilant.
 Delusions are not only seen in isolated individuals. Shared delusions may occur in
couples (folie a deux) and in families (folie a famille).

HALLUCINATION
Definition:
The English word "hallucination" comes from the Latin verb hallucinari, which means "to
wander in the mind."
"Hallucination is a Perception of visual, auditory, tactile, olfactory, or gustatory
experiences without an external stimulus and with a compelling sense of their reality,
usually resulting from a mental disorder or as a response to a drug."
"A hallucination in the broadest sense is a perception in the absence of a stimulus."

Etiology:
 Drugs - Hallucinogenics such as ecstasy (3,4-methylenedioxymethamphetamine, or
MDMA), LSD (lysergic acid diethylamide, or acid), etc.
 A hallucinatory sensation-usually involving touch-called an aura, often appears
before, and gives warning of, a migraine.
 Schizophrenia, brain damage etc.

Types of Hallucinations:
Hallucinations may occur in any sensory modality—visual, auditory, olfactory, gustatory,
tactile, and psychomotor.

1. Visual hallucinations: In this condition the sufferer visualizes non-existent sights.

He observes something without anything being present in his front.
 Charles Bonnet syndrome is the name given to visual hallucinations experienced
by blind patients. The hallucinations can usually be dispersed by opening or

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 closing the eyelids until the visual images disappear. The hallucinations usually
occur during the morning or evening, but are not dependent on low light
conditions. These prolonged hallucinations usually do not disturb the patients
very much as they are aware that they are hallucinating.
 In alcoholic delirium tremens, Lilliputian hallucinations, i.e. hallucinations of small
animals and human beings, are reported (person sees figures in reduced size
like midgets or dwarfs).
2. Auditory hallucinations: These are false perception of sound, usually voices, but
also other noises, such as music. Most common hallucination in psychiatric
disorders.
3. Olfactory hallucination: Hallucination primarily involving smell or odors; most
common in medical disorders, especially in the disorders of temporal lobe. Olfactory
hallucinations those found in Schizophrenia are often unpleasant, such as the smell
of burning rubber or of an offensive body odor.
4. Tactile hallucinations (Haptic hallucination): Tactile hallucinations include a
sensation of being touched. Tactile hallucinations such as that bugs are crawling
over one's skin (formication), are common in cocaine intoxication and alcohol
withdrawl syndromes (delirium tremens).
5. Command hallucinations: These consist of instructions spoken to the patients;
some patients feel compelled to obey these commands.
6. Gustatory hallucination: Hallucination primarily involving taste.

Forensic significance of hallucinations:

Command hallucinations are dangerous as they may command acts of violence towards
self or others, such as 'jump off the roof, you are not worth anything'. The person is not
held fully responsible for the deeds committed during the hallucinations.

ILLUSION
Definition:
The term illusion refers to a false perception of a real external stimulus. Unlike a
hallucination, which is a distortion in the absence of a stimulus, an illusion describes a
misinterpretation of a true sensation.

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For example, hearing voices regardless of the environment would be a hallucination,
whereas hearing voices in the sound of running water (or other auditory source) would
be an illusion.

Types of Illusions:
Illusions may occur with more of the human senses than vision, but visual illusions,
optical illusions, are the most well known and understood.
1. Optical illusions: An optical illusion is always characterized by visually perceived
images that, at least in common sense terms, are deceptive or misleading.
2. Auditory illusion: An auditory illusion is an illusion of hearing sounds which are not
present in the stimulus.
3. Tactile illusions (Touch illusion): Examples of tactile illusions include phantom
limb (A phantom sensation is a feeling that a missing limb is still attached to the
body and is moving appropriately with other body parts), the thermal grill illusion(a
sensation of strong, often painful heat is elicited by touching interlaced warm and
cool bars to the skin), and the cutaneous rabbit illusion (The cutaneous rabbit
illusion (also known as cutaneous saltation) is a tactile illusion evoked by tapping
two separate regions of the skin. A rapid sequence of taps delivered first near the
wrist, and then near the elbow creates the sensation of sequential taps hopping up
the arm from the wrist towards the elbow, although no physical stimulus was applied
between the two actual stimulus locations).
4. Other senses: Illusions can occur with the other senses including that of taste and
smell.

DISORDERS OF AFFECT OR EMOTIONS

PHOBIA
Definition:
A phobia (from Greek: phobos, "fear"), is an irrational, intense, persistent fear of certain
situations, activities, things, or persons. The main symptom of this disorder is the
excessive, unreasonable desire to avoid the feared subject.

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Types of Phobias:
Phobias are classified based on the nature of the feared object or situation, which
includes:
1. Acrophobia – fear of heights.
2. Agoraphobia – fear of open spaces.
3. Aviophobia – fear of flying.
4. Claustrophobia – fear of enclosed spaces.
5. Cynophobia – fear of dogs.
6. Gamophobia – fear of marriage.
7. Hydrophobia – fear of water.
8. Nyctophobia – fear of night.
9. Odynophobia – fear of pain.
10. Ophidiophobia – fear of snakes.
11. Thalassophobia – fear of the ocean.
12. Xenophobia – fear or dislike of strangers or the unknown, sometimes used to
describe nationalistic political beliefs and movements. It is also used in fictional work
to describe the fear or dislike of the space aliens.

OBSESSION
Definition:
Obsessions are defined as recurrent, intrusive, and generally persistent thoughts that
are experienced by the individual as a distressing and a product of one's own mind.
These thoughts or images are usually described as generating or associated with
feelings of anxiety, tension, disgust or aversion.

Most frequently encountered obsessions are:

 Washing hands again and again.
 Checking the locks repeatedly at bedtime.
 Counting the money again and again before going for shopping.

DISORDERS OF CONATION OR BODY FUNCTIONS

SOMNABULISM (Sleep Walking)

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Definition: Somnambulism (also called Sleepwalking or noctambulism) is a parasomnia
or sleep disorder where the sufferer engages in activities that are normally associated
with wakefulness while he or she is asleep or in a sleep-like state.
Semi-somnolence or somnolentia is half way between sleep and walking and is often
called sleep drunkenness.

Etiology:
Sleepwalking is more commonly experienced in people with high levels of stress,
anxiety or psychological factors and in people with genetic factors (family history), or
sometimes a combination of both.
Forensic significance of Somnambulism:
 Sleepwalking has in rare cases been used as a defense (sometimes successfully)
against charges of murder.
 Sleepwalkers are more likely to endanger themselves than anyone else. When
sleepwalkers are a danger to themselves or others (for example, when climbing up
or down steps or trying to use a potentially dangerous tool such as a stove or a
knife), steering them away from the danger and back to bed is advisable. It has even
been reported that people have died or were injured as a result of sleepwalking.
 A recent case in England is reported where the defendant was acquitted on 3
charges of rape on the basis of automatism due to somnambulistic sexual
behaviour.

AUTOMATISM
Definition:
Automatism is an unconscious, involuntary act, where the mind does not go with what is
being done or performance of an act, of which he is not aware of and over which he has
no control.
Etiology:
 Catatonic schizophrenia
 Cerebral tumour
 temporal lobe epilepsy
 Cerebral concussion
 Hypoglycemia (low blood sugar)

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 Drugs (medically administered): Barbiturates, Amphetamines
 Alcohol – idiosyncratic or pathological intoxication
 Sleepwalking
Forensic significance of automatism:
Automatism has in rare cases been used as a defense (sometimes successfully)
against charges of criminal acts on the basis that he is not aware of and over which he
has no control.

IMPULSE
Definition:
Impulse is a sudden and irresistible force compelling a person to the conscious
performance of some action without motive or forethought
Types of Impulses:
1. Kleptomania (Pathological stealing) – Kleptomania is the repetitive theft of items
that are usually of little monetary value and are not realistically needed. The items
may be discarded, given away, or stored.
2. Pyromania (Pathological fire setting) – Pyromania is the recurrent failure to resist
impulses to set fires, intense fascination with the setting of fires, and seeing fires
burn.
3. Dipsomania – Dipsomania is a term which describes an uncontrollable craving for
alcohol. The etymology breaks down as "compulsive thirst" but the term when used,
is reserved primarily related to the uncontrollable consumption of alcohol. As a
result, a dipsomaniac is a person in which this condition appears, in the form of a
physical and psychological craving for ethyl alcohol, especially liquor.
4. Pathological gambling: Pathological gambling is a frequent, repeated episode of
gambling that dominate the patient's life, to the detriment of social, occupational,
material, and family values and commitments.
5. Trichotillomania: Trichotillomania is a chronic disorder characterized by repetitive
hair pulling, driven by escalating tension and causing variable hair loss.
6. Sexual impulses: Compulsive urge to perform sexual intercourse, which may often
be in a perverted way.

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HYPNOTISM
Definition:
Hypnosis (from the Greek hypnos, "sleep") is often thought to be "a trance-like state
that resembles sleep but is induced by a person whose suggestions are readily
accepted by the subject."

Forensic significance of Hypnotism:

 Hypnotism, as a defense in the criminal act, is not generally recognized in courts. No
one can be compelled by hypnotic influence to commit any act of which he/she was
not capable in the normal state. It can be said that a person cannot take advantage
of his/her own misconduct if he violates the law under the effect of hypnotism.
 Evidence extracted under the influence of hypnotism is not accepted by the court
and the status of such evidence may be comparable to situations wherein evidence
is obtained under influence of alcohol/ truth serum.

MENTAL RETARDATION (MR)

Through the ages, understanding of persons with mental retardation has moved like a
pendulum between extremes. At one extreme, persons with mental retardation have
been exalted, considered les enfants du Bon Dieu (childrens of the Good God). To this
day, movies such as "Forest Gump" convey the message that persons with mental
retardation are somehow blessed with simpler, more straightforward understandings of
basic human truths. Yet, at the same time, such persons have also been vilified.

Synonyms:
"Mentally challenged" or "intellectual disability" or "mental sub-normality"

Definition:
Sub average general intellectual functioning that originates in the developmental period
and is associated with impaired maturation and learning, and social misadjustement.

Etiology:
Down syndrome, fetal alcohol syndrome and Fragile X syndrome are the three most
common inborn causes.

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Parameters Determining Mental Retardation:

Degree of Mental
IQ Mental Age Adult life and needs
Retardation
Can achieve social and vocational skill
Mild MR (Morons) 50-70 6-11yrs
enough for minimum self- support
Moderate MR May perform unskilled/ semi-skilled work,
35-49 3-6 yrs
(Imbeciles) needs supervision
Cannot speak intelligibly, needs nursing
Severe MR (Idiocy) 20-34 of 3yrs
care
No/ minimum capacity for sensory- motor
Profound MR (Idiots) <20 <3yrs
functioning, needs nursing care

PSYCHOSIS
 Psychosis is a generic psychiatric term for a mental state often described as
involving a "loss of contact with reality." People suffering from it are said to be
psychotic.
 People experiencing psychosis may report hallucinations or delusional beliefs, and
may exhibit personality changes and disorganized thinking. This may be
accompanied by unusual or bizarre behaviour, as well as difficulty with social
interaction and impairment in carrying out the activities of daily living.

NEUROSIS
Neurosis, also known as psychoneurosis or neurotic disorder, is a term that refers to
any mental imbalance that causes distress, but, unlike a psychosis or some personality
disorders, does not prevent or affect rational thought. It is particularly associated with
the field of psychoanalysis.
DIFFERENTIATING FEATURES OF TRUE AND FEIGNED INSANITY

Points of Difference True Insanity Feigned Insanity

Usually gradual or rarely sudden
Always sudden and there is some
Onset but almost always without any
motive
motive
Usually present ,e.g. Family
No predisposing or exciting cause
Predisposing factors history of insanity, grief, sudden
is usually present
loss of money etc

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 Generally normal even when the
person pretends to be insane.
Usually peculiar in well
Facial Expression Frequently changes of facial
developed cases of insanity
expression are not characteristic of
insanity.
Looks Vacant , agitated or worried Not so
Excited, depressed or May overact to show abnormality in
Mood
fluctuating mood
Carefully does something to
Activity Careless
indicate insanity.
Signs and symptoms are not
Usually point to a particular type uniform and do not indicate any
of mental illness. The individual particular type of mental illness.
shows signs and symptoms of The individual pretends to be
Signs- Symptoms
insanity irrespective of his insane only when he is observed
conduct being observed or not. and there may be total absence of
symptoms when he thinks that he is
not being observed.
Minimum, even with continuous Gets exhausted like a normal
over activity. Can stand violent person. Violent exertion necessary
Physical Exhaustion exertion for several hours or to feign maniacal frenzy (which is
days without exhaustion, or generally imitated by impostors)
sleep. leads to exhaustion, and sleep.
Manifestation like dry and harsh
Physical skin , furred and coated tongue , Manifestations characterizing true
manifestation constipation, anorexia and insanity are absent.
insomnia present
Invariably dirt or filthy. An insane Usually not dirty or filthy, though a
Habits may smear his body with stool false show may be posed to that
or urine effect
Repeated Not worried about being
Resents for fear of being detected
examination repeatedly examined

RIGHTS OF A MENTALLY ILL PERSON

"All persons with a mental illness, or who are being treated as such persons, shall be
treated with humanity and respect for the inherent dignity of the human person...There
shall be no discrimination on the grounds of mental illness..."

The rights of a mentally ill person can be briefly summarized as following:

1. A right to be admitted, treated and taken care of in a Psychiatric hospital or
Psychiatric nursing home established or maintained by the Government or any

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 other person for the treatment and care of mentally ill persons (other than
general hospitals, or nursing homes of the Government).
2. Even mentally ill prisoners and minors have a right to treatment in psychiatric
hospitals or psychiatric nursing homes of the Government.
3. Minors who are under the age of 16 years, persons who are addicted to alcohol
or other drugs which lead to behavioural changes and those convicted of any
offence are, entitled to admission, treatment and care in separate Psychiatric
hospitals or nursing, homes established or maintained by the Government.
4. Mentally ill persons have the right to have regulated, directed and co-ordinated
mental health services from the Government which through the Central Authority
and the State Authorities set up under the Act have the responsibility of such
regulation and issue of licenses for establishing and maintaining Psychiatric
hospitals and nursing homes.
5. Treatment at Government hospitals and nursing homes mentioned above can be
had either as in patient or as out-patients.
6. Mentally ill persons can seek voluntary admission in such hospitals or nursing
homes and minors can seek admission through their guardians. Relatives of
mentally ill persons on behalf of the latter can seek for admission. Applications
can also be made to the local magistrate for grant of reception orders.
7. The police have an obligation to take into protective custody a wandering or
neglected mentally ill person and inform his relative and have such person
produced before the local magistrate for issue of reception orders.
8. Mentally ill persons have the right to be discharged when cured and entitled to
‘leave’ in accordance with the provisions in the Act.
9. Where mentally ill persons own properties including land, which they cannot
themselves, manage, the District Court upon application has to protect and
secure the management of such properties by entrusting the same to a Court of
Wards, by appointing guardians of such mentally ill persons or appointment of
managers of such property.
10. The costs of maintenance of mentally ill persons detained as in-patient in any
Government Psychiatric hospital or nursing home shall be borne by the State
Government concerned.

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 11. Mentally ill persons undergoing treatment shall not be subjected to any indignity
(whether physical or mental) or cruelty. Nor can such mentally ill person be used
for purposes of research except for his diagnosis or treatment, or with his
consent.
12. Mentally ill persons who are entitled to any pay, pension, gratuity or any
allowance from the Government (such as Government servants who become
mentally ill during their tenure) are not to be denied such payments.
13. A mentally ill person shall be entitled to the services of legal practitioner by order
of the Magistrate or District Court if he has no means to engage a legal
practitioner or his circumstances so warrant in respect of proceedings under the
Act.

RESTRAINTS OF THE MENTALLY ILL

Restraint may be:
 Immediate
 Admission to an asylum.

IMMEDIATE RESTRAINT
This can done in case of:
 an insane person who is dangerous to himself or to others, or who is likely to
injure or wastefully spend his property or that of others,
 person suffering from delirium due to disease, and
 delirium tremens.

Immediate restraint is done under the personal care of attendants, e.g., by safely
locking-up in a room. The consent of the lawful guardian of the insane person has to be
taken, but if there is no time to take the consent and the insane person is dangerous to
himself or the others, he can be immediately restrained. Such restraint is lawful only as
the danger exists.

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ADMISSION IN PSYCHIATRIC HOSPITAL
The following procedures are adopted.
1. Admission on Voluntary Basis:
 Any major person, who considers himself to be mentally ill person, may request the
medical officer-in-charge of psychiatric Hospital (or psychiatric nursing home) for
admission and treatment.
 In case of a minor, the guardian may make such request.
 The officer-in-charge should make such inquiry as he may deem fit within 24 hours,
and if he is satisfied that the person requires treatment as an in-patient, he may
admit such person.

2. Admission under Special Circumstances:

 A mentally ill person may not be able to express his willingness for admission as a
voluntary patient. Such person can be admitted in a psychiatric hospital (psychiatric
nursing home) for a period of ninety days, if an application should be in the
prescribed form and should be accompanied by two medical certificates, one of
which shall be by a medical officer in the service of government.
 If the application is not accompanied by medical certificates, the officer-in-charge of
the psychiatric hospital can get the mentally ill person examined by two doctors
working in the hospital.

3. Reception Order on Application or petition:

 The officer-in-charge of a psychiatric hospital can make an application to the
Magistrate in case of a mentally ill person who is undergoing treatment under a
temporary treatment order, if he is satisfied that
(a) The treatment is required to be continued for more than six months, or
(b) It is necessary in the interest of the health and personal safety of the mentally ill
person, or
(c) For the protection of others.
 The husband or wife of the mentally ill person, or any other relative, can make an
application in the prescribed form to the Magistrate. The applicant must be a major
and must have personally seen the patient within fourteen days of the date of the

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 application. The exact manner of relationship, and the circumstances under which
the application is being made, and whether any previous application had been made
for inquiry should be stated. The application should be signed and verified by the
applicant.
 Two medical certificates should be submitted issued by two medical practitioners,
who must have separately examined the patient within ten days of the presentation
of the application. One certificate should be from a medical practitioner in the service
of government.
 Each doctor should certify that the alleged mentally ill person is suffering from
mental disorder of such a natures and degree, that such person should be admitted
in a psychiatric hospital, and that such admission is necessary in the interests of the
health and personal safety of that person, or for the protection of others. On receipt
of application, the Magistrate must consider the allegations in the petition, and the
evidence of mental illness a disclosed by the medical certificates. He can personally
examine the alleged mentally ill person. If he is satisfied, he may pass a Reception
Order immediately, or he many fix a date for consideration of the petition.
 If he fixes a date, he must give notice to the petitioner and to any person to whom in
his opinion, notice should be given. On the date fixed, the petition must be
considered in private in the presence only of the petitioner, the alleged mentally ill
person a representative of the alleged mentally ill person, and such other persons as
the Magistrate thinks should be present. If the Magistrate is satisfied that it is
necessary to detain the alleged mentally ill person in a psychiatric hospital, he
passes a Reception Order which is valid for 30 days.
 If he is not satisfied, he may refuse the application, giving his reasons in writing, a
copy of which is supplied to the applicant. A certified copy of the Reception Order is
sent to the officer in- charge of the psychiatric hospital.

CIVIL RESPONSIBILITY OF MENTALLY ILL PERSON

1) Management of property and affairs of insane:
After a due inquiry, if a person is found incapable of managing his property and affairs,
but is not dangerous to him or to others, the court appoints a manager to look after his

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property, granting him necessary power. The court may order the sale on disposal of
the lunatic's property for the payment of his debts and expenses.

2) Illegal Detention:
Any unauthorized person who detains mentally ill person or an alleged mentally ill
person in a psychiatric hospital or psychiatric nursing home or for gain; detains 2 or
more mentally ill persons in any place NOT being a psychiatric hospital or nursing
home, is punishable with imprisonment for a term which may extend to 2 years or with
fine or with both.

3) Insanity and Contracts:

A contract is invalid if one of the parties at the time of making it, was incapable of
understanding what he was doing due to insanity. A person, who is usually of unsound
mind, but occasionally of sound mind, may make a contract when he is of sound mind.

4) Insanity and Marriage Contract:

A marriage contract is considered invalid, if at the time of marriage either party is:
Incapable of giving a valid consent to a marriage in consequence of unsoundness of
mind.

5) The competence of Insane to be a witness:

He is competent to give evidence, if a mentally ill person is in the stage of lucid interval
or if he is suffering from monomania, though it rests with the Judge and Jury to decide
whether they should give credence to it.

6) Insanity and testamentary capacity:

 Testament = will; It is the mental ability of a person to make a valid will.
 The requirement for a valid will is as follows:
 A written and properly signed and witnessed document must exist.
 The testator must be major and of sound disposing mind at the time of making
will.
 Force, under influence, or dishonest representation of facts should not have
been applied by other.

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  A sound disposing mind is a mind which has capacity of recollecting, judging
and feeling the relations, connections and obligations of his family and blood
relations.
 Holograph will: is one, which is written by a testator in his own handwriting.
 Doctors are sometime called upon to witness the execution of the will of a sick
person. The doctor should proceed in usual way.
 Physical examination.
 Mental state including intelligence testing.
 Laboratory investigation.
 The testator is said to be of sound mind if he is capable of disposing of his property
with understanding and reason.
 A person affected by an insane delusion can make a valid will if the delusion is not
related in any way to disposal of the property or the persons affected by the will.
Prejudices, dislikes and hatred however ill found or however strongly entertained
cannot be classed as insane delusions.
 Wills made by a person in extremis (at the point of death) may be regarded with
suspicion, because at the time a clear mind is unusual.
 A will is considered valid even though the testator committed suicide shortly after
making a will, if there is no other evidence of mental disorders.
 Person suffering from motor or sensory aphasia, agraphia (failure to communicate
by writing) and alexia (failure to understand by reading) or who is blind can make a
valid will, if he knows what he does by it, if he can make clear by gestures that he
wishes to make a will and is able to understand the meaning of questions put to
him in this connection.
 Partial drunkenness does not invalidate a contract or will, but when drunkenness
has caused a temporary loss of reasoning power the person cannot make a valid
will.

7) Protection of Human rights of mentally ill persons:

 No mentally ill person shall be subjected, during treatment to any indignity
(whether physical or mental) or cruelty.

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  A mentally ill person under treatment shall not be subjected to mechanical
restraint, solitary confinement or other harsh measure unless medical practitioner
thinks such measures are necessary and he shall record his reasons therefore in
writing.
 No mentally ill person under treatment shall be used for purpose of research
unless research is of direct benefit to him.

CRIMINAL RESPONSIBILITY
The notion that an individual who suffers from mental disorder may not bear the full
weight of responsibility for their actions dates back to ancient times. Much of forensic
psychiatry is guided by significant Court rulings or laws that bear on this area which
include the following standards:
1. McNaughten Rules Or Right-wrong Test (1843):
The M'Naghten Rules (McNaughton) were the first serious attempt to codify and
rationalize the attitude of the criminal law towards mentally incompetent defendants.
They arise from the attempted assassination of the British Prime Minister, Robert
Peel, in 1843 by Daniel M'Naghten. The House of Lords asked a panel of judges, to
set down guidance for juries in considering cases where a defendant pleads
insanity. The House of Lords, having deliberated, declared that insanity was a
defense to criminal charges, and delivered the following exposition of the Rules:
"the jurors ought to be told in all cases that every man is presumed to be
sane, and to possess a sufficient degree of reason to be responsible for his
crimes, until the contrary be proved to their satisfaction; and that to establish
a defence on the ground of insanity, it must be clearly proved that, at the time
of the committing of the act, the party accused was labouring under such a
defect of reason, from disease of the mind, as not to know the nature and
quality of the act he was doing; or, if he did know it, that he did not know he
was doing what was wrong (Queen v. M'Naghten, 8 Eng. Rep. 718 [1843])"

2. Durham rule:
The Durham Rule or "product test" was adopted by the United States Court of
Appeals for the District of Columbia Circuit in 1954, in the case of Durham v. U.S.

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 (214 F.2d 862 ), and states that "... an accused is not criminally responsible if his
unlawful act was the product of mental disease or defect".

3. American Law Institute Rule:

A 1962 US rule used as a test of criminal responsibility and stating that an individual
accused of a crime is not criminally responsible if at the time of such conduct as a
result of mental disease or defect the person lacks substantial capacity either to
appreciate the wrongfulness of the conduct or to conform such conduct to the
requirements of law.

4. Curren's Rule:
This rule postulates that an accused is not criminally responsible, if at the time of
committing the act, he did not have the capacity to regulate his conduct to the
requirements of law as a result of mental disease or defect.

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 GENERAL PRINCIPLES OF TOXICOLOGY

“There is poison in the fang of the serpent, in the mouth of the fly and in the sting of a scorpion; but
the wicked man is saturated with it.” - Chanakya

“Poisons and medications are oftentimes the same substance given with different intents.” - Latham

IMPORTANT DEFINITIONS

 Toxicology is the science dealing with properties, action, toxicity, fatal dose,
detection and estimation of, interpretation of the result of toxicological
analysis and management of Poisons.
 Forensic Toxicology is a branch of Forensic Medicine dealing with Medical
and Legal aspects of the harmful effects of chemicals on human beings.
 Clinical Toxicology deals with study of human diseases caused by or
associated with abnormal exposure to chemical substances
 Toxinology refers to toxins produced by living organisms which are
dangerous to man, eg.: snake venom, fungal and bacterial toxins etc.
 Eco-toxicology is concerned with the toxic effects of chemical and physical
agents on living organisms, especially in population and communities within
defined population.
 Acute poisoning is caused by an excessive single dose, or several dose of a
poison taken over a short interval of time.
 Chronic Poisoning is caused by smaller doses over a period of time,
resulting in gradual worsening. eg: arsenic, phosphorus, antimony and opium.
 Fulminant poisoning is produced by a massive dose. In this death occur
rapidly, sometimes without preceding symptoms.

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POISON
DEFINTION
Any substance which, when in relatively small amounts are ingested, inhaled, or
absorbed, or applied to, injected into, or developed within the body, has chemical
action that may cause damage to structure or disturbance of function producing
symptomology, illness, or death. (Stedman’s Medical Dictionary, 26th ed.,
Williams & wilkins, Baltimore, 1995)

CLASSIFICATION
Poisons are classified as according to the mode of action as:
1. Corrosive Poisons
These produce both inflammation and ulceration of tissues. This group
consists of acids, alkalis, and metallic salts.
A. Acids:
a. Mineral or Inorganic Acids: e.g., Sulphuric acid, Nitric acid and
Hydrochloric acid.
b. Organic acids: e.g., Oxalic acid and Carbolic acid.
B. Alkalis: e.g., Sodium hydroxide and potassium hydroxide.
C. Metallic salts: e.g., Zinc chloride, ferric chloride.
2. Irritant Poisons
These produce symptoms of pain in the abdomen, vomiting and purging.
A. Inorganic Irritants:
a. Metallic: e.g., Arsenic, antimony, mercury, lead and copper.
b. Non Metallic: e.g., Phosphorus, chlorine, bromine and iodine.
B. Organic Irritants:
a. Vegetable: e.g., Ricinus, abrus, calotropis.
b. Animal: e.g.: Snakes, scorpions, spiders.
C. Mechanical Irritants: e.g., Glass powder, pins and needles, chopped
hairs etc.
3. Systemic Poisons

A. Neurotic Poisons:
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 These chiefly act on the central nervous system.
a. Cerebral poisons:
i. Somniferous: e.g., Papaverum somnifera, barbiturates
ii. Inebriants: e.g., Alcohol, ether,
iii. Deliriants: e.g., Dhatura, cannabis, cocaine

b. Spinal poisons: e.g., Strychnos nux vomica, gelsemium.

c. Peripheral poisons: e.g.,Conium, curare

B. Respiratory Poisons: e.g., Carbon monoxide, carbon dioxide,

hydrocyanic acid.
C. Cardiac Poisons: e.g., Digitalis, oleanders, Aconite, tobacco.
D. Nephrotoxic Poisons: e.g., Cantherides.
E. Hepatotoxic Poisons: e.g., Chloroform, carbon tetrachloride.
F. Miscellaneous Poisons: e.g., Analgesics, antipyretics and insecticides.

Poisons are classified as according to motive or nature of use as:

1. Homicidal: e.g., Arsenic, Aconite, Digitalis, Abrus Precatorius, Strychnos nux
vomica.
2. Suicidal: e.g., Opium, Barbiturate, Organophosphorus, carbolic acid, copper
sulphate.
3. Accidental: e.g., Aspirin, organophosphorus, copper sulphate, snakes bite,
ergot, carbon monoxide, carbon dioxide, hydrogen sulphide.
4. Abortifacient: e.g., Ergot, Quinine, calotropis, plumbago.
5. Stupefying agent: Dhatura, cannabis, chloral hybrate.
6. Agents used to cause bodily injury: Corrosive acids and alkalies.
7. Cattle Poison: Abrus precatorius, calotropis, plumbago.
8. Used for malingering: Semicarpus anacardium

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SOURCES OF POISON
1. Domestic or household sources:
In domestic environment poisoning may more commonly occur from
detergents, disinfectants, cleaning agents, antiseptics, insecticides,
rodenticides etc.
2. Agricultural and horticultural sources:
Different insecticides, pesticides, fungicides and weed killers.
3. Industrial sources:
In factories, where poisons are manufactured or poisons are produced as by
products.
4. Commercial sources:
From store-houses, distribution centers and selling shops.
5. From uses as drugs and medicines:
Due to wrong medication, overmedication and abuse of drugs.
6. Food and drink:
Contamination in way of use of preservatives of food grains or other food
material, additives like coloring and adoring agents or other ways of
accidental contamination of food and drink.
7. Miscellaneous sources:
Snakes bite poisoning, city smoke, sewer gas poisoning etc.

ROUTES OF ADMINISTRATION OF POISONS

1. Ingestion: The most common method is by oral intake

2. Inhalation: The poison act very quickly when inhaled.
3. Injection: By this route also the poison act very quickly.
4. Introduction: This is by placing the poison through the anus, vaginal, nasal,
rectal, urethral, ulcers, wounds etc.
5. Inunction: This is absorption of the poison through the skin on rubbing.

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MECHANISM OF ACTION OF POISONS
1. Local Action:
 There are poisons which act only on the part with which it comes in
contact with. Such action is known as local action.
 E.g., Mineral acids like sulphuric acid, nitric acid, hydrochloric acid etc.
2. Remote Action:
 Some poisons act on being absorbed into the system by the body.
Secondary to absorption into the bloodstream they cause systemic effects
/ organ damage. They are said to have remote action.
 E.g., Alcohol, opium etc.
3. Combined Action:
 Some poisons have both local and remote action.
 E.g., Oxalic acid, carbolic acid etc.

FATE OF POISON IN BODY

 A part of the poison taken orally gets eliminated unabsorbed by means of
defecation and vomiting.
 Before absorption the poison may exert its effects in the G.I. Tract.
 When absorbed, the poison reaches different parts of the body and organs
through circulation. Some poisons reach some tissues easily. Others may not
cross some tissue barrier.
 Cumulative poisons get accumulated in some organs or tissues.
 Major part is detoxified or metabolized in the body and than excreted after
exerting its toxic effects on the body. Liver is the main organ to detoxify or
metabolize most of the poisons.
 Certain poisons like Chloroform, Phosphorus, Nitrates and Acetic acid
disappear by evaporation or oxidized or destroyed in the body and no trace of
them can be detected in the body if post-mortem is delayed.
 A part of poison is eliminated as such through different route of elimination.

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EXCRETION OF POISONS
 Unabsorbed poisons are excreted through faeces and vomitus.
 Absorbed poisons are excreted mostly by urine.
 A part of volatile poison is exhaled out.
 Some portion of poison is excreted through bile, saliva, milk, sweat, tear, hair
and nails.

CONDITIONS AFFECTING / MODIFYING ACTION OF POISONS

 Most drugs or poisons do not have a magical dose at which they will
necessarily cause sickness and/or death. While there are statistical LD (lethal
dose) 50 levels for many substances, this concept cannot be extrapolated
wholesale to predict effect in individuals.
 The levels of these substances detected in body fluids and/or tissues at
autopsy must be interpreted together with the circumstances surrounding the
death, the medical history of the deceased, and the autopsy findings.
 Factors influencing the actions of a poison in the body
1. Quantity:
 A high dose of poison acts quickly and often resulting in fatal
consequences. A moderate dose causes acute poisoning. A low dose may
have sub-clinical effects and causes chronic poisoning on repeated
exposure.
 Very large dose of Arsenic may produce death by shock without dose
irritant symptoms, while smaller dose than lethal dose produces its
therapeutic effects.
2. Physical form:
 Gaseous or volatile poisons are very quickly absorbed and are thus most
rapidly effective.
 Liquid poisons are more rapid than solid poisons.

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  Some poisonous vegetable seeds may pass through the intestinal canal
ineffective when taken intact due to their impermeable pericarp. But when
taken crushed, they may be rapidly fatal.
3. Chemical form:
 Chemically pure arsenic and mercury are not poisonous because these
are insoluble and are not absorbed.
 But white arsenic (arsenic oxide) and mercuric chloride are deadly
poisonous.
 Barium sulphide is deadly toxic but barium sulphate is non-toxic.
4. Concentration (or dilution):
Concentrated form of poison are absorbed more rapidly and are also more
fatal but there are some exceptions too.
5. Condition of the stomach:
 Food content presence of food-stuff acts as diluent of the poison and
hence protects the stomach wall.
 Dilution also delays absorption of poison. Empty stomach absorbs poison
most rapidly.
 In cases of achlorohydria, KCN and NaCN are ineffective due to lack of
hydrochloric acid, which is required for the conversion of KCN and NaCN
to HCN before absorption.
6. Route of administration:
Absorption rate is different for different routes.
7. Age:
 Some poisons are better tolerated in some age groups.
 In general, children and the elderly are more susceptible to poisons.
 Hepatic detoxification systems are relatively underdeveloped in young
children.
8. State of body health:
A well built person with good health can tolerate the action of poison better
than a weak person.
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9. Presence of disease:
 In general, ill-health is likely to accelerate the effects of a poison. This is
especially true if there is dysfunction of the organ primarily responsible for
the detoxification of the poison concerned.
 In certain diseased conditions some drugs are tolerated exceptionally well
e.g.: sedatives and tranquilizers are tolerated in very high dose by manic
and deliriant patients.
10. Intoxication amid poisoning states:
 In certain poisoning cases some drugs are well tolerated, like, in case of
strychnine poisoning, barbiturates and sedatives are better tolerated.
 In case of barbiturate poisoning any sedative or tranquilizer will
accentuate the process of death.
11. Cumulative action of poisons:
 Preparations of cumulative poisons (poisons which are not readily
excreted from the body and are retained in different organs of the body for
a long time) like lead may not cause any toxic effect when enters the body
in low dose.
 But when such poisons remain in the body for a long period of time, may
cause harm when their concentration in different tissue reaches high level
due to their cumulative property.
12. Tolerance
A person accustomed to taking a drug, or who has been exposed to low
doses of a poison over a period of time may be able to tolerate far more than
the usual lethal dose e.g. drug addicts or people on continuous drug therapy
such as epileptics. Amphetamines, barbiturates, benzodiazepines and
morphine and its derivatives all exhibit this phenomenon.

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13. Idiosyncrasy:
 Some persons may react adversely to a particular drug though the general
population tolerates the drug well.
 Because of hypersensitivity a person may succumb to a much smaller
dose of a drug/poison than normal. Penicillin, aspirin, cocaine and heroin
fall into this category.
14. Synergism:
Two compounds may combine to cause a much more lethal effect than the
dose of either one by itself would have been expected to do e.g. barbiturates
taken with alcohol.

LAWS IN RELATION TO POISON AND DRUGS

Indian Statutes on drugs/poisons are as follows:
1. Opium Act, 1857: Earliest enactment related to the licenses for cultivation of
poppy, delivery and time to time renewal of licenses.
2. Opium Act, 1858: Act for regulating the possession, transport, export, import
and sale of opium.
3. Poisons Act, 1904: This Act was mainly for prevention of arsenic import and
export.
4. Poison Act (12 of 1919): to repeal the Poisons Act of 1904 to regulate import,
possession and sale of poisons.
5. The Dangerous Drugs Act (1930): It regulates the manufacture, cultivation,
export, import, possession, sale and use of dangerous drugs (drugs of
abuse), narcotics, hypnotics and stimulants, like Opium, Morphine etc.
6. The Drugs Act (1940): Act to regulate the import, manufacture, sell, stock or
exhibit for sale and distribution of proprietary medicine.

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7. The Drugs and Cosmetics Rules (1945): Framed under the Drugs Act, to
regulate the functions and procedures to be followed by The Central Drugs
Laboratory, Licensing authorities, and to control the quality and strength of
the drugs. Under these rules , the drugs are classified in certain schedules
example:
 Schedule C: Biological and special products
 Schedule E: List of poisons
 Schedule F: Vaccines and sera
 Schedule G: Hormone preparations
 Schedule H: Drugs sold only on registered medical practitioners’
prescription
 Schedule J: List of disease for cure of which no drug should be advertised
 Schedule L: Antibiotics, Antihistaminics and other chemotherapeutics
8. The Pharmacy Act, 1948: To regulate the pharmacist, and rules to constitute
pharmacy councils.
9. The drugs Control Act, 1950: It regulates the control of sale, supply and
distribution of drugs.
10. Drugs and Magic remedies (Objectionable advertisement) Act, 1954: To
prohibit the advertisements of drugs on the name of procuring abortion or
prevention of contraception or to increase sexual efficiency.
11. The Narcotic Drugs and Psychotropic Substance Act, 1985: It was to repeal
a) The Opium Act, 1957 b) The Opium Act, 1978 and c) The Dangerous
Drugs Act, 1930. It was to reinforce or strengthen the then prevailing laws.
12. Prevention of Illicit Traffic of drugs as per Narcotic and Psychotropic
substances Act, 1988: To take measures against the drugs being exported
from outside, from countries of the Golden Triangle (Burma, Laos and
Thailand) and Golden Crescent (Pakistan, Iran and Afghanistan).

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Different sections of Indian Penal Code (Criminal Law) related to poisons
are as follows:
1. Sec. 272 I.P.C: Punishment for adulterating food or drink intended for sale, so
as to make the same noxious, may extend up to 6 months imprisonment of
either term and/or fine up to one thousand rupees.
2. Sec. 273 I.P.C: Punishment for selling noxious food or drink may be
imprisonment of either description for a period of 6 months and or fine up to
one thousand rupees.
3. Sec. 274 I.P.C: Punishment for adulteration of drugs in any form with any
change in its effect knowing that it Will be sold and used as un-adulterated
drug, may be imprisonment of either description for a period-of 6 months and
or fine.
4. Sec. 275 l.P.C: Punishment for knowingly selling adulterated drugs with less
efficacy or altered action serving it for use as unadulterated may be
imprisonment of either description for 6 months and or fine.
5. Sec. 276 I.P.C: Punishment for selling a drug as a different drug or
preparation may be imprisonment of either description which may extend up
to 6 months and or fine.
6. 277 I.P.C: Punishment for fouling water of public spring or reservoir may be
imprisonment of either description which may extend up to a period of 3
months and or fine.
7. Sec. 278 I.P.C: Punishment for voluntarily making atmosphere noxious to
health is fine which may extend up to five hundred rupees.
8. Sec. 284 I.P.C: Punishment for negligent conduct with respect to poisonous
substance may be imprisonment of either description which may extend up to
6 months and or fine which may extend up to one thousand rupees.
9. Sec. 299, 300 I.P.C: Deliberate administration of poison sufficient to cause
death of the victim. Punishment under this situation as under sec 302 I. P. C.
is death or imprisonment for life and shall also be liable to fine.
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10. Sec. 304A I.P.C: Punishment for causing death by negligence is
imprisonment of either description for a term which may extend to two years,
or with fine, or with both.
11. Section 324, 326 and 328 I.P.C: Punishment will be depending on grading of
injury, whether it is hurt or Grievous hurt.
12. Sec. 328 I.P.C: Punishment' for causing hurt by means of poison or any
stupefying, intoxicating or unwholesome drug or any other thing with the
intent to commit an offence shall be imprisonment of either description for a
term which may extend to ten years with or without fine.

IDEAL SUICIDAL POISON

Ideal Suicidal poison should have following properties:
 Easily available.
 No bad taste.
 Should not cause pain.
 Cheap.
 Highly toxic.
 Tasteless or pleasant taste.
 Capable of being taken with food or drink.

IDEAL HOMICIDAL POISON

There are certain characteristics that characterize an “ideal” poison, and the
homicidal poisoner will select their murderous compounds to encompass as
many of these characteristics as possible. What follows are some of the
characteristics of an “ideal” homicidal poison:
 Odorless
 Tasteless
 Colorless
As these allow administration to the intended victim, providing no warning signs
that the victim can detect by the normal bodily senses of smell, taste, and sight.

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 It should be readily soluble, preferably in water, as this allows for easy
administration in normal foods and drinks that the victim may take.
 It should have a delayed onset of action, as this allows for a time period in
which the poisoner can attempt to create an alibi.
 It should be undetectable, and certainly the more exotic the poison the more
likely that it will not be detected in routine toxicological analysis.
 It should have a low dose lethality, which means less of the toxic material
needs to be administered in the dose. It is much easier to administer a pinch
of a substance, rather than a pound.
 It should be easily obtained, but not traceable, so it will leave no investigative
trail that would lead to the poisoner.
 It should be chemically stable, which makes it easy to store without loss of
potency.
 Probably one of the greatest things desired is for the poison to mimic a
natural disease state, as he poisoning will be missed.
The heavy metals (e.g., arsenic, antimony, mercury, lead, etc.) are elements or
elemental compounds, and are as toxic today as they were when they first
created millions of years ago. This also can be advantage for law enforcement
investigator, as these compounds tend to remain detectable many years after
burial of the victim.

MANAGEMENT OF A CASE OF POISONING

Five steps constitute the fundamentals of poisoning management. They are,
1. Supportive care.
2. Prevention of further poison absorption.
3. Enhancement of poison elimination.
4. Administration of antidotes.
5. Prevention of re-exposure.

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1. SUPPORTIVE CARE
 The goal of Supportive therapy is to maintain physiologic homeostasis
until detoxification is accomplished and to prevent and treat secondary
complications.
 It includes the following:
 Airway protection
 Treatment of arrhythmia
 Oxygenation / Ventilation·
 Hemodynamic support
 Correction of metabolic derangements
 Prevention of secondary complications such as aspiration, pulmonary
edema, renal failure, sepsis, hypoxia and shock.
2. PREVENTION OF FURTHER POISON ABSORPTION
(DECONTAMINATION)
A. Inhaled Poisons:
 Removing the patient from the source of the poison.
 Giving oxygen by mask (CO poisoning).
 Inhalation of water aerosol for diluting inhaled irritant in the
nasopharynx.
B. Contaminated Eyes:
 Irrigating the eyes with the copious amounts of plain water for at least
15 to 20 minutes.
C. Contaminated skin:
 Washing the skin with plenty of cold water and then washing with non
germicidal dilute soap solution.
 Discarding all contaminated clothes.
 Phenolic burns should be treated by application of polyethylene.
D. Injected Poisons:
 Application of tourniquets, proximal to the point of injection may slow
absorption.

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 E. Ingested Poisons:
EMESIS:
 The only recommended method of inducing a poisoned patient to vomit
is administration of syrup of Ipecacuanha (or ipecac).
 Source-Root of a small shrub (Cephaelis ipecacuanha or C.
acuminate).
 It contains active principles namely cephaeline and emetine
 It should be given to a conscious and alert poisoned patient who has
ingested a poison not more than 2 to 3 hours earlier.
 It acts by local activation of peripheral sensory receptors in the
gastrointestinal tract and by central stimulation of the chemoreceptor
trigger zone with subsequent activation of the central vomiting centre.
 Dose is 15ml orally for children and 30ml for adults followed by 2-3
glasses of plain water. This induces the vomiting within 20-30 min and
can be repeated after 30 min.
 The vomitus should be inspected for remnants of pills or toxic
substances, its appearance and odor should be noted.
 Apomorphine is a parenteral emetic, and can be used with caution
because of its CNS and cardiac side effects.
 Household emesis techniques includes stimulating the pharynx by
introducing finger, ground mustard etc.
 Contraindications to the induction of emesis are Caustic (alkali) or
corrosive (acid) ingestion; in infants less than 6 months of age; and
ingestion of foreign bodies.

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 GASTRIC LAVAGE (STOMACH WASH):
 Lavage should be considered only if a patient has ingested a life-
threatening amount of a poison and presents to the hospital within 1 to
2 hours of ingestion.
 Indications:
 Gastric lavage is recommended mainly for patients who have
ingested unabsorbed poison, who present within 1 to 2 hours of
ingestion. Lavage beyond this period may be appropriate only in
delayed gastric emptying, or sustained release preparations. Some
authorities still recommend lavage up to 6 to 12 hours post-
ingestion in the case of salicylates, tricyclic antidepressants,
carbamazepine, and barbiturates.
 In case of parenteral poisons such as morphine, in which the
poison gets re-secreted into the stomach through entero-heaptic
circulation.
 Contraindications:
 Absolute Contraindications: Absolute contraindications are those
wherein gastric lavage should not be undertaken under any
circumstances. E.g., Ingestion of mineral or organic acid (Sulphuric
Acid, Hydrochloric Acid, Nitric Acid)
 Relative Contraindications: Relative contraindications are those
wherein gastric lavage can only be undertaken under protection of
airways i.e. by using cuffed endotracheal tube. E.g.,Haemorrhagic
diathesis, oesophageal varices, coma, convulsant or petroleum
distillate ingestion.

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  Gastric Lavage Tube:

Funnel (to pour

Length: 1.5 m
the gastric lavage
Diameter of the Bore: 0.5 inch
fluid)

Mouth Gag (to prevent

biting of the tube and
causing obstruction)

Siphon or
Two openings
Suction Bulb (to
aat the tip (to
suction out the
aavoid blockage)
stomach contents)

GASTRIC LAVAGE TUBE

 Procedure
 Explain the exact procedure to the patient and obtain his consent. If
refused, it is better not to undertake lavage because it will amount
to an assault, besides increasing the risk of complications due to
active non-cooperation.
 Endotracheal intubation (cuffed) must be done prior to lavage in
case of relative contraindication for the procedure.
 Place the patient head down on his left lateral side. The greater
curvature of the stomach being on the left side, the poison and the
water introduced in to the stomach can be completely evacuated
because of the formation of pouch.
 Mark the length of tube to be inserted (50 cm for an adult, 25 cm for
a child).

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  The ideal tube for lavage is the lavacuator (clear plastic or gastric
hose).
 In India, however, the Ewald tube is most often used, which is a
soft red rubber tube with a funnel at one end. Whatever tube is
used, make sure that the inner diameter corresponds to at least 36
to 40 French size. In a child, the diameter should be at least 22 to
28 French (RyIe's tube may be sufficient).
 The preferred route of insertion is oral.
 Lubricate the inserting end of the tube with vaseline or glycerine,
and pass it to the desired extent. Use a mouth gag so that the
patient will not bite on the tube.
 Once the tube has been inserted, its position should be checked
either by air insufflations while auscultation over the stomach, or by
aspiration.
 Lavage is carried out using small quantities of liquid. In an adult,
200 to 300 ml of warm (38°C) saline or plain water is used. In a
child, 10 to 15 ml/kg body weight of warm saline is used each time.
Water should preferably be avoided in young children because of
the risk of inducing hyponatraemia and water intoxication. It is ad-
visable to hold back the first wash for chemical analysis.
 In certain specific types of poisoning, special lavage solutions may
be used in place of water or saline. It includes:
a. Potassium permanganate (1:5000) for oxidizable poisons such
as alkaloids, salicylates etc.).
b. Sodium thiosulphate (25%) for cyanides.
c. Castor oil and warm water (1:2) for carbolic acid.
d. Calcium gluconate for oxalates.
 Lavage should be continued until no further particulate matter is
seen, and the efferent lavage solution is clear. At the end of lavage,
pour slurry of activated charcoal in water (1 g/ kg).
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  Complications:
 Aspiration pneumonia.
 Laryngospasm.
 Perforation of stomach or oesophagus.

ACTIVATED CHARCOAL:
 It is a fine odorless powder.
 It is produced in a two step process:
 Burning or pyrolysis of carbonaceous material such as wood pulp,
coconut shells etc.
 Followed by treatment at high temperature with an activating
(oxidizing) agent such as steam or carbon dioxide to increase its
absorptive capacity by forming internal pores with a huge surface
area.
 It irreversibly binds the drugs within the bowel and reduces the blood
concentration by reducing drug absorption and by creating a negative
diffusion gradient between the gut lumen and blood (gastrointestinal
dialysis).
 It decreases the systemic absorption of a number of drugs like aspirin,
acetaminophen, barbiturates, phenytoin etc.
 It is administered as slurry in water.
 The dose of activated charcoal is 1gm/Kg orally or by gastric lavage
tube, followed by 15-20 gms every 4 to 6 hours.

CATHARSIS:
 Cathartic salts (disodium phosphate, magnesium citrate and sulphate,
sodium sulphate) or saccharide (mannitol, sorbital), promote the rectal
evacuation of gastrointestinal contents.
 The dose of sorbitol is 1-2 gm/kg.
 Their aim is to prevent constipation following charcoal administration.

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 WHOLE BOWEL IRRIGATION:
 It is performed by administering a bowel cleansing solution containing
electrolytes and polyethylene glycol orally or by gastric tube until rectal
effluent is clear.
 It is useful in patients who have ingested foreign bodies, packets of
illicit drugs, slow releasing or enteric coated medicines or heavy
metals.
ENDOSCOPIC or SURGICAL REMOVAL OF POISONS:
 It is useful in rare cases wherein ingestion of a potentially toxic foreign
body that fails to transit the gastro-intestinal tract (heavy metals,
sustained release preparations).
3. ENHANCEMENT OF POISON ELIMINATION
 The decision to use measures to enhance drug elimination should be
based on a rational understanding of drug properties and the clinical
condition of the patient.
 The various methods are:
A. Forced Alkaline Diuresis.
B. Extracorporeal Techniques.
 Hemodialysis
 Hemoperfusion.
 Peritoneal dialysis.
 Hemofiltration.
 Plasmapheresis.
FORCED ALKALINE DIURESIS:

 This is most useful in the case of barbiturates, lithium, and salicylates.

 This is achieved by administering combination of 5% dextrose and 1.4%
sodium bicarbonate. Lasix or 5% mannitol may be added. Serum
electrolytes to be monitored periodically.

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 EXTRA CORPOREAL REMOVAL OF TOXINS:
 Haemodialysis:
 During hemodialysis, toxin is removed from the blood into a dialysate
solution across a semi-permeable membrane.
 Haemodialysis may be considered in those patients not responding to
standard therapeutic measures while treating a dialyzable toxicant.
 The toxin must be relatively water soluble and not highly protein
bound.
 It is effective in removing methanol, ethylene glycol, salicylates and
lithium.
 Peritoneal Dialysis:
 In general, it is only 10 to 25% as effective as haemodialysis, and often
only slightly more effective than forced diuresis.
 It is also time consuming, requiring 24 hours for successful completion
as compared to the 2 to 4 hour cycles of haemodialysis and
haemoperfusion.
 Hemoperfusion:
 In hemoperfusion, blood is pumped through a column of adsorbent
material (charcoal or resin) and returned to the patient’s circulation.
 Vascular access similar to that for hemodialysis is required.
4. ADMINISTRATION OF ANTIDOTES
 Antidotes are therapeutic agents intended to modify or counteract with the
clinical effects of particular toxic substances in the human body.
 Universal Antidote is a combination of physical and chemical antidotes.
When the exact nature of poison is not known then universal antidote is
used which acts against a wide range of poisons. Constituents are
Activated charcoal 2 parts; Magnesium oxide 1 part; Tannic acid 1 part. In
this activated charcoal acts as a physical antidote, magnesium oxide acts
as chemical antidote and tannic acid precipitates poison.

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  Antidotes are classified based on their mechanism of action into following:
A. Physical Antidote.
B. Chemical Antidote.
C. Physiological Antidote.
D. Antagonistic Antidote.
E. Competitive Antagonistic Antidote.
F. Receptor Antagonistic Antidote.
G. Antigen Antibody Reaction Antidote.

PHYSICAL ANTIDOTE:
 Physical or mechanical antidote prevents the action of poison
mechanically, without destroying or inactivating the damaging actions of
the poisons.
 E.g., adsorbents like activated charcoal, demulcents like egg albumin,
starch or milk, diluents like water or milk, bulky food like boiled rice or
vegetables.
CHEMICAL ANTIDOTE:
 It consists of neutralizing agents and chelating agents.
 Neutralizing agents are substances which disintegrate and inactivate
poisons by undergoing chemical reaction with them. Eg: Weak acids and
alkali, KMNO4.
 Chelating agents are the substances which act on absorbed metallic
poisons. They have greater affinity for metals as compared to endogenous
enzymes. The complex of agent and metal is more water soluble than
metal itself, resulting in higher renal excretion of the complex. E.g., British
anti-lewisite (B.A.L., Dimercaprol), E.D.T.A. (ethylene diamine tetra acetic
acid), Penicillamine (Cuprimine), Desferroxamine etc.
 B.A.L. (British Anti-Lewisite, 2-3 dimercaptopropanol) has 2
unsaturated sulphydryl (SH) radicals which combines with metal in

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 circulation, thus tissue enzymes are spared. Useful in cases of
Arsenic, mercury, copper, bismuth, gold etc. Given as deep intra-
muscular injection.
 E.D.T.A. (Ethylene diamine tetra-acetic acid) it combines with sodium
to form sodium salt and then with calcium to form disodium calcium
edetate which combines with free metal and inactivates it biologically.
It is best chelate for lead. Given as slow I.V. injection.
 Penicillamine: It has stable SH radical which combines with free metal.
It is a chelate for arsenic, mercury and copper. It can be given orally as
tablets.
 Desferrioxamine: It is specific antidote for iron. Given as I.V. injection.

PHYSIOLOGICAL ANTIDOTE:
 Physiological antidotes have their own action producing signs and
symptoms opposite to that produced by the poison.
 E.g., Naloxone for morphine, Neostigmine for datura, Barbiturate for
strychnine.

ANTAGONISTIC ANTIDOTE:
 It acts by antagonizing the action of poison.
 E.g., Diazepam acts as an anticonvulsant for convulsions due to any
cause.

COMPETITIVE ANTAGONISTIC ANTIDOTE:

 It competes with the poison for the enzyme.
 E.g., Ethanol competes with methanol for the enzyme alcohol
dehydrogenase.

RECEPTOR ANTAGONISTIC ANTIDOTE:

E.g., Atropine is antagonist for acetyl choline at muscuranic receptor.
ANTIGEN ANTIBODY REACTION ANTIDOTE:
E.g., Digoxin specific antibodies.

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5. PREVENTION OF RE-EXPOSURE
 Victims of accidental exposures should be instructed regarding safety
measures and advised to avoid circumstances that result in poisoning.
Poisons should be kept in places inaccessible to children.
 Depressed or psychotic patients should receive psychiatric assessment
and regular follow-ups.
 Prescriptions should be given for a limited supply of drugs.

MEDICO-LEGAL DUTIES OF A DOCTOR IN SUSPECTED POISONING

The duties of a doctor in a suspected case of poisoning can be dealt with under
the following headings:
1. TREATMENT
 Whatever the nature of case, every hospital (Government run or privately
owned) is under a legal obligation to treat to best possible extent and no
case can be turned away on the pretext that the hospital concerned is not
authorized to handle medico legal case.
 If adequate facilities don't exist for proper treatment, the victim should be
administered first - aid and such other medical or surgical help that is
possible under the circumstances before referring him to the nearest
hospital where required facilities exist.
 The treatment given must be the one that has been approved by at least
one school of thought.
 Over the telephone consultation and the treatment must be avoided.
2. INTIMATION
 As soon as a case of poisoning is brought to the hospital, the doctor is
duty bound to inform this to the police.
 However discretion may be used in the following situations:
 If working in a government hospital, a doctor is bound to inform the
legal authorities of all the cases of poisoning regardless of their
manner, either suicidal/accidental/homicidal.

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  A private medical practitioner, on the other hand, is not legally bound
to inform the legal authorities of all the cases of poisoning. He only has
a legal obligation to inform in homicidal cases of poisoning as per
Section 39 Cr.P.C. He is not bound to inform the legal authorities if he
is sure the case is suicidal/ accidental in nature. However, as doctor is
not an investigating officer and can never be sure about the manner of
poisoning, to be on the safer side, he should always inform the legal
authorities about any case of poisoning.
 If an investigating officer inquires about a case of poisoning, regardless of
its nature, the medical practitioner is expected to report all details to him
(without taking excuse of professional secrecy) failing which he can be
penalized under Sections 193 IPC (punishment is imprisonment of either
description up to 7 years with fine) and 202 IPC (punishment is
imprisonment of either description up to 6 months or fine or both).
 If the doctor provides false information, then he is liable to be punished
under Section 177 IPC (punishment is of simple imprisonment for 6
months or fine of Rs. 1000 or both).
 Failure to inform the police in a case of homicidal poisoning makes the
doctor liable for prosecution under Section 176 IPC.
 In case a doctor comes across a case of poisoning arising out of a public
eating place or where further exposure to other people is anticipated, as
his duty towards the State, he must inform the authorities concerned.
3. DOCUMENTATION
 It is a good practice to document the findings in the case register.
 To be a good doctor one has to have a good knowledge on the subject but
to be a good witness one must have the document. One never knows
when the case comes up in the court of law.
 This document must contain all the important findings that have a bearing
on the case, like history, manifestations, treatment, progress, any
untoward outcome etc.
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4. PRESERVATION
 All the evidentiary materials must be preserved for analysis. These include
the first wash from the gastric lavage, blood, urine any vomitus stain,
faecal stain, salivary stain etc.
 Failure to do so attracts penalization under Section 201 IPC (punishment
is imprisonment of either description up to 7 years depending upon the
nature of offence tried to shield). In this case, the onus of proving a non-
deliberate omission to collect and preserve the samples would lie on the
medical practitioner.
5. CONSULTATION
 In case of doubt, it is always a good practice to have the consultation from
the senior or the experienced doctor regarding the management.
6. DYING DECLARATION
 In spite of all the honest effort put forth by the doctor, the victim may die.
 If the treating doctor anticipates such an eventuality or if the death is
imminent but still the victim is conscious and is able to talk, it is preferable
to call the local magistrate to record the dying declaration. If the time does
not permit, the treating doctor himself may take the dying declaration.
7. DEATH INTIMATION
 If the victim dies, it is mandatory to inform the police regarding the death
of the victim regardless of the fact that whether he was under the care of a
private practitioner or the government doctor.
 In circumstance of death in a case of poisoning (irrespective of whether
the police was informed of the case or not due to any reason), death
certificate should not be issued and the body should be handed over to
the legal authorities for a medico-legal postmortem examination.

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VISCERA & BODY FLUID PRESERVATION IN SUSPECTED CASE OF
POISONING
Collection of proper autopsy specimen is an essential step in the process of
toxicology casework. Improper collection of these specimens can greatly alter or
negate chemical and toxicological analysis.
PRINCIPLE
Ingested poison

Poison reaches stomach

Absorbed into the blood through the proximal part of small intestine

Liver metabolizes and detoxifies the poison

Excreted through kidney into the urine

VISCERA & BODY FLUIDS ROUTINELY PRESERVED

Routinely following viscera and body fluids are preserved in suspected
poisoning:
1. Stomach and its contents
2. Proximal 30 cm of the small intestine and its contents
3. 500 grams of liver with gall bladder
4. Half of each kidney (both kidneys to exclude the possibility of one kidney
being non functional)
5. Blood (10-20 ml.)
VISCERA & BODY FLUIDS PRESERVED IN ADDITION TO ROUTINE
VISCERA IN SPECIAL CASES
1. Narcotic drugs/ cyanide/ strychnine: Brain
2. Alcohol: C.S.F / Vitreous Humor
3. Cardiac poisons (nicotine, oleander, digitalis, chloroform) : Heart
4. Heavy metals (Arsenic, lead, antimony, copper, mercury): long bone, 500
micrograms (20 to 30 hairs) of plucked hair, finger or toe nail

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5. Snake bite or injection sites: 2.5 x 2 cm 2 skin with subcutaneous tissue and
underneath muscles from affected site, and similarly from the opposite side
as control
6. Pesticides/ anesthetic agents: fatty tissue from abdominal wall.

PRESERVATIVES TO BE USED FOR VISCERA AND BODY FLUIDS

A. For Viscera
 Rectified spirit is the preservative of choice.
 Common salt being less costly, easily available and having lesser chances
of wastage and misuse as compared to rectified spirit, is widely used for
the viscera for chemical analysis.

B. For Blood
 The most satisfactory way of obtaining a venous blood sample is
venepuncture of the femoral vein by direct puncture in the groin before the
autopsy begins.
 Potassium oxalate (anticoagulant) & Sodium fluoride (enzyme inhibitor)
[sodium fluoride of 10mg/ml and potassium oxalate, 30 mg/10 ml].
 Sodium fluoride protects blood from postmortem changes such as
bacterial production of ethanol or other alcohols. It also helps to protect
other labile drugs such as cocaine, nitrazepam and clonazepam from
degradation.
C. For Urine
Rectified spirit or thymol crystals or sodium fluoride (10 mg/ml).

CONTRAINDICATIONS FOR USING CERTAIN PRESERVATIVES

 Saturated sodium chloride solution is contraindicated in aconite poisoning,
heavy metal poisoning, vegetable poison and corrosive acids.
 Rectified spirit is contraindicated in alcohol, acetic acid, carbolic acid,
kerosene, paraldehyde and phosphorous (luminescence property lost with
rectified spirit) poisoning.

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PACKING
1. 1st bottle (2 litres; glass bottle; wide mouthed)
Stomach with its contents + Proximal 30 cms of small intestine with its
contents preserved in saturated solution of common salt.
2. 2nd bottle (2 litres; glass bottle; wide mouthed)
500 grams of liver with gall bladder + Half of each kidney preserved in
saturated solution of common salt.
3. 3rd bottle (100ml; glass bottle)
10-20 ml of blood preserved in sodium fluoride of 10mg/ml and potassium
oxalate, 30 mg/10 ml of blood concentration.
4. 4th bottle (100ml; glass bottle)
50 ml of saturated solution of common salt to exclude the presence of poison
if any, in the preservative used itself.

PACKING TIPS
 Stomach and intestines are opened before packing.
 Kidney and liver should be cut into pieces to ensure better penetration of
preservative.
 Preservative should be filled up to 2/3rd of the bottle so as to prevent bursting
of the bottle, in case of any decomposition.
 Stoppers of the bottles should be well fitting.

FORWARDING SAMPLES
 All samples should be properly sealed and labelled with the deceased’s
name, postmortem number, nature of sample, collection site, preservative
used, date and time of collection.
 Particular attention should be paid to the packaging of samples to avoid loss
during transport, and to comply with health and safety regulations. It should
be protected by the use of tamper-evident seals around the lids, and
accompanied by an intact chain of custody record.

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 It should be handed over to the investigating officer be delivered to Forensic
Science Laboratory / Regional Forensic Science Laboratory for chemical
analysis after obtaining proper receipt.
LETHAL DOSE 50 (LD 50)
 LD stands for "Lethal Dose". LD50 is the amount of a material, given all at
once, which causes the death of 50% (one half) of a group of test animals.
The LD50 is one way to measure the short-term poisoning potential (acute
toxicity) of a material.
 In 1927, J.W. Trevan attempted to find a way to estimate the relative
poisoning potency of drugs and medicines used at that time. He developed
the LD50 test because the use of death as a "target" allows for comparisons
between chemicals that poison the body in very different ways.
 Toxicologists can use many kinds of animals but most often testing is done
with rats and mice. It is usually expressed as the amount of chemical
administered (e.g., milligrams) per 100 grams (for smaller animals) or per
kilogram (for bigger test subjects) of the body weight of the test animal. The
LD50 can be found for any route of entry or administration but dermal (applied
to the skin) and oral (given by mouth) administration methods are the most
common.
 The most common units are milligrams of chemical per kilogram of test
animal (mg/kg).
 For example oral LD50 in Rats
 Aldicarb (carbamate) ………………. 1mg/kg.
 DDT (chlorinated hydrocarbon) ……. 307mg/kg.
 Malathion (organophosphate)……….. 885mg/kg.
 Parathion (organophosphate)……….. 3mg/kg.
 Pyrethrins (plant extract) …………….. 200mg/kg.

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POISON INFORMATION CENTER (PIC) / POISON CONTROL CENTER (PCC)
 A Poison Control Center (PCC) or Poison Information Center (PIC) is a
medical facility that is able to provide immediate, free, and expert treatment
advice and assistance over the telephone in case of exposure to poisonous or
hazardous substances. Poison Control Centers answer questions about
potential poisons in addition to providing treatment management advice about
household products, medicines, pesticides, plants, bites and stings, food
poisoning, and fumes.
 The poisons information centre was first installed on a national scale in
Netherlands in 1949. Now most of the nations have established centres on
similar lines.
 In most countries around the world poison control centers can be reached toll-
free, 24 hours a day, 7 days a week, 365 days a year.
 WHO recognized Poison Information Centers in India are at,
 National Institute of Occupational Health, Ahmedabad.
 Amrita Institute of Medical Sciences & Research, Cochin.
 Government General Hospital, Chennai.
 All India Institute of Medical Sciences, New Delhi.
 The functions of these central units are two fold:
1. To collect and make available information on the constituents of
household, agriculture and industrial chemicals as well as drugs.
2. To advise by telephone on the management of an individual poisoning
case. In addition, many units have the facility for the estimation of
plasma and urine concentrations of a wide range of poisons and to
conduct screening tests.

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 IDENTIFICATION
DEFINITION
Identification means the establishment of the individuality of a person.
TYPES OF IDENTIFICATION
The identification is of two types
1. Complete Identification
2. Incomplete Identification
1. Complete Identification: Also known as ‘total’ identification, where the person is
known by the name with complete address.

2. Incomplete Identification: Also known as ‘partial’ identification, where only other

details like age, sex, race, religion etc. can be established.

MEDICO-LEGAL SIGNIFICANCE OF IDENTIFICATION

 The question of identity arises both in the living and in the dead.
 In the living the question of identity arises in Civil and criminal cases.
1. Civil Cases:
Civil cases like marriage, divorce, inheritance, paternity disputes, business
contracts etc need identification.

2. Criminal Cases:
Criminal cases like assault, murder, sexual offences etc. usually turn baseless in
the absence of proper identification.

 In the dead the question of identity arises, when unknown bodies are recovered
from the forests, wells, roadside, areas of mass disaster like earthquake, train
accidents etc.,

PARAMETERS OF IDENTITY

The parameters of identity may be classified as primary, secondary and

comparative.

1. Primary Characteristics: This includes age, sex, race and stature.

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2. Secondary Characteristics: Personal effects (pocket contents, clothes,
jewellery etc.), hairs, scars, tattoos, Race, Religion, Nationality, any deformities
due to any natural diseases.

3. Comparative Data: Fingerprints, footprints or handprints, superimposition

techniques, and anthropometry.

CORPUS DELECTI
 The term Corpus Delecti, literally means “The body of Offense” Or “Body of the
Crime” or “The Essence of Crime” or “The Essential Element of the Crime”.
 In a homicide “Corpus Delecti” includes,
1. It must be established that a certain person is dead.
2. That death was the result of criminal act.
3. It occurred under certain circumstances and at a certain places.
 Following people can contribute in establishing the Corpus Delecti
 Medical Officer who conducts the autopsy.
 Relative or friend who identifies the body.
 Police who investigates.
 Corpus Delecti includes not only the dead body of the victim but any other
evidence which helps to prove death by foul play. E.g., Clothing worn by the
deceased; Bullets; Drawings and photographs depicting injuries.
 Following points are considered in proving the Corpus Delecti in Homicidal
Poisoning
1. Proof that the accused had access to the poison responsible for death
2. Proof that accused had access to the victim.
3. Proof that death was caused by poison.
4. Proof that death was homicidal.

MEDICO-LEGAL SIGNIFICANCE OF CORPUS DELECTI

1. According to the Honorable Supreme Court a conviction for an offence does not
necessarily depend upon the “Corpus Delecti” being proved. Because sometimes
the recovery of the dead body, from the very nature becomes impossible.
2. Existence of dead body is no doubt a proof of death but its absence is not fatal to
the trial of the accused for the homicide.

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3. There are instances in history, where a trial continued even in the absence of
recovery of the dead body. E.g., Ruxton case, Crippen case; Sydney Shark case,
Parkman murder case, and acid bath murder case.

