Exam Preparatory Manual of

Forensic
Medicine and
Toxicology
Questions and Answers
Including Solved Last 5 Years Professional and
Supplementary Examination Question Papers of
More than 20 Universities
Exam Preparatory Manual of
Forensic
Medicine and
Toxicology
Questions and Answers
Gautam Biswas
MD (Forensic Medicine)
Professor and Head
Department of Forensic Medicine and Toxicology
Dayanand Medical College and Hospital
Ludhiana, Punjab

Tejpreet Singh
MBBS
Junior Resident
Department of Forensic Medicine and Toxicology
Dayanand Medical College and Hospital
Ludhiana, Punjab

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Preface

T his book is meant for the last minute revision before the examination. It will be
helpful to the students in their professional examinations as well as the semester
or terminal examinations and class tests.
The academic year 2020-21 has been an exception as many students were unable to
cope up their studies due to the current pandemic situation of COVID-19. Most of the
colleges were having online classes and it was not possible to address the difficulties
faced by the students. There must have been many queries which the students wanted
to ask, but it was not possible since the physical classes were not held. It has taken a
toll on most of the students and some of them were not able to study the subjects
properly.
This book will help the students to quickly revise the important questions and their
answers that were asked in the last 5 years in various universities in India. The students
need to have gone through the textbooks earlier for retaining the information given in
this book. They can cover the important questions in 1–2 days. It will help them to sail
through their professional examination and even score good marks in their theory
paper. This book is not meant to cover the whole syllabus and will not solve the purpose
of a textbook.
The answers have been written based on an examiner’s expectation from the students
and will fetch them a decent score. There may be some unexpected questions too,
which is the norm in some of the universities.
Best wishes...
Gautam Biswas
Tejpreet Singh
Acknowledgements

W e are thankful to the following faculty (in a random order) and students for
their help in preparing this book:
Dr Parmod Goyal Dr Anil Kohli
Dr Murugesa Bharati Dr Viswaskanth B
Dr Pramod Tiwari Dr Tapas Kumar Bose
Dr Chandresh Tailor Dr Aditya Sharma
Dr Vijay Kumar Dr Swapnil S Agarwal
Dr Jagadeesh Narayanareddy Dr Pradeep Kumar MV
Dr Soumeek Chowdhuri Dr Lalit Kumar Varshney
Dr Amarjyoti Patwory Dr SK Dhattarwal
Dr Vijay Pal Khanagwal Dr Jitender Kumar Jakhar
Dr Binay Kumar Dr Vivek Kumar
Dr Uzma Waseem Bachh Dr Sudha R
Dr Somshekhar Sharma Tejasvi Jhamb (Final year student)
Dr Virendar Pal Singh, Professor, Department of Forensic Medicine and Toxicology
(FMT), Dayanand Medical College and Hospital (DMCH), deserves special appreciation
for providing positive feedback and valuable suggestions. Special thanks go to
Mr Kuljeet Singh, Mr Amit Kumar and Mr Luv Sharma for their help in typing the
manuscript without any complaints.
Sincere thanks and gratitude go to Shri Prem Kumar Gupta, Secretary, Managing
Society, DMCH, and Dr Sandeep Puri, Principal, DMCH, for their continuous support,
motivation, encouragement and invaluable suggestions.
Last but not least, admiration and appreciation to the whole team of CBS Publishers
& Distributors, especially to Mr SK Jain (CMD), Mr Varun Jain (Director), Mr YN Arjuna
(Senior Vice President—Publishing, Editorial and Publicity), Ms Ritu Chawla (General
Manager), Mr Sumit Behl (Asst. Marketing Manager), Mr Neeraj Prasad and Ms Baljeet
Kaur (Graphic Designers), Mr Parmod Rajput and Ms Jyoti Kaur (DTP Operators) and
Mr Prasenjit Paul (Copy Editor) for their patience, encouragement and professionalism
during the entire process.

Gautam Biswas
Tejpreet Singh
Exam Guidelines
1. Read the question paper properly and thoroughly. Spend 5–7 minutes and think as
to how to approach the paper before you start answering.
2. If some question is out of syllabus or you have not covered it before the examination
or you have forgotten it, try to use common sense and read the question a few more
times. The answer may be there within the question itself.
3. Your answer should be to the point. Do not write what you have not been asked. It
will be unnecessary wastage of time.
4. Since the examiner usually spends on an average 7–12 minutes on theory paper, it
is advisable that:
a. Long questions should be in detail, at least 3–4 pages along with flowcharts and
line diagrams wherever possible.
b. Short notes should touch all the important points. It should be in structured form
with headings, subheadings and diagrams.
c. Differentiation should be in tabulated form, mention the important differentiating
features on the left side column.
5. Write the dosages for the drugs that you mention in treating a person in case of
poisoning.
6. Add MLI wherever possible/needed.

Students may scan and send their University Question Papers either to [email protected] or
WhatsApp at 8699511456. It will be duly acknowledged.
Contents

Preface v
Exam Guidelines ix

1. Medical Jurisprudence, Acts and Legal Procedure 1

2. Autopsy and Thanatology 26

3. Identification 46

4. Asphyxial Deaths 63

5. Injury 81

6. Sexual Jurisprudence and Infanticide 122

7. Forensic Psychiatry 150

8. Toxicology 161
 1
Medical Jurisprudence,
Acts and Legal Procedure
LONG QUESTIONS

1. Define professional negligence along with its various components and types.
What are the normal defences against negligence? (Sher-i-Kashmir Institute,
Srinagar Supple 2019) (North Eastern Hill University Shillong 2018, Gujarat Supple 2017)

Define negligence. Name the different types of negligence. Discuss medical

negligence. (North Eastern Hill University, Shillong Supple 2019) (VNS, Gujarat 2017)
Ans:
Definition of Professional Negligence
It is defined as lack of reasonable care and skills on part of a doctor that resulted in
injury/death of the patient.
Components of Medical Negligence (4D’s)
1. Duty of doctor
2. Dereliction of duty
3. Damage to patient
4. Direct causation
For a case of medical negligence to be established, all four conditions must be present.
Types of Negligence
1. Civil negligence
2. Criminal negligence
Civil negligence Criminal negligence
Injury or damage is mild More serious than civil negligence as injury is
very serious
The patient goes to civil court or consumer court The patient/ family reports the matter to the
to ask for the compensation as the injury or damage police
suffered by him can be compensated by money Gross negligence on part of doctor leads to
serious injury/death of the patient
Punishment—in form of fine, no imprisonment Sec. 304 A IPC deals with criminal negligence—
for doctor punishment of 2 years of imprisonment and fine
E.g. Failure to take consent for blood transfusion E.g. Operation on wrong limb
1
 2 Exam Preparatory Manual of Forensic Medicine and Toxicology

Civil and Criminal Negligence

When patient goes to the civil court or consumer court and also reports the matter to
police. In this case, medical negligence can be fought in both civil and criminal courts
simultaneously.
For examples of medical negligence—Refer to long question no. 2.

Defences against Negligence

1. No duty owed to patient: The doctor did not treat the patient, so no duty exists.
2. Res judicata: The things have already been decided by the court, it cannot be tried
again by the same court.
3. Contributory negligence: Not only doctor, even patient is also found to be negligent.
So, doctor can take this as a defence.
4. Therapeutic misadventure
• Occurrence of damage or mishap with the patient due to some drug or procedure.
• Doctor is not liable
• For example: Hypersensitivity to penicillin, fatal complications with blood
transfusion
5. Limitation: The case against the negligence of doctor should be filed within 2 years
from the date of alleged negligence.
6. Error of judgement: It has been recognized by the courts and law. Since a doctor’s
decision turned out to be wrong, he cannot be liable for medical negligence.
7. Products liability: When a manufacturer supplies defective drug/instrument which
was prescribed by the doctor to the patient and the patient sustains injury. In this
case, the manufacturer is held responsible for the injury.
8. Informed consent for the act: The patient was duly informed of the consequences.

2. Define professional negligence. What are the various instances wherein a

registered medical practitioner can be held guilty of professional negligence?
What will be the punishment, if he/she is found guilty? (Sardar Patel University,
Gujarat 2020, Supple 2018) (Delhi University 2015)
Ans:
Definition of Professional Negligence
Refer to long question no. 1.
Various Examples of Medical Negligence
1. General examination
• Failure to examine the patient himself/herself.
• Failure to attend a patient with consequent damage.
• Failure to obtain informed consent for any procedure.
• Making a wrong diagnosis in the absence of skill and knowledge.
2. Surgery
• Delayed diagnosis of acute abdominal lesions (e.g. appendicitis).
• Retention of instruments, sponges, swabs, etc in operation sites.
• Operating on the wrong patient, wrong limb/organ, etc.
 Medical Jurisprudence, Acts and Legal Procedure 3

3. Emergency medicine
• Missing fractures
• Overtight or prolonged use of plaster casts
• Inadequately treated hand injuries
• Undiagnosed intracranial hemorrhage
4. Obs-Gynae
• Performing abortion without indication
• Mismanagement of delivery (under influence of alcohol/drug)
• Unwanted pregnancy due to failed tubal ligation
5. Medicine: Failure to diagnose MI

Punishment for Professional Negligence

1. Fine
2. Imprisonment
3. Warning
4. Penal erasure
Sec. 304-A IPC deals with criminal negligence where the doctor may be punished
with imprisonment for 2 years and fine.
Penal erasure: It is the removal of the name of a doctor from the State Medical Register
as a penalty which can be temporary or permanent.
• Temporary erasure—the doctor is not allowed to practise his medical profession
for a specified period (may be days, weeks, months or years) in which his name
remains removed from the register.
• Permanent erasure of name—is also known as professional death sentence.
But the doctor can appeal to Central Health Ministry/Central Government (within
30 days of the decision) which forwards to NMC and the decision is given.

3. Define professional misconduct. Illustrate with suitable examples. What is the

action taken against the guilty doctor and by whom? (Adesh, Bathinda 2018)
(AIIMS Patna 2019, 2017) (Rajiv Gandhi University, Bengaluru 2015) (Sai Tirupati
University, Rajasthan 2019)

Define professional misconduct. Describe various instances wherein a

registered medical practitioner can be held guilty of professional misconduct.
Differentiate professional misconduct with professional negligence. (Sardar Patel
University, Gujarat 2019, 2018) (AIIMS Patna 2017)
Ans:
Definition of Professional Misconduct
Any conduct on part of doctor which is considered disgraceful or dishonourable as
judged by professional men of good repute and competence.

Some Examples of Professional Misconduct (6A’s)

1. Adultery: Voluntary sexual intercourse between a man (married or unmarried,
does not matter) and a married woman.
 4 Exam Preparatory Manual of Forensic Medicine and Toxicology

2. Advertisement: A physician should not overadvertise himself. He should not

a. Affix a signboard on a chemist shop
b. Use touts or agents to procure patients
c. Advertise himself through manufacturing firms directly or indirectly.
3. Association with unqualified persons
4. Addiction: To drugs, e.g. cocaine, LSD, etc.
5. Alcoholism: The doctor should not practise under the influence of alcohol which
interferes with proper practice of medicine.
6. Abortion: Doctor performing an illegal abortion is against the medical ethics.
7. Dichotomy: (Fee-splitting or fee sharing). It is giving or receiving commission
from fellow doctors, manufacturers or chemists.
8. Issuing a false certificate: In connection with sickness, insurance, passport, public
services, attendance in court
9. Sex determination test with an intention of female foeticide.
10. If a doctor does not maintain the medical records of indoor patients for a period of
3 years.
Punishment
1. Warning 2. For serious professional misconduct—penal erasure
• Disciplinary action is taken by the • It is the removal of the name of a doctor from the State
Medical Council Medical Register as a penalty
• Which is issued to the doctor who is • Which can be temporary or permanent
guilty of the professional misconduct • In temporary erasure—the doctor is not allowed to
practise his medical profession for a specified period in
which his name remains removed from the register.
• In permanent erasure—also known as professional
death sentence.
• But the doctor can appeal to Central Health Ministry/
Central Government (within 30 days of the decision)
which forwards to NMC and then decision is given

Difference Between Professional Misconduct and Professional Negligence

Refer to difference no. 4.

4. A young man of 25 years allegedly assaulted by some persons brought to the

emergency in unconscious state. On examination, there is bleeding scalp
wound on the right-side scalp. Just during CT scan within half an hour, the man
regained consciousness and wanted to tell something.
a. How will you proceed to record the dying declaration?
b. Duties of emergency medical officer in management of this case.
c. In case of death what is the probable autopsy findings determining the
cause of death? (West Bengal Supple 2019)
Ans:
a. Steps in recording of dying declaration
1. Ideally, Magistrate should be informed to record the dying declaration in presence
of witness. But in case the person is about to die, then statement should be recorded
by the doctor in presence of two or more witnesses.
 Medical Jurisprudence, Acts and Legal Procedure 5

2. The preliminary particulars of the patient is noted—name, age, sex, address, Reg.
No., MLC No., police station, date and time of admission, location of patient
(ward, hospital), ID marks, etc.
3. The doctor should certify that the patient is conscious and fit for giving statement
(i.e. compos mentis)—orientation to time, place and person, GCS, BP, pulse,
respiratory rate, temperature, ability to speak.
4. Oath is not required (as it is believed that dying person speaks the truth)
5. Statement should be recorded in simple narrative without any alterations, in
patient’s own words. Date and time of commencement of recording and
completion of statement, mode of statement (writing/speech/gesture).
6. If possible, the written statement should be read over to the patient so that it can
be rechecked.
7. After taking the dying declaration, it should be signed by the doctor (along with
registration no.) and witness.
8. Declaration is sealed and handed over to concerned police officer along with the
receipt.
MLI: If the declarant survives, the declaration is not admitted, but has
corroborative value.
b. The emergency medical officer should maintain the ABC of the patient. He should
make a quick examination and try to settle the patient.
• Any bleeding should be dressed and fractures stabilized with temporary splint.
• He should be sent for CT scan head and X-rays of any suspected fracture.
• A neurosurgery consult should be arranged immediately.
c. The patient must have had extradural hemorrhage (EDH). Since the initial injury
was concussion, subsequently middle meningeal bleed caused the ensuing
decompensation from the expanding blood collection leading to coma.

Autopsy Findings
1. Laceration on right side temporal scalp.
2. Hematoma in the epidural space on removal of the skull cap.
3. There may be fissure fracture of the temporal bone.
4. Diffuse brain swelling and cerebral contusions may be seen.
5. Subfalcine herniation extending from the side of the hematoma to the opposite
side.
6. Swelling of the cerebral hemisphere under the hematoma with smooth appearance
of the brain.

5. What do you mean by evidence? Write the procedure of recording of evidence

of a witness in a court of law. (North Eastern Hill University, Shillong, 2017)

Ans:
Definition of Evidence
It is defined as legal means to prove or disprove any medico-legal fact under inquiry.
 6 Exam Preparatory Manual of Forensic Medicine and Toxicology

Procedure of Recording of Evidence

1. Oath • The witness has to take oath that whatever he will say, he will speak the
truth, whole truth and nothing but the truth.
• MLI-Perjury: When person gives false evidence under oath, he is punishable
under Section 193 IPC.
2. Examination-in-chief • Definition: It is the examination of witness by the party who calls him or by
the prosecution lawyer (in case of criminal cases).
• Main purpose: To place all the facts known by the witness in front of court·
Leading questions are not asked in examination-in-chief except when witness
is declared hostile by the court.
3. Cross-examination • Definition: It is the examination of the witness by the opposite party or the
lawyer of the accused party.
• Main purpose
1. To elicit facts favourable to the case.
2. To test the accuracy of the statements of the witness
3. To modify victim’s statements
4. To give a new look to the case
• Leading questions are allowed in cross-examination.
• Witnesses must be very careful while answering the questions in cross-
examination as defence lawyer will try to weaken the evidence of witness.
There is no time limit for cross-examination.
4. Re-examination • Definition: It is the examination of a witness subsequent to the cross-
examination by the party who called him/ prosecutor lawyer.
• Main purpose
1. To clarify the doubts that has been raised.
2. To explain some facts more deeply, to avoid misinterpretations
• New points are not discussed.
5. Court questions • Judge can ask any question at any stage of examination.

6. What is a summon? How is it served? Briefly describe the different steps of

recording of evidence of a witness in the court of law. (North Eastern Hill
University, Shillong Supple 2018)

Ans:
Definition of Summon
It is a written document issued by the court, which compels the attendance of the
witness in the court of law, on a particular day, at a particular date and time, under
penalty.
• It is also known as ‘subpoena’ and Section 61–69 CrPC deals with summon.
• It is issued by the court in writing, in duplicate signed by the Magistrate and bears
the seal of the court.
• It is delivered to the witness through a police officer or an officer from the court.
• On getting the summons, the witness keeps a copy and signs on the back of the
other copy of summon.
 Medical Jurisprudence, Acts and Legal Procedure 7

• The witness must appear before the court on the specified date and time with proper
records.
• A witness must attend the court unless there are valid and urgent reasons for not
attending.

A. If a Doctor Gets More than one Summon on the Same Date

But from two different courts Then he should attend the:

1. Criminal court (given priority over civil court)
2. Higher court
Same type of court Should attend the court from which he received the
summons first and should inform the other court.

B. In Case Witness Fails to Attend the Court

1. With valid reason (like illness) 2. Without any valid reason

Then message must be conveyed to the • Civil cases—liable to pay damages
court, so that a new date of hearing will be • Criminal court—court may issue notice and asks the
issued to him reason for nonattendance. In case of no justification,
he may be imposed a fine or/and imprisonment and
warrant may be issued against him

Recording of Evidence in Court

Refer to long question no. 5

7. Write in detail about medical evidence and its types. (Pondicherry 2015) (VNS,
Gujarat 2017)
Ans:
Definition of Evidence
It is defined as legal means to prove or disprove any medico-legal fact under inquiry.
Types
1. Oral evidence
2. Documentary evidence
1. Oral Evidence
It means all statements (oral or verbal) which the court permits or requires to be made
before it by witnesses, in relation to matters of fact under inquiry.
Types of oral evidence
1. Direct evidence
2. Hearsay evidence/indirect evidence
MLI: Oral evidence is more important than documentary evidence, as it permits cross-
examination.
Documentary evidence is accepted by the court only after oral testimony by the
person concerned.
 8 Exam Preparatory Manual of Forensic Medicine and Toxicology

Exceptions to it are:
1. Dying declaration
2. Matter written in the books
3. Evidence given by witness in lower court
4. Reports of certain scientific experts. (ballistic expert, fingerprint expert, DNA
fingerprint expert)
5. Public records
6. Hospital records, etc

2. Documentary Evidence
All the documents (written or printed) that are produced for the inspection of the
court.

Different Types of Documentary Evidence are

1. Medical certificates These are issued by Registered Medical Officer, e.g.

• Fitness Certificate
• Illness Certificate
• Birth Certificate
• Death Certificate
• Disability Certificate
• Mental illness Certificate
Doctors must retain one duplicate copy of these certificates
2. Medico-legal certificates • Reports prepared by a doctor at the request of the investigating
officer/victim, usually in criminal cases, e.g.
a. Injury report
b. Wound certificate
c. Post-mortem report
d. Report after examination of victim of sexual assault
These reports do not serve as evidence, until the doctor attends
the court and testifies to the facts under oath.
3. Dying declaration Definition: It is written or oral statement which is made by the dying
person as a result of unlawful act, leading to his or her death.
Section 32 IEA deals with dying declaration.
4. Dying deposition 1. It can only be recorded by the magistrate.
2. In the presence of accused party/lawyer.
3. Oath is taken.
4. Cross examination is permitted.
MLI
• Has more legal value as acts as bedside court
• Not followed in India

8. Define evidence. Discuss documentary evidence. (Sher-i-Kashmir Institute, Srinagar

Supple 2017)

Ans: Refer to long question no. 7.

 Medical Jurisprudence, Acts and Legal Procedure 9

9. Discuss briefly the duties of a doctor in court while giving evidence. (Adesh,
Bathinda supple 2018)

Ans:
The Duties of a Doctor in Court While Giving Evidence are:
1. He should attend the court punctually
2. He should be well prepared before entering the witness box
3. Take all records and relevant reports as required by court
4. He should be well dressed
5. He should switch off the mobile or keep the mobile in silent mode
6. He should not discuss the case with anyone in the court except prosecutor lawyer
7. He should speak slowly, distinctly and audibly and should use simple language
(not technical language)
8. He should address the Judge by his proper title such as ‘Sir’ or ‘Your honor’
9. If a question is not understood, he can ask the lawyer to explain it better
10. He should be pleasant, polite and courteous in the court
11. He should not lose temper
12. He should not volunteer any information beyond what is asked until or unless
he feels that his answer to a particular question does not reflect the whole truth.
13. If he does not wish to make any statement, he can say ‘no opinion’ or ‘no comments.’
14. He should avoid speaking on a subject in which he has little or no practical
experience.

10. A surgeon attends a late night new year party where he consumes substantial
amount of alcohol. While returning home, he receives an emergency call for
appendicitis surgery of a young patient. He goes to the hospital and
undertakes the surgery. During surgery, the small intestine sustains cuts by the
surgeon which remains unnoticed. The patient reports back with complications
for which another surgery was done. Three months later patient files the case
of negligence against the doctor. (Rajasthan University 2017)
a. Does the case fulfil the criteria for criminal negligence when the second
surgery is successful and does not leave any complications? Give reasons
for your answer.
b. Does the surgeon’s behavior amount to unethical practice and why?
c. What should the surgeon have done on receiving the emergency call while
returning home?
Ans:
a. Yes, the case fulfils the criteria for criminal negligence. During surgery small
intestine sustained cuts by the surgeon leading to an injury which resulted in
complications to the patient (damage). Any damage suffered is negligence.
Successful second surgery does not vitiate (annul) the wrongdoing done in the
first surgery.
Sec. 304-A IPC deals with criminal negligence where the doctor may be punished
with imprisonment up to 2 years and fine.
 10 Exam Preparatory Manual of Forensic Medicine and Toxicology

b. Yes, the surgeon’s behavior amounts to unethical practice. It is considered

‘professional misconduct” as per the Indian Medical Council (Professional
Conduct, Etiquette and Ethics) Regulations. He should not “be drunk and
disorderly so as to interfere with proper practice of medicine.”
c. He should have informed that he had alcohol and not in a position to operate when
he received the call. He should have delegated this duty one of his colleagues and
should not have established therapeutic relationship with the patient.

11. A patient had undergone laparotomy for acute abdomen. He died after
14 days of operation. During the postoperative period, he constantly
complained of abdominal pain which was treated symptomatically by the
surgeon. Alleging negligence in treatment, the relatives asked for a
postmortem examination. At autopsy, two gauze pieces were recovered from
the peritoneal cavity and cause of death was found to be septic shock
following peritonitis. With reference to the case, answer the following
questions: (Sardar Patel University, Gujarat 2016)
a. In the terminology of medical negligence, what does findings of gauze
piece amount to?
b. Who all can be held liable for the negligence act and why?
c. What all punishments would each of the guilty are liable to be awarded?
Explain with reasons.

Ans:
a. In the terminology of medical negligence, finding of gauze pieces amounts to gross
negligence and comes under “Doctrine of Res ipsa loquitur” which means thing/
fact speaks for itself. The negligence is so gross and obvious that patient does not
need to prove any negligence (which is required in other cases).
For application of this rule, three conditions which must be fulfilled are very
clear:
i. In the absence of negligence, the injury would not have occurred—it occurred
due to negligence of surgeon; the surgeon should have been more careful in
instructing his staff to get the gauze pieces counted before closing the abdomen.
ii. The doctor had a full control over the treatment resulting in injury the patent—
the surgeon operated on the patient.
iii. Patient is not guilty of contributory negligence—which is obvious, as this
happened postoperative and was under the care of surgeon.
b. The surgeon along with the support staff will be held responsible as they were
responsible for the well-being of the patient. There was dereliction of duty on the
part of surgeon which resulted in damage (death) of the patient and he was directly
involved in the causation.
c. The surgeon will be tried under Sec. 304-A IPC which is death due to rash and
negligent act (criminal negligence) and the doctor may be punished with
imprisonment up to 2 years and fine. There may be penal erasure by the State Medical
Council.
 Medical Jurisprudence, Acts and Legal Procedure 11

12. Define inquest. What are the types of inquest? Describe various types of
inquest in brief. (AIIMS Patna 2015)
Ans:
Definition of inquest
It is an inquiry or investigation by legal authorities into the cause of death where
death is due to unnatural means.
Types of Inquest Conducted by
Police inquest Police
Magistrate inquest Magistrate
Coroner’s inquest Coroner
Medical examiner system Medical examiner

1. Police Inquest: Section 174 CrPC

• Definition: The investigation or inquiry by the police into the cause of death is
called police inquest.
• Most common type of inquest in India.
• Which is held routinely
• Investigation is done by the police officer/investigation officer not below the cadre
of Senior Head Constable.
Purpose of police inquest
To find out the
• Identity of the deceased
• Place of death
• Time of death
• Cause of death
Procedure
1. Information of death is given to the police
2. Police officer informs the nearest Executive Magistrate in order to proceed with the
inquest
3. Preparation of Panchnama
• Investigating officer holds an inquiry into the matter, in the presence of two
witnesses (neighbours of that locality—panchas)
• Statements are also recorded from the family members
• Finally, inquest report is prepared which is called panchnama
• It is then signed by the investigating officer himself and by the panchas
4. In case of foul play/when unnatural death is suspected: Investigating officer
forwards the body for postmortem examination with the copy of inquest papers
5. Then, report is finally forwarded to the magistrate.
2. Magistrate Inquest: Section 176 CrPC
• Definition: The inquiry into the case of death conducted by magistrate is called
Magistrate Inquest.
• It may be conduct by executive magistrate or judicial magistrate.
 12 Exam Preparatory Manual of Forensic Medicine and Toxicology

Magistrate inquest is conducted in:

1. Death of person in prison
2. Death in police custody
3. Death of person due to police firing
4. Rape in police custody
5. Dowry death
6. Exhumation
In India, only Police and Magistrate Inquest is allowed
3. Coroner’s Inquest
Definition: It is the inquiry into the cause of death conducted by coroner.
• Coroner is a person with medical and legal knowledge of the rank of first-class
judicial Magistrate, appointed by State Government.
• It was followed earlier in Kolkata and Mumbai but was abolished subsequently.
• At present, it is followed in countries such as UK, USA, etc.
• It is similar to magistrate inquest in quality.
• Coroner is authorised only to conduct inquest; he is not authorised to conduct trial.
4. Medical Examiner System
• This type of inquest is conducted in the USA.
• It has a Board Certified Forensic Pathologist who visits the crime scene, gather
evidence and interviews the people to gather information and even conducts autopsy
• Best system for inquest.

13. Define ‘consent’. What is informed consent? Discuss about the privileged
communications with suitable examples. (Pondicherry 2017)

Describe rules of consent in brief. (AIIMS Patna 2016)

Ans:
Definition of Consent
It means voluntary agreement, compliance or permission for some act.

Types of Consent
1. Implied consent
• When a patient comes to the doctor for his medical examination and treatment
• It neither expressed in words nor in written form
• It is basically limited to inspection, palpation, percussion and auscultation
2. Expressed consent: It is the consent which is specifically expressed by the patient
Oral consent Written consent
Obtained for minor procedures Obtained for:
1. All major diagnostic/ therapeutic procedures
2. General anaesthesia
 Medical Jurisprudence, Acts and Legal Procedure 13

Informed Consent
Also called Doctrine of Informed Consent
The doctor should explain
• The condition or nature of illness
• The need for diagnostic tests to be done
• All the treatment options
• And the alternative procedures
• Risk benefit ratio of the procedures
• Associated complications or consequences
• Prognosis of the treatment
• Duration and treatment cost
It should be in simple and proper language so that patient can decide if he/she
wants to undergo the treatment or not.
Exceptions to informed consent:
1. In case of emergency—as per Section 92 IPC
2. Therapeutic privilege: If doctor feels that full disclosure to patient can cause anxiety,
then doctor can disclose full information to any of the family members. For example,
cancer report
3. Therapeutic waiver: The patient having full faith in the doctor may waiver his/her
rights of informed consent
4. Prisoners: Convicted person has no right as any other citizen
5. Medical examination requested by the police officer of an arrested accused—under
Sec. 53 (1) CrPC
6. Treatment of notifiable diseases for community interest
7. Medico-legal postmortem—as per Section 174 CrPC.

RULES OF CONSENT
1. Should be free, voluntary, cleared, informed and there should not be any undue
influence, fraud, misinterpretation of facts.
2. All the procedures beyond routine physical examination requires expressed
consent.
3. When written consent is obtained, it should also be signed by some other
witness.
4. In case of children less than 12 years of age and in case of insane person, the consent
comes from the parent or guardian.
5. As per Section 90 IPC—consent given by an insane or intoxicated person, is not
valid.
6. As per Section 92 IPC—in case of emergency, if a patient is unconscious and no
guardian is available to give consent, then doctor can perform emergency
procedure/surgery without the consent, if it is essential to save the life of the
patient.
7. Any person of more than 18 years of age can give valid consent.
 14 Exam Preparatory Manual of Forensic Medicine and Toxicology

8. Consent given for a diagnostic procedure cannot be considered as consent for

therapeutic treatment or for some other procedure.
9. No consent is required in case of medico-legal autopsies.
10. Consent of both partners (husband and wife) is required for contraceptive
sterilisation and artificial insemination.
11. Pregnant female (>18 years) alone can give consent for termination of pregnancy
12. Husband or wife has no right to deny the treatment for his or her spouse.
13. For examination of victim of a criminal case (e.g. rape), consent is mandatory.

PRIVILEGED COMMUNICATION
Definition of Privileged Communication
Disclosure of confidential information by the doctor to the concerned public authority
due to his legal, moral and social duty to protect the interest of the community.
• It is an exception to professional secrecy.
• The doctor has the moral duty to keep the information about the illness of his patient
secret or confidential. But he also has a moral duty to protect the interests of the
community. So here, privileged communication plays an important role.
• The doctor will not be liable to damage because it is in the interest of the community.

Some Examples of Privileged Communication are:

1. Court of law: In court of law, doctor cannot claim professional secrecy concerning
the facts about illness of his patient.
2. Civic benefit: In case drivers are suffering from epilepsy, alcoholism, drug
addiction, color blindness, the doctor should advise him to change the employment
because of the dangers of his present occupation both to himself and to the
public. If he refuses, then doctor can disclose this information to the concerned
authority.
3. Venereal disease: If the person is suffering from syphilis or HIV infection and is
going to marry, it is the duty of the treating doctor to advise him not to marry till he
is cured. If patient refuses, doctor can disclose the details of the disease to the other
party.
4. Suspected crime: If the physician comes across any suspected crime, such as assault,
traffic offence or homicidal poisoning while treating the patient, he should inform
police (Sec. 39 CrPC).
5. Notifiable clauses: It is the duty of the doctor to notify births, deaths, stillbirths,
infectious diseases, epidemic and food poisoning to public health authorities.
6. In patient’s interest: Doctor may disclose patient’s condition to his relatives in case
person is suffering from certain symptoms like suicidal tendencies, so that he can
be treated properly.
 Medical Jurisprudence, Acts and Legal Procedure 15

SHORT NOTES

1. Functions of State Medical Council. (Adesh, Bathinda supple 2020) (KHMS 2016)
(Rajasthan University 2016) (Rajiv Gandhi University, Bengaluru 2015)

1. Maintaining the medical register • Maintains a register of medical practitioners within its
jurisdiction
• After passing the medical degree, provisional registration is
done, and after completing the internship, permanent
registration is given
2. Renewal of registration • Permanent registration certificate has to be renewed after
every 5 years
• For renewal, it is mandatory for doctor to show certificate
of participation in CME programmes for at least 30 hrs
3. Disciplinary control • State Medical Council has the power of taking disciplinary
control over the doctor found indulging in unethical practice
by:
1. Issuing warning
2. Suspension
3. Penal erasure (temporary/ permanent)

2. Consent (BFUHS, Punjab supple 2020, 2017, 2016) (Andhra Pradesh 2016, supple
2016) (VNS, Gujarat supple 2018) (JIPMER supple 2018)

Ans: Refer to long question no. 13.

3. Implied consent (Uttarakhand University 2015)

Implied consent is one which is not expressly granted by a person (verbally or written),
but rather implicitly granted by a person’s actions and the facts and circumstances of
a particular situation (or in some cases, by a person’s silence or inaction).
Implied consent can be:
a. When a patient comes to the doctor’s clinic for medical examination and treatment.
It is basically limited to inspection, palpation, percussion and auscultation.
b. Medical treatment given to an unconscious patient is implied, despite the
unconscious person being unable to expressly grant consent for that treatment.

4. Defences available to registered medical officer against alleged medical

negligence (Sardar Patel University, Gujarat 2015) (AIIMS, Patna 2016)

Ans: Refer to long question no. 1.

 16 Exam Preparatory Manual of Forensic Medicine and Toxicology

5. Contributory negligence (BFUHS, Punjab supple 2020) (North Eastern Hill University,
Shillong supple 2020)

Ans:
Definition of Contribution Negligence
Any unreasonable conduct from the part of the patient/attendant which combined
with the doctor’s negligence contributed to the injury complained of, as a direct cause
and without which the injury would not have occurred.
Patient contributes to his negligence when he:
• Fails to follow doctor’s instructions regarding medicines
• Fails to give proper medical history to the doctor (not informing about the drug
allergies)
• Fails to follow up (in spite of doctor’s suggestion)
Example: Doctor applied a tight plaster cast on the patient’s hand (doctor’s negligence)
As a result, the patient developed numbness in his fingers, but he did not inform the
doctor (patient’s negligence). Consequently, the patient had suffered permanent injury
as it is resulted to the formation of gangrene.

Limitations to Contributory Negligence

1. Last clear chance doctrine
2. Avoidable consequences rule

MLI:
1. Acts as a good defence for the doctor in civil cases but burden of proof lies with the
doctor
2. Not act as defence in case of criminal cases

6. Professional negligence. (Rajiv Gandhi University, Bengaluru 2020) (Uttarakhand

University 2017) (KHMS, Tamil Nadu 2018, 2017, 2016) (North Eastern Hill University,
Shillong 2017) (Himachal Pradesh 2017) (Sher-i-Kashmir, Srinagar supple 2015) (JIPMER
2016)

Ans: Refer to long question no. 1.

7. Documentary evidence. (Andhra Pradesh supple 2015) (Pondicherry, 2019)

Ans: Refer to long question no. 7.

 Medical Jurisprudence, Acts and Legal Procedure 17

8. Perjury (Rajiv Gandhi University, Bengaluru 2020, 2015) (KHMS, Tamil Nadu 2018)
(Andhra Pradesh 2015)

Ans:
Definition As per Sec. 191 IPC, it is defined as wilfully giving false evidence under oath.
Punishment for perjury As per Sec. 193 IPC, imprisonment up to 7 years and fine.
Reasons behind perjury a. Witness may have taken bribe
b. He may be under threat
c. He may have personal bias towards one party

9. Doctrine of Calculated Risk. (Adesh, Bathinda supple 2019)

Ans:
Definition: Every procedure has an inherent risk, which unavoidable in spite of
providing a reasonable care.
• It means doctor is not liable if he has provided reasonable care and taken calculated
risk to save the life of a patient but during the process, the patient suffered damage.
• An exception to Doctrine of Res ipsa loquitur
• And acts as a good defence to any doctor.
• For example—a patient undergoing CABG dies during the surgery, will not amount
to negligence rather it becomes a case of professional accident as there is a calculated
risk of danger.