RACE
The identification of a by person’s race becomes important in mass disasters like air
crash, train accidents, shipwrecks etc., where there is a likelihood of people of
different races would be traveling together.
CLASSIFICATION OF RACE
 The world population is divided into three races based on their ancestry:
A. Caucasians (These include Europeans, Arabs, Jews and Indo-Aryan
people).
B. Mongolians (These include Chinese, Japanese, Burmese, Thais, and
Malays).
C. Negro’s (African Population).
 Krogman sub-classified Caucasians into Nordic, Alpic and Meditteraneous.
RACIAL IDENTIFICATION PARAMETERS
1. Hair:
 Caucasian: Light brown, straight and wavy.
 Mongolian: Coarse, straight or wavy, and black or brown.
 Negro: Thick, wooly, curly and self spiraled.
2. Complexion:
 Caucasian: Fair.
 Mongolian: Yellowish.
 Negro: Black.
3. Forehead:
 Caucasian: Raised.
 Mongolian: Inclined backwards.
 Negro: Small and compressed.
4. Teeth:
 “Shovel” shaped central incisors and depressed groove on their posterior
surface is characteristic of Mongoloids.
 “Bull tooth” (here the pulp cavity of molars is wide and deep; and its root are
fused and bent) in Mongoloids.
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  A congenital absence of the 3rd upper molar is most common in mongoloids.
 Negro race will have a preponderance of mandibular 1st premolar containing
lingual cusps.
5. Cephalic Index:
 The formula used for the ‘cephalic index’ is as follows:
Maximum breadth of the skull
Cephalic index = --------------------------------------- X 100
Maximum length of the skull
 It is always measured by a caliper.
 Maximum breadth of the skull is the distance between parietal eminences.
 Maximum length of the skull is the distance between the glabella and
external occipital protuberance.
 Based on the figure thus obtained the human race is divided in to three races as
follows:
 Negroid: 70 to 74.9 (Dolicocephalic).
 Caucasoid: 75 to 79.9 (Mesaticephalic).
 Mongoloid more than 80 (Brachycephalic).
SEX
The identification of sex of an individual is also a very important medicolegal point.
MEDICO-LEGAL IMPORTANCE OF SEX DETERMINATION
1. The determination of sex has importance in relation to rights and duties reserved
to one sex alone.
2. It may also be relevant to causes, which are concerned with legitimacy,
inheritance, divorce, and nullity of marriage etc.
3. In cases of sports meets.
PARAMETERS OF SEX DETERMINATION
 Data in the living, from which sex can be determined are as follows:
 Presumptive evidence of sex, by clothes, hair, gait, habits and voice.
 Probable evidence of sex by the evidence of secondary sexual
characters like breast development, general built waist, gluteal regions,
thighs, limbs.

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  Sure determining evidence such as signs of sex by gonadal biopsy,
demonstration of sex chromatin or Barr body (Nuclear sexing), which can
be seen in cells of skin, buccal mucosa, and in polymorphonuclear cells.
 Determination of sex is not always simple from the skeletal remains.

NUCLEAR SEXING
BARR BODIES
 Barr bodies were discovered by Barr and Bertram.
 They noticed a nodule in the nuclei of some cells of the female cat.
 Later investigations revealed that this nodule was normally found in a percentage
of all normal women’s cells.
 Presence of nodule in the person is termed as “Chromatin Positive”.
Microscopically, this is seen as a condensed material towards the nuclear
membrane in the nucleus of the cell. This is called as “Sex Chromatin” or “Barr
Body”.
 It is presumed that this is due to the inactivation of an X chromosome.
 It can be demonstrated in buccal mucosal cells, skin, cartilage, nerve cells,
amniotic fluid, polymorphs and lymphocytes.
 In a buccal smear from the normal female, the sex chromatin is demonstrated as
a plano-convex basophilic, intra nuclear structure usually located near the
nuclear membrane.
 To diagnose as a female, buccal smear must show at least 20% to 30% Barr
bodies as against 0 to 4% Barr bodies often detected in normal males.
 This can be demonstrated by:
 By staining with fluroscent dye and viewing with ultraviolet light. This may
be performed on neurons in a brain smear or in cells from kidney.
 By Quinacrine staining and fluroscent in situ hybridization.
DAVIDSON BODIES
 Discovered by Davidson and Smith.
 Davidson described these neutrophilic drumsticks as a dense chromatin head,
attached to the nucleus by a thread like connecting neck.
 They are pathognomic of females.

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 They are solitary nuclear appendages of drumstick form in neutrophil of females
where its incidence was about 6 in each of 227 neutrophils examined, but none
was found in 500 neutrophils.
 To diagnose sex by this, the peripheral smear must show minimum of 6% counts.
 Leishman or Hemotoxylin Eosin stain can be used.

INTER SEX
 Chromosomal sex, established at the moment of fertilization goes to form the
gonadal sex, which in turn causes the development of phenotypic sex.
 If any anomaly occurs any where in this development, it results in mistakes in sex
identification.
 Since the development of sex organs in both sexes is closely similar there can be
disturbance in the development of external genitalia.
DEFINITION
Intersexuality is a set of medical conditions that features congenital anomaly of the
reproductive and sexual system. That is, a person with Intersex condition is born with
sex chromosomes, external genitalia, or an internal reproductive system that is not
considered “standard” for either male or female.

CLASSIFICATION OF INTERSEX
Davidson divides the congenital intersex states into four groups.
1. Gonadal Agenesis:

2. Gonadal Dysgenesis: This includes:

A. Klinefelter Syndrome (Male Hypogonadism).

B. Turners Syndrome (Female Hypogonadism).

3. True Hermaphroditism.

4. Pseudo Hermaphroditism: This includes:

A. Female Pseudo-hermaphroditism.

B. Male Pseudo-hermaphroditism.

GONADAL DYSGENESIS

 In this condition the sexual organs (testes or ovaries) have never developed.

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 The individuals will have either male or female external genitalia with absence of
testes or ovary.

 The nuclear sex in these cases is negative.

 The secondary sexual characters fail to develop at puberty.

KLINEFELTER SYNDROME (MALE HYPOGONADISM)

 This occurs when there are two or more X chromosomes and one or more Y
chromosomes.
 This is the most common cause of hypogonadism in males.
 The classical pattern is associated with 47 XXY karyotype.
 Characteristic features include:
 Eunuchoid body with abnormally long legs.
 Small atrophied testes.
 Small penis.
 Lack of male secondary sexual characteristics such as deep voice, beard,
pubic hair).
 Gynaecomastia.
 It is a principal cause of male infertility.

TURNERS SYNDROME (FEMALE HYPOGONADISM)

 Results from partial or complete monosomy of the X chromosomes.
 Characterized primarily by hypogonadism in phenotypic females.
 Nuclear sexing indicates that she is chromatin negative, like a male.
 It is the most common sex chromosome abnormality in females.
 Characteristic features include:
 Short stature.
 Low posterior hairline.
 Webbing of neck.
 Widely spaced nipple.
 Cubitus valgus.
 Coarctation of aorta.

TRUE HERMAPHRODITISM

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 True Hermaphroditism indicates the presence of both ovaries and testicular
tissues.
 In some cases, there is a testis on one side and an ovary on the other.
 In some cases, there may be combined ovarian and testicular tissue on same
side. This is known as “Ovotestes”.
 Karyotype is 46 XX in 50% of cases; and 46 XY in 25% of cases.

PSEUDO-HERMAPHRODITISM
 A pseudo-hermaphroditism represents a disagreement between the
phenotypic and gonadal sex.
 A Male Pseudo-hermaphrodite has testicular tissue but female type
genitalia. Karyptype is 46 XY.
 A Female Pseudo-hermaphrodite has ovaries but male external genitalia.
Karyptype is 46XY.
 The basis of this disorder is excessive and inappropriate exposure to
androgenic steroids during early fetal life.

INTERSEX ANATOMICAL SEX NUCLEAR SEX

1. Gonadal Agenesis - -
2. Klinefelter’s Syndrome Male Female
3. Turner’s Syndrome Female -
4. True Hermaphroditism Bisexual Female
5. Male Pseudo-hermaphroditism Female Male
6. Female Pseudo-hermaphroditism Male Female

MEDICO-LEGAL SIGNIFICANCE OF INTERSEX

1. Gender Determination:
Identification of sex is an important tool of identification. It is needed in sport
events, joining school or college, applying for job,. It is also important in cases of
heirship, marriage, divorce, legitimacy, rape etc.
2. Birth Registration:
 Gender is an important criterion to be incorporated in registration of birth.
 In Intersex condition parents can avail more time for registration, so as to fix a
gender to their newborn after proper investigations.
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3. Rearing of sex:
Parents can opt for child rearing surgeries in Intersex condition.
4. Supernumery Y chromosome (XYY Syndrome):
The extra Y chromosome has a bearing on the behavior. Several studies
indicate that these individuals are susceptible for begetting antisocial behavior.
5. Supernumery X chromosomes (Multi X Female):
These ladies may develop mental retardation and menstrual irregularities.

DETERMINATION OF SEX WITH THE EXAMINATION OF SKELETON

 This is an examination of skeleton and it is mostly based on the appearances of
pelvis, sternum and skull.
 According to Krogman,
 Entire skeleton is available, sex can be determined in with 100%
certainty,
 Pelvis alone, sex can be determined in with 95% certainty.
 Skull alone, sex can be determined in with 90% certainty.
 Skull and pelvis, sex can be determined in with 98% certainty.
 Long bones it can be done with 80% certainty.
SKULL
IMPORTANT FEATURES MALE FEMALE

General
Larger, heavier, more Smaller, lighter, less
1. Appearance marked muscular marked muscular
markings markings
Features viewed from front
2. Supra-oribital ridge Prominent Less prominent
3. Glabella Prominent Less prominent
4. Shape of orbit Squarish Rounded
5. Superior orbital margin Rounded margins Sharp margins
6. Location of orbit Set lower on face Set higher on face
Features viewed from side
7. Forehead Steeper, less rounded Vertical, rounded
8. Fronto-nasal angulation Distinct angulation Not well marked
Small, smooth,
9. Mastoid process Large, round, blunt
pointed
Features viewed from above
10. Frontal eminence Less prominent More prominent
11. Parietal eminence Less prominent More prominent
12. Zygomatic arch More prominent Less prominent or
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 compressed
Features viewed from back
External occipital More prominent Less prominent
13.
protuberance
Features viewed from below
14. Occipital condyles Large Small
15. Digastric groove Deep Shallow
16. Palate Larger, U-shaped Smaller, Parabolic

MANDIBLE
IMPORTANT FEATURES MALE FEMALE

1. General appearance Larger, thicker Smaller, thinner

2. Chin (symphysis menti) Square or U-shaped Pointed or V-shaped
3. Body height At symphysis greater At symphysis smaller
4. Angle of body and ramus Less obtuse (<125) More obtuse (>125)
5. Angle region Everted Not everted
6. Condyles Larger Smaller

FEMUR

IMPORTANT FEATURES MALE FEMALE

Heavier, stronger and Lighter, less
1. General appearance prominent muscular prominent muscular
markings markings
Larger and articular Smaller and articular
2. Head surface is more than surface is less than
2/3rd of a sphere 2/3rd of a sphere
Vertical diameter of the
3. Larger (> 48mm) Smaller (<44mm)
femoral head
Neck – shaft angle Less obtuse, almost
4. Obtuse, 125
(Between Neck & shaft) right angle
5. Bicondylar width More (74-89mm) Less (67-76mm)
Outer angle
6. (Between axis of shaft & More (80) Less (76)
base of condyles)

ARTICULATED PELVIS

IMPORTANT FEATURES MALE FEMALE

1. Ilium Less expanded More expanded

2. Pelvic brim or inlet Heart shaped Circular or oval
3. Pelvic outlet Smaller Larger
4. Inlet and outlet Outlet < Inlet Outlet  Inlet
Conical or funnel Broad and round
5. Pelvic cavity
shaped bowl shaped
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 Narrower, shallower,
Larger, deeper, directed
6. Acetabular fossa directed antero-
laterally
laterally
Larger & oval with base Small and triangular
7. Obturator foramen
upwards with apex forwards
8. Greater sciatic notch Narrow and deep Wider and shallower
Narrow, V-shaped (70- Wider, U-shaped
9. Subpubic angle
75) (90 - 100)
Shorter, wider,
10. Sacrum (inner curvature) Longer, narrower,
abruptly curved at
uniform curvature
the last 2 segments

HIP BONE

IMPORTANT MALE FEMALE

FEATURES
Massive, rough, prominent
1. General appearance Light, smooth
muscular markings
2. Greater sciatic notch Narrow and deep Wider and shallower
When present indicates
3. Pre-auricular sulcus that she has born
-
atleast one child
Larger, deeper, directed Narrower, shallower,
4. Acetabular fossa
laterally directed antero-laterally
Larger and oval with base Small and triangular
5. Obturator foramen
upwards with apex forwards
6. Body of pubis Narrow, triangular Broad, rectangular
7. Ischial tuberosity Inverted Everted

SACRUM
IMPORTANT FEATURES MALE FEMALE

Larger, heavier, rough, Smaller, lighter,

1. General appearance
narrow smooth, broader
Breadth of the body of 1st More than breadth of Less than breadth of
2.
sacral vertebrae individual ala individual ala
3. Sacral promontory More prominent Less prominent
Abruptly curved at
4. Inner curvature Uniformly curved
the last 2 segments
Sacral-index
5. Breadth of base Less than 114 More than 114
= x 100
Anterior length
Corporo-basal index
Breadth of body of S1
6. More than 42 Less than 42
= x 100
Breadth of base
7. Sacro-iliac articulation Extend upto 2½ - 3 Extend upto 2 – 2 ½
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 segment segment

AGE
 From the moment of conception, ageing of human being starts.
 During the span of life, various features of development and growth occur in
chronological order. A systematic study of these will be helpful in assessing the
age, because they occur in specific periods of life. However, it should be borne in
mind that these milestones are subjected to the influences of race, sex,
environment and nutrition.
 Krogman reviewed the reliability of the identification of the human skeletal
remains. Where the age exceeds 25 years, there occurs great variability due to
extrinsic and intrinsic factors, but it is possible to attain accuracy for a time frame
of one year in the first two decades. After 25 years, reliability is only within
decades.
MEDICO-LEGAL SIGNIFICANCE OF DETERMINATION OFAGE
Age determination is essential to establish an exact identity of an individual. In cases
of an infanticide, fixing criminal responsibility, kidnapping, competence as a witness,
employment eligibility, sexual offences, marriage contracts etc. a forensic pathologist
may be called upon to give opinion regarding the age.

1. Age and Criminal Responsibility:

Age also has a bearing on fixing the criminal responsibility. A person becomes
criminally liable for his act from the age of 7 years according to the section 82
IPC, whereas according to the section 127- 130 of Indian Railways Act, a child of
5 to 8 years and above is considered criminally responsible for the damage of
railway property.

2. Consent:
 A child under 12 years of age cannot give valid consent to suffer any harm
which may occur from an act done in good faith and for its benefit, like the
medical examination, according to the section 89 and 90 of IPC. However, the
guardian of a child under 12 years of age can give his consent for the
infliction of harm on the child, provided it is done in good faith and for its

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 benefit. For example, a child of this age group cannot give consent for an
operation to be performed on him by a surgeon, but his guardian can do so.
 A person under 18 years of age cannot give a valid consent to suffer any
harm which may result from an act not intended or not known to cause death
or grievous hurt.
3. Competence as a Witness:
 All persons shall be competent to testify unless the court considers that they
are prevented from understanding the questions put to them or from giving
rational answers to those questions because of tender age, old age, disease
either of body or mind or any other cause of similar nature.
 There is no fixed lower age limit at which a person may or may not give
evidence in the court of law. A child below 12 years can also be admitted as
a witness, if the presiding officer of the court satisfied about the credibility.

4. Rape Age Limit:

According to section 375 IPC, sexual intercourse of a man with women who is
even his wife, but under the age of 15 years, and any other woman who is under
the age of 16 years, even with her consent constitutes rape.

5. Marriage Contract:
The marriageable age for a girl is 18 years and for a boy is 21 years.
6. Kidnapping:
According to section 369 IPC, abduction of a child below the age of 10 years,
with intent of taking dishonestly any movable property from its person, constitute
an offence of kidnapping.
7. Attainment of Majority:
 A person is deemed to have attained majority on completion of 18 years and
he assumes full civil rights and responsibilities and can make a valid will.
 When a minor is under a guardian appointment by court, he attains majority
on completion of 21 years.

8. Employment:
 Ordinarily, a person must be at least 18 years of age before he is employed in
government service.

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  As per The Labour (prohibition and regulation) Act, 1986(Act 61), a child is a
person who has not completed his 14th year of age. As per the Indian
Factories Act, 1948, a child below 14 years of age is not allowed to work in
any factory. Article 24 of Indian Constitution provides that “no child below the
age of 14 shall be employed to work in any factory or mine or engage in any
hazardous employment. An adolescent between 15 and 18 years can be
employed in the factory only if he obtains a certificate of fitness from an
authorized medical doctor.

9. Infanticide:
In an alleged case of infanticide, it is important to decide whether the child has
attained the age of viability. Although there is no Indian law regarding the age of
onset of viability, the English law (The Infant life Preservation Act, 1929) states
that a gestation period of 28 weeks or more is prima facie proof that the new born
was viable. Fetal age is also significant as per the Indian Penal Code (IPC)
where there is an enhanced punishment for causing death of a quick unborn child
by act amounting to culpable homicide.

10. Criminal Abortion:

Women become sterile after reaching menopause.
11. Age and Judicial Punishment:
A Juvenile offender is one who is below the age of 18 years and is tried in
juvenile court and if convicted is sent to a Borstal Reformatory or a Correctional
school but not to jail. Such an institution as the name suggests is meant to reform
the juvenile offender. The object is to convert him in to a useful citizen by
imparting some useful trade or occupation such as carpentry, weaving etc. A
juvenile offender is not sent to jail so as to prevent these youngsters from falling
in to the company of hardened criminals who may be present there. Also, a
juvenile offender is generally not awarded the death sentence.

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12. Age and Fetus:
 The term' developing ovum' is used for the first 7 to 10 days after conception
and 'embryo' from one week to the end of 2 months and later it is called a
fetus. It becomes an infant when it is completely born.
 The length of the fetus roughly indicates the age of the fetus. According to
Haase's rule, if the crown heel length of the fetus is 25 cm and less, the
gestational age in lunar months represents the square root of this length in
cms. According to Morison's Rule, if the crown heel length of the fetus is more
than 25 cms, the gestational age in lunar months is - crown heel length in cm
divided by 5.
PARAMETERS FOR DETERMINATION OF AGE
Data for ascertaining age includes the following:
1. Physical Examination
2. Dental Examination (Forensic Dentistry)
3. Radiological Examination
PHYSICAL EXAMINATION
A. General configuration and bodily development indicate a certain age within broad
limits. According to the height and weight of the person whose age is sought can
be fixed and a comparison with standard height and weight charts, would give a
rough indication of age.
B. Signs of secondary sexual characheristics:
 In Males, at about 14 years fine hair begins to appear on pubis. At about 15
years, hair s moderately grown over pubis and appear in axillae. At about 16
years hairs begin to appear over the face and voice becomes hoarse.
 In Females, breast begins to develop around 14 years and few fine hairs
appear on mons pubis. At about 16 years pubic hairs are well grown and hairs
appear in the axillae.

FORENSIC DENTISTRY
 Application of Dentistry to forensic problems is known as forensic odontology.
 It has been observed that the timing and sequence of various stages of growth in
the developing dentition follows a rigid pattern, particularly before birth and first
few years after birth.
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 The factors like racial, familial, disease and nutrition have a say in the particular
growth of the tooth.

MORPHOLOGY OF TOOTH
The teeth are heavily calcified organs comprising of four main tissues. Dentine is a
highly mineralised, quasi-vascular tissue having the processes of odontoblasts
housed in its main structure. The dentine forms an armature comprising of tubules,
a series of parallel tunnels running from the enamel to the pulpal chamber. The
pulpal chamber is a cavity in the dentine that is filled with ground substance and the
structures for the vascular supply of the tooth, and lining it is a layer composed of the
cell bodies of the odontoblasts. Other cells inhabiting the pulp chamber are
fibroblasts, undifferentiated ectomesenchymal cells and macrophages. Enamel is
the hardest, most heavily mineralised tissue in the human body and covers the
coronal half of the dentine to form the hard occlusal surface. Cementum covers the
apical half of the dentine and is similar in composition, but is not similar in structure
to the dentine. This forms a base for the attachment of the tooth into the alveolar
bon
e.

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TYPES OF DENTITION
In man there are two sets of natural teeth (Didentuous). They are,
1. Primary dentition or temporary dentition which is otherwise known as deciduous
teeth or milk teeth (The temporary teeth are 20 in number).
2. Secondary dentition or permanent teeth (In the adult, there are 32 permanent
teeth arranged in eight symmetrically opposed pairs, in the upper jaw and in the
lower jaw).

DIFFERENCES BETWEEN TEMPORARY AND PERMANENT TEETH

Characteristics Temporary Teeth Permanent teeth

Heavier, stronger, broader,
Smaller, lighter, narrow,
Size except permanent
except temporary molars.
premolars.
Anterior teeth are usually
Direction Anterior teeth are vertical
inclined little anteriorly
Crown
China white colour Ivory white colour
Neck
More constricted Less constricted
Narrower and longer and Broader and shorter and
roots of molars are smaller roots of molars are larger
Root
and more divergent and less divergent

SUCCESSIONAL PERMANENT TEETH

 Temporary teeth are 20 in number, namely: four incisors, two canines, and four
molars, i.e. ten teeth in each jaw.
 They begin to erupt at about 6th month after birth and begin to shed off by the
sixth year.
 These deciduous teeth are replaced by permanent incisors, canines and
premolars. Hence they are known as successional permanent teeth.
SUPER ADDED PERMANENT TEETH
All the three permanent molars which appear do not have predecessor milk teeths;
and are known as super added permanent teeth. They are six in each jaw.

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AGE OF MIXED DENTITION
 During early period of life, a child and adolescent may have both temporary and
permanent teeth present in their jaw and this period is known as “age of mixed
dentition”.
 Starting from the day of eruption of one permanent 1st molar till before the day of
eruption of last permanent canine, there will be both permanent and temporary
teeth are present in the jaws. This is known as period of mixed dentition.
 This period of mixed dentition is the age interval between 6 and 11 years; may
sometimes persist until 12 to 13 years of age.

MEDICOLEGAL IMPORTANCE OF TEETH

1. Assessment of age:
Age is assessed from teeth on the basis of time of eruption, root calcification, root
resorption, secondary tooth changes (Gustafson Technique), counting of
incremental lines (Boyde’s Method), weight of the tooth (Stack’s Method), root
transparency (Mile’s Method), Gelatinase-A estimation and Aspartic acid
racemization. .
2. Determination of sex:
Sex can be determined by examination of sex chromatin of the gum tissue.
3. Grievous hurt:
Fracture or dislocation of tooth is a grievous hurt.
4. Identification of criminals:
 Blood grouping and DNA studies can be done from the extracts of pulp cavity.
 Some times, criminals may leave half eaten fruits or cheese at the site of
crime and from the teeth bite pattern imprinted on these articles, identity can
be fixed from a comparison of apprehended criminals.
 Scanning electron microscopy is said to be useful in these cases. Sometimes,
bite marks are seen on the breast and cheeks of victims especially in sexual
offense. By a comparison of these with the apprehended criminals identity can
be fixed.

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211
5. Occupation:
In a cobbler or tailor or electrician the upper incisors are notched from wear and
tear from constant weaning.
6. Habits:
In smokers the teeth are stained blackish brown with nicotine while in the pan-
chewer, the teeth are stained brownish red.
7. Nature of the crime:
The teeth bite pattern and their presence on a particular anatomical part of the
victims body give a clue as to the nature of the crime such as bite marks on the
breasts or cheeks suggest a sexual offense.
8. Cause of death:
Certain poisons are deposited in teeth and gums. Chemical analysis will reveal
the nature of poison and give a clue as to the cause of death, for ex., poisoning
by lead and mercury.

ERUPTION OF THE DECIDUOUS TEETH

Tooth Eruption

Lower Central Incisor 6-8 months

Upper Central Incisor 7-9 months
Upper Lateral Incisor 7-9 months
Lower Lateral Incisor 10-12 months
First molar 12-14 months
Canine 17-18 months
Second molar 20-30 months

ERUPTION OF PERMANENT TEETH

Tooth Eruption
1st Molar 6 to 7 yrs
Central Incisor 7 to 8 yrs
Lateral Incisor 8 to 9 yrs
1st Bicuspid 9 to 10 yrs
2nd Bicuspid 10 to 11 yrs
Canine 11 to 12yrs
2nd Molar 12 to 14yrs
3rd Molar 17 to 25yrs

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GUSTAFSON’S TECHNIQUE
To estimate the age of individual above 25 years, Gustafson has taken six
parameters to assess the age basing on the physiologic changes that occur in teeth
due to age.
CRITERIA FOR GUSTAFSON’S TECHNIQUE
Those SIX parameters include the following:
1. Attrition.

2. Periodontosis.

3. Secondary dentin.

4. Cementum opposition.

5. Root resorption.

6. Transparency of the root.

1. Attrition:

As age advances the occlusal surface gets destroyed due to mastication

involving enamel, then dentin and then the pulp.
2. Periodontosis:
Due to bad oral hygiene there is regression of the gums and periodontal tissues
surrounding the teeth as age advances.
3. Secondary Dentin:
Development of secondary dentin in the pulp cavity diminishes the size of the
cavity as age advances.
4. Cementum Apposition:
Deposition of cementum at the root, thereby increasing thickness of the
cementum as age advances.
5. Root Resorption:
This is noticed first at the apex and gradually extends upward as age advances.
6. Transparency of the Root:
When the dentin is devoid of minerals, as in young age, it looks opaque. Due to
ageing process more and more minerals gets deposited in the root and give a
transparent picture. This happens to be the most reliable criterion of all the
abovementioned parameters as per Miles.

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PROCEDURE
 Anterior teeth are more suitable than the posterior teeth, and the merit decreases
from incisors to premolars, while 3rd molars quite unsuitable.
 Before tooth is extracted from a body, the degree of Periodontosis is estimated.
 The tooth is grinded on glass slab or carborandum stone from both sides of the
tooth to about 1 mm, which allows the estimation of transparency.
 Then the section is ground further down to about 0.25mm, for microscopic
examination.
 Arbitrarily, 0,1,2,3 points are allotted to indicate the degree of changes that take
place as age advances for each parameter.
 Stage 0 indicates no change.
 Stage 1 indicates involvement of enamel only.
 Stage 2 indicates involvement up to dentine.
 Stage 3 indicates involvement up to pulp cavity.
APPLICATION OF GUSTAFSON’S FORMULA
 The total point values are added and the sum total is applied in a
regression formula (Total points: A+P+S+C+R+T)
 Regression formula for assessing age is,
Age (in years) = 11.43 + 4.56 x (Total points)
 3.63 is the standard error (S.E).
 If for example, total point score is 0, that is each dental factor is ranked as 0, the
estimated age is about 11.43 years.
DENTAL CHARTING
Following systems are used for dental charting:
1. Universal System:
 Each tooth is given a number, 1 to 16 for upper jaw, from right side to left.
 Each tooth is given a number, 17 to 32 for lower jaw, from left side to right.
2. Palmer’s Notation:
 Permanent teeth are indicated by 1 to 8.
 Temporary teeth are indicated by A to E.

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3. Federation Dentaire Internationale (FDI) System:
 Permanent teeth: 1 for right upper quadrant; 2 for left upper quadrant; 3 for
left lower quadrant; 4 for right lower quadrant.
 Temporary teeth: 5 for right upper quadrant; 6 for left upper quadrant; 7 for left
lower quadrant; 8 for right lower quadrant.
4. Modified Federation Dentaire Internationale (FDI) System:
 Permanent teeth: 1 for right upper quadrant; 2 for left upper quadrant; 3 for
right lower quadrant; 4 for left lower quadrant.
 Temporary teeth: 5 for right upper quadrant; 6 for left upper quadrant; 7 for
right lower quadrant; 8 for left lower quadrant.
HAIR
 Examination of hair is of considerable help in criminal investigation.
 When material alleged to be hair is produced before him, the medical officer has
to determine the following
 Whether it is hair or some other fiber.
 Whether it is human or animal hair
 From which part of the body it has come
 Whether there is any injury to the hair, and if so how it has been caused
 Whether it helps in establishing the identity of the individual
 Whether there are any stains on it, and if so their significance
 Whether it is from a cause of poisoning and
 Whether any other useful information can be provided
1. Whether it is hair or some other fiber:
The fibers, which are likely to be mistaken for hair are cotton, nylon and silk.
None of these has the appearances of hair. Sufficient to say that each of these of
fibers has its own characteristics morphological appearance and that it is possible
to differentiate them from hair.
2. Whether it is human or animal hair:
 Animal hairs are coarser, thicker and have a wider medulla than a human hair.
 Pigment is concentrated more towards the periphery of the cortex in human
hair, while in the animal, it is more concentrated towards the medulla.
 The precipitin test is helpful in differentiating the two.

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3. From which part of the body it has come:
 Scalp hair is long and the end tapering, while eyebrow hair is short, thick and
stumpy.
 Microscopic examination of cross-sections of hair is generally oval or circular
in outline, while moustache hair is nearly triangular in outline.
4. Injury to hair:
 If injury is suspected, the hair must be carefully studied, end-to-end, under a
magnifying lens or microscope.
 A sharp weapon with a cutting edge produces a clean cut to the hair, and if
recent, the edges are regular.
 A blunt weapon will crush the hair or cause a ragged edged end.
 When hair is forcibly plucked out the hair bulb is distorted, irregular in shape
 On the other hand, if it is shed naturally, the hair root is atrophic, appears
shrunken and has a smooth surface.
 Hair may get singed as a result of bums of firearms injury. Carbon is
deposited on the hair externally. It gives off a peculiar & offensive odour,
because of burning of Keratin contained in the cortex.
5. Hair and identity:
 Since hair resists putrefaction, it forms an important means of establishing the
identity of a person, even when the rest of the body is putrefied. Thus, the
following features of identity can be established.
 Race:
The character of the hair may offer clue regarding the race of the
individual, ex., the close curly hair of the Negro and the straight hair of the
Indian.
 Age:
 The lanugo hair of newborn infant is soft, fine downy, non-pigmented
and so colourless, and has no medulla.
 Hair begins to grow first on the pubis and then in the axilla.
 Pubic hair begins to grow in females at the age of 13 years and in
males at 14 years.
 Axillary hair begins to grow to grow a year after pubic hair.

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  Hair begins to grow on the chin and upper lips of males between 16 to
18 years.
 Grey ness starts in the scalp hair at 40 years, first in the temples, and
spreads later to involve the beard and moustache.
 In the female there is loss of axillary hair with advancing age
 Sex:
 Distribution of hair on various parts of the body may aid in determining
the sex of the person. Presence of hair on the ear pinna, the lips, the
chin, around the nipple, and hair extending from the pubic to the
umbilicus would suggest male.Male hair is generally thicker, coarser
and darker than female hair.
 The texture of hair is also of importance in determining sex. For
example, feminine scalp hair is fine, long and gently taper to an end. In
the female, the upper border of the pubic hair is horizontal while in the
male, it runs towards the umbilicus.
 It is also possible to determine the sex of hair from a study of sex
chromatin in the epithelial cells of the root.
 Neutron Activation Analysis (N.A.A):
It also helps in establishing identity. This is an extremely sensitive method of
quantitative estimation of three elements. It is known that trace elements in
hair form a unique pattern for each individual, and they can therefore be
identified thus.
6. Hair and stains on it:
 One must carefully look for stains such as mud, saliva, semen, blood, carbon
and dye stains on hair.
 Mud stains indicate struggle, seminal stains may be seen in sexual offences,
and bloodstains in injury or sexual offence. Salivary stains may be seen in
asphyxial deaths.
 Saliva is identified as such by testing for the presence of amylase,
phosphatase, nitrite and thiocynate.
 Presence of carbon is the result of bums or firearm injury.
 Presence of a dye indicates that an attempt has been made to alter or conceal
the natural colour.

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217
7. If it is from a case of poisoning:
One must bear in mind that in case of Chronic arsenical poisoning, the poison
can be detected by chemical analysis, in hair, nails & bone, & so these must also
be preserved and sent to the chemical examiner for analysis.
8. Miscellaneous:
 Weapons that are alleged to have been used in inflicting injuries must be
carefully examined for the presence of hairs, because of comparison of this
hair with the hair of the victim will pinpoint the weapon used. In other words,
presence of hair on the weapon may provide the link between the victim of
assault and the weapon. Crime hair and sample hair must be compared under
the comparison microscope.
 Similarly in vehicular accidents, hair sticking to the vehicle must be compared
with that of the victim, and this will pinpoint the vehicle.
 In rape and other sexual offences, the pubic hair of the victim may be matted
with blood or semen, or public hair of the assailant may be found on the victim
and vice versa. In bestiality, animal hair may be found on the accused, and
human hair on the animal.
 Growth of hair on the face helps in determining the time of death (if shaving
habits are known) the rate of growth of hair is about 0.4 mm per day. For
example, if the face is found to be clean-shaven, he probably died after a
morning shave. Hair ceases to grow after death; but there is an apparent
appearance of growth of hair after death; but there is an apparent appearance
of growth of hair after death. This results from shrinkage of the skin because
of drying. Loosening of hair occurs after death due to decomposition of skin.
This also gives an idea of the time of death.

SKELETAL CHANGES
 The bones of human skeleton develop from a number of separate ossification
centers in a skeleton preformed in cartilage.
 At the 11th prenatal week in human, there are some 806 centers of bone growth
at birth about 450, while the adult skeleton has only 206 bones. From the 11th
prenatal week to the time of final union some 600 centers of bone growth
disappear, ie; they coalesce or unite with adjacent centers to give rise to the

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 definitive adult bones as we know them. This process of appearance and union
has in the normal human skeleton, a fairly definitive sequence and time table that
makes it a reliable age indicator. In females the centers appear and unite by one
or two years in advance of males. Estimated skeletal age based on appearance
of ossification centers and union of epiphysis must always be expressed in a
range. However, it must be remembered that the appearance of ossification
center and its union with the diaphysis is influenced by race, sex, environment,
nutrition and hormones.
 These can be studied by using radiographs or X-rays of different joints are taken
to study the degree of ossification. To determine the age, skiagram of shoulder,
elbow, wrist, hip, knees, ankles, pelvis and skull should be taken in antero
posterior view. It can be also achieved by studying the skeletal remains if
possible

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SHOULDER JOINT

Bone &
Age of
Sr. ossification Age of Appeared
appearance Inference
No center fusion or not Fused or
not

Fuse to
1 Capitulum 1 year form
Composite
Epiphysis
2 Trochlea 9-11 years at 14-16
years

Lateral
3 11 years Fuses with
Epicondyle
the shaft by
16-17
years

Medial 16-17
4 5-6 years
Epicondyle years

Head of 16-17
5 5 years
Radius years

Olecranon 16-17
6 9 years
Process years

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Wrist Joint

Bone &
Age of
ossification Age of Appeared
Sr. No appearance Inference
center fusion or not Fused or
not

1 Capitate 2 months ---

2 Hamate 3 months ---

3 Triquetral 3 years ---

4 Lunate 4 years ---

5 Scaphoid 4-5 years ---

6 Trapizium 4-5 years ---

7 Trapizoid 4-5 years ---

8 Pisiform 10-12 years ---

Lower end of 17-18

9 2 years
Radius years

Lower end of 17-18

10 5-6 years
ulna years

Base of 1st 15-17

11 2-3 years
metacarpal years

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Hip joint

Bone &
Age of Age of Appeared Fused
Sr. No ossification Inference
appearance fusion or not or not
center

Head of 17-18
1 ½ - 1 year
Femur years

Greater 17-18
2 4 years
Trochanter years

Lesser 17-18
3 12-14 years
Trochanter years

Ischio-pubic 6-8
4 ---
rami years

Triradiate 13-15
5 ---
cartilage years

18-20
6 Iliac crest 14 years
years

Ischial 20-21
7 16 years
Tuberosity years

Knee joint

Bone &
Age of Age of Appeared Fused
ossificatio Inference
Sr. No appearance fusion or not or not
n center

1 Lower end 9 months of 18-19

of Femur I.U.L years

2 Upper end 10 months of 18-19

of Tibia I.U.L years

3 Upper end 4 years 18-19

of fibula years

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Ankle Joint

Bone &
Age of Age of Appeared Fused or
Sr. No ossification Inference
appearance fusion or not not
center

Lower end 16-17

1 1 year
of Tibia years

Lower end 16-17

2 1 year
of fibula years

Calcaneum 14-16
3 6-8 years
Tuberosity years

DETERMINATION OF AGE BASED ON SUTURAL CLOSURE OF THE SKULL

 The basi-occiput fuses with basi-sphenoid during 18 to 20 years.
 Closure of the sutures begins on the inner aspect (endocranially) by 5 to 10 years
earlier than on the outer aspect (ectocranially).
 Closure of the skull sutures occur in the following order:
 Metopic suture at 2 to 8 years.
 Posterior one third of sagittal suture at 30 to 40 years.
 Anterior one third of sagittal and lower half of coronal at 40 to 50 years.
 Middle one third of sagittal and upper half of coronal at 50 to 60 years.
 Lambdoid suture at 50 to 70 years.
 Tempero parietal sutures at 80 years.
 Estimation of age by sutural closure of skull is not reliable and can be given only
in the range of decade.
 The usual reliability falls in the order of sagittal, lambdoid and then coronal.

DETERMINATION OF AGE BASED ON PUBIC SYMPHYSIS CHANGES

 The right and left pubic bones, separated from each other by the symphyseal
cartilage. Each pubic bone presents a symphyseal surface, which possess more
or less oval outline.
 According to Krogman, the pubic symphysis is probably the best single criteria of
age in skeleton (+/- 2).

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 Pubic symphysis has five main features. surface; ventral border or rampart;
dorsal border or plateau; superior extremity; and inferior extremity.
SYMPHYSEAL AGE CHANGES:
 Below 20 years: The symphyseal surface has an even appearance with a layer of
compact bone over its surface.
 Between 20 and 30 years: Symphyseal surface looks markedly ridged and
irregular, the ridges or billowing run transversely and irregularly across the
articular surface.
 Between 25 and 35 years: The articular surface billowing gradually disappears
and giving a granular appearance with its well defined anterior and posterior
margins.
 Between 35 and 45 years: The articular surface looks smooth and oval with
raised anterior and posterior margins.
 Between 45 and 50 years: Narrow beaded rims develop in and around the
margins of the articular surface.
 Above 50 years: Symphyseal surface shows varying degree of erosion with
breaking down of ventral margins.
DETERMINATION OF AGE BASED ON APPEARANCE & FUSION OF
OSSIFICATION CENTRES OF STERNUM
 Appearance:
 Manubrium: 5th month of Intra-uterine Life.
 Body of Sternum appears in 4 segments,
 1st segment appears at 5th month of Intra-uterine Life.
 2nd segment appears at 7th month of Intra-uterine Life.
 3rd segment appears at 7th month of Intra-uterine Life.
 4th segment appears at 9th month of Intra-uterine Life.
 Xiphoid process appears at 3 years.
 Fusion:
 Manubrium is fused with the body in old age (usually above 50 years).
 Four pieces of sternum fuse with one another from below upwards between
14 to 25 years.
 At about 40 years the xiphoid process unite with the body.

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ARCUS SENILIS
 Arcus Senilis is an opaque zone around the periphery of the cornea, which may
be noticed after 40 years of age; it is seldom complete and circular before 60
years.
 Its formation is attributed to deposition of lipids (cholesterol, phospholipids and
neutral fat) and is considered to occur more in males (by 45-50 years) and in
females (by 55-60 years).
 Arcus Juvenilis appears as white lines around cornea in young adults suffering
from hyperlipaemia.
STATURE
DEFINITION:
Stature is defined as the height or tallness of a person standing.
 After reaching its maximum, between 18 to 21 years, stature falls short by about
2.5 cm, for every 25 years.
 Stature of same person measure greater by 1 to 3 cm on lying down, than on
standing. Varies by 1.5 cm to 2 cm at different times of the day. Less in the
evening because of variation in elasticity and diminished muscle tone.
 Postmortem changes in stature:
 Immediately: No change.
 After few hours: increases by 2 cm due to flaccidity.
 After the onset of rigor: shortens.
ESTIMATION OF STATURE:
It can be grouped under following,
1. Using dismembered body parts.
2. Stature from long bones.
3. Stature from long bone fragments.
4. Stature from fetal bones.

STATURE FROM DISMEMBERED BODY PARTS

By using following calculations,
a. Stature = Length between tip of the middle finger of both sides when arms are
fully stretched.
b. Stature = {2 x Length of one upper limb} + 34 cm.

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 c. Stature = 2 x length from vertex to pubic symphysis.
d. Stature = 2 x length from pubic symphysis to either heel.
e. Stature = 8 x Height of skull.
f. Stature = 19/5 x length of forearm.
STATURE FROM LONG BONES
By using mathematical formulas developed by Rollet; Manouvrier; Karl Pearson;
Dupertius & Hadden; and Trotter &Glesser for western population. By using
mathematical formulas developed by Pan, Nat, Siddique & Shah, Singh & Sohal for
Indian Population.

STATURE FROM LONG BONE FRAGMENTS

The stature from long bone fragments can be determined based on studies of Muller,
Steele & Mc Kern.
STATURE FROM FETAL BONES
It can be achieved by using Smith & Fiddes formulae for stature.
TATTOO MARKS
One of the remarkable cases of identification from tattoo marks is so called ‘Sydney
Shark case’. The victim James Smith was identified by a tattoo design of ‘two men
boxing’ over the severed forearm.
DEFINITION
These are the designs or marks made over the body artificially by pricking the skin
with needles dipped in some pigments.
DYES USED
 They are permanent and do not fade with time.
 The dyes that are commonly used are black, blue or red.
 Carbon, China ink and Indian ink are black dyes.
 Vermilion (mercuric sulphide), Mercuric Chloride are red dyes.
 .Potassium Dichromate is a green dye.

TATTOO SITES
The sites commonly chosen for tattooing are the outside of the arms, the front of the
forearms and the chest, any part of the body can be tattooed.

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MEDICO-LEGAL SIGNIFICANCE OF TATTOO
1. It is customary to tattoo one's own name. Thus gives a clue regarding the identity
of the person. It must however be remembered that some take a fancy to tattoo
not his own name, but that of one spouse or parents.
2. Tattoo marks may give a clue regarding the religion of the individual, e.g., the
figure of Hanuman or Lord Krishna suggests a Hindu.
3. Mental make up of the person, such as criminality, sexual perversion, may be
exhibited through the tattoo marks.
4. One given to sexual excess may have the figures of naked women or of lewd and
indecorous female figures or that of cupid tattooed on him. These are called
erotic tattoo marks and they denote an interest in sex.
5. Blue bird tattoo mark over the dorsum of the hand is seen amongst the
homosexuals.
6. Drug addicts like to tattoo in the mucous surface of the lip for their own
identification or conceal their needle marks by tattoo designs.
TATTOO REMOVAL (MEDICAL METHODS)
A. Skin Grafting:
Surgical removal with skin grafting can remove a tattoo mark completely and
permanently.
B. Laser Therapy:
Experimental study has own that tattoo marks may be removed by exposure to
laser beams. It has been found, that by exposure to laser beams the dye particles
get vaporized and expelled from the tissues in gaseous form. The advantages
are said to be that the skin appendages remain undamaged, and that the process
is almost painless.
C. Carbon Dioxide Snow:
In case of small tattoo marks, application of CO2 snow may remove it.
D. Electrolysis:
Electrolysis by using 5 to 8 milliamp of current will remove the tattoo marks.

REVEALING LATENT TATTOO MARK

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 A faded tattoo mark may be revealed by the use of ultraviolet light or may be
rendered visible by rubbing the part and examining it with a magnifying glass in
strong light.
 When a tattoo disappears from its site for whatever reason, the dye used in
tattooing may be found in the regional lymph nodes on histological examination.
From this, it can be said that the person once had a tattoo.
 In decomposed material it can be made viible by trating suspected area with 3%
H2O2.
ADVERSE EFFECTS OF TATTOO
1. Systemic infection dissemination due to the infected needles.
2. Spread of contagious disease including HIV.
SCAR
 If there is dislocation in continuity of the skin, repair of the injury begins at once,
culminating in the formation of fibrous tissue, which is called a scar.
 A few layers of simple epithelium cover a scar. There is no pigment layer in a
scar, nor is there sweat or sebaceous glands or hair follicles.
 While examining a scar, the following points must be noted:
 Its exact anatomical situation
 Size
 Shape
 Colour
 Consistency
 Whether tender or not
MEDICO-LEGAL IMPORTANCE OF A SCAR
1. It gives a clue regarding identity.
2. It provides information regarding the weapon or agent responsible for the injury.
3. The time of infliction or causation of such injury can be assessed.
4. A scar like linea albicantes (straie abdominalis) suggests a previous pregnancy.
5. Linea albicantes results from stretching of the abdominal skin during pregnancy
an the resultant formation of scar tissue in the deeper layers of the dermis.

ANTHROPOMETRY

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 Anthropometry deals with the measurement of the various parts of the human
body (anthropos=man, metron= measure).
 It is also called the Bertillon system or Bertillonage, after Alphonse Bertillon a
French criminologist, who proposed it in 1882.
 Bertilonage is based on the principle that after the age of 21 years, the skeleton
stops growing and so the measurements of the various parts of the body remain
constant, and that no two persons will have bones of identical dimensions. This
system is therefore applicable only to the adults.
 The system consists in classifying individuals based on the following data:
Colour of hair and eyes, complexion, size, shape and disposition of nose and
ears, Length of right ear, standing and sitting height, arm reach, length and
breadth of hand, length of left middle and ring fingers, and length of foot.

DACTYLOGRAPHY or FINGERPRINTS
 Dactylography or dactyloscopy is also known as the fingerprint system or the
Galton system.
 Sir Francis Galton, a famous English anthropologist, systematized this method of
identification of individuals, although the credit for its discovery should go to Sir
William J. Herschel.
 The fingerprints can be transmitted from one place to another by telegraphic code
message or by telephone or fax. This helps the police in quick and 'prompt
identification.
 Fingerprint is the arrangement of the papillary ridges on the skin of the balls of
the fingers, which are formed, in the fourth month of pregnancy. No change
occurs during the subsequent growth. These ridges are present both on the
epidermis and dermis.
 Criminals sometimes mutilate the fingerprint pattern by inflicting injuries (injury,
burns). Fingerprint pattern gets altered in leprosy, celiac disease, eczema,
acanthosis nigricans, electrical injury and in radiation injury.

MEDICO-LEGAL SIGNIFICANCE OF FINGERPRINTS

1. The characteristic feature of a fingerprint is the individuality, for no two persons
have identical fingerprints. They are highly individualistic even in monozygotic
twins. Galton estimated that that the chances of two persons having identical
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 fingerprints are about one in 64,000,000,000 (sixty four thousand millions).
Dactylography is infallible and fool proof, the accuracy being 100%. Therefore it
is commonly used for maintenance of records and identity cards.
2. To identify chance impression of accused left at the crime scene.
3. To establish identity of a missing person and unidentified dead bodies.
4. To prevent impersonation.
5. It is used in lieu of signature in many legal documents.
TYPES OF FINGERPRINTS
 Galton classified fingerprints in to four main types based upon arrangement of
papillary ridges on the fingertips into
1. Loops (65-67%): Papillary ridges are arranged in the shape of loop.
2. Whorls (25%): Papillary ridges are arranged in the shape of whorl.
3. Arch (6-7%): Papillary ridges are arranged in the shape of arch.
4. Compound or Composite (2%): A composite or compound fingerprint is a
mixture of more than one of the arch, loop or whorl.
 Based on the appearance at the scene of crime, they can be grouped under
following:
A. Visible or Patent Fingerprints:
These are the impressions made by a finger contaminated with the blood,
paint, dust, dyes etc. which can be recorded by photography with suitable use
of lights and filters.
B. Latent Fingerprints:
These are the prints which are not usually visible by naked eye and cannot be
made visible, by using usual contrast methods. For example over papers,
fabrics, skin etc.
C. Plastic Fingerprints:
Impressions made on a soft materials like soap, wax, clay, etc., which can
be recorded by photography or by means of a cast.

RECORDING OF FINGERPRINTS
 Fingerprints can be easily recorded by applying printers ink to the fingers and
pressing on unglazed white paper.
 Finger prints can be taken in two different ways, namely:

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 A. Plain fingerprint: A Plain finger print is taken by simply pressing the inked
finger directly on paper
B. Rolled fingerprint: Rolled finger print is better than a plain finger print because
it has greater surface area and so offers a better study of the pattern of the
ridges.
COMAPARISON OF FINGERPRINTS
 Fingerprints at the scene of crime are compared with those of the suspected
hand and the criminal is pinpointed, if the finger prints tally.
 The characteristics of the ridges may take the form of ridge endings
 Bifurcations
 Lake formations
 Island formations
 In practice, 16 to 20 points of fine comparison are accepted as proof of identity.
Now a day’s just 8 to 10 similarities can be considered to be enough for positive
identification.
LIFTING / DEVELOPING OF FINGERPRINTS
A. Visible Fingerprints:
 When it is visible against the background, with contrast, it is to be
photographed for comparison.
 When it is not visible against the contrast, it is to be made visible, by dusting
some contrast material like Aluminum oxide (white powder) and carbon dust
(black powder). The sebum being sticky, will hold the powdered to make it
visible.
 These prints can be stored by photographs or lifting them using scotch tape.
B. Latent Fingerprints:
Latent fingerprints can be made visible by several methods
 Exposing them to iodine vapors in a gas chamber, the iodine makes the prints
visible by reacting with the amino acids of prints of papillary ridges.
 Soaking the suspected article in a Silver nitrate solution which makes the
invisible prints visible.
 By dipping the suspected article in Ninhydrin solution, which makes the prints
visible.

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  By dipping the suspected article in Diazofluorenone solution, which makes the
prints visible.
 In auto-radiographic method, wherein formaldehyde vapors makes the print
visible.
 Electro-radiography or Grenz rays examination after dusting the suspected
area with lead powder.
 Laser induced demonstration of luminescence of fingerprints.
C. Decomposed Body:
 The degloved skin should be hardened with formalin and the impression is
taken.
 Mummified fingers should be immersed in 1% caustic soda or potash solution
until they get their normal state, then it is fixed in formalin and print is taken.

POROSCOPY or LOCARD’S METHOD

 The papillary ridges of the skin of the fingers are studded with minute pores,
which are the mouths of the ducts of the sweat glands.
 Each millimeter of a ridge contains 9 to 18 pores.
 These pores, which are permanent and of varying size, shape, position and
number over a given length of the ridges in each person.
 This method of identification of a person by examining the pores is called
'Poroscopy', and this was introduced by Edmund Locard. In a way it is a further
study of fingerprints.
 They help in establishing the positive identity.

LOCARD'S PRINCIPLE OF EXCHANGE

 "Every contact leaves a trace"
 "Wherever he steps, whatever he touches, whatever he leaves, even
unconsciously, will serve as a silent witness against him. Not only his fingerprints
or his footprints, but his hair, the fibers from his clothes, the glass he breaks, the
tool mark he leaves, the paint he scratches, the blood or semen he deposits or
collects. All of these and more bear mute witness against him. This is evidence
that does not forget. It is not confused by the excitement of the moment. It is not
absent because human witnesses are. It is factual evidence. Physical evidence

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 cannot be wrong, it cannot perjure itself, it cannot be wholly absent. Only human
failure to find it, study and understand it, can diminish its value."
Prof. Edmond Locard, c. 1910
 It is the basis for evidentiary material collection in sex related crimes, accidents
and assaults etc.
FOOTPRINTS (PODOGRAM)
 Similar to the hand, which gives fingerprints, the foot also gives an impression
known as footprint or podogram from which it is possible to identify a person.
 The skin patterns of the toes and heels are as distinctive and permanent as those
of the fingers.
 Ridge pattern if clearly visible on the material against a contrasting background,
is highly individualistic. The comparison of the suspect with the test print can be
carried out in the same way as in the case of fingerprint.
 In the absence of ridges the length and width of the foot, length and width of the
toes, toe pads etc. aid in distinguishing the footprints of one individual from
another.
 They are recorded by photography or making casts.
.LIP PRINTS or CHEILOSCOPY or FORENSIC STOMATOLOGY
 Lip prints are extensively studied by Professor Suzuki of Tokyo.
 Lip prints are claimed to be unique and do not change during the life of a person.
They recover completely after undergoing alterations like trauma, inflammation
and disease like herpes, and that the disposition and form of a furrows does not
vary with environmental factors.
 It is claimed that the cracks, grooves and wrinkles in the lips are individualistic,
just like finger or footprints, and that a study of lip prints help in establishing
identity.
 Cheiloscopic Pattern are classified as:
1. Linear: Lines are predominant.
2. Bifurcate: Bifurcation of lines are dominant.
3. Reticular: Lines cross each other.
 Lip prints can be easily lifted from individuals by using lipsticks.
 Establishment of 7 to 9 characteristics leads to a saliva, cosmetics etc. can be
used as a corroborative evidence.

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RUGOSCOPY
 Rugoscopy refers to the study of the ridges and grooves in the palate and is a
newly developing field of identification.
 It was suggested by Harrison Allen in 1889.
 It is said that the pattern of ridge is highly individualistic.
 The shape of the rugae could be either curved, wavy, straight, or circular.
 The advantages of using palatal rugae as a tool of postmortem identification
includes:
 Protected from trauma because its safe location.
 Insulated from heat by the tongue and buccal fat pads.
 They do not chage during growth.
 No two palates are alike in their configuration.
SUPERIMPOSITION
 Identification of the dead from the skull is of primary importance in criminal cases.
It is often necessary to undertake examinations in the Forensic Science
Laboratory to determine whether skull could have belonged to a person in
question.

 It was Professor Brash who in 1935 suggested that the photographs of the
missing person and the skull could be superimposed as an identification
technique.

 Professor Brash employed this technique for the first time in Infamous Ruxton
murder case. The two females skulls recovered in this case were identified that to
be belonging to missing victims Mrs. Isabella Ruxton and her maid Mary
Rogerson based on Skull-Photo Superimposition. The ‘tiara’ was used as a
reference object in this case.

DEFINITION
Superimposition is a technique where a postmortem record is placed over a
comparable antemortem record for comparison.
TYPES OF SUPERIMPOSITION TECHNIQUES
The various superimposition techniques employed are,
1. Skull Photo Superimposition.
2. Video Superimposition.
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 3. Computer Assisted Superimposition.
Skull Photo Superimposition:
 Skull Photo Superimposition is the technique in which the skull to be identified is
superimposed on a recent ante-mortem photograph of the deceased.
 Ante-mortem photograph is enlarged to life size, the enlargement factor being
based upon the measurements of the fabric on the victim, or measurable items
seen in the photograph, or the dimensions of the anterior teeth or the width of the
collar in a photograph. The reference object should be available for the purpose
of enlargement of photograph to life size.
 Now a life size photograph of the skull in question is taken, after positioning it
similar to the positioning of face in the antemortem photograph.
 The superimposition is achieved by ‘seeing through’ techniques, in which
orientation of skull to facial photograph is achieved by looking through a
transparent face film. Life size picture of the skull is superimposed on the
transparency of the life size antemortem photograph, making allowances for the
soft tissues.
 The anatomical landmarks compared for a positive match include:
 Relation of eyebrow to supraorbital margins.
 Relation of ear to external auditory meatus.
 Relation of eye to orbit.
 Relation of lips to teeth.
 Relation of nose to anterior nasal spine.
 Relation of chin to symphysis menti.
 Mandibular angle.
 Zygomatic processes.
 This test can help in exclusion rather than inclusion. If there is a match it can at
best be said that the skull could be that of the person in the photograph.
Video Superimposition:
 A more modern variety of the superimposition technique is with the use of video
cameras, where two images, one of photograph and other of skull, are mixed on
one video display unit.
 By altering the camera angles and the degree of magnification of the images, test
can be done quickly.

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 This method was used in 1994 to identify victims notorious “House of Horror” in
Gloucester.
Computer Assisted Superimposition:
 This method involves predefined anthropometric data and analysis of facial
landmarks.
 3D digital photographs are taken by 3D digital stereophotographic geometric
scanner.
 8 photographs of face are taken from different angles simultaneously.
 From these photographs ultimately 61 different facial landmarks are available for
matching purpose.
 It is only probability and not certainty of matching.

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 IMPOTENCE.
Definition:
Inability of a male to perform a normal sexual intercourse is known as impotence. Similarly,
in inability to initiate or maintain the sexual arousal pattern by a female is known as
frigidity.

Causes:
The causes of impotence in a male are:
 Iatrogenic
 Malformation
 Psychological
 Obstruction
 Trauma
 Endocrinal
 Neurological
 Chronic illness
 Excessive drug abuse
 Iatrogenic Causes:
Any cause resulting from any treatment.
 Antihypertensive drugs like methyl dopa
 Partial or complete amputation of the penis
 Spinal surgeries injuring the S2 – S4 nerves or the cauda-equina or the pudendal
nerves.
 Malformations:
 Absence of penis
 Non development of penis
 Intersexuality
 Double or adherent penis
 Pre-pubertal castration

 Psychological Causes:
 Emotional disturbances
 Fear of inability
 Anxiety, depression, overindulgence in sex
 Quoad (impotentia quoad persona): impotence with a particular female, usually the
wife.

 Obstructive causes:
 Acute diseases like gonorrhea, sores on the glans, mumps

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  Large hernias, elephantiasis
 Paraphimosis or adherent prepuce (temporary impotence corrected by surgery)

 Trauma:
 Fracture vertebrae with cord injury
 Damage to cauda equina or spina bifida

 Endocrinal disorders:
 Metabolic disorders: diabetes mellitus of more than five years duration can result in
impotence.
 Hormonal disorders: hypopitutarism can produce sexual infantilism and impotence.

 Neurological causes:
 General paralysis of insane
 Tabes dorsalis
 Syringomyelia
 Paraplegia / hemiplegia
 Damage to S2 – S4 nerves or pudendal nerves or pelvic plexus

 Chronic illness:
 Elephantiasis
 Hydrocele
 Spinal cord tumors
 Gonorrhea
 Syphilis

 Excessive drug abuse:

 Alcohol
 Opium / morphine / cocaine
 Cannabis
 Tranquilizers
 Tobacco
 Bromides

Medico-legal importance: The question of impotence arises in civil or criminal cases.

1. Civil Cases:
 Nullity of marriage
 Divorce
 Legitimacy
 Disputed paternity
 Compensation claims

2. Criminal cases:
 Rape
 Adultery
 Unnatural sexual offences

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 INFANTICIDE …..
INTRODUCTION
 Infans (Latin) meaning 'unable to speak'.
 Oxford dictionary defines 'infant' as a child during the earliest period of life,
especially a child in arms.
 As per the Infanticide Act 1938 (U.K), Infanticide is the killing of a child under the
age of 12 months by its mother, 'by willful act (commission) or omission' during a
period of mental disturbance caused by stress of pregnancy, delivery and
lactation.
 The infanticide of illegitimate children continues to be a major social problem.
 The majority of cases of infanticide occur a very short time (minutes to hours)
after the birth of the baby.
 The history of infanticide/neonaticide traces back to ancient times and is a
fascinating reflection of cultural attitudes towards gender and the value of the
child in society.
 There is a strong association of infanticide with illegitimacy (illegitimate child).
 Infanticide by the mother is considered equivalent to manslaughter and not
murder (in England).
 Infanticide by any person other than the mother amounts to murder (in England).
 In India, infanticide caused even by the mother is treated in terms with murder
(IPC section 302).

IMPORTANT TERMINOLOGIES

 Infanticide is the unlawful destruction of a child within one year of its birth.
 Feticide means acts done to prevent the child from being born alive or to kill the
fetus in utero at any time prior to its birth.
 Filicide means killing of a child by its parents.
 Neonaticide means unlawful destruction of the newly born infant (less than 24
hours of life) following live birth. The neonatal period extends for the first 30 days,
but for these cases the term is applied to babies killed at birth or shortly
thereafter.(Potters Pathology of the fetus, infant and child, 2007)

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CAUSES FOR INFANTICIDE

 Infanticide is commonly committed by unmarried woman, widows and married

woman living apart from husband (illegitimacy).
 It is also committed as a reason of social customs (family pride), problem related
to dowry leading to female infanticide (poverty) and problem related to
prostitution leading to male infanticide (unwanted sex).
MEDICO-LEGAL SIGNIFICANCE OF INFANTICIDE or OBJECTIVES OF FETAL
AUTOPSY
Forensic expert on conducting fetal autopsy should able to reason out following
questions of legal consequences:
1. Whether the child attained viability or not at birth?
2. Was the child still born or dead born?
3. Was the child born alive?
4. If born alive, how long did the child survive?
5. What was the cause of death or was the death due to the deliberate act of
commission or omission?
VIABILITY
Introduction:
 An immature fetus may be born alive, but be incapable of maintaining an
independent existence.
 The limiting factor for viability in a premature newborn is the state of maturity of
its lungs.
 From about 22-24 weeks gestation, the alveoli of the lungs begin to differentiate
from their primitive fetal state to a more mature state which will eventually allow
gas exchange to take place and make respiration possible.
 The English law (The Infant Life Preservation Act 1929) states that a gestational
period of 28 weeks or more is prima facie proof that the newborn was viable, i.e.
capable of achieving and sustaining a separate existence from its mother.
 Age of onset of fetal viability is not defined in the Indian law.

Definition:

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Viability is defined as the physical ability of the fetus to lead an independent
existence after birth by virtue of certain degree of development

Determination of gestational age in lunar months:

 This is calculated by 'Rule of Haase & Morison Rule"
 According to Haase's rule, if the crown heel length of the fetus is 25 cm and less,
the gestational age in lunar months represents the square root of this length in
cm.
 According to Morison's Rule, if the crown heel length of the fetus is more than 25
cm, the gestational age in lunar months is - crown heel length in cm divided by 5.

Gestational age for viability:

 210 days/ 7 calendar months
Or
 Weight more than 1 kg

Development of the fetus at the end of 7th lunar month (At the age of onset of
fetal viability):
 Crown–heel length: 35 cm.
 Crown–rump length: 23 cm.
 Weight: 900 – 1100 gm.
 Subcutaneous fat begins to deposit.
 Nails are thick but do not extend to the tips of fingers and toes.
 The eyelids are open, and the pupillary membrane has almost disappeared.
 Testicles (in a male foetus) are found at the deep inguinal ring.
 Meconium is seen almost throughout the large intestine.
 Centre of ossification for calcaneum appears at 5th month intrauterine life (IUL).
 Centre of ossification for talus appears at 7th month intrauterine life (IUL).
 Ossification centers for the manubrium and the body of sternum (first three
segments) are usually evident.

DEVELOPMENT OF THE FOETUS

Intrauterine:
 Fertilized ovum : 7 to 10 days (from the time of fertilization to the time of
implantation)
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 Embryo: until the end of 2 months of gestation (1 week – 2 months)
 Foetus: beyond 2 months until birth.

Extra uterine:
 Neonate: first 28 days of extra-uterine life.
 Infant: 28 days – 12 months (1 year).
Gestational period:
 40 weeks / 10 lunar months / 280 days
(1 lunar month = 28 days; 1 calendar month = 30 days)
 Appearance of fetus at the end of 10th lunar month (40 weeks/full term fetus)
 Crown–heel length: 50 cm.
 Crown–rump length: 30 cm.
 Head circumference: 35 cm.
 Bi-parietal distance: 9.5 cm.
 Weight: 2500 – 3000 gm.
 Finger and toe nails have grown beyond the tips of the respective fingers and
toes.
 Pupillary membrane is absent.
 Both the testicles have descended into the scrotum (palpable in the scrotum).
 Meconium is seen throughout the large intestine.
 Ossification centre for the lower end of the femur (9th month IUL) and upper
end of tibia (10th month IUL) are present.
 Foetal end of the umbilical cord attachment is midway between the
xiphisternum and pubis.
 Lanugo has completely disappeared, or is present only on the shoulders.
 Head/scalp hair is 2-3 cm in length.
 Skin is covered with vernix caseosa (It is a mixture of sebaceous gland
secretions and exfoliated epidermal cells) which is readily seen in the flexures
of the joints and neck folds.
 Fetal hemoglobin forms 70-80% of total hemoglobin.
 Umbilical cord:
 Length: 50 cm.

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  Diameter : 1.5 cm
 Placenta: (Ratio of placental weight to the fetal weight is 1:5)
 Thickness at the center: 2.5 cm
 Diameter: 15 – 20 cm
 Weight: 500 gm
 Fetal Hemoglobin:
 At full term birth, HbF forms 70-80% of the total Hb.
 HbF is completely replaced by HbA at 6 months (6-12 months).
 Meconium:
 Contents of the foetal intestinal tract are collectively known as
meconium.
 Foetus begins to swallow amniotic fluid (liquor amnii) during the
4th month IUL.
 Meconium is a mixture of shredded lanugo and exfoliated epithelial cells
from the fetal skin which are swallowed with the amniotic fluid. Intestinal
mucus and exfoliated intestinal cells add to the content.
 At the end of 4th lunar month IUL, meconium is seen in the upper part of
small intestine.
 At the end of 5th month, meconium is seen at the beginning of the large
intestine (ilio–caecal junction).
 At the end of 6th month meconium is seen in the proximal part of the
large intestine.
 At he end of 7th month meconium is seen almost throughout the large
intestine.
 8th / 9th / 10th month – meconium throughout the large intestine.
 It is generally expelled in a day or two after birth.
Centers of Ossification:
 Examination of ossification centers may be performed radio-graphically or by
dissection during autopsy.
 Age of appearance of ossification centers in intra – uterine lunar months.
 Foot :
 Calcaneum – 5 months of IUL.

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  Talus – 7 months of IUL.
 Cuboid – 9 months of IUL.
 Sternum : (Body of sternum is made of 4 segments)
 Manubrium – 5 months of IUL.
 Body of sternum, 1st piece – 5 months of IUL.
 2nd piece – 7 months of IUL.
 3rd piece – 7 months of IUL.
 4th piece – 9 months of IUL.
 Knee :
 Lower end of femur – 9 months of IUL.
 Upper end of tibia – 10 months of IUL.
Lanugo:
 Fine, soft, thin, downy, foetal body hair
 Visible on the body at the end of 4th month
 Lanugo disappears from the face at the end of 8th month.
 At full term, lanugo may be present only on the shoulders (or disappears
completely).
Hair:
 Scalp hair begins to appear at the end of 5th month.
 At term, it is 2-3 cm in length.
Nails:
 Begin to appear in the form of thin membranes on the fingers and toes at the end
of the 3rd month.
 Nails are thick but do not extend to the tips of fingers and toes at the end of 7th
month.
 Nails reach the tips of fingers and toes at the end of 8th month.
 At term, nails project beyond the finger and toe tips.

Descent of the testis: The left testis descends earlier than the right.

5th month
[present in relation to the kidney]

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 6th month
[still intra – abdominal / in relation to psoas (posterior abdominal wall)]

7th month
[at the superficial inguinal ring]

8th month
[in the inguinal canal]

9th month
[at the deep inguinal ring]

10th month
[present in the scrotum]

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LAWS IN RELATION TO INFANTICIDE & FETICIDE
 Section 315, Indian Penal Code, act done with intent to prevent child from being
born alive or to cause it to die after birth
 Section 316, Indian Penal Code, causing death of quick (Quickening denotes
the perception of active fetal movements by the mother which is felt at about 18th
week) unborn child by act amounting to culpable homicide.
 Sec 317, Indian Penal Code, ‘Abandonment of child under 12 years, by parent
or person having care of it’
 Sec 318, Indian Penal Code, Concealment of birth by secret disposal of dead
body.

STILL BIRTH
Definition:
Conventionally it is defined that, the still born child is one, which has issued forth
from the mother after 28 weeks of pregnancy and did not breathe or show any signs
of life after being completely expelled (The Infanticide Act, 1922, England).
Or
The World Health Organization defines stillbirth as death of a fetus before complete
expulsion or extraction from the mother, irrespective of the gestational age.
 This legal definition of stillbirth does not coincide completely with medical
interpretation. For instance, to a doctor, a baby might be obviously alive when
half born.
 This loophole was later plugged by the Infant Life (Preservation) Act 1939
(England). The term ‘child destruction’ was framed to describe the deliberate
killing of a child during labour before being completely expelled from the mother.
 As per the explanation under section 299, Indian Penal Code, which describes
culpable homicide, the causing of the death of child in the mother’s womb is not
homicide. But it may amount to culpable homicide to cause the death of a living
child, if any part of that child has been brought forth, though the child may not
have breathed or been completely born.
 Causes of Still Birth are,

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  Chronic disease in mother – E.g.: Tuberculosis, Syphilis, and Diabetes
Mellitus.
 Difficulty in labour- E.g.: Malposition of fetus, Abnormality of bones of pelvis.