10. Res ipsa loquitur (Rajiv Gandhi University, Bengaluru 2020, 2015) (AIIMS, Patna 2019,
2017, 2015) (Pondicherry 2019, 2017) (North Eastern Hill University, Shillong 2018)
(Adesh, Bathinda Supple 2017) (Rajasthan University 2016) (Uttarakhand University
Supple 2017, 2016) (BFUHS, Punjab 2015) (VNS, Gujarat 2018, supple 2019) (Sai
Tirupati University, Rajasthan 2018)

Ans:
1. Doctrine of Res ipsa loquitur means “thing/facts speaks for itself”.
2. Normally, in case of professional negligence of doctor, burden of proof lies with the
patient.
3. But in some cases where rule of “Res ipsa loquitur” applies, the negligence is so
gross and obvious that patient does not need to prove any negligence.
4. For application of this rule, three conditions must be fulfilled:
i. In the absence of negligence, the injury would not have occurred.
ii. The doctor had a full control over the treatment/instrument resulting in injury
the patient
iii. Patient is not guilty of contributory negligence.
5. Examples
a. Operating on a wrong patient or wrong part of the body. For example, instead of
operating on right leg, doctor operates on the left leg.
b. Leaving surgical instruments in abdomen after surgery.
c. Blood transfusions mismatch hazard.
 18 Exam Preparatory Manual of Forensic Medicine and Toxicology

11. Consumer court/Consumer Protection Act (AIIMS, Patna 2019, 2017) (SGRD,
Amritsar 2019) (VNS, Gujarat supple 2018)

Ans:
1. In 1986, Consumer Protection Act was introduced to protect the interest of the
consumer and for the settlement of consumer disputes.
2. In 1992, medical services were also covered under Consumer Protection Act.
3. The Consumer Protection Act, 2019 replaced the more than three decades old
Consumer Protection Act, 1986.
4. E-filing of complaints: The consumer can file complaints with the jurisdictional
consumer forum located at the place of residence/work of the consumer. It also
enables the consumer to file complaints electronically and for hearing and/or
examining parties through video-conferencing.
5. Mediation: There is a provision for settlement of disputes by way of mediation at
the stage of complaint or at any later stage, if acceptable to both parties. In the event
of failure to settle the dispute, the respective commissions shall continue to adjudicate
the dispute.
6. Products liability: Consumers have the right to seek compensation for any harm
caused.
7. Advantages of consumer court
a. They provide speedy and simple solutions to the consumer disputes (A/k/a fast-
track courts)
b. Do not require any lawyer
c. No court fee is taken
8. Limitation period: The complaint has to be lodged within 2 years from the date of
cause of action.

Consumer Disputes Redressal Agencies

District Commission State Commission National Commission

Level At District level At State level At National level
Headed by District Judge Judge of High Court Judge of Supreme Court
Jurisdiction Up to ` 1 crore ` 1 crore to 10 crores More than ` 10 crores

Medical Services
In 1995, it was decided to cover Medical Services under Consumer Protection Act,
and hospitals were divided into 3 categories:

Category 1: Government hospitals, dispensaries, non-government hospitals or nursing home where services
are provided for free (i.e., no charge is taken from the patient). Do not fall under Consumer Protection
Act
Category 2: Hospitals or nursing homes where some patients (who are not able to pay for treatment) are
given services for free while others those who can afford are given services on payment basis. Fall under
Consumer Protection Act
Category 3: Medical services provided on Payment Basis. Fall under Consumer Protection Act
 Medical Jurisprudence, Acts and Legal Procedure 19

12. Privileged communication. (BFUHS, Punjab supple 2019, supple 2016) (Uttarakhand
University Supple 2018) (Delhi University 2015) (VNS, Gujarat 2018)

Ans:
Refer to long question no. 13.

13. Inquest. (West Bengal University supple 2019) (Rajasthan University 2018) (BFUHS,
Punjab 2017)

Ans:
Refer to long question no. 12.

14. Section 53 CrPC (Pondicherry 2016) (JIPMER 2016)

Sec. 53 CrPC deals with examination of accused by medical practitioner at the request
of police officer.
1. When a person is arrested on a charge of committing an offence and there are
reasonable grounds for believing that an examination of his person will afford
evidence as to the commission of the offence, it shall be lawful for a doctor, to make
an examination of the person arrested as is necessary in order to obtain evidence,
even by using reasonable force if requested by a police officer not below the rank of
sub-inspector.
This includes examination of blood, bloodstains, semen, swabs in cases of sexual
offences, sputum and sweat, hair samples and fingernail clippings using modern
and scientific techniques including DNA profiling.
2. Whenever a female accused is to be examined under this section, the examination
shall be made only by, or under the supervision of, a female doctor. Such an
examination by a male doctor must not be carried out even in the presence of a
female nurse.

15. Vicarious liability/Doctrine of ‘Respondent Superior’. (BFUHS, Punjab 2019,

Supple 2019) (Rajiv Gandhi University, Bengaluru 2019) (Delhi University 2018) (West
Bengal University 2017) (Himachal Pradesh 2017) (Jammu and Kashmir 2017)
(Uttarakhand University 2016) (Sardar Patel University, Gujarat 2015) (KHMS, Tamil
Nadu 2015) (VNS, Gujarat 2016)

Ans:
Definition: An employer will be held responsible for any negligent act done by his
employees.
• The term means “let the master answer”.
• It is also called “Captain of ship doctrine”: Chief surgeon, will be answerable for his
subordinate’s negligence. Doctor (employer) will be held responsible for the mistake
of the nursing staff (employee).
• Under this, the hospital is responsible for all the negligence of his employees who
are acting under its supervision and control.
 20 Exam Preparatory Manual of Forensic Medicine and Toxicology

• For application of this principle, following conditions must be fulfilled:

1. Employee–employer relationship.
2. The employee’s conduct should be within the scope of employment.
3. The act should have occurred while on the job.
Examples:
a. Hospital management is held responsible for the mistakes committed by the residents
and interns in training but a physician will be held responsible for the acts of interns
and residents carried out under his direct supervision and control.
b. Hospital management is not held responsible for the mistakes committed by the
senior medical staff.
c. If a doctor after operating the patient, leaves a swab or instrument inside the
patient’s body, he will be held responsible. The anesthetist will not be held
responsible.

16. Subpoena/ Summon. (Sardar Patel University, Gujarat 2020, 2019, 2018, supple 2019)
(Adesh, Bathinda 2018) (Sher-i-Kashmir, Srinagar Supple 2018) (North Eastern Hill
University, Shillong 2016) (AIIMS, Patna 2015) (VNS, Gujarat 2018, supple 2017)

Ans: Refer to long question no. 6.

17. Cross examination. (Adesh, Bathinda supple 2018) (Delhi University 2017)
(Uttarakhand University 2016, supple 2017)

Ans: Refer to long question no. 5.

18. Novus actus interveniens. (Adesh, Bathinda Supple 2018)

Ans:
• Novus actus interveniens (‘new intervening act’) is an independent event which,
after the accused’s act has been concluded either caused or contributed to the
consequence concerned.
• This new act breaks the causal chain between the accused’s action and the liability
that is implicated to him as a result thereof.
• As a novus actus is an ‘independent’ intervening act, it can be caused by anyone or
anything other than the accused. This general category also includes the injured
party himself, doctor or even an act of God.
• Novus actus is a defense for the accused who wish to prove that his liability is
limited or non-existent and should be attributed on another party.
• Example: When a patient is hospitalized with head injury due to an assault, sustains
fracture of femur in hospital due to fall on wet floors.
 Medical Jurisprudence, Acts and Legal Procedure 21

19. Powers of judicial magistrates. (AIIMS, Patna 2018) (Sai Tirupati University, Rajasthan
2018)

Ans:
Magistrate Imprisonment (up to) Fine
1. Chief Judicial Magistrate 7 years Unlimited
2. Judicial 1st Class Magistrate 3 years ` 10,000/–
3. Judicial 2nd Class Magistrate 1 year ` 5000/–

20. Various courts and their powers (Sardar Patel University, Gujarat June 2016)
(Pondicherry 2016) (VNS, Gujarat supple 2018) (JIPMER 2016)

Ans:
Criminal courts Punishment Fine
1. Supreme Court (Highest court Can pass any sentence including Unlimited
in country) death sentence
2. High Court Can pass any sentence Unlimited
• Highest Court in State including death sentence
• Death sentence given by sessions court
is confirmed by High Court.
3. Sessions Court Can pass any sentence including death Unlimited
• Highest Court in district sentence (but forwarded to High
Court for confirmation.)
4. Magistrate Court
Chief Judicial Magistrate Up to 7 years of imprisonment Unlimited
Judicial 1st Class Magistrate Up to 3 years of imprisonment ` 10,000/–
Judicial 2nd Class Magistrate 1 year of imprisonment ` 5000/–

21. Schedule of MCI. (AIIMS, Patna 2018, 2016)

Ans:
1st Schedule All the recognised medical qualifications granted by medical universities in
India
2nd Schedule It comprises all the medical qualification granted by medical universities that
are located outside India
Part: 1 of 3rd Schedule Comprises qualification granted by medical institutions not included in first
schedule
Part: 2 of 3rd Schedule Comprises medical qualification granted medical institutions outside India but
not included in second schedule

22. Dying declaration. (North Eastern Hill University, Shillong supple 2020)
(BFUHS,Punjab 2019, 2017, 2015) (SGRD, Amritsar 2019) (West Bengal University 2019)
(Sardar Patel University, Gujarat 2015) (Uttarakhand University 2016, 2015)

Ans: Refer to long question no. 4.

 22 Exam Preparatory Manual of Forensic Medicine and Toxicology

23. Dying deposition. (BFUHS, Punjab Supple 2018) (AIIMS, Patna 2016)

Ans: Refer to long question no. 7.

24. Penal erasure. (BFUHS, Punjab Supple 2018) (Rajiv Gandhi University, Bengaluru
2015) (VNS, Gujarat 2019, supple 2019)

Ans:
Definition of Penal Erasure
It is the removal of the name of a doctor from the State Medical Register as a penalty.
Penal erasure can be temporary or permanent.

Temporary Erasure of name Permanent Erasure of name (also called

professional death sentence)
The doctor is not allowed to practise his • It is the permanent removal of name of the doctor
medical profession for a specific period of from the State Medical Register
time (like weeks/months/years) in which his • After removal of the name permanently, the doctor
name remains removed from the register is not allowed to practise his medical profession for
his whole life

But if the doctor is not satisfied with the decision of State Medical Council, he can
appeal to Central Health Ministry (within 30 days of the decision) which forwards to
NMC, and the decision is given.

25. Professional misconduct/Infamous conduct. (West Bengal University 2018, supple

2019) (North Eastern Hill University, Shillong 2016, 2015, Supple 2018) (Sardar Patel
University, Gujarat 2017, 2015, supple 2015) (KHMS, Tamil Nadu 2015) (GMC,
Chandigarh 2015) (GMC, Chamba 2019)

Ans: Refer to long question no. 3.

26. Leading questions (North Eastern Hill University, Shillong 2018)

Ans:
Definition of Leading Question
Any question suggesting the answer, which the person putting it wishes or expects to
receive.
Answer for leading questions is either Yes/No.
Examples:
• Was the injury caused by knife?
• Was kerosene used to burn her?
1. Leading questions are not allowed in Examination-in-Chief and Re-Examination.
 Medical Jurisprudence, Acts and Legal Procedure 23

2. But leading questions may be asked in Examination-in-Chief under two conditions.

– When the witness is declared hostile by the court
– When court give permission to ask leading questions
3. Leading questions are allowed in cross-examination.

27. Conduct money (Rajiv Gandhi University, Bengaluru 2015) (GMC, Chamba 2019)
Ans:
Definition of Conduct Money
It is the fee paid to a witness in civil cases at the time of serving the summons to meet
the expenses for attending the court.
• If the conduct money is not sufficient or not paid, then it can be brought into the
notice of court before giving evidence and court will decide the amount.
• In criminal cases—no conduct money is paid at the time of serving the summon.
The witness must attend the court in interest of State or justice. However,
Government usually pays TA and DA allowances.

28. Professional death sentence. (Rajiv Gandhi University, Bengaluru 2018) (Rajasthan
University 2018)

Ans:
Definition of Professional Death Sentence
It is defined as the permanent removal of name of the doctor from the State Medical
Register (penal erasure).
• This punishment is given to a medical practitioner when he is found guilty of the
serious professional misconduct, like
1. Adultery
2. Addiction to drugs
3. Alcoholism
4. Criminal abortion
5. Female feticide
• After removal of the name permanently, the doctor is not allowed to practise his
medical profession for his whole life.

29. Conduct of a doctor in witness box. (Rajasthan University 2018) (Pondicherry,

2017)

Ans: Refer to long question no. 9.

30. Informed consent (SGRD, Amritsar 2019) (Sardar Patel University, Gujarat Supple
2018) (Adesh, Bathinda supple 2018, 2016) (Rajasthan University 2018, 2016) (North
Eastern Hill University, Shillong 2016)

Ans: Refer to long question no. 13.

 24 Exam Preparatory Manual of Forensic Medicine and Toxicology

31. Police inquest (KHMS, Tamil Nadu 2016)

Describe the procedure of police inquest. (Rajiv Gandhi University 2015)

Ans:
Refer to long question no. 12.

32. Magistrate’s inquest/Section 176 CrPC (Uttarakhand University 2017) (KHMS, Tamil
Nadu 2015) (Delhi University Supple 2016) (Himachal Pradesh 2017) (Rajiv Gandhi
University, Bengaluru 2015)

Ans: Refer to long question no. 12.

33. Expert witness (Sai Tirupati University, Rajasthan 2019)

Ans:
Definition: An expert witness is a person who is skilled in a particular field (law,
science or art).

Legally Defined Under Sec. 45 IEA.

• He can draw conclusions on facts observed by him or by others.
• He can express an opinion on observations made by others.
• He can volunteer information, and highly responsible for his/her comments.

DIFFERENTIATIONS

1. Examination-in-Chief and cross-examination (BFUHS, Punjab Supple 2020)

Examination-in-Chief Cross-examination
Definition The first statement which is recorded The statement which is recorded by
by the prosecution lawyer/the party the lawyer of the accused party
who calls him
Leading questions Not allowed Allowed
Order of sequence Oath is followed by Examination-in-Chief Examination-in-Chief is followed by
cross-examination
Objectives To place before the court all the facts that To elicit facts favorable to his case; test
bear on the case the accuracy of the statements, and
to discredit the witness
 Medical Jurisprudence, Acts and Legal Procedure 25

2. Dying Declaration and Dying Deposition (University of Health Sciences, Rohtak

2019, 2017, supple 2020) (GMC, Chandigarh 2015) (Rajasthan University 2017, 2016)
(North Eastern Hill University, Shillong supple 2016) (VNS, Gujarat 2018)

Dying declaration Dying deposition

Oath Not required Must
Recorded By anyone (magistrate/doctor/police officer) Only by magistrate
Accused party Not allowed Allowed
Cross-examination Not allowed Allowed
Followed in India Yes No
If person survives Loses its value, but has corroborative value Value is retained
Legal value Less More
Type of evidence Documentary Oral
Role of doctor Assess compos mentis and record the statement Assess compos
in absence of magistrate, but in presence of witnesses mentis only

3. Civil negligence and criminal negligence (University of Health Sciences, Rohtak

2019, 2017, supple 2020) (Adesh, Bathinda 2019, 2017) (BFUHS, Punjab 2019, supple
2019) (Delhi University 2017) (GMC, Chandigarh 2016) (North Eastern Hill University,
Shillong Supple 2016)

Civil negligence Criminal negligence

Trial by Civil court/consumer court Criminal court
Negligence Simple absence of care and skill Gross negligence
Punishment Monetary compensation Imprisonment, fine or both
Evidence Strong evidence is sufficient Guilt should be proved beyond reasonable
doubt
Complainant Sufferer party Public prosecutor on behalf of the State
Contributory negligence Act as defense for doctor Not a defense for doctor
Consent for act —do— —do—
Litigation Between two parties State vs doctor

4. Professional misconduct and professional negligence (Sher-i-Kashmir, Srinagar

2020, supple 2017) (West Bengal University 2017) (Sardar Patel University, Gujarat
supple 2016) (Delhi University Supple 2016) (Uttarakhand University 2015)

Professional misconduct Professional negligence

Definition Conduct which is considered disgraceful and Lack of reasonable care and skills
dishonorable by professional colleagues of that resulted in damage /death of
good repute the patient
Offence Violation of Code of Medical Ethics Absence of care and skill
Duty of care Need not be present Should be present
Damage to person —do— —do—
Trial by State Medical Council Courts- civil/ criminal
Punishment Warning or erasure of name Fine, imprisonment or both
Appeal To NMC or central government Higher court
 26 Exam Preparatory Manual of Forensic Medicine and Toxicology

2
Autopsy and
Thanatology
LONG QUESTIONS

1. Classify the changes occurring in the body after death. Discuss their role in
the determination of ‘Time Since Death’. (BFUHS, Punjab 2019, 2015, supple 2018)
(North Eastern Hill University, Shillong 2018, 2017, supple 2017) (VNS, Gujarat supple
2018, supple 2019) (Sai Tirupati University, Rajasthan 2018)

What are the early signs of death? How may the TSD be estimated from the
postmortem changes? (North Eastern Hill University, Shillong supple 2016, supple 2019)
Ans: Classification of changes occurring after death.