DEAD BIRTH
Definition:
A dead born child is one which has died in utero before the birth process began and
shows either rigor mortis at delivery, intra-uterine maceration, intra-uterine
mummification or intra-uterine putrefaction after it is completely born [period of
gestation is immaterial].
1. RIGOR MORTIS AT DELIVERY:
 If rigor mortis is present at delivery then death has occurred at least 2 to 3
hours prior to expulsion.
 Due to the rigor mortis there will be difficulty in delivery.
2. INTRA-UTERINE MACERATION
 It is a process of aseptic autolysis which occurs when the dead fetus remains
in the uterus for some period surrounded with liquor amnii, but with exclusion
of air (intact fetal membranes).
 Prerequisites for intra-uterine maceration:
 Dead born child in utero for 12 hours or more.
 Plenty of liquor amnii.
 Exclusion of air.
 Intact membranes.
 If a child is born less than 12 hours after being dead in utero, it would be
difficult to say whether the child died in utero or during the birth process
(parturition).
 Signs of maceration:
 First sign of maceration is separation of the epidermis from the dermis on
applying pressure (expected if the infant has been dead in utero for 12
hours or more).
 Development of "parboiled" appearance due to the increased vascular
permeability.

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  By 24 hours after death, there is collection of fluid beneath the epidermis
to form bullae. If these bullae are disrupted during birth or on handling of
the dead fetus, large areas of the skin may separate and leave a raw
weeping body surface.
 Uniform deep reddish purple discoloration of all internal tissues due to the
progressive hemolysis.
 After several days (usually 5 to 7 days after fetal death, but can be seen
as early as 48 hours after fetal death), there will be shrinkage of the brain
and the dura gradually becomes separated from the cranial bones leading
to loss of alignment, loosening and overriding of the cranial vault bones.
Overriding of the cranial vault bones when seen radio-graphically is known
as Spalding’s sign.
 If the dead born fetus is retained in utero for more than a week, there is
gradual fading of the tissue from reddish purple to a yellowish brown color
(coppery brown color).
 Body of a macerated foetus is soft, flaccid and flattened
 It emits a sweetish disagreeable smell, different from that of putrefaction.
 Joints are abnormally mobile, easily separable.
 Serous cavities may contain red turbid fluid
3. PUTREFACTION
 Following fetal death in-utero, putrefaction takes place when the fetus is
surrounded with amniotic fluid and exposed to air (rupture of fetal membranes
provides fetal access to air entering through the mother’s external genitalia).
 Putrefaction occurring after the delivery of the child may not be
distinguishable from that occurring in-utero.
4. MUMMIFICATION
 Occurs when the fetus dries up from the deficient supply of blood and more
importantly scanty amniotic fluid, but with the exclusion of air.
 Prerequisites for intra-uterine mummification:
 Dead fetus in utero.
 Scanty liquor amnii.
 Intact fetal membranes.

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  Exclusion of air.
 Longer time in utero
 Usually seen in twin pregnancy - in which the fetus is one of two or more
sharing the uterus. If the fetus is older than eight weeks at the time of its
death, and is retained in the uterus for at least ten weeks, it may undergo
mechanical compression such that it takes on a flattened, mummified
appearance with a surface texture resembling that of parchment termed as
Fetus Papyraceus (ie, a "mummified" or compressed fetus).
 A Lithopedion (Greek: litho = stone; pedion = child), literally “stone-child” in
Greek, is a rare obstetric phenomenon in which the remains of an
undiagnosed extra-uterine pregnancy calcify.

RADIOLOGICAL SIGNS OF FETAL DEATH IN UTERO

A. SPALDING'S SIGN
 Classical radiological sign of fetal death.
 Spalding's sign: After several days (usually 5 to 7 days after fetal death, but
can be seen as early as 48 hours after fetal death), there will be shrinkage of
the brain and the dura gradually becomes separated from the cranial bones
leading to loss of alignment, loosening and overriding of the cranial vault
bones. Overriding of the cranial vault bones when seen radiographically is
known as Spalding's sign.
B. ANGULATION OF THE SPINE: i.e. Exaggeration of the fetal spine curvature is
caused by loss of tone of para-spinal muscles and ligaments. On radiograph it
appears as a crumpled up fetus with its spine angulated and ribs crowded
together.
C. ROBERTS SIGN: Gas in the large vessels caused by degeneration of blood.
D. DEUEL'S HALO SIGN: Elevation of pericranial fat.

LIVE BIRTH
Definition:
Medically the term live birth is used when a child has showed signs of life, even if
only a part of the child was not out of the womb, though the child may not have
breathed or been born completely.

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Signs of live birth:
1. In Civil Cases, as preponderance of evidence is sufficient, any sign of life after
birth of the child is accepted as proof of live birth.
 Cry of the baby
 A child may cry in uterus, termed as Vagitus Uterinus.
 A child may cry in vagina, termed as Vagitus Vaginalis.
 Movements ( muscles may twitch for sometime after death )
2. In Criminal Cases, things are to be proved or established beyond reasonable
doubt. As the law presumes that every newborn child found dead, was born
dead until the contrary is proved. So infanticide charges are to be proved beyond
reasonable doubt. Therefore signs of live birth are to be demonstrated by
autopsy.

Signs of live birth at autopsy include:

1. Signs of respiration.
2. Other signs of live birth:
 Changes in the stomach & intestine.
 Extraneous material in the lungs.
 Changes in the middle ear.
 Skin changes.
 Umbilical Cord.
 Blood.
 Changes in circulation.
 Cephal-hematoma.
 Caput Succedaneum.
 Meconium.
SIGNS OF RESPIRATION:
A. Difference between Respired and Un-respired lungs
Features Respired Lungs Un-respired Lungs
Shape of Chest Arched or drum shaped. Flat.
Diaphragm Level of 6th or 7th rib Level of 4th or 5th rib
Lungs:
Volume Voluminous, fill the thoracic Small, lying at the back of
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 cavity , overlap heart, thoracic cavity behind the
heart.
Edges/Margins Rounded to varying extent Clearly defined and sharp
Uniformly reddish brown or
Color Mottled pink
bluish red
Marbled or mottled due to
expanded air vesicles and Smooth and not marbled
Appearance
development of circulation (reddish brown in color)
(pinkish color)
Soft, spongy, elastic and Dense, firm ,liver-like and
Consistency
crepitant non-crepitant
Expanded, rising above the
Alveoli Not so
surface
Exude little blood but no
Cut section Exude frothy blood
froth
Weight of the lung :
Weight of the lungs is 1/35th Weight of the lungs is 1/70th
body weight
of body weight of body weight
(Ploucquet's Test).
Hydrostatic test and
‘Limited value’
microscopy -
Amount of blood in
Doubles after respiration Less
lungs
Weight of both the
lungs (Static or 60-70 grams 30-40 grams
Fodere's Test)
 Presence of Hyaline membrane is a confirmatory sign of initiation of respiration.
 Histology of the lungs and demonstration of alveolar aeration is a corroborative
evidence of respiration. For this purpose, thoracic contents should be removed
intact up to the larynx by 'no-touch' technique of Osborn.
HYDROSTATIC LUNG TEST OR RAYGER'S TEST:
This is an experiment in which lungs of a new born victim are placed in a vessel
containing water, in order to judge from their specific gravity whether or not child has
breathed. Karl Rayger is entitled to the honour of being the original proposer of the
hydrostatic lung test. Dr. John Schreyer is said to have actually employed this test in
a medico-legal case. The principle of which was explained by Galen.
Principle:
It is based on the principle that the specific gravity of the unrespired lungs varies
from 1.04 to 1.05 and that of respired lungs is 0.94, because of increase in volume
due to inhalation of air and that of the water is 1. The fetal lungs therefore sink in
water, and those that have respired, float.

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Procedure:
The lungs are carefully removed as far as the trachea along with the larynx, by tying
at the laryngeal end after ligating the large vessels of the neck and placed in a jar of
water and noted for their floatation. A piece of liver is also placed in the same jar to
exclude the putrefaction (Control Specimen). The lungs are then separated and each
is tested separately for the presence and absence of floatation. Finally, each lung is
then cut into fragments which are again tested for floatation.
Inference:
If in all such events, floatation is present the test is positive (provided putrefaction is
absent). If there is some decomposition, then the fragments should be compressed
to remove the tidal air under water (if escaping air bubbles are of equal size and
shape, it indicates the presence of respired air). The fragments are again placed in
water. If they continue to float even after this compression, it indicates the floatation
due to presence of residual air, the test is positive and respiration has taken place. If
some of the pieces sink and some float, it shows feeble respiration owing to the
partial penetration of the air.
Fallacies of Hydrostatic Lung Test:
 False positive findings: These may be evoked under the following circumstances,
 Expanded lungs may sink from:
 Oedema.
 Bronchopneumonia.
 Atelectasis (non-expansion).
 Unexpanded lungs may float from:
 Presence of putrefactive gases
 Artificial Respiration: The fetal lungs may be artificially inflated by
 blowing air through a tube or catheter or by mouth-to-mouth method.
Hydrostatic test is not necessary when:
 The fetus is born before 180 days of gestation.
 The fetus is a monster and incapable of leading a separate existence.
 The fetus shows signs of intrauterine maceration.
 The umbilical cord has separated and the umbilicus has cicatrized.
 The stomach contains milk showing active digestive function.

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CHANGES IN THE STOMACH & INTESTINE:
 Presence of milk in stomach is positive proof that child has lived for some time.
 STOMACH BOWEL TEST OR BRESLOW'S SECOND LIFE TEST
Principle:
During the process of respiration, some air is likely to be swallowed, going into
the stomach and further into the intestine due to the peristalsis. Air which is
swallowed during crying can be seen in the stomach of the infant 5-15 minutes
after the birth, in the small intestine after 1-2 hours, in the large intestine after 5-6
hours and in the rectum after 12 hours. Demonstration of this air specially in the
intestine (duodenum) which can only enter if there is active peristalsis, is a
reliable evidence of child being born alive.
Procedure:
Stomach along with the duodenum is removed after applying double ligatures at
each end of the stomach and at the end of the duodenum. They are first placed
together in the wide mouthed jar containing water. Then the stomach and
duodenum are placed separately in the water with ligature at the ends of the
stomach and intestine intact.
Inference:
If the stomach along with the duodenum floats when placed in water it is a
reliable evidence child being born alive. More so when there is floating of
duodenum when placed separately, is a confirmatory sign of child being born
alive because air can enter duodenum only if there is active peristalsis.
PRESENCE OF EXTRANEOUS MATERIAL IN THE LUNGS:
Demonstration of extraneous material in the secondary bronchi and beyond is
strongly indicative of its inhalation and of child being born alive.

CHANGES IN THE MIDDLE EAR (WREDIN'S TEST):

In the fetus middle ear contains gelatinous connective tissue, which is replaced by
air after the onset of respiration.

SKIN CHANGES
 Color:
 Skin is bright red at birth.

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  Skin becomes darker on the second or third day.
 Physiological jaundice is evident over the skin between the third and sixth
day.
 Exfoliation of the skin occurs during the first three days after birth.
 Skin attains its normal colour, week after birth.
 Vernix Caseosa:
 The vernix caseosa is chiefly present in the flexures of the joints and neck
folds. Vernix caseosa is a dirty white, fatty cheesy material comprising of
sebaceous secretions, fat droplets, lanugo hairs and epithelial cells.
 It is removed by washing. Being sticky, it cannot be easily removed and
persists for a day or two.
UMBILICAL CORD
 Changes in the umbilical cord begin to appear in the cut end to its base at
umbilicus in the following order:
 Within 2 hours blood clots at the cut end of the umbilical cord.
 Within 12 to 24 hours, cord attached to body begins to shrink and desiccate.
Drying starts at the free end of the cord.
 Within 36 to 48 hours, inflammatory red zone forms at and around the base of
the cord accompanied by slight serosanguinous discharge from the area.
 Within 2 to 3 days, cord gets shriveled up and mummified (no medico-legal
significance as same process is seen in dead also).
 Within 5 to 6 days, cord falls off leaving a raw ulcerated area.
 Within 10-12 days, raw ulcerated area heals up and gets completely
cicatrized.
 Dry & withered cord that has fallen off if placed in water will swells up to its
original state, more or less.

BLOOD
 Hemoglobin:
 Initially hemoglobin is of fetal type (22).
 From 24th week of gestation, adult type of hemoglobin (22) appears.
 At term 75% to 80% of total hemoglobin is fetal type.
 3 months after birth fetal type hemoglobin gets reduced to 6% to 8%.
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  Fetal hemoglobin is completely replaced by Adult hemoglobin at 6 months (6-
12 months)
 Red blood cells: Nucleated red blood cells usually disappear from the circulation
within 24 hours or so.

CHANGES IN CIRCULATION
After birth following essential changes in circulation take place:
 Umbilical arteries (medial umbilical ligament) get completely obliterated by 3
days.
 Umbilical veins (remnant is ligamentum teres of liver) get completely obliterated
by 4 to 6 days.
 Ductus arteriosus (remnant is ligamentum arteriosum) gets completely obliterated
by 7 to 10 days.
 Ductus venosus (remnant is ligamentum venosum) gets completely obliterated by
9 to 10 days.
 Foramen ovale gets completely obliterated by 2 to 3 months.
CEPHALHEMATOMA
 Cephalhematoma is the localized collection of blood between peri-cranium and
flat bone of skull most frequently parietal bone.
 It is due to the rupture of small emissary veins from the skull and may be
associated with the fracture of skull bone.
 Never present at birth, gradually develops after 12 to 24 hours.
 May be caused by forceps delivery but may also be met with following a normal
delivery.
 The circumscribed swelling is limited by the suture lines of the skull as the
pericranium is fixed firmly to the margins of the suture.
 Resolves like a bruise and disappears in 10-14 days.

CAPUT SUCCEDANEUM
 Caput Succedaneum is a edematous swelling over the presenting part (of head)
 during delivery (in vertex presentation) due to the presence of rigid cranial ring.
 Most common site is fronto-parietal region.

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 This is formed by serum due to the interference with venous return and lymphatic
drainage from unsupported dependent area leading to stagnation of fluid and
appearance of swelling in scalp.
 The swelling is due to the stagnation of fluid in the layers of the scalp and is
diffuse boggy in nature.
 It is not limited by the suture line.
 Disappears within 2 to 5 days after birth (some times spontaneously within 1
day).
MECONIUM: It is expelled 1 to 2 days after birth.
PERIOD OF SURVIVAL AFTER BIRTH
This can be ascertained by the changes in the skin, changes in the umbilical cord,
changes in the circulation, changes in the blood, caput succedaneum and
Cephalhematoma which has been already explained.
CAUSE OF DEATH
Cause of death can be divided into two types:
1. Natural Cause.
2. Unnatural cause.
 Natural death may be due to immaturity, debility due to lack of general
development, congenital diseases, malformations, Rh incompatibility, intrapartum
or antepartum anoxia and neo natal anoxia.
 Unnatural causes of death can be divided into,
 Accidental
&
 Criminal (Acts of omission & Commission).
 Accidental causes of death:
 Accidental deaths may be due to prolonged labour, cord prolapse, birth in caul
("born in the caul" simply means a child is born with the amniotic sac or
membranes still intact around a newborn's body. The sac consists of two
adherant membranes (chorion and amnion) of fetal origin which separate the
amniotic fluid and fetus from the maternal uterine wall. When a baby is born in
the caul, the sac balloons out at delivery, covering the baby's face and body
as he or she emerges from the mother), precipitate labour ( wherein all the

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 three stages of labour are merged into one as a result sudden and rapid
delivery of the fetus without previous warning or knowledge of the mother).
 Precipitate labour:
 It is an entity wherein all the three stages of labour are merged into one
leading to sudden and rapid delivery of fetus without previous warning or
knowledge of the mother. Usually occurs while attending natures call.
 Commonly seen in multi-para with wide roomy pelvis and old perineal tear
more so under strong uterine contraction, premature and small fetus
relative to the size of pelvis, and large amount of amniotic fluid.
 Salient features include, since there is no evidence of moulding of head
there is no caput succedaneum, umbilical cord is usually found torn
across, tear is commonly close to the fetal end than placenta, foreign
materials like mud, gravel and sand found struck to hairs of scalp, and
fissured fracture usually limited to parietal bones.
 Medico-legal significance of precipitate labour:
a) Mother or her relatives can be accused of infanticide while baby died
due to effects of precipitate labour.
b) Plea of precipitate labour is put forward as a defence in case of charge
of infanticide.
 Acts of omission (failure to save child after birth –criminally negligent) are failure
to – provide proper assistance during labour, seek medical help, ligate the cord
after cutting, clear the air passages, protect child from heat and cold and supply
the child with proper and adequate food.
 Acts of commission (acts done positively to cause death of infant) are
smothering, gagging, strangulation, drowning, blunt force impact over head,
sharp weapon injuries, administration of poison in the milk , and inflicting
concealed injuries (sites are anterior fontanelle, ear, nape of the neck, inner
canthus of the eye, nostrils, soft palate, axilla and genitalia.

THE BATTERED BABY SYNDROME

Battered child syndrome refers to injuries sustained by a child as a result of physical
abuse, usually inflicted by an adult caregiver.

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Synonyms:
 Battered child syndrome.
 Shaken Baby Syndrome.
 Child abuse syndrome.
 Non-accidental injury in childhood’ syndrome.
 Caffey’s syndrome (John Caffey, a Radiologist. described the condition as typically
having subdural haematomas, retinal haemorrhages, fractures of the long bones of
the limbs, rib fractures and little or no sign of external trauma to the head).
 Whiplash Infant Syndrome.
[[

Classical and characteristic features of battered baby syndrome:

1. Inexplicable delay between serious injury and the seeking of medical or other
assistance.
2. Disparity between clinical findings and the parental explanation (history of
presenting complaints).
3. Injuries inflicted are of different duration.

Salient Features:
 Main injuries: bruises (contusions), fractures of bones (skull / long bones),
damage to internal abdominal organs.
 Bruises around mouth, eyes and ears (face).
 Bruises on arms, legs, abdomen.
 Black eye.
 Bruising and laceration of lips.
 Circular “six penny bruises” from adult finger pads.
 Bruises may be of different colours and thus duration, signifying intermittent
abuse.
 Multiple fractures.
 Subdural haemorrhage may be found.

Diagnosis:
 Radiology is essential to detect multiple fractures and fractures of different ages,
indicating intermittent abuse.
 Radiological signs:
 Large periosteal haematomas.
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  Callous formation on X-ray is seen as ‘string of beads’ appearance in the
paravertebral gutter (Nobbling fracture).
 Transverse and spiral fracture of long bones.
 Old fractures and especially metaphyseal and epiphyseal injuries in various
stages of healing.
 Seperation of epiphysis especially around the elbow and knee joint although
any limb may be involved.
 History indicating classical features and characteristics of injry sustained.
Medico-legal significance of battered baby syndrome:
Offences against children may be dealt with on the same basis as if the victim were
adult.
MUNCHAUSEN SYNDROME BY PROXY
Munchausen's Syndrome by Proxy (MSP) is a type of factitious disorder, is a mental
illness where parents, usually the mother, fabricate symptoms in their children, thus
subjecting the child to unnecessary medical tests and/or surgical procedures, in
order to attract attention, sympathy, or to fill other emotional needs. In some cases,
the parents also inflict injury and can kill their children in the process. It has been
known by this name as, due to its similarity to Munchausen syndrome, in which a
person feigns or induces illness in them for similar emotional reasons.
Clinical Features:
The adult falsifies history and may injure the child with drugs or other agents or add
blood or bacterial contaminants to urine specimens to simulate disease. The parent
seeks medical care for the child and appears to be deeply concerned and protective.
The child typically has a history of frequent hospitalizations, usually for a variety of
nonspecific symptoms, but no firm diagnosis. Victimized children may be seriously ill
and sometimes die.

Medico-Legal Significance of Munchausen Syndrome by Proxy:

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Sometimes these babies do not survive the damage induced by the parent. If there is
no autopsy or death scene investigation, these infants can wrongly be labeled as
SIDS.
SUDDEN INFANT DEATH SYNDROME ( SIDS)
Synonyms:
 Cot death
 Crib death
 Sudden unexplained infant death syndrome
Definition:
Sudden Infant Death Syndrome is the term for the sudden and unexplained death of
an apparently healthy infant aged one month to one year. SIDS is a definition of
exclusion and only applies to an infant whose death remains unexplained after the
performance of an adequate postmortem investigation including (1) an autopsy, (2)
investigation of the scene and circumstances of the death and (3) exploration of the
medical history of the infant and family.
Risk Factors for SIDS:
 Babies who sleep on their stomachs.
 Babies who have soft bedding in the crib.
 Multiple birth babies.
 Premature babies.
 Babies with a sibling who had SIDS.
 Mothers who smoke or use illegal drugs.
 Teen mothers.
 Short intervals between pregnancies.
 Late or no prenatal care.
 Situations of poverty.

INCOMPLETE LIST OF QUESTIONS FROM INFANTICIDE

1. Objectives of fetal autopsy.
2. Development of the fetus at the end of 7th lunar month (at the time of viability)
3. Explain the fetus at the end of 10th lunar month (40 weeks/full term fetus).
4. Laws in relation to infanticide & feticide
5. Signs of live birth at autopsy.
6. Skin changes in a case of live birth.

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7. Umbilical cord changes after live birth.
8. Blood and circulatory changes indicating period of survival after birth.
9. Explain the signs indicative of period of survival after birth.
10. Write briefly on the following:
A. Viability.
B. Still birth.
C. Dead birth.
D. Intra-uterine maceration.
E. Radiological signs of fetal death in utero.
F. Live birth.
G. Hydrostatic lung test.
H. Stomach bowel test.
I. Cephalhematoma.
J. Caput Succedaneum.
K. Precipitate labour.
L. Acts of omission.
M. Acts of commission.
N. Battered baby syndrome
O. Munchausen syndrome by proxy.
P. Munchausen syndrome.
Q. Sudden infant death syndrome (SIDS).

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 INSECTICIDES
Insecticides are compounds that are used to kill insects.
CLASSIFICATION
Insecticides are classified under the following three categories.
A. INSECTICIDES OF CHEMICAL ORIGIN
 Organophosphate insecticides:
 Hexaethyl tetra phosphate (HETP)
 Tetra ethyl pyrophosphate (TEPP)
 Octamethyl pyrophosphoramide (OMPA)
 Follidol
 Tic–20
 Parathion
 Malathion
 Organochloro compounds: DDT, Endrin etc.,
 Carbamates: Baygon liquid

B. INSECTICIDES OF PLANT ORIGIN

 Pyrethrins
 Pyrethroids
 Nicotine
 Rotenone
SOME OF THE IMPORTANT TERMINOLOGIES
Pesticides, are compounds that are used to kill pests.
Rodenticides, are compounds that are used to kill rats, mice, and other rodents
E.g., Strychnine
Warfarin
Thallium
Zinc phosphide
Arsenic
Yellow phosphorus
Herbicides, are compounds used to kill weeds
e.g: Paraquat
Diquat
Glyphosate
Dioxins
Fungicidies, are compounds used to ill fungi and moulds
e.g.: Pentachlorophenol

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 Daminozide
Chlorthalonil
MEDICO-LEGAL SIGNIFICANCE OF INSECTICIDE POISONING
Insecicides (organophosphates, organochlorines and carbamates) are the commonest
substances used for suicide in India, because of their easy availability.

ORGANOPHOSPHATES
 Derivatives of phosphoric acid
 Often involved in serious human poisoning
E.g.:
 Parathion
 Malathion
 Fenthion
 Tetraethylpyrophosphate
 Organophosphates are rapidly absorbed via the gastrointestinal, dermal,
conjunctival (ocular) and respiratory routes, metabolized by the liver, and exerted in
the urine.
MECHANISM OF ACTION
Organophosphates

Combines with enzyme acetylcholinesterase

Phosphorylates and deactivates enzyme acetylcholinesterase

Accumulation of acetylcholine at synapses and neuromuscular junctions

Effects caused by excess acetylcholine

 Phosphate radicals of the organophosphate compounds bind to the active sites of

the enzyme acetylcholinesterase, forming phosphorylated enzyme that is inactive
(Phosphorylation of the enzyme).
 This renders the enzyme incapable of degrading the neurotransmitter acetylcholine.

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 This leads of accumulation of acetylcholine at synapses and neuromuscular
junctions.

 The excess of acetylcholine initially excites and then paralyses transmission in

cholinergic synapses, which include:
1. Muscarinic effects resulting from potentiations of parasympathetic activity
primarily on smooth muscles
2. Nicotinic effects resulting from accumulation of acetylcholine at the motor end
plate and autonomic ganglia, and
3. Central nervous system effects causing initial stimulation and eventually
depression.
4. Delayed neurotoxicity

ACETYL CHOLINESTERASE
 Acetylcholine is the most important chemical transmitter at synaptic functions.
 Acetyl-cholinesterase breaks down acetylcholine by hydrolysis into inert fragments.
 Cholinesterases:
 Pseudocholinesterase (plasma cholinesterase) is found in the liver and
serum / plasma.
 True cholinesterase (acetylcholinesterase / red cell cholinesterase) is
found in the nervous tissue and erythrocytes.
 Plasma and RBC cholinesterase levels are depressed in organophosphate
poisoning.
 The inactivation of cholinesterase enzymes by organophosphates becomes
progressively irreversible after 24-36 hours.
 Gradual increase in cholinesterase levels generally parallels chemical improvement.
 Clinical features of organophosphate poisoning usually appear when plasma
cholinesterase levels decline to less than 50% of the normal value.
 Rough guide of acute stage of OP poisoning.
 20-50% of the normal value is found with mild OP poisoning.
 10-20% of the normal value is found with moderate OP poisoning.
 <10% of the normal value is found with severe OP poisoning.

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CLINICAL FEATURES OF ORGANOPHOSPHATE INSECTICIDE POISONING
 Clinical features of OP poisoning depend on the balance between stimulation of
muscarinic and nicotinic receptors.
 Kerosene – like odour of the breath (organophosphates are packaged in a
hydrocarbon vehicle / petroleum distillate carrier).
 Duration of symptoms depends on the severity of the poisoning, the
organophosphate compound involved, and the therapeutic intervention.
 Signs and symptoms are usually seen within 12-24 hours of exposure.
 Clinical features due to stimulation of muscarinic receptors (mnemonic –
DUMB3ELS).
 Diarrhoea
 Urination
 Miosis
 Bradycardia / Bronchospasm / Bronchial secretions
 Emesis
 Lacrimation
 Salivation
 Clinical features due to stimulation of nicotinic receptors. (mnemonic – MATCH)
 Muscle weakness and fasciculation’s
 Adrenal medulla activity increase
 Tachycardia
 Cramping of skeletal muscles
 Hypertension
 CNS effects of organophosphates:
 Anxiety, restlessness, seizures, lethargy, coma, depression of respiratory
and cardiovascular centers.

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 Full recovery generally occurs within 10 days when optimum treatment is quickly
instituted.
 Death occurs secondary to respiratory arrest caused by respiratory muscular
weakness, CNS depression, and excessive bronchial secretions.
 Untreated patients usually die within 24 hours, and treated patients who die do so
within 10 days.

CLINICAL EFFECTS OF ORGANOPHOSPHATE POISONING

(Acetylcholine excess)
Anatomic site of action Physiologic effects
Muscarinic effects
Sweat glands --- Sweating
Lacrimal glands --- Lacrimtion
Salivary glands --- Excessive salivation
Urinary bladder --- Urinary incontinence
Gastrointestinal --- Vomiting, diarrhea
Bronchial tree --- Wheezing
Cardiovascular --- Bradycardia, fall in blood pressure
Pupils --- Constricted pupils
Ciliary body --- Blurred vision
Nicotinic effects
Skeletal muscles --- Fasciculations, cramps, weakness,
twitching, paralysis, respiratory
embarrassment, cyanosis, respiratory arrest.
Sympathetic ganglia --- Tachycadia, elevated blood pressure
CNS effects --- Anxiety, restlessness, convulsions, coma,
respiratory and circulation depression

 Organophosphate intermediate syndrome

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  Occurs approximately a week after poisoning due to long lasting
cholinesterase inhibition and muscle necrosis.
 Features include paralysis of proximal limb muscles, neck flexor muscles,
respiratory muscles and various motor cranial nerves.
 Delayed peripheral neuropathy
 May occur 2-5 weeks after exposure to organophosphates.

MANAGEMENT OF ORGANOPHOSPHATE POISONING

General measures
1. Airway management
 Frequent suctioning of secretions
 Respiratory support / intubation
 Adequate oxygenation
2. Dermal decontamination
 Removal of clothes
 Repeated washing of the skin with soap and water.
3. Gastrointestinal decontamination
 Gastric lavage after precautionary measures.
 Activated charcoal
 Cathartic (eg. Magnesium citrate)
4. Control of seizures
 Intravenous diazepam or I.V. lorazepam
 If seizures persist, I.V. Phenobarbital or I.V. phenytoin
 General anaesthesia for status epilepticus uncontrolled by the above
measures.
5. Control of arrythmias
 Lidocaine or procainamide or by defibrillation

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6. Patients who intentionally ingest organophosphates in a suicide attempt should
undergo psychiatric evaluation and counseling.

Specific Measures
1. Atropine
 Atropine is an antagonist of acetylcholine at muscarinic receptor sites.
 It is a tertiary amine that crosses the blood brain barrier.
 Atropine antagonizes both muscarinic and CNS effects of organophosphate
poisoning.
 It has no effect on muscle weakness or respiratory failure in severe poisoning,
since this drug does not reactivate the cholinesterase enzymes. (Atropine has
no effect on skeletal muscle and autonomic ganglia).

 After the patient is oxygenated to minimize the risk of atropine – induced

ventricular (cardiac) irritability, atropine is administered in the following initial
doses:
 Adult : 1 to 2 mg I.V.
 Paediatric : 0.01 mg / kg body wt, I.V.
 Atropine should be used for at least 24 hours as a physiologic antidote to block
the effect of acetylcholine, while the organophosphate is being metabolized.
 Repeat doses of atropine are given as follows:
 Adult : 2 mg I.V.
 Paediatric : 0.05mg / kg, I.V.
 These repeat doses are repeated every 15 minutes until bronchial secretions are
controlled, as this muscarinic receptor – mediated effect poses the greatest life
threat.
 Other parameters, such as papillary size, should not be used to gauge the
therapeutic efficacy of atropine.
 Once bronchial secretions have been controlled, atropine administration should
be repeated whenever the secretions begin to recur.
 Atropine should be tapered in those patients who begin to show signs of
improvement usually after 12-24 hours.

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  The average patient poisoning with organophosphates requiring 40 mg of
atropine / day. At times larger doses may be required.

2. Oximes:
 Pralidoxime or Obidoxime.
 Obidoxime is not available in India.
 Pralidoxime is a quaternary amine, and does not cross the blood – brain barrier.
 Pralidoxime reverses both muscarinic and nicotinic effects of organophosphate
toxicity.
 Pralidoxime cleaves the phosphorylated acetylcholinesterase, thus freeing and
reactivating acetylcholinesterase.
 Pralidoxime should be administered in all known or suspected OP poisoning, in
addition to atropine.
 Pralidoxime is more likely to be effective if administered early. It’s efficacy
reduces after 24 hours of OP poisoning (because of the ageing of the enzyme
where in the enzyme becomes permanently inactive).
 Initial dosage of pralidoxime:
 1 to 2 g I.V. slowly (adult)
 25-50 mg/kg I.V. slowly (paediatric)
 Pralidoxime can be repeated in 1 hour and then every 8-12 hr until the patient is
clinically well.

POSTMORTEM EXAMINATION FINDINGS ORGANOPHOSPHATE POISONING

1. Characteristic kerosene – like odour (clothes; around mouth and nostrils; stomach
contents).
2. Frothing at mouth and nose
3. Airways flooded with frothy fluid
4. Pulmonary oedema
5. Congestion of gastrointestinal tract
6. Congestion of other viscera

CARBAMATES
 Derivatives of carbonic acid
 Cholinergic toxins

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 Anticholinesterases
 Cholinesterase inhibitors
MECHANISM OF ACTION
 Carbamates inhibit cholinesterase enzymes by carbamylation.
 Inhibition of cholinesterase by carbamates is self-limited (Carbamate insecticides
are reversible cholinesterase inhibitors).
 The spontaneous return of cholinesterase activity by carbamates accounts for the
less severe intoxication seen with carbamates versus organophosphates
(Spontaneous regeneration of enzyme is usually complete by 24 hours).
 Carbamates cause less central nervous system (CNS) toxicity as they are less able
to penetrate the blood brain barrier.

CLINICAL FEATURES OF CARBAMATE INSECTICIDE POISONING

 Carbamate toxicity is seen more quickly than with organophosphates (Carbamate
toxicity usually manifests within 15 min to 2 hr).
 The unresponsiveness of carbamates to pralidoxime is a useful tool to distinguish
between these toxins.
 Lacks of CNS effects can be presumptive evidence of carbamate poisoning
 Carbamate toxicity usually abates within 24 hr regardless of treatment.

MANAGEMENT OF CARBAMATE INSECTICIDE POISONING

 Carbamates have transient and minimal effects on plasma and RBC
cholinesterases measurements; thus these tests are generally not useful.
 Atropine is the mainstay of carbamate intoxication therapy. 6-12 hr of therapy is
usually all that is required.
 Pralidoxime has no role to play in carbamate intoxication.

SUMMARY OF ORGANOPHOSPHATE VERSUS CARBAMATE POISONING

Organophosphate Carbamate
1. Phosphorylation of cholinesterase 1. Carbamylation of cholinesterase
2. Irreversible inhibition of 2. Reversible inhibition of

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 cholinesterase. cholinesterase
3. ONSET of symptoms slower (hours 3. ONSET of symptoms – Rapid (15
to days) min – 2 hr)
4. DURATION of symptoms – slow 4. DURATION of symptoms – Self
recovery (upto 4 weeks in severe limited (usually completed by 24 hrs)
cases)
5. DIAGNOSTIC TESTING – serum 5. DIAGNOSTIC TESTING – generally
cholinesterase levels depressed. not helpful (enzyme activity returns
to normal within a few hours)
6. Treatment: Atropine
6. Treatment: atropine and pralidoxime 7. LONG TERM SUQUELAE - None
7. LONG TERM SEQUELAE – Many
(eg. Peripheral neuropathy)

ORGANOCHLORINES
 Examples:
 Endrin (known as “plant penicillin” because of its wide spectrum of activity)
 Aldrin
 Endosulfan
 Lindane (gammexane)
 Kerosene – like odor (due to a petroleum derivative used as a solvent
organochlorines)
 Mechanism of action – Organochlorines affect nerve impulse transmission altering
membrane Na+ and K+ flux, resulting in CNS hyperexictability.
 Atropine and pralidoxine are of no benefit, as cholinesterases are unaffected.
PYRETHRINS & PYRETHROIDS
1. These are derived from Chrysanthemum plant.
2. Used as insect repellents in sprays, coils and mats.
3. On contact they cause irritation of the skin, eye, gastrointestinal tract and throat.
4. There is no antidote for plant insecticides.

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5. They are treated symptomatically.

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 IRRITANTS
Irritants are broadly categorized into inorganic, organic, and mechanical irritants.
 Inorganic irritants of non metallic type: phophorous, chlorine etc.
 Inorganic irritants metallic type: heavy metals like arsenic, lead, mercury etc.
 Organic irritants of plant origin: ricinus, abrus, calotropis etc.
 Organic irritants of animal origin: snakes, scorpions, wasps, bees etc.
 Mechanical irritants: glass powder, pins and needles, chopped hairs etc.

HEAVY METALS
 Many metallic elements in trace quantities are essential for various biological
processes.
 Most of these trace elements are acquired in adequate quantities through
food; excessive exposure (nutritional, occupational, or environmental) can
lead to progressive accumulation and toxicity resulting in serious
consequences.
 Heavy metal poisoning (acute or chronic) is a major cause of morbidity and
mortality all over the world.

ARSENIC
Arsenic is a metalloid i.e., it is an element which resembles a metal in some
respects, and is by itself not very toxic. However, almost all the salts are toxic to
varying degree. Arsenic is a silver-grey or tin-white, shiny, brittle, crystalline and
metallic-looking element.
MECHANISM OF ACTION OF ARSENIC
 Arsenic is absorbed through all portals of entry including oral, inhalational,
and cutaneous routes.
 After absorption it is redistributed to the liver, lungs, intestinal wall, and
spleen, where it binds to the sulphydryl groups in the mitochondrial enzyme
systems leading to interference with their action. Arsenic causes uncoupling
of mitochondrial oxidative phosphorylation.
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 Acute arsenic poisoning results from increased permeability of small blood
vessels, and inflammation and necrosis of the intestinal mucosa; these
changes manifest as hemorrhagic gastroenteritis, fluid loss and hypotension.
 Arsenic replaces phosphorus in the bone where it may remain for years.
 It gets deposited also in hair.

CLINICAL FEATURES OF ARSENIC POISONING

ACUTE ARSENIC POISONING:
 Acute arsenic poisoning mimics cholera, the differences can be summarized
as follows:
Feature Acute arsenic Cholera
poisoning
1. Throat pain Pain in throat before Pain in throat after
vomiting vomiting
2. Purging Purging after vomiting Purging before vomiting
3. Stools Dark colored stools Rice water stools
4. Blood in stools Later rice water stools No blood in stools
become blood mixed
5. Tenesmus Tenesmus and anal No tenesmus and anal
irritation present irritation
6. Vomiting Vomitus contains mucus Watery vomitus without
mucus and with bile &
blood
7. Voice Not affected Rough and whistling
8. Conjunctiva Inflamed Not inflamed
9. Diagnosis Chemical analysis of Microbiology analysis of
excreta reveals presence excreta reveals vibrio
of arsenic cholera
10. Circumstantial Evidence of poisoning Similar cases in the
evidence present vicinity

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CHRONIC ARSENIC POISONING:
 Chronic poisoning may occur among persons engaged in the smeltering and
refining of ores, in the manufacturing of weed killers, paints, dyes etc.
 Clinical features of chronic arsenic poisoning can be discussed under
following categories:
 GIT symptoms.
 Dermatological symptoms
 Neurological symptoms.
 Hematological findings.
 GIT symptoms:
It includes,
 Salivation.
 Loss of weight.
 Constipation or sometimes diarrhea.
 Edema of eyelids and ankle.
 Dermatological features:
It includes,
 Raindrop Pigmentation – Patchy areas of hyperkeratotic skin
and desquamation. This is more prominent in the distal parts of
the body. It resembles to that of the rain drops on a dusty road.
 Aldrich Mee’s Lines or Striate Leukonychia – These are
transverse white striae of the fingernails. It can be seen 2 weeks
after the exposure. Number of striae gives a rough idea
regarding the number of exposures.
 Neurological symptoms:
Sensory and motor polyneuritis (sensory symptoms usually predominates)
manifesting as numbness and tingling in a “stocking glove” distribution.
 Hematological findings:
Anemia and leucopenia are commonly seen.
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MANAGEMENT OF ARSENIC POISONING
A. Supportive measures:
Gastric lavage, intravenous fluids, cardiac monitoring, etc.
B. Chelation therapy:
 BAL (British Anti Lewisite or Dimercaprol) is the chelating agent of choice
and is administered intramuscularly.
 DMSA (Dimercapto succinic acid or succimer) and DMPS (Dimercapto
propane sulfonate), which can be given orally. DMSA and DMPS said to
be superior to BAL.
C. Haemodialysis or exchange transfusion:
Chelation therapy is not very effective for chronic poisoning. The latter should
be treated with emphasis on respiratory stabilization and haemodialysis.
POST-MORTEM APPEARANCE IN ARSENIC POISONING
 Gastrointestinal congestion is a noteworthy feature in acute arsenic poisoning
and varies from a mere reddening of mucosa (red velvet) to frank
hemorrhagic gastritis. Focal hemorrhages giving rise to ajlea bitten
appearance is said to be characteristic. The intestines may be inflamed and
may contain "rice water" contents.
 Subendocardial hemorrhages are often seen in the heart.
 There may be evidence of fatty degeneration of heart, liver, and kidneys.
FORENSIC SIGNIFICANCE OF ARSENIC POISONING
1. Arsenic had an outstanding reputation as an ideal homicidal poison especially
in the West. Arsenic trioxide being almost tasteless and colorless in solution
can be administered without arousing the suspicion of a victim. On chronic
successful administration to a victim, arsenic produces insidious but
relentlessly progressive symptoms which are likely to be mistaken even by a
medical practitioner for natural causes such as neurological disease,
alcoholism, tuberculosis, and hepatic failure. One of the most shocking cases
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 which remained speculative until recently, when scientific evidence finally
established the truth beyond reasonable doubt was that of Napoleon
Bonaparte (Emperor of France).
2. There is a long held belief that arsenic preserves a dead body by delaying
putrefaction, though there is 'not enough scientific validation for this.
3. It is conventional to preserve apart from the routine viscera and body fluids, a
piece of long bone (preferably femur), a bunch of pulled scalp hair, a wedge
of muscle, and a small portion of skin (from the back of the trunk) for chemical
analysis.
LEAD
 Lead is the commonest metal involved in chronic poisoning.
 Elemental lead exists as a highly lustrous, heavy, silvery grey metal.
 Several of its salts occur as variously colored powders or liquids and are used
widely in industry and at home producing cumulative toxicity on chronic
exposure.
 Lead acetate (sugar of lead) has been used in therapeutics.
 Lead carbonate (white lead) is still used in paints.
 Lead oxide (litharge) is essential for glazing of pottery and enamel ware.
 Tetraethyl lead is mixed with petrol as antiknock to prevent detonation in
internal combustion engines.
 Lead tetroxide is the most common compound in vermilion ("sindoor") applied
by married Hindu women to the parting of their scalp hair.
 Lead sulfide is used as eyeliner ("surma") by Muslims.
 Exposure to lead in the general population occurs from inhalation of
contaminated air and dust of various types, or ingestion of food and water
containing lead.
MECHANISM OF ACTION OF LEAD
 Lead is absorbed through all portals of entry. Occupational exposure results
mainly from inhalation, while in most other situations the mode of intake is
ingestion. Tetra ethyl lead can be absorbed rapidly through intact skin.
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 Lead combines with sulphydryl enzymes leading to interference with their
action.
 It decreases haeme synthesis by inactivating the enzymes involved such as
amino-laevulinic acid dehydrase, aminolaevulinic acid synthetase,
coproporphyrinogen oxidase (or decarboxylase), and ferrochelatase. This
results in anaemia.
 It increases haemolysis as a result of which immature red cells are released
into circulation such as reticulocytes and basophilic stippled cells (the result of
aggregation of ribonucleic acid due to inhibition of the enzyme pyrimidine-5' -
nucleotidase which normally eliminates degraded RNA).
 In the CNS, lead causes oedema and has a direct cytotoxic effect leading to
decreased nerve conduction, increased psychomotor activity, lower IQ, and
behavioural learning disorders. Children are especially susceptible.
 Lead also has deleterious effects on the CVS (hypertension and myocarditis),
kidney (nephritis), and reproductive organs (infertility).
CLINICAL FEATURES OF LEAD POISONING
ACUTE POISONING:
 This is rare. Many reported cases of acute poisoning may actually be
exacerbations of chronic lead poisoning when significant quantities of lead
are suddenly released into the bloodstream from bone.
 Symptoms include metallic taste, abdominal pain, constipation or diarrhoea
(stools may be blackish due to lead sulfide), vomiting, hyperactivity or
lethargy, ataxia, behavioral changes, convulsions, and coma.

CHRONIC LEAD POISONING (PLUMBISM OR SATURNISM):

 Facial pallor:
Especially circum-oral is said to be a characteristic feature of chronic lead
poisoning and is due to vasospasm mainly of capillaries, though anaemia
may contribute to a significant extent.
 Lead line or Burtonian line:

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 This is a bluish black discoloration due to sub epithelial deposition of lead
sulphide granules on the gums at the junction with the teeth. Its color is due to
the action of hydrogen sulphide liberated by micro-organisms from
decomposing food material around carious teeth in the presence of circulating
lead. It is seen in whom dental hygiene is poor.

 Retinal stippling:
This is noticed by ophthalmoscopic examination showing presence of grayish
glistening lead particles, in the early phase of chronic lead poisoning.
 Lead colic:
It is spasmodic, intermittent pain and relieved by pressure.
 Lead palsy:
Lead induced peripheral demyelination is reflected by prolonged nerve
conduction time and subsequent paralysis, usually of extensor muscles of the
hands of the hands and feet resulting in wrist or foot drop.
 Lead encephalopathy:
It is more common in children and is often associated with organic lead
toxicity, especially tetra ethyl lead which is lipid soluble and is distributed
widely in lipophilic tissues such as the brain. TEL is metabolised to tri ethyl
lead which is the major toxic compound. There is sudden onset of vomiting,
irritability, headache, ataxia, vertigo, convulsions, psychotic manifestations,
coma, and death. Even if recovery occurs, there is often permanent brain
damage manifesting as mental retardation, cerebral palsy, optic neuropathy,
hyperkinesis, and periodic convulsions.
 Lead osteopathy:
In children, lead is deposited beyond the epiphysis of the growing long bones.
 Anemia with punctuate basophilia;
The anaemia that is encountered in plumbism is similar to that due to iron
deficiency, i.e., it is hypochromic and microcytic in type. In plumbism there will
be reticulocytosis and basophilic stippled cells. The basophilic stippling of the
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 red cells is due to condensation of iron containing ribonucleic acid near the
mitochondria. These are stained with basic dyes and hence the name.
 Lead also has deleterious effects on the CVS (hypertension and myocarditis),
kidney (nephritis), and reproductive organs (infertility).

MANAGEMENT OF LEAD POISONING

A. Thiamine 10 to 50 mg/kg is said to improve neurological manifestations of
lead poisoning.
B. In acute poisoning, or in the event of radiopacities in the GI tract on X-ray,
stomach wash can be done.
C. Lead colic usually responds to IV calcium gluconate.
D. If intracranial pressure is high due to cerebral oedema, administer mannitol or
steroids as required.
E. Organic lead poisoning is mainly managed symptomatically. Chelation is
done only if there is production of inorganic lead in the body from organic
lead.
F. Chelation theraphy:
 For elimination of absorbed part of lead, EDTA is given by slow I.V.
infusion.
 DMSA (Dimercapto succinic acid or succimer) is an effective oral chelator.
POST-MORTEM APPEARANCE IN LEAD POISONING
 Burtonian line.
 Lead lines on X-ray.
 Pathological lesions or changes are sometimes found in kidneys, liver, male
gonads, nervous system, blood vessels.
FORENSIC SIGNIFICANCE OF LEAD POISONING
1. Most of the lead poisonings are accidental in nature.

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2. Workmen who contract disease during the course of and by reason of their
employment are entitled to compensation from their employer during such
time as they are incapacitated from earning their livelihood and in the event of
death; their dependants are entitled to such compensation.

MERCURY (QUICKSILVER, LIQUID SILVER)

 Metallic or elemental mercury (HgO) is a heavy, silvery liquid which is per se
non-toxic.
 Common mercuric salts include mercuric chloride (corrosive sublimate),
which is a white crystalline corrosive powder.
 Mercuric oxide, which is a red crystalline powder that turns yellow when
treated with caustic soda or potash;
 Mercuric sulfide (vermilion or sindoor), which is a red crystalline powder.
 Occupations which have the greatest exposure to mercury vapors include
mining and processing of cinnabar ore, the chlor-alkali industry, and occupa-
tions in which mercury-containing instruments or materials are manufactured
or handled.
 Dietary exposure to mercury (in the form of methyl mercury) from
consumption of fish, shellfish and marine mammals.
MECHANISM OF ACTION OF MERCURY
After absorption it is redistributed to the liver, lungs, intestinal wall, and spleen,
where it binds to the sulphydryl groups in the mitochondrial enzyme systems
leading to interference with their action.
CLINICAL FEATURES OF MERCURY POISONING
ACUTE MERCURY POISONING:
 Inhalation:

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  This usually occurs while heating metal in a closed room, or following gold
refining in an enclosed area.
 Symptoms include dyspnoea, cough, fever, headache, chills, GI dis-
turbances, metallic taste, and blurring of vision. Stomatitis, swelling of the
salivary glands and gingivitis may develop within a few days of acute
exposure to mercury.
 Teeth may become loose due to gum inflammation.
 In severe cases there may be non-cardiogenic pulmonary edema,
dyspnoea, convulsions, etc.

 Ingestion:
 Small quantities of elemental mercury usually cause no harm on ingestion.
Sometimes even a relatively large amount may pass out of the body
uneventfully (egged on by a mild laxative).
 There is a report of an English nobleman in 1515 that "overheated on his
marriage night with love and wine" rose to quench his thirst, and drank by
mistake a large draught of quicksilver without suffering any harm.
 Ingestion of mercuric salts produces corrosion leading to abdominal pain,
vomiting, diarrhoea, and shock.
 The mucosa of the GI tract usually appears grayish. There may be
haematemesis.
 Injection:
 Subcutaneous or intramuscular injections of elemental mercury may
cause abscess formation with ulceration, extruding tiny droplets of
mercury.
 Intravenous injection can result in mercurialism characterised by
thrombophlebitis, granuloma formation, and pulmonary embolism.
Repeated haemoptysis is a characteristic feature.
 Intra-arterial injection can result inadvertently from arterial blood gas
sampling with syringes which contain liquid mercury as an anaerobic seal,
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 or from arterial pressure monitors which employ a liquid mercury manom-
eter connected directly to the intra-arterial needle. Leakage of mercury
into arterial blood results in peripheral embolisation with ischemia, and
sometimes frank gangrene.
 There may also be abscess formation and ulceration.
 X-ray usually reveals multiple, tiny spheres in the veins draining the entry
site. Mercury globules may also be seen in various organs.

CHRONIC MERCURY POISONING (HYDRARGYRISM)

 This can occur due to:
 After attacks of acute attack.
 Injudicious medical use.
 Accidental absorption in individuals working with metal or a salt as in the
thermometer, barometer industry etc.
 Clinical features can be discussed under following headings:
 Tremors.
 Mercuria lentis.
 Mercurial erethism.
 Acrodynia (Pink disease).
 Tremors:
Tremors can be categorized into the following based on their severity,
 Danbury tremor is a classical and most consistent manifestations of
chronic mercury poisoning. It begins in the hands and is of a coarse,
intentional type, interspersed with jerky movements.
 Later it progresses to the lips, tongue, arms, and legs. The advanced
condition is referred to as Hatter’s shakes when the tremor becomes so

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 severe that daily activities involving some delicacy of movement become
grossly impaired, e.g., shaving, writing, holding a tumbler or spoon, etc.
 The most severe form of the condition is referred to as concussio
mercurialis when literally no activity is possible.
 Mercuria lentis:
Characterised by the brown reflex of anterior lens capsule of the eye. There
may be fine punctate opacities. Visual blurring is often present, and
sometimes there is concentric constriction of visual fields ("tunnel vision").
Mercuria lentis usually indicates chronic exposure to elemental mercury
rather than toxicity. Diagnosis is made by slit lamp examination.
 Erethism:
Another classic manifestation, it refers to a cluster of psychiatric symptoms
including abnormal shyness, loss of self confidence, depression, irritability,
amnesia, excitability, progressing in later stages to delirium with
hallucinations, or suicidal melancholia, or manic depressive psychosis (mad
hatter).
 Acrodynia (Pink disease):
This is seen mainly in children.
 Formerly most cases were related to chronic use of teething powders
containing mercurous chloride. But almost any form of chronic mercury
exposure can cause this condition including inhalation of elemental
mercury vapor or cutaneous application of ammoniated mercury
ointments.
 The onset is usually insidious with anorexia, insomnia, profuse sweating,
skin rash, and photophobia. The hands and feet become puffy, pinkish,
painful, paraesthetic, perspiring, and peeling (the child pees!). Teeth may
be shed, with ulceration of gums.
 In older children and adults the disease is milder, and is characterized by
antisocial behavior, insomnia, aching extremities, and alopecia.

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  Today the incidence of childhood acrodynia is uncommon since the use of
mercurial teething powders and diaper rinses has been abandoned.
MANAGEMENT OF MERCURY POISONING
B. Airway assessment and stabilization.
C. Antero-posterior and lateral chest radiographs that visualize the neck, chest,
and abdomen.
D. Egg albumin which forms an insoluble albuminate of mercury can be given.
E. For the absorbed part of the poison, any of the following chelating agents can
be used:
 BAL (British Anti Lewisite or Dimercaprol) intramuscularly.
 DMPS ( Dimercapto Propane Sulfonate) intravenously or orally.
 DMSA (Dimercapto Succinic Acid or Succimer) orally.
 Other chelating agents which are being studied in relation to mercury
poisoning include N-acetyl penicillamine (NAP), methicillin, and alpha
mercapto beta acrylic acid.
POST-MORTEM APPEARANCE IN MERCURY POISONING
 In death due to acute mercury poisoning, the mucosa of the mouth, throat,
esophagus, and stomach appears grayish in color with softening and
superficial corrosion.
 There may be hemorrhagic points.
 If there had been survival for a few days, the large intestine may reveal
ulceration.
 Kidneys are often pale and swollen due to oedema of renal cortex.
Microscopy usually demonstrates necrotic changes in the renal tubules.
FORENSIC SIGNIFICANCE OF MERCURY POISONING
1. Mercury and its compounds constitute important industrial, agricultural, and
occupational toxic hazards. In the past when mercury was used in its various
forms for the therapy of a wide variety of ailments including syphilis,
iatrogenic poisoning was common.

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2. Domestic exposure though not often reported is today a distinct threat. Such
exposure may result from inadvertent mercury spills (broken thermometers),
or from home gold-ore processing.
3. An important area that must be considered in relation to chronic mercury
exposure is dentistry. Dental amalgams used for fillings often contain
mercury. Dental surgeons may get chronically exposed due to this reason.
4. Food poisoning (especially involving fish) through mercury compounds has
been reported in the literature as Minimata disease derived from Minimata
bay disaster.
 On the island of Kyushu around Minimata Bay in Japan, more than 2000
people were diagnosed to be suffering from a curious cluster of
neurological symptoms comprising paraesthesiae, narrowing of vision,
dysarthria, and diminution of hearing, amnesia, ataxia, staggering gait,
weakness, and emotional instability. Some developed paralysis and
became stuporous, and out of all the people afflicted nearly a hundred
died. The condition came to be known as the Minimata disease, and
intensive investigations pointed to one inescapable conclusion: it was
caused by consumption of fish contaminated with methyl mercury, which
originated from a nearby vinyl chloride plant. The most severely affected
victims were actually infants who had been exposed in utero.
 Later similar outbreak of poisoning was reported from another part of
Japan: Niigata along the Agano river. Forty-three cases were diagnosed
as having the Minimata disease out of whom six died.
 Then came the shocking tragedy in Iraq during seventies, when 500
people died out of a total of 6530 victims due to consumption of imported
wheat and barley meant for sowing, treated with methyl mercury. Nearly
95,000 forms of seed grain treated with methyl mercury was baked into
bread!

PLANT IRRITANTS

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As the name indicates these poisons, on gaining entry in to the body causes sign
and symptoms attributable to irritation of the gastrointestinal tract. They produce
nausea, vomiting, abdominal pain, severe diarrhoea etc. On external contact they
cause irritation and blisters. All these plants contain certain active principles
called toxalbumin (ricin, abrin, crotin etc). A toxalbumin is a substance which is a
toxic protein, has actions resembling the actions of bacterial toxins, lyses the
blood and when injected shows antigen-antibody reaction.
CASTOR (MOLE BEAN, MAY BEAN, PALMA CHRISTI)
 Botanical Name: Ricinus communis.
 It is a tall shrub bearing large lobate leaves with toothed margins.
 The fruit (seed pod) has a prickly capsule and contains (usually) three shiny,
mottled, hard-coated, greyish-brown seeds.
 Seed pods are green or red, about one inch long, and hold elliptical, glossy
seeds, which may be mottled with black, brown, gray, or white colours, and
are 1 to 2 cm in length.
 All parts, but the most toxic are the seeds.
 The main toxic principle is the phytotoxin ricin, which is a toxalbumen. It is not
present in castor oil which contains a much milder irritant - ricinoleic acid.

USES
 Ornamental plant.
 Oil extracted from the seeds is used medicinally as a purgative, and as a
lubricant for engines.
 Castor beans have found wide use, both systemically and topically, in
stimulating breast milk production in many countries.
 Ricin (the main active principle) has been used as a chemical warfare agent,
a reagent for pepsin and trypsin, an experimental antitumour and immunosup-
pressive agent, and as a commercial mole killer.
CLINICAL FEATURES OF POISONING WITH CASTOR

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 The seed when swallowed whole does not have any harmful effects. The
cover of the seed is so thick that they do not get digested in the human
intestinal tract. However when the seeds are crushed and swallowed, they b
show the signs and symptoms of gastrointestinal irritation, in the form of
diarrhoea. Ricin, when injected exhibits the properties of toxalbumin.
 There is usually a delay of several hours before manifestations begin.
 There is at first a burning sensation in the GI tract which is followed by colicky
abdominal pain, vomiting, and diarrhoea. Frequent stools, including bloody
diarrhoea and tenesmus, are well-known signs of toxalbumin toxicity.
 In severe cases, there is haemorri1agic gastritis and dehydration.
Dehydration may occur in over a third of symptomatic patients. Urea nitrogen,
amino acid hydrogen, and inorganic phosphate levels are usually elevated.
 Delayed CNS toxicity may occur, especially involvmg the cranial nerves.
USUAL FATAL DOSE
It is generally believed that ingestion of a single castor seed can be lethal,
whereas actually 8 to 10 seeds are required to produce a fatal outcome.

MANAGEMENT OF POISOINING WITH CASTOR

A. Decontamination:
Syrup of ipecac or stomach wash, activated charcoal, catharsis.
B. Supportive measures:
IV fluids, monitoring for hypoglycaemia, haemolysis, and complications of hy-
povolaemia.
C. Alkalinization of urine probably has a role in preventing crystallization of
haemoglobin, and should be considered in severe poisonings.
FORENSIC SIGNIFICANCE OF CASTOR POISONING
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1. Reports from some countries suggest that it is not unusual to find a clustering
of cases of toxic gastroenteritis among young children who ingest the seeds
of castor. It is presumed that the unique marbled pattern of the seeds may be
very attractive to children thereby leading to accidental poisoning.
2. The exaggerated notion about the lethality of castor (and more particularly
ricin) stems from the celebrated case of Georgi Markov.
Georgi Markov was a Bulgarian who had defected to the West, and was
working as a broadcaster for the BBC World Service in London. One day
when he was waiting for his evening bus home he felt a prick in his left thigh
The man behind him dropped his furled umbrella (the tip of which had
apparently accidentally poked into him), apologised, and moved away. He
subsequently hailed a taxicab and left the scene. Late that night he fell ill with
fever and vomiting. Next morning, his wife called their family doctor over who
became quite alarmed at Markov's condition and rushed him to hospital. The
puncture wound in his thigh had become inflamed and painful. The body
temperature rose relentlessly and septicaemia was diagnosed. Over the
weekend Markov became delirious, passed into coma, and died shortly
thereafter.Owing to the circumstances of the death, a high-level police
investigation was launched. An autopsy was ordered, during the course of
which the tissues around the puncture wound in the thigh were dissected and
revealed the presence of a tiny pellet, the size of a pinhead. Electron
microscopy revealed the pellet (made of an alloy of platinum and iridium) to
have two small holes bored through it. To drill holes 0.35 mm wide in a pellet
of 1.5 mm diameter, made of a notably hard substance, plainly indicated the
involvement of someone with access to highly specialized equipment. The
position of the pellet in the body suggested that the mysterious assailant's
umbrella must have also been equally specialized. Investigators surmised
that there must have been a firing device in the ferrule, silently powered by a
gas cylinder.Chemical analysis of the pellet did not reveal the presence of any
poison. However experimental injection of laboratory animals with a few of the
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 known "supertoxic" poisons suggested the possibility of ricin. The negative
chemical analysis only reinforced this possibility, since ricin is known to get
degraded rapidly in the body leaving behind no trace of its original presence.
The assessin with his lethal umbrella was never caught.
3. The seeds are sometimes used as an abortifacient and as arrow poison.

ABRUS (ROSARY PEA, JEQUIRITY BEAN , INDIAN LIQUORICE)

 Botanical Name: Abrus precatorius.
 This green vine belongs to family Leguminosae, and is a tropical, ornamental,
twining, woody vine.
 Leaves are alternate, opposite, pinnately divided (feather-like) with small
oblong leaflets.
 Flowers are pink, purple, or white and borne in clusters.
 But the distinctive part of the plant is the seed which is oval, 5 mm in
diameter, and has an attractive hard glossy outer shell that is usually scarlet
red with a black centre. The seeds are present inside fruit pods, each
containing 3 to 5 seeds. The pods split open when ripe. The pod is a legume
(pea-shaped pod), and is about 3 cm long.
 Toxic parts are seeds, root and leaves.
 Toxic principles includes abrin and abric acid.
USES
 The seeds are often used in rosary beads, necklaces, and folk jewellery.
 Jewellers in India sometimes use the seeds as a weighing measure for gold
or precious stones.
 Quacks use extracts of various parts of the plant for the treatmemt of a wide
variety of ailments.
CLINICAL FEATURES OF POISONING WITH ABRUS
 Dermal contact: redness, rash.
 Ocular exposure: reddening, swelling, blindness.
 Ingestion:
 Burning pain in the mouth and throat.
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  Severe vomiting.
 Abdominal pain.
 Bloody diarrhoea.
 Cardiac arrhythmias.
 Convulsions.
 CNS depression.
 Cerebral edema.
USUAL FATAL DOSE
 1 to 3 seeds.
 If the seed of these plants are swallowed whole, symptoms are much less
likely to occur.
MANAGEMENT OF POISONING WITH ABRUS
A. Gastric decontamination (lavage, charcoal).
B. Whole bowel irrigation is said to be helpful, but some investigators dispute
this.
C. Supportive measures, with special emphasis on rehydration. Close attention
should be given to hematological parameters.
D. Alkalinization of the urine probably has a role in pre venting crystallization of
hemoglobin, and should be considered in severe poisonings.
E. Treating convulsions in the usual manner with diazepam.
F. Renal failure can be managed by haemodialysis.
G. Anti Abrin serum is available for treatment.
H. Ocular exposure necessitates copious irrigation with running water for at least
15 minutes.
POST-MORTEM APPEARANCE IN ABRUS POISONING
Evidence of gastrointestinal hemorrhage, edematous bowel, cerebral edema,
and congested liver and kidneys.
FORENSIC SIGNIFICANCE OF ABRUS POISONING
1. Accidental poisoning is not uncommon among children playing in the
countryside who find the seeds very attractive and may bite or chew on them.
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2. The extract of the seed is used in rural India to kill cattle by injecting needle
("suis") made out of the dried seed paste.
Suis are prepared by mixing the powdered decorticated seed of Abrus with
flour and datura seed powder. These powders are mixed in water, kneaded in
to small sharp needles and are dried in the shade. These needles are fixed
on a wooden plank and are jabbed on the thighs of the cattle. There are two
punctured marks at the site of penetration of these needles. This site swells
and a serosanguinous fluid starts oozing. The cattle become lethargic, stops
eating, froths through the mouth and nostrils and falls dead in a day or two.
Anybody would mistake the death to be due to viper bite. This method of
killing the cattle is used for the illegal procurement of hide.
3. Powdered seeds may be used by malingerers to produce conjunctivitis.
4. The seeds are sometimes used as an abortifacient and as arrow poison.

CHILLI (RED PEPPER)

 Botanical Name: Capsicum annum.
 It is a small herb bearing longish tapering fruits which become red when ripe
with a pungent odour and taste, and contain a number of small and flat
yellowish seeds.
 The latter bear a superficial resemblance to datura seeds and serious
poisoning sometimes results from mistaken identity.

Chilly seed Datura seed

Small Large
Yellow Brown
Rounded and smooth Reniform and pitted

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 Pungent odor Odorless
Pungent taste Bitter taste
On section, the embryo is seen to curve
Embryo curves outwards
inwards towards the hilum.

 The main active principle, capsaicin, is sometimes, used in the treatment of

neuralgia and diabetic neuropathy.
USES
 The fruit and seeds are very popular in Indian cuisine as a condiment and
flavouring agent. It is also used in pickles and sauces.
 In medicine it is sometimes used as an appetite stimulant and carminative.
CLICAL FEATURES OF POISONING WITH CHILLY
 Cutaneous exposure; Burning, pain. Occupational handling of chillies can
result in burning pain, irritation, and erythema (“Hunan hand”).
 Ocular exposure: Intense pain, lacrimation, conjunctivitis, and
blepharospasm.64
 Inhalation/aspiration if chilly powder:
 Occupational exposure results in increased coughing (“chilly worker’s
cough”).
 Ingestion: Nausea, vomiting, burning pain, salivation, Phys abdominal
cramping, burning diarrhoea.
MANAGEMENT OF POISONING WITH CHILLY
A. Cutaneous exposure:
 Copious local washing with water.
 Local and systemic analgesics.
 Immersion in cool water and/or vegetable Oil.
B. Ocular exposure: Copious local irrigation and local analgesics. Even severe
cases usually resolve without sequelae in 24 hours.
C. Ingestion: Sips of cool water or crushed ice.
D. Systemic analgesics.
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FORENSIC SIGNIFICANCE OF CHILLI
1. Occupational exposure results in health problems among workers.
2. Accidental deaths have been reported due to aspiration of chilly. Sometimes
datura seeds are consumed in mistake for chilly seeds giving rise to serious
poisoning.
3. The powder is occasionally used for torture or extortion by forcible
introduction into the anus or vagina sometimes termed as “Hyderabadi goli’.
4. Robbery, rape, etc., may be facilitated by rendering a victim suddenly
agonized and helpless by throwing pepper into the eyes.
ANIMAL IRRITANTS
Irritants of animal origin mainly comprise envenomation by way of stings and
bites of various reptiles, arthropods and arachnids.
SNAKES
 Nearly 100% of the deaths due to snake bite poisoning are accidental in
nature. The mortality can be reduced by giving timely first aid measure and
the appropriate hospital management. As the deaths due to snake bite
envenomation is unnatural in nature, all such deaths are made as medico
legal cases and the post mortem examination is necessary to rule any foul
play.
 It is important to distinguish to the poisonous snakes from the non poisonous
snakes, if the victim of the bite is brought to the hospital along with the killed
snake. All the poisonous snakes have ventral scales which stretch along the
entire breadth of the belly. Poisonous snakes have the fangs. Therefore there
are two prominent fang marks in a poisonous snake bite and many punctured
bite marks in non poisonous snake bites. The snake venom may be either
neurotoxic as in cobras or haemotoxic as in vipers.
 Indian cobra (Naja Naja) are mostly bespectacled. There is no distinction
between the head and the neck. They have a hood near the head which
expands when angered. The third supra labial scale touches both the eye and
the nostril. The venom is predominantly neurotoxic in nature.
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 Vipers have a triangular head and a distinct neck. The venom is
predominantly haemotoxic in nature.
 Kraits have a cylindrical body and hexagonal scales. The venom is
predominantly neurotoxic in nature.
CLINICAL FEATURES OF SNAKE BITE
 Neurotoxic snake bites
 Predominant neurotoxic symptoms seen as in the case of cobra and krait
bites include vomiting, hypersalivation, heaviness of eye lids, blurred
vision, paraesthesiae around the mouth, dizziness and vertigo.
 Paralysis is first detectable as ptosis and external ophthalmoplegia. Later
the face, palate, jaws, tongue, neck muscles and muscles of deglutition
may become paralysed. In the terminal stages paralysis affects intercostal
muscles and diaphragm resulting in fatality.
 Haemotoxic snake bites
 Predominant hemotoxic symptoms seen as in the case of viper bites
include swelling, persistent bleeding from fang punctures, epistaxis,
haematemesis, hemoptysis, retroperitoneal and intracranial
haemorrhages.
 Victims of viper bite may become oliguric within a few hours of the bite
leading to renal failure which may result in fatality.
MANAGEMENT OF SNAKE BITE
Snake bite mostly happens in the fields or in places where the hospital facility
may not be available in the immediate vicinity. Therefore it is important to
manage the case with first aid measures till the victim can be transported to the
hospital.