Changes after Death

Immediate changes Early changes Late changes
1. Irreversible cessation of 1. Facial pallor 1. Decomposition/putrefaction
the function of: 2. Changes in the eye 2. Adipocere
a. Brain 3. Algor mortis 3. Mummification
b. Respiration 4. Livor mortis (PM staining) (Mnemonic: MAD)
c. Circulation 5. Rigor mortis
6. Primary flaccidity of muscles
7. Loss of elasticity of skin

Role in Determination of Time Since Death (TSD)

1. Changes in eye
1. Eyeball—becomes flaccid due to fall in IOP (from 10 to 0 mmHg) within 4–6 hrs after death
2. Sclera
Tache noire
• Deposition of dust particles over sclera giving dark brown-black color, triangular in appearance
with apex towards canthus and base at limbus
• Occurs within 3–6 hrs after death
3. Cornea—hazy and opaque 6–8 hrs after death
2. PM staining
Mottled patches 30 min–1 hour after death
Coalesce 4–6 hours after death
PM fixation 8–12 hours after death

26
 Autopsy and Thanatology 27

3. Algor mortis: Not a reliable method; the body attains environmental temperature in about 16–20 hours
after death.
4. Rigor mortis
Starts Within 1–2 hours after death
Appearance of rigor mortis Takes 12 hours to develop
Persistence of rigor mortis Persists for next 12 hours
Vanishes off In next 12 hours
5. Putrefaction
Greenish discolouration of 12–24 hours after death
right iliac fossa
Marbling 36–48 hours after death
Skin slippage 36–48 hours after death
Peeling of skin 48–72 hours after death
Loosening of hair >72 hours after death
6. Adipocere: Starts 3 days after death
7. Mummification: 3 months–6 months after death

Other Changes which are Used in Determining TSD

1. Insect activity: By 18–36 h, flies lay their eggs. The eggs hatch into maggots or
larvae in about 12–24 h. In 4–5 days, maggots develop into pupae, and by 8–12 days
pupae into adult flies. Lice usually dies within 3–6 days after death.
2. Stomach contents: From the state of digestion and quantity of food in the stomach,
TSD can be estimated. If the quality, quantity and the time of last meal taken can be
known, the TSD can be estimated. If the stomach is full and contains undigested
food, then death occurred within 2–4 h of eating of the last meal.
3. Intestinal contents: From the content of the pelvic colon and rectum, it can be said
if the person attended the nature’s call within last few hours or not. If it contains
feces, death may have occurred in the night and if empty, sometime after evacuation
in the morning (depending upon the person’s habit).
 28 Exam Preparatory Manual of Forensic Medicine and Toxicology

4. Contents of urinary bladder: The amount of urine in the bladder may give some
idea of TSD. If a body is found in the morning with the bladder full, then he might
have died before the usual time of leaving his bed.
5. Biochemical and enzymatic changes
• Blood: Potassium and magnesium rise, whereas sodium and chloride fall after
death.
• CSF: Potassium, creatine and uric acid increase, and glucose values decrease after
death.
• Vitreous humor: Potassium, magnesium, urea and creatinine increase after death.
6. Facial hair growth: If the time of his last shave is known, then survival time can be
calculated, and the TSD can be estimated indirectly.
7. Circumstantial evidences: Pocket articles, mobile, diary, cinema tickets, etc. may
indicate the date and time up to which the person survived.

2. Define somatic death. Enumerate usual PM changes occurring after death.

Describe immediate signs of death. (AIIMS, Patna 2015) (VNS, Gujarat 2017)
Ans: Definition of somatic death: It is defined as complete and irreversible cessation
of brainstem functions.
PM changes occurring after death—refer to long question no. 1.

Immediate signs of death

1. Irreversible cessation of Tests to confirm cessation of brain and brainstem
the function of brain • Loss of reflexes
• Dilated pupils
• Loss of muscle tone
• Flat EEG
2. Irreversible cessation of Tests to confirm cessation of reparation clinical examination
respiration • Inspection—chest movements not visible
• Palpation—chest movement cannot be felt
• Auscultation—breath sounds not heard
3. Irreversible cessation of circulation Tests to confirm cessation of circulation
• Pulsations—absence of radial, femoral and carotid pulses
• Absence of the heart beat on auscultation
• Flat ECG for 5 min

3. Define rigor mortis. Describe in brief its mechanism of formation. Discuss the
other conditions mimic rigor mortis. (West Bengal University, 2017) (University of
Health Sciences, Rohtak 2017) (Rajasthan University, 2016) (Sai Tirupati University,
Rajasthan 2019)
Ans: Definition of rigor mortis: It is defined as stiffening of muscles of body after death.

Mechanism of Rigor Mortis

• It involves both voluntary and involuntary muscles
• Seen after primary flaccidity
• It is based on the concept of actin-myosin complex
 Autopsy and Thanatology 29

• In relaxed position—interdigitation of actin-myosin filaments is seen to a small extent

• After death—ATP generation stops but consumption continues. So, depletion of
ATP occurs leading to a permanent link in actin-myosin complex giving rise to
stiffening of muscles

Conditions Simulating Rigor Mortis

1. Heat stiffening—refer to short question no. 19
2. Cold stiffening—refer to short question no. 14
3. Cadaveric spasm—refer to short question no. 20
4. Gas stiffening

4. Define death. Enumerate usual PM changes occurring after death. Discuss

changes occurring in muscles after death (Sher-I-Kashmir Institute, Srinagar supple
2018) (Sardar Patel University, Gujarat 2017) (VNS, Gujarat 2016) (Sai Tirupati
University, Rajasthan 2019)
Ans: Definition of death: The word ‘death’ denotes the death of a human being, unless
contrary appears from the context (Sec. 46 IPC). It is defined as permanent and
irreversible cessation of functions of brainstem.
Enumerate PM changes after death—refer to long question no 1.
For changes in muscles after death—refer to long question no 3.

5. Define rigor mortis. Describe in brief regarding mechanism and time of

development of rigor mortis. How will you differentiate Rigor Mortis and
cadaveric spasm? (AIIMS Patna, 2016)
Ans: Definition and mechanism of rigor mortis—refer to long question no. 3.
Time of development of rigor mortis—refer to short question no. 17.
For difference rigor mortis and cadaveric spasm—refer to difference no. 1.

6. Define and classify types of death. Discuss different modification to the

process of decomposition. (BFUHS, Punjab 2020)
Ans: Definition of death—refer to long question no. 4.
 30 Exam Preparatory Manual of Forensic Medicine and Toxicology

Types of Death
1. Somatic death: It is defined as complete and irreversible cessation of brainstem
functions.
2. Molecular death: It is defined as progressive disintegration of body cells and tissues
which occurs after somatic death.
Refer to difference no. 2 for more details.

Modification of the Process of Decomposition

1. Adipocere—refer to the short question no. 3.
2. Mummification—refer to the short question no. 10.

7. Describe in brief about PM hypostasis. (AIIMS, Patna 2019, 2017) (Sai Tirupati
University, Rajasthan 2018)
Ans: Hypostasis
1. Definition: It is defined as bluish-red or purplish-red discolouration of the skin
over the dependant body parts after death. It is also known as livor mortis, PM
staining, PM lividity.
2. Mechanism: After death, blood stops flowing and due to force of gravitation gets
collected in vessels and capillaries of dependant body parts resulting in PM staining.
3. Fixation of PM staining: Time taken for fixation—8 hrs
If position of body is changed before fixation—position of lividity also changes
Staining fixed TSD >8 hrs
Staining not fixed TSD <6 hrs
4. Testing for fixation
• Firmly press the area with thumb for 30–45 seconds
• If hypostasis disappear—PM staining not fixed
• If hypostasis remains—PM staining fixed
5. Development of PM staining
Onset 30 min
Well developed 4 hrs
Completely develops 6 hrs

6. Areas of contact pallor: PM staining is not seen in areas which are in direct contact
with the ground, i.e. PM staining is not seen over pressure areas. For example, in
case of supine position—pressure points are at back of head, shoulder blade, gluteal
region, back of foot.
7. Distribution and extent of PM staining
Supine position Back of head, chest and legs, except areas of contact pallor
Prone position On front of face, chest and abdomen
Hanging Lower parts of forearm and legs (glove and stocking distribution)
Drowning In stagnant water—found on face, upper part of chest, hands and legs
In moving water—PM staining not seen as body moves continuously
 Autopsy and Thanatology 31

8. Color of PM staining
Color of PM staining Cause of death
Bluish-purple Normal
Cherry red Carbon monoxide
Bluish-green Hydrogen sulphide
Black Opiates
Brick red Cyanide poisoning

9. MLI
i. It is a sign of death
ii. It helps in estimation of TSD
iii. Helps in determining position of body after death
iv. Determination of cause of death
v. Mistaken for bruise

8. Discuss algor mortis. (Sher-i-Kashmir Institute, Srinagar supple 2017)

Ans: Algor Mortis
Definition: It is the cooling of body after death.
• It is usually the first sign of death.
• Fall in body temperature is not uniform from the moment of death onwards.
Therefore, it follows a Sigmoid shape curve.

Average rate of fall of body temperature is 0.4°–0.7°C/hour and attains

environmental temperature in 15–18 hrs after death
Normal body temperature – Rectal temperature
TSD =
Rate of cooling per hour

Recording of Temperature after Death

Site Method
• Rectum Thermocouple
• Subhepatic space Thanatometer—25 cm long
• External auditory canal
 32 Exam Preparatory Manual of Forensic Medicine and Toxicology

Factors affecting Algor Mortis

Environmental temperature Most important factors
Rate of fall of body temperature is directly proportional to the difference
between the temperature of the dead body and the environmental
temperature.
Humidity Cooling is rapid in humid environment
Movement of air Body in open air cools faster than that in closed room
Clothing As clothes do not allow dissipation of heat therefore, body cools slowly

MLI
i. Helps in estimation of TSD
ii. It is a sign of death
iii. Rapid cooling of a dead body delays the processes of rigor mortis and decomposition.

9. What do understand by the legal concept of death? Discuss in detail about

the diagnosis of brainstem death. (North Eastern Hill University, Shillong 2019) (Sai
Tirupati University, Rajasthan 2018)
Ans: The legal concept of death is “brainstem death”.
1. The traditional cardiopulmonary standard (cessation of heart beat and breathing)
is not considered currently, since circulation and respiration could be maintained
by means of a mechanical respirator, despite loss of all brain functions.
2. Brain death is the complete and irreversible cessation of functioning of the brain.
Brain includes all the central nervous system (CNS) structures, except the spinal
cord.
3. Brain death is now accepted as brainstem death. The respiratory center which
controls respiration lies within the brainstem. If this area is dead, the person is
unable to breathe spontaneously or regain consciousness.
4. Since a normal functioning reticular formation within the brainstem is essential for
the proper functioning of the cortex, brainstem death is considered to be sufficient
for brain death.
Refer to long question no. 10 for diagnosis of brainstem death.

10. A 25-year-old male was brought to the casualty with the history of fall from
height with GCS score 3 and was later shifted to neurosurgery care. On day
two of the treatment, the treating physician suspected brainstem death of the
patient. (Pondicherry 2019)
a. Mention the criteria to pronounce brainstem death.
b. Who are the members of the brainstem death declaration committee and
what are the procedures followed by them to declare the same?
c. What are the different types of donors for organ transplantation?
Ans: The two essential requirements for the diagnosis of brain death are:
1. Establishment of cessation of all brain functions, i.e. cerebral and mainly brainstem
functions—determined clinically and confirmed by laboratory tests which include
EEG (flat isoelectric EEG).
 Autopsy and Thanatology 33

2. Demonstration that cessation of these functions is irreversible:

Irreversibility is established by:
a. Determination of the cause of loss of brain function.
b. Exclusion of reversible conditions like hypothermia, electrolyte imbalance, drug
intoxication, shock, hypotension, etc.

Brainstem Death Certification

a. Two medical practitioners of which one should be neurologist or neurosurgeon
must perform the brainstem death tests.
b. Patient’s attending physician should participate in determination of death.
c. Such tests should not be performed by transplant surgeons or any doctor in the
transplant team.
The three important findings seen in brain death are coma, absence of brainstem
reflexes and apnea
1. Coma or unresponsiveness: No cerebral motor response to pain in all extremities
2. Absence of brainstem reflexes
a. Absent pupillary response to bright light.
b. No oculocephalic reflex or absent oculovestibular reflex.
c. No corneal reflex to touch with a cotton swab or no grimacing to deep pressure
on nail bed, supraorbital ridge.
d. No gag reflex or cough response to bronchial suction.
3. Apnea test: It is based on the fact that loss of brainstem function results in loss of
centrally controlled breathing, with resultant apnea.

Types of Donor for Transplants

1. Autograft: Tissue transplanted from one part of the body to another in the same
individual—autotransplant or homologous transplantation.
2. Allograft: Organ or tissue transplanted from one individual to another of the same
species with a different genotype—homograft.
3. Isograft: Organs or tissues are transplanted from a donor to a genetically identical
recipient.
4. Xenograft: Organs or tissue transplanted from one species to another, e.g., grafting
of animal tissue into humans.
5. Split transplants: Deceased-donor organ (e.g. liver) may be divided between two
recipients.

11. What is medico-legal autopsy? What are the objectives of medico-legal

autopsy? Describe the type of skin incisions for opening scalp, chest, and
abdomen. (North Eastern Hill University, Shillong 2016)
Ans: Medico-legal autopsy: It is a type of scientific examination of a dead body carried
out in case of sudden, suspicious, obscure, unnatural, litigious or criminal deaths in
order to establish the cause and manner of death and time since death.
• A complete autopsy should be done (all the body cavities should be opened and
every organ must be examined)
• It should be done by the doctor himself and not by any attendant
 34 Exam Preparatory Manual of Forensic Medicine and Toxicology

Objectives of Medicolegal Autopsy

1. To find out the cause of death
2. To find out time since death, mode of death and place of death
3. To find out manner of death (accidental, homicidal or suicidal)
4. To establish identity of deceased when not known/not identifiable
5. To identify if injuries are AM or PM in nature
6. In case of newborns, to determine the question of live birth and viability of the baby

Types of Skin Incisions

Skin incisions are of following types:
1. I-shaped or standard midline incision: Most common method. It extends from the
chin down to the symphysis pubis and avoiding the umbilicus.
2. Y-shaped incision: The straight line of Y corresponding to the xiphisternum to pubis
incision of I-shaped incision. The forks of Y run down medially to the chest and
extending towards the acromion process.
3. Modified Y-shaped incision: It is used to study the neck, like in hanging or
strangulation. An incision is made in midline from suprasternal notch to symphysis
pubis. The incision extends from suprasternal notch over the clavicle to its center
on both sides and then passes upwards towards mastoid process.

1. Scalp 1. An ear-to-ear bone deep incision is made along the vertex of the scalp.
2. The scalp is reflected forwards to the superciliary ridges, and backwards to a point just
below the occipital protuberance.
3. Look for hematoma, edema or any fracture.
4. Sawing of skull is done by making a saw-line in slightly V-shaped direction (angle of 120°).
5. Skull cap is removed and dura is exposed which is examined from outside for EDH, then
dura is cut from periphery and then falx cerebri, and examined for SDH and SAH.

2. Chest 1. The skin and muscles of the chest are dissected sidewise and carried back to the
midaxillary line, down to the costal margin and up over the clavicles.
2. Examine the ribs and sternum for fractures.
 Autopsy and Thanatology 35

3. Open the chest by cutting the costal cartilages from second rib onwards close to the
costochondral junctions with help of cartilage knife.
4. Sternoclavicular joints are finally disarticulated on both sides.
5. Sternum is removed. Pleural cavity is examined for presence of any blood, pus, adhesions.
3. Abdomen 1. An incision to rectus abdominis till 5 cm above pubis symphysis.
2. A small nick is made in the fascia to admit the left index and middle fingers with palmar
surfaces up.
3. Peritoneum is cut up to the xiphoid and abdominal cavity is looked for presence of any
blood, pus, fluid or perforation.
4. Finally, evisceration of the organs is done.

SHORT NOTES

1. Negative autopsy. (Rajiv Gandhi University, Bengaluru 2020) (Rajasthan University, 2016)
Ans: Definition of negative autopsy: An autopsy in which cause of death cannot be
found even after with gross, microscopic, radiological and toxicological analysis.
• For example, SIDS can be considered as ‘negative autopsy’.
Incidence: 4–6% of all autopsies are found to be negative autopsy.

Reasons
i. Inadequate history about signs and symptoms prior to death
ii. Lack of experience on part of doctor
iii. Inadequate examination of external injuries—e.g., needle marks in case of drug
addicts, entry wound in case of electrocution
iv. Inadequate examination of internal injuries—e.g., air embolism and pneumothorax
are often missed.
v. Inappropriate methods for collection and preservation of samples

2. Postmortem caloricity. (AIIMS, Patna 2019, 2018, 2017) (Adesh, Bathinda Supple
2018, 2017) (North Eastern Hill University, Shillong Supple 2018)
Ans:
Definition of postmortem caloricity—the initial rise of body temperature for first
two hours after death.

Causes of PM Caloricity
Causes of PM caloricity Mechanism
1. Infectious diseases/septicemia Due to increased bacterial activity
2. Hot temperature (tropical countries) As dead body absorbs heat from the environmental
temperature
3. Convulsions (tetanus, strychnine poisoning) Due to increased muscular contractions
4. Pontine hemorrhage Due to loss of heat regulation centre

MLI—PM caloricity leads to wrong estimation of TSD.