FIRST AID MEASURES

A. Reassurance:

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 First and the foremost point in the first aid is to reassure the victim. This is
because many deaths happen by the sheer psychological fear even when the
victim is bitten by a non poisonous snake.
B. Tourniquet:
Apply a tourniquet about 3 to 5 cms proximal to the bite marks. Application of
the tourniquet must be resorted to, only when the bite is over the limbs. As
the venom is deposited in the sub cutaneous tissues, the further spread is
only by lymphatic drainage. Therefore the tightness of the tourniquet must be
only to prevent the lymphatic flow, not the venous or the arterial. The
tourniquet is loosened for 1 minute for every 10 minutes, to allow some
drainage to take place further in to the body. As the dose that further enters
the body is insufficient to kill the victim, the poison is neutralized by the
antibodies that are developed in response to the snake venom.
C. Immobilization:
The victim is immobilized as otherwise the muscular action will further pump
the venom in to the system.
D. Incision:
Putting an incision over the bite marks to allow for the free flow of blood,
which was in vogue in the yester years, is now being discouraged for the fear
of introducing more harmful bacteria than helping the victim.
E. While the above mentioned procedures are being instituted, arrangements
must be made for the transportation of the victim to the hospital where anti
snake venom is available.
HOSPITAL MANAGEMENT
A. If the victim is really envenomed, administration of polyvalent anti snake
venom is the only treatment of choice to save the life of the victim. Polyvalent
serum is prepared from the blood of the immunized horse which has been
injected with the venom extracted from Cobra, Krait, Saw-scaled viper and
Russell’s viper.

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B. As this serum is antigenic in nature to the humans, the likelihood of an
anaphylactic developing must be anticipated. Hence it is imperative to give a
test dose before injecting the full dose. Even if the victim is allergic to the
serum, he is desensitized by adequate amount of adrenaline, antihistamines
and the steroids.
C. Rest of the treatment is symptomatic.
POSTMORTEM APPEARANCE IN SNAKE-BITE POISONING
 Fang marks can give clues regarding the type of snake (deeper fang marks
suggestive of viper bite whereas cobra bite marks are not so prominent and
krait bite marks are very difficult to appreciate)
 In viper bite the blood is generally fluid and hemolysed causing early staining
of the blood vessels causing early staining. There may be hemorrhages in the
lungs and also extravasations of blood in the serous membranes such as
pleura and pericardium.
FORENSIC SIGNIFICANCE OF SNAKE-BITE POISONING
1. Majority of snake-bites are accidental in nature.
2. Homicide may rarely be committed for instance by throwing a venomous
snake on a sleeping victim or slipping it under the bathroom door or through a
window.
3. Suicides are virtually unreported with the famous exception of Queen
Cleopatra who is reputed to have committed suicide by a venomous snake,
an asp which is an exotic variety of viper.
4. Snake venom is used to kill cattle by a peculiar method for the sake of hides.
For this purpose, a cobra is placed in an earthen vessel with a banana. The
cobra is irritated by applying heat to the vessel. It bites the fruit, the pulp of
which is then smeared on a rag thrust into the animal’s rectum with the help
of a bamboo stick.
5. Skin and underlying tissue surrounding the fang punctures, wound and blister
aspirate, serum and urine should be collected and sent to the laboratory. This

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 can be analyzed for the snake specific venom antigens by radio-
immunoassay (RIA) or enzyme immunoassay (EIA).
SCORPION
 Scorpion carries a cephalothorax, an abdomen and a six segment tail, which
terminates in a bulbous enlargement called telson. The telson contains the
stinger and venom apparatus. In addition, the scorpion also has two claws,
which help to grasp its prey.
 The venom predominantly carries neurotoxic action. It is a potent autonomic
stimulator resulting in the release of massive amounts of catecholamine from
the adrenal glands and nerve endings into the circulation. The venom also
has direct effect on the myocardium resulting in conduction defects.
 The victims mostly experience severe burning pain which increases as the
time passes.
 It is treated by application of moist ice packs, analgesics and antihistamines.
WASP
 Of the various types of wasps, the yellow jackets are most ill tempered and
may sting without provocation.
 The stinger of the wasp does not have barbs and hence can easily be
withdrawn and reinserted.
 Venom of wasp consist of mixture of serotonin, histamine, acetylcholine and
several kinins.
 Multiple stings can result in rhabdomyolysis and intravascular hemolysis
leading to renal failure.
BEES
 Honey bees can sting, but do so when threatened or harmed.
 The stingers of the bees have barbs resulting in anchoring of two lancets to
human skin causing separation of the whole apparatus from the abdomen.
The eviscerated bee soon dies, but the reflex action of the attached muscles
may continue to inject venom for some time.

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 Venom of wasp consist of mixture of serotonin, histamine, acetylcholine and
several kinins.
 Multiple stings can result in rhabdomyolysis and intravascular hemolysis
leading to renal failure.

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 LEGAL PROCEDURE
Forensic Science: (Forensic; Latin Forensis = belonging to the market place or
forum”; Ancient Rome the "forum” was where legal cases were tried and pleaded)
• Forensic Science means the application of the knowledge of science for the
administration of justice.
Forensic Medicine:
• Forensic Medicine means the application of medical knowledge for the
Administration of justice.
Medical Jurisprudence:
• Medical jurisprudence means the knowledge of legal aspects of practice of
medicine.
Forensic Pathology:
• Forensic Pathology means the application of the knowledge of pathology for
the administration of justice.
Forensic psychiatry:
• Forensic psychiatry means the application of the knowledge of psychiatry for
the administration of justice.
Medical Ethics:
• Medical ethics deal with the moral principles which should guide members of

medical profession in their dealings with one another, with their patients and
with their State.
• Indian Penal Code 1860 (I.P C.) describes various offences and with their

punishments in the court of law. I.P.C consists of total of 511 sections.

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 • Criminal Penal Code 1973 (Cr. P.C.) deals with the procedure of investigations

and trial of offences. Cr. P.C. consists of total of 484 sections.

• Indian Evidence Act 1872 (1. E.A.) deals with the evidences on which the courts

come to some conclusion. I.E.A. consists of total of 167 sections.

INQUEST (Latin; in=into; quest=to seek or look for)

• An inquest is an enquiry or investigation into the cause of death where death
is unnatural sudden, suspicious, unexpected, and litigious.
• Section 174 of the Code of Criminal Procedure defines unnatural death when,
1. A person has committed suicide.
2. He has been killed by another.
3. He has been killed by an animal.
4. He has been killed by machinery.
5. He has been killed an accident.
6. The person has died under circumstances raising a reasonable suspicion
that some other person has committed an offence.
• There are FIVE types of inquests:
A. Police Inquest (Prevalent in India; Conducted by a Police officer)
B. Magistrate's Inquest (Prevalent in India; Conducted by a Magistrate)
C. Coroner’s Inquest (Not prevalent in India; Conducted by a Coroner)
D. Medical Examiner system (Not prevalent in India; Conducted by a
Medical Examiner)
E. Procurator Fiscal system (Not prevalent in India; Conducted by a
Public Prosecutor)

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 POLICE INQUEST
• This is commonest inquest held in India.
• The police inquest is held under section 174 of the Cr.P.C.
• Police inquest is conducted by a police officer, not below the rank of a head
constable.
• A police officer conducting art inquest is known as an investigating Officer.
• On receiving the information that a person has Committed suicide, or has
been killed by another or by an animal or by machinery or by an accident, or
has died under circumstances raising a reasonable suspicion that some other
person has committed an offence, the Investigating Officer immediately
informs the nearest Executive Magistrate, proceeds to the place of recovery of
such dead body.
• On reaching the place of recovery of dead body Investigating conducts an

inquiry into the cause of death in the presence of two or more respectable
witnesses of the locality. These witnesses are known as Panchas, Panch
Witnesses or Panchayatdars. Investigating Officer examines the dead body
for the presence of any evidence of injury, poisoning, etc.
• The Investigating Officer based on his findings after examining the body, as

well the information gathered from the witnesses, he prepares a report

on the portable cause of death, describing such wounds, fractures,
and other marks of injury as may be found on the body and stating in
what manner, or by what weapon or instrument; such marks appear to
have been inflicted. This report is called the Panchnama Report or the
Inquest Report.
• After preparing the inquest report, the police officer may come to one of

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 the two conclusions; either there has been a foul play or there has been
none. In either case, his subsequent action would be different.
• After preparing the inquest report, the police officer may conclude, either
there has been a foul play or there has been no foul play in the death.
• If the police officer on conclusion of inquest report finds that there is no
foul play involved in the death, he may hand over the body to the relatives
for performing last rites or cremation.
• If the police officer on conclusion of inquest report finds that there is foul

play involved in the death, he may hand over the body to the authorized
Medical Officer for conduct of post-mortem examination to unravel the
mystery behind the death.

MAGISTRATE'S INQUEST
• The magistrate’s inquest is held under section 174 (3) and section 176 of

the Cr.P.C.
• Magistrate’s Inquest is the inquiry or investigation by Magistrate into cause of

death or to ascertain matters of fact.

• It is conducted all over India but only in certain special circumstances.

• District Magistrate or Sub-divisional Magistrate and any other Executive

Magistrate specially empowered in this behalf by the State Government or the

District Magistrate are authorized to hold this type of inquest.
• Magistrate inquest is held in following circumstances:

1. Death as a result of police firing.

2. Disappearance or death of a person in police custody or during police
interrogation.

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 3. Death of a convict in jail
4. Exhumation cases (body is dugged out of a grave).
5. Rape alleged to have been committed on any women in the custody of
police.
6. Dowry deaths (Section 304(B) I.P.C.).
7. Admission of a mentally ill person in a psychiatric hospital or a psychiatric
nursing home under certain provisions of the Mental Health Act, 1987.
• On receipt of information of death from the police officer, magistrate reserves

the right to hold an inquest in any other case of death which he deems fit.
• Rationale of conducting Magistrate Inquest: Magistrate inquest is held on the

presumption that justice cannot be met by allowing a police officer to conduct

an inquest wherein either their involvement is suspected or in cases wherein
law presumes that inquest should be conducted by a authority which superior
to Police or in peculiar circumstances associated with dowry death.

CORONER'S INQUEST {Coroner=keeper of the pleas of the Crown)

• Coroner’s Inquest means an inquiry conducted by a coroner into the cause

and manner of death.

• It is prevalent in Sri Lanka, Japan, Hong Kong, UK, Canada, and New Zealand

• The coroner’s court was established in India in 1902. Coroner's inquest is no

more prevalent in India. Abolished from Kolkata since 1978 and from Mumbai
in 1999.
• The Coroner shall have a legal qualification (advocate / attorney /
pleader / magistrate) having a minimum of five years experience
in the legal field.

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 • Coroner required to conduct or order an inquest into the manner or cause of

death, and investigate or confirm the identity of an unknown person who has
been found dead within his jurisdiction.
• Coroner's court was not a court of trial. Coroner’s court only conducts enquiry.

It had no power to grant punishment to the culprit.

• After conducting an enquiry into the cause of death, if the Coroner finds

sufficient evidence against the suspect, he would forward a copy of his

inquest report to the Commissioner of Police, and he would take further
action in this regard.
• The Coroner's inquest was considered superior to the police inquest.

MEDICAL EXAMINER SYSTEM

• Medical Examiner System is prevalent in the USA and UK.

• In Medical Examiner System, a medically qualified person investigates the

death.
• The Medical Examiner not only conducts post-mortem examination but also visits

the scene of crime to get first hand information regarding the circumstances
of death. Therefore making it superior to other kinds of inquests, in which
non- medical personnel conduct an inquest.
• The medical examiner has no power to summon witnesses and examine them

on oath. He submits his report to the district attorney for further action.

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PROCURATOR FISCAL SYSTEM
• Procurator Fiscal is a public prosecutor in Scotland.

• Procurator fiscal investigates all sudden and suspicious deaths in Scotland;

and conducts fatal accident inquiries and handle criminal complaints against
the police.
• The procurator fiscal has the discretion not to prosecute and pursue

alternatives free from political interference, but is always subject to the

directions of Crown Office and the Lord Advocate.
• He presents cases in the court on behalf of prosecution.

COURTS OF INDIA
India has an integrated judicial system, Supreme Court being at its summit at the
National Level; High Court at the State Level and subordinate judiciary at the
District Level. In addition to this there are number of other courts and tribunals
established in India to govern specific aspects of law.

SUPREME COURT
• Supreme Court of India consists of a Chief Justice of India and thirty other

Judges.
• President appoints every Judge of the Supreme Court after consultation with

Judges of the Supreme Court and the High Courts.

• It sits in benches comprising of two or three judges.

• Supreme Court Judge holds office till the age of 65 years.

• The Supreme Court is located in Delhi.

• Powers of Supreme Court:

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  Supreme Court pronouncements are binding on all subordinate courts.
 It is appellate authority against the High Court orders.
 It is the final authority in enforcing fundamental rights.
 The Supreme Court can arbitrate disputes between States and the Union or
between States and States.
 It has deciding powers regarding disputes relating to election of a
President or Vice-President.
 Advises the President of India on Constitutional matters.

HIGH COURT

• Each state will be having a High Court.

• There are total 24 High Courts, three having jurisdiction over more than
one State.
• State of Mizoram, Arunachal Pradesh and Nagaland (common High Court of

Assam at Guwahati), Haryana and Punjab (common High Court at

Chandigarh); and Goa which falls under High Court of Bombay.
• Chief Justice of the high Court heads the High Court.

• President appoints the Judges of the High Court in consultation with the Chief

Justice of India, the Governor of the concerned State, and the Chief Justice of
the concerned High Court.
• High Court Judge holds office till the age of 62 years.

• Powers of High Court:

 It is appellate authority against the orders of sub-ordinate courts.

 High Court can to pass any verdict authorized by law.
 Enforcement of Fundamental Rights.

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 SUBORDINATE COURTS
• At the district level there are different layers of Courts.
• At the district level there is Court of Session, Court of Judicial Magistrate, Court
of Metropolitan Magistrate and Court of Executive Magistrate.
• District judges will be appointment by the Governor of the State
in consultation with the presiding officer of the High Court.

CRIMINAL COURTS GF INDIA AND THEIR POWERS

Sl.No Court Sentencing Powers
1 Supreme Court Any sentence authorized by law
2 High Court Any sentence authorized by law
3 Court of Sessions Any sentence authorized by law. However, any
Judge sentence of death shall be confirmed by the respective
High Court
4 Court of Additional Any sentence authorized by law. However, any
Sessions Judge sentence of death shall be confirmed by the respective
High Court
5 Court of Assistant
Any sentence authorized by law except a death
Sessions Judge
sentence or of life imprisonment or of
Imprisonment for a term exceeding 10 years.
6 Court of Chief Judicial Any sentence authorized by law except a death
Magistrate or Court of sentence or of life imprisonment or of
Chief Metropolitan imprisonment for a term exceeding seven years.
Magistrate
7 Court of Judicial Sentence of imprisonment for a term not exceeding

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 Magistrate of First three years, or of fine not exceeding 10 thousand
class or Court of rupees, or both.
Metropolitan
Magistrate
8 Courts of Judicial Sentence of imprisonment for a term not exceeding one
Magistrates of Second year, or of fine not exceeding five thousand rupees, or of
Class both.

EXECUTIVE MAGISTRATES
• State Government appoints Executive Magistrates.
• They include Collector (District Magistrate for entire District); Joint Collector
(Additional District Magistrate for entire District); District Revenue Officer
(Additional District Magistrate for entire District); Revenue Divisional Officer
(Sub Divisional Magistrate for Entire Revenue area); Tahsildar (Mandal
Executive Magistrate for Entire Mandal)

SENTENCE AUTHORISED BY LAW (SEC. 53 OF INDIAN PENAL CODE)

Section 53 of the Indian Penal Code prescribes various punishments authorized by

law:
1. Death sentence (It is given for rarest of rarest crimes).
2. Imprisonment for life_
3. Rigorous or simple imprisonment for any period.
4. Forfeiture of property.

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 5. Fine (any amount).
• Transportation for life (Kala Pani), and caning which was prevalent during

British raj now been abandoned.

SUBPOENA or SUMMONS (Latin: Sub+Poena; Sub=Under; Pena=Penalty)

• Summons is a written document issued by a Court, in duplicate, signed by the
presiding officer of the Court; bearing the seal of the Court, compelling the
presence of witness in the court on a particular date, time and place to give
evidence (Sec. 6 I of Indian Evidence Act).
• The summons should contain adequate particulars such as the date, time, and

place, of the offence charged.

• If the summoned witness fails to turn up, without a just cause, the court may

impose a fine upon him or may even order for this imprisonment (hence the
term "under threat of penalty") or may issue bailable or non-bailable
warrants to secure the presence of a witness in the court of law..
• Subpoena can be of two types:

1. Subpoena Ad Testificandum: Summons which compels a witness to attend

and give oral evidence.
2. Subpoena Duces Tecum: Summons which compels a witness to give
evidence and also produce certain documents in his possession before the
court.
• Procedure for serving a Summons:
 Every summons shall be served by a police officer or by an officer of t h e
Court issuing it.
 The summons shall, if possible, be served personally on the person

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 summoned, by delivering or tendering to him one of the duplicates of the
summons.
 Every person shall sign a receipt for receipt of the summons on the back
of the duplicate.
 Service of a summons on a corporation may be affected by serving it on
the secretary, local manager or other principle officer of the corporation.
 Where the person summoned is in Government service, the Court issuing
the summons shall ordinarily sent it in duplicate to the head of the
office in which such person is employed.
 When the person summoned resides at a place outside the jurisdiction of
the summoning authority, it shall be sent in duplicate to a Magistrate
within whose local jurisdiction the person summoned resides.
 Where the person summoned cannot be found, the summons nay be
served by leaving one of the duplicates for him with some adult male
member of his family residing with him or affixing one of the duplicates of
the summons to some prominent part of the house in which the person
summoned ordinarily resides.
 Summons also can be served by registered post addressed to the witness
at the place where he ordinarily resides. An acknowledgment or an
endorsement serves as proof of summons being served.
 When the summoned person resides out of India, summoned can be sent
directly to the residential address / official address in foreign land vide
Registered Post / Ack. Due, speed post (if service is available) and authorized
courier service (if service is available) and even by e-mail with the
approval of the court or through the Indian Embassy in the country via

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 Ministry of External Affairs.
 Priority of respecting summons are, Criminal courts have priority over
civil courts; Higher courts have priority over lower courts; and In case of
two courts of same status, the court summoned first has priority over
court which served the summons later.
DEPOSITION OR RECORDING OF EVIDENCE/WITNESS IN THE COURT OF LAW

• All persons shall be competent to testify useless the Court considers that they
are prevented from understanding the question put to them, or from giving
rational answers to those questions, by tender years, extreme old age,
disease, whether of body or mind, or any other cause of the same kind as per
section 118 of l.E.A. A lunatic is not incompetent to testify, unless he is
prevented by his Lunacy from understanding the questions put to him and
giving rational answers to them.
• The deposition or recording of evidence in the Court of Law is as per section
137 and 138 of the Indian Evidence Act, which includes following steps:
1. Oath.
2. Examination-in-Chief or Direct Examination.
3. Cross Examination.
4. Re Examination-in-Chief.
5. Re Cross Examination.
6. Questions by the Judge

OATH
 The first step in recording of evidence is the oath.
 If a witness does not believe in God, he must make a solemn affirmation.

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  Section 6 and 7 of the oaths act, 1969 ; and Section 51 of I.P.C. Oath is read as
follows
 I do (Swear in the name of God) / (Solemnly Affirm) that what I shall state shall
be the truth, the whole truth and nothing but the truth.
 After taking an oath, a witness becomes legally bound to speak the truth and
nothing but the truth. The Indian Penal Code (IPC) under Section 191
defines perjury as "giving false evidence under oath" and by interpretation it
includes the statements retracted later as the person is presumed to
have given a “false statement" earlier or later, when the statement is
retracted. Under section 191 of IPC, an affidavit is evidence and a person
swearing to a false affidavit is guilty of perjury punishable under Section 193
IPC which prescribes the period of punishment as seven years imprisonment.
In India perjury encompasses statement, material and/or any other form of
evidence. The use of false material and inconsistent declarations also fall under
the category of “perjury". For instance, in the Jessica Lall case, it has to be seen
whether the "sudden" invention of “two weapons" having been used
constituted false material. In Zaheera Sheikh's case it is her inconsistent
declarations and retractions.

EXAMINATION-IN-CHIEF OR DIRECT EXAMINATION

 This is the first stage of recording of evidence in the real sense.
 The examination of a witness, by the party who calls him, shall be called his
Examination-in-chief.
 This stage of examination is basically meant to bring out the facts of the case
before the court.

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  Leading questions are not permitted in Examination-in-Chief. A leading
q u e s t i o n and its essentials are discussed in section 141, 142 and 142 of the
IEA. Leading

 Question is a question suggesting the answer which the person putting it wishes
or expects to receive is called a leading question or it can be a question which
leads the witness to its own answer. For example, the question ‘Did you see Mr.
A stabbing Mr. B?’ is a leading question, wherein he is required to say either
‘Yes’ or 'No’; or He saw Mr. A stabbing M. B. The proper question in
Examination in-Chief should be 'Who stabbed Mr. A’ or ’Did you see anybody
stabbing Mr. A'?. Another instance, the question, “Are you 18 years old?", is a
leading question, because it can be answered in yes or no, but the question,"
What is your age?", is not a leading question, because it cannot be answered in
yes or no. One has to give a definite answer to this question. Leading questions
are permitted during Examination-in-Chief by the party who has called the
witness, when the witness turns hostile.

CROSS EXAMINATION
• After the Examination-in-Chief is over, the examination of a witness by the
Opposite party shall be called his cross-examination.
• The objectives of cross examination includes:
 To test the veracity of a witness.
 To contradict, destroy or discredit a witness thereby weakening the case of
the adversary.
 To attack the credibility, knowledge and recollection of the witness by
exposing the witness’ bias or prejudice towards the other side.
 To question the witness’ legal competence either to testify as a lay witness

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 or to render an opinion as an expert.
 To weaken, overcome, qualify or explain testimony given in the direct
examination.
 To establish the accuser's case through the opponent's witnesses.

• Leading questions are allowed in cross-examination.

• Cross examination act as a double edged sword, if the witness is well-informed,
honest, and truthful, and the lawyer in his anxiety to discredit the witness,
ask him questions which way go against his client. Cross examination brings
out the truth from the witness also. A witness who is willfully speaking lies will
always end up contradicting himself, if questions were put through to him
cleverly during cross examination.
• Cross-examination is not a essential stage of the recording of the evidence. If no
questions are asked by the other lawyer, the recording of evidence ends here. It
is recorded as 'cross examination nil, opportunity given, which means that no
cross examination was done, despite having been given the opportunity to do
so.

RE EXAMINATION-IN-CHIEF
 The examination of a witness, subsequent to the cross-examination
by the party who called him, shall be called his Re Examination-in-Chief.
 This takes place if in the cross examination stage, inconvenient answers are
given by the witness. The goal in this stage is to nullify the effect of such
answers and to re-establish the credibility of the evidence given by the witness.
 Leading questions are not allowed during Re Examination-in-Chief.

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RE CROSS EXAMINATION
 Re-cross examination refers to resumption of cross-examination by
the original cross examiner in order to respond to matters that may have
arisen during the Re Examination in-Chief of a witness. However this can only
deal with those issues addressed in the Re Examination-in-Chief.
QUESTIONS ASKED BY THE JUDGE
 Presiding officer may ask questions from the witness himself to clarify certain
doubts which were not been properly elucidated during the examination of
the witness, by either of the lawyers. This is the end of deposition or recording
of the evidence in the court of law.
At the end of deposition, the recorded deposition of witness is handed over to the to
be read carefully and to be signed at the bottom of each page, and on the last page
immediately below the last paragraph; and to be initialed for any corrections.

CONDUCT MONEY
 Conduct money is money paid to a witness to compensate for their expenses
to attending the court.
 It generally incorporates a daily rate for each day the witness must attend in
court (with a one-day minimum), plus a travel allowance to allow the
witness to get to the place of the hearing.
 In a civil case, the conduct money is paid by the party who calls him, and the
money is paid at the time of the serving of summons. A witness may not refuse
to appear merely because they believe the conduct money is insufficient to
make up for their lost wages or actual travel expenses. If the witness thinks

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 the money is insufficient, he should attend the court, and before giving the
evidence inform the presiding officer of the court, that the conduct money
that has been paid to him by the party is insufficient. The court would decide
about the right quantum of money.
 In a criminal case, the money is not paid at the time of summons, but after
attending and giving the evidence. In case of summoning of a medical officer,
some courts only give a certificate to the effect, that the doctor had attended
the court and was paid nothing by the court. On showing this certificate the
doctor would get reimbursement of his travelling and other incidental
expenses from his institute where lie is working

WITNESS
 Witness is an individual who give testimony/evidence under oath in court,
connecting what they have seen, heard, or otherwise observed.
 All persons shall be competent to testify unless the Court considers that they
are prevented from understanding the question put to them, or from giving
rational answers to those questions, by tender years, extreme old age, disease,
whether of body or mind, or any other cause of the same kind as per section
118 of I.E.A. A lunatic is not incompetent to testify, unless lie is prevented by
his Lunacy from understanding the questions put to him and giving rational
answers to them.
 Witness can be classified into:
1. Common witness or Ordinary witness or Lay witness: A common witness
is a individual who testifies regarding the facts known to him. A
medical witness is merely a common witness when he merely testifies

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 regarding size, shape and location of wounds on the body. Common witness
is not expected to render their opinion. In criminal proceedings these are the
common people who saw a crime being committed.
2. Professional witness: A professional witness is one who gives factual
evidence. For example, a casualty medical officer may confirm that a leg
was fractured or that a laceration present and relevant treatment
given. A physician May confirm that an individual has been diagnosed as
having or angina.
3. Expert witness or skilled witness: As per section 45 of IEA, an expert
witness is a person especially skilled in foreign law, science or art. He is an
expert is some branch of art or science, and can draw useful inferences from
the observations made by him and others. A forensic expert is an expert
witness. Some example for forensic expert being expert witness are: he can
look at the dead body and say what is time since death Or he may look at
the wounds on the body and opine how they must have been produced.
Other examples of expert witnesses are chemical examiner, ballistic expert,
handwriting expert etc.

Forensic Expert can be ordinary witness, professional witness or expert witness. For
instance a forensic expert just testifies regarding size, shape and location of wounds
on time body he is an ordinary witness. The forensic expert will prepare a
report based on post-mortem examination (professional aspect) and then forms
conclusions and interpretation based upon their findings (expert aspect).

HOSTELS WITNESS

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  Hostile witness is also known as unfavourable witness or adverse witness o r
unwilling witness.
 The term 'hostile witness’ does not find any clear mention in any Indian laws,
however principles dealing with the treatment of hostile witnesses are
encompassed in section 154 of 1. E.A.
 The hostile witness technically is an witness in a trial who is found by the judge
to be hostile (adverse) to the position of the party whose lawyer is questioning
the witness, even though the lawyer called the witness to testify on behalf of
his/her client.
Or
Hostile witness is one who is not desirous of telling the truth at the
instance of one party calling him.
Or
Hostile witness as one “who is not desirous of telling the truth at
the instance of one party calling him".
Or
A hostile witness is one who from the manner in which he gives evidence
shows that he is not desirous of telling the truth to the court. Within which is
included the fact that he is willing to go back upon previous statements made by
him.
 When the lawyer calling the witness finds that the answers are
contrary to the legal position of his/her client or the witness becomes openly
antagonistic, the lawyer may request the judge to declare the witness to be
"hostile" or “ adverse." If the judge declares the witness to be hostile (i.e.
adverse), the lawyer may ask "leading" questions which suggest answers or

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 are challenging to the testimony just as on Cross examination of a witness who
has testified for the opposition.
 Both common and expert witness may turn hostile.
 Zaheera Habibullah Sheikh, the star witness who turned hostile in the
landmark Best Bakery case, pertaining to the 2002 Gujarat riots, has been
sentenced to one year in jail and fined Rs 50,000 for perjury by the Supreme
Court of India.

EVIDENCE
 Latin: evidence; implies to show distinctly, to make clear to view or sight, to
discover clearly, to make plainly certain, to certain, to ascertain, to prove.
 Section 3 of the Indian Evidence Act, defines evidence as all the statements
which the court permits or requires to be made before it by witnesses, in
relation to matters of fact under enquiry (oral evidence) and all the documents
including electronic records produced for the inspection of the court
(documentary evidence).
 Hon’ble Supreme Court of India defined evidence as all valid meanings,
includes all except agreement which prove disprove any fact or matter whose
truthfulness is presented for Judicial Investigation.
 Medical evidence means the evidence given or produced by a medical man.
 Evidence may be classified as Oral Evidence (sec. 60 IEA) and Documentary
Evidence (sec. 61 - 65 IEA); Primary Evidence (sec. 62,64 IEA) and Secondary
Evidence (sec.63,65 IEA); and Direct Evidence and Circumstantial Evidence.
 Oral Evidence: All those statements which the court permits or expects the

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 witness to make in his presence regarding the truth of the facts are called Oral
Evidence. Oral Evidence is that evidence which the witness has personally seen
or heard. Oral evidence must always be direct or positive. Oral evidence has
got a greater value than documentary evidence, because the person giving such
evidence can be cross examined. Wherever the evidence has been cross
examined, it acquires more sanctity. Statements made by gestures may be
considered as oral evidence. The oral evidence includes Direct Oral Evidence
and Indirect Oral Evidence. Direct oral evidence refers to the evidence given by
a person who actually saw or heard something. For example, Mr. A saw Mr. B
killing Mr. C. Later on Mr. A tells his friend Mi. D that he has seen Mr. b killing
Mr. C. Later on Mr. A tells his friend Mr. D that he has seen Mr. B killing Mr. C.
Now both Mr. A and Mr. D know that Mr. B has killed Mr. C. But A is the one
who actually saw the actual killing, so if he gives evidence in the court, his
evidence is direct oral evidence. Section 60 of I.E.A. states that wherever
possible, oral evidence should be direct. Indirect Oral Evidence or Hearsay
Evidence is that evidence which the witness has neither personally seen nor
heard, nor has he perceived through his senses and has come to know about it
through some third person. For example, Mr. A saw Mr. B killing Mr. C. Later
on Mr. A tells his friend Mr. D that he has seen Mr. B killing Mr. C. Now both
Mr. A and Mr. D know that Mr. B has killed Mr. C. But A is the one who actually
saw the actual killing, so if he gives evidence in the court, his evidence is direct
oral evidence. On the other hand if Mr. D is called to the court and he says that
Mr. B killed Mr. C, it is an indirect type of evidence or hearsay because he
never saw actual killing. He is merely repeating what Mr. A told him.
 Documentary evidence: Section 3 of The Indian Evidence Act says that all

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 those documents which are presented in the court for inspection such
documents are called documentary evidences. Words printed, lithographed or
photographed, a map or plan and a caricature are documents. This means
that the evidence given is in the form of some documents, which
includes:
1. Medical certificate: It includes certificates such as sickness certificate, fitness

certificate, certificate of pregnancy, vaccination certificate, death certificate

etc. It is given to a patient when he or she requests the medical officer to do
so. For instance, if a woman has been found pregnant by a doctor, he may be
requested by the woman to give her a certificate to that effect. She might
need it to produce it in her office to avail maternity leave. The medical officer
may be called in court to verify on oath that what he had written in the
certificate was correct. He may lie cross questioned on that too.
2. Medico-legal reports: This is a document prepared by a medical man in

response to a request from some investigating authority, either a police

officer or a magistrate. Medico-legal reports are usually made in criminal
cases, and are meant for the guidance of the investigating authority. Most
commonly the doctors would find themselves making injury reports in the
casualty. Other medico-legal reports include post-mortem reports, age
reports, certificate of mental illness, certificate of drunkenness, certificates
relating to impotency, sexual assault and so on. The medical certificates are
made on the request of the patient and the medico-legal report is wade on
the request of the investigating authority.
3. Dying Declaration:

All documentary evidence are accepted by the Court of law only on oral

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 testimony by the person concerned. The person preparing the document
should come to the court and face cross-examination to make it admissible
except in following cases wherein law exempt the person from supplementing
documentary evidence by oral evidence. These exceptions are:-
a. Dying declaration: It is documentary evidence. Since the person who made
this declaration has died, he cannot come to the court for oral
evidence.
b. Opinion of an expert: If an expert has opined upon something in some treatise,
and he is now dead, his documentary evidence would have to be admitted.
c. Deposition of a medical witness in a lower court: When a witness has given
his evidence in a court of law, his evidence will be admissible in a higher court,
without compelling his presence.
d. Evidence given by a witness in a previous judicial proceeding is admissible in
subsequent judicial proceeding, when the witness is dead or cannot be found,
or is incapable of giving evidence.
e. Evidence of a Mint Officer or an officer of the Indian Security Press.
f. Reports of certain Government scientific experts: These include Reports of
Chemical examiner; Reports of Chief Inspector of Explosives; Reports of
Director, Haffkine Institute, Bombay; Reports of Director Fingerprint Bureau;
Reports of Director Central Forensic Science Laboratory, or State Forensic
Science Laboratory; and Reports of serologist to the Government.
g. Records of births and deaths, marriage certificates etc are admissible as such.
h. Routine entries such as date of admission and discharge of the patient,
treatment given may be admitted as such without the concerned doctor to
appear before the court.

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 • Sec 61 IEA states that the contents of a document may be proved
either by primary or by secondary evidence. Primary Evidence means 'the
document itself produced for the inspection of the court'. Secondary
Evidence (sec 63 IEA) includes certified copies of the original documents,
copies made from the original by mechanical process which assure the
accuracy of the copy, copies made from or compared with the original,
Counterpart of a document against the party who did not sign it, Oral
account of the contents of a document given by a person who has himself
seen the document. Direct evidence is based on a witness’s personal
knowledge or observation of a fact. Direct evidence does not require any
reasoning or inference to arrive at the conclusion to be drawn from
the evidence. If the witness personally saw the defendant stab the
victim that is direct evidence; the stabbing is within the witness’s actual
experience. Whether the judge or jury, whose duty is to listen to the evidence
and determine the truth, believes the witness is a separate issue regarding
credibility, but does not change the nature of the testimony as direct
evidence. Direct evidence has traditionally been described as eye witness
testimony. In the modern age photographs, video and audio recordings are
also direct evidence. The recorded presentation of an event can establish
directly that the event took place. Circumstantial evidence, also called
indirect evidence, requires that an inference be made between the
evidence and the conclusion to be drawn from it. A witness did not see the
stabbing above. The witness did see the defendant go into the house carrying a
knife. The witness heard a scream inside the house and saw the defendant ru n
out, not carrying the knife. The victim is later found inside with a knife in her

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 back. A reasonable inference is that the defendant stabbed the victim.
Whether that fact is true will determine if the defendant is guilty. In the
stabbing above, no one saw the victim stabbed, and the defendant said he
did not do it, but the eye witness saw things that lead to the conclusion that
the man running out of the house stabbed the victim. The witness' testimony is
circumstantial evidence of the defendant's guilt. Circumstantial evidence is a
collection of facts that, when considered together can be used to infer a
conclusion about something unknown. Circumstantial evidence is used to
support a theory of a sequence of events. The sum total of multiple pieces of
corroborating evidence, each piece being circumstantial alone, build an
argument to support how a particular event happened. Other examples of
circumstantial evidence are fingerprint, blood analysis or DNA analysis of
the evidence found at the scene of a crime. These types of evidence may
strongly point to a certain conclusion when taken into consideration with
other facts—but if not directly witnessed by someone when the crime was
committed, they are still considered circumstantial. However, when
proved by expert witnesses, they are usually sufficient to decide a case,
especially in the absence of any direct evidence.

DYING DECLARATION
• As per 32 (1) of IEA, A dying declaration is “a statement, written or verbal
made by a person as to the cause of his or her death or as to the
circumstances of the transaction resulting in his or her death".
• It is based on the principle that "no-one on the point of death should be
presumed to be lying" or "A Man Will Not Meet His Maker with a Lie in His

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 Mouth". Thus the oath is not administered when dying declaration is recorded.
• There is a clear distinction between Indian law and the English law regarding
dying declaration. The credence and relevancy of dying declaration under the
English law is only when the declaring is in hopeless condition and under the
expectation of death. However in Indian law it is not necessary that the deceased
at the time of giving the statement should be under the expectation of death
and the dying declaration is admissible not only in the case of homicide but
also in civil suits. Under the English law, the admissibility of dying declaration
is confined to criminal charges of murder or manslaughter only.
• It is essential that the declaring must be in a sound state of mind
(compos mentis) at the time of making the declaration. The doctor
is required to certify that the patient is in a sound mental condition to take a
statement before it is recorded. He should also record date and time of giving
compos mentis.
• But even in conditions where it was not possible to take fitness from the
doctor, other witnesses can testify that victim was in such a condition of the
mind which did not prevent him from making statement.
• Recording of the statement should not be under the influence of anybody or
prepared by prompting, tutoring or imagination. Indian law doesn’t provide
any prescribed manner, format or procedure for recording dying declaration.
But ideally it is recorded in local dialect in narrative form. It gives less chance
of asking leading questions. In question and answer forms, most of the points
will be missed and the declarant concentrates only on the questions which he
was asked.
• Calcutta High Court has ruled that where a dying person is unable to speak

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 and can make only signs to the questions put to him, such questions and
signs put together might be regarded as 'verbal statement' made by a
person as to the cause of his death.
• The law does not provide direction on who can record a dying declaration. Any
member of the public can record the statement of a dying declaration, but he
should make sure that the one making the statement should be conscious and
his mental status are normal. But ideally, magistrate should record the dying
declaration.
• Dying declaration should be recorded in the presence of independent
witnesses by recording the date and time of starting and ending of
statement. Declarant should not be under the influence of anybody nor
prepared by prompting, tutoring or imagination.
• The declaration after being recorded should be read over to the declarant,
who should affix his or her signature/ thumb impression to it and if not,
then should mention the reason for not taking it in the end of the statement.
If the declarant writes his statement himself, the statement should be signed
and attested by both the witness and investigating officer. If the declarant
becomes unconscious while the statement being recorded, person who is
writing it must elicit as much as information and sign it. If a victim loses
Consciousness in the middle of recording statement, the evidentiary value of
such incomplete declaration is again questionable. Law does not provide any
information on this issue.
After recording statement its confidentiality is maintained. It should be sealed in
a proper envelope with a seal and sent to the concerned authorities and a
photocopy should be kept in case file.

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DYING DEPOSITION
• A dying deposition is a dying declaration made on oath in the presence of the
accused or his legal representative who has the opportunity to cross examine
the dying man. This is recorded by magistrate.
• Difference between dying declaration and dying deposition include the
following:
1. The dying declaration can be recorded by anyone (magistrate, doctor,
police officer or any other) when the dying deposition is recorded only by
magistrate.
2. Oath is not necessary in the dying declaration when it is
must to take oath in dying deposition.
3. Presence of the accused in not essential in the dying declaration
when presence of the accused/ his lawyer is essential in the
dying deposition.
4. Cross examination is not allowed in dying declaration, when it is allowed
in the dying deposition.
5. Legally, dying deposition is more valuable than dying declaration as
the accused has the opportunity to challenge and cross examine.
6. The dying declaration is followed in India when the dying deposition isn't
followed in India.

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 MECHANICAL INJURIES
Medical definition of Injury is different from legal definition of injury. In the medical
field an injury is defined as “discontinuation or breach in the continuation of any living
tissue”. However, law defines injury under Sec. 44 IPC as “any harm whatever
illegally caused to any person, in body, mind, reputation or property”. Accordingly,
harm to the body means the physical injury, harm to the mind means mental injury,
harm to the reputation means defamation and harm to the property means stealing
or destroying the movable or immovable property. Wound is the word which is used
synonymously with physical injury.

Classification of Injuries:
1. Mechanical injuries: These are the injuries caused by mechanical or physical
forces such as blunt weapons, sharp cutting weapons, pointed weapons and
firearms.
2. Thermal injuries : These are the injuries caused by heat and cold
3. Chemical Injuries: These are the injuries caused by chemicals such as acids and
alkalies.
4. Electrical injuries : These are the injuries caused by electric current
5. Radiation injuries: These are the injuries caused by radiations such as X-Rays,
UV rays, infra red rays etc.

MECHANICAL INJURIES: These are the injuries caused by mechanical or physical

forces such as blunt weapons, sharp cutting weapons, pointed weapons and
firearms.
Classification of Mechanical Injuries:
I. Caused by blunt weapons
1. Abrasions
a. Scratch abrasion.
b. Graze abrasion.
c. Pressure abrasion
2. Contusions
a. Superficial contusion

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 b. Deep contusion.
c. Patterned/imprint contusion
d. Ectopic/migratory contusion.
3. Lacerations
a. Cut/split/incised looking laceration.
b. Stretch laceration.
c. Avulsion laceration.
d. Tear laceration.
4. Fractures
II. Caused by sharp cutting weapons
1. Incised wounds
2. Chop wounds
3. Fractures
III. Caused by pointed weapons
1. Stab wounds
a. Incised punctured wound.
b. Lacerated punctured wound.
c. Incised penetrated wound.
d. Lacerated penetrated wound.
e. Incised perforated wound.
f. Lacerated perforated wound.
2. Fractures
IV. Caused by Firearms
1. wounds caused by rifled firearms
2. Wounds caused by smooth bored firearms.

ABRASION
Definition: Abrasion is a type of mechanical injury in which there is destruction or
damage to the superficial layer (epidermis) of the skin or mucous membrane.

Characteristics of Abrasions:
 It bleeds less, heals fast and does not leave any scar after complete healing, as
the dermis is not involved.
 Abrasion is a two dimensional injury.
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Classification of Abrasions:
Abrasion is classified into the following based on its mechanism of causation,
1. Scratch Abrasion or Scratches: This is caused when objects such as pin,
thorn, finger nail etc. is drawn across the skin, injuring only the epidermis.
The object causing the abrasion takes the skin debris along its course, so that the
heaped up epithelium is seen at the terminal end of an abrasion. This helps in
knowing the direction of injury.
2. Graze Abrasion or Gravel Rash or Brush Burn: This is caused when the skin
scrapes against a broad rough surface like ground. This is commonly seen in
RTA e.g., when the rider or pillion rider of a two wheeler falls on the ground, fall
while running, dragging a person on the rough surface, glancing kicks with rough
surfaced shoes etc.This results in multiple parallel scratches with a broad base,
narrow apex and a filing up of epithelium on its exit point. Serrated edges are
seen at the beginning and heaped up epithelium at the terminal end of grazed
abrasion which helps in knowing the direction of the injury. Scene of occurrence
can be known in the presence of foreign bodies such as sand, soil, grass etc., in
the floor of the wound. The other terms used for grazed abrasion are “brush
burn’, ‘friction burn’ and ‘Gravel rash’ because it is caused by the friction between
the skin and any other rough object. In extreme cases, due to generation of heat
at the time of friction there may be actual burn. Depending on the causative
object it is termed “rope burn”, ‘carpet burn’ or ‘rug burn’ etc.,
3. Pressure Abrasion: Here the abrasion is caused due to the pressure of an
object on the skin. Due to the pressure the epidermis gets crushed thereby
leaving the exact shape of the causative object. The pressure abrasion caused
by a momentary impact is called imprint abrasion, e.g., impact by radiator grill,
whip, tire tread marks etc. and the pressure abrasion caused by a sustained
impact is called patterned abrasion, e.g., ligature mark in case of hanging. The
shape of the pressure abrasion helps in the identification of the causative object.

Medico Legal Importance of Abrasion:

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1. Site of impact: The presence of an abrasion gives an idea about the site of
impact, which is especially useful in case of unconscious patients.
2. Direction of impact/injury: The direction of injury can be ascertained by the
presence of heaped up epithelium at the termination of an abrasion, e.g., in a
case of victim of rape, the direction of scratch abrasions on the thigh (if present)
will be above downwards and from inner to outer, whereas in case of self inflicted
scratch abrasions caused by the victim with an intention of false accusation, the
direction will be from below upwards and from inner to outer.
3. Place of occurrence: Presence of any foreign bodies on the wound helps in
determining the place of occurrence of injury.
4. Cause of injury/death: Presence of abrasions on the body helps in ascertaining
the cause of injury and/or death, e.g., abrasions around the mouth and nostrils in
case of smoothing, ligature mark around the neck in case of hanging and
strangulation, finger nail marks over the neck in case of throttling, abrasions
around the vulva in case of rape, abrasions around the anus in case of sodomy,
tire tread marks in case of road traffic accidents etc.,
5. Identification of causative object: The presence of patterned abrasions help in the
identification of causative object, e.g., the patterned abrasions caused by tire
tread, radiator grill, whip, rope, cane etc.
6. Age of Abrasion / Healing of an Abrasion / Dating of an Abrasion: The age of the
injury can be estimated based on healing process of an abrasion as mentioned
below:
 A fresh abrasion (less than 12 hours) will be bright red because of raw surface
of the dermis.
 The serum, lymph and tissue debris over the abrasion get dried up and forms
a reddish scab in 12 - 24 hours.
 The scab becomes reddish brown in 2 - 3 days.
 The growth of new epithelium begins beneath the scab from periphery in 4 - 7
days; meantime the scab becomes dried and shrunken, begins to separate
from its periphery.
 The scab falls off in 7 -10 days leaving a hypopigmented surface by which
time healing is completed.
Fresh : bright red

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 12-24 hours : reddish scab
2-3 days : reddish brown scab
4-7 days : separation of scab from periphery
7 - 10 days : scab falls off

CONTUSION or BRUISE
Definition: It is a type of mechanical injury in which there is extravasation and
infiltration of blood into the surrounding tissue by the rupture of capillaries and
sometimes venules caused by blunt force impact.
 The capillaries involved may be those of skin, subcutaneous tissue, muscle or
bone.
 The size of contusion may vary from a few millimeters to large haematoma. A
contusion of less than 3 mm is known as petechiae, 3 mm to 1 cm as purpura,
and 1 cm to 3 cm as echymosis.
 Most of the contusions we come across in day to day life are nothing but uniform
infiltration of blood into the tissue, but sometimes it may form a pocket of blood
known as hematoma.
 In contusions the skin is intact.

Characteristics of Contusions:
 Contusion are formed not only over skin and underlying tissues but also in the
internal organs such as brain, lung, liver, spleen, kidney, intestine etc.
 The intensity of bruise is directly proportional to the force of impact.
 Bruises are usually become more prominent as time elapses; meantime it may
increase in size due to continued seepage of blood.
 Contusions can be produced by blows, squeezing or pinching.
 The contused area is raised from the adjacent normal skin and the margins are
diffused.
 Unappreciable contusions can be appreciated by using Ultraviolet light.
 Contusions of the scalp are better felt than seen.
 Multiple extensive contusions may prove fatal due to hemorrhagic shock.
 Even though the contusions are three dimensional in nature, in a living person it
is measured in two dimensions. However, on postmortem examination it can be
measured in three dimensions.
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Classification of Contusions:
1. Superficial Contusion: These are the contusions which involve only the skin or
the skin and subcutaneous tissue. These bruises appear immediately at the site
of impact
2. Deep Contusion: These contusions involve the deeper structures such as
muscle. These contusions are caused by forcible impact over the body or by the
fracture of bones such as femur, pelvis etc. Deep bruises may not be appreciable
soon after the trauma, but with the passage of time the extravasation of blood
may reach the skin. That’s why a second examination after a period of 24-48
hours is advisable to appreciate the deep contusions at surface.
3. Patterned Contusion: The exact shape of the causative object is imprinted over
the skin in the form of contusion by the impact, e.g., contusions caused by
radiator grill, tire tread, whip, muzzle imprint of a firearm etc.
4. Ectopic Contusion: These are the contusions which are formed at a place other
than the area of impact, e.g., in case of impact over frontal region or forehead the
blood may seep through the loose areolar tissue due to gravity resulting in black
eye, an impact over outer aspect of thigh may form a contusion around the knee
due to passage of blood over fascia lata, fractures involving the jaw may result in
bruising in the neck etc. Because the contusion is formed by the migration of
blood from one place to the other, it is also known as ‘migratory bruise’.

Factors Modifying the Appearance of Bruises:

1. Age: Bruises can occur easily in elderly and in children. In elderly due to thinner
and less elastic skin as well as atherosclerotic changes in the vessels and in
children due to the delicacy of the tissue.
2. Sex: Bruises can occur easily in females than males due to increased amount of
sub-cutaneous fat.
3. Obesity: Obese people tend to bruise easily due to increased amount of
subcutaneous fat.
4. Situation: The bruises readily occur over eye lids, scrotum and vulva because of
more vascularity and laxity of the tissue whereas it is difficult for the bruises to
occur over palms and soles due to toughness and firmness of the tissues.
Bruises are formed easily where the skin is underlying by bone such as forehead,

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 cheek, shin etc., because the skin and sub-cutaneous tissue will get caught
between the bone and striking object and injures easily whereas it is difficult to
form bruises over the abdomen since the abdominal wall is not supported by
bones and due to yielding of the abdominal wall.
5. Vascularity: The greater the vascularity of the tissue, the greater is the bruising,
e.g. face.
6. Looseness of tissue: Soft tissues tend to bruise easily and extensively due to
easy infiltration of blood into the tissues, e.g. face, scrotum etc.
7. Color of skin: Bruises are easily appreciable over fair skinned individual than that
of dark skinned ones.
8. Disease: Bruises are formed with minor trauma in case of people suffering from
diseases such as purpura, hemophilia, Vitamin K deficiency, leukemia, liver
disease, scurvy etc., due to extensive bleeding.
9. Force of impact: The causation of contusions depend on the degree of force of
impact. The greater the force, the larger is the contusion and vice versa.
10. Gravitational shifting of the bruise: The site of bruise may be different from the
site of impact as in case of ectopic bruise.

Medico Legal Importance of Contusion:

1. Contusions are caused by blunt weapons.

2. Contusions are usually homicidal or accidental and rarely suicidal in manner.
3. Site of impact: The presence of a contusion gives an idea about the site of
impact, which is especially useful in case of unconscious patients.
4. Degree of violence: The extent of contusions help in knowing the degree of
violence. The greater the degree of force, the extensive is the contusion.
5. Identification of causative object:
 The presence of patterned contusions help in the identification of causative
object, e.g., the patterned abrasions caused by tire tread, radiator grill, whip,
rope, cane etc.
 If the body is struck by a cylindrical and elongated object, e.g., rod, pipe, stick,
cane etc., the resulting contusion will appear as two parallel linear contusions
with a pale zone in between. This is because the convex surface of the
causative object compresses the capillaries, displaces the capillary blood
sideways, increases the capillary pressure on both sides and resulting in
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 rupture of capillaries, giving rise to an appearance of tramline, known as
‘tramline contusions’ or ‘railway line bruises’. This helps in the identification of
causative object.
 The pressure applied by the pads of finger give rise to round or oval or discoid
shaped contusions, known as ‘finger pad bruises’. These bruises are slightly
larger than the finger tips due to outward spread of blood.
 Elliptical bruises over the neck and breast may be suggestive of love marks
caused due to suction and biting. Suction by mouth causes negative pressure
leading to contusion.
 Continuous longitudinal contusions running around the body curvature
indicate that these are caused by flexible materials such as whip, belt, rope
etc.
 Doughnut bruises, i.e., circular bruises indicate that these are caused by a
spherical object such as a cricket ball, sphere etc.
6. Cause of injury/death:
 Presence of contusions on the body helps in ascertaining the cause of injury
and/or death, e.g., contusion around the mouth and nostrils in case of
smothering, contusions over the neck in case of throttling, contusions around
the vulva in case of rape, contusions around the anus in case of sodomy, tire
tread marks in case of road traffic accidents etc.
 The finger pad bruises may be seen over the face and arms of a child in case
of child abuse, over the thighs in case of rape, over the neck in case of
throttling and over the arms in case of forceful restraint.
 Contusions over trigger zones such as sides of upper neck, epigastrium and
scrotum without any other positive findings may indicate death due to vagal
inhibition.
7. Age of Contusion / Healing of a Contusion / Dating of a Contusion: Age of bruises
can be compared to the date of its infliction from the color changes
 When fresh (less than 12 hours), a contusion appears red because of
oxyhemoglobin of extravasated blood.
 It changes in color due to deoxyhemoglobin and appears blue from about 12
hours to 2 days.

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  Deoxyhemoglobin converts into hemosederin and the contusion appears
brown or brownish black in 3-4 days.
 The hemosedrin converts into hemotoidin and contusion becomes green in 5-
7 days.
 The conversion of hemotoidin into bilirubin turns the color of contusion and
appears straw yellow in 7-10 days.
 The contusion heals in about 2 weeks and the skin appears normal. However,
the healing process varies depending on the depth of the contusion. The color
changes in a contusion start from its periphery and extend towards the centre.
Sub-conjunctival bruises gradually decrease in size without routine color
changes, finally become yellow and disappear.

Fresh (less than 12hours) : Red (oxyhemoglobin)

12 hours-2 days : Blue (deoxyhemoglobin)
3-4 days : Brown/Brownish black (hemosiderin)
5-7 days : Green (hemotoidin)
7-10 days : Straw yellow (bilirubin)
2 weeks : Disappears

LACERATION
Definition: Laceration is a type of mechanical injury in which skin and underlying
tissue such as subcutaneous tissue and muscles are torn as a result of application of
blunt force.
Characteristics of Laceration:
 The margins are irregular.
 The edges are contused and/or abraded.
 The underlying tissue such as subcutaneous tissue and muscles are torn
irregularly.
 The hair bulbs if any are crushed.
 The arteries, veins, lymphatic channels and nerves which are present along the
wound are crushed, whereas these structures which are running deep in the
wound may be intact due to lesser force of impact.

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 Bleeding is usually minimal in comparison with incised wounds due to crushing of
the blood vessels, unless larger blood vessels are involved.
 The foreign bodies may be present.
 The blood clots are seen in the wound.
 On healing it forms a permanent scar.
 Blunt force on the body may cause laceration of internal organs depending on the
site of impact.
 The lacerations are measured in three dimensions, i.e., length, breadth and the
depth. The depth is mentioned as whether the wound is skin deep or sub
cutaneous deep or muscle deep or bone deep.
Classification of Lacerations:
1. Split Laceration or Cut Laceration or Incised Looking Laceration: These
lacerations are caused by a perpendicular blunt force of impact. These are seen
over the body where the skin is underlined by bone such as scalp, forehead,
cheek, chin, shin etc. The skin and sub cutaneous tissue get crushed between
the perpendicular blunt force impact and the underlying bone so that the skin gets
split. On naked eye examination the margin looks regular as in case of incised
wounds (that’s why it is also known as incised looking laceration), but
examination under hand lens reveals the irregularity of the margin and tissue
bridging.
2. Stretch Laceration: When the force of impact is applied tangentially, the skin
stretches in the direction of the force of impact and when the skin is stretched
beyond the limit of its elasticity, it tears. An example of stretch laceration is a
glancing kick encountered in the sports field. The beveled edge of the wound
indicates the direction of impact.
3. Avulsion Laceration: These are seen usually in road traffic accidents (run over
injuries) and in some machinery accident where the skin gets detached from the
underlying tissues in the form of a flap due to the grinding compression force.
The direction of compressing force is almost horizontal. This laceration is also
known as ‘degloving injury’ or ‘flaying injury’.
4. Tear Laceration: These lacerations are caused when the force of impact is
applied in multiple irregular direction, e.g., fall on broken stones/earthen-ware
pot, punch on the glass window, blows by broken bottle etc.,

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Medicolegal Importance of Laceration:
1. Lacerated wounds are caused by blunt weapons.
2. Site of impact: The presence of a laceration gives an idea about the site of
impact, which is especially useful in case of unconscious patients.
3. Identification of a causative weapon: The presence of foreign bodies in the
wound helps in identification of the causative weapon. Sparrow feet lacerations
may be seen in occupants of a four wheeler involved in road traffic accidents
(Refer Transportation Injuries).
4. Lacerated wounds are mostly accidental or homicidal and very rarely suicidal in
nature.
5. Direction of Injury: It can be ascertained especially in case of stretch laceration.

INCISED WOUND or CUT WOUND

Definition: This is a type of mechanical injury which is caused when sharp edge of
weapons such as razor blade, knife, barbers knife, scalpel, etc., is drawn across the
skin, the length is the greatest dimension

Characteristics of Incised Wound

 The margins are regular.
 The edges are not contused or abraded.
 The underlying tissue such as subcutaneous tissue and muscles are cut neatly.
 The hair bulbs if any are cut neatly.
 The arteries, veins, lymphatic channels and nerves which are present along the
wound up to the depth are transected neatly.
 Bleeding is more in comparison with lacerated wounds as the blood vessels are
transected neatly.
 The foreign bodies are usually absent.
 The blood clots are seen in the wound.
 On healing it forms a linear permanent scar.
 The incised wounds are measured in three dimensions, i.e., length, breadth and
the depth. The depth is mentioned as whether the wound is skin deep or sub
cutaneous deep or muscle deep or bone deep.
 The margins may appear irregular if the incised wound occurs in areas with
redundant skin such as axilla, back of elbow, scrotum, groin and sometimes over
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 the neck and abdomen of obese people (lacerated looking incised wound).
Examination of wound after stretching the skin reveals the features of incised
wound.
 The incised wounds tend to gape due to stretching of collagen and elastic fibers
of the skin (Cleavage Lines of Langer) and in case of deeper wounds due to
stretching of muscle fibers. Gaping is more in case the direction of cut is
perpendicular to the direction of these fibers. The length of the wound is
measured after approximation of the edges.
 When a sharp weapon is drawn across the skin, as it leaves the skin the wound
becomes less and less deeper and finally it tails off, known as ‘tailing of the
wound’. This signifies the direction of the wound.

Medico-legal Importance of Incised Wounds:

1. Incised wounds are caused by sharp cutting weapons.
2. Tailing signifies the direction of the wound.
3. Incised wounds usually homicidal or suicidal and rarely accidental in manner. The
history and situation of cuts help in differentiation.
4. Hesitation Cuts or Tentative Cuts or Exploratory Cuts or Trial Cuts: Hesitation
cuts signify the suicidal nature of the injuries. When a person is intending to
commit suicide by cutting his wrist or neck, before gathering sufficient courage to
make a deeper cut, usually he goes for preliminary half hearted superficially cuts.
These cuts are multiple in numbers, parallel to each other and superficial in
nature. As these injuries are produced by a person due to his hesitation before
deep cut, these cuts are known as ‘hesitation cuts’ or ‘tentative cuts’ or
‘exploratory cuts’ or ‘trial cuts’. These wounds are seen at the commencement of
the deep wound and usually merge with the main wound. Many a times the
person may revert his decision of committing suicide, whereas there will be only
hesitation cuts without the any deep cut. In a right handed person these cuts are
seen on the left side of the wrist or neck and vice versa. Hesitation cuts are not
seen in case of homicidal cut throat or cut wrist injuries.

CHOP WOUNDS
Definition: This is a type of mechanical injury caused by a relatively sharp cutting
edge of a heavy weapon such as axe, sword, chopper, heavy sickle etc.

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Characteristics of Chop Wound:
 These wounds are caused by forcible impact by a relatively sharp cutting edge of
a heavy weapon such as axe, sword, chopper, heavy sickle etc.
 Usually seen over the exposed parts of the body such as head, face, neck,
shoulder and extremities.
 The margins may be regular or irregular depending on the sharpness of the
cutting edge.
 The edges may be abraded and/or contused.
 The shape of the wound corresponds to the cross section of the penetrating
blade, e.g., when the blade of an axe penetrates the body partially, the wound will
be triangular in shape and when the blade penetrates completely, the shape will
be quadrangular. The base of the triangle is known as ‘toe end’ and the apex is
known as ‘heel end’.
 The underlying structures including bone are grossly destructed.
Medico-legal Importance of Chop Wound:
1. These are caused by relatively sharp cutting heavy weapons.
2. Chop wounds are invariable homicidal in nature.

STAB WOUNDS
Definition: This is a type of mechanical injury caused by a pointed weapon when it
is thrust into the body; the depth is the greatest dimension.

 Stab wound is a three dimensional injury, i.e., length, breadth and depth.
 The external appearance of stab wounds depends on the causative weapon.
When it is caused by weapons such as kitchen knife, dagger etc., the skin and
underlying tissues are incised, whereas when it is caused by weapons such as
screw driver, iron rod etc., the skin and underlying tissues are lacerated.
 When a stab does not enter a cavity it is called punctured wound, whereas when
the wound of entry enters into a cavity such as cranial cavity, thoracic cavity and
abdominal cavity, it is called penetrating wound. If the wound of entry of a stab is
associated with wound of exit, it is called perforating wound.

Classification of Stab Wounds:

1. Incised punctured wound.

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2. Lacerated punctured wound.
3. Incised penetrated wound.
4. Lacerated penetrated wound.
5. Incised perforated wound.
6. Lacerated perforated wound.

Characteristics of a Stab Wound:

 Wound of Entry: As most of the weapons have tapering tip, the wound of entry
is usually bigger than the wound of exit.
 The shape of the wound depends on the type of the weapon, e.g., a
double edged knife (dagger) causes an elliptical (spindle) or semilunar
wound, a single edged knife causes a wedge or triangular or boat shaped
wound, a pointed round weapon (e.g. ice pick) causes a circular wound
and an irregular pointed weapon causes a cruciate wound. The shape of
the wound is altered, if the victim moves during the act of stabbing and
when the assailant twists or changes the position of the weapon while
removing it.
 The margins are regular in case of incised stab wounds, whereas the
margins are irregular in case of lacerated stab wounds.
 The edges are usually inverted. However sometimes the margins may be
everted due to the elasticity of the skin. When a heavy weapon is used the
thrusting force and the friction between the weapon and the invaginated
skin result in contusion and/or abrasion at the edge of the wound. In case
of complete penetration, the hilt (guard) of the weapon may cause a
contusion around the wound, reproducing the shape of the hilt, known as
‘hilt contusion’. The shape of the hilt contusion depends on the direction of
the force. The presence of hilt contusion helps in identification of the
causative weapon, to know the direction of the force of impact and to
estimate the time since injury from its color changes.
 The size of the external wound depends on the size of the weapon. In
general, the breadth and the width of the penetrated blade correspond with
the length, and the breadth of the stab wound. However, the dimensions of
the wound may vary depending on factors such as elasticity of the skin,

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 and the relative movement of the victim and the assailant. The length of
the wound may be little smaller than the breadth of the blade due to
elasticity of the skin. The movement of the victim and the assailant may
give rise to upward or downward movement of the blade resulting in a
bigger length of the wound than the maximum breadth of the blade.
 Depth and Direction: The depth is the greatest dimension in a stab wound. The
depth of the wound corresponds with the length of the penetrated blade.
However, the yielding nature of the abdomen may cause the greater depth of the
wound than the length of the penetrated blade. In case of perforated wound a line
connecting wounds of entry and exit suggest the depth and direction. An attempt
to measure the depth of the wound should not be made in a living individual
because of the risk of bleeding by dislodging the clot. In case of dead, a probe
can be passed passively to know the depth and direction of the wound. Care
should be taken not to create a false track or false extension. Confirmation can
be done by internal dissection. Other method which is employed to know the
wound track is X-ray examination after infusing radio-opaque substance such as
barium sulphate. The beveled edge with overhanging margin at the wound of
entry suggests the direction of the wound. A rough estimation of the depth of the
penetrating wound can be made by measuring the distance between the wound
of entry and the extent of the injury in the internal organ. When the weapon
passes through solid hard structures such as bone and cartilage, the shape and
size of the resulting wound corresponds with the cross section of the penetrating
weapon.
 Wound of Exit: The presence of wound of exit indicates the degree of violence.
Usually these are smaller than the wound of entry due to the tapering tip of most
of the weapon. The margins are not abraded or contused and the edges are
everted.

FABRICATED WOUND
Definition: These are the wounds caused by a person on his body by himself or
caused by others acting in agreement with him. The injuries produced by himself or
herself are known as self-inflicted wounds. These wounds are also known as
fictitious wounds or forged wounds.

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Characteristics of fabricated wounds:
 They are usually seen on the easily accessible parts of the body such as head,
face, front of chest and abdomen, front and outer aspect of extremities, unless
caused by others. These injuries are not seen over the vital parts of the body.
 Most of the wounds are incised wounds or contusions or scratch abrasions and
sometimes stab wounds.
 These injuries are multiple, superficial and half-hearted.
 As the injuries are produced usually after removal of the clothes, the tear in the
clothes corresponding to the injuries are absent.

Medico-legal Importance of Fabricated Wounds:

1. These are caused to level false allegation on an enemy such as assault,
attempted murder, rape etc.
2. To convert simple injury to grievous injury with an intension of getting more
compensation or to charge an enemy with more punishment.
3. To avert suspicion on oneself, e.g., by an assailant to show that he was
defending an attack, by police or security personnel who are acting in agreement
with robbers, claiming that they have injured while defending the property.
4. By the criminals to allege the police officials or jail personnel for ill treatment in
their custody.
5. A component of attention seeking behavior, e.g., as seen in Manchausen
syndrome.

DEFENSE WOUNDS
Definition: These are the wounds sustained by a person while defending himself
from an attack. These can be by blunt or sharp weapons.
 When a person is attacked when he is aware, the reflex spontaneous reaction is
to grasp the weapon to prevent the injuries or to protect himself from sustaining
injuries to the vital parts such as head, face, neck by raising the upper limbs to
ward off the attack. Grasping the weapons such as knives, sword etc., produce
cuts corresponding with the position of the edges of the weapon. Such injuries
are usually found on the palms and on the opposing bends of the fingers. As
grasping the knife will loosen the skin tension the cuts produced are usually

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 irregular and ragged. Grasping the blunt weapon may give rise to contusion of
the palm with or without underlying fractures
 Injuries sustained by grasping the weapon, as in stabbing episodes.
 Injuries sustained during raising the hand or arm towards off an attack to protect
his face and head. They may be in the form of cut wounds or contused wounds or
contusions according to the causative instruments.

Medico legal Importance of Defense Wounds:

The presence of defense wounds indicates that the person was defending himself
from an attack which is generally suggestive that he was a victim of an assault.
However, even an assailant may sustain defense wounds during counter attack.

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 MEDICAL ETHICS
RIGHTS AND PRIVILEGES OF REGISTERED MEDICAL PRACTITIONER
Rights and Privileges of Registered Medical Practitioners Conferred by the Indian
Medical Council Act, 1956 are as follows:
1. Right to choose a patient.
2. Right to add title, descriptions of the academic qualifications to the name.
3. Right to practice medicine.
4. Right to dispense medicines.
5. Right to possess and supply dangerous drugs to the patients
6. Right to recovery of fees
7. Right of appointment to public hospitals and local hospitals.
8. Right to issue medical certificates.
9. Right to give evidence as an expert in a Court of law.

DUTIES OF A MEDICAL PRACTITIONER

The Registered Medical Practitioner has multiform duties towards the patient,
colleagues and State. Some of these are as follows:

TOWARDS PATIENTS
1. Duty to exercise necessary care and skill:
When a patient comes to a doctor, the doctor has right to refuse him but once he
starts treating the patient his duty towards the patient starts. For patients coming
to the hospital for treatment, the duty towards the patient arises when the patient
gets treatment. However, in cases of emergency the doctor cannot refuse the
patient and only after giving the first aid and other life saving measures, if
available with due precautions he can refer the patient to the nearest hospital
where advanced facilities are available. The doctor should use reasonable skill
and care according to his knowledge and qualification for treating the patient.

2. To examine the patient properly:

It is the duty of the doctor to examine the patient thoroughly after obtaining proper
history from him or from his attendant.

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3. To prescribe proper medicines:
The doctor should prescribe proper medicines after carefully evaluating the
patient. In patients getting treatment from government hospitals, if the medicines
are not available, the doctor should advice the patient to purchase them from the
market. When the doctor prescribes a wrong medicine or does not provide proper
instructions that cause harm to the patient, he will be liable to the damages.

4. Duty to inform the risks:

The doctor should inform the patient about the disease and possible risks
involved with the treatment. If the patient is not of sound mind, the guardian
should be informed about them. Only after obtaining the consent the doctor
should start the treatment. In circumstances where the doctor feels that there are
chances of psychological upset once he discloses all the risks to the patient, he
can withhold some of the risks.

5. Duty to give proper instructions:

The doctor should give full instructions to the patient or to the attendants
regarding the proper administration of medicines and type of diet to be taken. He
should also mention the dose and frequency of the medicines to be used. In
addition, in cases of any untoward reaction the patient should be advised to
report immediately.

6. Instructions to those patients who cannot take care of themselves:

In cases of mentally ill or comatose patients, their attendants or guardians should
be properly instructed about the use of medicine.
7. Duty in relation to operations:
After careful diagnosis when the surgeon thinks that it is necessary to operate
the patient, he should explain the nature and extent of operation to the patient.
The possible risks involved in these cases and any alternative method available
should also be explained. He must obtain consent before performing operation.
He must not experiment on the patient.

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TOWARD COLLEAGUES
1. Never criticize:
A medical practitioner should never criticize his colleagues. When a patient
comes to him after leaving another doctor, he must not criticize that doctor in
front of the patient. Neither should he criticize the medicines prescribed by that
doctor earlier in order to gain cheap popularity.
2. Never take fees:
When any specialist examines or treats another doctor, he should not demand
any fees from him. It is the professional courtesy he has to extend to his
colleagues.
3. Always help:
The doctors should always help his fellow colleagues at the time of need
especially in any professional matters.
4. Consultation:
It is the duty of a doctor to consult another specialist depending upon the type of
disease he is treating. In cases of operation or other emergency situations, he
has to take consultation from a specialist in the relevant field. In these situations,
the patient must be told that he is being referred to a specialist for consultation.

TOWARDS STATE
1. Notifiable diseases:
A doctor is bound to inform the communicable diseases like cholera, plague etc.
to the Health Authorities. He is also bound to inform the birth and death to proper
authorities. If a doctor fails to inform, a civil suit can be brought against him, but
not a criminal suit
2. Geneva Convention (1949):
A Medical Practitioner is bound to treat or provide medical aid in cases of person
wounded or sick of the armed forces (I Convention), ship wrecked persons (II
Convention); prisoner of war (III convention) and civilians of enemy nationalist (IV
Convention). All the above categories of person should be treated without any
discrimination based on race, religion or political grounds.

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3. It is a duty of doctor to inform police or magistrate of medico-legal cases
brought to him during his medical practice.
4. Poisoning cases:
When the doctor attends a suspected poisoning case, he has to do the stomach
wash with plain water so that the sample can be sent for chemical analysis. He
has to preserve vomitus, blood and urine for chemical analysis. After that he
should treat the patient with suitable antidote and then carry out further
management. The doctor should inform the police in case of suspected homicidal
poisoning.

INDIAN MEDICAL COUNCIL

Indian Medical Council came into existence in 1933 by a legislature called Indian
Medical Council Act 1933, to control the medical profession in India. This act was
repealed and superseded by the Indian Medical Council Act 1956. Indian medical
council was reconstituted accordingly. The council consists of elected and nominated
members. The president and vice-president are elected by the members from
amongst themselves.
FUNCTIONS OF MEDICAL COUNCIL OF INDIA
1. Medical education:
The council has the authority to prescribe the standards of both undergraduate
and post graduate medical education.
2. The council recognizes qualifications granted by institution in India and
abroad for purpose of registration.
3. Recognition of foreign medical qualifications.
4. Medical register:
The council maintains a register of medical practitioners known as the Indian
Medical Register.
5. The council publishes Indian pharmacopoeia.
6. Appellate tribunal:
The council has appellate powers over the decisions of state medical councils in
the matters concerning professional misconduct.
7. Warning notice:
It can issue warning notice containing certain practices which are regarded as
falling within the meaning of the term “serious professional misconduct”.
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STATE MEDICAL COUNCIL
The various state of republic of India have constituted medical councils of their own.
Sometimes two states may have a common council. It is composed of members of
medical profession elected from among themselves, as well as those nominated by
the state government. The president and vice-president are elected by the members
from amongst themselves.
FUNCTIONS OF THE STATE MEDICAL COUNCIL
1. Medical register:
The state medical council maintains a Medical register containing the names,
addresses and qualifications of those medical professionals who are registered
with the council.
2. Disciplinary control:
The state medical council may remove the name of a medical practitioner found
guilty of infamous conduct in a professional respect from the register permanently
or for a specific period.
3. Warning notice:
It can issue warning notice containing certain practices which are regarded as
falling within the meaning of the term “serious professional misconduct”.

PROFESSIONAL MISCONDUCT or INFAMOUS CONDUCT

Definition:
The phrase ‘‘infamous conduct in a professional respect’’ was defined in 1894 by
Lord Justice Lopes as follows:

‘‘It is the conduct of the medical man in the pursuit of his profession which has
reasonably regarded as disgraceful or dishonorable by his professional brethren of
good repute and competency”

Examples:
The Medical Council exercises disciplinary control over members of the medical
profession. The council prescribes minimum standards of professional conduct,
ethics, and etiquette. These are listed in warning notice. The warning notice is the
list of offences which are considered as infamous conduct. This list is given to
doctors at the time of registration with the council. This includes,
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1. Adultery:
A medical practitioner may enter into a sexual relationship with a patient (or with
a member of a patient’s family) which disrupts that patient’s family life or other-
wise damages, or causes distress to, the patient or his or her family.
2. Advertisement:
 A medical practitioner should not contribute to the lay press articles and give
interviews regarding diseases and treatments which may have the effect of
advertising himself or soliciting practices; but is open to write to the lay press
under his own name on matters of public health, hygienic living or to deliver
public lectures, give talks on the radio/TV/internet chat for the same purpose
and send announcement of the same to lay press.
 A medical practitioner is however permitted to make a formal announcement
in press regarding the following :
A. On starting practice.
B. On change of type of practice.
C. On changing address.
D. On temporary absence from duty.
E. On resumption of another practice.
F. On succeeding to another practice.
G. Public declaration of charges.

3. Association:
Association with unqualified person to perform abortions or any illegal operations,
or operations for which there is no medical, surgical or psychological indication.
This type of association with unqualified Persons in the treatment of patients is
termed as Covering. The medical practitioner should not issue certificate of
efficiency in modern medicine to unqualified or non-medical persons.
4. Abortion:
The termination of pregnancy is regulated by the law and doctors must observe
the law in relation to such matters (Medical Termination of Pregnancy Act, 1971).
The doctor should not perform an abortion that is not under the provisions of law

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 and he should not assist any unqualified person while performing criminal
abortion.
5. Alcohol:
Medical practitioner should not practice medicine under the influence of alcohol,
which interferes with the skilled performances.
6. Addiction:
Medical practitioner should not use any drugs of addiction that can hamper the
practice.
7. Dichotomy or Fee splitting (Rebates and Commission):
A medical practitioner shall not give, solicit, or receive nor shall he offer to give
solicit or receive any gift, gratuity, commission or bonus in consideration of or
return for the referring, recommending or procuring of any patient for medical,
surgical or other treatment.
8. Issuing false certificates:
A medical practitioner’s signature is required by statute on certificates for a
variety of purposes on the presumption that the truth of any statement which a
doctor may certify can be accepted without question. Doctors are accordingly
expected to exercise care in issuing certificates and similar documents, and
should not certify statements which they have not taken appropriate steps to
verify. Any doctor who in his professional capacity signs any certificate or similar
document containing statements which are untrue, misleading or otherwise
improper renders himself liable to disciplinary proceedings.
9. Sex Determination Tests:
 On no account sex determination test shall be undertaken with the intent to
terminate the life of a female fetus developing in her mother's womb, unless
there are other absolute indications for termination of pregnancy as specified
in the Medical Termination of Pregnancy Act, 1971.
 Any act of termination of pregnancy of normal female fetus amounting to
female feticide shall be regarded as professional misconduct on the part of
the medical practitioner leading to penal erasure besides rendering him liable
to criminal proceedings as per the provisions of this Act.

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10. Conviction by Court of Law:
Conviction by a criminal court for an offence which involves moral turpitude and
which is cognizable within the meaning of the Code of Criminal Procedure, 1974.

11. Contravention of provisions Of Drugs And Cosmetics Act:

 A registered medical practitioner shall not contravene the provisions of the
Drugs and Cosmetics Act and regulations made there under, i.e.:
A. Prescribing steroids/ psychotropic drugs when there is no absolute
medical indication
B. selling Schedule 'H' & 'L' drugs and poisons to the public except to his
patient
 Contravention of the above provisions shall constitute gross professional
misconduct on the part of the medical practitioner.

12. Disclosure of professional secrets:

 The registered medical practitioner shall not disclose the secrets of a patient
that have been learnt in the exercise of his / her profession except -
A. In a court of law under orders of the Presiding Judge
B. In circumstances where there is a serious and identified risk to
a specific person and / or community; and notifiable diseases.
 In case of communicable / notifiable diseases, concerned public health
authorities should be informed immediately.

PROCEDURE OF DISCIPLINARY ACTION BY STATE MEDICAL COUNCIL IN

PROFESSIONAL MISCONDUCT
 All councils at the state level are empowered to discipline the erring practitioners
on their rolls and their inquiries enjoy the status of civil courts. They cannot only
enforce court attendance and examination under oath but can also compel the
production and submission of documents, and issue summons for examination of
witnesses.
 Decision on complaint against erring medical practitioner shall be taken within a
time limit of 6 months.

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 During the pendency of the complaint the appropriate council may restrain the
medical practitioner from performing the procedure or practice which is under
scrutiny.
 State Medical Council initiates disciplinary proceedings against medical
practitioner on the following instances:
A. Convicted by a court for cognizable offence
B. Censured by judicial authority in relation to his professional character
C. Complaint made by some person or body against doctor

Information reaches the Registrar of concerned State Medical Council (SMC)

President of SMC

Refers the matter to Executive Committee

Forms a Ethical / Penal Committee for the conduct of enquiry

If no prima facie case of professional misconduct is established, the complaint is

dismissed and the complainant informed accordingly

If requires enquiry –notice is served to the practitioner specifying the contents of

complaint, directing him to clarify his stand in writing

He can be asked to appear before the council in person or through his legal advisor;

but his presence is mandatory

The onus of proving the wrong doing lies on the complainant

On conclusion of enquiry-vote on enquiry is taken

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If majority of penal committee members finds him guilty of Professional Misconduct,
disciplinary action is taken after taking due legal advice (i.e.: warning; temporary
erasure of name from medical register; permanent erasure of name from medical
register)

PUNISHMENT FOR PROFESSIONAL MISCONDUCT

At the conclusion of any inquiry in which a doctor has been alleged to have been
involved in the professional misconduct, the Penal or Ethical Committee of the
medical council must decide on one of the following alternative courses after taking
due legal advice:
1. Dismiss the case.
2. Warning.
3. Temporary Erasure.
4. Permanent Erasure.
(Penal Erasure = Temporary erasure and permanent erasure are together called
as penal erasure).
1. To dismiss the case:
If after going through the submission by the complainant regarding the alleged
professional misconduct to the Medical Council, it can be dismissed if there is no
prima facie evidence.
2. Warning:
A warning is issued to the medical practitioner to conduct himself according to the
expectations of ethical standards prescribed by the council.
3. Temporary Erasure:
The name of the medical practitioner is erased from the, medical register for a
specified period after which it is restored. If a doctor’s registration is suspended,
the doctor ceases to be entitled to practice as a registered medical practitioner
during that period.
4. Permanent Erasure:
The name is permanently removed from the medical register. This is also known
as ‘professional death sentence’. Here the doctor is deprived off all the privileges
of being registered medical practitioner.

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 Professional incompetence shall be judged by peer group as per guidelines
prescribed by Medical Council of India.
 Decision on complaint against delinquent physicians shall be taken within a time
limit of 6 months
 Deletion from the Register shall be widely publicized in local press as well as in
the publications of different Medical Associations/ Societies/Bodies.
 In case the punishment of removal from the register is for a limited period, the
appropriate Council may also direct that the name so removed shall be restored
in the register after the expiry of the period for which the name was ordered to be
removed.
 Aggrieved doctor can appeal to the Health Ministry, Government of India against
the disciplinary action. Ministry of Health has the power to reconsider the action
taken after consultation with Medical Council of India.

CONSENT
 ‘Cum’ means together and ‘sentire’ means to feel or to perceive.
 Consent connotes agreement, compliance, or permission given voluntarily
without compulsion.

Definition:
 ''Two or more persons are said to consent when they agree upon the same thing
in the same sense" as per the section 13 of The Indian Contract Act, 1872.
 Section 90 of Indian Penal Code defines consent in the negative form (i.e. what is
not a consent) as “A consent is not such a consent as is intended by any section
of this code, if the consent is given by a person under fear of injury, or under a
misconception of fact, and if the person doing the act knows, or has reason to
believe, that the consent was given in consequence of such fear or
misconception ; or if the consent is given by a person who from unsoundness of
mind or intoxication is unable to understand the nature and consequences of that
to which he given his consent; or unless the contrary appears from the context, if
the consent is given by a person who is under twelve years of age”.

REASONS FOR OBTAINING THE CONSENT

 The concept of consent comes from the ethical issue of respect for individual
integrity as well as self determination. In law, the tort of ‘battery’ is defined as
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 ‘application of force to the person of another without lawful justification’ and
therein lies the essence of requirement of consent for any medical treatment.
 Each individual has the right to do what he likes with his body in order to preserve
and protect his health and personal privacy. This is a constitutional right,
protected by the law.

TYPES OF CONSENT
There are two primary types of consent commonly recognized in the medico-legal
world:
1. Implied Consent.
2. Express Consent.

IMPLIED CONSENT or TACIT CONSENT

 Implied consent is consent that may be implied from the conduct of the patient in
a particular case.
 This is seen in routine medical practice and is quite adequate.
 Here consent is implied in the mere fact that the patient comes to the medical
practitioner with a problem or when a patient holds out his arm for an injection.
 The patient does not spell out his consent for treatment specifically. It is
understood to have been given.
 The reason for this is that, the procedure of diagnosis and treatment is simple
and straight forward, the risks negligible and uncommon, and the conduct of the
patient implies willingness of undergo treatment.
 However, as no proof can be produced in the court of law in case of litigations,
better the doctor takes the express consent.

EXPRESS CONSENT
 This may be verbal (oral) or written.
 The written type of express consent is generally referred to as Informed Consent.
 Generally express consent should be obtained whenever any of the following
treatments or procedures are to be performed on a patient:
 Major or minor surgery that involves an entry into the body cavity, either
through an incision or through one of the natural body openings.

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  All procedures in which anesthesia is used, regardless of whether an entry
into the body cavity is involved.
 Non-surgical procedures involving more than a slight risk of harm to the
patient or that involve risk of change in the patient’s body structure (e.g.,
myelograms, arteriograms, and pyelograms).
 Procedures involving the X-ray therapy.
 Electroshock therapy.
 Experimental procedures.
 Sterilization.
 Blood or blood product transfusion.
 Bone marrow biopsies.
 Consent must be taken before the proposed act and not at that time of admission
to the hospital.
 Consent must be taken by the medical practitioner who is the in charge of the
treatment aspects.
 It should be obtained in the presence of a disinterested third party, such as a
nurse or receptionist.
 The nature and consequence of the procedure should be explained to the patient
before getting the consent.
 Oral consent in the presence of a disinterested third party is as good as a written
one. But the only drawback is non availability of documentary proof of doing so.

INFORMED CONSENT
Definition:
Informed consent is the process that involves an exchange of information between
the doctor and the competent individual who has received the necessary information;
who has adequately understood the information; and who after considering the
information, has arrived at a decision without being subjected to coercion, undue
influence, inducement or intimidation.
PRINCIPLE BEHIND INFORMED CONSENT
Informed consent is more than simply getting a subject to sign a written consent
form. It is a process of communication. Informed consent is based on three
fundamental ethical principles:

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1. Respect for Autonomy:
The word ‘autonomy’ is a legacy from ancient Greece, where autos refers to self
and nomos refers to rule or law. In moral philosophy personal autonomy refers to
personal self governance: personal rule of the self by adequate understanding
while remaining free from controlling interferences by others and rom personal
limitations that prevent choice.
2. Beneficence:
The welfare of the patient is the goal of health care and also of what is often
called ‘therapeutic research’. This value of benefiting the person has been treated
as a foundational value in medical ethics. It also attained its existence in the
Hippocratic traditions in the form of the maxim ‘primum non nocere’ meaning
‘above all, do no harm’. This maxim is now changed into ‘help, or atleast do no
harm’. Beneficence has 4 elements, namely one ought not to inflict evil or harm;
one ought to prevent evil or harm; one ought to remove evil or harm; and one
ought to do or promote good.
3. Justice:
This refers to the treating an person in accordance with the principle of justice if
treated according to what is fair, due or owed.
INGREDIENTS
 In informed consent, the doctor informs the patient about the following (full
disclosure):
 his/ her condition or disease,
 nature of the proposed treatment i.e. whether surgical or medicinal"
methods to be used,
 availability of any alternative procedure,
 possible risks and benefits of the procedure
 percentage of chances of success and failure.
 total number of hospital stay.
 Total cost of the treatment.
 right of informed refusal (Informed refusal: The doctor has a duty to
inform the patient that he has a right to refuse the treatment or
investigations to be undertaken. After listening to the doctor, the patient
can refuse to consent for the proposed investigation/treatment.)
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 The patient should be explained in a simple language that he can understand
fully and give consent in the presence of third party who acts as a witness.

VALID CONSENT
A valid consent should fulfill following criteria’s:
A. Voluntariness
B. Capacity
C. Knowledge

A. Voluntariness:
 The consent to be valid must be intelligent, free, given without fear, fraud, with
no favor or force and must be ‘informed’, especially for surgery.
 Consent is said to be free (section 13 of The Indian Contract Act, 1872), when
it is not caused by
 Coercion,
 Undue influence
 Fraud
 Misrepresentation
 Mistake
B. Capacity:
The patient should be in a position to understand the nature and implication of
the proposed treatment, including its consequences. In this regard the law
requires the following:
i. Age of consent:
In our country only a person who is above age of 18 years for invasive
procedure and above age of 12 years for general physical examination
can give valid consent.
ii. Mental incapacity;
 This implies that patients who are mentally retarded or mentally
incapable due to any disease process may not be capable of giving
their own consent. In such cases consent from the legal guardian is
essential.
 Patients under the influence of alcohol or drugs are incapable of giving
their own consent.
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 ii.

C. Knowledge:
The patient should have knowledge regarding what is being done to him so as to
make an informed decision.

THERAPEUTIC PRIVILEGE or DISCRETE DISCLOSURE

 ‘Therapeutic privilege” is an exception to the rule of “full disclosure”.
 In this category the medical practitioner can be excused of full disclosure in
informed consent when disclosure of information could have a detrimental
effect on the patient.
 The circumstances of exercising this privilege are following:
 In some cases the patient may delegate the right to the medical
practitioner or to a third party especially the close relatives to make the
decision for him.
 The doctor believes that full disclosure has emotional bearing on the well
being of the patient.
 The commonly side effects which are believed to be universally known.
 The doctor may in confidence, consult his colleagues to establish that the patient
is emotionally disturbed. Apart from this, it is good for the doctor to reveal all risks
involved in confidentiality to one of the close relatives and involve them in
decision making.
 If one of the exceptions to the full disclosure applies, the medical practitioner
should document the exception.

LOCO PARENTIS
 In emergency situations involving children, when their parents or guardians are
not available consent is taken from the people who are on the spot. For example
a school teacher can give consent for treating a child taken acutely ill during a
picnic away from home town.
 Even if the parent refuses consent no blame will be attached to the surgeon for
an operation done to save the life of a child.

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DOCTRINE OF EMERGENCY CONSENT (DOCTRINE OF ‘JUS
NECESSITATES’)
 In emergencies, when the patient requires immediate care to preserve life and
health, the doctor is reasonably privileged to treat the patient. This is not implied
consent by the patient, but rather is consent derived from the duties and
obligations imposed by law in these emergencies. This is the doctrine of ‘jus
necessitates’.
 Legal principle that assumes a patient's consent to an emergency medical
procedure when he or she is in manifest danger but incapacitated to give an
informed consent. It is based on the reasoned belief that the patient would have
consented if he or she could.
 Emergency is defined as a situation in which, in competent medical judgment,
the proposed medical or surgical treatment or procedure is immediately
necessary and any delay occasioned by an attempt to obtain consent would
reasonably be expected to jeopardize life, health, or safety of the patient.
 Section 92 of Indian Penal Code safe guards the interest of the medical
practitioner in the emergency situations, which says that “Nothing is an offence
by reason of any harm which it may cause to a person for whose benefit it is
done in good faith, even without that person’s consent, if the circumstances are
such that it is impossible for that person to signify consent, or if the person is
incapable of giving consent, and has no guardian or other person in lawful charge
of him from whom it is possible to obtain consent in time for the thing to be done
with benefit”.
 The emergency consent exist in the following conditions:
 The patient is incapable of giving or withholding consent for him or herself
and there is no advance directive or living will describing the wishes of the
patient.
 There is no other person immediately available who is authorized,
empowered, or capable of giving consent.

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CONSENT IN DIFFERENT SITUATIONS
1. CONSENT & AGE (IPC 87; 88; 89)
 A person above 18 years can give valid consent to suffer any harm which may
result from an act done in good faith and which is not intended or known to
cause death or grievous hurt (IPC 87 and 88). Thus if a surgeon operates on
a patient in good faith and for his benefit, the surgeon cannot be held
responsible if the operation ends fatally.
 A child above twelve years can give valid consent to suffer any harm which
may result from an act done in good faith and for its benefit. Thus a child
above 12 years can give valid consent for physical examination, diagnosis
and treatment. A child below twelve years or an insane cannot give valid
consent to suffer any harm which may occur from an act done in good faith
and for its benefit (IPC 89).The consent of the parent or guardian should be
taken. If they refuse, the doctor cannot treat the patient.
 The concept of “mature minor” i.e. person under 18 years of age who
possesses sufficient understanding and appreciation of the nature and
consequences of treatment despite chronological age, though well
established in some western countries is not routinely recognized in India.
 “Emancipated minors” are individuals who are under 18 years of age and
married, or are parents of their own children, or are self sufficiently living away
from the family docile with parental consent.
2. MARRIAGE AND CONJUGAL OBLIGATIONS
 Marriage contract provides bilateral conjugal obligations in the form of
reproduction (begetting children) and fidelity for sexual relationship. Therefore
in procedures involving the sexual and reproductory organs of a married
partner it is advisable to obtain informed consent from both the husband and
wife. This includes procedures like sterilization, artificial insemination etc.
 For artificial insemination written informed consent should be obtained from
both partners of donor and recipient. Failure in this situation may result in
doctor being sued for damages for negligence.

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3. MEDICAL TERMINATION OF PREGNANCY ACT 1971
According to MTP Act of 1971 consent of the pregnant woman alone is sufficient
provided she has attained the age of 18 years and is not a lunatic.
4. CRIMINAL ABORTION
 Consent for committing a crime or illegal act such as criminal abortion is
invalid, whether or not the act causes injury to the consenting party (IPC 91).
 According to IPC 91,”Acts which are offences independently of any harm
which they may cause, or be intended which they may cause, or be intended
to cause or be known to be likely to cause, to the person giving the consent,
or on whose behalf the consent is given”.
5. SEXUAL INTERCOURSE
 A woman is deemed to have consented to an act of sexual intercourse when
she freely and voluntarily agrees to submit herself to the act knowing fully well
its nature and consequences; consent is invalid if it is obtained under unlawful
means.
 Consent given by a female below 16 years or an insane or one whose mind is
immature (idiot, imbecile) is not valid.
6. CRIMINAL CASES
 According to Cr. P.C. 53, 1973, medical officer can examine an accused in a
crime who is under arrest, without his consent when the request is made by a
Police Officer not below the rank of an Sub Inspector of Police. If the person is
not willing, reasonable force can be used.
 When it is a female that has to be examined. It should be done only by or
under the supervision of a female medical practitioner.
 For the mentally deficient and minor, consent of the parent, guardian or next
of kin is requested.
7. OPERATION AND TREATMENT
The consent of a spouse is not necessary for an operation or treatment of the
other. But it is advisable to take the consent of the spouse if it involves danger to
life, impairment of sexual function or destruction of an unborn child.

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8. AUTOPSY
 Medico-legal autopsies do not require consent. Here autopsy is done on
authorization by the state. The statutory enactment enables the state to order
an autopsy in all suspicious and unnatural deaths.
 Clinical autopsy requires the consent of the surviving spouse or next of kin.
9. TISSUE / ORGAN FOR TRANSPLANTATION
 A living donor above 16 years, provided he is not mentally defective can give
consent for removal of tissues from his body during life. Consent should be
obtained in writing after having been given independent medical advice as to
the risk.
 To remove tissues from the body after death, consent of the deceased should
be obtained in writing at any time, or orally in the presence of two or more
witnesses, during his last illness. Even if consent was given by the deceased
during life, permission must be obtained from the person in possession of the
body, before removal of tissues.
 The legal possessor is also entitled to permit removal of tissues from the
deceased, unless the deceased had expressed a desire to the contrary and
the surviving spouse and relatives object to it.

PROFESSIONAL SECRECY
 Professional secrets are those secrets of the patients which the medical
professional comes to known during his professional relationship with the patient
in the course of treatment.
 In the Hippocratic Oath there is an affirmation by the doctor that whatever in
connection with his professional practice or not in connection with what he see or
hear in the life of men, which ought not be spoken of abroad, he will not divulge,
as reckoning that all such be kept secret'.
 The following examples may be kept in mind:
 Doctor should not discuss any point with others relating to the patient's illness
that he came to knew in his professional practice except with the consent of
the patient
 If the patient is a major a doctor should not disclose anything learnt about his
illness even to his parents without obtaining his consent

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  In case of husband and wife the facts relating to the nature of illness of one
should not be disclosed to the other without the consent
 If the doctor examines a domestic servant at the request of the master who is
paying the fees still he should not disclose the nature of his illness even to the
master without the consent of the servant
 Criminals in police custody has right not to allow the treating doctor to
disclose about the nature of illness to any person. However once the person
is convicted he has lost this right and the doctor can disclose to the proper
authorities for the sake of justice
 While reporting any case report in a medical journal care should be taken not
to disclose the identity of the person
 When a person submits himself for medical examination before taking life
insurance policies, the doctor can disclose the result to the proper authorities
because here the concept of implied consent will apply
 Examination of the dead body at times may reveal certain facts that affect the
reputation of the deceased as well as the family members. Thus the doctor
should not disclose the fact to the relatives e.g. pregnancy discovered in an
unmarried girl during autopsy examination. But the medical practitioner can
document these findings in the post-mortem examination report.

PRIVILEGED COMMUNICATION
 The rules of professional secrecy can be broken in certain situations that are
known as Privileged Communication. Therefore this is considered as an
exception for professional secrecy.
 Privileged Communication is defined as a statement made by a person who has
an interest to protect, or a legal, or social, or moral duty to perform to another
person having a corresponding interest, even though such communication may
under normal conditions, amount to defamation or slander.
 To be privileged it must be disclosed only to the concerned person or authority.
 Following are some of the examples of privileged communications:

1. Infectious diseases:
If anybody having infectious diseases gets an employment, the doctor should
persuade not to undertake the job till he is completely cured. If somebody is
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 found to be suffering from infectious diseases during his employment, he/she
should also be asked to go on leave till he/she is cured. If the patient refuses,
the doctor can inform his employer about his illness e.g. a schoolteacher who
is suffering from tuberculosis or cook of the hostel suffering from typhoid.
2. Notifiable diseases:
Medical persons have statutory duties to notify births, deaths and notifiable
diseases to the Public Health Authority.
3. Suspected crimes:
The doctor must inform the police of commission of crimes such as
homicides, suspected suicides.
4. Servants and employees:
When an employee is suffering from a serious disease such as color
blindness in drivers, epilepsy in cooks, they should be persuaded to change
their profession; otherwise the employer should be informed about the illness.
5. Sexually transmitted diseases:
Person having a sexually transmitted disease intending to join in swimming
pool should be persuaded not to join the swimming pool. If he does not
comply, then the doctor should inform concerned person or authority.
6. In patient's interest:
If the patient is having suicidal tendency, the parents/guardians may be
informed about so that they can take proper care and provide proper
treatment.
7. Court of Law:
In the court of law, the doctor cannot claim the privilege about the illness of
his patient. When asked to communicate regarding the illness of his patient,
he should appeal to the court of providing information in writing in order to
avoid disclosing secrets learnt during the treatment of the patient. However, if
the court rejects his application he has to communicate before the court of
law.
8. Negligent suits:
When a patient files any suit of negligence against a doctor and he employs
another doctor to examine the patient, the information thus acquired is not
privileged and he can divulge it in the court of law.

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 9. Self-interest:
When a patient files a civil or criminal suit, the doctor can disclose information
learnt during his professional practice.

MEDICAL NEGLIGENCE (MALPRAXIS)

 The law of negligence is applicable to the conduct of all individuals whether
layman or professional.
 In present times doctors can not be sure that they will never be threatened with
an action for negligence. In Hatcher vs. Black and others (1954) Lord Denning
compared negligence with a dagger. The doctors' professional reputation is as
much dear to him as his body, perhaps more so, and an action for negligence
could wound his reputation as severely as a dagger to his body.
DEFINITION
 In 1856, Baron Alderson defined negligence (Blyth vs. Birmingham Waterworks
Co., 1856) as:" the omission to do something which a reasonable man, guided by
those considerations that ordinarily regulate the conduct of human affairs, would
do, or doing something which a prudent or reasonable man would not do".
 According to Winfield (Winfield & Colonics Tort), “negligence as a tort (civil
wrong) is the breach of a legal duty to take care which results in damage,
undesired by the defendant to the plaintiff”.
 According to Curzon LB, “negligence is the the breach of a legal duty to take
care, resulting in damage to the claimant which was not desired by the
defendant.
TYPES
Depending upon the court to which the case of professional negligence is taken,
professional negligence is of two types:
1. Civil medical negligence.
2. Criminal medical negligence.

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DIFFERENCE BETWEEN CIVIL AND CRIMINAL NEGLIGENCE
Civil Negligence Criminal Negligence

1. Court Civil court Criminal court

2. Outcome Demand compensation Compensation + Punishment

Simple absence of care Gross negligence, inattention or
3. Dereliction
and skill lack of competency
Strong evidence is Guilt should be proved beyond
4. Evidence
sufficient reasonable doubt
5. Role of contributory
Applicable Not applicable
negligence

INGREDIENTS OF NEGLIGENCE
A typical formula for evaluating negligence requires that a plaintiff prove the
following four factors (4 D’s) by a "preponderance of the evidence":
1. Duty was owed:
 For any complaint to be substantiated, the establishment of a legal
doctor/patient relationship is a must.
 The relationship is straightforward in the case the patient seeks medical
advice from the doctor in his clinic.
 Sometimes, however, this relationship may not be apparent and in such case,
the Neighbor Principle applies. In plain language, it means that you are
responsible for your action or inaction, directly or indirectly, that may cause
harm to your patient.
2. Dereliction of duty of care or Breach of duty of Care:
 The patient must prove that the medical practitioner failed to comply with the
standards required and dictated by the profession.
 Breach of duty of Care is established if a doctor's standard of care does not
conform to the current practice as advocated by a body of learned opinions.
 However there may be more than one recommendation for any given medical
condition and "Guidelines" from professional body may not be the ultimate
yardstick for "proper care". Deviation from "normal" practice can be justified

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 with the support of opinion of another responsible body of men skilled in the
faculty.
3. Damage:
 Damage refers to the injuries suffered by the patient. (Whereas damages
refers to the pecuniary compensation awarded by the court to plaintiff for the
injury or damage caused to him by the negligent act of the defendant).
4. Direct Causation or Proximate cause:
 The plaintiff or patient has the burden of establishing a causal relationship
between the breach in the standard of care and the patient’s injuries or
damage.
 If a breach in standard of care did not cause the alleged injuries or damage,
there is no proximate cause.

DIFFERENCES BETWEEN THE DAMAGE & DAMAGES

DAMAGE
Damage is the injury or disability suffered by the patient due to the negligent act of
the medical professional.
DAMAGES
 Damages are the financial compensations awarded to the successful plaintiff.
 There are no special rules applied to damages awarded in cases of medical
negligence. The general aim is to return the claimant, as far as possible, to their
position before the tort occurred.
 The damages are calculated to compensate for their losses and generally not to
funish the defendant.
 There are three kinds of damages:
A. Nominal: These are awarded where the purpose of the action is merely
to establish a right, no substantial harm or loss having been suffered.
B. Ordinary or Compensatory: These are awarded where it is necessary
to compensate the plaintiff fairly for the injury he has in fact sustained.
Whatever sum is awarded, whether large or small, must afford a fair
measure of compensation to the plaintiff with reference to the actual
harm sustained by him.
C. Exemplary: These are awarded not to compensate the plaintiff but to
punish the defendant and to deter him from similar conduct in future.
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DEFENSES AVAILABLE IN CASES OF MEDICAL NEGLIGENCE
Following defenses can be used by a medical practitioner when charged for medical
negligence:
1. No duty owed to the plaintiff.
2. The duty was discharged according to the prevailing standard.
3. It was a Therapeutic Misadventure.
4. It was Error of Judgment.
5. Novus Actus Interveniens.
6. Contributory Negligence
7. Res Judicata (Latin, the thing already been decided):
Once the case has been decided it cannot be taken to another court. Only appeal
can be made.
8. Res Indicata:
The case should be filed within two years from the date of alleged negligence. If it
is alleged that there was a breach of duty to take care under some particular
contract between doctor and patient, then the period is three years from the date
of breach of contract.
9. Medical mal-occurrence.
10. Contributory Negligence.

CONTRIBUTORY NEGLIGENCE
 According to Law Reform (Contributory Negligence) Act of 1945, “Where any
person suffers damage, partly as the fault of others, a claim in respect of that
damage shall not be defeated by reason of the fault of the person suffering the
damage; but the damages recoverable in respect thereof shall be reduced to
such an extent as the Court thinks just and equitable, having regard to the
claimant’s share in the responsibility for the damage.”
 In other words, if the plaintiff’s (patient) negligence contributed in some degree to
the damage or injury, the defendant (doctor) succeeded by pleading contributory
negligence irrespective of the fact that the damage or injury was principally
caused by the doctor’s negligence.
 It can be taken as defense in cases of civil negligence only.

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 It does not completely free defendant from paying the damages, but damages
are reduced to a lesser extent in case of contributory negligence.
 In claiming that there was contributory negligence, the burden of proof is on the
defendant (doctor) to show that it existed.
 Examples:
 A woman with facial skin ailment consulted a dermatologist and was
prescribed Chloroquine, which she took for six months on prescription. Since
she was a medical receptionist she was able to go on obtaining the drug after
the period by buying it cheaply from a drug salesman without prescription,
and she continued to use it in this way for a further thirty months. Although
the dermatologist had in the meantime been alerted serious visual effects of
the drug and referred all known users to an ophthalmologist he did not give
any importance to the latter’s report. She subsequently became blind. She
sued the doctor. It was held that the doctor was liable for negligence for
failing to properly consider the eye specialist’s report. The patient was guilty
of contributory negligence in obtaining the prescription drugs without her
doctor’s knowledge. The court apportioned liability at two-thirds to the doctor
and one-third to the patient. (Crossman v. Stewart British, 1977; Columbia
Supreme Court)
 The doctor prescribed some sedatives to an insomniac patient but failed to
prescribe the dosage to be taken. The patient although had a chance of
asking him regarding the instruction failed to do so and took the entire tablets
at ones. This resulted in respiratory embarrassment and admission into the
ICU. The doctor can plead the defense of contributory negligence so as to
lessen the damages, although he is the one who is principally negligent.
 This rule caused great hardship to the patient because for a slight negligence on
his part, he may lose his claim against a defendant (doctor) whose negligence
may have been the main cause for his damage (injury). The courts modified the
law relating to contributory negligence by introducing the so called rule of “Last
Opportunity” or “Last Chance”. It means that the if the defendant (doctor) is
negligent and plaintiff (patient) having a later opportunity to avoid the
consequences of the negligence of the defendant (doctor), he cannot make the
defendant (doctor) liable for that. Similarly the last opportunity to avoid the

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 damage was with the defendant (doctor), he will be liable for the entire loss to the
plaintiff (patient).

NOVUS ACTUS INTERVENIENS

 The concept of ‘Novus Actus Interveniens’ is another Latin concept that basically
translates to mean ‘a new act intervening’ or ‘an intervening act that breaks the
chain of causation’, and is thus considered to be something of a general defense
in the negligence cases.
 This is because it basically revolves around the idea that the act of a third party
will serve to intervene between the original act or omission and the damage that
is produced as a result, unless that original act or omission is still considered to
be the main contributing factor to the damage that results because the act of the
third party had no impact upon the events as they unfolded.
 Examples:
 Accused ‘A’ stabs ‘B’ and injures him causing laceration of vessels of the
thigh. The patient ‘B’ gets the first aid at a primary health centre and
referred to a referral hospital for the further management. On the way the
vehicle in which he was being shifted meets with an accident and he dies.
In this the accident is the ‘new act intervened’. Herein the person who
stabbed cannot be charged for murder because a new act has broken the
chain of causation.
 A surgical registrar made such a poor job of suturing tendons at the wrist
after trauma, that a consultant was called to rectify the situation. He
inadvertently cut the radial artery (new act) and caused far worse damage,
thus swamping the less serious negligence of the registrar.

ERROR OF JUDGMENT
 In spite of proper examination and investigation, a case can be diagnosed
wrongly and the type of treatment adopted can become injurious to the patient.
 This is known as error of judgment.
 In all cases of negligence, the important issue is that whether the act was not
done in good faith and the doctor has deviated from his duties. An error of
judgment will be condoned depending upon the circumstances.

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 For example a young patient reports at the emergency department with an
abdominal pain in the right iliac fossa, would be diagnosed as acute appendicitis,
renal colic, amoebic colitis, a twisted ovarian twist or an ectopic pregnancy.
Hence an error of judgment is not an negligence.

THERAPEUTIC MISADVENTURE
 Therapeutic Misadventure can be used as a defense only when the doctor has
taken all the precautionary steps to avoid a situation and all the necessary
measures to revive the patient are taken, inspite of which the patient suffers
damage.
 An event in life has certain element of inherent risk. This also true for course of
treatment. Certain mishaps are bound to occur.
 The mishaps during the course of patient care can either be diagnostic or
therapeutic and should not be considered as negligence.
 For example, the doctor keeps all the life saving measures ready while injecting
the dose of penicillin. While giving the test dose of the injection the patient
develops hypersensitivity. The doctor employs all the life saving measures to
revive him, in spite of which the patient succumbs. This is not negligence; it is an
accident, which falls under the description of Therapeutic Misadventure.
MEDICAL MAL-OCCURRENCE
 Human body cannot be equated with the machine and it is not right to expect the
same outcome in all the patients for a given situation, unlike the machine which
responds in a similar way for a given situation in all circumstances.
 It is not negligence if a patient responds abnormally to a given medication, which
does not happen in others.

CORPORATE NEGLIGENCE
 Corporate negligence is a doctrine under which the hospital is liable if it fails to
uphold the proper standard of care owed to the patient, which is to ensure the
patient’s safety and well being while in the hospital. This theory of liability creates
a nondelegable duty which the hospital owes directly to a patient. Therefore, an
injured party does not have to rely on and establish the negligence of a third
party.
 The doctrine of corporate negligence asserts that there exists an independent
duty of the hospital for the medical care rendered in its institution. It holds the
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 hospital liable for an independent physician’s negligence. However, a corporate
negligence claim is based on the hospital’s independent negligence in allowing
an incompetent physician to practice on its premises.

COMPOSITE NEGLIGENCE
Composite negligence is constituted when a person suffers any harm or any injury
as a result of combined effect of the negligent acts of more than one person, without
any negligent act in the part of the sufferer. In such composite negligence, the
compensation awarded may not be partitioned amongst the negligents in
accordance to their fault. The sufferer may claim the compensation from any one of
such negligents according to his choice. However, the defendant negligent may
claim contribution from his fellow negligent/negligents.

PRODUCT LIABILITY
 Sometimes, injury or death of a patient may result from the use of faulty,
defective, or negligently designed medical or surgical equipment, or due to the
use of a drug that is adulterated, contaminated, or of inferior quality, or due to
lack of accurate guidelines in the use of any equipment or drug. In such cases,
the manufacturer concerned becomes liable for harm resulting to the patient. The
doctor must prove that the manufacturer departed from standards of due care.
This is referred to as product liability.
 However, the manufacturer will not be liable in the following situations:
 If the doctor or hospital misused an equipment or medical product.
 If the instrument was functioning well at the time of supply, and was not
defective.
 If the instrument malfunctioned due to improper use, or due to wear and tear,
and was not serviced regularly, or replaced in time.

VICARIOUS LIABILITY
 Vicarious liability is a legal doctrine that assigns liability for an injury to a person
who did not cause the injury but who has a particular legal relationship to the
person who did act negligently. It is also referred to as imputed negligence.
 Legal relationships that can lead to imputed negligence include the relationship
between parent and child, husband and wife, owner of a vehicle and driver, and
employer and employee.
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 The prerequisites for the vicarious liability are: There must be an employer-
employee relationship and the employees conduct must occur within the scope
of his employment while on job.
 Vicarious liability has following three components:
1. Respondeat superior.
2. Captain of the ship doctrine.
3. Borrowed servant doctrine.

 The doctrine of respondeat superior (Latin for "let the master answer") is based
on the employer-employee relationship. The doctrine makes the employer
responsible for a lack of care on the part of an employee in relation to those to
whom the employer owes a duty of care. For respondeat superior to apply, the
employee's negligence must occur within the scope of her employment.For
example; the doctor usually employs or supervises other members of staff who
are less qualified. He distributes the work amongst and supervises them. If one of
the members does any negligence, then the principal doctor is held responsible
for the act of that member, known as respondeat superior. For the acts of general
practice, the consultant or the principle doctor is responsible for the act of his
assistants such as interns, house surgeons or residents. All of these may be
sued along with the head consultant by the patient. When two doctors are
working as partners both are liable for negligence for the other even if one has no
role to play in the management of the patient.
 The captain of the ship doctrine applicable in surgical procedures wherein the
surgeon generally supervises or captains all the activities. If something goes
wrong in the hands of his subordinates he is liable for the damages.
 The borrowed servant doctrine is commonly applicable in consultancy set up.
In this the consultant visits many hospitals and treat patient. The paramedical
staffs of those hospitals assist him (borrowed servants) in treating those patients
although they has not appointed by him. If something goes wrong in the hands of
these subordinates in the course of the treatment he is liable for the damages.
 Vicarious Liability is applicable only in civil matters, not in criminal cases.

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RES IPSA LOQUITOR
 The Latin phrase “Res Ipsa Loquitar” meaning literally’ the thing speaks for itself’.
 As applied to a claim for injuries, it means that the wrongdoing or negligence is
so obvious that the act itself proves the case.
 The doctrine of Res ipsa loquitur requires the following pre-requisites:
 The instrument that inflicted the damage was under the sole management or
control of the defendant.
 There is no contributory negligence.
 The dereliction of duty is the sole cause for damage.
 In a medical malpractice case we usually need medical experts to prove that a
doctor, hospital or other health care provider did something wrong.
 Res ipsa loquitur is the exception for this wherein the burden to prove innocence
shifts to the defendant.
 It relates chiefly to cases of foreign bodies or slipping instruments in surgical
procedures, burns from heating modalities, and injury to a patient’s body outside
the field of treatment. .
PRECAUTIONS AGAINST MEDICAL NEGLIGENCE
To avoid negligence suits the doctor should take following precautions:
1. Never guarantee a cure.
2. Obtain informed consent from the patient.
3. Diagnosis to be confirmed by proper investigation depending upon the nature
of case.
4. Reasonable skill and care to be taken.
5. Proper, accurate and legible records to be maintained.
6. Immunization to be done specially tetanus in cases of injuries.
7. Sensitivity test to be performed before injecting the drugs known to cause
hypersensitivity reactions especially in cases of penicillin, streptomycin and
antivenins.
8. Patient or his attendant should be advised that the medicine should be given
in the proper dosage and in time and no telephonic consultation should be
done.
9. Consultation to be undertaken with appropriate specialist in case of need.
10. Never criticize your colleagues regarding his professional ability.

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 11. During labor, the patient should not be left unattended when she is
undergoing labor.
12. In case of absence from practice the patient should be informed or qualified
substitute should be arranged
13. A written informed consent should be obtained before carrying out surgery
and anesthesia and the detailed surgical procedures and possible risks
should be explained to the patient.
14. Before a surgical operation, the surgeon should make sure that all the
instrument are in good working condition and' proper count of the instruments
should be done by the nurse before and after completing the operation
15. Whenever a death occurs from anesthesia or during surgical operation the
doctor should report to the police
16. For carrying out any research work on the patient his consent should be taken
17. No female patient to be examined without the presence of a third person
preferably a female or by a female Registered Medical Practitioner
18. The doctor should be well versed with the advanced medical knowledge in the field

CONSUMER PROTECTION ACT (CPA) 1986

 Negligence is an integral part of human nature and medical practitioners are no
exception to this. Medical practitioner’s were, are and will remain accountable for
their professional misconduct or Medical Negligence.
 Consumer protection act 1986 was enacted by parliament to provide for better
protection of the interest of consumers in the background of guidelines contained
in the consumer protection resolution passed by U.N. general assembly in 1985.
 This act has been enacted to give better protection to the interest of the
consumer and to provide speedy remedy in case of dispute between the
consumer and the seller.
 In the beginning, the medical practice was not covered under this act, but due to
the landmark of judgment of Supreme Court in 1995 (IMA vs V. P. Shantha) the
medical practices, barring some minor exception came within the ambit of CPA.

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TERMINOLOGIES USED
 Consumer: user of product or service by paying money
 Forum: law court, place of public discussion.
 Redress: (Redress = to remedy) compensation, reparation.
 Plaint: a Statement of Grievance in court.
 Plaintiff: Complainant, prosecutor in law suit.
 Prosecute: To bring legal suit.
SALIENT FEATURES
 Redressal forums constituted at three levels: district (district consumer dispute
redressal forum); state (state consumer dispute redressal forum); national
(national consumer dispute redressal forum)
 Complaint can be filled on plain paper.
 By consumer himself or his Lawyer.
 No lawyer or court fee is required.
 Forum should deliver its decision within 90 days (3 months).
 Forums decision has the same legal sanctity as the verdict of civil court.
 Provision of appeal is there to the next higher level and ultimately to the supreme
court of India.
 Appeal against decision of the forum can be made in the higher court within a
period of 1 month or 30 days.
POWERS OF DIFFERENT CONSUMER REDRESSAL FORUMS
Jurisdiction in term of
Title Level Type of Members cost of goods or
services
1. District consumer District Retired District Judge
dispute redressal forum +
Dispute involving upto Rs.
Member of eminence
+ 20 lacs.
Lady social worker
2. State consumer dispute State Retired High court judge
redressal forum +
Dispute involving between
Member of eminence
+ Rs. 20 lacs and 1 crore.
Lady social worker
Retired Supreme court
judge
3. National Consumer National + Dispute involving
dispute redressal forum 3 Members of eminence more than Rs. 1 crore
+
Lady social Worker
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Penalties:
 Non compliance of any order made by the District forum, state commission or
national forum is punishable with imprisonment ranging from 1 month to 3 years.
 Dispute is settled on the basis of the evidence brought to its notice by the
complainant.
 Cases are decided on the basis of equity, conscience and natural justice.

MEDICAL INDEMNITY INSURANCE

It is a contract under which the insurance company agrees, in exchange for the
payment of premium, to indemnity the insured doctors as a result of his claimed
professional negligence.
Objectives of Medical Indemnity Insurance:
 To look after and protect the professional interest of the insured doctor.
 To arrange, conduct and pay for the defense of such doctor.
 To arrange all other professional assistance including pre-litigation advice.
 To indemnify the insured doctor in respect of any loss or expenses directly arising
from action claims and demands against him or grounds of professional
negligence, misconduct etc.
TRANSPLANTATION OF HUMAN ORGANS ACT 1994 (THOA)
 The transplantation of an organ from one body to another is known as the
organ transplant.
 The person who gives the organ is called the donor while the one who receives
is called the recipient.
 Organ Transplantation is a boon to medical industry as it has helped in saving
the lives of those who would have died otherwise.
 Kidney, Liver, heart, lung, pancreas, small bowel and sometimes skin etc. are
some of the organs that can be donated for an organ transplant.
 Due to inefficient and corrupt healthcare system, illegal trafficking of organ is
really high in India.
 To stop illegal organ transplant, Indian Government has come up with a 1994
law that criminalizes organ sales.
 The Transplantation of Human Organs Act, 1994 has laid down certain rules
and regulations that are to be followed while conducting organ transplant.

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Rules and regulations that are to be followed while conducting organ
transplant:
 The act permits any registered medical practitioner to transplant human organs
for therapeutic purpose without any motive of financial gains, neither to the doctor
not to the donor.
 Any adult healthy person can volunteer to donate tissues from his body to any
needy patient; such donations can be made during ones life time if they don’t
pose danger to ones life, after taking his consent or after his death (Cadaveric
donation) by permission of next of kin. If no consent (living will) is present, then
also the legal possessors of body can allow removal, if they don’t have any
reason to believe deceased’s refusal for the same.
 In hospital deaths, if bodies are unclaimed for 48hrs after death then hospital can
dispose the body and use the organs as directed by the deceased.
 Live donations are exclusively made, to save the life of a patient, preferably by a
near relative (parents, children, brothers, sisters, and spouse).
 Unrelated donations are made in inevitable circumstances, on approval by
appropriate authorization authority.
Penalties for violation of the rules as per THOA:
 Any transplantation which is not in accordance with transplantation of human
organ act is illegal and doctor, donor as well as recipient can be punished.
Punishment can be imprisonment up to 5 years and fine up to Rs.10000/-
 Whosoever, engages in commercial dealings in human organs is punished with
imprisonment of 2-7 years and a fine of Rs.10000 to Rs.20000.
 When a doctor is convicted under the act, action is also taken by medical council.
It can lead to temporary erasure of name from medical register (2 years) for the
1st offence and penal erasure for subsequent one.

PRE-CONCEPTION AND PRE-NATAL DIAGNOSTIC TECHNIQUES

(PROHIBITION OF SEX SELECTION) ACT1994 (PCPNDT ACT)
 The pre-dominantly patriarchal, social, cultural and religious set up based on the
foundation that the family line runs through a male has contributed extensively to
the secondary status of women in India. This has led to strong desire to avoid the
birth of a female child in the family resulting in decline in the child sex ratio at an
alarming rate in some of the States and Union Territories.
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 Misuse of the techniques like amniocentesis to determine the sex of the fetus and
subsequent abortions if the fetus was found to be female was noticed by social
activists in the 1980s. Thereafter due to the relentless efforts of activists and after
intensive public debate all over India, the Parliament enacted the Pre Natal
Diagnostic Techniques (Regulation and Prevention of Misuse) Act 1994 and was
later amended in 2003 as “Pre-conception and Pre-Natal Diagnostic Techniques
(Prohibition of Sex Selection) Act, 1994”.
 The PCPNDT Act 1994 provides for:
 Prohibition of sex selection, before and after conception.
 Regulation of prenatal diagnostic techniques (e.g. amniocentesis and
ultrasonography) for detection of genetic abnormalities, by restricting their
use to registered institutions. The Act allows the use of these techniques
only at a registered place for a specified purpose and by a qualified person,
registered for this purpose.
 Prevention of misuse of such techniques for sex selection before or after
conception.
 Prohibition of advertisement of any technique for sex selection as well as
sex determination.
 Prohibition on sale of ultrasound machines to persons not registered under
this Act
 Punishment for violation of provisions of the Act (It is illegal to determine or
disclose the sex of the fetus. The law specifies the punishment for violators:
imprisonment, which may extend to 5 years, and fine up to Rs. 100,000.).

INCOMPLETE LIST OF QUESTIONS FROM MEDICAL ETHICS

1. Enumerate the duties of a medical practitioner.
2. Enumerate the rights and privileges of registered medical practitioner.
3. Enumerate the functions of medical council of India.
4. Enumerate the functions of the state medical council.
5. Define and explain professional misconduct with any six examples.
6. Outline the procedure of disciplinary action by state medical council in
professional misconduct.
7. Define and classify consent. Briefly explain the different types of consent.

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8. Explain the doctrine of informed consent.
9. Define and classify negligence. Explain the components of negligence.
10. Enumerate the difference between civil and criminal negligence
11. Enumerate the defenses available in cases of medical negligence and briefly
explain any two of them.
12. Describe the doctrine of vicarious liability with suitable examples.
13. Write briefly on the following:
i. Medical register.
ii. Warning & warning notice.
iii. Dichotomy or fee splitting.
iv. Various types of disciplinary powers of medical council.
v. Penal erasure.
vi. Implied consent.
vii. Express consent.
viii. Informed refusal
ix. Valid consent
x. Therapeutic privilege or discrete disclosure.
xi. Loco parentis.
xii. Emergency consent.
xiii. Professional secrecy.

xiv. Privileged communication.

xv. Differences between the damage & damages.
xvi. Contributory negligence.
xvii. Novus actus interveniens.
xviii. Error of judgment.
xix. Therapeutic misadventure.
xx. Medical mal-occurrence.
xxi. Corporate negligence.
xxii. Composite negligence.
xxiii. Product liability.
xxiv. Res ipsa loquitor.
xxv. Precautions against medical negligence.
xxvi. Powers of different consumer redressal forums.
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 xxvii. Medical indemnity insurance
xxviii. Transplantation of Human Organs Act 1994 (THOA)
xxix. Pre-conception and pre-natal diagnostic techniques
(PCPNDT) Act 1994.

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 MEDICO-LEGAL AUTOPSY
“To the living we owe respect, but to the dead we owe only the truth”
-Voltaire
 The etymology of the word autopsy is fascinating. It comes from the Greek “auto”
meaning self and “opsy” meaning eye. In making an inference, one can assume
that the word means “to see oneself.” According to the Oxford English Dictionary,
the autopsy first meant “seeing with one’s own eyes, eye-witnessing; personal
observation or inspection.”

 An autopsy also known as a post-mortem (Latin: ‘after death’) examination

necropsy, or obduction, is a medical procedure that consists of a thorough
examination of a corpse to determine the cause and manner of death and to
evaluate any disease or injury that may be present.

TYPES OF AUTOPSY
There are generally two types of autopsies:
1. The Clinical or Pathological or Academic Autopsy.
2. The Medico legal or Forensic Autopsy.
DIFFERENCES BETWEEN VARIOUS TYPES OF AUTOPSIES
Medico-legal / Forensic Clinical/Pathological/Academic
Autopsy Autopsy
1. Identity Frequently in question Always known
Sudden, suspicious,
2. Nature of death Natural death
unexpected, litigious, or
unnatural death
For the research purpose; to study
the details of that natural death; to
3. Need Administration of justice evaluate effect of medical treatment
for the purpose of improving the
patient care
Determine cause & manner of
4. Objective Determine mechanism of death
death
Statutory requirement,
5. Consent Permission of kin required
permission of kin not required
6. Extent of Autopsy of the area of the body
Complete autopsy
autopsy known to have complications
7.Chemical
Frequently done Not done
analysis
8. Histopathology Always done Done for confirmation
9.Conducted by Forensic expert Pathologist
10.Confidentiality Public record Confidentiality applies
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INDICATIONS FOR MEDICO-LEGAL AUTOPSY
Autopsies should be conducted in the following situations:
1. Homicide or suspected homicide
2. Sudden unexpected death
3. Suspected medical malpractice and neglect
4. Accidents, either transportation, occupational, recreational or domestic
5. Occupational disease and hazards
6. Technological or environmental disasters
7. Death in custody or death associated with police or military activities
8. Unidentified bodies or body parts
9. Suspected violation of human rights such as suspicion of torture and/or any other
form of ill-treatment.

OBJECTIVES OF MEDICO-LEGAL AUTOPSY

The aims of death investigation are to answer the following questions:
1. Who died? (Identification of the deceased)
2. Where? (Place of death)
3. When? (Time of death)
4. Why? (Cause of death)
5. How? (Manner & mechanism of death)

OBJECTIVES OF AUTOPSY ON ADULT BODY

In case of adults, autopsy is done in following circumstances:
1. Identity of the deceased in case of an unknown body
2. Cause of death
3. Time since death
4. Manner of death whether suicidal (a death from a self-intentional act), accidental
(a death from unintentional and unpredictable event/act) or homicidal (a death
from the harmful intentions of another)
5. Place of death if there is a suspicion of dead body being shifted from some other
place
6. Documenting the injuries, their description, nature and distribution
7. Ascertaining whether the injuries found were inflicted before or after death
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8. Ascertaining whether the injuries and their distribution are consistent with the
given history
9. Collecting trace materials on the victim which may help to solve a crime such as
tracing a hit and run vehicle, arresting a rapist murderer etc.
10. Reconstruction the event of death when a proper eye witness account or a
history is not available.

OBJECTIVES OF AUTOPSY ON FETUS / INFANT

In case of fetus / infant, autopsy is done to determine:
1. Gestational age of the fetus
2. Whether fetus is viable or not
3. If viable, whether it was still, dead or live birth
4. If born alive, period of survival after birth
5. Cause of death
6. Manner of death
7. Time since death

OBJECTIVES OF AUTOPSY ON SKELETAL REMAINS

 The bones sent for examination are ordinarily those recovered after exhumation.
 It is not unusual for the police to recover skeletal remains from a jungle or
deserted area. Bones may also be recovered from dustbins, ditches and
cupboards.
 The examination of skeletal remains should be undertaken with a view to answer
following questions:
1. Do they belong to a human being or not?
Whether the bones are human or not can be determined by noting the
morphological features. It is easy when the entire skeleton is available but
difficult when small fragments are provided. The precipitin test will be helpful
in such circumstances.

2. Do they belong to male or female?

After puberty the sex difference in the bones become evident and can be
determined from an examination of the pelvis, skull, sacrum, atlas etc.

3. Do they belong to one or more individuals?

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 This can be done by assorting and assigning the individual bones to their
anatomical positions. If there are no disproportionate or duplicate bones and if
the age and sex of all the bones are the same, then it can be concluded that
all the bones belong to the same individual.

4. What is the probable stature of the individual?

The stature (or height) of the individual can be assessed by the measuring the
long bones and applying Karl Pearson’s formula or any other standard
formula.

5. What is the age of the individual?

Age can be determined from the examination of the teeth, long bones and
skull.

6. To whom exactly do the bones belong?

 Skeletal traits or anomalies that could serve to positively identify the
decedent.

 DNA analysis of the bone marrow helps in positively establishing identity.

The superimposition technique has been tried in several cases.

PRE-REQUISITES FOR MEDICO-LEGAL AUTOPSY

Pre-requisites for medico-legal autopsy include the following:
1. Authorization for conducting medico-legal autopsy:
A letter from the Investigating Officer (police or magistrate) asking the medical
officer to carry out the ML autopsy and authorizing him to collect any material
from the body for further investigations, if necessary. Although the wordings of
the letter may be in the form of a request, it is an order.

2. Authorized mortuary:
Medico-legal autopsy should be conducted in an authorized mortuary except in
case where the body is in advanced stage of putrefaction or when there is a law
and order problem it can be conducted at the site of recovery of the dead body.
3. Illumination:
Hence as a rule, autopsy is not to be carried out at night under artificial lighting.
However, some state governments (e.g: Maharashtra, Karnataka) have permitted

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 autopsy at night provided the lighting is near natural or with the help of artificial
incandescent light.
4. Prosector:
Unlike clinical autopsy, minimum qualification sufficient to carry out medico-legal
autopsy is graduation in medicine. According to MCI curriculum, a MBBS student
is supposed to witness medico-legal autopsies during 2nd MBBS so as to be
capable of observing and interpreting medico-legal autopsy findings. As an intern
he is supposed to acquire skill of performing medico-legal autopsy. Hence any
medical graduate is presumed to be capable of carrying out medico-legal
autopsy.
5. Consent:
For a medico-legal autopsy to be conducted, consent of the family members is
not necessary. This is because the law enforcing agency is the legal heir of the
dead body in case of suspicious, unnatural deaths. State or law of the land gives
consent for the autopsy.
6. Identification of the deceased:
The accompanying police constable identifies the dead body.
7. Personnel:
Apart from autopsy surgeon, investigating officer and mortuary staff, no casual
observer should be present during the procedure. However, the treating doctor
and medical students may observe or witness the autopsy.

AUTOPSY PROCEDURES
EXTERNAL EXAMINATION
1. Clothing:
The examination of the clothing and worn accessories is an essential part of the
external examination and all findings are to be clearly described. This is
especially important in cases where the clothing or accessories have been
damaged or soiled: each area of recent damage must be described fully and
relevant findings are to be related to the site of injuries on the corpse.
2. Therapeutic Evidence:
All signs of recent or old medical and surgical intervention and resuscitation must
be described.
3. Examination proper:

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  Age, sex, build, height and weight, nutritional state, skin color and special
characteristics (such as scars, tattoos or amputations)
 Post-mortem changes, including details relating to rigor and hypostasis
distribution, especially their intensity, color; and putrefaction
 Inspection of the head and the facial orifices. This includes hair and beard ,
nasal skeleton, lips, oral mucosa, dentition and tongue, ears (bleeding from
the ear, mastoid contusion), eyes (Petechial hemorrhage, congestion), skin
(including a description of presence or absence of petechiae)
 Inspection of the neck: checking for excessive mobility and/or creptiation,
Inspection of the thorax: crepitation and shape of the chest;
 Inspection of the abdomen: abnormal bulging and change in the color;
Inspection of the anus, perineum and genitals;
 Inspection of the extremities: shape and abnormal mobility;
 Material findings under fingernails.
 Injuries must be described and documented.

INTERNAL EXAMINATION
 The opening of the three body cavities is by standard procedure.
 All internal lesions and injuries must be precisely described by size and location.
Special procedures:
 In cases of suspected gas embolism, pre-autopsy imaging procedures should be
performed. The autopsy technique must enable the forensic pathologist to
diagnose an eventual gas embolism, to estimate the gas volume in the heart and
to sample the intravascular gas.
 In case of deaths due to pressure over the neck structures, neck should be
dissected in a bloodless field layer by layer.

RELEASE OF THE BODY

After a medico-legal autopsy has been carried out the body has to be returned in a
dignified condition. This includes suturing of all incisions, and, if necessary and as far
as possible, of facial injuries. The body should contain all internal organs. If whole
organs are retained, this must be documented in the autopsy protocol.

INCISIONS USED FOR OPENING OF THE BODY

Incisions used for opening the trunk are:
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A). I shaped incision
B). Y shaped incision
C). Modified Y shaped incision
D). X shaped incision

A) ‘I’ SHAPED INCISION

This is the commonest incision drawn from the symphysis menti to the pubic
symphysis avoiding the umbilicus (cutting across this tough fibrous structure
leads to difficulty in suturing it back, thereby resulting in defective approximation)
and any injuries in the line of incision.

B) ‘Y’ SHAPED INCISION

 In this method, the two incisions commence on either side of the neck from
mastoid bone to meet at supra-sternal notch and then continued as a single
incision down to pubic symphysis avoiding umbilicus.
 This method is specially suited when a detailed study of neck structures is
desired as in the case of deaths due to pressure over the neck structures.

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C) MODIFIED ‘Y’ SHAPED INCISION
 In this method, two incisions are made, commencing on either side of the
chest from acromion process or anterior axillary fold, curving under the
breasts to meet at xiphisternum and to be continued as a single incision down
to pubic symphysis avoiding umbilicus.
 This is desirable in those cases (especially ladies) where it is customary to
restore the body in a reasonable cosmetic condition for view for some time
after death

D). ‘X’ SHAPED INCISION

 Death in custody frequently raises suspicion of ill-treatment on the part of the
custodians. The meticulous postmortem search for evidence of injury is the
paramount consideration in objective investigation. Detection and evaluation
of hidden subcutaneous hemorrhages facilitate reconstruction of ante-mortem
circumstances.

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  X shaped incision of the back and limbs and reflecting the skin useful in the
examination of deeper tissues without any noticeable disfigurement. It is
made from shoulder tip to opposite heal on both the sides.It extends from the
protuberance of the 7th cervical vertebra downwards to the buttocks. The
upper branches of the X are formed by continuing the incision above the
shoulders through the posterior aspect of the upper limbs. The lower
branches bifurcate from the midline along the posterior surface of the leg all
the way down to the ankle.

X incision

Incisions used for opening the head are:

A) SCALP INCISION (BI MASTOID INCISION)
This incision is drawn from behind one ear (mastoid bone), passing through
vertex and ending behind the other ear. Scalp is reflected up to supra-orbital
ridge in the front and up to occiput in the back.

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B) SKULL INCISION
 The cranium is to be opened using an oscillating stryker saw cutting the skull
along a line extending from a point just above the supra orbital ridge in the
front, to the point just above the mastoid on the sides and to external occipital
protuberance as depicted in the picture given below.

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TECHNIQUES USED FOR REMOVAL OF THE ORGANS

1. VIRCHOW TECHNIQUE (INDIVIDUAL ORGAN REMOVAL METHOD)

In the Virchow technique, the organs are removed one by one and dissected as
removed. This approach is good for demonstrating pathological change in
individual organs, especially in high risk autopsies. The disadvantage of this
technique is that relationships between various organs may be hard to interpret.

2. ROKITANSKY TECHNIQUE (IN SITU METHOD)

This procedure is characterized by in situ dissection, in part combined with en
bloc removal. The term "Rokitansky technique" is used erroneously by many
pathologists to designate the en masse technique.

3. LETULLE'S TECHNIQUE (EN MASSE METHOD)

Thoracic, cervical, abdominal, and pelvic organs are removed en masse and
subsequently dissected into organ blocks.. The major disadvantage is that the
organ mass is often awkward to handle, and the autopsy is difficult to perform
without an assistant.
4. GHON'S TECHNIQUE (EN-BLOC METHOD)
Thoracic and cervical organs, abdominal organs, and the urogenital system are
removed in functionally related blocks. This procedure is a compromise between
the Virchow and en masse techniques, preserving anatomical relationships
sufficiently for most cases while being simpler for one person to execute.

DISSECTION OF HEART
Method employed:
Inflow-outflow method following the direction of blood flow.

Procedure:
Pericardial sac is opened by a longitudinal anterior midline dissection using scissors

Heart is separated from vessels entering and leaving it as far away as possible
from the base

The right atrium is cut between the openings of superior and inferior vena cava
using enterotome

The right auricle is exposed and looked for any thrombus

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Through tricuspid valve using tongue knife right ventricle is cut along its lateral
border (looked for- thrombus, ischemic area, rupture of papillary muscle, tricuspid
stenosis)

Using enterotome pulmonary trunk was cut which opens in the right ventricle (looked
for thrombus)

The left atrium is opened between the pulmonary veins using scissors

The left auricle is exposed and looked for any thrombus

Through mitral valve using tongue knife left ventricle is cut along its lateral border
(looked for- thrombus, ischaemic area, rupture of papillary muscle, mitral stenosis)

Using curved scissors (because curvature of scissor corresponds to the arch of the
aorta) cut the aorta which opens in the left ventricle (looked for thrombus)

Patency of the coronary arteries checked by making serial sections of the coronary
branches about 2-3mm apart

At the end of the procedure heart is weighed (to get rid of erroneous weight of heart
due to the presence of clots)

BLOODLESS & FLAP / LAYERED DISSECTION OF NECK

Indication:
Bloodless and flap dissection of neck is employed in deaths due to pressure over the
neck structures, e.g.:
A. Hanging
B. Ligature strangulation
C. Throttling
D. Mugging
E. Bansdola
Purpose:
1. To avoid artifacts arising from seepage of blood from the neck veins.

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2. To more adequately document injuries (or absence of injuries) in deaths due to
pressure over the neck structures.

Procedure:
 The dissection is performed by a step-by-step, layer wise reflection of neck
tissues after the thoraco-abdominal organs and the brain have been removed.
 This allows the blood in the neck drain away, providing for a cleaner dissection
field. This is achieved by putting an incision from sternal notch to pubic
symphysis keeping neck intact. The organs of chest and abdominal cavity
dissected.
 Then the cranial cavity is opened and brain dissected. This makes the neck
bloodless. Over neck, incision is placed from symphysis menti to sternal notch.
Structures of the neck are examined carefully avoiding artefacts layer by layer
(flap), i.e.
1. Skin is examined for any injuries
2. Subcutaneous tissue for features of compression
3. Cervical strap muscles are reflected in the facial plane, starting with the
sterno-cleidomastoid muscles and then reflecting deeper muscle layers
(sterno-hyoid, sterno-thyroid, thyro-hyoid, omo-hyoid) - they are examined for
blood extravasation or contusions
4. Vessels of the neck (carotid artery and jugular vein) are examined for any
tears
5. Thyroid gland is examined for any contusions
6. Tracheal rings are examined for any fractures
7. Hyoid bone, thyroid cartilage and cricoid cartilage examined for any fractures
and contusions

DISSECTION OF STOMACH
Indication:
1. In suspected poisoning, the stomach content odor gives an important clue
regarding the nature of poison taken.
2. If the time of last meal is known, it helps in the determination of probable time
since death.
Procedure:

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 In suspected poisoning, the stomach is removed after tying a double ligature just
above the cardiac end and the pyloric end.
 It is then opened along the greater curvature in a clean container and the
contents may be poured in a in a glass bottle for being sent to the Chemical
Examiner. Mucous surface should be carefully examined noting its appearance,
and any suspicious particles found adherent, preferably sent separately for
chemical examiner.
 The contents of the stomach should also be measured and examined as regards
their smell, color and character.
 In estimating time since death, the status of the contents should be noted i.e.
whether they are fully digested, partially digested but unrecognizable, partially
digested but recognizable or food particles are intact.