 36 Exam Preparatory Manual of Forensic Medicine and Toxicology

3. Adipocere formation (Rajiv Gandhi University, Bengaluru, 2018)

Ans:
a. Definition of adipocere: It is a modification of putrefaction in which putrefaction
is arrested and body fat is changed into fatty acids and wax-like substance called
adipocere.
b. Formation

c. Sites of adipocere formation: Fat rich tissues (breast, cheeks, face, abdomen,
buttocks) due to presence of abundant subcutaneous tissue.
d. Factors favouring adipocere formation
i. Warm and moist environment
ii. Presence of bacteria esp. Clostridium welchi
iii. Abundance of fatty tissues, therefore, adipocere is formed quickly in obese people
iv. Dead bodies placed in airtight coffins
e. MLI
i. It gives a rough estimate of TSD.
ii. The features are well-preserved, which helps in identification.
iii. The cause of death can be determined, since injuries are recognizable.
iv. Some idea about the place of disposal of the body can be made; adipocere requires
a warm and humid place or presence of water.

4. Suspended animation/apparent death (Rajasthan University, 2018) (Uttarakhand

University 2018) (Adesh, Bathinda Supple 2017) (Rajiv Gandhi University, Bengaluru
2015) (North Eastern Hill University, Shillong 2015) (Andhra Pradesh Supple 2016)
Ans: Definition of suspended animation: It is a condition in which vital signs of life
(like heart beat and respiration) cannot be detected by routine clinical methods, as the
functions are reduced to a minimum.
Mechanism: BMR is greatly reduced so that the requirement of the oxygen decreases
but dissolved oxygen in body fluids is enough to satisfy the demands of the body.

Types
1. Voluntary Seen in yoga practitioners
2. Involuntary (Mnemonic—DENTIST) Drowning, Electrocution, Newborn, Typhoid, Insanity, Sunstroke, TB
 Autopsy and Thanatology 37

MLI
• The patient can be resuscitated by cardiac massage and artificial respiration.
• Before certifying death, ECG or EEG should be done to rule out suspended animation

5. Postmortem findings in starvation death. (Rajasthan University, 2018) (Uttarakhand

University 2018) (Pondicherry Supple 2017) (Pondicherry 2016) (JIPMER 2016)
Ans: PM findings in starvation death
General Emaciation with loss of body weight, sunken eyes and pronounced rib cage.
Subcutaneous tissue Complete loss of fat in subcutaneous tissue, loss of adipose tissue of mesentery
Muscles Atrophy of skeletal muscles
GIT Mucosal atrophy and atrophy of GIT walls (thin paper like)
Stomach and intestines Empty with dry stools in colon
Liver Centrilobular necrosis due to protein deficiency
Gall bladder Distended with bile, bigger in size
Urinary bladder Empty
Brain Normal, no atrophy

6. Brain death. (Rajasthan University, 2018) (BFUHS, Punjab 2016) (Rajiv Gandhi
University, Bengaluru 2019)
Ans: Refer to long question no. 10.

7. Tests to be performed to diagnose brainstem death (Sardar Patel University,

Gujarat 2019)
Ans: Refer to long question no. 10.

8. Describe marbling and its medico-legal importance. (Rajiv Gandhi University,

Bengaluru, 2019)
Ans: Marbling
1. Definition of marbling: It is the greenish discoloration
of superficial vessels over the skin due to formation
of sulfmethemoglobin.
• It is a sign of putrefaction.
2. Mechanism of formation
3. Onset: 36–48 hours after death
4. Sites of appearance: Marbling first appears on neck,
chest, shoulders and upper aspects of limbs
5. MLI
i. It helps in estimation of TSD.
ii. Indicates initiation of putrefactive changes.
 38 Exam Preparatory Manual of Forensic Medicine and Toxicology

9. Rigor mortis. (BFUHS, Punjab 2017) (Sardar Patel University, Gujarat Supple 2015)
(Rajiv Gandhi University, Bengaluru 2015) (Rajasthan University 2017)

Postmortem rigidity. (University of Health Science, Rohtak Supple 2020)

Ans: Refer to long question no. 3.

10. Mummification. (Uttarakhand University 2017, 2016) (Rajiv Gandhi University,

Bengaluru 2020) (GMC, Chandigarh 2015)
Ans: Mummification
1. Definition: It is the rapid dehydration and shrivelling of the dead body due to
evaporation of water from the body.
• It is a modification of putrefaction (dry decomposition)
2. Features of mummification
• Mummified bodies are colorless, odorless.
• The entire body loses weight and becomes thin and brittle.
• Internal organs become shrunken, hard or unidentifiable.
• It begins in the exposed parts of the body (face, hands, feet) and extends to entire
body.
• Skin is stretched tightly across anatomical prominences, such as the cheek bones,
chin, costal margins and hips, adheres closely to the bones, and often covered
with fungal growths.
3. Time taken for development of mummification: 3 months to 1 year.
4. Conditions required for mummification
Hot environment Like desert
Poisoning Arsenic poisoning favours mummification
Free air movement Favours mummification
Dry atmosphere Mummification does not occur in humid conditions

5. MLI
i. TSD can be estimated.
ii. Helps in identification as the features are well-preserved.
iii. Injuries are preserved and cause of death can be established.
iv. Place of disposable of body can be obtained—requires hot, dry environment.

11. Modern concept of moment of death (Delhi University 2017)

Ans:
1. The moment of death is the exact time when the person dies. The concept of the
moment of death has changed through the years. The traditional cardiopulmonary
standard (cessation of heartbeat and breathing) was the measure used during most
of the 20th century to determine the presence of life.
2. As ventilator technology advanced, circulation and respiration could be maintained
by means of a mechanical respirator, despite loss of all brain functions, and thus
have brought the concept of brain death, i.e., irreversible loss of cerebral functioning.
Refer to long question no. 9 also.
 Autopsy and Thanatology 39

12. Time since death. (West Bengal Supple 2017)

Ans: Refer to long question no. 1

13. Cold stiffening (AIIMS, Patna 2016)

Ans: Cold Stiffening
1. It occurs when a body is exposed to freezing temperature (below–3.5°C) for a long
period, the tissues becoming frozen and stiff, simulating rigor.
2. On forcibly flexing the joints, crackling sounds of ice crystals can be felt.
3. Reason for occurrence
• Freezing of body fluids at the tissue level and in the synovial sacs of the joints
• Hardening of the subcutaneous fatty tissue.
4. MLI: If body is exposed to warm temperature, the stiffness disappears and normal
rigor mortis occurs.

14. Changes in the eyes after death. (BFUHS, Punjab Supple 2016) (SGRD, Amritsar
2019)
Ans:
1. Loss of corneal reflex Not a reliable sign
2. Cornea Become hazy and opaque 6–8 hrs after death
3. Pupils Become dilated and fixed
4. Eyeball Becomes flaccid due to fall in IOP (from 10 mmHg to 0 mmHg) within
4–6 hrs after death
5. Sclera Tache noire
• Deposition of dust particles over sclera giving dark brown-black color,
triangular in appearance with apex towards canthus and base at
limbus
• Occurs within 3–6 hrs after death
6. Retina Kevorkian sign/trucking of blood vessels
• Segmentation of retinal blood vessels
• Occurs immediately after death
• Seen with ophthalmoscope
7. Vitreous humor Increase in—K+, hypoxanthine
Decrease in—Na+, Cl–, Glucose

15. Mode of death. (GMC, Chandigarh 2016)

Ans: Definition of mode of death: It is an abnormal physiological state existing at the
time of death, e.g. coma, congestive cardiac failure, cardio-respiratory failure, cardiac
arrest or pulmonary edema. There are three modes of death depending upon the system
most obviously affected are:
1. Coma
2. Syncope
3. Asphyxia
 40 Exam Preparatory Manual of Forensic Medicine and Toxicology

Coma Syncope Asphyxia

Definition: State of deep Definition: Death from failure Definition: Death due to failure
unconsciousness from which of the function of the heart of functioning of lungs
a person cannot be roused, resulting in hypoxia and hypo-
with minimal or no detectable perfusion of the brain.
responsiveness to stimuli.
Seen in cases of Seen in cases of Seen in cases of
• Disease of the brain • Heart disease • Hanging
• Systemic disorders—diabetic • Hemorrhage • Strangulation
ketoacidosis, uremia, • Vagal inhibition • Throttling
eclampsia • Poisoning like digitalis,
• Intoxication—alcohol, opium aconite, etc.

16. Rule of 12 (Andhra Pradesh Supple, 2016) (VNS, Gujarat 2019)

Ans:
1st phase Appearance of rigor mortis Takes 12 hrs but involves only proximal parts
2nd phase Persistence of rigor mortis Next 12 hrs (12–24 hrs), rigor mortis present at distal parts
3rd phase Passing off rigor mortis Takes another 12 hrs (24–36 hrs)

17. Postmortem hypostasis (Uttarakhand University 2016) (JIPMER supple 2018)

Ans: Refer to long question no. 7.

18. Heat stiffening. (AIIMS, Patna 2015)

Ans: Heat Stiffening
1. When the body is exposed to a temperature of >65°C, coagulation of muscle protein
occurs leading to rigidity.
 Autopsy and Thanatology 41

2. Usually, flexors are affected and muscles are contracted giving rise to a condition
called pugilistic attitude.
3. Rigidity of muscles is more in heat stiffening than that in rigor mortis
4. MLI
i. It remains until decomposition occurs leading to softening of muscles and
ligaments
ii. Rigor mortis is absent
iii. Seen in death due to burns

19. Cadaveric spasm. (Andhra Pradesh, 2015)

Ans: Cadaveric Spasm
1. Definition of cadaveric spasm: It is a condition in which the muscles of the body
that were in state of contraction at the time of death continue to be in contracted
state even after death without passing through the stage of primary relaxation.
2. The other muscles of the body are in stage of primary relaxation.
3. Involvement of muscles
Spasm of voluntary group of muscles Involvement of whole body (rare)
• Presence of grass and weeds in hands—in case of drowning For example: Soldiers shot in battle
• Weapon clenched in hands—in case of suicides

4. Mechanism of development: Depletion of ATP in affected muscles with persistence

of contraction even after death leading to the failure of muscle relaxation during
molecular death and impairment in ATP resynthesis
5. Cadaveric spasm continues till rigor mortis appears, then vanishes off with rigor
mortis
6. MLI
i. Indicates sudden death with great emotional stress (excitement, exhaustion, fear,
fatigue)
ii. It suggests manner of death
• Suicidal death—weapon/pistol held clenched tightly in hand
• Homicidal death—clothings, hair or buttons of assailant may be held firmly in
hand
iii. It suggests antemortem death
In case of drowning—presence of weed, grass and mud clenched in hands

20. Causes of sudden natural death. (Rajiv Gandhi University, Bengaluru 2015)
Ans: Definition of sudden death: Death occurring instantaneously or within 1 h of
the onset of morbid symptoms (as per WHO, within 24 hrs).
• It is the sudden and unexpected death of a person, who prior to death was not
suffering from any dangerous disease, poisoning or injury.
1. Cardiovascular diseases • Myocardial infarction
(MC cause of sudden death) • Coronary artery disease
• Congenital heart disease
 42 Exam Preparatory Manual of Forensic Medicine and Toxicology

• Valvular heart disease

• Cardiomyopathies
• Aortic aneurysm
2. Respiratory system • Pneumothorax
• Acute epiglottitis
• Air embolism
• Pulmonary embolism
• Obstruction of respiratory passage by foreign body
3. GIT • Appendicitis
• Pancreatitis
• Strangulated hernia
• Peritonitis
• Massive GIT hemorrhage
4. CNS • SAH
• Intracerebral hemorrhage
• Stroke
• Brain tumor
• Meningitis
5. Genitourinary and • Ruptured ectopic
reproductive system • Uterine hemorrhage
• Tumors of bladder and kidney
• Chronic nephritis
6. Endocrine causes • Diabetic coma
• Pheochromocytoma
• Adrenal insufficiency
7. Miscellaneous • Anaphylaxis
• Drug abuse
• Mismatched blood transfusion

21. Objectives of medico-legal autopsy. (Rajiv Gandhi University, Bengaluru, 2015)

(Rajasthan University 2018) (KHMS, Tamil Nadu 2016) (VNS, Gujarat supple 2019)
Ans: Objectives of medico-legal autopsy
1. To find out the cause of death (natural or unnatural)
2. To find out time since death, mode of death and place of death
3. To find out manner of death (accidental, suicidal or homicidal)
4. To establish identity of deceased when not known/not identifiable
5. To identify if the injuries are antemortem or postmortem in nature
6. In case of newborns, to determine the question of live birth and viability of the
baby.
7. To find out if any treatment was given to deceased before death.
8. To investigate into the case so that, it can help in identifying the criminal (e.g.,
foreign materials, fingerprints)

22. Algor mortis (KHMS, Tamil Nadu Supple 2019) (Pondicherry 2015) (VNS, Gujarat
2017, 2019)
Ans: Refer to long question no. 8.
 Autopsy and Thanatology 43

23. Casper’s dictum (SGRD, Amirtsar 2019)

Ans:
1. Casper’s dictum is related to rate of putrefaction.
2. One week of putrefaction in air is equivalent to two weeks in water, which is
equivalent to eight weeks buried in soil, given the same environmental temperature.
3. The rate of decomposition in air, water and deep burial is 1: 2: 8.
Decomposition
Air 1
Water 2 (2 times slower)
Deep burial 8 (8 times slower)

4. Therefore, the deeper is the burial of the body, better will be the preservation for a
period of time.
5. The process of decomposition in water is slow due to:
i. Absence of air
ii. Clothing provides protection
iii. Early cooling of the body.
6. MLI
i. After removal of body from water—rate of decomposition is rapid due to
imbibition of water and optimum temperature for the growth of microorganisms.
ii. In submerged dead bodies—decomposition starts early in the head and face.

24. Exhumation (AIIMS, Patna 2019, 2017, 2015) (Delhi University supple 2016) (Rajiv
Gandhi University, Bengaluru 2015) (BFUHS, Punjab 2016) (VNS, Gujarat 2019) (JIPMER
supple 2018)
Ans:
Definition of exhumation: It is the lawful digging out of an already buried body from
the grave for postmortem examination.
• It is not frequent in India because mostly the bodies are cremated. But there is no
time limit for exhumation.
• Authorization: Exhumation orders are only given by the magistrate.
Purpose for Exhumation
1. For identification of the diseased
2. To determine the cause of death, time since death and manner of death
3. For doing autopsy for the second time when the first autopsy was not done
4. To retrieve some vital objects (bullets) from the body
5. When the body has been disposed of without conducting any autopsy and later on
foul play is suspected.

Procedure
1. It should be done in daylight, under the supervision of magistrate, doctor and police
officer.
2. The area should be properly screened off from the public.
 44 Exam Preparatory Manual of Forensic Medicine and Toxicology

3. Before digging out grave, burial spot should be identified.

4. Photographs should be clicked and samples of the soil from above, below and sides
of the grave are taken.
5. The body is taken out and identification marks are noted.
6. Autopsy is conducted, and in case of suspected poisoning, viscera may be preserved
for chemical analysis.

DIFFERENTIATIONS

1. Cadaveric spasm and rigor mortis (Jammu and Kashmir 2017) (Himachal Pradesh
University 2017) (Adesh, Bathinda supple 2017) (Pondicherry 2016) (Rajasthan
University, 2015) (GMC, Chandigarh 2015)
Ans:
Cadaveric spasm Rigor mortis
Onset Instantaneous Within 2 hrs after death
Muscles involved Voluntary muscles All the muscles (voluntary and
involuntary)
Molecular death Does not occur Occurs
Response to electrical stimulus Yes No
Primary flaccidity Not seen Occurs before rigor mortis
Mechanism Not known Breakdown of ATP below
critical level
Predisposing factors Excitement, extreme exhaustion No
Other methods of producing No other method By freezing
By exposing to temp >65°C
Intensity Very strong Comparatively moderate
MLI Suggests manner of death Time since death can be estimated

2. Somatic death and Molecular death. (Delhi University 2018) (KHMS, Tamil Nadu 2016)
Ans:
Somatic death Molecular death
Definition Complete and irreversible Progressive disintegration of body
cessation of brainstem functions cells
Occurs Before molecular death After somatic death
Cells Alive Dead
Response to external stimulus Present Absent
Conditions simulating Suspended animation No condition resembles it
Confirmed by Flat ECG and EEG, absent pulse Rigor mortis, algor mortis, PM
and absent breath sounds staining
 Autopsy and Thanatology 45

3. Rigor mortis and pugilistic attitude (KHMS, Tamil Nadu 2018)

Ans:
Rigor mortis Pugilistic attitude
Mechanism Breakdown of ATP of muscles Due to coagulation of muscle
proteins
Type of phenomenon Postmortem phenomenon Can be antemortem or postmortem
Degree of stiffness Moderate High
Onset In sequence Diffuse
Disappearance In sequence Uniform
External characteristics Not specific Signs of exposure to heat (blisters,
singeing, burning)

4. Medicolegal autopsy and Pathological autopsy (Sher-i-Kashmir Institute, Srinagar

Supple 2019) (KHMS, Tamil Nadu 2015) (West Bengal University 2017)
Ans:
Medicolegal autopsy Pathological/clinical autopsy
Done in Unnatural deaths Natural deaths
Purpose Cause of death and TSD To know pathophysiology of
disease causing death
Done by Forensic medicine experts Pathologists
Consent From State From relatives
Body handed over to Investigating officer Relatives
 46 Exam Preparatory Manual of Forensic Medicine and Toxicology

3
Identification

LONG QUESTIONS

1. Define identification. Enumerate various data of identification. Describe the

surest data of identification. (North Eastern Hill University, Shillong 2015) (Sai
Tirupati University, Rajasthan, 2019)

What is the dactylography? Briefly describe the different types of

dactylographs. What is the medicolegal importance of dactylography? (AIIMS
Patna 2019, 2017) (North Eastern Hill University, Shillong 2016) (VNS, Gujarat 2017)

What are the parameters that help in identifying the individuals? Describe the
role of fingerprints in personal identification. (Rajiv Gandhi University, Bengaluru
Supple 2015)

Ans:
Definition of Identification
Determination of the individuality of a person by recognizing certain characteristics
that are unique to that person.
Types
1. Complete/absolute identification: Dactylography
2. Incomplete/partial identification: Race, age, sex, height

Data of Identification

General Miscellaneous Forensic study

Age Anthropometry Dactylography
Sex Superimposition DNA fingerprinting
Race Marks Hair
Religion • Tattoo marks
Stature • Scars
Bones
Teeth

46
 Identification 47

The Surest Method of Identification is Dactylography

Definition of Dactylography
• It is the study of fingerprints as method of identification.
• Fingerprints appear by 12 weeks of IUL, completely formed by 20 weeks of
IUL
• It is the surest data of identification/most reliable method of identification as
a. Patterns are not inherited
b. Different even in identical twins

Definition of Fingerprints
Impression of the patterns as a result of secretion of oils from the glands in the skin

History
• First person to use fingerprinting—William Hershel
• Systemised by—Sir Francis Galton
• Improved by—Sir Henry, hence called Henry and Galton System

Classification of Fingerprints

Loops (most common) 70%

Whorls 25%
Arches 5%
Composite (least common) 1%

Locard’s Principle of Exchange

When two objects come into contact with each other, there is always some transfer of
material from one to the other. Latent prints are example of this principle.