VISCERA & BODY FLUID PRESERVATION IN SUSPECTED CASE OF

POISONING

Collection of proper autopsy specimen is an essential step in the process of

toxicology casework. Improper collection of these specimens can greatly alter or
negate chemical and toxicological analysis.

Principle:
Ingested poison

Poison reaches stomach

Absorbed into the blood through the proximal part of small intestine

Liver metabolizes and detoxifies the poison

Excreted through kidney into the urine

ROUTINE VISCERA & BODY FLUIDS PRESERVED

Routinely following viscera and body fluids are preserved in suspected poisoning:
1. Stomach and its contents
2. Proximal 30 cm of the small intestine and its contents
3. 500 grams of liver with gall bladder
4. Half of each kidney (both kidneys to exclude the possibility of one kidney being
non functional)
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5. Blood (10-20 ml.)

VISCERA & BODY FLUIDS PRESERVED IN ADDITION TO ROUTINE VISCERA

IN SPECIAL CASES
1. Narcotic drugs/ cyanide/ strychnine: Brain
2. Alcohol: C.S.F / Vitreous Humor
3. Cardiac poisons (nicotine, oleander, digitalis, chloroform) : Heart
4. Heavy metals (Arsenic, lead, antimony, copper, mercury): long bone, 500
micrograms (20 to 30 hairs) of plucked hair, finger or toe nail
5. Snake bite or injection sites: 2.5 x 2 cm2 skin with subcutaneous tissue and
underneath muscles from affected site, and similarly from the opposite side as
control
6. Pesticides/ anesthetic agents: fatty tissue from abdominal wall
PRESERVATIVES TO BE USED FOR VISCERA AND BODY FLUIDS
A. For Viscera
 Rectified spirit is the preservative of choice.
 Common salt being less costly, easily available and having lesser chances of
wastage and misuse as compared to rectified spirit, is widely used for the
viscera for chemical analysis.

B. For Blood
 The most satisfactory way of obtaining a venous blood sample is
venepuncture of the femoral vein by direct puncture in the groin before the
autopsy begins.

 Potassium oxalate (anticoagulant) & Sodium fluoride (enzyme inhibitor)

[sodium fluoride of 10mg/ml and potassium oxalate, 30 mg/10 ml].

 Sodium fluoride protects blood from postmortem changes such as bacterial

production of ethanol or other alcohols. It also helps to protect other labile
drugs such as cocaine, ntrazepam and clonazepam from degradation.

C. For Urine
Rectified spirit or thymol crystals or sodium fluoride (10 mg/ml).

CONTRAINDICATIONS FOR USING CERTAIN PRESERVATIVES

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 Saturated sodium chloride solution is contraindicated in aconite poisoning, heavy
metal poisoning, vegetable poison and corrosive acids.
 Rectified spirit is contraindicated in alcohol, acetic acid, carbolic acid, kerosene,
paraldehyde and phosphorous (luminescence property lost with rectified spirit)
poisoning.

PACKING
1. 1st bottle (2 litres; glass bottle; wide mouthed)
Stomach with its contents + Proximal 30 cms of small intestine with its contents
preserved in saturated solution of common salt.
2. 2nd bottle (2 litres; glass bottle; wide mouthed)
500 grams of liver with gall bladder + Half of each kidney preserved in saturated
solution of common salt.
3. 3rd bottle (100ml; glass bottle)
10-20 ml of blood preserved in sodium fluoride of 10mg/ml and potassium
oxalate, 30 mg/10 ml of blood concentration.
4. 4th bottle (100ml; glass bottle)
50 ml of saturated solution of common salt to exclude the presence of poison if
any, in the preservative used itself.

PACKING TIPS
 Stomach and intestines are opened before packing.
 Kidney and liver should be cut into pieces to ensure better penetration of
preservative.
 Preservative should be filled up to 2/3rd of the bottle so as to prevent bursting of
the bottle, in case of any decomposition.
 Stoppers of the bottles should be well fitting.

FORWARDING SAMPLES
 All samples should be properly sealed and labelled with the deceased’s name,
postmortem number, nature of sample, collection site, preservative used, date
and time of collection.

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 Particular attention should be paid to the packaging of samples to avoid loss
during transport, and to comply with health and safety regulations. It should be
protected by the use of tamper-evident seals around the lids, and accompanied
by an intact chain of custody record.

 It should be handed over to the investigating officer be delivered to Forensic

Science Laboratory / Regional Forensic Science Laboratory for chemical analysis
after obtaining proper receipt.

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EXHUMATION
Exhumation is the lawful digging out of an already buried body from the grave.
 In India exhumations are less because the majority of people burn the body
(majority belong to Hindu religion).
 There is no time limit for exhumation in India.
 The time limit is 10 years in France whereas in Germany it is 30 years.
INDICATIONS
Civil Cases
 Disputed identity cases
 Accidental death claims
 Liability for medical negligence
 Workman’s compensation claims
Criminal Cases
 Suspected homicide labeled earlier as natural or accidental
 Suspicious poisoning

GENERAL STEPS RECOMMENDED IN EXHUMATION

1. A court order legally permitting the exhumation.
2. An exhumation is commenced in the early hours of the day, so as to complete
entire process by end of the day and to avoid unwanted crowd.
3. An exhumation must be done in the presence of the medical officer and the
police officer.
4. Before digging the grave precaution to be taken not to open a wrong grave, by
properly identifying the grave.

PROCEDURE
 After proper identification of the spot, the area should be enclosed from the
public.
 While digging the condition of soil, water content and vegetative growth should be
noted.
 Grave is dug up to the coffin or dead body and photographs taken and a sketch is
prepared.
 In a case of poisoning, 500 grams of earth from top of the coffin or cadaver,
similar quantities from the sides and below along with the control samples from
the other parts of the grave are taken.

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 The coffin or cadaver removed must be identified by the friends or relatives.
 The magistrate then examines the cadaver, and orders for an autopsy.
 Then the complete examination was conducted, if necessary at the site itself and
the report is submitted to the magistrate.

ARTEFACTS
DEFINITION
Artefacts are the spurious findings on the dead body, induced at the time of death or
thereafter and are of great medico-legal significance, if ante-mortem in nature.

MEDICO-LEGAL SIGNIFICANCE
 Postmortem Artefacts are due to any change caused or features introduced in a
body after death. The artefacts are physiologically unrelated to the natural state
of the body or tissues or the disease process, to which the body was subjected to
before death. Ignorance and misinterpretation of such postmortem artefacts leads
to:

1. Wrong cause of death.

2. Wrong manner of death.
3. Under suspicion of criminal offence.
4. Unnecessary spending of time and effort as a result of misleading findings
or even miscarriage of justice.

 It is the duty of medico-legal expert to differentiate artefacts from that of

injuries thereby preventing false interpretation of findings and misleading of
investigation.

TYPES OF ARTEFACTS
A. Resuscitation Artefacts
 Caused during the process of resuscitation procedure.
 E.g.: Contusion marks due to defibrillation, Rib fracture during cardiac
massage, Needle injuries caused during the attempt of reviving the patient.
 Endotracheal intubations, positive pressure artificial respiration may lead to
surgical emphysema and pneumothorax.

B. Agonal Artefacts
 Caused during the terminal events of death.
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  E.g.: Aspiration of food particles into the airway during the terminal events of
death.
C. Post-mortem Artefacts
Caused due to improper handling of the dead body during transportation, post-
mortem changes, refrigeration, decomposition, animal and insects, autopsy
procedures, embalming and exhumation.
a. Improper handling of the body:
In the process of removal of the body from the crime scene to the mortuary,
fresh abrasions may be produced, blood stains may form on parts of the
garments originally free from them and fresh tears in clothes may result from
rough handling.

b. Artefacts due to post-mortem changes:

 Existing rigor mortis may be broken down at least partially while removing
the body from the crime scene to the mortuary, and all these may cause
errors in interpretation of time since death. Artefacts due to postmortem
lividity:

 Isolated patches of postmortem lividity may be mistaken for bruises. Such

patches on the front and sides of the neck may be mistaken for bruising
due to throttling (manual strangulation).Lividity of the internal organs may
be mistaken for congestion due to disease.

c. Artefacts due to refrigeration in cold chamber:

 Pink hypostasis is seen in bodies kept in cold storage.

d. Artefacts of decomposition:
 Formation of fluid filled blebs beneath the epidermis is common
phenomenon of putrefaction. Differential diagnosis of such blebs from
ante-mortem burns is important.

 In a warm atmosphere, body fluids frequently start purging out of mouth

and nostrils of dead body.

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 e. Artifacts due to animal and insect bites:
 Marine animals mostly attack exposed areas and projecting body parts,
such as lips, nose, ears, fingers and scrotum, etc. All theses injuries are
without a vital reaction and their edges appear nibbled.

 The feeding action of ants can cause many irregular, serpiginous,

scalloped areas of superficial skin loss, and small punctate and scratch-
type lesions. Usually ant injuries are orange-pink to yellow in color and
diffusely scattered over the skin surface. These injuries consist of small
and rather shallow gnawed holes that can be easily misinterpreted as
ante-mortem abrasions or resulting from strong acids.

f. Autopsy surgeon induced artefacts:

 During opening of skull, pulling of dura and pulling of neck structures.

g. Embalming artifacts:
 The trocar wound may simulate a stab wound.
h. Exhumation artefacts:
 In bodies which have been buried, fungus growth is usually seen at body
orifices, eyes and at the sites of open injuries. After the removal of the
fungus, the color of the underlying skin resembles bruising.

 Grave diggers can produce post mortem fractures, abrasions, and

lacerations.

 Postmortem imbibition of toxicological elements in earth causes problems

for toxicological analysis.

NEGATIVE AUTOPSY
Definition:
When all ancillary investigations, such as microscopic examination of tissues,
microbiology, toxicology and virology prove negative, then cause must remain
unascertainable, these autopsies are termed as negative.
Causes:
Physiological causes of death such as vagal inhibition, ventricular arrhythmias,
where no anatomical findings would be present to correlate with the findings.

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OBSCURE AUTOPSY
A meticulous autopsy with ancillary investigation may fail to ascertain the cause of
death because of trivial or obscure findings. This is termed as obscure autopsy.

SECOND AUTOPSY
 Autopsy of the already autopsied body.
 There may be circumstances where the body is buried after due autopsy but
discrepancy arose after sometime, may be due to public hue and cry or some
political overtones. Then the dead body may be subjected for second autopsy.

PSYCHOLOGICAL AUTOPSY
Synonyms: Reconstructive Psychological Evaluation (RPE) or Equivocal Death
Analysis (EDA)
Explanation:
 The psychological autopsy was originally devised to assist certifying officials to
clarify deaths that are initially ambiguous, uncertain, or equivocal as to the
manner of death.
 This approach is useful in cases of suspected suicide when initial information is
limited.
 Interviews with family, friends, co-workers, physicians, and others by
investigators provide insight into the deceased’s state of mind and behavior in the
past, and in the period preceding death. This will assist in analysis of an
individual’s suicidal intent.

INCOMPLETE LIST OF QUESTIONS FROM INFANTICIDE

1. Enumerate the differences between medico-legal and pathological autopsies.

2. Enumerate the indications for medico-legal autopsy.
3. Enumerate the objectives of medico-legal autopsy.
4. Describe the various incisions used for opening of the body.
5. Explain the bloodless & flap / layered dissection of neck.
6. Viscera & body fluid preservation in suspected case of poisoning.
7. Write briefly on the following:
A. Objectives of autopsy on adult body.
B. Objectives of autopsy on fetus / infant.
C. Objectives of autopsy on skeletal remains
D. Incisions used for opening the trunk.
E. Incisions used for opening the head.
F. Techniques used for removal of the organs
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 G. Dissection of heart.
H. Dissection of stomach.
I. Exhumation.
J. Artefacts.
K. Negative autopsy.
L. Obscure autopsy.
M. Psychological autopsy.

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 MEDICO-LEGAL ASPECTS OF INJURIES
EXPLANATION FOR CERTAIN IMPORTANT TERMINOLOGIES
1. Injury.
2. Culpable homicide.
3. Murder.
4. Abetment of suicide.
5. Attempt to murder.
6. Dangerous weapon.
7. Battery.
8. Assault.
9. Cognizable Offence.
10. Warrant Case.
11. Summons Case.

INJURY:
As per section 44 of Indian Penal Code, the word “injury” denotes any harm whatever
illegally caused to any person, in body, mind, reputation and property.

CULPABLE HOMICIDE (not amounting to murder):

As per section 299 of Indian Penal Code, whoever causes death by doing act with the
intention of causing death, or with the intention of causing such bodily injury as is likely
to cause death, or with the knowledge that he is likely by such act to cause death,
commits the offence of culpable homicide.

MURDER (culpable homicide amounting to murder):

As per section 300 of Indian Penal Code, except in the cases herein after excepted,
culpable homicide is murder,
1stly. - If the act by which the death is caused is done with the intention of causing
death, or
2ndly. - If it is done with the intention of causing such bodily injury as the offender
knows to be likely to cause the death of the person to whom the harm is caused, or
Explanation: Here death is a surprise.
3rdly. - If it is done with the intention of causing bodily injury to any person and the
bodily injury intended to be inflicted is sufficient in the ordinary course of nature to
cause death, or
Explanation: Here survival is a surprise.

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4thly. – If the person committing the act knows that it is so imminently dangerous that it
must, in all probability, cause death or such bodily injury as is likely to cause death,
and commits such act without any excuse for incurring the risk of causing death or
such injury as aforesaid.
Explanation: Here death is eminent.

ABETMENT OF SUICIDE:
As per section 306 of Indian Penal Code, if any person commits suicide, whoever
abets the commission of such suicide, shall be punished with imprisonment of either
description for a term which may extend to ten years, and shall also be liable to fine.

ATTEMPT TO MURDER:
As per section 307 of Indian Penal Code, whoever does any act with such intention or
knowledge, and under such circumstances that, if he by that act caused death, he
would be guilty of murder, shall be punished with imprisonment of either description for
a term which may extend to ten years, and shall also be liable to fine, and if hurt is
caused to caused to any person by such act, the offender shall be liable either to
imprisonment for life, or to such punishment as is hereinbefore mentioned.
DANGEROUS WEAPON OR MEANS:
 As per section 324 ( voluntarily causing hurt by dangerous weapon or means) &
326 (voluntarily causing grievous hurt by dangerous weapon or means) of Indian
Penal Code, dangerous weapons or means are any instruments used for shooting,
stabbing, or cutting, or any instrument which, used as a weapon of offence, is likely
to cause death, or by means of fire, heated substance, or by means of any poison,
or any corrosive substance, or by means of any explosive substance, or by means
of any substance which is deleterious to the human body to inhale, to swallow, or to
receive into the blood, or by means of any animal.
 Punishment as per IPC 324 is imprisonment for three years, or with fine, or with
both.
 Punishment as per IPC 324 is imprisonment for ten years, or with fine, or with both.
 Hard blunt weapons, light sharp cutting weapons, heavy sharp cutting weapons,
pointed weapons, and firearms are few of the weapons that can be included in the

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 category of dangerous weapons. In reality any weapon can be used as a
dangerous weapon.

BATTERY:
Battery is the criminal offence whereby one party makes physical contact with another
party with the intention to harm them. In order to constitute battery, an offense must be
intentional and must be committed to inflict injury on another. Battery is different from a
similar offense called assault. An assault is any attempt to threaten or attack another
party. Physical contact is not required to constitute an assault.

ASSAULT:
 As per section 307 of Indian Penal Code, whoever makes any gesture, or
preparation intending or knowing it to be likely that such gesture or preparation will
cause any person present to apprehend that he who makes that gesture or
preparation is about to use criminal force to that person, is said to commit an
assault.
 Explanation: When the accused, armed with a sharp edged weapon, went to the
shop of a man and hurled a challenge to him from some distance asking him to
come out and threatening him that he would not go back without killing him, it was
held by the honorable court that manner in which the accused hurled the challenge,
he committed an assault.

COGNIZABLE OFFENCE:
A cognizable offence is a case where the Police can arrest without a warrant. All
cognizable cases involve criminal offences. Murder, robbery, theft, rioting,
counterfeiting etc. are some examples of cognizable offences.
NON-COGNIZABLE OFFENCE:
 Non-cognizable offences are those criminal infractions, which are relatively less
serious. Examples of non-cognizable offences include Public Nuisance, Causing
Simple Hurt, Assault, Mischief etc.

 The Police cannot register criminal cases or cause arrests with regard to non-
cognizable offences. In all such cases, the Police have to take permission from a
magistrate for registration of a criminal case.

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WARRANT CASE & SUMMONS CASE:
 Section 2 Cr.P.C defines summons case and warrant case.
 Warrant case means a case punishable with death, imprisonment for life or
imprisonment for a term exceeding two years.
 Summons case has been defined in a negative manner i.e. not being a warrant
case. This would mean that wherever the extent of punishment is less than two
years, the same would be treated as summons case.

CLASSIFICATION OF INJURY BASED ON THEIR SEVERITY OR LEGAL

CLASSIFICATION OF INJURY
Wounds can be categorized based on their severity into the following:
1. Hurt.
2. Grievous hurt.
3. Likely to cause death.
4. Sufficient to cause death.
5. Necessarily fatal.
1. HURT - IPC 319:
As per section 319 of Indian Penal Code, Whoever causes bodily pain, disease or
infirmity to any person is said to cause hurt.
Explanation:
 Bodily pain: The pain must be bodily, not mental. The breaking of alarming news
to one may cause pain, but it is not bodily pain. It is not bodily pain. It is not,
therefore hurt.
 Disease: A person communicating a specific disease to another would be guilty
of hurt.
 Infirmity: Infirmity denotes an unsound or unhealthy state of the body.

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2. GRIEVOUS HURT - 320 IPC:
As per section 320 of Indian Penal Code, the following kinds of hurt only are
designated as “grievous”
First – Emasculation.
(It means loss of masculine power and the term is only applicable to males. The
loss of power can be due to direct trauma to genitalia or due to indirect trauma
resulting from lumbo-sacral trauma.)
Secondly - Permanent privation of the sight of either eye.
(Examples include corneal scarring, retinal detachment etc. The person is deprived
of using the organ and also disfigures him.)
Thirdly - Permanent privation of the hearing of either ear.
(Examples include rupture of the tympanic membrane due to a blow to the head.)
Fourthly - Privation of any member or joint
(A member means any organ or tissue capable of performing distinct function in the
body.)
Fifthly - Destruction or permanent impairing of the powers of any member or joint.
(If any joint is destroyed so as to cause loss of its function or there is damage to
any other organ or part of the organ, causing loss of its function is grievous hurt. It
causes great hardship to the person in maintaining normal life.)
Sixthly - Permanent disfiguration of the head or face.
(Even a small scar on a young girl may be considered as grievous while a large
scar on an old aged man may not be considered as grievous hurt.)
Seventhly - Fracture or dislocation of a bone or tooth.
(Dislocation of the tooth by a blow is taken as grievous hurt. All fractures including
hairline fracture and even of the outer table of skull is sufficient for the purpose of
law to be labeled as grievous.)
Eighthly - Any hurt which endangers life or which causes the sufferer to be during
the space of twenty days in severe bodily pain, or unable to follow his ordinary
pursuits.
(Ordinary pursuit’s means acts which are a daily routine in ever human beings day
to day lifelike eating food, taking bath, brushing teeth, combing hair, going to the
toilet etc.)
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3. LIKELY TO CAUSE DEATH – 300 IPC:
Act done with the intention of causing such bodily injury as the offender knows to be
likely to cause the death of the person to whom the harm is caused.
Explanation: Here death is a surprise.
4. SUFFICIENT TO CAUSE DEATH – 300 IPC:
Act done with the intention of causing bodily injury to any person and the bodily
injury intended to be inflicted is sufficient in the ordinary course of nature to cause
death.
Explanation: Here survival is a surprise.
5. NECESSARILY FATAL – 300 IPC:
Act which is imminently dangerous that it must, in all probability, cause death or
such bodily injury as is likely to cause death, and commits such act without any
excuse for incurring the risk of causing death or such injury as aforesaid.
Explanation: Here death is an eminent.

CAUSES OF DEATH FROM WOUNDS

Causes of death from wounds can be divided into following categories:
A. Immediate causes.
B. Delayed causes.
C. Remote causes.

IMMEDIATE CAUSES OF DEATH:

It includes hemorrhage, shock and injury to vital organs.
1. Hemorrhage (oligaemic shock): It is the most common cause of death in wounds.
The loss of 2 liters (one third of the total blood volume) is dangerous to life.
2. Shock: It is of two types, neurogenic or primary shock and traumatic or secondary
shock.
 Neurogenic or primary shock is a reflex neurovascular disturbance which follows
immediately after an injury .It results from either parasympathetic inhibition of
the circulation (vagal stimulation) or sympathetic-adrenal stimulation of the
circulation. It results either from severe pain or severe fright.

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  Traumatic shock (secondary shock) develops gradually after injury due to
reduction of total circulating blood volume, with a secondary decline in venous
return, cardiac output and blood pressure.
3. Injury to vital organs: Injury to heart, brain, spinal cord and lungs may cause
immediate death.
DELAYED CAUSES OF DEATH:
It includes embolism, crush syndrome and sepsis.
1. Embolism: Types that have special medico legal importance are Air embolism
(venous air embolism and arterial air embolism), fat embolism and thrombo-
embolism.
 Venous air embolism can be as a result of cut throat injury (cut jugular vein
results in negative pressure which sucks blood), intravenous infusion, tubal
insufflations (during evaluation of fallopian tube patency), and criminal abortion.
The minimum amount of air required to cause fatality is 100-200 cc. Death
results from the admixture of air and the blood in the right side of the heart
leading to formation of frothy non compressible blood causing blockage of
pulmonary circulation.
 Arterial air embolism can be as a result of induction of artificial pneumothorax, if
the needle is passed in a pulmonary vein. Few cc of air is enough to cause
fatality. Death results from the occlusion of coronary and cerebral arteries.
 Fat embolism can be as result of fracture of a long bone with torn vein, burns in
a fatty area, and trauma to a fatty area. Death results from the acute heart
failure due to obstruction of the right side of the heart and pulmonary artery with
fats.
 Thrombo-embolism can be as a result of prolonged recumbence in bed.
Prolonged recumbence in bed → deep vein thrombosis→ may be detached
→.pulmonary embolism after about 10 days of the injury or may be earlier (2-3
days).
2. Sepsis: It can be as a result of contused and lacerated wounds. These wounds are
the most liable to severe infection particularly, tetanus and gangrene due to
devitalized tissue of the wounds.

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3. Crush syndrome: Severe crushing of muscles → liberation of myoglobin→
blocking of renal tubules→ acute renal failure.
REMOTE CAUSES OF DEATH:
This includes malignancy arising from wounds.
DIFFERENCES BETWEEN ANTE-MORTEM & POST-MORTEM WOUNDS

Ante-mortem wounds Post-mortem wounds

Swollen Not swollen

Hard Soft
1.Edges of the wounds
Separated due to tissue Closed together and not
retraction retracted

Lymph exudation and Lack of lymph exudation

suppuration and suppuration
Abundant hemorrhage Lack of bleeding and
2.Hemorrhage infiltrating surrounding infiltration of surrounding
tissues tissues
3.Coagulation of blood Coagulated blood inside Lack of coagulated blood
the wound or on the skin
Presence of inflammatory Inflammatory changes
4. Vital reaction
changes absent
RBC’s & WBC’s Absent
5. Microscopy
6. Enzyme studies Positive Negative

VITAL REACTION
 One characteristic of living organisms is the ability to respond in the presence of an
external stimulus.
 When this stimulus is a traumatic offense, whether biologic, physical, or chemical,
the tissue response consists mainly of an inflammatory reaction that is proportional
to the magnitude of the tissue offense.
 It includes the following:
A. Enzyme-histochemical changes.
B. Biochemical changes.
C. Inflammatory response.
D. Hemodynamic changes.
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 E. Vascular changes.
F. Cellular activity.
MEDICO-LEGAL SIGNIFICANCE OF VITAL REACTION:
 If body suffers any insult, during the period between life and cellular death, a vital
reaction of reduced intensity is seen, which has been called an “agony reaction” or
“intermediate reaction”.
 There is an “uncertainty period” of approximately 6 hours around the time of death
in which it is not possible to establish the vital or possible to establish the vital or
post-mortem origin of a wound.
 The vital reaction components have helped the forensic pathologist to reduce
uncertainty periods to minutes.
ENZYME-HISTOCHEMICAL MARKERS OF WOUND VITALITY:
 A vital wound or an ante-mortem wound results in two clearly demarcated zones of
differing enzymatic activity: a central zone and a peripheral zone.
 The central zone is an area 200 to 500 micron wide that is located at the edges of a
vital wound and shows a gradual decrease in enzymatic activity, which can be
detected between 1 to 4 hours after wound infliction. This enzymatic response has
been called as “negative vital reaction”.
 The peripheral zone is an area 100 to 200 micron wide circumscribing the central
zone. This area shows a remarkable increase in enzymatic activity 1 hour after
wound infliction. This enzymatic response has been called as “positive vital
reaction’.

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 The sequence of increasing enzymatic activity is as follows:
1. Esterases, 10 minutes.
2. Acid phosphatase, 1 hour.
3. Alkaline phosphatase, 3 hours.
4. DNA polymerizes at 4 hours.
5. DNA polymerizes at 4 hours.
 The histochemical or non-enzymatic markers of wound vitality include:
A. When stained with acridine orange, vital wounds of at least 1 hour duration
showed a greenish yellow fluorescence at the edges and the base of the wound.
This is attributed to the release of nucleic acid following tissue necrosis.
B. Increase in C3 factor, immunoglobulin G, A, and M in wounds older than 10
minutes.
BIOCHEMICAL MARKERS OF THE WOUND VITALITY:
Parameters helping biochemical diagnosis of the wound vitality include:
1. 5 minutes: slight increase or decrease of histamine, increase of serotonin.
2. 5 to 15 minutes: increase in histamine greater than increase of serotonin.
3. 15 to 60 minutes: increase of serotonin greater than increase of histamine.
4. Prostaglandins levels will be increased in vital wounds produced 10 to 60
minutes before death.

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INFLAMMATORY MARKERS OF WOUND VITALITY:
 This can be demonstrated histologically.
 Replacement of polymorphonuclear leukocytes by mononuclear leukocytes,
lymphocytes and fibroblasts
DATING OF INJURIES
Dating of following injuries plays a vital role in medico-legal practice helping in the
proving or disproving of causal relation between alleged times of infliction to injury
caused:
1. Abrasion.
2. Contusion.
3. Fracture.
ABRASIONS:
 Dating of abrasions based on the color changes occurring in the wound as a result
of healing.
 Following color changes helps to date the abrasions:
 Fresh: bright red wound.
 12-24 hours: dry red scab.
 2-3 days: reddish brown scab.
 4-7 days: epithelial growth beneath the scab, which causes separation of
scab from the base starting from the periphery.
 After a week: scab dries, shrinks and falls off leaving a hypopigmented area,
which attains a normal skin color after around 2 weeks without any scar.

CONTUSIONS:
 Color changes in the contusion start from periphery and extend towards the centre.
 Sub conjunctival bruises gradually decrease in size and disappear without color
changes.
 Following color changes helps to date the abrasions:
 Immediately: dark red (oxy hemoglobin).
 Few hours to 2 days: blue (reduced hemoglobin).
 3 to 4 days: brown (haemosiderin).
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  5 to 7 days or more: green (haemotoidin).
 7 to10 days or more: straw yellow (bilirubin).
 14 to15 days: disappears or completely heals.

FRACTURES:
Healing of fractures involves following steps:
1. Haematoma formation phase (1st stage).
2. Cellular formation phase (2nd stage).
3. Callus formation phase (3rd stage).
4. Ossification phase (4th stage).
5. Remodeling phase (5th stage).
1. Haematoma formation phase (1st stage):
 ~ 4 days (acute inflammation).
 Hematoma forms in medullary canal and surrounding soft tissue in first 48-72
hours.

2. Cellular formation phase (stage 2nd):

 Acidic environment but turning neutral.
 Influx of endosteal cells from cambium layer produce a fibrous callus
(environment has high oxygen tension) then cartilage (has a low oxygen tension
environment).

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3. Callus formation phase (3rd stage):
 Fibroblast deposit collagen in the granulation tissue.
 Soft Callus is formed (Unorganized network of woven bone).
 Internal callus (grows quickly to create rigid immobilization).
 During soft callus fracture line can be visualized by x-ray.
 The hard callus lasts 3-4 months.
 Hard callus – a gradual connection of bone filament to the woven bone (Acts
like a temporary splint).
 Fracture line cannot be visualized during hard callus.

4. Ossification phase (4th stage):

 Occur with adequate immobilization.
 Bone ends become crossed with a new haversian system that will eventually
lead to the laying down of primary bone.
 Fracture is bridged and united.

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5. Remodeling phase (5th stage):
 Remodeling hard callus to compact bone.
 May take a few years.
 Completed when the fractured bone has been restored to its original form or
shape or when it can withstand the imposed stresses placed on it.

TRAUMA AND DISEASE

The role of trauma in the causation of disease is a potent source of medico-legal
argument and in many cases the problem is insoluble. However, it must be
emphasized that the probability of an injury giving rise to disease varies greatly
according to the type of disease under discussion and there can be no generalization
possible in this respect. The probabilities of some diseases precipitating from trauma
are discussed herewith.
CORONARY ARTERY DISESASE:
There is no evidence whatsoever that injury or exertion can cause the underlying
disease, that is, trauma and effort play no part in the etiology of coronary atheroma.
However, in a person who already has coronary artery disease, it cannot be denied
that over-exertion may precipitate an acute episode in the natural history of the
disease, usually myocardial infarction or death from ventricular fibrillation or cardiac
arrest.

HYPERTENSION:
If the effort or stress of the injury causes a sudden rise in blood pressure, which may
cause rupture of an atheromatous plaque in a diseased coronary artery or of an
aneurysm or precipitation of death from valvular disease or hypertensive heart disease.
INFECTIONS:

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Infection can be due to a penetrating injury which carries infection into the wound, or
because tissue damage rendering the body more susceptible.
EPILEPSY:
The onset of fits after a focal head injury (almost always a localized skull fracture or
brain damage) is well established, but direct evidence of a local area of injury in a site
that neurologically can be related to the fits must be produced, as well as assurance
that no fits were suffered before the head injury.

TUMORS:
The relationship between malignant disease and injury is a frequent source of
controversy. Certain criteria, known as ‘Ewing’s postulates’, must be satisfied before
any connection can be maintained:
1. the tumor must arise exactly at the site injured
2. definite and substantial trauma must be proved
3. the tumor must be confirmed pathologically
4. the tissue at the site must have been healthy before the trauma
5. a reasonable interval – neither too long or too short – must elapse between the
time of the trauma and the appearance of the tumor
6. there should be some good scientific reason for ascribing the tumor formation to
the injury.

INCOMPLETE LIST OF QUESTIONS FROM MEDICO-LEGAL ASPECTS OF

INJURIES
1. Classification of injury based on their severity or legal classification of injury.
2. Describe the causes of death from wounds.
3. Explain the differences between ante-mortem & post-mortem wounds.
4. Explain vital reaction.
5. Write briefly on the following:
a) Injury.
b) Dangerous weapon or means.
c) Battery.
d) Assault.
e) Warrant case & Summons case.
f) Hurt.
g) Grievous hurt.
h) Enzyme-histochemical markers of wound vitality.

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 i) Dating of abrasions.
j) Dating of contusions.
k) Dating of fractures.
l) Ewing’s postulates.

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 PREGNANCY.
 Pregnancy is a condition of having a developing embryo or foetus in the female, due to
the fertilization of the ovum by the spermatozoon.
 The question of pregnancy needs to be determined in the conditions where a woman
pleads pregnancy to
 Avoid attending court
 Avoid death sentence
 Claim succession to the estate after her husband’s demise
 Assess damage in breach of promise to marriage
 Blackmail a man to marriage
 Get more compensation in negligence or alimony in a divorce
 It also needs to be determined in cases where pregnancy is alleged to be the motive of
suicide or homicide, or in allegations on widow or unmarried ladies being pregnant.
Diagnosis of pregnancy:
The signs and symptoms of pregnancy are classified into
 Presumptive signs
 Probable signs
 Positive signs

Presumptive Signs:
 Amenorrhea
 By third month, on pressing the breasts, a clear transparent fluid known as colostrum is
discharged.
 Nausea and occasional vomiting early in the morning while getting up from the bed,
known as morning sickness.
 Peculiar subjective sensation of fetal movements within the abdomen felt by the mother at
about 16th to 20th week of pregnancy. This is known as quickening.
 A dark line known as linea nigra will extend from the lower end of xiphisternum to the
pubis.
 The color of the mucus membrane of the vagina and the vulva changes from pink to violet
deepening to blue – Jacque Mir’s / Chadwick’s sign.

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 Probable signs:
 Enlargement of the abdomen
 By the beginning of the 2nd month the cervix becomes progressively softened from below
upwards and is well marked by 4th month – Goodell’s sign
 By the end of the second month, on bimanual examination the firm hard cervix and the
elastic body of uterus can be felt by per vaginal examination – Hegar’s sign.
 Painless intermittent uterine contraction alternating with relaxation felt by 4th month
onwards – Braxton – Hick’s Sign.
 Uterine Soufflé – a soft blowing murmur heard on auscultation on either side of the uterus
just above the pubis by the end of 4th month.
 Human chorionic gonadotropin test (HCG test): A sample of urine from the pregnant lady
is mixed with anti HCG in appropriate amount and incubated together for one hour. The
HCG in the urine will neutralize the anti HCG from the serum. Now latex particle coated
with HCG are added to the mixture and incubated for another 2 hours. This mixture is
centrifuged. If the mixture remains turbid without any deposit, it indicates neutralization
of HCG in the urine by the anti HCG of the serum and no agglutination of the HCG
coated latex particles has occurred. This is a positive test.
 Progonsticon or Gravindex test: In these tests, sensitized test sera are used and reaction of
agglutination can be observed on a slide by mixing the sera with suspected urine.

Positive signs:
 Fetal heart sounds: it is moist certain sign of pregnancy and is usually heard from 4th
month of pregnancy.
 Feeling of fetal parts and movements: These can be palpated through the abdominal wall
from 6th to 7trh month of pregnancy.
 Ultrasonography (USG): Visualizing fetal heart beat, fetal parts and movements by
abdominal passing sound waves through sonography is a confirmatory sign of pregnancy.

PSEUDOCYESIS:
 The term "Pseudocyesis" was introduced by John Mason Good in 1823 based on Greek
words pseudes = pseudo (false); and kyesis = pregnancy.
 In literature it is also called false pregnancy, pseudopregnancy, hysterical pregnancy, or
phantom pregnancy.

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  Pseudocyesis is a state in which a woman, who is not pregnant, firmly believes that she is
pregnant. At the same time she has almost all the signs and symptoms of pregnancy.
 Causes:
 Pseudopregnancy occurs in patients with determined organic cerebral or
endocrinologic pathology, In patients with chronic mental disorders.
 It is mainly a psychological answer to intensive stress in persons who want to have a
child and to be pregnant and, at the same time, are frightened by pregnancy.
 The signs of false pregnancy are:
 irregularity of menses
 amenorrhea
 abdominal distention
 changes in breast size and shape
 areolar hyperpigmentation
 linea nigra
 inverted umbilicus
 increased weight
 lordotic posture during walk
 morning sickness and vomiting
 A person can hear the fetal heart; feel fetal movements
 Outcome: In untreated cases recovery is spontaneous, but often ends in birth pain. In
some cases, when a patient finds out she is not pregnant, serious complications can occur
in the form of a heavy depressive episode.

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 REGIONAL INJURIES
HEAD INJURY:
Definition:
"Head Injury" as defined by the National Association of Neurological Diseases & Stroke
Council (United States Department of Health, Education and Welfare) "is a morbid state,
resulting from the gross or subtle structural changes in the scalp, skull and/or the contents
of the skull produced by mechanical forces." By the same definition the concept of
"mechanical forces" is restricted to those forces applied externally to the head, thus
excluding surgical ablations and internally acting forces such as increased intra cranial
pressure resulting from edema, hydrocephalus, or a mass occupying lesion "without
antecedent head trauma".
CLASSIFICATION OF HEAD INJURY:
Head Injury can be classified into two types based on the status of the dura
1. Closed head injury:
In this type of injury the dura is intact and the brain is not exposed to the external
environment irrespective of the injury to the scalp and fracture of the skull bone.
2. Open head injury:
In this type of injury the dura is torn and the brain is exposed to the external
environment.

LAYERS OF THE SCALP:

Layers of the scalp include the following:
 Skin.
 Connective tissue (Dense).
 Aponeurosis (Galea aponeurotica).
 Loose connective tissue.
 Periosteum.
 Scalp injuries bleed profusely, because of the prevention of contraction and
retraction (Tunica adventitia of the arteries supplying the scalp is anchored to the

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 fibrous septa that bind the skin to the epicranial aponeurosis) of major feeding vessels
present in the dense connective tissue layer in the scalp.
 Scalp allows accumulation of large amount of blood in case of injury because of
the loose composition of the connective tissue.
 Scalp wound usually gapes because of the involvement of galea aponeurotica
leading to pull of occipito-frontalis muscle.
 The layer of loose connective tissue between galea and the periosteum termed
as dangerous layer of the scalp because of the presence of the numerous valveless
emissary veins which connect the veins of the scalp with the diploic veins of the skull
bone, and to the intracranial venous circulation, providing an easy pathway for the
propagation of pathogenic organisms from the scalp to the skull bones producing an
osteomyelitis, or thrombosis of the venous sinuses, resulting in cerebral oedema and
possibly death.

BLACK EYE:
Synonyms:
"Raccoon's Eyes", “Spectacle Eyes”, “Periorbital Bruising”

Explanation:

 Black-eye is the bruising of the eyelids or bleeding beneath the skin around the eye.
 The skin around the eye is very loose, with mostly fat underneath. This makes it an
ideal site for blood to accumulate. The effects of gravity also help to swell this part of
the face.

Medico-legal significance of black eye:

1. Black eye may be an indication for the underlying severe head injury.
2. Based on the color changes of the contusion time since injury can be ascertained.
Causes:
A. Direct trauma such as punch upon the eye.
B. Seepage of blood beneath the scalp into the eyelids from an injury on the frontal area
due to gravity.

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C. Percolation of blood into the orbit from behind or above, due to fracture of the walls of
the orbit.

SKULL FRACTURES:

Explanation:
A skull fracture is a break in one or more of the bones in the skull caused by a head injury.
Mechanism of skull bone fracture:
Mechanisms of skull fracture were studied by Rowbotham & Gurdjian
According to Rowbotham’s Hypothesis fractures of skull are caused by the,

1. Direct application of the force to the skull.

2. Indirect application of the force to the skull.

Direct application of the force to the skull may result in:

A. Local deformation of the bone at the site of the impact.
B. General deformation of the skull.

Sequences of events in the local deformation of the skull at the site of the impact
are,

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Sequences of events in the general deformation of the skull are,

Indirect application of the force to the skull may result in (fall from a height, Blast
explosions from below):

Fall from a height

Lands on the feet or buttocks

The force of impact transmitted through the vertebral column

To the base of the skull

“Ring Fracture” around the foramen magnum

Gurdjian estimated,
A. Magnitude of force involved in skull fracture and
B. Pattern of fractures produced on impact at different regions of the skull and their
mechanism.
Medico-legal significance of skull fractures:
1. Like any other fractures skull fractures are also considered to be Grievous in nature as
per I.P.C section 320.
2. A skull fracture above the brim of the hat (vertex) always raises the suspicion of
assault.

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3. When there is impact with the heavy weapon with a small striking surface (hammer) it
leaves the imprint of the weapon used (Signature Fractures).
4. In the case of a blow subsequent to the fall, the linear fracture lines resulting from the
fall are arrested by those produced by the blow or when there are two blows the
fracture lines produced by the 2nd blow are arrested by the 1st blow (Puppe’s rule).
5. Based on the union of skull fractures time since injury can be estimated.

TYPES OF SKULL FRACTURES:

Skull fractures belong to two groups,
A. Fractures of adult skull.
B. Fractures of infant skull.

FRACTURES OF ADULT SKULL:

Fractures of the adult skull are:
1. Fissured Fracture.
2. Diastatic Fracture.
3. Ring Fracture.
4. Hinge Fracture.
5. Depressed Fracture.
6. Comminuted Fracture.
7. Gutter Fracture.

FISSURED FRACTURE
 Also called “Linear Fracture”.
 These are linear cracks without any displacement of the fragments and may involve
whole thickness of the bone or one or other table only.
 Difficult to be detected by and may not be demonstrable by X rays.
 Fissured fractures are usually caused by,
 Impact against broad resisting surface e.g.: fall from a height.
 Blows with a weapon having broad striking surface.

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 In the case of a blow subsequent to the fall, the linear fracture lines resulting from the
fall are arrested by those produced by the blow or when there are two blows the
fracture lines produced by the 2nd blow are arrested by the 1st blow (Puppe’s rule).

DIASTATIC / DIASTIC / SUTURAL FRACTURE

 It is a linear fracture, which in children and adults (before the sutural closure) passes
into a suture line and causes diastasis or opening of weaker areas between sutures.
 These are encountered in,
 Impact with a weapon having broad surface.
 Road traffic accidents.

RING FRACTURE
 This is a type of fissured fracture conventionally employed to describe any fracture
occurring around the foramen magnum.
 Ring fracture usually encountered in,
 Fall from a height on to the feet or buttocks wherin the force is transmitted
through vertebral column to the base of the skull causing a ring fracture.
 Fall of heavy load over vertex wherein the vault may be driven against the spine.

HINGE FRACTURE
 This is a type of fissured fracture of the base of the skull that completely bisects the
base of the skull, creating a ‘hinge’.
 It is also called as “Motorcyclists Fracture” because it is commonly encountered in
motorcycle accidents.
DEPRESSED FRACTURE
 Here the outer table or whole thickness of the skull is driven inwards into the skull
cavity.
 The area struck is driven along the same line of force into adjacent structures, the
depth varying according to the velocity with which the impact is delivered.
 Depressed fractures are usually caused by heavy weapon with a small striking surface
e.g.: hammer, brick, or stone.

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 They are also called “Fracture a la Signature” a descriptive term which aptly
emphasizes medico-legal significance. They are often veritable imprints of the weapon
or agent which caused the fracture.
 When the “butt” of a firearm strikes the skull it produces a depressed fracture which is
rectangular if the impact is full faced or triangular if only the corner of the butt strikes
the skull.
COMMINUTED FRACTURE
 The term “comminution” refers to the fracture division of a bone into several fragments.
 In this type of fracture several fissure fractures are connected to each other giving a
mosaic appearance.
 When it is associated with the depressed fracture it is called as “Depressed
comminuted fracture”.
 Comminuted fractures are produced by,
 Road traffic accidents.
 Fall from a height on hard surface.
 Blows by a weapon having large striking surface e.g.: iron bar, thick stick etc.

GUTTER FRACTURE
 When a glancing blow is given to the head, like when a bullet grazes only the outer
table, it removes that part of the outer table of the skull forming a gutter like defect.
 This type of fracture is commonly produced by glancing bullet wounds over the
skull.

FRACTURES OF INFANT SKULL:

POND / INDENTATION FRACTURE

 This is a descriptive term for a shallow, depressed fracture forming a concave pond.
 These fractures occur in skulls which are unduly elastic, similar to that of infant skulls.
 The shape of the skull bone gets deformed on pressure, akin to the dent caused on a
ping pong ball or squeezing of the table tennis ball.
 It is produced by forcible compression of skull by obstetric forceps during delivery.

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INTRA CRANIAL HAEMORRHAGES:

Based on the site of bleed intracranial haemorrhages are divided into,

1. Epidural or Extradural Hemorrhage.
2. Subdural hemorrhage.
3. Subarachnoid Hemorrhage.
4. Intracerebral Hemorrhage.

EPIDURAL / EXTRADURAL HEMORRHAGE

Explanation:

Collection of the blood between the inner surface of the skull and the outer surface of the
dura (above the dura) is known as epidural or extradural hemorrhage.

Source of bleeding:
1. Middle meningeal artery:
Fracture of the squamous part of the temporal bone causes fracture of the groove
containing middle meningeal artery. This is the commonest location and source of
extradural hemorrhage.
2. Anterior meningeal artery:
Fracture of the frontal bone causes laceration of anterior meningeal artery.

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3. Posterior meningeal artery:
Fracture of occipital bone causes laceration of posterior meningeal artery.
4. Superior sagital sinus:
Fracture of the skull vault causes laceration of superior sagital sinus.

Sequence of events:
Head injury

Fracture of the squamous part of the temporal bone

Fracture of the groove containing middle meningeal artery & concussion of the brain
causes temporary unconsciousness

Bleeding into the extradural space

Since it is arterial bleed (active bleeding), the arterial pressure gradually strips the dura
from the skull to form a large haematoma

Compresses the adjacent brain

Rise in the intracranial pressure and when it exceeds the threshold

Unconsciousness

Clinical Manifestations:
Based on the onset of symptoms extradural hemorrhage is classified into,
1. Acute Extradural hemorrhage, wherein signs of raised intracranial pressure develops
within 24 hours.
2. Chronic Extradural hemorrhage requires many days for the development of the signs
of raised intracranial pressure.

LUCID INTERVAL / LATENT INTERVAL

 Lucid interval in the head injury is the period of consciousness between the two periods
of unconsciousness.
 During the initial impact on the head, the victim looses his consciousness due to
concussion. He regains his consciousness after a few minutes when the brain recovers

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 from concussion and regains its normal function. After a while again for the second
time he becomes unconscious because of the raised intracranial pressure.

Medico-legal significance of extradural hemorrhage:

1. Head injury victim should be kept under medical observation at least for a period of 24
hours so as to avoid allegation of medical negligence. If the doctor discharges the
patient after recovering from initial unconsciousness without keeping in mind the lucid
interval and if the victim sustains any damage due to the raised intracranial pressure,
the doctor stands the risk of being sued in the court of law for negligence.
2. It is the duty of the Autopsy surgeon to explain the entity of lucid interval to the court so
as to build a causal connection between the injury and death.
3. During the period of Lucid Interval he is conscious, normal and is responsible for
whatever he does (Criminal Responsibility, Testamentary Capacity, Valid Consent and
Contract).
SUBDURAL HEMORRHAGE

Explanation:
Collection of the blood between the dura-mater and arachnoid-mater (below the dura) is
known as subdural hemorrhage.

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Source of bleeding:
1. Rupture of bridging or communicating veins traversing the subdural space to drain into
the para sagital sinus.
2. Rupture of the dural venous sinuses.

Sequence of events:
Head injury

Gliding movement between the dura and arachnoid mater

Stretching of the communicating or bridging veins that traverse the subdural space which
are thin walled and having the straight course

Rupture of communicating veins (Venous bleed-Passive bleeding)

Bleeding into the subdural space

Clinical Manifestations:
Based on the onset of symptoms subdural haemorrhage is classified into,
1. Acute subdural hemorrhage, wherein symptoms of raised intracranial pressure
develops within 24 hours.
2. Chronic subdural hemorrhage requires many weeks for the development of
symptoms.

Medico-legal significance of subdural hemorrhage:

1. From the changes that take place in the sub dural blood, the time since injury can be
estimated, i.e.: based on the organization of clot.
Collection of blood in the subdural space

Because of the absence of mesothelial lining on the dural surface it does not get absorbed

After 1 to 5 days blood becomes clotted in the subdural space

From the edges of the clot several layers of new cells are laid resulting in the formation of
new membrane (neomembrane) and cover the non-dural surface encysting the clot
(subdural hematoma)- 1 to 3 weeks

New capillaries are formed due to the proliferation of fibroblasts at the dural surface and
penetrating the clot thereby anchoring it to the dural surface.
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Over a period of time the clot gets liquefies resulting in separation of blood components
with settling down of heavy particle and the supernatant yellowish layer. Now this is termed
as cystic hygroma.

Cerebrospinal fluid leaks into the above cyst through the semipermeable arachnoid
membrane due to the higher osmolarity of the cystic content than that of the cerebrospinal
fluid present in Subarachnoid space. Now this is termed as cystic hydroma due to the
watery appearance.
[[[[ [[

If the victim survives the cyst may get solidified due to the deposition of calcium or there
may be leakage of watery contents leading to union of neomembrane & dura mater-
months to years.

2. Subdural haematoma can be used for estimation of blood alcohol concentration at the
time of sustaining the injury because the blood which has come out of the circulation
and encapsulated in the cyst will not renter the circulation to undergo metabolism.
3. SDH is especially common in the elderly (brain atrophy widens the gap), children
(shaking injury as part of the child abuse syndrome) and alcoholics (frequent
unprotected falls and prolonged bleeding times).

SUBARACHNOID HEMORRHAGE

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Explanation:
Collection of the blood between the arachnoid-mater and the Pia mater (below the
arachnoid mater) is known as subarachnoid hemorrhage.

Causes:
1. Natural or Non-traumatic causes:
The non traumatic causes of subarachnoid hemorrhage are,
A. Rupture of Berry (Congenital) aneurysms.
B. Rupture of Mycotic (Infective) aneurysms.
C. These aneurysms anywhere in the Circle of Willis may rupture spontaneously
due to hypertension, excitement or physical exertion.
2. Traumatic causes:
A. Traumatic Subarachnoid hemorrhage is usually associated with contusion or
laceration of the brain surface.
B. Rarely due to a kick or blow to the side of the neck which stretches and ruptures
vertebral artery as it enters the cranial cavity. Most often it is due to a blow to the
side of the chin or jaw in a fist-fight.

Diagnosis:
Diagnosis of Subarachnoid hemorrhage is confirmed by lumbar puncture: In this the
collection of the blood is between the arachnoid mater and the pia mater leading to
diffused blood tinged cerebrospinal fluid.

Medico-legal importance of subdural hemorrhage:

1. The autopsy surgeon should explain whether the Subarachnoid hemorrhage is
traumatic or non traumatic in origin.
2. It is also important to establish whether the bleeding preceded or followed the head
injury.

INTRACEREBRAL HEMORRHAGE

Explanation:

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Collection of the blood anywhere in the brain substance is known as intracerebral
hemorrhage.

Common sites:
1. Pons (Rupture of perforating branch of basilar artery, can lead to sudden death, clinical
picture characterized by pin point pupil, pyrexia and paralysis- 3P’s).
2. Ventricles (Malformed choroid plexus).
3. Thalamus.
4. Lobes of the brain.
5. Cerebellum.

Causes:
1. Natural or Non-traumatic causes:
The non traumatic causes of intracerebral hemorrhage are,
A. In patients undergoing anticoagulant therapy.
B. In patients having hypertension.
2. Traumatic causes:
Traumatic Intracerebral hemorrhage is due to extension of hemorrhage from surface
contusions deep into the substance of the brain.

Medico-legal importance of intracerebral hemorrhage:

1. The autopsy surgeon should explain whether the Subarachnoid hemorrhage is
traumatic or non traumatic in origin.
2. It is also important to establish whether the bleeding proceeded or followed the head
injury

BRAIN INJURIES:

Mechanism of Brain Injuries:

The brain may be injured by:
A. Direct intrusion of foreign object such as penetrating weapon either bullet or fragment
of fractured skull.
B. Deformation of the brain in closed head injury.
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Various theories explaining deformation of brain in closed head injury are:

1. ACCELERATION INJURY
When the head is pushed forward, the skull moves forward but the brain lags behind for
a brief period and the skull strikes the brain.

2. DECELERATION INJURY
When the moving head strikes a solid stationary object, the skull comes to a stop
suddenly but the brain continues to move in the direction of force for a brief period and
the moving brain strikes against the skull.

3. ROTATIONAL STRAIN or SHEAR STRAIN INJURY

Skull is situated eccentrically in relation to the vertebral column. Therefore if a blow is
given on the chin from the side, the head turns to one side resulting in rotational
movement to the brain. This rotational movement imparts rotational strain or shear
strain to the contents of the skull. As a result of this shear strain the skull moves in
relation to the meningeal membranes, the meninges moves in relation to the brain and
upper part of the brain moves in relation to the lower part of the brain like a pack of
cards, causing shearing of the delicate connections between the nerve fibres.
4. SHOCK OR TRANSIENT WAVE INJURY
If the energy of blow to the head is severe enough i.e.: bullet striking head or in case of
bomb blasts, it is transmitted in the form of shock waves.
Types of Cerebral Contusions:
Based on the causative mechanisms the cerebral contusions are of following types:
A. "COUP TYPE" CONTUSIONS
 Coup contusion is a contusion of the brain that is located beneath the area of
impact and result directly from impacting force.
 A blow to the head when it is free to move accelerates the head and causes
cerebral contusion at the point of impact. Scalp injury (bruise, abrasion or
laceration) is likely to occur at the point of primary impact. Contusion or laceration of
the brain surface often occurs at the site of a fracture, especially if it is depressed.

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B. "CONTRE-COUP TYPE" CONTUSIONS
 Contre-coup Contusion is a contusion of the brain present in an area opposite to the
site of impact.
 When the falling head strikes the ground it decelerates abruptly while the semi-fluid
brain continues moving towards the point of impact. This causes more severe
contusions in the area diametrically opposite to the point of impact.
 In this way a backwards fall causes contre-coup contusions at the front of the brain
(to the frontal and temporal poles). Similarly, a fall onto one side of the head causes
contre-coup contusions at the opposite side of the brain (temporal lobe). However, a
forwards fall does not cause contre-coup contusions over the back of the brain due
to the interior of the skull being smooth at this point.
C. INTERMEDIARY COUP CONTUSIONS
These are brain contusions in deeper structures of the brain along the line of impact,
anywhere between the coup and contre-coup contusions.

Medico-legal importance of Cerebral Injuries:

1. It is duty of the autopsy surgeon to explain how the coup injuries are produced-
otherwise the defense counsel may put forward that his client never intended to harm
him and the death occurred due to the indirect effect (contre-coup) rather than the
injury.
2. This pattern of brain injuries helps the autopsy surgeon in distinguishing injuries due to
falls from those due to blows.

CONCUSSION (COMMOTIO CEREBRI; STUNNING):

Definition:
According to Trotter concussion is “a transient paralytic state due to head injury which is of
instantaneous onset, does not show any evidence of structural cerebral injury and is
always followed by amnesia from the actual moment of the accident”.
It is characterized by:
 Sudden loss of consciousness.
 Retrograde amnesia.
 Flaccid paralysis of the limbs.
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Medico-legal significance of concussion:
It is important to keep in mind the entity of concussion in victims of head injury, wherein
victim is not able to remember the immediate past. His remote memory is intact. The
investigating officer (Police) may misconstrue that the victim is trying to evade the
answering. This phase may last up to 6 hours not more than that.

Postmortem findings:
Grossly there is no demonstrable structural brain damage at the postmortem examination.

DIFFUSE AXONAL INJURY (DAI):

Explanation:
This is a prolonged traumatic coma lasting more than 6 hours. Based on the duration of
coma it can be Mild (6-24 hours), Moderate (more than 24 hours without signs of
brainstem involvement), and Severe (more than 24 hours associated with signs of
brainstem involvement).
Diagnostic findings:
Characteristic lesions include the following:
 Hemorrhage or necrosis of the corpus callosum.
 Hemorrhage or necrosis of the dorsolateral quadrant of rostral pons.
 May see focal contusions in adjacent structures (fornix, cingulate gyri, septum
pellucidum, caudate nuclei, dorsal thalamus).
Microscopic findings:
 Reactive axonal swellings (retraction balls) secondary to shearing of nerve fibers.
 Scattered microglial clusters.
 Debris-laden macrophages.

BRAIN SWELLING (CEREBRAL OEDEMA):

Explanation:
Cerebral Oedema is defined as an increase in brain volume that is due to an increase in its
water content.

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Medico-legal significance of cerebral edema:
Cerebral Edema, when mild in degree, is associated with little or no clinical evidence of
brain dysfunction, but when severe, it may lead to fatal outcome resulting from medullary
failure of respiration and circulation.
Autopsy features of cerebral edema:
 Dura is stretched and tense.
 On putting a nick over the dura, the brain substance bulges out.
 A swollen brain is heavy with increased weight.
 Brain is soft in consistency.
 Cerebral gyri (convolutions) are pale and flattened.
 Cerebral sulci (intervening gaps) are obliterated.
 Ventricles may be slit like.
 Severe oedema leads to herniation of cingulated gyrus (Cingulate coning), uncal part of
temporal lobe (Uncal or Jefferson coning) or herniation of cerebellar tonsils (Cushings
coning).

PUNCH-DRUNK SYNDROME:
Synonyms:
Dementia Pugilistica, Traumatic Encephalopathy, Boxer's Dementia, Slug Happy, Slug
Nutty, Goofy.
[

Explanation:
Punch-Drunk Syndrome is a neurological disorder which affects some career boxers and
wrestlers which is caused by repeated cerebral concussions and characterized by
weakness in the lower limbs, unsteadiness of gait, slowness of muscular movements,
hand tremors, hesitancy of speech, and mental dullness. The condition develops over a
period of years, with the average time of onset being about 12-16 years after the start of a
career in boxing. (Muhammad Ali a well known boxer, was suffering from this entity).

Clinical Manifestations:
The condition, which occurs in people who have suffered multiple concussions, commonly
manifests as dementia, parkinsonism and lack of coordination. It can also cause unsteady
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gait, inappropriate behavior, and speech problems. Individuals displaying these symptoms
also can be characterized as "punchy," another term for a person suffering from dementia
pugilistica.
Lesions:
 Subdural hemorrhage.
 Subarachnoid hemorrhage.
 Diffuse axonal injury.
 Focal ischemic lesions.
 Cortical atrophy.
 Hydrocephalus.
 Thinning Of corpus callosum.
 Brain contusion.

WHIPLASH INJURY:
Explanation:
 Fracture of the spine need not injure the cord, but the cord is rarely injured without
associated fractures of the vertebral column, “Whiplash Injury” is an exception to this
general rule [Container (vertebral column) intact but the contents are damage (spinal
cord)].
 Commonly seen in the front seat occupants of a vehicle or in blow against the spinal
process of the upper cervical vertebra.
Sequence of events:
Vehicle suddenly decelerated and the vehicle stops suddenly

Passenger is still in motion and it takes some time for him to stop. But during this lag
period head is thrown forwards resulting in “acute hyperflexion” of the neck.

This hyperflexion is stopped on head hitting the windshield in the front and head is thrown
backwards resulting in “reactionary hyperextension”.

Fatal contusion or laceration of the spinal cord.

[
May lead to fatality

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RAILWAY SPINE:

Explanation:
 This is the concussion of the spinal cord without the evidence of external injury after a
lapse of several hours or days.
 Railway spine was a nineteenth-century diagnosis for the post-traumatic symptoms of
passengers involved in railroad accidents.
Causes:
 Railway accidents.
 Fall from a height.
 Blow on the back of the neck.
 Bullet injury.
Clinical Manifestations:
The victim might complain of
 Paralysis.
 Hysteria.
 Post Traumatic Neurosis.
RECOVERY IS A RULE.

JEFFERSONS FRACTURE:
Severe impact to the top of the head may cause multiple fractures of the atlas ("spreading
fractures") termed as Jefferson's Fracture.
HANGMANS FRACTURE:
Fracture of C2 and C3 vertebrae, are known as hangman's fracture because of their
common occurrences in Judicial hanging victims.
FLAIL CHEST or STOVE IN CHEST:
Explanation:
Flail chest occurs when three or more ribs are fractured in two or more places, enough ribs
are broken allowing that segment of the thoracic wall to displace and move independently
of the rest of the chest wall. On inspiration, the chest wall moves inward instead of outward
and the opposite on expiration.

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Causes:
 Crush injuries.
 Fall from a height on the chest.
 Road Traffic Accidents.
Clinical Manifestations:
Characterised by paradoxical motion of the flail segment,
 During normal inspiration, the diaphragm contracts and intercostal muscles push the rib
cage out. Pressure in the thorax decreases below atmospheric pressure, and air
rushes in through the trachea. However, a flail segment will not resist the decreased
pressure and will appear to push in while the rest of the rib cage expands.
 During normal expiration, the diaphragm and intercostal muscles relax, allowing the
abdominal organs to push air upwards and out of the thorax. However, a flail segment
will also be pushed out while the rest of the rib cage contracts.
Medico-legal significance of flail chest:
The constant motion of the ribs in the flail segment at the site of the fracture is exquisitely
painful, and, untreated, the sharp broken edges of the ribs are likely to eventually puncture
the pleural sac and lung, which may be fatal.

INCOMPLETE LIST OF QUESTIONS FROM REGIONAL INJURIES

1. Define and classify head injury.
2. Write briefly on black eye.
3. Discuss the mechanism of skull bone fracture.
4. Briefly discuss various skull fractures.
5. Enumerate intracranial hemorrhages.
6. Write briefly on the following:
A. Epidural hemorrhage. H. Diffuse Axonal Injury.
B. Lucid interval. I. Cerebral edema.
C. Subdural hemorrhage J. Punch Drunk Syndrome.
D. Subarachnoid Hemorrhage. K. Whiplash injury.
E. Pontine hemorrhage. L. Railway Spine
F. Cerebral contusion. M. Flail chest.
G. Concussion.
7. Discuss the mechanism of brain injuries.

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 SEX RELATED CRIMES…..
In any civilized society, both law and custom, permit only heterosexual gratification, within
accepted norms laid down by the law of land.

Definition of Sexual Offence:

A statutory offense that provides that it is a crime to knowingly cause another person to
engage in an unwanted sexual act by force or threat.
Classification:
Sexual offences can be categorized under three classes,
I Natural sexual offences :
 Rape
 Incest
 Adultery
II Unnatural sexual offences:
 Sodomy
 Bestiality
 Buccal Coitus

III Sexually linked offences:

 Indecent Assault
 Sexual Perversions
 Offences under the Immoral Traffic act.
E.g.:
 Procuring, inducing or taking person for the sake of prostitution.
 Detaining a person in premises where prostitution is carried on.
 Seducing or soliciting for purpose of prostitution.
 Seduction of a person in custody.

RAPE
Rape is derived from the Latin term Rapio means 'to seize'
Definition:
Rape is defined by Section 375 of Indian Penal Code as,

A man is said to commit "rape" if he-—

a. penetrates his penis, to any extent, into the vagina, mouth, urethra or anus of a woman
or makes her to do so with him or any other person; or
b. inserts, to any extent, any object or a part of the body, not being the penis, into the
vagina, the urethra or anus of a woman or makes her to do so with him or any other
person; or

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c. manipulates any part of the body of a woman so as to cause penetration into the vagina,
urethra, anus or any ~ of body of such woman or makes her to do so with him or any
other person; or
d. applies his mouth to the vagina, anus, urethra of a woman or makes her to do so with
him or any other person, under the circumstances falling under any of the following
seven descriptions:

First - Against her will.

Secondly - Without her consent.
Thirdly - With her consent, when her consent has been obtained by putting her or any
person in whom she is interested, in fear of death or of hurt.
Fourthly - With her consent, when the man knows that he is not her husband and that her
consent is given because she believes that he is another man to whom she is or believes
herself to be lawfully married.
Fifthly - With her consent when, at the time of giving such consent, by reason of
unsoundness of mind or intoxication or the administration by him personally or through
another of any stupefying or unwholesome Substance, she is unable to understand the
nature and consequences of that to which she gives consent.
Sixthly - With or without her consent, when she is under eighteen years of age.
Seventhly - When she is unable to communicate consent.

Explanations:
1. For the purposes of this section, "vagina" shall also include labia majora.
2. Consent means an unequivocal voluntary agreement when the woman by words,
gestures or any form of verbal or non-verbal communication, communicates willingness
to participate in the specific sexual act:
Provided that a woman who does not physically resist to the act of penetration shall not by
the reason only of that fact, be regarded as consenting to the sexual activity.

Exceptions:
1. A medical procedure or intervention shall not constitute rape.
2. Sexual intercourse or sexual acts by a man with his own wife, the wife not being under
fifteen years of age, is not rape.'.
 The use of two phrases 'against her will' and 'without her consent' denotes different
concepts. Every act done against the 'will' of a person is done without his or her
'consent', but an act done without the consent of a person is not necessarily against his
or her 'will'. A woman may be 'willing' for sexual intercourse but may not give consent for
fear of detection or social stigma.

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Punishment for rape:
Punishment for rape is prescribed by section 376 (subsection 1) of Indian Penal Code, shall
be punished with rigorous imprisonment of either description for a term which shall not be
less than seven years, but which may extend to imprisonment for life, and shall also be
liable to fine.

RAPE CAUSING DEATH / PERSISTENT VEGETATIVE STATE OF VICTIM (Sec. 376A

IPC)

Whoever, commits an offence punishable under sub-section (l) or sub¬section (2) of section
376 and in the course of such commission inflicts an injury which causes the death of the
woman or causes the woman to be in a persistent vegetative state, shall be punished with
rigorous imprisonment for a term which shall not be less than twenty years, but which may
extend to imprisonment for life, which shall mean imprisonment for the remainder of that
person's natural life, or with death.

SEXUAL INTERCOURSE BY HUSBAND UPON HIS WIFE DURING SEPARATION (SEC.

376B IPC)

Whoever has sexual intercourse with his own wife, who is living separately, whether under a
decree of separation or otherwise, without her consent, shall be punished with
imprisonment of either description for a term which shall not be less than two years but
which may extend to seven years, and shall also be liable to fine.

 In this section, "sexual intercourse" shall mean any of the acts mentioned in clauses (a)
to (d) of section 375.

CUSTODIAL RAPE

Sexual intercourse by person in authority or Custodial Rape (Sec. 376C IPC)

Whoever, being:
a. in a position of authority or in a fuduciary relationship; or
b. a public servant; or
c. superintendent or manager of a jail, remand home or other place of custody established
by or under any law for the time being in force, or a women's or children's institution; or
d. on the management of a hospital or being on the staff of a hospital, abuses such
position or 6duciary relationship to induce or seduce any woman either in his custody or
under his charge or present in the premises to have sexual intercourse with him, such

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 sexual intercourse not amounting to the offence of rape, shall be punished with rigorous
imprisonment of either description for a term which shall not be less than five years, but
which may extend to ten years, and shall also be liable to fine.
 In this section, "sexual intercourse" shall mean any of the acts mentioned in clauses (a)
to (d) of section 375.

GANG RAPE (Sec. 376D IPC)

 Where a woman is raped by one or more persons constituting a group or acting in
furtherance of a common intention, each of those persons shall be deemed to have
committed the offence of rape and shall be punished with rigorous imprisonment for a
term which shall not be less than twenty years, but which may extend to life which shall
mean imprisonment for the remainder of that person's natural life, and with fine:

INDECENT ASSAULT - SECTION 354 OF INDIAN PENAL CODE

Assault or criminal force to a woman with the intent to outrage her modesty - whoever
assaults or uses criminal force to any woman, intending to outrage or knowing it to be likely
that he will thereby outrage her modesty, shall be punished with imprisonment of either
description for a term which may extend to two years, or with fine or both.

STATUTORY RAPE
 Statutory rape is the sexual intercourse with a female, whether or not she has consented
to such an action, who was neither a child nor reached the age of consent. The age of
consent and age limit of a child varies from country to country.
 In India when the victim is below 16 years of age, sexual intercourse, in any case,
amounts to rape and the question of consent or non consent does not arise. This is
termed by some authors as statutory rape.

EXAMINATION OF A RAPE VICTIM

 Rape is a crime against basic human rights and is also violative of the victim's most
cherished of the fundamental rights, normally, the right to life contained in Article 21.
Rape is a crime, which has a devastating effect on the survivors; it has been described
as a “beginning of a nightmare”. The after shocks include depression, fear, guilt-
complex, suicidal-action, diminished sexual interest. etc., “one becomes afraid
of'……..writes a victim, “half the human race”.

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 Rape is not a medical diagnosis; it is a legal provision under section 375 of the Indian
Penal Code. Rape is an allegation easily made, hard to prove and harder to disprove’.
 Physicians responsibilities in the medico-legal examination of the victim of an alleged
sexual assault are both therapeutic (tackling physical and emotional consequences), as
well as evidentiary, in order to facilitate the scientific investigation of rape.

Objectives of the examination:

The examination doctor must plan his entire examination, so that at the end he will be in a
position to answer the following questions:
1. Is there medical evidence to confirm the allegation?
2. Has sexual intercourse taken place recently?
3. Is there evidence of previous sexual intercourse?
4. Are there physical signs present to confirm the use of force or of stupefying drugs?
5. Are the physical findings consistent with the history?
6. Have all the relevant specimens been taken to confirm the allegations and to assist in
identifying the parties involved.

Essentials in the medical examination of victims of rape:

CONSENT
Consent must be obtained by the examining doctor for his examination and for his
subsequent report. This consent, in the case of an adult, should be obtained directly from
the patient. In the case of a minor, or of a female suffering from severe mental sub-
normality or abnormality, consent in writing should be obtained from a parent or guardian.
The examination notes should record that consent was obtained, and any written consent
form should be fastened to the original examination notes. Unless the rape victim consents
she cannot be examined under any provisions of law in India. The examination has to be
done preferably by a lady doctor if available [section 53(2) of Criminal Procedure Code], if
not it should be carried out in presence of a lady attendant.
GENERAL HISTORY
A general history should be obtained from the patient herself, and must include details of all
past illness, surgical operations and serious accidents.
MENSTRUAL HISTORY
It is important that the past menstrual history be explored, with special reference to the date
of the last menstrual period, the type of menstrual protection normally used (pads, internal
tampons) and the use of any hormonal or contraceptive medication.

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OBSTETRIC HISTORY
Obstetric history must be recorded, with special reference to the dates of birth of any
children, and of any surgical involvement in delivery. Episiotomies or forceps deliveries
may alter the normal genital anatomy and may have some relevance to the pattern of
genital injury found.
SEXUAL HISTORY
Enquiry must be made as to past sexual experience, and the relevance of such enquiry is
two fold. Firstly it is of relevance if prior virginity is being claimed by the complainant, for if
the clinical findings are not consistent with such as claim the reliability of the complainant’s
evidence is immediately suspect. Apart from the claim of prior virginity, the complainant’s
previous sexual experience is of no evidential value. Secondly, recent consenting
intercourse is obviously of the greatest importance when the alleged victim is a married
woman.
SPECIFIC HISTORY
The specific history of the alleged incident must be very carefully taken and recorded, for it
is this portion of the history that will be later found to be consistent or inconsistent with the
examination findings. It includes:
1. The date, time and place of the alleged acts;
2. The time of first complaint, and an explanation for any delay in this complaint;
3. What clothing was removed from the victim, and how and by whom it was removed?
4. What clothing was removed from the assailant, how and by whom?
5. Was any general force used by the assailant and, if so, where and how?
6. Was any pain experienced either at the time of the incident or subsequently?
7. What were the relative positions of victim and assailant during the acts complained of?
8. Did ejaculation take place during the act, either within the vagina or outside?
9. What are the details of the act or acts alleged?
10. Was any form of contraception used during the act?
11. Did the victim struggle, scream or injure the assailant in any way?
12. Has the victim changed clothes, or washed any of the clothes since the alleged assault?
13. Has the victim bathed or washed any part of her body since the alleged assault?
GENERAL OBSERVATION
 Distressed
 Tearful
 Calm or aggressive.

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EXAMINATION OF CLOTHING
 Patient should be made to stand upon a large clean sheet (if same clothing is worn) of
paper so that anything that falls out of the clothing will fall on to the paper and can be
preserved for laboratory investigation. Patient herself has to undress garment by
garment.
 Observe and note soiled areas and to retain the garments for laboratory examination.
The use of an ultraviolet lamp will assist in the location of areas of possible seminal
soiling, for these will fluorescence. The dried clothing’s should be placed in a paper bag
and sent to Forensic science laboratory.
 Damage to any of the undergarments which may be due to the forceful removal of
clothing, particularly if against resistance, and should be inspected.
GENERAL CLINICAL EXAMINATION
 Height.
 Weight.
 Build.
 Routine examination of the body systems. It is only by such a complete clinical
examination that signs of pre-existing disease, injury or intoxication by alcohol or other
drugs can be found.

A. Skin
Skin must be carefully examined from the top of the head to the soles of the feet, and
during the examination all areas of skin soiling must be noted, with special reference to
the hands, the backs of the legs and the buttocks, the abdomen and the tops of the
thighs.
 Soiled Area:
Any soiled areas must be swabbed with plain cotton swabs, moistened with sterile
water, and the swabs should be air dried before being placed in sterile containers for
laboratory examination. The use of an ultraviolet lamp will reveal areas of
fluorescence on the skin that may represent areas of seminal soiling and all such
areas must also be swabbed.
 Foreign Material:
During the examination of the skin, careful search must be made for any loose hairs
or other foreign substance on the skin surface, and anything found must be removed
and placed in a secure container for laboratory examination.

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  Injury:
A very careful search of the whole body surface must be made for signs of injury,
and all injuries must be noted, including old injuries.
 Bruise:
 Bruises are often the most important corroborative sign of force, and the exact
position, size and shape must be carefully noted.
 ‘Finger-tip’ type of bruise, consistent with grasping injury, such bruises are often
found on the neck, hands, wrists, arms, inner surfaces of the thighs and knees
(consistent with the victim’s legs being forced apart by pressure from the knees of
the assailant), and the ankles. .
 The ultraviolet lamp has a place in the examination for bruising: before the onset
of color changes.
 Abrasion:
 These injuries may be the result of fingernail scratch marks; or frictional
movements against a hard floor or ground; or scratches by thorns, grasses or
other foliage.
 All abrasions must be carefully searched for, and their exact position, size,
appearance and color must be noted.
 Lacerations and incised wounds:
As with bruises and abrasions, their exact size, shape and location must be carefully
noted.
 Bite marks on the skin surface must be carefully noted. They are commonly found on
the neck, breasts and chest wall, but they may be found on the lower abdomen and
the tops of the thighs.
B. Oral Cavity
 Lips commonly get injured by mild blows to the face, by the pressure of a hand
across the mouth to prevent screaming, or by violent attempts to kiss the victim.
Under all these circumstances the lip tends to be forced backwards to impact sharply
against the teeth, and there is almost invariably a very small impact abrasion
produced.
 The teeth may also show signs of damage such as looseness or chipping consistent
with a blow to the mouth.

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C. Fingernails
 The fingernails must be examined for length, and the presence of ragged or broken
nails.
 The presence of blood and skin tags underneath the nails should be looked for.
D. EYES
 The eyes must be carefully examined. The pupils and the reflex activity may give an
indication of intoxication or concussion following a blow to the head.
 Petechial hemorrhages on the conjunctivae, eyelids and skin of the face are strongly
indicative of grasping pressure on the throat compressing the venous return.

DETAILED EXAMINATION OF THE GENITAL AREA

1. PUBIC HAIR
 Pubic hair should be carefully inspected and any matted areas should be noted. The
entire matted area should then be cut away as close to the skin surface as possible,
and should be retained for laboratory examination.
 Pubic hair should be combed with a clean and fine-toothed comb and the comb
together with any loose hairs removed should be retained for laboratory examination.
2. LABIA
 Fingernail scratches may be present at the tops of the thighs and on the labia,
particularly the labia minora.
 Swabs must be taken at this stage of the examination from the area of the introitus,
the perineum and the anal margin, before any digital contact has been made by the
examining doctor.
3. HYMEN
 The hymen should next be inspected, and the presence of any fresh hymenal injury
must be noted. Where there is hymenal tearing, the extent and position of the tear must
be noted.
4. VAGINA
 Two swabs (low vaginal swab and a high vaginal swab) vaginal swabs and a swab of
the cervical mucus should be taken and sent to forensic science laboratory.
 Interior of the vagina should be inspected for signs of bruising and abrasion as well as
for the more serious but much rarer laceration of the vaginal vault or walls.
 During the digital examination, the examining doctor must asses the laxity of the vaginal
orifice, the length of the vagina into the posterior fornix, the number of examining fingers

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 that can be introduced through the hymenal orifice, and the areas and degree of
tenderness complained of by the patient.

THE OPINION:
By the end of his clinical examination the doctor should be in a position to answer the
following questions:
1. Could intercourse have taken place in that particular vagina?
2. Are there general signs of force or intoxication present?
3. Has there any evidence of recent sexual intercourse?

FINDINGS IN A RAPE VICTIM

Findings in a rape victim can be categorized into:
 General Findings
 Local/ Specific /Genital Findings
GENERAL FINDINGS IN A RAPE VICTIM:
General Findings in a rape victim are almost similar for all age groups. They can be
grouped under following:
A. Skin
B. Oral Cavity
C. Eyes
D. Fingernails
SKIN:
Skin must be carefully examined from the top of the head to the soles of the feet
1. Soiled Area:
The use of an ultraviolet lamp will reveal areas of fluorescence on the skin that may
represent areas of seminal soiling and all such areas must also be swabbed
2. Injury:
 Bruise
Finger-tip type of bruise, consistent with grasping injury, such bruises are often found
on the neck, hands, wrists, arms, inner surfaces of the thighs and knees (consistent
with the victim’s legs being forced apart by pressure from the knees of the assailant),
and the ankles.
 Abrasion
These injuries may be the result of fingernail scratch marks; of frictional movements
again a hard floor or ground; of scratches by thorns, grasses or other foliage.
 Lacerations and incised wounds
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  Bite marks on the skin surface must be carefully noted. They are commonly found on
the neck, breasts and chest wall,
 Foreign Material
During the examination of the skin, careful search must be made for any loose hairs
or other foreign substance on the skin
ORAL CAVITY:
 Lips commonly get injured by mild blows to the face, by the pressure of a hand
across the mouth to prevent screaming, or by violent attempts to kiss the victim.
FINGERNAILS:
 Ragged broken nails.
 Nail polish chipping.
 Blood/skin tags under the nails (Used to link the crime to the accused).
EYES:
 Petechial hemorrhages on the conjunctivae, eyelids and skin of the face are strongly
indicative of grasping pressure on the throat compressing the venous return.
 The pupils and the reflex activity may give an indication of intoxication or concussion
following a blow to the head.

GENITAL or LOCAL or SPECIFIC FINDINGS IN A RAPE VICTIM:

Genital findings varies according to the age of the victim, they can be discussed under
following:
A. Child victim.
B. Pre-pubertal or virgin victim.
C. Post-pubertal victim.
D. Post menopausal victim.

FINDINGS IN A CHILD VICTIM OF RAPE

General signs
 The younger the child, the less able it is to resist its assailant, and the fewer signs of
general injury that will be found on the body.
 A full ‘head to toe’ examination is of course vital, and in the older child typical ‘grasping’
injuries and bruises resulting from blows may be found.
 All signs of injury tend to be absent in cases where the sexual assailant is one of the
parents, or is a person well known to the child.

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Genital signs
 In children hymen is deep seated and vagina is small, therefore penetration of the adult
male organ is usually prevented.
 Due to the small vagina there may be only simulated intercourse such as intercrural
connection (i.e.: penile friction between the inner thighs and external genitalia).
 When there is complete penile penetration, there will be more widespread genital
injuries:
 Bruising of the labia with extensive haematoma.
 Circumferential tear of the mucosa of the vestibule (circumferential mucosal tears are
indicative of attempted penetration by an object the size of an erect adult penis)
 Posterior linear tears of the hymen extending up the posterior vaginal wall and
downward to involve the skin of the perineum and the perineal body.
 Anterior vaginal wall tears can involve the bladder
 Posterior vaginal wall tears can involve the ano-rectal canal viscera.

FINDINGS IN A PRE-PUBERTAL or VIRGIN VICTIM OF RAPE (AGE LESS THAN 14

YEARS)
In a pre-pubertal victim of rape, genital findings can be discussed under following headings:
1. Clitoris.
2. Labia majora.
3. Labia minora.
4. Hymen.
5. Posterior fourchette.
6. Fossa navicularis.
7. Vaginal wall.
8. Cervix.
Clitoris
Congestion and swelling of clitoris due to the friction of the male organ during forceful
penetration.
Labia majora & Labia minora
 Redness and swelling of labia.
 Fingernail scratches on the labia minora.
 Labia minora is tender to touch.
Hymen
 Vaginal penetration usually results in tearing of the hymen posteriorly between 3 and 9
o'clock position.
 Tears due to penile penetration extend to the margin of the hymen with vaginal wall.

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 These hymenal lacerations are associated with bruising.
 Hymenal lacerations usually heal within a week.
 Fresh tears look raw, red, swollen, and painful to touch
 Bleeds on touch within 1 to 2 days
 Heal in 5 to 7 days.
 Shrunken and look like granular tags of tissues within 8 to 10 days.

Posterior fourchette & Fossa navicularis

Minor tears seen on the fourchette and fossa navicularis produced due to the excessive
stretching of the skin.
Vaginal wall
 There may be abrasions, lacerations and bruising of vaginal wall depending on the
disproportion between the vagina and penis.
 Bruising appears as dark red areas against a overall redness of the vaginal mucosa.
 There may be pooling of seminal fluid in the vagina which is indicative of recent sexual
intercourse (Motile spermatozoa will be detected up to 6 hours after the intercourse in
the vagina).
Cervix
There may be cervical abrasion which is almost invariably due to vaginal penetration.

FINDINGS IN A POST-PUBERTAL VICTIM OF RAPE (MARRIED WOMAN WHO IS

ACCUSTOMED TO SEXUAL INTERCOURSE)
 Findings similar to that in pre-pubertal victim.
 Hymen becomes elastic thereby all the findings observed in a pre-pubertal victim are in
milder form.
 The vaginal rugae tend to become less pronounced (20 acts of sexual intercourse
required for complete disappearance of vaginal rugae).

FINDINGS IN A POST-MENOPAUSAL VICTIM OF RAPE (AGE MORE THAN 45 YEARS)

 Findings similar to that in post-pubertal victim.
 Injuries to genitalia are more pronounced because of the non oestrogenized atrophic
mucosa, which is dry and easily friable.
 Elderly may develop bruising with less force.
 Frequent sexual intercourse and parturition usually destroys the hymen which is then
represented by several small tags of tissue, called as Carunculae Hymeneals or
Myrtiformes.
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SPECIMENS TO BE TAKEN IN CASES OF ALLEGED VICTIM OF RAPE
Objective of collection of evidentiary material in a victim of rape:
1. To obtain confirmation of the allegations.
2. To attempt to establish a link between the victim and the scene.
3. To attempt to establish a link between the victim and the assailant.

Principle:
The basis of the scientific investigation of sexual offences is found in Locard’s principle of
transfer of physical traces, and can be summarized as: ‘Every contact leaves a trace’.

Prof. Edmond Locard, 1910

"Wherever he steps, whatever he touches, whatever he leaves, even unconsciously, will
serve as a silent witness against him. Not only his fingerprints or his footprints, but his hair,
the fibers from his clothes, the glass he breaks, the tool mark he leaves, the paint he
scratches, the blood or semen he deposits or collects. All of these and more bear mute
witness against him. This is evidence that does not forget. It is not confused by the
excitement of the moment. It is not absent because human witnesses are. It is factual
evidence. Physical evidence cannot be wrong, it cannot perjure itself, and it cannot be
wholly absent. Only human failure to find it, study and understand it can diminish its value."

Materials to be collected:
Clothing
 Patient should be made to stand upon as large clean sheet (if same clothing is worn) of
paper so that anything that falls out of the clothing will fall on to the paper and can be
preserved for laboratory investigation.
 All areas of clothing wet with secretions should be air dried and should be placed in a
paper bag and sent to Forensic science laboratory.
Head hair
To be obtained either by combing or by avulsion, for comparison with hairs found at the
science on the alleged assailant.
Pubic hair
 For comparison with any pubic hairs found at the scene and with the pubic hair of the
alleged assailant.
 Samples should be obtained by combing with a fine toothed comb so that any loose and
possible foreign hairs are recovered, and also by avulsion for comparison purposes.

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 Matted pubic hair for identification of the contaminating substance. The entire matted
area should be cut off as close to the skin as possible and dried before packing to
Forensic Science Laboratory.
Buccal swabs
 For seminal testing if there has been any allegation of oro-penile contact.
Bite marks
 Must be swabbed so that possible saliva grouping of the biter can be established.
 If such marks are swabbed, a control swab must be taken from an uncontaminated area
of skin for laboratory comparison.
Soiling
So that the laboratory may attempt to identify its nature and compare it with material at the
scene or from the assailant. All soiled areas on the body must be swabbed.
Fingernail samples
For identification of any soiling trapped below the nails. These samples may be taken by
scraping the soiled material out from beneath the nails, or by clipping the nails. In either
case, each nail or soiling must be placed in a separate container.
Genital swabs
 For identification of seminal traces, infecting organisms.
 Swabs must be taken from the area of the introitus, the perineum and the anal margin,
before any digital contact has been made by the examining doctor.
 Two swabs (low vaginal swab and a high vaginal swab) vaginal swabs and a swab of
the cervical mucus should be taken and sent to forensic science laboratory.
Blood
 For grouping and for analysis for alcohol and drugs if the latter is indicated by the history
or by the examination findings.
Urine
For routine testing for glucose and albumen, as well as for screening for drugs if the history
indicates that this is needed.

ESSENTIALS OF MEDICAL EXAMINATION OF A MAN SUSPECTED OF RAPE

CONSENT
 Consent must be obtained by the examining doctor for his examination and for his
subsequent report. The examination notes should record that consent was obtained,
and any written consent form should be fastened to the original examination notes.

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 If the accused refuses the consent Under section 53 (1) of the Criminal Procedure Code,
an accused can be examined even without his consent and by the use of reasonable
force if such an examination is desirable to ascertain the accuser’s part in a sexual
offence.
GENERAL HISTORY
 A general medical history should be taken from the patient, and this must include details
of all past illnesses, surgical operations and serious accidents.
 It must also include details of all recent medical attention, medication and consumption
of alcoholic drinks.
SPECIFIC HISTORY
It includes,
1. Has the man been informed of the reason for the medical examination?
2. Has consenting intercourse taken place with any person within the previous 24 hours?
3. When was the last bath or wash?
4. When was the last change of clothing?
5. What are the explanations for any marks or injury found?

GENERAL OBSERVATION
 Distressed or calm.
 Co-operative or aggressive.
 Dazed or shocked.
 Intoxicated or in command of his senses.
EXAMINATION OF CLOTHING
 Patient should be made to stand upon as large clean sheet (if same clothing is worn) of
paper so that anything that falls out of the clothing will fall on to the paper and can be
preserved for laboratory investigation.
 Observe and note soiled areas and to retain the garments for laboratory examination.
The use of an ultraviolet lamp will assist in the location of areas of possible seminal
soiling, for these will fluorescence. The dried clothing’s should be placed in a paper bag
and sent to Forensic science laboratory.
 Damage to any of the undergarments which may be due to the forceful removal of
clothing, particularly if against resistance, and should be inspected.

GENERAL CLINICAL EXAMINATION

 Height.
 Weight.
 Build.

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 Routine examination of all the bodily systems. It is only by such a complete clinical
examination that signs of pre-existing disease, injury or intoxication by alcohol or other
drugs can be found.
 The entire body must be carefully searched for any loose hairs or other foreign objects,
and any thing found must be retained for laboratory examination.
INJURIES
 Fingernail injuries are the most common, and tend to be found on the face and neck, the
hands and wrists, and only very rarely indeed on the genitals. The characteristic
fingernail injury commences with a curved indentation, and then tails off both in width
and depth, often with visible ‘piling’ up of superficial tissue at the distal end.
 Slapping marks can sometimes be seen if the examination takes place soon after the
event, and there may be signs of superficial injury to the inner surface of the lips
following even mild blows to the mouth.
 Bite marks can be found as signs of resistance by the victim, and such marks tend to be
on the hands, arms or face. This is not the case where sexual biting occurs during
consenting lovemaking.

DETAILED EXAMINATION OF THE GENITAL AREA

Pubic Hair
 Firstly the pubic hair should be carefully examined and any matted areas must be noted.
The entire matted area should then be cut away as close to the skin as possible, and the
entire mat should be retained for laboratory examination.
 Entire pubic area should be combed with a sterile fine-toothed comb and the comb,
together with any loose hairs, should be retained for laboratory examination.
 A sample of pubic hair should next be avulsed to provide the laboratory with a control
sample of hair.
Penis
 The penis should be carefully examined, and any abnormality that could interfere with
erection or ejaculation should be noted.
 The penis should be examined for the presence of smegma under the prepuce in a
uncircumcised male (in circumcised individuals there will not be any deposition of
smegma after certain duration of circumcision). Smegma is a thick cheesy secretion with
a disagreeable odor produced by Mycobacterium smegmatis bacilli. It consists of
desquamated epithelial cells and smegma bacilli. The presence of thick uniform coating
of smegma under the prepuce or round about the corona glandis is inconsistent with a

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 recent intercourse. The smegma is rubbed off during the intercourse and it takes about
twenty-four hours to accumulate.
 The presence of a torn frenulum is consistent with a recent intercourse. The frenulum
may be torn due to forcible introduction of the organ into the vagina.
 In a recent case of sexual intercourse, the penis should be examined for the presence of
vaginal epithelial cells on its surface. For this purpose, the glans penis is wiped with a
clean filter paper and the paper exposed to the vapors of Lugol’s iodine, which turns
brown in color due to the presence high glycogen content in vaginal epithelial cells.
Testicles
The testicles must be examined for any abnormality including non-descent, large scrotal
herniae or testicular atrophy, and the skin of the scrotum should be inspected for abrasion
or injury.
Opinion:
By the end of his clinical examination the doctor should be in a position to answer the
following questions:
1. Is there anything which renders him incapable of performing sexual intercourse?
2. Has there any evidence of recent sexual intercourse?
SPECIMENS TO BE TAKEN FROM THE SUSPECT IN CASES OF ALLEGED RAPE
Objective of collection of evidentiary material in rape accused:
A. To confirm the allegations.
B. To attempt to establish a link between the suspect and the scene.
C. To attempt to establish a link between the suspect and the victim.
Materials to be collected
1. Blood for grouping, for the blood group will be unchanged whatever the time interval,
and will still be relevant for comparison with any seminal swabs etc., found during the
examination of the victim, victim’s clothes, or scene.
2. Head hair for comparison with any loose hairs found on the victim or at the scene.
3. Pubic hair should be carefully inspected and any matted areas should be noted. The
entire matted area should then be cut away as close to the skin surface as possible, and
should be retained for laboratory examination.
4. Pubic hair should be combed with a clean and fine-toothed comb and the comb together
with any loose hairs removed should be retained for laboratory examination.
5. Urine for analysis for alcohol or drugs if there are clinical signs of intoxication present.

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6. Bite marks must be swabbed and a control swab must be taken from an uncontaminated
area of skin.
7. Soiled areas of the body must be swabbed.
8. Fingernail samples, either by scraping the nails or by clipping them, must be taken so
that any foreign material trapped beneath them can be examined by the laboratory.
9. Penile swabs, taken from the corona sulcus, the prepuce and the urethral orifice should
be taken, for these swabs may also be present on the victim’s swabs. Penile shaft
swabs should also be taken, for these may reveal saliva traces in cases of alleged oro-
penile contact. Shaft swabs may also reveal mucosal epithelial cells which the forensic
science laboratories may be able to identify as vaginal debris.
[[[[

RAPE TRAUMA SYNDROME

Definition:
Rape Trauma Syndrome is a form of post traumatic stress syndrome experienced by a rape
victim. The term is used to characterize a group of signs, symptoms and reactions of a rape
victim.
Classical Features:
Acute Stage
Victims vary as to the amount of time they remain in the acute stage. The immediate
symptoms may last a few days to a few weeks and may overlap with the outward
adjustment stage. Behaviors which may be present in the acute stage are:
 Diminished alertness.
 Numbness.
 Dulled Sensory, affective and memory functions.
 Disorganized thought content.
 Paralyzing anxiety.
 Pronounced internal tremor.
 Obsession to wash.
 Hysteria and confusion.
 Bewilderment.
 Calmness and collectedness.
 Acute sensitivity to the reaction of other people.

The Outward Adjustment Stage

Victims in this stage seem to have resumed their normal lifestyle but there is internal turmoil
which may manifest itself in any of the following behaviors:
 Continuing anxiety.
 Sense of helplessness.
 Persistent fear and or depression.

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  Mood swings from relatively happy to depression or anger.
 Vivid dreams, recurrent nightmares, insomnia, wakefulness, flashbacks, loss
of concentration.
Lifestyle
Victims in this stage can have their lifestyle affected in some of the following ways:
 Their sense of personal security or safety is damaged.
 They feel hesitant to enter new relationships.
 Sexual relationships become disturbed. Many victims have reported that
they were unable to re-establish normal sexual relations and often shied
away from sexual contact for some time after the rape. Some report inhibited
sexual response and flashbacks to the rape during intercourse.
INCEST
 This is an act of sexual intercourse by a man with a woman within a certain degree of
blood relationship.
 Incestual practice is prohibited in most of the countries but not in India.
 The commonest example is of a father indulging in sexual activities intercourse with his
daughter.
ADULTERY
 Adultery is defined by section 497 of Indian Penal Code as "Whoever has sexual
intercourse with a person who is and whom he knows or has reason to believe to be the
wife of another man, without the consent or connivance of that man, such sexual
intercourse not amounting to the offence of rape, is guilty of the offence of adultery, and
shall be punished with imprisonment of either description for a term which may extend to
five years, or with fine, or with both. In such case the wife shall not be punishable as an
abettor."
 Section 497 unequivocally conveys that the adulteress "wife" is absolutely free from
criminal responsibility. She is also not to be punished (even) for "abetting" the offence.
Section 497, by necessary implication, assumes that the "wife" was a hapless victim of
adultery and not either a perpetrator or an accomplice thereof. Adultery, as viewed
under IPC, is thus an offence against the husband of the adulteress wife and, thereby,
an offence relating to "marriage".
 It is in consonance with this approach that Section 198 Cr. P. C mandates a court not to
take cognizance of adultery unless the "aggrieved" husband makes a complaint.

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SODOMY
Definition:
Sodomy means anal intercourse between two males (homosexual) or between a male and
female (heterosexual).
Introduction:
 Sodomy derived its name from town named "Sodom" where it is used to be practiced.
 It is also called as "Greek Love"(Greek of the golden age used to practice) and
"Buggery".
 Sodomy is popularly termed as "paederasty' (literally 'boy-love') when the passive agent
is a child, who is known as 'catamite".
 Gerontophilia means there is sexual attraction or preference for an aged partner.
Legal Implications of Sodomy:
 In India Homosexuality is illegal with anal intercourse punishable by life imprisonment
under S 377 of the Indian Penal Code. Section 377 also criminalizes male to male sex
with up to 10 years imprisonment.
 In the United Kingdom, acts of anal intercourse are no longer criminal offences if they
take place between consenting adult males (over the age of 21yrs) in private.
EXAMINATION OF THE PASSIVE PARTNER OF SODOMY
Objectives of the examination:
The routine medical examination of the passive partner of alleged anal intercourse follows a
similar pattern to the medical examination of the alleged victim of rape: the examining
doctor should plan his entire examination so that at its conclusion he will be able to answer
the following questions:
1. Could penile penetration have taken place in this anus?
2. Has penile penetration taken place recently?
3. Are there signs that indicate that this anus is well used to penile penetration?
4. Are there physical signs to indicate that general force or stupefying drugs have been
involved?
5. Have all the relevant specimens been taken to confirm the allegations and to assist in
identifying the parties involves.

Essentials in the medical examination of passive partner of sodomy:

 Consent to the medical examination and subsequent report is required, and must be
obtained by the examining doctor directly from the patient or from a parent or guardian in
the case of a minor or a patient unable to give valid consent.
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 A general medical history must be taken, preferably form the patient. The general history
must include all details of past illnesses, surgical operations and serious accidents. It
must also include details of recent medication and of intoxicating drinks consumed over
the previous 24 h.
 Special attention must be given to questions relating to the patient’s bowel habits,
including previous constipation, the regular use of laxatives, enemata or suppositories,
and details of any surgical operations or instrumentation of the bowel.
 In the case of female passive partner, details of previous childbirth and the extent of any
perineal laceration and repair must be noted, for these circumstances can alter the
normal anatomy of the anal verge and perineum.
 Enquiry should be made regarding any previous acts of anal intercourse, and a note
should be made of any such previous act and the frequency of such acts in the past.
 The specific history of the incident under investigation must be taken, preferably from
the patient. Special reference must be made to the following matters:
1. The date, time and place of the alleged act or acts;
2. The position in which penile penetration was achieved;
3. The use of general violence;
4. The use of any lubricant;
5. Did ejaculation take place?
6. Was pain experienced – at the time of penetration, during the act of anal intercourse,
immediately after withdrawal of the penis, for some time after withdrawal, on the
subsequent acts of defecation after the alleged act or acts?
7. Has there been any change of clothing since the alleged act and prior to the medical
examination?
8. Has the patient bathed or washed the anal area since the alleged act and prior to the
medical examination.
 General observation by the examining doctor should be maintained throughout the
history taking and the medical examination, and the patient’s demeanor should be
noted.
 If it is a recent complaint, and the clothing worn at the time of the alleged offence, then
the clothing must be removed item by item as in the case of a rape examination, and
each garment must be inspected and retained for laboratory examination.
 General clinical examination must follow in every case, with careful inspection of the
skin, for injury, areas of soiling and loose hairs. Loose hairs may be found on either the

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 front or back of the body for anal penetration can be accomplished in a variety of
positions.

DETAILED EXAMINATION OF ANAL AREA AND GENITALIA:

Pubic Hair
Firstly the pubic hair should be examined, and any matted areas should be noted. The
entire matted area should be cut away as close to the skin as possible, and retained for
laboratory examination.
Penis
 The penis should be carefully examined, for in many cases oro-penile contact is either a
preliminary to anal intercourse or is actually the entire extent of the sexual contact.
 Swabs must be taken from the penile shaft and the glans penis for the presence of
saliva traces, and control swabs should be taken from an area of skin likely to be
uncontaminated, such as the skin of the upper chest or shoulder. Any undue redness of
the penis, and any obvious injury, must be noted.
Anus
 Before any digital contact is made by the examining fingers, swabs must be taken from
the anal verge and the skin of the perineum, and these swabs should be examined by
the laboratory for seminal and lubricant traces.

LOCAL ANAL VERGE SIGNS OF PENETRATION:

The acute signs of first anal penetration:
 The acute signs of first anal penetration are only transient.
 Smoothness of the anal verge skin, spasm of the anal sphincter, and the fresh
appearance of abrasions may all have disappeared within 24-48 hours.
 If a fissure (produced by overstretching of the anal skin) has been produced it will
remain visible for many days, sometimes extending into weeks.
 Some degree of sphincter spasm will persist as will a history of sharp pain on
defecation.
 Peri-anal haematoma (The blood vessels immediately beneath the anal skin are poorly
supported, and become ruptured as the overlying skin is moved by the shearing force of
penetration. If the rupture is purely local the localized peri-anal haematoma results) will
take as long as 7-10 days to become absorbed.

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 Tearing of the sphincter muscle is rare in the case of adults and older children, but can
take place in the case of young children, and in cases where this has taken place there
will be considerable laxity of the anal orifice, sometimes with frank gaping.
 The entire lower rectum and anal canal must be carefully inspected through the
proctoscope, and any area of injury or of abnormality of the mucosal lining must be
noted. Bruising of the mucosa will be seen as darker red areas against the all over
redness of the background. Habitual and repeated acts of anal intercourse can produce
a smoothing of the anal columns.
SIGNS OF HABITUAL ANAL INTERCOURSE:
 Normal folds at the anal verge tend to be lost so that the anal margins appear much
smoother than normal.
 Thickening of the skin at the anal margin extending up into the anal canal to the muco-
cutaneous junction, and sometimes well into the mucous membrane of the upper anal
canal and lower rectum.
 The scars of healed fissures will be visible if carefully searched for, and this search may
require the use of a hand lens for healed fissures present as small pale scars and are
easily missed on cursory examination.
 The anus itself has the appearance of being ‘deep set’ so that the anal area looks as
though it is situated in a funnel shaped depression (indicative of repeated and regular
anal intercourse over many years).
 Digital examination in patients well used to anal intercourse may well extend to an easy
three or four finger examination, and the sphincter may easily stretch to accommodate
the examining fingers without any complaint of discomfort
 ‘Lateral buttock traction test’ in which a thumb is placed on the buttock cheeks on either
side of the anus, and gentle lateral traction is applied. In patients who are not
accustomed to anal penetration (penile or instrumental) the gentle lateral traction results
in a reflex constriction of the anal sphincter. Patients who are well used to anal
penetration react to the gentle lateral traction by a relaxation of the anal sphincter.
 Shaving of the peri-anal hair.
 Presence of lubricant in the anal canal.

BESTIALITY (ZOOPHILIA)
Bestiality means sexual intercourse with a lower animal (goat, cat, dog, pigs, cows etc.),
which may be practiced either through the anus or vagina of the animal.
 Bestiality may be as a result of sex starvation or some mental aberration.

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 It is commonly practiced by a person employed to look after the animals.
 A male accused may have his penis stained with his semen and the animal dung.
 Animal hair may be seen sticking to the penis.
 Human semen may be found in the vagina or the anus of the animal.
 It is punishable under section 377 of Indian Penal Code (unnatural sexual offence).
BUCCAL COITUS (SIN OF GOMORRAH)
 As per 'Bible', buccal coitus used to be practiced in the town of Gomorrah and hence the
name Sin of Gomorrah.
 'Fellatio' is the term used for the sucking of male organ by a female or another male.
 'Cunnilingus' is the term used for oral stimulation of female genitalia including clitoris by
a male or another female.
 It is punishable under section 377 of Indian Penal Code (unnatural sexual offence).

SEXUAL PERVERSIONS
Introduction:
 Paraphilias/ Deviations
 Greek
 Para means alternative; Philos means loving
Definition:
Recurrent abnormal sexual activity or fantasy directed towards orgasm, when normal sexual
activity, as approved by the society is possible.
Individual Paraphilias:
A. Fetichism
B. Paedophilia
C. Sadism
D. Masochism
E. Frotterism
F. Voyeurism/ Scotophilia
G. Exhibitionism
H. Transvestism
I. Satyriasis
J. Nymphomania
K. Pygmalionism
L. Klismaphilia
M. Coprophilia
N. Necrophagia
O. Necrophilia
FETISHISM
 Fetisso (Portuguese)= object with magical power

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 Recurrent, intense, sexual fantasies or behaviour involving the use of a non-living object
that are intimately associated the human body
 Fetishist articles (undergarments, brassieres, petticoats, stockings, shoes etc)
 Associated with Temporal lobe tumors
 Fetishism itself is not an offence.
 Subjects may get into trouble with the law through the way they obtain their fetish object.

PEDOPHILIA
 Pedophile should be at least 16 years of age and at least 5 years older than the victim.
 Recurrent, intense sexually arousing fantasies or behaviour involving sexual activity with
a prepubescent child.
SADISM
 Derived from the name of the French Novelist 'Marquis De Sade' an author and fiction
writer on crime, violence, love and sex.
 Recurrent, intense, sexual arousing fantasies, sexual urges or behaviors involving acts
in which the psychological or physical suffering of a victim is sexually exciting.
 Sadism breaches the law when their actions are with unwilling partners and constitutes
assaults of varying degree. In extreme cases, a sadist may be charged for murder.
MASOCHISM
 Recurrent, intense, sexual arousing fantasies, sexual urges or behaviors involving act of
being humiliated, beaten, bound or otherwise made to suffer.
 Derived from the name of an Austrian novelist 'Leopold Von Sacher Masoch
 Masochistic activities in themselves are not illegal.
FROTTEURISM (Toucherism)
 Frotter (French) means to rub.
 Recurrent, intense sexually arousing fantasies or behaviors involving touching & rubbing
against a non consenting person.
 Usually takes place in a crowded public place.
 Frotteurism is an offence and is punishable under section 209 and 291 of Indian Penal
Code.
VOYEURISM (Peeping Tom)
 Voir (French) means 'to look at'.
 Tom the tailor who allegedly peeped at Lady Go-diva as she rode naked as a protest
against her husband.

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 Recurrent, intense sexually arousing fantasies or behaviors involving the act of
observing an unsuspecting person who is naked or engaged in sexual activities.
 Commonly observed as sociopathic personality disorder.
 Voyeurism is an offence. The offender may be referred to psychiatrist for assessment.

EXHIBITIONISM
 Recurrent, intense sexually arousing fantasies or behaviors involving the exposure of
genitalia to an unsuspecting stranger or public with or without acts of masturbation to
obtain sexual gratification.
 It is punishable under section 294 of Indian Penal Code.
TRANSVESTISM (Eonism)
 Trans means across; vestis means garments.
 Recurrent, intense desire to wear the clothing of the opposite sex.
 It is not illegal to cross dress. People break rule by stealing clothes and other attires.
SATYRIASIS
Excessive, often uncontrollable sexual desire in a man.
NYMPHOMANIA
Nymphomania is a word that refers specifically to women who have an "excessive" or
"insatiable sex drive.
PYGMALIONISM
Sexual gratification is obtained by viewing or handling nude statues.
KLISMAPHILIA
Sexual excitement is obtained by giving or receiving an enema.
COPROPHILIA
Sexualized interest in viewing, smelling, even handling of the fecal matters of others.
NECROPHAGIA (Vampirism)
Sexual gratification is obtained by mutilating the body parts especially the genitalia of the
victim but also by licking the wounds, biting the skin and eating the flesh.
NECROPHILIA
Sexual gratification is obtained by having sexual intercourse on dead bodies.

INCOMPLETE LIST OF QUESTIONS FROM SEX RELATED CRIMES

1. Classification of sexual offences.
2. Define rape or Section 375 of Indian Penal Code.
3. Objectives of the examination of the victim of rape.
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4. Objectives of the examination of the accused of rape.
5. Describe the genital and extra-genital findings in a child victim of rape.
6. Describe the genital and extra-genital findings in a pre-pubertal or virgin victim of rape.
7. Describe the genital and extra-genital findings in a post-pubertal victim of rape.
8. Describe the genital and extra-genital findings in a post-menopausal victim of rape.
9. Explain the specimens to be taken in cases of alleged victim of rape.
10. Essentials of medical examination of a man suspected of rape.
11. Explain the specimens to be taken from the suspect in cases of alleged rape.
12. Explain the signs encountered in a victim of habitual anal intercourse.
13. Write briefly on the Locard’s principle of exchange.
14. Write briefly on the following:
A. Custodial rape
B. Gang rape
C. Indecent assault
D. Statutory rape
E. Rape trauma syndrome
F. Incest
G. Adultery
H. Sodomy
I. Bestiality (zoophilia)
J. Fetishism
K. Sadism
L. Pedophilia
M. Masochism
N. Frotteurism (toucherism)
O. Voyeurism (peeping tom)
P. Transvestism (eonism)

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 SOMNIFEROUS POISONS
This group of poisons is known as somniferous poisons because their preparations are
used therapeutically to lessen pain and induce sleep.

PAPAVER SOMNIFERUM (OPIUM PLANT or POPPY PLANT)

 Papaver somniferum is the plant from which opium is obtained.
 Growing the poppy plants, as they are more commonly known, without the
legitimate license from the government, is illegal and is punishable.
 The unripe fruits (green in colour) of the plants (known as poppy capsules) are given
superficial incisions either longitudinally or horizontally.

White milky latex oozes from the cut surface

On exposure to air this latex turns in to a brownish black mass

Opium (Afim)

 Opium has a characteristic smell and a bitter taste.

 Opium contains several alkaloids.
 Alkaloid is a substance, which like an alkali forms a salt when combined with an
acid, but truly is not an alkali (does not change litmus color).
 Alkaloids of opium are divided into TWO categories:
A. Phenanthrene Group: Morphine(Morpheus – Greek god of dreams), thebaine
and codeine
B. Isoquinolone Group: narcotene (noscapine) and papavarine
 Poppy seeds are a common and flavorsome topping for breads and cakes.
 Opiates: These are drugs which are derived from opium.
e.g.: Heroin (diacetylmorphine)
Apomorphine.
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 Opioids: These are drugs which have a similar action but are not derived from
opium.
e.g.: Pethidine
Methadone
Pentazocine
Fentanyl

MEDICOLEGAL SIGNIFICANCE
1. Accidental poisoning: Opiates and Opioids are among the commonest of the drugs
of abuse. Accidental poisoning may occur in addicts, in children or due to
therapeutic misadventure.
2. Suicidal purpose: Opium has been used for suicidal purposes as it lessens pain and
induces sleep. Some-times, morphine may be taken by injection to commit suicide.
3. Homicidal purpose: It is sometimes used as an infanticide agent to get rid of
illegitimate children (Death has resulted from the breastfeeding of an infant by a
woman who had smeared her nipple with tincture of opium with evil motive).
4. Criminal intent: It is also used to steady the nerves for doing some bold act. For
instance, in the ancient times, the Rajputs used to take the drug before they took
part in battles.
5. Opium withstands putrefaction and can be detected after a long time.

MECHANISM OF ACTION
It is considered that there are three major classes of opiate receptors to which different
opiates bind with different affinity:

 Mu () receptor - Most of clinically used opiates are relatively selective for 
receptors. They mediate euphoria, supraspinal and peripheral analgesia, respiratory
depression, gastro-intestinal dismotility and physical dependence.

 Kappa (K) receptor – They mediate miosis, spinal analgesia, central nervous system
depression, supraspinal analgesia, etc.

 Delta (δ) receptor – These are responsible for spinal and supraspinl analgesia.

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 More recently discovered N/OFQ or Orphan opiate receptor, has added a dimension
to the study of opiates.

CLINICAL FEATURES OF ACUTE OPIUM POISONING

Most of the drugs are absorbed from gastro-intestinal tract, but maximum effect is
produced by parenteral routes. The effects of acute poisoning may be studied under the
following stages:
A. Stage of Excitement
 This stage may be absent if a large dose is taken. Initially there is excitement with a
sense of well being. The person may hallucinate at this stage.
 The breath may smell of opium. In children, convulsions are usually the marked
feature of this stage. This stage lasts for a short time and the person goes in to a
state sopor or stupor soon.

B. Stage of Stupor
 The stage of excitement is soon succeeded by weariness, headache, giddiness, a
sense of weight in limbs, diminution of sensibility and an intense tendency to sleep
from which the patient can be aroused by applying external stimuli.
 The pupils are constricted, the face and lips cyanosed.
 The pulse and respiration are almost normal.

C. Stage of Narcosis
 From the stage of sopor he gradually passes in to a state of narcosis. He becomes
comatose.
 The pupils are pin pointed (This state of pupils, probably, is due to the depression of
supranuclear inhibition of the pupillary constrictor tone). They may dilate terminally
when anoxia ensues.
 The pulse is very weak and thready.
 The respiration slows down so much so that it is hardly visible. The respiratory rate
falls down to 2 to 4 per minute (Cheyne-Stokes breathing).
 Cold perspiration covers the body (Secretions are suspended except that of skin).
Death results from respiratory paralysis.
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MANAGEMENT OF ACUTE OPIUM POISONING

 Decontamination: Gastric lavage is indicated taking care to prevent the gastric

aspiration by introducing the cuffed endotracheal tube. Gastric lavage first with tepid
water (the retuming fluid kept for analysis) and then with the solution (1 :5000) of
potassium permanganate needs be done. This tends to oxidize opium into harmless
substances. Lavage should be continued till washed water returns with its original
pink colour. (Even when the drug has been administered through injection, the
permanganate treatment should be adopted since morphine is excreted in the
stomach. Some solution should be left in the stomach with the aim of oxidizing the
alkaloid that might be so excreted).
 Antibiotics to prevent pulmonary infection.
 The narcotic antagonists:
 Naloxone is the antidote in a dose of 0.4 to 0.8 mg i.v, repeated 10 to 15
minutes depending on the response. The opiate antagonists compete with
heroin and other opioids for receptors, reducing the effects of the opioid
agonists. Currently, the drug of choice is naloxone. It is pure opioid
antagonist and competes with opioids at receptor sites.
 Naltrexone is the antagonist in rehabilitation. It is free from agonist
properties, produces no known withdrawal symptoms when stopped and its
side effects tend to be mild.

POST MORTEM FINDINGS

A. Externally, deeply cyanosed face (It is probably responsible for the old belief that
the face of a poisoned person turns black after death), bluish finger nails, blackish
post mortem lividity are the characteristic features. Intense cyanosis of the face
almost approaching to blackness are the 'hallmark' of diagnostic findings. It is

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 probably responsible for the old belief that the face of a poisoned person turns black
after death.
B. Internally, the stomach may show the presence of small, soft, brownish lumps of
opium and the smell of the drug may be perceived which disappears with the onset
of decomposition. The characteristic features are oedematous lungs, froth in the
tracheo bronchioles and congestion of all the organs.

DIFFERENTIAL DIAGNOSIS FOR ACUTE OPIUM POISONING

 Alcohol poisoning (Alcoholic smell)
 Barbiturate poisoning (Dilated pupil)
 Carbolic acid poisoning (Phenolic smell)
 Pontine haemorrhage (Hyper pyrexia)
 Diabetic coma (Kusmaul’s breathing/ sweet acetone odor of breath)
 Organophosphate poisoning (Kerosene like smell)

CHRONIC POISONING (MORPHINO-MANIA; MORPHINISM)

INDICATORS OF OPIATE ADDICTION
 Withdrawal from family, friends, and social activities
 Long hours of unexplained absence from home
 Unexplained overspending
 Periodic disappearance into a locked room
 Impotence in males may occur as the drug decreased levels of luteinizing hormone,
with a subsequent reduction in testosterone, which might contribute to the
decreased sex drive reported by most opioid-dependent individuals.
 Females may show frigidity.
 A desire to procure drug by any means may be the other features.
 Use of morphine parenterally (known as 'skin popping' when used subcutaneously
and 'main lining' when injected intravenously); pigmentation and scar formation may
be there which are often masked by artificial tattooing.
MANAGEMENT OF MORPHINISM
 Gradual withdrawal of drug,

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 Maintenance of food, nutrition, vitamins, etc.,
 Physical restrain (if necessary) and good nursing care.
 Less potent drug need be given as a substitute to take care of the withdrawal
symptoms that are likely to develop. The drug of choice for this purpose is
methadone which needs be given at a dose of 30-40 mg/day and then gradually
tapered off. A beta adrenergic-blocker like propranolol is said to be effective in
relieving the anxiety and caving associated with opiate addiction,
 Psychiatric counseling is frequently necessary after the acute phase of de-addiction
is over.

SYMPTOMS OF WITHDRAWAL (WITHDRAWAL REACTION Or COLD TURKEY)

CLINICAL FEATURE
Withdrawal symptoms, usually the opposite of the acute effects of the drug include:
 Nausea and diarrhoea, coughing, lacrimation, mydriasis, rhinorrhoea, profuse
sweating, muscle twitching, piloerection (goose bumps) as well as mild elevation in
body temperature, respiratory rate and blood pressure.

 Diffuse body pain, insomnia and yawning occur along with intense drug craving.

TREATMENT
Methadone is preferred for this purpose. This should be gradually tapered off.

HEROIN
 The first semi-synthetic opium derivative diacetylmorphine (heroin) was introduced
into medicine in 1898.
 It is also known as smack, dope or junk.
 Heroin was created in an attempt to find a safer type of morphine and was named,
presumably due to drug's 'heroic' ability to mimic the effects of morphine without
causing addiction. Developers hoped that the new drug would be used to cure
morphine addiction. Unfortunately, heroin is in fact highly addictive.
 Heroin is preferred by the addicts due to its more intense action as compared to
morphine.
 It is a white or brown powder (depending on where it has been processed) that can
be smoked, sniffed or dissolved in water and injected.
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 Heroin can be volatilized and then inhaled, usually by heating on a spoon, bottle
cap, portion of a metal beverage can, or on a piece of tinfoil. It can be smoked when
the end of a cigarette is dipped in heroin powder and lighted (this is called ack-ack);
'chasing the dragon' (resembles a dragon's tail as the fumes rise) or 'playing the
organ'. The drug is lighted and smoke inhaled.
 Subcutaneous injection is called skin-popping, intravenous as mainlining. Heroin
is not taken orally because it is rapidly hydrolyzed in the stomach.
 Intravenous injection is known as shooting, banging, mainlining (when large
veins are used, especially those of the arm), shooting up, IV. Users determine
whether they are in a blood vessel by looking for a "register"; often this is by
pulling back on the plunger although the pressure of blood can cause it to shoot
up into the barrel of the syringe and those made of clear materials are often
called "self-registering."' In rare cases, people have been known to shoot up by
poking a hole in the vein with a safety pin then pressing the mouth of an eye-
dropper, plain syringe, or other similar item to the hole and then pushing the
liquid in.
 Intramuscular injection is called muscling, popping, poking, IM and other terms.
Anabolic steroids, when used outside of medical supervision are often injected
into the muscle being worked on. IM injection typically allows a drug to last
longer than the IV route, although the "rush" may not be present or as intense;
amongst opioids and some other categories or subgroups like non-cocaine
stimulants only a very few drugs can subjectively be distinguished from one
another by a user after the rush is over or never happened.
 Skin popping is a method of administration for the use of recreational drugs by
injecting or placing the substance or drug under the skin. It can include
subcutaneous placement or intradermal placement though is also rarely used to
mean intramuscular injection. Skin popping increases the duration of the high
one gets from drugs such as cocaine. The sites where skin popping is done have
an area of central pallor surrounded by ecchymosis. This pattern is due to the
vasoconstrictive properties of cocaine acting locally at the injection site with
hemorrhage occurring in the surrounding tissue. Skin popping puts one at risk for
developing Secondary Amyloid Associated (AA) Amyloidosis.

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 Large doses of heroin can cause fatal respiratory depression, and the drug has
been used for suicide or as a murder weapon. The serial killer Dr Harold Shipman
used it on his victims.
POSTMORTEM FINDINGS
 Autopsy findings are relatively non-specific.
 However, certain features can be useful pointers.
 Presence of injection marks (needle marks) commonly in the antecubital fossa
on the front of the elbow, or into one of the prominent veins of the forearms or
dorsum of the hand.
 In habitual users, sclerosis of the veins may lead to the arms being used
randomly. The veins of the dorsum of the foot may be used when the hands and
arms have become unusable because of thrombosis and scarring. Less common
sites are thighs, abdominal wall; where the injections may be subcutaneous,
which can lead to areas of subcutaneous sclerosis, fat necrosis and abscesses,
etc.
 The most striking change is severe congestion and oedema of the lungs with
abundant froth filling the bronchi, and trachea, and protruding from the nose and
mouth. This is the so-called heroin lung.

INVESTIGATIONS
 Heroin is rapidly metabolized in the body by blood esterases to 6-mono-acetyl
morphine, so that taking of either heroin or morphine results in the finding of
morphine toxicologically.
 Using an immunochemical method, excretion of morphine or morphine equivalents
may be detected for 2 weeks or more after the last dose, depending upon the
sensitivity of the testing method.
 Blood, urine and bile are good specimens for morphine recovery. In the absence of
urine and bile, kidney and liver need be retained for analysis.

SOME ADDITIONAL POINTS OF MEDICO-LEGAL INTEREST

 A new type of Mexican heroin called 'Black tar' is becoming increasingly popular in
the US because it is 40 times stronger and 10time cheaper than pure heroin.

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 The illicit heroin found on the streets of India frequently adulterated with 'diluent
powders', to increase the quantity and reduce the price. This sort of adulteration is
sometimes referred as cutting.
 The "speedball" was invented by Harry K. Thaw. Commonly, the speedball includes
an opioid like heroin, morphine, methadone, hydromorphone, oxymorphone,
nicomorphine, ketobemidone, pentazocine & plus a stimulant, usually cocaine but
often methamphetamine.
 Brompton's cocktail is a mixture of morphine, cocaine, chlorpromazine and alcohol
used alleviate severe and intractable pain (as certain types of cancer). The
Brompton cocktail is named after the Royal Brompton Hospital in London, England,
where it was invented in the late 1920s for patients with tuberculosis.
 Drug abusers elbow: Myositis ossificans resulting due to repeated needle puncture
near the elbow in the LV. drug abuser.

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 SPINAL POISONS..
 Spinal poisons includes Strychnos nux vomica (excitatory), gelsemium (depressive).
 The seeds of Strychnos nux vomica are biconcave and round. When swallowed it is not
poisonous as the pericarp (outer covering) is very hard and is not digested in the human
intestine. When crushed and swallowed they are poisonous.

Active principles: The active principles in the seeds that are poisonous are Strychnine and
Brucine.
Mechanism of action: They act on the anterior horn cells of the spinal cord, where glycine is
a major post synaptic inhibitory neurotransmitter, and prevents its effect. By inhibiting the
inhibitory transmitter, it brings about excitation (convulsion).
Clinical features: These can be grouped into agonal phase and excitatory phase
A. Agonal phase:
 To begin with the victim is in a state of restlessness, apprehensions, heightened acuity
of senses, abrupt movements and hyper reflexia.
 Initially the muscular contractions are intermittent (Tonic). The contractions gradually
become continuous (Clonic).
 The jaws are tightly clenched (Trismus)
 There is a fixed grin on the face (Risus Sardonicus) and a fixed stare.
 As the extensor muscles powerfully contract the body bends backwards supported
only by the head and the heel (Opisthotonus). Sometimes there may be lateral bending
(Pleurosthotonus) or even rarely forward bending (Emprosthotonus)
 There is a fixed stare. The pupils dilate.
 The heart rate increases and so also the blood pressure
 Due to sustained contractions of the intercostals muscles and the diaphragm, the
breathing literally stops and the body turns bluish as the cyanosis ensues.
B. Relaxation phase:
 In this phase there is a total relaxation. The victim goes to sleep out of sheer
exhaustion.
 The breathing resumes. Cyanosis disappears.
 The dilated pupils contract.
 Cold perspiration covers the skin.

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  The heart beats and the blood pressure returns to normal.
 At no stage the victim looses his consciousness.
 Hyper excitability soon returns. Noise, light etc., precipitates another paroxysm.

Soon another paroxysm of contractions sets in. one to ten such paroxysms occur before
recovery or death from respiratory arrest. Ordinarily five paroxysms are dangerous. With the
passage of time the contractions become more and more violent and the intermission becomes
shorter and shorter.
Complications: Repeated convulsions lead to lactic acidaemia, hyperkalaemia,
hyperpyrexia, and dehydration.
Sequelae: Rhabdomyolysis, myoglobinuria and acute renal damage are the usual sequelae.
Treatment:
 The victim must be placed in a dark, warm and in a sound proof room as light, cold and
noise may precipitate the paroxysms of muscular contractions.
 After anaesthetizing him with ether spray, short-acting barbiturates may be given to
control convulsions. I.V diazepam is the best physiological antidote.
Medico-legal importance:
1. Strychnos nux vomica poisoning is mainly accidental in nature, where children consume
the seeds mistaking them to be edible materials.
2. It is rarely used for committing suicide as it causes a very violent death.
3. Strychnos nux vomica poisoning manifestations resemble tetanus, therefore it is important
to distinguish spinal poisoning from tetanus in order to save the life. In tetanus at no stage
there is total relaxation. There is always a history of sustaining some trauma. The
contractions of the muscles are neither so violent nor so powerful.
4. Strychnos nux-vomica, has been used as a rodenticide.
5. In small amounts strychnine is known to be added to “street drugs,” such as LSD, heroin,
cocaine, and others.

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 SUBSTANCE ABUSE or DRUG ABUSE
Drug abuse is a serious public health problem that affects almost every
community and family in some way. Each year drug abuse results in around 40
million serious illnesses or injuries among people in the United States.
DEFINITION OF SUBSTANCE ABUSE
Substance abuse is a maladaptive pattern of drug use indicated by...continued
use despite knowledge of having a persistent or recurrent social, occupational,
psychological or physical problem that is caused or exacerbated by the use (or
by) recurrent use in situations in which it is physically hazardous.
MEDICOLEGAL SIGNIFICANCE OF SUBSTANCE ABUSE
Drug abuse plays a role in many major social problems, such as drugged driving,
violence, stress and child abuse. Drug abuse can lead to homelessness, crime
and missed work or problems with keeping a job. It harms unborn babies and
destroys families.
COMMONLY ABUSED DRUGS
Commonly abused drugs include
 Amphetamines
 Anabolic steroids
 Cocaine
 Heroin
 Inhalants
 Marijuana
 Prescription drugs
 LSD
 Psilocybin
 Mescaline etc.

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SUBSTANCE ABUSE V/S SUBSTANCE DEPENDENCE
 There are on-going debates as to the exact distinctions between substance
abuse and substance dependence, but current practice standard
distinguishes between the two by defining substance dependence in terms of
physiological and behavioral symptoms of substance use, and substance
abuse in terms of the social consequences of substance use.
 Dependence almost always implies abuse, but abuse frequently occurs
without dependence, particularly when an individual first begins to abuse a
substance.
 Dependence involves physiological processes while substance abuse reflects
a complex interaction between the individual, the abused substance and
society.
 Psychological dependence is characterized by a feeling of satisfaction, a
drive to repeat the use, changes in the mood and perception. While under the
influence of these drugs his senses become distorted. He sees the smell,
smells the sound and hears the colour. The distortion of the senses some
time may be so frightening so as to drive the person to commit suicide out of
sheer fear. There is a rapid development of high degree tolerance. The
psychic dependence is not very intense and the physical dependence is rare.
 Physical dependence is a state of adaptation where tolerance develops fast.
The user always feels the need to increase the dose progressively in order to
get the effect originally achieved by smaller doses. Initially he manages to buy
the drugs with his own money. When money is exhausted he still manages by
selling his belongings. When all the sources are exhausted he starts stealing
and thus become anti social and a physically, mentally and morally
degenerate person.

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 THANATOLOGY
.

PRESUMPTION OF DEATH
 Presumption of 'death of a person is very important in relation to inheritance, insurance,
pension and other retirement benefits, service of spouse etc.
 As per Sec. 107 & 108 of Indian Evidence Act, a person who was alive within 30 years
and there is nothing to suggest the probability of his death, there is presumption that he
is still alive unless proof be given and that the same person has not been heard of for
seven years by those friends and relatives who would naturally have heard from him
that he has been alive, he is presumed to be dead. The onus of proving' it lies on the
persons who claim the fact.
PRESUMPTION OF SURVIVORSHIP
 The question of presumption of survivorship usually arises when two or more persons,
natural heir to property to each other, died in a same accident like shipwreck,
earthquake, air-crash, building collapse, traffic accident etc.
 In India, law does not consider any presumption regarding probability of survivorship
and each case is judged on its on merit.

DEATH
The living body depends on the integrity of three principle interdependent life systems
circulation, respiration and brain function (Bishop's Tripod of life) and failure of anyone of
them will eventually cause failure of the other two and this leads to the extinction of life of
the individual.
DEFINITION
 Black’s Law Dictionary defines death as “The cessation of life, the ceasing to exist”,
defined by physicians as total stoppage of circulation and cessation of vital functions,
thereupon such as respiration and pulsation.
 According to Section 46 of Indian Penal Code the word "death" denotes the death of a
human being unless the contrary appears from the context.
TYPES OF DEATH
1. SOMATIC or CLINICAL DEATH
 In this condition even though the patient is clinically dead. i.e. His vital organs are
not functioning, some of the cells are still living and respond to electric stimuli.
 Our body consists of billions of cells, all of which require two major components to
live: oxygen and energy. The oxygen circulated to these cells by our blood is used in
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 complex biochemical processes involving glucose or fatty acids to synthesise
adenosine triphosphate (ATP) which, when broken down, releases a tremendous
amount of energy.
 Because oxygen is crucial to the cell system, oxygen loss is critical and, unless
rapidly restored, will ultimately lead to cell death and disintegration.
 The first thing to occur when a person dies is that their heart ceases to function1.
Because the function of the heart is to maintain blood flow in the circulatory system,
when the heart stops beating, circulation of blood ceases as well. Simultaneously,
the person ceases to respire, putting a stop to the input of fresh oxygen into the
system. Without a supply of oxygen, the cells begin to die one by one.
 The first cells to perish are those that are most sensitive to oxygen levels - the
ganglionic cells in the central nervous system, responsible for transmission of
information in the body. Brain death - the death of parts of the brain-stem, also
known as the vital centres, involved in the maintenance of the respiratory and
circulatory systems - occurs within minutes of anoxia2. Death of less sensitive cells
follows3. Aerobic metabolic processes within these cells cease, although certain
anaerobic chemical processes may continue for several hours after death.
Ultimately, however, when the body temperature falls and waste products
accumulate, these processes too will fail.
 Somatic death can be certified if after a lapse of 4 to 5 minutes, when these facts
have been confirmed. If the heart is then restarted and respiration is maintained
artificially, the result is a very elegant heart-lung preparation whereby the heart has
really been made to function under optimal conditions of viability. Removal of these
beating hearts for transplants is called as 'Beating heart transplant'. So the legal
certification of death depends on the diagnosis of Somatic death and not on
component parts (Cellular death), which allows organ transplantation.
2. CELLULAR or MOLECULAR DEATH
 Where each and every individual cell of the body is dead.
 This is the irreversible loss of properties of the living matter, constitutes its death. It
involves the irreversible loss of its coordinated activities (Somatic death) or its
component parts (Cellular death).

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SUSPENDED ANIMATION or APPARENT DEATH
 Suspended animation is a state wherein metabolic needs of the body are at such a ebb
that the person appears apparently dead.
 His pulse is not palpable, hearts sounds are not audible, respiratory movements are not
visually perceptible, and reflexes are either absent or not possible to elicit.
 Such suspended animation, which usually lasts from a few seconds to less than 5
minutes.
 It may be encountered under the following circumstances:
A. Voluntary Act (death trance): Some persons are capable of voluntarily arresting their
circulation and respiration at will, for short periods of time for instance Yogis.
B. In Hypothermia.
C. Apparently drowned persons
D. After anesthesia in cerebral concussion
E. In electrocution
F. Sedative poisoning
G. In newborn infants
H. In shock and
I. In sunstroke
 In these conditions, circulation and respiration may be temporarily arrested, and must
not be mistaken for death. He can be revived back by resuscitation.
 Recognizing this condition is important in order to prevent premature certification of
death.

MODE OF DEATH
 This is the abnormal physiological state that existed at the time of death.
 According to Bichat there are THREE modes of death, namely
1. Coma: Failure of brain function.
2. Syncope: Failure of heart function.
3. Asphyxia: Failure of respiratory system.
MECHANISM OF DEATH
 The mechanism of death refers to the physiological changes that take place within the
victim leading to death.
 Examples might be cardiac arrhythmia, hemorrhage, or anoxia.

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 The same mechanism may be associated with multiple cause of death. E.g.
hemorrhage might be associated with a gunshot wound, or it may also be associated
with the rupture of a blood vessel that has been eroded by cancer.
MANNER OF DEATH
 The manner of a person's death is...in the final analysis...a legal determination or finding
based on evidence and opinion. It is usually routinely assigned, but it is always subject
to dispute/challenge and might not come to a truly finalized assignment until decided in
a court of law after all appeals are exhausted.
 There are six categories of manner of death:
1. Natural: the death is a consequence of natural disease.
2. Accidental: unintended and essentially unavoidable death, not by a natural, suicidal or
homicidal manner.
3. Suicidal: death caused by self, with some degree of conscious intent.
4. Homicidal: death caused by another human.
5. Undetermined: not enough evidence, yet or ever, to choose the manner of death.
6. Unclassified: too complex to classify; it either stays in that category or has to be clarified
and declared in a court of law.
CAUSE OF DEATH
 The cause of death is defined as the pathological condition that produced death in the
victim.
 Some examples of a cause of death might include arteriosclerotic cardiovascular
disease, pneumonia, pulmonary embolism, gunshot wound, and blunt force trauma.

BRAIN DEATH
It means permanent and irreversible cessation of function of brain or brain stem.
Types
1. Cortical or Cerebral death or Persistent vegetative state:
 Whole or part of the brain can be irreversibly damaged due to hypoxia, intracranial
haemorrhage, or trauma to the brain.
 If the cortex alone is damaged, the patient passes into deep coma, but the brainstem
continues to function and maintain spontaneous respiration. This state of the body is
known as Persistent vegetative state and can remain in this state for years until
death occurs from extension of cerebral damage to the brainstem or may be from
intercurrent infection.

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2. Brain-stem death:
 Where cerebrum may be intact, though cut off functionally by stem lesion.
 Raised intracranial pressure, cerebral oedema, intracerebral haemorrhage may lead
to such condition.
3. Whole Brain death:
This is when cortex and brain stem death occur. This is possible when brain stem is
damaged due to reasons such as trauma, haemorrhage, hypoxia etc, leading to
respiratory and motor systems to fail and damage the ascending reticular activating
system causing permanent loss of consciousness, and failure of higher centers in the
cortex irreversibly.

BRAINSTEM DEATH
 This refers to the death of those parts of the brainstem concerned with the maintenance
of breathing, blood pressure and the circulation of the blood, and it does not include the
death of the cortical areas of the brain, which could take place subsequently.
 Brain stem is situated in the floor of the aqueduct, between the third and fourth
ventricles of the brain and contains ascending reticular activating system.
 Function is to maintain full consciousness, which enables the cerebral hemispheres to
work in an integrated way.
 Brain death can be electrical silence of brain as per EEG. However in certain cases of
drug induced coma and metabolic coma where the electrical activity of the brain will be
nil which has to be ruled out.

DIAGNOSIS OF BRAINSTEM DEATH

BRAIN STEM DEATH DIAGNOSIS AS PER HARVARD CRITERIA (BRITISH CODE)
1. Preconditions:
 Comatose patient on a ventilator.
 Positive diagnosis of cause of coma. There should be no doubt that the patient's
condition is due to irremediable structural brain damage.
2. Exclusions:
The patient is in deep coma, which must be shown not to be due to the following:
 Depressant drugs
 Hypothermia (<34°C)
 Metabolic or endocrine disturbances.

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3. Tests: (It’s customary to repeat the tests. The interval between tests depends upon the
progress of the patient and might be as long as 24 hours)
 Absent brainstem reflexes.
 Apnoea demonstrated by apnoea test.

BRAINSTEM REFLEXES
1. Pupillary reflex: Pupillary response to light making the pupil to constrict.

Afferent: 2nd cranial nerve (Optic nerve).

Efferent: 3rd cranial nerve (Oculomotor nerve).

2. Corneal reflex: blinking response to corneal stimulation.

Afferent: 5th cranial nerve (Trigeminal nerve).
Efferent: 7th cranial nerve (Facial nerve).

3. Eye movement:
It includes the following:
A. Oculocephalic reflex = doll’s eyes (deviation of the eyes to the opposite side of
head turning).
B. Vestibulo-ocular reflex or cold caloric test (Eye movement in response to irrigation
of tympanic membranes of the ear with ice cold water)
Afferent: 8th cranial nerve (Vestibulo-cochlear nerve).
Efferent: 3rd & 6th cranial nerve (Oculomotor & Abducent nerve).

4. Grimace reflex: Painful stimulus over face resulting in wrinkling over face.

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 Afferent: 5th cranial nerve (Trigeminal nerve).
Efferent: 7th cranial nerve (Facial nerve).

5. Gag / cough reflex: Gagging in response to intubation.

Afferent: 9th cranial nerve (Glosso-pharyngeal nerve).
Efferent: 10th cranial nerve (vagus nerve).

If all the reflexes are absent it confirms the fact that the brain stem is dead.

APNOEA TEST
 To prevent anoxia in the patient one must pre-oxygenate the patient thoroughly before
the test. This is done by administrating 100% oxygen for 10 Minutes then making the
subject to breath a mixture of 95% oxygen and 5% carbon dioxide. Before
disconnecting, estimate carbon dioxide in the arterial blood which should be below the
level of 50 mm of Hg.
 Disconnect the patient from the ventilator for a period of ten minutes and allow carbon
dioxide to buildup to a point to trigger off respiration if the respiratory center is
functioning.
PANEL OF EXPERTS AUTHORIZED TO CERTIFY BRAINSTEM DEATH
The panel comprises of following FOUR medical experts:
1. The Registered Medical Practitioner treating the patient whose death has to be certified
as brainstem.
2. The Registered Medical Practitioner in charge of hospital in which brainstem death has
taken place.
3. Neurologist/Neurosurgeon nominated from the panel of names approved by an
appropriate authority.
4. An Independent Medical Specialist nominated from the panel of names approved by the
appropriate authority.

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SUDDEN DEATH
 An instant unexpected death or A death that occurs within one hour of the onset of
symptoms. (Clinical Definition)
 Sudden death is defined as termination of life which comes suddenly within 24 hours
from the onset of terminal illness, other than unnatural deaths. (WHO)
MEDICO-LEGAL SIGNIFICANCE OF SUDDEN DEATH
 In case of sudden deaths, it becomes a problem for a medical practitioner and unless
having strongest evidence, he should not issue a death certificate but advice for a
medico-legal autopsy.
CAUSES OF SUDDEN DEATH
1. Central nervous system:
a. Cerebrovascular accident-Haemorrhage, thrombosis etc.
b. Fulminating type of viral encephalitis and meningitis.
c. Rupture of Berry Aneurysm (one of the commonest) at the 'Circle of Willis'.
d. Cerebral abscess, cerebral tumor, pontine haemorrhage etc.
2. Causes relating to neck:
a. Angio-neurotic oedema of the glottis.
b. Rupture of laryngeal tumor.
3. Causes related to heart:
a. Coronary thrombosis and its sequelae (rupture cordis) cardiac aneurysm.
b. Congenital and acquired valvular diseases.
c. Non-coronary cardiomyopathy (due to drugs, diet. bacterial action etc.).
d. Acute pericardial effusion and cardiac tamponade.
e. Rupture of Aortic aneurysm.
4. Causes related to respiratory system:
a. Rupture of emphysematous bullae.
b. Severe haemoptysis in a case of pulmonary tuberculosis, bronchogenic carcinoma
etc.
c. Pulmonary embolism (one of the commonest causes).
d. Rupture of lung abscess and pulmonary atelectasis.
5. Causes relating to gastrointestinal system:
a. Rupture of oesophageal varices.
b. Pathological perforation of stomach.
c. Pathological rupture of spleen.