Types of Fingerprints
1. Visible print—seen with naked eye. For example, fingerprints made from grease,
blood
2. Latent print—not visible to naked eye, therefore, needs developing to make it
visible
3. Plastic print—impressions over soft materials like soap, cheese
 48 Exam Preparatory Manual of Forensic Medicine and Toxicology

Recording of Fingerprints
Before recording the fingerprints, hands are washed, cleaned and dried and then
fingerprint is taken using Printer’s ink on an unglazed paper.
It is done by two methods
1. Plain impression—by gently pressing the inked surface on tip of finger on paper
2. Rolled impression—by rolling thumb/finger from side to side.
It is customary to take LTI in males and RTI in females.
Removal of Fingerprinting
1. Fingerprints can be erased permanently and deliberately by criminals to reduce
their chance of conviction.
2. Alteration of fingerprints are seen in eczema, celiac disease
3. Permanent impairment of fingerprints are seen in leprosy, electric injury, radiation
Medico-legal Importance
1. Identification of criminals
2. Identification in case of accidental exchange of newborn infants.
3. Identification of victims of mass disaster
4. Bank forgeries
5. Properties and legal documents
6. Identification in mummified bodies
7. Electronic fingerprints for security applications
8. Identification of licensing procedure
9. Sex determination: The amino acid content in fingerprints can be used to determine
sex.
10. Drug use: The secretions in fingerprint contain residues of various chemicals and
their metabolites, which can be detected.

2. Enumerate various parameters to establish identity of an individual. Describe

various intersex disorders. Write about medico-legal significance of age 14, 18
and 21 years. (Sardar Patel University, Gujarat 2018) (VNS, Gujarat 2016) (JIPMER
supple 2018)

Ans:
Definition of Intersex
These are individuals in which male and female characters, like gonads, physical
features and sexual behavior co-exist in varying proportions in the same
individual.
Types
They were classified into four groups:
a. Gonadal agenesis
b. Gonadal dysgenesis
c. True hermaphroditism
d. Pseudo-hermaphroditism
 Identification 49

Currently they are considered under disorders of sexual development (DSD) to

substitute the obsolete nomenclature of ‘intersex’, ‘hermaphroditism’ and ‘pseudo-
hermaphroditism’.
1. Gonadal agenesis: Sex organs (testes and ovaries) never develop. The individuals
are chromatin negative. This is determined very early in fetal life.
2. Gonadal dysgenesis: In these individuals, external sexual structures are present,
but the testes or ovaries fail to develop at puberty. Most common examples are
Klinefelter and Turner syndrome.
3. True hermaphroditism: The external genitalia may be of both sexes and the internal
genitalia may consist of either ovaries or testes. Rare condition, nuclear sex is usually
female but can be male.
4. Pseudo-hermaphroditism: In these individuals, there is lack of differentiation of
external genitalia while the internal genitalia are of only one sex (testes or ovary).
They are classified as male (testes present; nuclear sex XY) or female (ovaries present;
nuclear sex XX), independent of anomalies of external genitalia which is opposite
of normal.
MLI: Marriage, inheritance and civil rights

AGE MLI
14 years Cannot be employed in a factory before 14 yrs of age, according to Factory Act.
18 years 1. Minimum age of consent for
• Sexual intercourse (considered statutory rape even if intercourse was done with
her consent below this age)
• Major procedure/surgery
• Medical termination of pregnancy (under MTP Act)
• Removal/donation of body organ for therapeutic purpose (Transplantation of
Human Organs Act)
2. Age of majority
3. Age for marriage (girls)
4. Can cast vote
5. Can be employed in a factory
6. Mentally sound person can make a valid will (testamentary capacity)
7. Age for permanent license to drive a private motor vehicle
8. Abetment to suicide of a person below this age is punished severely
9. Taking away a girl without consent of parent/ guardian is kidnapping
10. Minimum age for entering a government service
21 years 1. Age for marriage (males).
2. Importation of girl of age <21 yrs from foreign country for the purpose of illicit
intercourse is punishable
3. Age of majority when individual is under guardianship of court or ward.
 50 Exam Preparatory Manual of Forensic Medicine and Toxicology

3. What is criminal responsibility of an individual? Discuss in brief the various IPC

sections defining it. (Adesh, Bathinda supple 2016)
Ans:
In law, criminal responsibility means liability to punishment.
IPC Section Deals with
82 Child under 7 years of age is not liable for any criminal act
83 Child of 7–12 years is liable and presumed to be capable of committing an offence, if has
attained sufficient mental maturity to judge the nature and consequences of the act
84 A person of unsound mind is not liable for act (McNaughten’s Rule)
85 A person under involuntary (fraudulently) intoxication is not liable for act
86 A person under voluntary intoxication is liable for his act
87 A child under 12 yrs cannot give valid consent to suffer any harm which can occur from an
act done in good faith and for his benefit
89 A person under 18 yrs of age cannot give valid consent to suffer any harm which may
result from act not intended or not known to cause death or grievous hurt

4. Police has recovered a bundle of bones and submitted for medico-legal

examination. Discuss what medico-legal information can be provided to derive
scientific conclusion. (Delhi University Supple 2016)
Ans:
1. To determine whether it’s a bone or not?
Forensic expert with his anatomical background can differentiate a bone from the
substances that may look like bone, e.g., wood, plastic.
2. If it is a bone, does it belong to human or animal?
Fragmented bones
1. Old/ burnt/cremated bones a. Gross anatomical characteristics
b. Microscopic characteristics (Haversian system)
c. Chemical analysis of bone ash may be done
2. Fresh/ones which still has some Serological test (precipitin test) can be done
blood constituents

But it’s very easy to identify the species if whole skeleton is available.
3. Whether the bones belong to one individual or not?
Bones available are placed in anatomical position
of articulation
• If all the available separate parts fit to each other and
• If age, sex and race of all the bones are same } It belongs to the single individual

4. Determining the stature of individual

Hepburn’s osteometric board is used to measure length of the long bones
Best bone to determine stature—femur
Methods: Regression formula
Percentile formula
Karl Pearson’s formula is used for Americans.
 Identification 51

5. Determining the race of the individual

Race can be determined from the cephalic index.
Maximum transverse breadth of skull × 100
CI =
Maximum AP length of skull
The Indian skull is Caucasian with few Negroid characters, and the value is
75–79.9.
6. Determining the age of the individual
a. Dentition and mandible
b. Ossification centres of bones (studied by means of X-rays)
c. Closure of cranial sutures (—do—)
d. Symphyseal surfaces of pubic bone.
7. Determining sex of the individual: Sex is determined from skeleton based on
sexual characteristic of skull, pelvis, mandible, sacrum and long bones (seen after
puberty).
Krogman’s degree of accuracy in sex determination from bones:

Whole skeleton 100%

Pelvis + Skull 98%
Pelvis 95%
Skull 92%
Long bones 80%

8. Identification of the individual: It can be determined from:

• DNA analysis
• Teeth: Extractions, artificial dentures
• Superimposition
• Neutron activation analysis
• Radiological investigations
9. Determining cause of death
a. Fractures of bones
b. Foreign body (bullet)
c. Chemical analysis for detection of metallic poison
10. Determining time of death: It may be determined from the condition of parts and
decomposition changes.
11. Determining type of weapon: From antemortem injuries it may be possible to
determine whether a hard blunt weapon, a light or heavy sharp cutting weapon, a
pointed weapon or a firearm was used.
 52 Exam Preparatory Manual of Forensic Medicine and Toxicology

SHORT NOTES

1. Gustafson’s method (Sher-i-Kashmir Institute, Srinagar 2020) (Rajiv Gandhi University,

Bengaluru 2019) (Adesh, Bathinda supple 2018) (Rajasthan University 2018)
(Pondicherry Supple 2017) (Andhra Pradesh 2016)

Ans:
• It is a method used for age estimation in dead
• To access the pathological changes—longitudinal section of the tooth is taken
• Best teeth for study—anterior teeth (incisors/canines)
• Estimates age between 25 and 60 years
• It is based on the criteria given below:

Criteria
1. Attrition
2. Secondary dentin
3. Peridontosis
4. Root resorption
5. Transparency of root: Most reliable criteria
6. Cementum apposition

(Mnemonic—AS PRTC)

Limitation
Useful only in dead (as teeth have to be extracted for examination)

2. Turner syndrome (Adesh, Bathinda 2019)

• Most common sex chromosome disorder associated with female hypogonadism
• Most common cause of primary amenorrhea
• Chromosomal abnormality—mosaic karyotype (45XO/46XX)
• Barr body—false negative
• Anatomically—female

Clinical Features

External Internal
1. Short stature 1. CVS anomalies: Bicuspid aortic valve > Coarctation of aorta
2. Webbed neck 2. Renal abnormalities: Horseshoe kidney, hypertension.
3. Low hairline 3. Streak ovaries (ovarian dysgenesis), uterus hypoplasia
4. Ptosis with low-set ears
5. Widely spaced nipples
6. Cubitus valgus
7. Short fourth metacarpals
8. Lymphedema of hands and feet
 Identification 53

Diagnosis
• Decreased estrogen levels lead to raised LH, raised FSH (hypergonadotropic
hypogonadism)
• Karyotype showing 45XO chromosomes

3. Klinefelter’s syndrome (Adesh, Bathinda Supple 2019)(North Eastern Hill University,

Shillong Supple 2019)
• Most common sex chromosome disorder associated with male hypogonadism
• Chromosomal abnormality: 46XXY
• Anatomically: Male
• Barr body: False positive

Clinical Features Due to

Low testosterone levels Raised estrogen levels Other features
1. Delay in onset of puberty Gynecomastia at puberty 1. Tall stature (height greater than
2. Axillary and pubic hair are absent arm span)
3. Hair on chest and chin are reduced 2. Testes: Firm, fibrotic small,
4. Azoospermia non-tender
3. IQ—low

Diagnosis
• Karyotyping (46XXY)
• Serum testosterone is low, leading to raised LH, FSH and estrogen levels.

4. Locard’s principle of exchange (BFUHS, Punjab 2019, 2015) (Rajiv Gandhi University,
Bengaluru 2015) (Andhra Pradesh 2016) (VNS, Gujarat 2017)
1. Dr Edmond Locard formulated the Locard’s principle of exchange: “When two
objects come into contact with each other, there is always some transfer of material
from one to the other”.
2. Once this transfer is detected and the substance classified and/or individualized,
the forensic specialist will have a clue as to what may have occurred at the scene.
The forensic scientist’s job is to uncover and reconstruct how the evidence fits into
the investigation of a crime.
3. For example, fingerprints left behind on a knife in crime scene or semen deposited
in vagina in sexual assaults.
 54 Exam Preparatory Manual of Forensic Medicine and Toxicology

5. Sequence of appearance of permanent teeth (BFUHS, Punjab 2019) (VNS, Gujarat

2019) (Sai Tirupati University, Rajasthan, 2019)
Ans:
Mnemonic Tooth Eruption (yrs)
Mummy 1. First molar 6–7
Is 2. Central incisor 6–8
In 3. Lateral incisor 7–9
Pain 4. First premolar 9–11
Papa 5. Second premolar 10–12
Can 6. Canine 11–12
Make 7. Second molar 12–14
Medicine 8. Third molar 17–25

Successional Teeth
• 20 in number
• Comes in place of temporary teeth
Superadded Teeth
• 12 in number
• All permanent molars belong to this category

6. Temporary dentition (KHMS, Tamil Nadu Supple 2020)

Ans:
20 in number with dental formula 2-1-0-2 (2 incisors, 1 canine, no premolars, 2 molars)

Tooth Eruption (months)

Central Incisors
• Lower 6
• Upper 7
Lateral Incisors
• Upper lateral 9
• Lower lateral 10
1st Molar 12
Canines 18
2nd Molar 24

(Mnemonic—I’m CM)

7. Poroscopy and cheiloscopy (Rajiv Gandhi University, Bengaluru 2018)

Ans:
Poroscopy
• Definition: It is a method of identification by comparing the impressions of sweat
pores found on the papillary ridges of the fingers.
• Discovered by Dr Edmond Locard.
 Identification 55

• Just like the ridges, the pores are also permanent, immutable and individualistic,
and these are useful to establish the identity of individuals.
• MLI
1. Helpful in identification of an individual from a group of suspected individuals.
2. Useful when only the fragments of fingerprints are available.
Cheiloscopy
Definition: The impressions produced by the wrinkles and grooves of the lips is known
as lip prints.The study of these lip prints is called cheiloscopy.
Classification: Suzuki classified lip prints into 4 types.

Type I Complete longitudinal fissures

Type I' Partial longitudinal fissures
Type II Branched grooves
Type III Intersected grooves
Type IV Reticular grooves
Type V Undetermined pattern

MLI
1. Sex can be determined as type I, I’, II is more common in females but type III, IV
more common in males
2. Useful for personal identification.

8. Tattoo marks (Adesh, Punjab 2017) (KHMS, Tamil Nadu 2015)

Ans:
Definition: These are patterns made in the skin by multiple small puncture wounds
with needles or an electric vibrator dipped in colouring matter (e.g. pigment or dye)
Dyes used: Indian ink, indigo, cobalt, carbon black, Prussian blue, etc.
Classification: Traumatic tattoos, amateur tattoos, professional tattoos, cosmetic
tattoos, medical tattoos.
Fading of Tattoo
Tattoos may fade if:
• Pigments are not introduced deep into the skin
• On exposed parts of body
• Parts which undergo constant friction
That is why tattoos on the hands disappear early due to constant friction.
Associated risk: Infection, hepatitis B, AIDS, syphilis, sepsis, etc.
Removal of tattoos
1. Dermabrasion using dermabraders or laser therapy: Q switched Nd:YAG laser
2. Surgical methods
• Complete excision and skin grafting
• Burning by means of red-hot iron
• Scarification
3. Electrolysis.
 56 Exam Preparatory Manual of Forensic Medicine and Toxicology

MLI
1. Identification: Tattoo marks give information about the person that helps
identification of both living and dead, for e.g. in Sydney shark case
2. Providing information about race, religion and nationality
3. Political connections
4. Profession/occupation
5. May provide information about personal details, e.g. date of birth
6. In decomposed dead bodies, tattoo pigments can be found in the regional lymph
nodes.

9. Cephalic Index (Uttarakhand University 2017, 2016) (Rajiv Gandhi University,

Bengaluru 2015) (GMC, Chamba 2019)
Ans:
Max transverse breadth of skull
Cephalic index = × 100
Max AP length of skull
Skull can be classified into three types based on cephalic index (CI)—

Skull type Cephalic index Race

D Dolichocephalic (long-headed) 70–75 Aryans, Negroes AN
N=M Mesaticephalic (medium-headed) 75–80 Europeans, Chinese Exam
B Brachycephalic (short-headed) 80–85 Mongolian Medicos

(Mnemonic—DNB AN Exam for Medicos)

10. Age with reference to kidnapping from lawful guardianship (Rajiv Gandhi
University, Bengaluru 2015)
Ans:
• Taking out or enticement of a male under 16 years or a girl below 18 years of age, or
any person of unsound mind from custody of her lawful guardian without the
consent of such guardian amounts to kidnapping (Sec. 361 IPC).
• Lawful guardian includes any person lawfully entrusted with the care or custody
of such minor or other person.
• If a girl below 21 years of age is ‘imported’ to India from foreign country for the
purpose of illicit intercourse, the act amounts to kidnapping (Sec. 366 B IPC).

11. Latent fingerprint (West Bengal University 2017)

Ans:
• Latent fingerprints are friction skin impression made of moisture, eccrine gland
secretions and sebaceous oils.
• They are generally not visible to the unaided eye.
• Latent prints are the most prominent example of Locard’s principle of exchange.
• Most crime scene fingerprint impressions are commonly latent prints.
 Identification 57

• Composition: Sodium and potassium chlorides, amino acids, urea, lactic acid, free
fatty acids, triglycerides and wax esters.
• Most methods for the development of latent prints were developed on the basis of
knowledge about the latent print residue composition.
• Latent print requires additional processing to be rendered visible and suitable for
comparison. Processing of latent prints to render them visible and suitable for
comparison is called development, enhancement or visualization.