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 d. Rupture of a liver abscess.
e. Fulminating type of viral hepatitis.
f. Acute haemorrhagic pancreatitis.
g. Acute intestinal obstruction.
6. Causes relating to genitourinary system:
a. Acute nephritis.
b. Testicular torsion.
c. Pathological rupture of gravid uterus, rupture of ectopic pregnancy, torsion or rupture
of an ovarian or para-ovarian cyst.
7. Miscellaneous (systemic causes) :
a. Death due to vagal inhibition (Physiological sudden death).
b. Anaphylactic shock.
c. Metabolic disorder (e.g. diabetic coma, uraemic coma, sudden hypoglycaemia).
THANATOLOGY
Thanatology is a branch of science that deals with the study of death. It is important to
recognize the changes that take place in the body after death. Proper interpretation of
these postmortem changes help in estimating the time that has elapsed since death.
MEDICO-LEGAL SIGNIFICANCE STUDYING POSTMORTEM CHANGES
1. Civil Cases:
A. Transfer of property.
B. Insurance claims.
2. Criminal Cases:
Helps to break the alibi
Establishing the times of an assault and death has a direct bearing on the legal
questions of alibi and opportunity. If the suspect is able to prove that he was at some
other place when the fatal injury was inflicted then he has an alibi and his innocence is
implicit. Conversely, if the time of a lethal assault coincides with the time when the
suspect was known to be in the vicinity of the victim, then the suspect clearly had an
opportunity to commit the crime.

SOURCES OF EVIDENCE FOR DETERMINING POSTMORTEM INTERVAL Sources of

evidence for determining postmortem interval can be studied under following:
 Corporal evidence - present in the body.
 Environmental and associated evidence - at the site of crime.

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  Anamnestic evidence i.e. that based on the deceased's ordinary habits,
movements, and day to day activities.

POSTMORTEM CHANGES
Postmortem changes can be studied under following:
IMMEDIATE POSTMORTEM CHANGES:
 Absence of EEG rhythm
 Cessation of respiration
 Cessation of circulation
 Primary muscular flaccidity
 Eye changes

EARLY POSTMORTEM CHANGES:

 Postmortem cooling
 Postmortem lividity
 Rigor mortis
 Biochemical changes in the body fluids

LATE POSTMORTEM CHANGES:

 Decomposition (Autolysis + Putrefaction)
 Modification of putrefaction: e.g.: Adipocere Or Mummification
 Larval invasion of the body Or Forensic Entomology

ABSENCE OF EEG RHYTHM

Even though it is considered to be best test of brain death, for practical applicability, it is not
feasible.

CESSATION OF RESPIRATION
Stoppage of respiration for more than 3-5 minutes will signify the death of the subject,
though voluntary stoppage of respiration even for 10 minutes, is not unusual, as seen in
cases of persons doing yogic exercises and the professional pearl and sponge divers of
southern coastal India.

CESSATION OF CIRCULATION
Total stoppage of circulation for more than 5 minutes is considered to be one of the
immediate sign of death, but, under certain circumstances, even after total stoppage of
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respiration, heart may continue beating for even more than 10 minutes and may be up to
15 mins, as in cases of judicial hanging, sudden beheading, etc.

PRIMARY MUSCULAR FLACCIDITY

 Muscle loses their tonicity and become flaccid, loose and lax
 The jaw drops, limbs fall flat and sphincter relax
 But muscles are capable of responding to electrical and mechanical stimuli.
 Even though it is considered to be the earliest sign of death this is not considered to be
the positive sign because it is seen even in cases of deep coma and narcosis.
EYE CHANGES
Eye changes can be grouped under external and internal changes:
A. External changes.
B. Internal changes.
EXTERNAL EYE CHANGES
 Loss of Corneal luster:
Cornea looses its luster and becomes dull and hazy, due to drying and if the lids are
closed this process is delayed.
 Loss of Corneal reflex:
Blinking response to corneal stimulation lost.
 Tache Noire De La Sclerotique:
 It is triangular in shape and present over the Cornea, The base of the triangle will be
along the sclero-corneal junction, and is actually formed by drying and deposition of
dust and debris over the sclera, if the eye was left half open at the time of death.
 It may sometime look like an antemortem injury.
 Pupillary changes:
 Immediately after death, pupil will become dilated and fixed because of the
relaxation of muscles of the iris. Pupils are not reacting to light.
 After rigor-mortis sets in, it will become little contracted, but still not reacting to light.
 After rigor mortis has passed off, it becomes again dilated.
 The pupil reacts to atropine for about an hour after death.

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INTERNAL EYE CHANGES
 Retina:
Retina is pale for the first 2hrs. At about 6hrs the disk becomes hazy and then blurred
by 7 to l0hrs.
 Trucking or Segmentation of retinal vessels:
 It can be appreciated using ophthalmoscope.
 Immediately after death, if eye is tested by an ophthalmoscope, will show the
immediate fragmentation of retinal vessels and the column of blood in the retinal
vessels. This is compared to rail-roading movement or unbreaked goods-wagon like
breaking.
 The sign is considered to be the best sign of brain death.
 Flaccidity of eyeball:
 The normal intraocular tension is 14-25 gm of water.
 Immediate after stoppage of heart beat, intraocular tension falls below 12 gm, within
1/2 hour it falls to 3 gm and in 2 hours, it becomes zero.
 Chemical changes in vitreous humor:
 Steady rise in K+ of vitreous humor after death,
 Ascorbic acid concentration-which is said to be the highest in the body in vitreous
humor-falls over a period of 20 hrs of death.

POSTMORTEM COOLING OF THE BODY

 Synonyms: Algor Mortis (Latin: algor—coolness; mortis—of death)
 Normal body temperature:
 Oral- 980 F (370 C)
 Axilla- 970 F (360 C)
 Rectum- 990 F (380 C)

 During life a balance between heat production and dissipation (by convection,
conduction and radiation) maintain the body temperature more or less at a constant
level.
 Estimation of time since death based on postmortem cooling is only useful in places
having temperate and cold climate not in tropical countries like ours (because in
temperate and cold climate body loses heat so long as there is vide variation between
body temperature and that of body)

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 Normally after death, the body cools at a rate of about 20 F per hour during 1st hour;
about 10 F next 12 hours.
MEDICO-LEGAL SIGNIFICANCE
 Estimation of time since death using Glaister’s formula
Normal body temperature (37.2 oC) – Rectal temperature
Time since death in hours = ----------------------------------------------------------------------
Rate of fall of temperature/hour

METHODS OF RECORDING
 Using Chemical thermometer (An ordinary clinical thermometer is useless because its
range is too small and the thermometer is too short. A chemical thermometer 10-12"
long with a range from 0-50 o Celsius is ideal).
 by inserting it into the rectum.
 by inserting it into the intra-abdominal region (sub-hepatic).
 Modern methods using- Thermoelectric couple.
 Henssge Nomogram Method.

“SIGMOID SHAPE CURVE” or “S – SHAPED CURVE” OF POSTMORTEM COOLING

Body
temperature

Environmental temperature

Upper flattened part of the curve because the metabolic heat production does not cease
uniformly and some heat generation continues for sometime after death due to cellular
metabolism, mainly in the liver. Therefore, the surface may start losing heat immediately
after death but the ‘inner core’ of the body cannot begin to cool until a ‘temperature
gradient’ is set up and hence the rectal temperature will not show any fall for sometime

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after death. This is responsible for initial plateau. This plateau is followed by a sudden drop
of temperature curve corresponding to the period of quickest cooling and finally the graphs
flattens at the end as the temperature differential between body and environment becomes
zero. This explains the sigmoid nature of the curve.

HENSSGE NOMOGRAM
 The best researched and documented method for assessing time of death from body
temperature is that of Henssge.
 This is a nomogram method rather than a formula.
 The nomogram corrects for any given environmental temperature. It requires the
measurement of deep rectal temperature and assumes a normal temperature at death
of 37.2o C.
 Henssge's nomogram is based upon a formula which approximates the sigmoid shaped
cooling curve. This formula has two exponential terms within it.
 The first constant describes the post mortem plateau and the second constant
expresses the exponential drop of the temperature after the plateau according to
Newton's law of cooling.
 Henssge evolved two nomograms, the one for ambient temperatures above 23oC and
the other for ambient temperatures below 23oC.
 Within each of these two nomograms there is a differing allowance for the effect of
environmental temperature on the rate of cooling as well as an allowance for the effect
of body weight.
 For environmental temperature below 230C:
- 0.625
Death time (t): Trectum - Tambient = 1.25 exp (Bt) – 0.25 exp (5 Bt); B= - 1.2815 (kg ) + .0284

37.2 - Tambient

 For environmental temperature above 230C

- 0.625
Death time (t): Trectum - Tambient = 1.11 exp (Bt) – 0.11 exp (5 Bt); B= - 1.2815 (kg ) + .0284

37.2 - Tambient
FACTORS INFLUENCING THE POSTMORTEM COOLING OF THE BODY

1. Temperature of the body prior to death:

All formulae of calculating time since death considers body temperature as being 37C.
Therefore following points complicates the accuracy of such calculations,
 Temperature varies from time to time & person to person

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  Temperature may rise at the time of death in conditions like- asphyxial death, fat
embolism, heat stroke, septicemia, drug reactions and in cerebral hemorrhage.
 Temperature may be lowered at the time of death in conditions like- cholera,
congestive cardiac failure, massive hemorrhage.

2. Temperature difference between body and the surrounding:

The rate of cooling of the body is roughly proportional to the difference of temperature
between the cadaver and its surroundings. The greater is difference between the two,
more is the rate of flow.
3. Clothing’s and Coverings:
 Conduction and convection are markedly reduced by clothing’s. These insulate the
body from the environment and therefore cooling is slower.
 Simpson states that cooling of a naked body is half again as fast as when clothed.
 Henssge has graded the effect of clothing by the number of layers and thickness. He
states that only the clothing or covering of the lower trunk is relevant.
 Wet clothing’s will accelerate cooling because of uptake of heat for evaporation.
4. Body built:
 The greater the surface area of the body relative to its mass, the more rapid will be
its cooling. Consequently, the heavier the physique and the greater the obesity of
the body, the slower will be the heat loss.
 In obese individuals the fat acts as an insulator, but for practical purposes body
mass, whether from muscle mass or adipose tissue, is the most important factor.
Children lose heat more quickly than adults because their surface area/mass ratio is
much greater.
 Prominent oedema in individuals with congestive cardiac failure is said to retard
cooling because of the large volume of water present with a high specific heat whilst
dehydration has the opposite effect. The effect of oedema fluid is said to be more
potent than body fat.
 The exposed surface area of the body radiating heat to the environment will vary
with the body position. If the body is supine and extended, only 80% of the total
surface area effectively loses heat, and in the fetal position the proportion is only
60%.
5. Movement and humidity of the air:
 Air movement accelerates cooling by promoting convection and even the slightest
sustained air movement is significant.

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  Cooling is said to be more rapid in a humid rather than dry atmosphere because
moist air is a better conductor of heat.
 The humidity of the atmosphere will affect cooling by evaporation where the body or
its clothing is wet.
6. Immersion in water:
 A cadaver cools more rapidly in water than in air because water is a far better
conductor of heat.
 For a given environmental temperature, cooling in still water is about twice as fast as
in air, and in flowing water, about three times as fast.
 Clearly the body will cool more rapidly in cold water than warm water.
 It has been said that bodies will cool more slowly in water containing sewage effluent
or other putrefying organic matter than in fresh water or sea water.

POSTMORTEM CALORICITY
It is a condition where there is a rise of body temperature after death instead of cooling of
the body.
EXPLANATION
 Glycogenolysis, which occurs in all dead bodies soon after death, can raise the body
temperature by about 2 degree C, but in postmortem caloricity temperature shows
further rise.
 The rise in body temperature occurs due to various reasons:
a. Heat regulating center has been disturbed before death such as in cases of heat
stroke.
b. Increased heat production in muscles due to convulsions in cases of tetanus and
strychnine poisoning
c. Deaths due to excessive bacterial activity like septicemia.
 Following are the some of the examples for postmortem caloricity cited in the literature:
 The body temperature may be raised at the time of death in heat stroke, some
infections, and pontine haemorrhage.
 Simpson cites a personal observation of a case of pontine haemorrhage with an
initial temperature at death of 42.8oC (109oF) and another instance of a
temperature of 37.4oC (99.4oF) about three hours after death in a case of manual
strangulation. However, another author claims that there is no convincing proof
that asphyxia by strangulation leads to a raised agonal temperature.

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  Where there is a fulminating infection, e.g. septicaemia, the body temperature
may continue to rise for some hours after death.

POST-MORTEM HYPOSTASIS
 Synonyms:
 Post-mortem staining.
 Post-mortem lividity.
 Livor mortis (Latin: livor—bluish color, mortis—of death).
 Post mortem suggilation.
 Lucidity.
 Cogitation.
 After death, due to stoppage of heart, fluid blood in the vessels gradually gravitate down
on the dependent parts of the body, except over the areas of contact flattening and
show up through the skin as purplish blue areas of discoloration and is known as post-
mortem staining.
 Like external post-mortem staining, hypostasis will also appear in the internal viscera
and will appear as a dark zone on the dependent part of the viscera.
 But there are instances wherein postmortem lividity can be seen in living. E.g., in a
slowly dying person, dying after terminal illness with prolonged circulatory failure like
congestive cardiac failure.

TIME OF APPEARANCE
 Usually in adult healthy individuals it starts appearing within ½ -1 hour, as patchy areas
of discoloration which gradually coalesce forms completely within 2 hours.
 After 6-8 hours, due to intravascular clotting of blood, collapse of major vessels and
rigor mortis the post-mortem staining becomes fixed and will not change its position
with alteration of change of position of the body.

DEMONSTRATION OF POSTMORTEM LIVIDITY

 By application of thumb pulp pressure over the lividity area for 30 seconds will not
cause blanching of that area indicating its fixation. If there is blanching it indicates its
appearance but not fixation.
 Evaluation of hypostasis using calorimetric measuring systems.

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FACTORS MODIFYING FORMATION OF POST-MORTEM STAINING
1. It depends upon presence of amount of fibrin or fibrino-lysin in the blood.
2. Amount of still fluid blood present in the circulation. ..

CONDITIONS WHERE POST-MORTEM STAINING WILL NOT BE VISIBLE

A. In dark complexioned person: Though postmortem staining appears, it will not be easily
visible due to darkness of complexion.
B. In severely anemic person or a person dying following to severe hemorrhage.
C. In the bodies, which keeps on rolling and frequently changing position, may not develop
postmortem staining (e.g., drowning death in a turbulent flowing water).
D. Those parts of the body on which the body rests on the surface they lie on (shoulder
blades, buttocks, calves etc.), does not reveal any hypostasis. These areas are termed
as areas of contact flattening. This is because of the compression of toneless capillaries
resulting in driving out of the blood.

ARETEFACTS OF POSTMORTEM STAINING

 Unstained area in between the stained areas may mislead an autopsy surgeon, as in a
case of a body kept in prone or supine position and the person wearing a tight collar,
post-mortem staining may not appear along that band and the case may appear like a
strangulation mark.
 Although livor mortis may be confused with bruising, bruising is rarely confused with
livor mortis. Livor mortis can be differentiated from bruising in following points:
 Application of pressure to an area of bruising will not cause blanching.
 An incision into an area of contusion or bruising shows diffuse hemorrhage into
the soft tissues. In contrast, an incision into an area of livor mortis reveals the
blood to be confined to vessels, without blood in the soft tissues.
 Postmortem lividity in the certain internal organs can mimic pathology:
 Lividity in lungs mimics Pneumonia.
 Lividity in the heart mimics Myocardial Infarction.
 Lividity of intestinal coils mimics intestinal ischemia.

MEDICO-LEGAL IMPORTANCE OF POST-MORTEM STAINING

1. It helps in the determination of time since death.
2. It gives an idea about the position of the individual immediately after death.

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 This settling of blood in the dependent parts of the body is in accordance with the law of
gravity.
 If the body is in supine position the postmortem lividity is seen on the back.
 In death due to hanging (if body remains suspended for a considerable amount of
time), lividity is seen on the hands, feet, and the lower parts of the face above the
ligature.
 In drowning (normal floating position of dead body with back facing up and the limbs
dropping down, the lividity seen over the limbs, abdomen and the face.
 The hypostasis at two unrelated dependent areas indicate that the body has been
shifted from original position before being completely fixed.
3. It gives idea about the cause of death:
Normal color of post-mortem staining is purplish blue and, in certain cases of poisoning
color of post-mortem staining will indicate cause of death as follows:
 In carbon monoxide poisoning staining will be cherry red or cherry pink in color.
 In hydrocyanic acid poisoning it will be bright red in color.
 In potassium chlorate, potassium bicarbonate, nitrobenzene, aniline dyes it will be
chocolate brown or coffee brown in color.
 In phosphorus and phosphate poison it will be in dark brown in color.
RIGOR-MORTIS or CADAVERIC RIGIDITY
It is a state of post-mortem stiffening of voluntary and involuntary muscles of the body with
apparent shortening which appears after the stage of primary flaccidity-it appears after a
variable period after death.
MECHANISM OF FORMATION OF RIGOR MORTIS
 Following death, the muscles become initially flaccid (is known as primary flaccidity,
which lasts for 1 to 2 hours) and the lower jaw extremities can be passively moved.
 The flaccidity is followed by an increasing stiffness or rigidity of the muscular mass,
which freezes the joints and is known as postmortem rigidity or rigor mortis. The rigidity
then gradually subsides, and the body becomes flaccid again.
 The physio-chemical changes after death, which are responsible for formation of rigor
mortis are:
 The rigor mortis affects all the muscles in the body, both skeletal and smooth.
 The muscle mass is made up of a number of bundles of long fibers which are
nothing but packed myofibrils, the contractile elements. These myofibrils are

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 made up of actin and myosin filaments, which are interdigitated in a loose
physiochemical combination.
 During life, the separation of the actin and myosin filaments, and the energy
needed for contraction are dependent on adenosine tri phosphate (ATP). This
energy in the form of ATP is used for muscle contraction. Normally ATP inhibits
the activation of the linkages between actin and myosin; a fall in the level of
ATP allows the irreversible development of these linkages ATP loss is
replenished during life by resynthesis. Thus, there is no difficulty in subsequent
contraction of the muscle.
 But after death, there is no further recycling of ATP and the available level of
ATP falls progressively-this results in loss of power to contract on application of
stimulus and also suppleness and elasticity of muscle is lost. It is being
observed that there may be some degree of resynthesis from reduction of
Pyruvic acid and Lactic acid, being produced anaerobically when supply of
oxygen is not available and, as long as this equilibrium is maintained, Rigor-
mortis will not develop. Enough ATP is present at the time of primary relaxation.
When ATP levels start falling the muscles get rigid and it is maximum when the
fall is 15% of the normal.
 Rigor-mortis develops irrespective of nerve supply (develops even in paralyzed
limbs), so it is actually a biophysical process.
Actin
Myosin

Relaxed muscle

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 Contracted muscle

Muscle in Rigor

DEVELOPMENT OF RIGOR MORTIS

 The Rigor mortis appears first in the voluntary muscles; the myocardium become rigid in
an hour.
 In the voluntary muscles rigor mortis noticeable in the eyelids, then the muscles of the
face, jaw and neck. Then it seen to affect the muscles of the chests, upper limbs,
abdomen and lower limbs and lastly in the fingers and toes.
 Rigor-mortis can be elicited in the following sequence-muscles of eye-face-neck-trunk-
upper extremity-lower extremity-and last to appear-in small muscles of fingers and toes.
When disappearing, it follows the same sequence.
 This proximo-distal progression and disappearance of rigor is more apparent than real.
Because in reality smaller muscles having less muscle mass and less glycogen
reserves (fingers and toes) are first to be affected than the larger muscles thus
contradicting the myth of its progression.

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 Shapiro, has suggested that this apparent progression through the muscles of the body
reflects the fact that although rigor begins to develop simultaneously in all muscles, it
completely involves small masses of muscle much more rapidly than large masses.
TIMING OF RIGOR MORTIS
 In involuntary muscle rigor mortis first appears in the muscles of the eye lids (orbicularis
oculi) towards the end of the first hour after death
 In voluntary muscles its sequence is as follows:
 Muscles of eyelids: 3 to 4 hours.
 Muscles of face: 4 to 5 hours.
 Muscles of neck, trunk: 5 to 7 hours.
 Muscles of upper extremity (thorax, upper limb and abdomen): 7 to 9 hours.
 Muscles of leg: 9 to 12hours.
 Under the average condition, rigor becomes apparent within half an hour to one hour
and fully develop by 12 hours and starts disappearing progressively within next l2 hours.
This phenomenon is similar in all muscles. This is termed as “Rule of Twelve” or “March
of Rigor”.
 Thus, if the entire body is stiff, the time since death is more than 12 hours. If the upper
part of the body is relaxed and the lower part of the body is stiff, it means that the rigor
is passing off and the time since death is more than 24 hours but less than 36 hours. If
the body is warm and relaxed the time since death is less than two hours (because, the
cooling of the body has not yet started and the muscles are in a state of initial flaccidity).
On the other hand if the body is cold to touch and relaxed (flaccid) the time since death
is more than 24 hours, as cooling of the body is completed and the muscles are in a
state of secondary flaccidity.
 With the passing away of the rigor, the muscles once again become softened. This is
the phase of secondary flaccidity.

THEORIES OF RIGOR MORTIS DISAPPEARANCE

Various theories of disappearance of rigor-mortis are:
1. Formation of excess amount of lactic acid, which dissolves the gel-like acto-myosin in
the tissue, thus making the muscles loose and lax.
2. Formation of excessive alkaline juice, due to onset of decomposition, resulting into
solution of actin-myosin gel formed.
3. Due to autodigestion of the tissues, by enzymes of the body.

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CONDITIONS MODIFYING ONSET AND DURATION OF RIGOR MORTIS
1. Condition of body:
Rigor-mortis appears early and passes-off early in thinly-built bodies. It appears late and
passes after a longer period in muscular and healthy subjects.
2. Age:
 Rigor-mortis appears early and passes off early in children and old people (because
of the lesser muscle mass).
 It appears late and persists longer in cases of dead bodies of young adults (because
of the larger muscle mass and good glycogen reserve).
3. Conditions of muscle before death:
Rigor mortis will appear early and pass-off early in the muscles, which were subjected
to excitability and exhaustion before death (because of ATP depletion). Hence Rigor
mortis appearance and disappearance is accelerated by prior exercise, convulsion
(strychnine poisoning, tetanus), electrocution, hyperpyrexia, asphyxial death or hot
environmental temperature.
3. Environmental condition:
 Warm weather enhances formation of rigor-mortis and its continuation will also be
shortened.
 In cold weather, the onset and duration of rigor-mortis will be delayed; temperature
less than 10°C (40°F) can delay onset of rigor-mortis indefinitely.

4. Cause of death:
 Rigor-mortis usually sets in early in deaths due to cholera, typhoid, TB, uremia,
plague and cancer and also in chronic nephrites.
 It is delayed in cases of death due to pneumonia, asphyxia, arsenic and carbon
dioxide poisoning, mercuric chloride poisoning and in death where muscle paralysis
(e.g. hemiplegia) occurred before death.

ARTEFACTS OF RIGOR MORTIS

Rigor mortis develop in involuntary muscles also giving artefactual reference for example in
the muscles of the iris, causing dilatation of pupils, erector pilae causing gooseflesh or cutis
anserine, contraction of seminal vesicles, semen maybe forced out of it.

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MEDICO-LEGAL IMPORTANCE OF RIGOR MORTIS
1. It helps in the determination of time since death based on the appearance and
disappearance of rigor mortis.
2. It gives an idea about the position of the individual immediately after death. This is
based areas of contact flattening.
3. It gives a clue regarding whether there was any effort to shift the body in a particular
position: If a body is moved before the onset of rigor then the joints will become fixed in
the new position in which the body is placed. For this reason, when a body is found in a
certain position with rigor mortis fully developed, it cannot be assumed that the
deceased necessarily died in that position. Conversely, if the body is maintained by
rigor in a position not obviously associated with support of the body, then it can be
concluded that the body was moved after rigor mortis had developed.
4. It gives some idea about the cause and nature of death, assessing the modifying
factors.

CONDITIONS SIMULATING RIGOR MORTIS

There are 4 conditions which may simulate rigor-mortis, but of these two (heat & gas
stiffening) can be differentiated just by visual examination:
1. Cadaveric spasm or Instant rigor.
2. Cold stiffening.
3. Heat stiffening.
4. Gas stiffening.

DIFFERENCES BETWEEN RIGOR MORTIS AND CADAVERIC SPASM

Rigor mortis Cadaveric spasm

Occurs half to one hour after death. Is instantaneous in onset.

Is confined to a small group of muscles

Occurs all over the body.
only.

Involves voluntary and involuntary muscles. Occurs only in voluntary muscles.

Not so. Certain pre - conditions are

Occurs in all deaths.
necessary for its formation.
Degree of stiffening not marked, i.e., rigor Degree of stiffening very marked. So great
can be broken. force is necessary to break it.
Underlying mechanism not clearly
Underlying mechanism known.
understood.

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CADAVERIC SPASM
 Synonyms: instantaneous rigor, instantaneous rigidity, cataleptic rigidity.
 It can be defined as a state of continuation of antemortem contraction of group of
muscles, which continues after death, without passing through the initial stage of
primary relaxation.
 This involves usually to a single group of muscles and frequently involves the hands;
occasionally whole body as seen in the soldiers dead in battle where the body retains
the posture, which it assumed at the moment of death.
 Cadaveric spasm is seen in a small proportion of suicidal deaths from firearms, incised
wounds, and stab wounds, when the weapon is firmly grasped in the hand at the
moment of death. This state cannot be reproduced after death by placing a weapon in
the hands. It is also seen in cases of drowning when grass, weeds, or other materials
are clutched by the deceased. In this circumstance, it provides proof of life at the time of
entry into the water. Similarly, in mountain fatalities, branches of shrubs or trees may be
seized.
 This condition, though of unknown cause, usually associated with violent deaths having
emotional aspect.

COLD STIFFENING
 Usually it occurs when body is exposed to freezing temperature i.e. sub zero
temperature immediately after death
 This stiffening is due to freezing of muscles, tissues and the fluid present, which
usually gets frozen at 2.5°-4°C. There will be icicle formation in the joint spaces
which will give a crackling feel during demonstration of rigor.
 If the body is taken off the cold area (e.g. cold chamber) and kept in a rather
warmer area (thawing) gradually the stiffening passes off and rigor-mortis starts
appearing.

HEAT STIFFENING
 This stiffening and shortening of muscles occur when the body is exposed to high
temperature resulting into coagulation of muscle protein.
 It is usually seen when the body is exposed for a considerable time to a temp
more than 65°C or even for a shorter time in a temperature of much higher
degree. This take a posture of flexed limbs and arms at knees and elbows giving
the appearance of a pugilist, hence known as pugilistic attitude.
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GAS STIFFENING
 Gas stiffening in a body, occurs when the body goes into a stage of putrefaction
and the putrefactive gases collects into the tissues-space, as well as joint-space
and due to this, the body gets stiffened.
 Medico-legal importance of rigor-mortis:
1. It helps in the determination of time since death.
2. It gives an idea about the place of death.
3. It gives some idea about the cause and nature of death, assessing the
modifying factors.

DECOMPOSITION

 It usually follows disappearance of rigor mortis. It is the final stage of dissolution

of the body tissues resulting in the breakdown of complex organic compounds in
to simpler forms (inorganic compounds) by the action of bacteria, fungi and
protozoa etc.

 Decomposition involves Autolysis and Putrefaction.

 Autolysis (Auto=self; lysis=destruction) is an aseptic process where organic

compounds are broken by the enzymes of the body. Immediately after death,
there is breakdown of cell membranes and they also become permeable. The
lytic enzymes present in the cytoplasm are released causing autodigestion of
the cells and tissues. This autodigestion occurs without any bacterial
influence.
 Putrefaction is brought about mainly by the action of anaerobic bacterial
enzymes, fungi and insects. Putrefaction is brought about mainly due to the
action of: (i) Anaerobic bacterial enzymes (CI. Welchii, B. proteus, B coli,
Streptoccocus, staphylococcus), Coliform organisms, Micrococci, Diptheroids
and Proteus organisms. These organisms normally present in respiratory or
intestinal tracts. (ii) Anaerobic fungi (iii) Insect larvae (proteolytic enzyme
system) (iv) Protozoa (v) Adult insects. The agent commonly responsible is
CI. welchii that causes hemolysis, liquefaction of postmortem clot, emboli,
thrombi, breakdown of tissues and gas formation.

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MECHANISM OF PUTREFACTION
 Shortly after death bacterial and coliform organisms make their way into the
tissues from the gastrointestinal tract through the blood vessel, respiratory tract
and open skin wounds.
 Blood acts as a good media for distribution of these organisms and it also
provides nutrition to them.
 The fall in oxygen concentration and rise of hydrogen favors bacterial growth and
their spread.
 Bacteria liberate a number of enzymes, one such enzyme is lecithinase liberated
by CI. Welchii that hydrolyses the lecithin, which is present in all cell membranes
including the red blood cells. This enzyme is responsible for postmortem
haemolysis of blood.
 During the process of putrefaction the soft -parts of the body are affected first and
the bones are affected much later.

 Following changes are brought about after death due to putrefaction:

 Color changes

 Evolution of foul smelling gases

 Effects produced by pressure of the gases (bloating, distension, blisters and

purge)

 Conversion of soft parts in to thick semifluid black mass which separates from
the bones and fall off leaving the skeleton exposed (colliquative putrefaction).

COLOUR CHANGES

 Hemolysis occurs within the vessel at an early stage of putrefaction. When the
hemoglobin is released from the hemolysed red cells, it diffuses through the
vessel wall and stains the surrounding tissues, a red or reddish brown colour. In
the tissues, the hemoglobin undergoes chemical changes and various derivatives
of hemoglobin are formed. These derivatives include sulphur containing
compounds and the tissues gradually change to a greenish-yellow, greenish-
blue, or greenish-black colour.

 The earliest external sign of putrefaction is a greenish discolouration of the skin

over the region of the right iliac fossa. It is due to the presence of caecum that

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 lies superficially and close to the abdominal wall. As the contents of the caecum
are more fluid and full of bacteria that is why it develops putrefaction at the
earliest. The greenish discolouration is due to the change in the blood pigment
and as a result of formation of sulphmethaemoglobin which is formed by the
action of hydrogen sulphide (liberated by the bacterial action) on haemoglobin.
The putrefaction then spreads to other parts of the body. The colour appears in
12 to 18 hours. The green colour changes to dark green and later purple or dark
blue with the passage of time. The colour change is more marked in a fair
complexioned body.

 Marbling of the skin: The marbling of skin occurs due to haemolysis and
decomposition of blood in the superficial veins of neck and chest that stains the
vessel walls. It appears as purplish red, bluish or greenish streaks against
background of black or green skin. The marbling of skin occurs in 24 to 36 hours.

EVOLUTION OF GASES IN THE TISSUES

During this stage, the proteins and carbohydrates are split into simpler compounds.
As a result, a number of gases such as hydrogen sulphide, phosphorated hydrogen,
methane, carbon dioxide, ammonia and hydrogen are formed during the process.
The offensive odor emitting out of a dead is due to formation of hydrogen sulphide
gas and Mercaptans. In the early stages the gases are noninflammable but as
putrefaction progresses lots of hydrogen sulphide is formed which can be ignited to
burn with a blue flame. The gases are collected in the intestine within 12 to 18 hours.

Effects of gases:
 Bloating features: The gases at different places render the body bloated and
distorted. In the advanced stages, identification becomes impossible, the face is
swollen and discoloured, eyes bulge out and tongue protrudes out caught
between the teeth. The lips are swollen and the tissues of the neck become
swollen. The breasts become distended and scrotum and penis are swollen.
 Distension of abdomen: The abdomen becomes distended and on opening a
noise is heard due to release of gases.
 Formation of blisters: There is blister formation at different parts of the body that
contains reddish fluid and blood and there is slippage of skin at different places.

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 This is caused by the gas pressure forcing the blood stained fluid, air or liquid fat
between the epidermis and dermis.
 Postmortem purge: Extrusion of fluid from mouth and nostrils along with stomach
contents is known as postmortem purge. There is escape of urine and faeces
and prolapse of the rectum as the sphincters relax. In advanced stage of
putrefaction, expulsion of fetus occurs from the uterus because of the pressure of
the gases it contains.

COLLIQUATIVE PUTREFACTION

Colliquative putrefaction is conversion of soft parts into a thick semifluid black mass.
Walls of abdomen becomes soft and burst open as a result the stomach and
intestine comes out. In the final stage of putrefaction, cartilage and ligaments are
softened.

PUTREFACTION OF INTERNAL ORGANS

Internally, decomposition proceeds at the same rate as is seen externally.

Putrefaction of internal organs depends upon firmness, moisture content, density
and quantity of blood. The blood decomposes and the colouring matter transudes
into tissues colouring them. The viscera becomes softened and greasy. The
changes seen are:

 Larynx and trachea: Their mucous membrane becomes softened and colour
changes to brownish red and later on greenish.

 Stomach and intestine: They show dark red to brownish patches first on the
posterior wall and then on the anterior wall. The mucosa appears macerated and
the whole intestine becomes a dark soft pulpy mass.

 Spleen: It softens and liquefies in two to three days.

 Liver: Liver softens and becomes flabby in 12 to 24 hours in summer. Blisters

appear on its surface in 24 to 36 hours. Clostridium welchii form characteristic
small clumps in a tissue space and produce gas, which soon increases in size.
These lesions appear first as small, opaque, yellowish grey, dendritic figures in
the parenchyma. When bubbles develop, the organ has a "honey coombed" or
"foamy" appearance on cut section. The liver develops greenish discolouration

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 that later changes to coal-black and extends to the whole organ. The organism
responsible for the gas production is CI. welchii.

 Gall bladder. Gall bladder is quite resistant to putrefaction but the bile pigments
diffuse through its walls to the adjacent tissues quite early.

 Pancreas: It softens and becomes hemorrhagic

 Heart: It dilates and becomes flabby and soft.

 Lungs: Gaseous bullae are formed under the pleura which later coalesce and the
lungs soften, collapse and are reduced to a small black mass.

 Kidneys: Kidneys become soft and flabby. The surface looses its luster and
becomes dull. The cortex becomes dark and later turns greenish.

 Bladder. Bladder is also highly resistant to putrefaction, especially if it is empty

and contracted.

 Prostate: It resists putrefaction for a very long time and this is the last organ to
putrefy in males.

 Uterus: Virgin uterus is the last organ to putrefy in females. However, a gravid or
postpartum uterus putrefies rapidly.

 Brain: Brain shows greenish discoloration as putrefaction initiates and then

converted to semi fluid mass that is soft and flabby and finally turns to pasty liquid
due to liquefaction.

FACTORS INFLUENCING THE ONSET AND PROGRESSION OF

PUTREFACTION

 These can be studied under following groups:

A. Exogenous factors

B. Endogenous factors.

 Exogenous Factors include:

1. The atmospheric temperature: At temperature below 50° F putrefaction
slows down and below 32°F, it is almost arrested. Temperature between 50°F
and 70° F (21°C-38°C) is ideal for bacterial growth and at more than 70°F
putrefaction is accelerated.

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 2. The atmospheric humidity and air movement: Putrefaction is accelerated
when the atmospheric conditions are warm and humid. When there is little
movement of air and atmospheric conditions are warm and dry, the
development of mummification is favored.
3. Medium in which dead body is kept:
 “Casper's Dictum”: At a tolerably similar average temperature, the
degree of putrefaction present in a body after lying in the open air for one
week corresponds to that found in a body after lying in the water for two
weeks, or after lying in the earth in the usual manner for eight weeks.
 Running water may retard, and heavily polluted water accelerate, the
process of decomposition.
 Endogenous factors include:
1. Hydration of the tissues: Moistures are essential for bacterial growth.
Putrefaction is accelerated when the tissues are oedematous. Putrefaction is
delayed when the tissues are dehydrated.
2. Clothes: Initially clothes hasten putrefaction by maintaining body
temperature. The areas underneath the tight clothing develop putrefaction
slowly due to bloodlessness in these areas. Also clothes protect against flies
and insects.
3. Condition of the body: In fat and flabby bodies putrefaction is accelerated
due to retention of heat.
4. Age and nutrition of the deceased: Dead bodies of unfed newborn and
stillborn are sterile. Thus putrefaction occurs very slowly with the invasion of
external bacteria. In old people putrefaction is delayed due to less moisture
content.
5. Cause of death:
 Acute diseases lead to rapid decomposition due to increased temperature
and increased bacteria
 In septic diseases due to increased bacterial activity rapid decomposition
occurs
 Chronic diseases: In diseases with general oedema, rapid decomposition
occurs. In emaciated and anemic individuals, putrefaction is delayed due
to less amount of blood, atrophy and dryness of tissues.

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  Poisons: In poisoning due to arsenic, antimony and zinc putrefaction is
retarded due to inhibitory effect of poisons on organisms. In chronic
arsenic and antimony poisoning due to preservative action on the body
tissues, putrefaction is retarded. In chronic alcoholism and strychnine
poisoning putrefaction is rapid.

ADIPOCERE
 Adipocere formation replaces the putrefaction changes when the body remains
submerged in water for appreciable time, buried in moist graves or water logged
soil. The substance so formed is called adipocere and its properties are
between adipo (fat) and cere (wax).

 Gradual hydrolysis and hydrogenation of preexisting fat like olein that is con-
verted to higher fatty acids like palmitic acid, stearic acid, hydroxystearic acid,
glycerides etc by the action of bacterial enzymes.

 As adipocere is the product of hydrolysis and hydrogenation of fat, water is

essential for its formation. Intrinsic water content of the body may be sufficient for
its development.
 Common sites of formation are female breasts, cheeks, face, buttocks and the
limbs. It is patchy in distribution and is quite unusually extensive.

PROPERTIES OF ADIPOCERE
 Soft, waxy looking substance
 Greasy to touch
 Dull white to dark brown in colour
 Disagreeable rancid odour
 Specific gravity is less than water
 It is inflammable and burns with faint yellow flame
 Soluble in ether and alcohol
 When fresh, it is soft and moist and when old it is dry and brittle

PRE-REQUISITES FOR ADIPOCEROUS FORMATION

 Abundant body fat
 Humid climate or abundance of moisture
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 Optimal temperature
 Still air and
 Bacteria like Clostridium welchii which produce fat splitting enzymes
MEDICO-LEGAL SIGNIFICANCE OF ADIPOCEROUS CHANGES

1. It helps in identification since it preserves the facial features.

2. Due to the preservation of wounds, cause of death can be determined.
3. It also provides some clues regarding the place of disposal of the body.
4. Time since death: It occurs rapidly in bodies submerged in water than damp soil.
In obese persons and mature new borne it is formed quickly. The adipocere
formation is accelerated by heat and retarded by cold. In India, it has been
reported varying from 3-35 days. The time taken to develop has been roughly
estimated to be 3 weeks to 3 months.

MUMMIFICATION
 It is a modified form of putrefaction and is characterized by drying or shriveling of
the tissue that is due to dehydration of the body constituents. The body assumes
a dried, shrivelled, dark and leathery appearance.
 When climate is dry and warm with a free circulation of air around the dead body,
the putrefaction is inhibited. Due to high temperature and moving air the body
fluids evaporate rapidly, organism cannot thrive due to lack of moisture and
mummification sets in. It begins in the exposed parts of the body like face, hands
etc. and then spreads to other parts. The skin hardens, becomes leathery and
adheres to the bones.

PRE-REQUISITES FOR MUMMIFICATION

 Hot and dry climate
 Deprivation of moisture
 Warm air currents freely flowing over the body

MEDICO-LEGAL SIGNIFICANCE OF MUMMIFICATION

1. It helps in identification since it preserves the facial features.

2. Due to the preservation of wounds, cause of death can be determined.

3. Time since death can be calculated. At times few parts of a dead body are
mummified and other parts show adipocere formation. Time varies greatly for its

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 formation. The average time it takes is from 3 months to 6 months. The time is
also influenced by temperature, place of disposal and size of the body.

GASTRIC EMPTYING

 Before being released in to the duodenum, food stays in the stomach for a
considerable period. The physical state of the food is also progressively altered
by the gastric juices and movements. Therefore, its appearance and volume is
taken to be a measure of the time since it was last swallowed.

 Stomach begins to empty within 10 minutes of swallowing;

 'light' meal takes two hours

 'medium' meal takes 3-4 hours

 'Heavy' meal takes 4-6 hours to empty from the stomach.

 Factors which, influence the emptying time, are:
 Motility of the stomach
 Consistency of the gastric contents
 Osmotic pressure of the gastric contents
 Quantity of material in the duodenum
 Physical nature of the meal: The meals containing carbohydrate empty from
stomach faster than protein whereas protein leaves quicker than fats. A fatty
meal inhibits gastric motility. Fluids and semi-fluids leave the stomach almost
immediately after being swallowed.
 Emotion, fear, anxiety etc. delays emptying.

 If undigested food is present then the deceased must have died within 3-4 hours
of ingestion of the last meal that can be known from the circumstantial evidence
and the time of death can be estimated from this.

FORENSIC ENTAMOLOGY
 Forensic entomology is the application and study of insect and other arthropod
biology to criminal matters.
 Forensic entomology can be divided into three subfields: urban, stored-product
and medico-legal/medico-criminal entomology.

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 1. Urban forensic entomology typically concerns pest infestations in buildings or
gardens that may be the basis of litigation between private parties and service
providers such as landlords or exterminators.
2. Stored-product forensic entomology is often used in litigation over infestation
or contamination of commercially distributed foods by insects.
3. Medico-legal forensic entomology covers evidence that may be gathered
through arthropod studies at events such as murder, suicide, rape, physical
abuse and contraband trafficking.

 Life cycle of the insects infesting the cadaver:

 The flies lay their eggs on the body at the muco-cutaneous junctions within
10 to 24 hours.
 The eggs hatch in to larvae (12 to 24 hours).
 The larvae grow in to maggots (4 to 5 days) which devour the body.
 The maggots transforms in to pupae over a period of time (4 to 5 days) and
from the pupae emerge the young flies Nymph.

MEDICO-LEGAL SIGNIFICANCE OF ENTOMOLOGY

1. Time since death:

 Insect fauna on the body will change with the time and as decomposition
progresses. The nature of fauna that is the composition of the species will
change with the passage of time. Knowledge of appearance if new species
and decrease in numbers of other species which were previously present will
unable the entomologist to arrive at an estimate of how long the body has
been lying in that location.

 Time since death can be determined using “Pradhan’s formula”.

i.e. Time since death = A + B x (cd)

 Where, ‘A’ is the time of invasion of species

 ‘B’ is the age of the most advanced insect form on the corpse

 ‘cd’ is the climatic correction factor (temperature, humidity)

 Time since death can also be determined by the migratory distance of the
larvae (maggots) away from the corpse, and the color changes of pupae.

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2. Place of death: Since some of the species appear in a particular geographic
area or a particular locality, from the examination of the insects, the particular
geographic and ecologic place can be known.
3. Establish the geographical location of death: This can be helpful in
determining location of a death in question. Since many insects exhibit a degree
of endemism (occurring only in certain places), or have a well-defined phenology
(active only at a certain season, or time of day), their presence in association with
other evidence can demonstrate potential links to times and locations where
other events may have occurred.
4. Acquire alternative toxicology samples: This involves the utilization of
entomological specimens found at a scene in order to test for different drugs that
may have possibly played a role in the death of the victim.
5. Provide alternative DNA samples (Human Mitochondrial DNA), which may be
linked either to assailant or victim.
6. Origin of contraband drugs: During the extraction and preparation of opium
and cannabis, it has been noted that insect pests, mostly beetles, wasps, and
ants, also gets incorporated in these substances. Many of these insect species
may be specific to a locality or a country.

COLLECTION AND PRESERVATION

 Insects can be collected from a corpse or its surroundings in three groups,
namely maggots, insects from soil and other insects.
 Maggots should be placed in separate tubes and placed directly in acetic alcohol
(3 parts 70% alcohol and 1 part glacial acetic acid) or 80% isopropyl alcohol or
Pampel’s solution (formalin+glacial acetic acid+alcohol+water). If no preservative
is available, killing of the specimens may be done by putting them in hot water.
 Rearing of maggots can be done that is they can be kept alive on some meat or
liver and reared to adult stage.
 Any puparia either empty or with the pupae inside them should be preserved in a
specimen tube. All the containers carrying live specimens must be perforated for
gaseous exchange. A large number of maggots should be collected.
 Soil insects: The soil samples should be collected in specimen bags from which
insects can later be extracted in 1he laboratory. Each soil sample should be as
much as would fit into a 'pint' bottle. Soil should not be compacted.
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POSTMORTEM CHEMISTRY
 Postmortem chemistry is the term applied to the measurement of endogenous
constituents in dead bodies.
 Various body fluids used in postmortem chemistry:
 Blood
 CSF
 Vitreous Humor
 Pericardial fluid
 Synovial fluid
 Amniotic fluid
 Urine
MEDICO-LEGAL SIGNIFICANCE OF POSTMORTEM CHEMISTRY
1. Estimation of time since death:
 Following components increases after death,
 Lactic acid
 Amylase
 Glutamate oxalate transaminase
 Following components decreases after death,
 Sodium
 pH
2. Determination of cause of death:
 Increased serum strontium indicates Salt water drowning
 Increased serum testosterone levels in males indicates suicidal deaths
 Increased vitreous humor hypoxanthine indicates hypoxic deaths

EUTHANASIA (MERCY KILLING)

The term euthanasia comes from the Greek words "eu"-meaning good and
"thanatos"-meaning death, which combined means “well-death” or "dying well".

DEFINITION
1. The intentional killing by act or omission of a dependent human being for his or
her alleged benefit.

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2. According to the House of Lords Select Committee on Medical Ethics, the precise
definition of euthanasia is "a deliberate intervention undertaken with the express
intention of ending a life, to relieve intractable suffering”.
TYPES
1. Voluntary euthanasia: When the person who is killed has requested to be killed.
2. Non-voluntary: When the person who is killed made no request and gave no
consent.
3. Involuntary euthanasia: When the person who is killed made an expressed
wish to the contrary.
4. Assisted suicide: Someone provides an individual with the information,
guidance, and means to take his or her own life with the intention that they will be
used for this purpose. When it is a doctor who helps another person to kill
themselves it is called "physician assisted suicide."
5. Euthanasia by Action: Intentionally causing a person's death by performing an
action such as by giving a lethal injection.
6. Euthanasia by Omission: Intentionally causing death by not providing
necessary and ordinary (usual and customary) care or food and water.
LEGALITY OF EUTHANASIA
1. The argument for legalizing euthanasia is that the individual's freedom entails
liberty or choice in all matters as long as the rights of any other person are not
infringed upon. The argument against legalizing euthanasia is that it will lead to
disrespect for human life. Euthanasia can then be abused for criminal purposes.
2. Euthanasia is legalized in countries like: Netherlands; Belgium; Oregon in the
U.S.; Norway; Sweden; Finland; Luxembourg; Switzerland; Thailand
3. Patients are of the opinion that it is their vested right to end their lives. They
believe that they have the right to execute their decision whilst maintaining their
dignity. Living a bed-ridden life where the daily natural chores (urinal & stool) is
taken care by someone else hurts the sentiments of these patients. Instead they
would like to die a dignified soul.
4. Medical Council of India has included Euthanasia in its list of Professional
Misconduct and Unethical Acts.

INCOMPLETE LIST OF QUESTIONS FROM THANATOLOGY

1. Define death. Write briefly on somatic death and molecular death.
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2. Describe the brain-stem reflexes.
3. Enumerate the changes seen in eye after death.
4. Explain cadaveric spasm.
5. Difference between Rigor mortis and cadaveric spasm.
6. Enumerate the early changes seen after death.
7. Describe postmortem cooling.
8. Describe the mechanism, onset, progression and medico-legal importance of postmortem
lividity. How to distinguish it from contusion?
9. Describe the mechanism, onset, progression and medico-legal importance of rigor mortis.
Mention four conditions, which simulate rigor mortis.
10. Describe the various changes occur during putrefaction (color changes, gas formation and
effects of gases). Add a note on Casper's dictum.
11. Write short note on colliquative putrefaction.
12. Describe the modified forms of putrefaction (adipocere, mummification) - environmental pre-
requisites, pattern of distribution and forensic application.
13. Write briefly on the following
A. Presumption of death N. Chemical changes in vitreous
B. Presumption of survivorship humor
C. Somatic death O. Sigmoid shape curve of
D. Cellular death postmortem cooloing
E. Apparent death P. Henssge nomogram
F. Mode of death Q. Postmortem caloricity
G. Mechanism of death R. Cause of death from livor mortis
H. Manner of death S. Proximo-distal progression of rigor
I. Cause of death mortis
J. Brain death T. Rule of twelve
K. Apnoea test U. Factors influencing putrefaction
L. Sudden death and its causes. V. Gastric emptying
M. Trucking of retinal vessels: W. Euthanasia

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 TRANSPORTATION ACCIDENTS
Ever since vehicles were invented accidentally, accidents are happening. In most of the
cases accidents are caused, the fault being either due to man, machine or the method.
There are a certain set pattern of injuries, which differ from the driver, passengers and
the pedestrians. Identifying these injuries is important from the point of view of
reconstruction of the scene of the accident.

INJURIES TO THE PEDESTRIAN

When a speeding vehicle hits the pedestrian, he does sustain some injuries due to the
impact. He may then be thrown forward and fall on the road to sustain some more
injuries or he may be bounced upward only to fall on the same vehicle to sustain
injuries, this time due to the subsequent impact by the vehicle. Accordingly the injuries
sustained by the pedestrian are classified under following three categories:
1. Primary impact injuries.
2. Secondary impact injuries and
3. Secondary injuries.
PRIMARY IMPACT INJURIES:
 These are injuries sustained by the pedestrian in road traffic accidents in the form of
abrasion (imprint), contusion or lacerated wounds, fractures of bones as a result of
offending vehicle striking for the first time (primary).

 Normally the primary impact injuries are caused by projecting parts of the vehicle
such as head light, bumper, bonnet, and radiator grill etc.

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 The behavior of the body after being hit depends on several factors. The centre of
gravity of a standing adult pedestrian is located above the umbilicus and is usually
above the level of the bonnet of a car. An impact from the front therefore pushes the
legs forward and causes the victim to rotate towards the vehicle. Children, whose
centre of gravity is below the level of the bonnet, are usually pushed down to the
ground.
 The location of the injuries will depend upon the position of the victim at the time of
collision in relation to the vehicle. In side impacts the parts facing the vehicle will
show primary impact injuries whereas secondary injuries due to fall are seen on the
other side. In frontal impacts the primary impact injuries are seen on the front of the
body and secondary injuries on the back. The reverse happens when the person is
hit from behind.
 ‘Bumper Injuries’:
These may be seen in the case of adult victim stuck by the front of the automobiles.
The extent of these injuries depends upon the speed of the car, the shape of the
bumper and the amount of the clothing covering the area that was stuck. Absence of
bumper injuries suggests that the pedestrian struck the side of the automobile. If the
victim is walking at the time of impact, the bumper injury will be higher on the weight
bearing leg. The fracture of tibia and femur may present a wedge shaped fragment,
the base which indicates the direction of impact and the front of the wedge the
direction in which the vehicle was travelling.
 While describing these injuries care should be exercised particularly to observe the
distance between these injuries and the heel of the foot. By taking the relative
measurements on the vehicle one may be able to pinpoint the vehicle causing the
accident.

Medico-legal significance of primary impact injuries:

1. These injuries help to identify the offending vehicle either from the imprint abrasions
or pattern contusions.
2. It is important to note down the height of the fracture from the heel. If the police
apprehend the offending vehicle, the height of the bumper from the ground must be
noted. The fracture site must correspond to the height thus measured. If the height

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 of the bumper is at higher level than the height of the fracture, it is prudent to
conclude that the driver had made an attempt to apply the brake and the front
portion of the vehicle thus had dipped downward causing the fracture at a lower
level. This does not absolve the driver from the crime, but at least indicates that
there was an attempt to avoid the accident.
3. Primary impact injuries are seen on the part of the body facing the vehicle, and
hence are of value in establishing the position of the person when struck.

SECONDARY IMPACT INJURIES:

 These are injuries sustained by the pedestrian in road traffic accidents in the form of
abrasion, contusion or lacerated wounds as a result of second impact with the
vehicle, subsequent to the primary impact injury.

 A proper examination of the injuries should help the doctor to categories them into
primary or secondary impact injuries and this helps in reconstruction of the accident.
 For example when the feet of the victim slide forwards, the whole body will fall
backwards and may even in certain instances, slide up the bonnet resulting in
secondary impact of the head against the pillar of the windshield or it may even
shatter the windshield.
 These also includes run over injuries by the same automobiles after the primary
impact resulting in wheel passing over the body. The bones of the legs and arms
may be crushed against the road surface (run-over injuries). Fractures are restricted
to the areas of contact between the wheel and extremities. Such fractures do not
have the spiral character of bumper fractures. The spinning of the wheel as it passes
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 over the limb cause traction, grinding, crushing and tearing of the tissues. The skin
may be stripped off from the subjacent tissues (avulsion injuries). There may be tyre
marks or imprints on the body in the form of abrasion and contusions.

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Medico-legal significance of secondary impact injuries:
1. During the striking of offending vehicle for the second time, there will be transfer of
evidentiary material from vehicle to the victim and from the victim to the vehicle,
which helps in connecting the vehicle to the injuries on the victim thereby building a
causal relation.
2. Tire marks when present indicate running over and often remains as trace evidence.
These may be especially helpful in establishing the identity of the vehicle involved in
the accident. No two tires are alike, due to small imperfections in the pattern of the
tread that are specific for each tire.

SECONDARY INJURIES Or TERTIARY IMPACT INJURIES:

 These are injuries sustained by the pedestrian in road traffic accidents in the form of
abrasion, contusion or lacerated wounds and sometimes fractures, resulting from
victim’s body striking the ground or any object other than offending vehicle after
being knocked down by the offending.

 Secondary injuries are produced due to the effects of fall resulting in contact with the
ground. These injuries are usually seen over the prominent parts of the body viz.
knee, hips, and on the front, back and sides of the body.
 Whenever there are graze abrasions, the direction of the graze will help to infer the
movement of the victim after the impact. In secondary injuries without rolling, the
lines of grazes run lengthwise, while in rolling over the lines run circumferentially.
 The sliding of the body against the ground releases great heat which produces a
kind of heat which leads to drying of the skin.

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 Medico-legal significance of secondary injuries: If the vehicle drags the victim on
the road, he sustains abrasions of grazed type (also known as brush burn abrasion).
The direction of the graze will help to infer the movement of the victim after the impact.

Type Site of impact Injuries

1. Primary Impact Injury Bumper Lower Extremity
2. Vehicle hood, pillar,
Secondary Impact Injury Head and torso
windscreen
3. Ground and fixed object Head and torso
Secondary Injury (Tertiary Impact) Crushing, car or another Abdominal and
vehicle thoracic

INJURIES TO THE OCCUPANTS OF A MOTOR VEHICLE

 The injuries differ according to the position of the victim in the car, the front seat
passenger including driver being the most vulnerable.
 The injuries sustained by the occupants can be described under following headings:
A. Injuries to the driver.
B. Injuries to the front seat passenger.
C. Injuries to the rear seat passengers.
D. Whip-lash injury.
E. Seat belt injuries.
F. Flail chest.

INJURIES TO THE DRIVER:

 Steering wheel impact injuries:
 The horn boss may hit against the sternum causing a transverse fracture. The
heart, aorta and roots of the lungs may be compressed leading to their rupture.
However this type of injury is not seen in accidents involving modern automobiles
which are provided with a collapsible steering wheel.
 The rim of the steering wheel may crush the liver, spleen, kidney, duodenum,
and sometimes the throat. Occasionally, several adjacent ribs on both sides will
be fractured causing a ‘stove in’ or ‘flail’ chest.

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 The driver may be thrown forward and the head may hit the mirror or windscreen,
causing laceration of the scalp and fracture of the skull and whiplash injury of the
spine.
 If the driver anticipated the accident, he might try to avoid impact on the chest by
throwing all his strength on his hands on the steering wheel, and may sustain
injuries of the wrist and forearms.
 The sudden application of the brake will cause the force of impact to be transmitted
along the shaft of the femur to the pelvis, to cause a fracture of the femur (neck is
the common site), posterior dislocation of the hip joint or both. There may be fracture
of the metatarsal bones with attempts at sudden breaking of the vehicle. While
performing autopsy the doctor should be careful to look for this type of injuries.
 Dicing or Sparrow feet lacerations:
These are seen usually seen over face, neck, and upper extremity. When the side
windows of a car shatter, they break into numerous small cube shaped pieces of
glass. These cubes actually have relatively sharp edges, so the resulting injuries in
the form of short linear, angular, rectangular and square superficial cuts, many of
which are right angled, referred to as ‘dicing injuries’, actually represent a patterned
sharp force injury. If they occur on the left side of the body in a right sided steering
wheel vehicle, then it is likely that the person was sitting on the right side of the
vehicle. If they occur on the right side of the body, then it is possible that the
individual was the driver. Such wounds referred to as dicing injuries to connote their
origin from “dice” shaped fragment of glass.
 Ladder tears:
Ladder tears of aorta are multiple intimal tears seen in the aorta of occupants of the
vehicle. The most important mechanism is sudden deceleration, possibly in
combination with compression and/or shearing. The laceration of the aorta may
occur either as a complete or partial transection. In the latter case the outer layers of
the vascular wall are not damaged; the intimal tears are often multiple, semicircular
and parallel (so-called ladder-rung tears).

INJURIES TO THE FRONT SEAT PASSENGERS:

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 For the front seat passenger, there is no steering wheel impact against (or impede
progress) and the main points of contact will be the legs on the fascia and the head
on the windscreen or its surround.
 As most automobiles accidents consist of a frontal impact, there is usually violent
deceleration. This gross deceleration lifts the unbelted or non restrained passenger
from the seat and projects him forwards. The first contact usually the knees, lower
legs or thighs against the parcel shelf or fascia, depending on the car design. This
may cause abrasions, lacerations or fractures of the legs. Fractures of the lower
ends of the femur with the separation of the condyles are less commonly observed.
Such fractures are due to the fact that in the sitting position, the wedge shaped
patella is forced between the condyles upon frontal impact. Another frequent
dashboard injury is the dislocation, with or without fracture, of the head of the femur,
which is literally pushed out of its socket into the pelvis by the impact of the knee.
 Then the upper part of the body folds forwards, but still rises as a whole and may be
smashed against and / or through the wind screen. The body may be completely
ejected through the glass and land in the road, to suffer secondary injuries and
perhaps running over.
 Alternatively, the head may strike the rim of the windscreen or side pillar, causing
severe lacerations and head injury.
 Dicing or Sparrow feet lacerations:
 These are seen usually seen over face, neck, and upper extremity. When the side
windows of a car shatter, they break into numerous small cube shaped pieces of
glass. These cubes actually have relatively sharp edges, so the resulting injuries in
the form of short linear, angular, rectangular and square superficial cuts, many of
which are right angled, referred to as ‘dicing injuries’, actually represent a patterned
sharp force injury. If they occur on the left side of the body in a right sided steering
wheel vehicle, then it is likely that the person was sitting on the right side of the
vehicle. If they occur on the right side of the body, then it is possible that the
individual was the driver. Such wounds referred to as dicing injuries to connote their
origin from “dice” shaped fragment of glass.
 Being unprepared the passenger may strike his head against the windshield or
window frame and may even ‘whiplash’.
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INJURIES TO THE REAR SEAT PASSENGERS:
 Fatalities less common than in the front seat occupants, but there are potentially
lethal risks.
 Rear seat passengers are thrown forwards and strike the seats in front, sustaining
head, chest and abdominal injuries and potentially adding to the injuries of those in
front.
 Injuries from interior fittings, such as door handles, window winders, mirrors and
lights may occur.

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WHIPLASH INJURY:
Explanation:
 Fracture of the spine need not injure the cord, but the cord is rarely injured without
associated fractures of the vertebral column, “Whiplash Injury” is an exception to this
general rule [Container i.e. vertebral column intact but the content i.e. spinal cord is
damage].
 Whiplash may occur at cervical or thoracic region.
 Commonly seen in the front seat occupants of a vehicle or in blow against the spinal
process of the upper cervical vertebra.
Sequence of events:
Vehicle suddenly decelerated and the vehicle stops suddenly

Passenger is still in motion and it takes some time for him to stop. But during this lag
period head is thrown forwards resulting in “acute hyperflexion” of the neck.

This hyperflexion is stopped on head hitting the windshield in the front and head is
thrown backwards resulting in “reactionary hyperextension” (Which is more dangerous)

Fatal contusion or laceration of the spinal cord.

May lead to quadriplegia and sometimes fatality.

SEAT BELT INJURIES or SEAT BELT SYNDROME:

 When a moving car meeting with an accident comes to sudden halt with the
occupant fastened with the seat belt (seat belts are fastened either transversely over
the lap or diagonally across front of chest) will escape from forward movement (to be
thrown over steer wheel or wind screen) or ejection from the car.
 Seat belts, though useful in preventing ejection, may be responsible for a wide
spectrum of injuries termed as ‘seat belt syndrome’, which includes following:
a) Directly resulting from seat belt itself – Abrasion, contusion or haematoma on the
lower abdomen
b) Due to acute flexion over the belt – Lacerations, avulsions or perforation of
mesentery or gas filled intestine and also injury to the vertebral column
particularly lumbar vertebra.

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 c) Due to compression of the abdominal organs between belt and vertebral column
– Rupture of liver, spleen, pancreas, caecum, urinary bladder.

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FLAIL CHEST or STOVE IN CHEST:
Explanation:
Flail chest most commonly occurs as a result of blunt trauma to the chest (usually after
falls, road traffic accident, or following cardiovascular resuscitation). When two or more
ribs or sternum are fractured in two different places, a flail segment is created; the
segment is detached from the chest wall and passively collapses inward during
respiration, secondary to the negative intra thoracic pressure.

Clinical Manifestations:
Characterized by paradoxical motion of the flail segment,
 During normal inspiration, the diaphragm contracts and intercostal muscles push the
rib cage out. Pressure in the thorax decreases below atmospheric pressure, and air
rushes in through the trachea. However, a flail segment will not resist the decreased
pressure and will appear to push in while the rest of the rib cage expands.
 During normal expiration, the diaphragm and intercostal muscles relax, allowing the
abdominal organs to push air upwards and out of the thorax. However, a flail
segment will also be pushed out while the rest of the rib cage contracts.

Medico-legal significance of flail chest:

The constant motion of the ribs in the flail segment at the site of the fracture is
exquisitely painful, and, untreated, the sharp broken edges of the ribs are likely to
eventually puncture the pleural sac and lung, which may be fatal.

MOTORCYCLISTS
 Motorcyclists usually sustain injuries by striking against some vehicle, roadside
object or the road itself.
 The face, head and spine are often injured.
 Temporo-parietal fractures are common and may extend across the base of the
skull.
 The majorities of skull fractures are localized or hinge fracture of the base, but
occasionally they are ring fractures, presumably caused by upward forces acting
through the spine or by impact to the top of the head during secondary impact.

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 Under-running or tail-gating: This is sometimes seen in the motor cyclists, where a
rider drives into the back of a truck or some other heavy vehicle. This may occur due
to sudden and unexpected stoppage of the heavy vehicle. In such cases, the motor
cyclists head and shoulders are smashed against the tail board and decapitation can
result in extreme cases.

RAILWAY ACCIDENTS
 Railway injuries may be accidental or suicidal in origin.
 Suicidal injuries occur from jumping in front of a moving train or jumping from the
train.
 Traumatic amputation of limbs or trunk, or decapitation, may occur.
 Accidental injuries may be due to walking on the track or by the side of the rails,
crossing the line, falling from a moving train, leaning out of the window, attempts to
boarding the running train, collision etc.
 Criminals may try to conceal the crime as railway accidents.
AIRCRAFT ACCIDENTS
 The majority of aircraft accidents happen during take off or landing of the aircraft.
 The occupants may sustain varying degrees of injury due to sudden acceleration
during a crash.
 Bad weather, lightning striking an aircraft and engine trouble are other causative
factors.
 During crash accidents, acute flexion of the trunk at the level of the safety belt may
cause the head to hit the back of the seat in front. The force will be so severe as to
split open the head.
 Head injury is an important feature of aircraft accidents. Cervical vertebrae are also
commonly fractured.
DRUNKENNESS AND DRIVING

Alcohol intoxication affects driving in the following manner,

1. Delay in the reaction time:
The drunken driver takes at least 15 to 20% more time than a normal person to react
to a given situation, like immediate application of brakes, changing the gears etc.
2. False and unjustified increase in confidence:

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 The drunken driver takes unjustified risks, skips over the traffic lights, over takes the
vehicles in a dangerous manner etc.
3. Impairs concentration and affects the judgment:
The drunken driver is unable to appreciate instantly the dangers of a given situation
and to react it.
4. Affects vision:
The drunken driver can not tolerate the brightly lit lights coming from the opposite
direction as his pupils are dilated. The peripheral vision is reduced (tunnel vision).
Therefore he can not visualize the vehicles coming from the sides, thus lowering his
ability to control the vehicle.
5. Affects muscular in-coordination:
Drunken state produces muscular coordination thereby risking his life and that of
others.
Under the influence of such amount of alcohol, the driver is adjudged to be incapable to
be in charge of the vehicle as he is not only a source of risk to himself but to the
passengers and also to the pedestrians.

INCOMPLETE LIST OF QUESTIONS FROM TRANSPORTATION INJURIES

1. Briefly describe the pattern of injuries sustained by pedestrian in road traffic accident
(primary impact injuries; secondary impact injuries and secondary injuries).
2. Briefly discuss the injuries to the front seat passengers of a car in road traffic
accident.
3. Briefly discuss the injuries to the driver of a car in road traffic accident.
4. Write short note on the following:
a. Primary impact injuries.
b. Secondary impact injuries.
c. Secondary injuries.
d. Bumper Injuries.
e. Dicing or Sparrow feet lacerations.
f. Whiplash injury.
g. Seat belt injuries.
h. Flail chest or stove in chest.
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 i. Drunkenness and driving.

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 VIRGINITY.
 A virgin (virgo intacta) is a female who has not experienced sexual intercourse. Loss of
virginity is known as defloration.
 The question of virginity arises in case of:
 Nullity of marriage
 Divorce
 Defamation
 Rape
 A single intercourse does not alter the female genitals much, except for the rupture of the
hymen.

HYMEN:
 Hymen is a fold of mucus membrane about one millimeter thick, situated at the vaginal outlet.
The structure of hymen varies considerably. It may be a thin membrane or a thick and fleshy
tissue. The normal hymen lies between these two extremities. Recognizable, though not
severe, hemorrhage occurs when the hymen ruptures.

 The different types of hymen are:

 Semilunar or cresentric: the opening is placed anteriorly
 Annular: the opening ids placed at the centre of the membrane.
 Cribriform: With numerous small opening
 Septate: Two lateral openings occur side by side.
 Imperforate: No opening
 Fimbriated: the margins of the opening show multiple notches.
 Medico-legal Importance:
 Vaginal penetration usually results in tearing of the hymen posteriorly between 3 and 9
o'clock position.
 Tears due to penile penetration extend to the margin of the hymen with vaginal wall.
 These hymenal lacerations are associated with bruising.
 Hymenal lacerations usually heal within a week.
 Fresh tears look raw, red, swollen, and painful to touch
 Bleeds on touch within 1 to 2 days
 Heal in 5 to 7 days.
 Shrunken and look like granular tags of tissues within 8 to 10 days.

 False Virgin: Hymen usually gets ruptured with the first act of sexual intercourse. However in
some cases hymen remains intact despite of sexual intercourse. Such condition where hymen
remains intact despite of sexual intercourse is called False Virgin.

Dr. Francis N.P. Monteiro, Professor & Head, Department of Forensic Medicine & Toxicology 1
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Dr. Francis N.P. Monteiro, Professor & Head, Department of Forensic Medicine & Toxicology 2
A.J. Institute of Medical Sciences & Research Centre, Mangalore, @ [email protected] Mobile: +91-9448327389

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