12. Changes in symphyseal surface of pubis with age (West Bengal University Supple
2017)
Ans:
Age (in years) Features on symphyseal surface
Around 20 Uneven surface with transverse ridges across articular surface
25–40 Granular appearance of surface and ridges gradually disappear
40–50 Oval smooth surface with raised ends
50–60 Erosion of surface and breakdown of ventral margins
> 60 Irregular erosions of surface

13. Medico-legal importance of scar (BFUHS, Punjab Supple 2016)

Ans:
1. Identification of the individual.
2. Disfigurement of face by scar due to assault/vitriolage is considered grievous hurt
under Sec. 320 of IPC.
3. Linear needle scars indicate an IV drug abuser.
4. Shape of scar may indicate the nature of weapon or agent that caused injury.
5. Age of scar indicates time of infliction of injury.
6. Scars on wrist or throat may indicate previous attempts at suicide.
7. A person may allege scar due to disease as those of wound caused in an assault.

14. Four applications of DNA fingerprinting (North Eastern Hill University, Shillong
2016)

Ans:
1. To solve paternity and maternity disputes.
2. In case of sexual offences like rape, sodomy.
3. In case of accidents/mass disaster for identification of skeletal remains/mutilated
bodies.
4. Diagnosis of inherited disorders in adults, children, newborn and prenatal babies.
Like thalassemia, sickle cell anaemia, cystic fibrosis.
5. Developing cures for inherited disorders by studying the DNA fingerprints of
relatives who have a history of some particular disorder.
6. Used to link suspects to evidence found at the crime scene like blood, hair or clothing.
 58 Exam Preparatory Manual of Forensic Medicine and Toxicology

15. Medico-legal importance of 16 years of age (Andhra Pradesh 2016)

Ans:
1. Taking away a male of age <16 years of age without consent of guardian amounts
to kidnapping.
2. Learner license to drive a vehicle of 50 cc engine and without any gear.
3. If a person of >16 years but below 18 years of age commits a crime, he will be tried
as an adult for the following three types of offences:
Offence Punishment
Heinous offence >7 yrs imprisonment
Serious offence 3–7 yrs imprisonment
Petty offence <3 yrs imprisonment

16. Superimposition (Rajiv Gandhi University, Bengaluru 2015)

Ans:
• Definition: It is a technique of identification in which an unknown recovered skull
can be matched with the available photograph (of face) of a suspected person.
• The complete skull along with mandible is required to obtain positive identification.
Technique (Photographic Method)
• The negatives are prepared, one from the original photograph (of face) and another
from the skull recovered.
• Appropriate magnification is done.
• The two negatives are then superimposed by keeping one over the other and
examined to judge whether or not the unknown recovered skull is of the presumed
person as interpupillary distance of a person never changes regardless of his age.
Limitation
This technique is criticised because the photographs of different persons can be fitted
in the photographs of skull.
Advancement in Technology
1. Computer-assisted superimposition system which has improved accuracy and
identification of the person takes very less time.
2. Video super-imposition
Test is of a more negative value, because it can be definitely be stated that the skull
and photograph are not those of the same person.

17. Bitemarks and its medico-legal importance (Rajiv Gandhi University, Bengaluru
2019) (North Eastern Hill University, Shillong 2019)
1. Bitemarks is semicircular or crescentic caused by the front teeth (incisors and canines)
with a gap on either side due to separation of upper and lower jaw.
2. There may be abrasions, bruises and lacerations or a combination of all these.
 Identification 59

3. MLI: Bitemarks are commonly seen in cases of:

i. Sexual assault: Marks are usually seen on breasts, neck, shoulders, thighs,
abdomen, pubis or vulva.
ii. Child abuse: Marks are seen anywhere on the body, such as arms, hands, shoulders,
cheeks, buttocks and trunk.
iii. Bitemarks on foodstuffs (apples, cheese or chocolate), leather (key rings or belts)
and wood (pencils) in cases where a perpetrator might have taken a bite out of
something in the victim’s home and left it behind.
iv. Police officers may be bitten by the resisting offenders.
v. In sporting events, such as football, rugby or wrestling.
vi. In assaults, where marks may be found anywhere on the body.
1. Self-inflicted bitemarks are present on accessible parts of the body, e.g., shoulders
or arms; seen in psychiatric patients or teenage girls.
2. In sexual assault, sucking action during bites produces multiple petechial
hemorrhages due to rupture of small capillaries and venules.
3. Accidental marks resulting from falls on to the face and during fits, biting of
tongue and lips may also be there.

18. Corpus delicti. (BFUHS, Punjab Supple 2018) (VNS, Gujarat 2019)
Ans:
a. Definition of corpus delicti: It means that it must be proved that crime has occurred
before a person is convicted for committing that crime.
b. It includes dead body and also other documents (like photographs, bullet, marks of
weapon, cartridges) which should be identified.
c. Most important of these is the identification of the dead body for the establishment
of crime.
d. If victim’s identity cannot be identified, then it becomes very difficult for the
investigating team to prove the crime.
e. MLI: In murder cases, before passing a sentence, it is essential to identify dead body
and to prove corpus delicti.

19. Dactylography (BFUHS, Punjab 2020, 2016) (North Eastern Hill University, Shillong
Supple 2020) (Rajiv Gandhi University, Bengaluru 2020) (West Bengal University Supple
2019) (Rajasthan University 2018, 2015) (KHMS, Tamil Nadu 2016) (GMC, Chandigarh
2015)

Ans: Refer to long question no. 1.

20. Types of fingerprints (GMC, Chandigarh 2016)

Ans: Refer to long question no. 1.
 60 Exam Preparatory Manual of Forensic Medicine and Toxicology

21. Intersex states (Adesh, Bathinda Supple 2020) (North Eastern Hill University, Shillong
2018)
Ans: Refer to long question no. 2.

22. Write medico-legal importance of age 21 years. (West Bengal University 2019)
Ans: Refer to long question no. 2.

23. Medico-legal importance of age 18 years (BFUHS, Punjab Supple 2019)

Ans: Refer to long question no. 2.

DIFFERENTIATIONS

1. Human hair and animal hair (Adesh, Bathinda supple 2020) (West Bengal University
2018) (North Eastern Hill University, Shillong supple 2017)

Human hair Animal hair

Texture Thin and fine Thick and coarse
Root Bulb-shaped Brush like
Cortex Broader Narrow
Medulla Narrow/ noncontinuous/ fragmented Broad/continuous
Medullary index <1/3 >1/3
Tip Cut/ frayed Tapered
Pigment granules Uniformly distributed Mostly present around the medulla
 Identification 61

2. Male and female pelvis (Delhi University 2018, 2017) (Rajasthan University 2017,
2016)

Male pelvis Female pelvis

Pre-auricular sulcus Narrow, shallow Broad, deep
Subpubic angle V-shaped (70°–75°) U-shaped (90°–100°)
Sciatic notch Small, narrow, deep Large, wide, shallow
Pubis body Narrow and triangular Broad and square
Ischial spines More prominent Less prominent
Ischial tuberosity Inverted Everted
Obturator foramen Oval Triangular, apex forwards
Pelvic inlet Heart-shaped Circular / elliptical
Pelvic cavity Funnel-shaped Broad
Pelvic outlet Smaller Larger
Sacroiliac joint surface Large, less angulated Small and L-shaped

3. Male and female mandible (Delhi University supple 2016)

Male mandible Female mandible

Chin Square Rounded
Body height Greater Smaller
Ascending ramus Greater breadth Smaller breadth
Angle of mandible Everted Inverted
Angle of body with ramus Less obtuse More obtuse
Condyles Large Small
Ramus flexure Rearward angulation of posterior border Straight ramus
Muscular markings Prominent Not prominent

4. Male and female skull (Delhi University 2015)

Male skull Female skull

Forehead Sloping/receding Vertical
Glabella and supraorbital margins More prominent Less prominent
Orbits Square–shaped and small Round-shaped and large
Mastoid process Large, round and blunt Small and pointed
Frontonasal junction Presence of angulation Smoothly curved
Zygomatic arch More prominent Less prominent
External occipital protuberance —do— —do—
Partial eminence Less prominent More prominent
Frontal eminence —do— —do—
Palate U-shaped Parabola-shaped
Suprameatal crest Present Absent
 62 Exam Preparatory Manual of Forensic Medicine and Toxicology

5. Male and female femur (University of Health Sciences, Rohtak 2019, supple 2020)

Male femur Female femur

General Heavy and rough Light and smooth
Length More Less
Head Large Small
Angle of shaft with condyles ≥80° <80°
Angle of neck with shaft ≥125° <125°

6. Temporary teeth and permanent teeth (Adesh, Bathinda 2019) (North Eastern
Hill University, Shillong Supple 2016)

Temporary teeth Permanent teeth

Color China white Ivory white
Size Smaller and lighter (except Heavier and stronger (except permanent
temporary molars) premolars)
Direction of anterior teeth Vertical Inclined forwards
Neck More constricted Less constricted
Roots of molars Smaller and divergent Larger and less divergent

7. True hermaphroditism and pseudo-hermaphroditism (Sardar Patel University,

Gujarat supple 2019)

True hermaphroditism Pseudo-hermaphroditism

Gonadal tissue Both ovarian and testicular tissues Gonadal tissue of only one sex
External genitalia External genitalia of both sexes exist External genitalia is of opposite sex
Karyotype Either male or female pattern 1. Male pseudo-hermaphroditism has
(46XX or 46XY or mosaics) male karyotype (nuclear sex—XY) and
testes.
2. Female pseudo-hermaphroditism has
female karyotype (nuclear sex—XX) and
ovary.

8. Klinefelter’s syndrome and Turner syndrome (Sher-i-Kashmir, Srinagar supple 2017)

Klinefelter’s syndrome Turner syndrome

Karyotype 47 XXY 45 XO
Sex chromatin Positive (similar to females) Negative (similar to males)
Incidence More common Less common
Phenotype Male Female
Nuclear sex Female Male
Stature Tall Short
CVS anomalies Rare More common
Recognised At puberty At birth
 4
Asphyxial Deaths

LONG QUESTIONS

1. Define asphyxia. What are the cardinal signs of asphyxia? What are the
differences between antemortem and postmortem hanging? (BFUHS, Punjab
2017)

Classify asphyxial deaths. Describe in detail the postmortem findings and

causes of death in a case of a hanging. (Himachal Pradesh 2017) (Sai Tirupati
University, Rajasthan, 2019)

Dead body of a middle-aged male subject was found in the state of hanging
from the branch of a tree. There was evidence of a prominent ligature mark
around the neck, cyanosis over finger nail beds and lips. There was presence
of multiple small lacerated injuries with bleeding over both side of front of
neck. How would establish: (WBUHS 2019)
a. Cause and nature of death
b. Likely internal findings during postmortem examination.
c. Time since death
(Note: Ignore the lacerated injuries over neck)
Ans:
Definition of asphyxia: It is a condition when there is reduced or no supply of oxygen
to body tissues.
Cardinal signs of asphyxia
1. Congestion of organs
2. Cyanosis of ear, lips, nail beds ASPHYXIAL TRIAD
3. Petechial hemorrhages/Tardieu spots on face, neck, chest
4. Right ventricular enlargement
5. Increased fluidity of blood

Classification of Asphyxial Deaths

a. Mechanical causes
63
 64 Exam Preparatory Manual of Forensic Medicine and Toxicology

Hanging Strangulation Suffocation Drowning

1. Based on degree 1. Ligature 1. Smothering 1. Typical (wet)
of suspension 2. Bansdola 2. Gagging a. Freshwater
• Complete 3. Manual 3. Choking b. Seawater
• Partial 4. Mugging 4. Overlaying 2. Atypical
2. Based on position 5. Garrotting 5. Burking a. Dry drowning
of knot 6. Traumatic asphyxia b. Near drowning
• Typical c. Immersion syndrome
• Atypical d. Shallow water drowning

b. Pathological causes: When oxygen is not able to enter lungs due to diseases of URT/
lungs; e.g., laryngeal edema, stridor, tumor, etc.
c. Environmental causes: Asphyxia due to lack of oxygen. Seen in high altitude, inhalation
of CO, sewer gas
d. Positional asphyxia: Asphyxia due to abnormal position. Seen in jack-knife position

PM FINDINGS IN CASE OF HANGING

External Findings
1. Head-inclined to side opposite to side of knot
2. Face
• Congested and swollen
• Le facie sympathetique—knot compresses the cervical sympathetic ganglion leading to opening of
eyelids and dilated pupils of same side
• Protrusion of tongue
• Dribbling of saliva—From angle of mouth (opp. to side of knot) leading to salivary stain (surest sign of
AM hanging)
• Petechial hemorrhages over face
• Cyanosis over lips, nail beds, ear
3. Neck
a. Ligature mark
• Pressure abrasion present in form of groove (rope burns)
• Brown color, dry, hard, parchment like
• Situated above the thyroid cartilage
• Runs obliquely passing backwards, upwards on either side of the
neck but leaves a gap at knot making an inverted V-shaped impression
b. Stretching of neck
c. Bending of neck to side opposite to knot
4. Glove and stocking pattern of PM staining
5. Seminal discharge, involuntary discharge of feces, urine.
Internal Findings
1. Tissues underneath ligature—dry, white and glistening
2. Neck
• Hyoid bone—anteroposterior compression fracture/abduction fracture
• Carotid artery—Amussat’s sign (transverse tear in carotid intima)
• Larynx—congested
• Thyroid cartilage—fracture of superior horn
3. Lungs and heart—congested and edematous with Tardieu spots
4. Abdominal viscera—congested
 Asphyxial Deaths 65

Causes of Death
Immediate causes Delayed causes
1. Asphyxia—due to constriction force of ligature 1. Aspiration pneumonia
2. Cerebral anoxia—due to compression of carotid artery 2. Infection
3. Reflex vagal inhibition and cardiac arrest 3. Edema of lungs
4. Venous congestion—due to compression of jugular vein 4. Brain abscess
5. Fracture and dislocation of cervical vertebrae

Refer to difference no. 2 for antemortem and postmortem hanging.

Refer to long question 3 for time since death.

2. A dead body of a female with a ligature around the neck is brought for the
autopsy. Discuss in brief postmortem findings differentiating hanging from
ligature strangulation. (Adesh, Bathinda 2018)
 66 Exam Preparatory Manual of Forensic Medicine and Toxicology

Define hanging. How are you going to come to conclusion that it is

antemortem in nature? How it differs from ligature strangulation? (BFUHS,
Punjab Supple 2016)
Ans:
Definition of Hanging
It is a form of violent asphyxial death produced by suspending the body with ligature
tied around the neck. The constricting force is the weight of the body or part of body
weight.

Signs of AM Hanging
1. Marks of dribbling of saliva from angle of mouth over clothes/skin
2. Signs of asphyxia can be seen
3. Ligature mark—dry, parchment-like, oblique and non-continuous which is present
above the level of thyroid
4. Le facie sympathetique—rare but a sure sign of AM hanging
5. Protrusion of tongue on side opposite to side of knot
6. Presence of seminal, fecal or urinary discharge
7. Glove and stocking pattern of PM staining—but not a definite sign of AM hanging
8. Presence of suicide note at the site of incident
Difference between hanging and ligature strangulation: Refer to difference no. 1.

3. A young woman of about 20 years was found hanging from ceiling of her room
with a dupatta and feet dangling from the ground, in her rented accommodation
by her landlord today morning 7:00 AM, she was fully clothed but her clothes
were turned inside out. She was seen last alive by her landlord at about 8:00
PM the previous night when she had left for a party. Police were called and
the body, with a ligature intact, was shifted to the mortuary by 8:00 AM. Paper
were prepared for postmortem examination and presented at about 10:30 AM.
You are the doctor conducting the postmortem examination. (Rajasthan
University 2017)
a. What findings on the body will help you arriving at the probable time since
death in this case? Give the specific time limits of each for this particular case.
b. Enumerate the specific samples that you should collect in such a case, give
reasons in support of the same.
c. Define hanging. Which type of hanging is present in this case?
d. How will you remove the ligature material from the neck of the victim?
Ans:
a. The findings which may help in determining time since death are:
1. Algor mortis: Most useful in temperate countries during the first 24 h after death.
The body attains environmental temperature in about 16–20 h.
2. Rigor mortis: It commences in 1–2 h after death, takes about 9–12 h to develop
from head to foot, persists for another 12 h, and gradually passes off in the same
order as it appeared.
 Asphyxial Deaths 67

3. PM staining: Mottled patches over the dependent parts occur within 1–3 h.
These patches coalesce in 4–6 h. The lividity is fully developed and fixed in about
8–12 h.
4. Decomposition changes
• Greenish discoloration of the abdomen over the cecum and the flanks appears
in about 12–24 h after death in summer. It spreads over the whole of the
abdomen and the rest of the body within the next 24 h.
• Marbling commences after 24 h. By 36–48 h, marbling is prominent.
• In 12–18 h after death, gases collect in the intestines and distend the abdomen.
From 18–36 or 48 h, gas formation is abundant.
• Putrefactive odor is noticed by 24h.
5. Food in stomach: A light meal usually leaves the stomach within 1–2 h, a medium-
sized meal in 3–4 h, and a heavy meal within 5–8 h. If the stomach is full and
contains undigested food, it can be said that death occurred within 2–4 h of eating
of the last meal, and if the food is digested (indistinguishable), then >4 h.
6. Eye changes: Segmented blood in retinal vessels seen up to 1 hr after death
(Kevorkian sign). Temporary opacity of cornea occurs by 2 hrs and permanent
by 8–12 hrs. Tache noire is seen in 3–4 hrs. Rise in vitreous potassium is seen in
up to 100 hrs after death.
7. Insect activity: By 18–36 h, flies lay their eggs. The eggs hatch into maggots
or larvae in about 12–24 h. In the course of 4–5 days, maggots develop into
pupae.
b. Specimens to collect and preserve:
1. Ligature material
2. Clothings
3. Viscera
4. Fingernail scrapings
5. Blood (grouping, alcohol, drugs)
6. Vaginal swabs
7. Any other stains
c. For definition refer to long question 2 above.
The hanging was homicidal in nature; must be
postmortem hanging as the clothes were turned inside
out. Exact cause and nature of death is given depending
on the findings.
d. The ligature is preserved and should be cut away from
knot and reconstructed by joining cut ends with tape
or another cord. This is done to verify and corroborate
with the findings of autopsy subsequently.

4. Classify violent asphyxia deaths. Discuss the postmortem findings in case of

freshwater drowning. (Andhra Pradesh 2015) (North Eastern Hill University, Shillong
Supple 2020)
 68 Exam Preparatory Manual of Forensic Medicine and Toxicology

Define drowning. Enumerate types of drowning and discuss postmortem

findings and laboratory investigation in a case of wet drowning. (Sher-i-Kashmir
Institute, Srinagar 2020, 2015) (University of Health Sciences Rohtak 2019) (North
Eastern Hill University, Shillong 2015, Supple 2016) (Sardar Patel University, Gujarat
Supple 2015) (BFUHS, Punjab 2016) (VNS, Gujarat 2018)

What is atypical drowning? Discuss briefly the postmortem findings of a case

of drowning. (Adesh, Bathinda Supple 2016) (Sai Tirupati University, Rajasthan, 2018)
Ans: Classification of violent asphyxia deaths: Refer to long question no. 1.
Definition of Drowning
It is a type of violent asphyxial death where entry of air into lungs is prevented due to
submersion of mouth and nostrils into water or any liquid medium.

Types of Drowning
Typical drowning (wet drowning) Atypical drowning
1. Fresh water drowning 1. Dry drowning
2. Sea water drowning 2. Immersion syndrome
3. Near drowning
4. Shallow water drowning

Definition of atypical drowning: It is a type of drowning in which water or fluid

does not enter the lungs but death of the person occurs immediately.
1. Dry drowning: As soon as water enters the lungs, laryngeal spasm occurs leading
to asphyxia
2. Immersion syndrome (hydrocution): Cold water stimulates the vagus resulting in
cardiac arrest
3. Near drowning (2° drowning): Person does not dies of drowning, rather dies of
complications like pneumonia, electrolyte imbalance
4. Shallow water drowning: When an unconscious person drowns even when there is
little amount of water

PM Findings in Case of Wet Drowning

External findings
1. Clothes—wet and mixed with mud
2. Froth
• Fine, white, tenacious, copious, lathery froth at mouth and nostrils
• It reappears on pressing the chest
• Pathognomic sign of AM drowning
3. Cadaveric spasm
• An important sign of AM drowning
• Grass, mud may be tightly clenched in hand
4. PM staining—present over face, neck, front of chest, upper and lower limbs (body floats with face down
and buttocks up, with legs and arms hanging down)
5. Cutis anserine/goose bumps
• Nonspecific sign (as seen in both AM and PM drowning)
• Skin appears puckered and granular with erection of hairs due to contraction of erector pili
 Asphyxial Deaths 69

6. Washerman’s hand and feet

• Nonspecific sign (as seen in both AM and PM drowning)
• Wrinkled, bleached appearance of palms, fingers due to submersion of body

Internal findings (seen in case of AM drowning)

1. Froth—present in trachea and bronchus
2. Lungs—voluminous, and show ballooning with impressions of ribs
a. Emphysema aquosum—when conscious person is thrown in water
b. Paltauf’s hemorrhage—due to rupture of alveolar capillaries
c. Edema aquosum—when unconscious person is thrown into water
3. Other changes
• Presence of water in the middle ear
• Presence of water in the stomach and small intestines
4. Congestion of viscera

Lab findings in Case of Wet Drowning

1. Gettler’s test
For comparison of concentration of chloride ions in right side and left side of heart
Normally Conc. of chloride ion same on both sides
FResh water drowning Rt> Lt
SaLt water drowning Lt> Rt

2. Diatom test
• It is an important test of AM drowning
• Diatoms are microscopic unicellular algae present in water
• They have silica shell which is acid and alkali resistant
• Best bone to analyse is bone marrow of femur
3. Serum Mg—increased in sea water drowning
4. Serum strontium—increased in sea water drowning

5. Define and classify strangulation. Describe the autopsy findings in case of

ligature strangulation. (North Eastern Hill University, Shillong 2018)
Ans:
Definition of Strangulation
It is a form of violent asphyxial death caused by constriction of air passage at the neck
by any means other than suspension of the body.

Classification of Strangulation
1. Ligature strangulation Ligature is used to compress the neck
2. Manual strangulation (throttling) Compression of neck by hands
3. Bansdola Strangulation by bamboo or stick
4. Mugging Strangulation by compressing neck in bend of elbow or knee
5. Garrotting Compression of neck by a ligature which is tightened by twisting
it with a lever (rod, stick)
 70 Exam Preparatory Manual of Forensic Medicine and Toxicology

PM findings in Case of Strangulation

External findings Internal findings
1. Face 1. Tissues beneath ligature mark
• Congested and swollen • Show hemorrhage
• Subconjunctival hemorrhage • Fracture of thyroid cartilage
• Bleeding from ear and nose 2. Lungs—congested, edematous with petechial
• Protrusion of tongue hemorrhages
• Presence of Tardieu spots all over the face 3. Abdominal viscera—congested
(all these signs are more prominent in
strangulation than hanging)
2. Neck
Presence of ligature mark which is
• Dry, hard, parchment-like with ecchymosed
margins
• Continuous and completely encircles the neck
• Below the level of thyroid
• Horizontally present around the neck
3. Signs of struggle
Presence of scratches and finger nail
abrasions on neck
4. Other signs
Presence of cyanosis on nail beds, tip of nose
Involuntary discharge of semen, urine, feces

6. Describe the external and internal postmortem findings of manual

strangulation. How strangulation is procured for homicidal purpose? (Rajasthan
University 2015) (VNS, Gujarat supple 2018) (GMC, Chamba 2019)

Enumerate various violent asphyxia deaths. What are the postmortem findings
in a case of throttling? Add a note on hyoid bone fractures. (Rajiv Gandhi
University, Bengaluru 2019)

Enumerate the different types of strangulation. Write the postmortem findings

in case of throttling. (North Eastern Hill University, Shillong Supple 2017)

Dead body of an adult female recovered from a bedroom. An area of pallor

on otherwise suffused face along with 1.2 × 0.1 cm crescentic abrasion on
the right side of face is present. (Adesh, Bathinda 2019)
a.What is your opinion regarding the cause of death?
b.Classify the violent asphyxia death.
c.What are the other postmortem findings and importance of circumstantial
evidence in this specific case?
Ans:
a. The cause of death in throttling is asphyxia due to obstruction of respiration.
b. Refer to long question no. 1 for classification.
c. PM findings in case of throttling/manual strangulation.
 Asphyxial Deaths 71

External findings Internal findings

1. Face 1. Tissues beneath ligature mark
• Congested with petechial hemorrhages • Show hemorrhage
• Subconjunctival hemorrhage • Most significant internal sign
2. Neck 2. Fractures
a. Abrasion—due to fingernail a. Thyroid cartilage Fracture of superior horn
Type of abrasion Produced by b. Cricoid cartilage Typical sign of homicidal
1. Crescentic abrasions Assailant throttling
2. Vertical abrasions Victim c. Hyoid bone Inward compression
So, it is important to examine the nails of fracture occurs
the victim and fingernail scrapings of Hyoid bone fracture most commonly seen in
the alleged assailant when possible throttling
b. Bruise 3. Lungs: Congested, edematous with petechial
• May be irregular/oval shaped hemorrhages
(six penny bruise) 4. Abdominal viscera: Congested
• More prominent of tip of thumb than
tip of fingers
• Presence and extent of fingertip bruising
depends on relative position of victim and assailant.
• In case of grip from right hand from front, there
is one mark on right side (thumb impression) and
four marks on left side of neck (finger impressions)
3. Involuntary discharge of feces and urine

Hyoid Bone Fractures

1. Abduction fracture 2. Adduction fracture 3. Side to side 4. Avulsion fracture

(anteroposterior (Inward compression compression fracture
fracture) fracture)
Fractured segment is Fractured segment is Fractured segment Also called TUG
displaced outward due to displayed inwards as the displaced to inwards fracture
anteroposterior compression, fingers of the grasping on one side and Occurs due to
Divergence of greater cornu hand squeeze the throat, outwards on other side hyperextension of
is increased causing fracture the greater cornu of the neck
hyoid causing fracture of
the bone on the outer
side and not on the inner.
Seen in hanging Commonly seen in Hanging/accidents Convulsions
throttling
 72 Exam Preparatory Manual of Forensic Medicine and Toxicology

1. Abduction fracture 2. Adduction fracture 3. Side to side 4. Avulsion fracture

(anteroposterior (inward compression compression fracture
fracture) fracture)

SHORT NOTES

1. Diatoms test (Adesh, Bathinda Supple 2020) (BFUHS, Punjab 2020) (VNS, Gujarat
2016)
Ans:
• Diatom test is an important laboratory test of AM drowning
• Diatoms are microscopic unicellular algae present in water
• They have silica shell which is acid and alkali resistant
• During drowning, diatoms (size up to 60 μ) can enter circulation
• Best bone to analyze is bone marrow of femur
In AM drowning In PM drowning
Water with diatoms enter airway Diatoms able to enter lungs but diatoms are
↓ not found in distant organs
Reaches alveoli and finally enters circulation
↓
Reaches distant organs—sign of AM drowning
like BM, spleen, kidney
Bone marrow of femur (best site for analysis)

• MLI
a. Diatoms resist putrefaction
b. Can differentiate AM and PM drowning
c. Diatom test is not useful in—dry drowning and hydrocution
d. Gold standard test for diagnosis of typical drowning.

2. Smothering (BFUHS, Punjab 2020)

Ans:
Definition of Smothering
It is a form of violent asphyxia caused by mechanical obstruction of nose and mouth
by hand, cloth, plastic bag or other materials.

Types
1. Homicidal Most common type of smothering
2. Accidental • Commonly seen in alcoholics or epileptics, when they fall accidentally in mud
 Asphyxial Deaths 73

• In autoerotic asphyxia
• In case of children, while playing with plastic bags over the head
3. Suicidal Rare

PM Findings
• Abrasions and bruises around the mouth and nostrils. But not seen if soft materials,
like cloth or pillow has been used.
• Presence of contusion/lacerations on inner side of lip

3. Café coronary (North Eastern Hill University, Shillong Supple 2020) (GMC, Chandigarh
2016) (AIIMS, Patna 2018) (BFUHS, Punjab Supple 2018) (Adesh, Bathinda 2017)
(VNS, Gujarat supple 2019)
Ans:
• Café coronary is a condition of accidental choking wherein a bolus of food produces
complete obstruction of the larynx.
• It’s called café coronary because it mimics a heart attack and is usually seen in an
intoxicated person.

Causes
1. Impairment of gag reflex Seen in
• Alcohol consumption
• Overdose of CNS depressant
2. Ingestion of large bolus Stimulates recurrent laryngeal nerve (vagus)—leading to
cardiac arrest

Cause of Death
1. Asphyxia
2. Reflex cardiac arrest (vagal inhibition)
Typical history: Victim apparently healthy while eating, collapses suddenly turning
blue.

Treatment
• First aid—Heimlich maneuvre
• A blow on the back or on the sternum may cause coughing and expel the foreign
body.
• If the object cannot be removed—tracheotomy/cricothyrotomy.

4. Emphysema aquosum (BFUHS, Punjab 2019) (VNS, Gujarat 2017)

Ans: Emphysema aquosum is the condition of lungs seen in typical (wet) antemortem
drowning.
Seen when the victim is live and conscious, so respiratory efforts are present.
Therefore, water enters the lungs actively, leading to formation of froth in the air
passages plus water in the lungs.
 74 Exam Preparatory Manual of Forensic Medicine and Toxicology

On Autopsy
• Lungs appear, voluminous, bulky, overinflated, that completely covers the heart
and chest cavity resulting in impressions of rib over the lungs.
• And on dissection of lung, presence of froth and blood-stained froth comes out.

5. Shallow water drowning (North Eastern Hill University, Shillong Supple 2019)
Ans:
Shallow water drowning is a type of atypical drowning; seen when:
• An unconscious person (under influence of alcohol, drugs)
• Epileptic patient
May be drowned even in little amount of water because of direct contact of
nose and mouth with water resulting in asphyxia and ultimately death of person
occurs.

6. Pathophysiology of fresh water and sea water drowning (Rajiv Gandhi University,
Bengaluru 2019) (Sardar Patel University, Gujarat 2018)
Ans:

Fresh water drowning Sea water drowning

7. Short note on froth from nose and mouth in deceased (West Bengal University
2018)
Ans:
 Asphyxial Deaths 75

Fine and tenacious froth Froth (not fine and tenacious)

• Fine, leathery, copious, tenacious froth is seen in case of Seen in death due to:
wet drowning (typical drowning). 1. OPC poisoning
• The mass of foam, consisting of fine bubbles, does not 2. Electric shock
collapse when touched with the point of a knife. 3. Acute pulmonary edema
• May be absent when wiped off, but reappears again by 4. Snakebite
itself or by applying pressure on chest. 5. Strangulation

8. Absence of froth does not rule out AM drowning (West Bengal University Supple
2017)
Ans:
1. Presence of froth is characteristic of antemortem wet or typical drowning. The
inhalation of water irritates the mucous membrane of air passages resulting in
secretion of large quantities of mucus and edema fluid. Forceful agitation of the
seromucoid secretion, surfactant, aspirated water and retained air results in froth.
2. In atypical drowning, froth is not seen.
3. There is very little or no inhalation of water or fluid in the air passages in many conditions.
4. Seen in:
a. Dry drowning: Water does not enter the lungs due to laryngeal spasm caused by
small amounts of water entering the larynx.
b. Immersion syndrome: Syncope resulting from cardiac arrhythmias on sudden
contact with water that is lower than body temperature.
c. Shallow water drowning: Alcoholics, infants, drugged, epileptics and
unconscious persons may die due to drowning in shallow water in a pit or drain.
d. Near drowning: Near drowning refers to survival beyond 24 hrs after a
submersion episode. Froth is not seen in such cases.
Hence, absence of froth does not rule out antemortem drowning.
 76 Exam Preparatory Manual of Forensic Medicine and Toxicology

9. Cutis anserine (Andhra Pradesh 2015)

Ans:
• Also called goose skin/goose flesh/goose bumps
• It is not a specific sign of pregnancy (as seen in both AM and PM drowning)
• Skin appears puckered and granular

Phenomenon of Cutis Anserina

• In case of AM drowning—over the extremities, when immersed in cold water due
to contraction of erector pili muscles.
• In case of PM drowning—when a dead body is immersed in water soon after death
(i.e., before molecular death) due to rigor mortis of erector pili muscles.

10. How histology of lungs helps in diagnosis of drowning? (Pondicherry 2019)

Ans: The histology of lungs in drowning has revealed significant findings in
antemortem drowning.
1. Findings are—foci of acute lung emphysema with distended alveoli, thinning and
rupture of the alveolar septa, scattered interstitial and intra-alveolar edema and
hemorrhages, narrowing and congestion of capillaries, and sometimes exogenous
particles in the airways. A wash-out effect of intra-alveolar macrophages can be
seen.
2. In addition, an increase of macrophage subtypes (myelomonocyte subtypes) in the
alveolar-intracapillary compartment by means of an immunohistochemical method
has been found. However, decomposition removes all fine histological details.
3. Other organs like kidneys, heart and brain show nonspecific changes like generalized
congestion and swelling of the capillary endothelia seen in any other form of asphyxia.

11. Lynching (Adesh, Bathinda 2018) (Andhra Pradesh 2015) (VNS, Gujarat 2018)
Ans:
• Lynching is a type of homicidal killing in which an angry mob kills an alleged
offender in public often by hanging, without a legal trial.
• It was prevalent in North America, where it was practiced by whites on colored
people.
• Usual methods used to kill an offender are hanging, burning, beating, etc
• Inquest in a case of lynching is done by police.
• Cause of death in lynching is asphyxia when person is hanged.
Post-mortem examination: In case of hanging, the features are of asphyxia. The body
may show various injuries inflicted by the mob, e.g. contusions, abrasions, head injuries,
fractures and so on.
MLI: Lynching is considered as murder/homicide. The persons belonging to a mob
committing lynching are punished according to Sec. 302 IPC.

12. Traumatic asphyxia (BFUHS, Punjab 2017) (Rajiv Gandhi University, Bengaluru 2015
(KHMS, Tamil Nadu 2015) (North Eastern Hill University, Shillong Supple 2018)
 Asphyxial Deaths 77

Ans:
Definition of Traumatic Asphyxia
It is a form of violent asphyxia resulting from respiratory arrest due to mechanical
fixation of chest preventing normal chest wall movements.

Causes
a. Person buried under the collapsed building.
b. Stampede by crowd due to fire in a movie theatre or public gathering.
c. Run over by a heavy vehicle.
d. Fall of tree or big rock over the person.

Postmortem Examination
External findings Internal findings
1. Above the line of demarcation • Retinal hemorrhages
Masque ecchymotique: (due to congestion of • Fractures of rib and clavicle (common)
blood in SVC and veins of head and neck) • Heart: Right side of heart distended
• Cyanosis and congestion over face and neck. • Contusions, lacerations and congestion
• Petechial hemorrhages or ecchymoses. of lungs and liver
• Bleeding from ears and nose
• Facial edema
2. Below the line of demarcation: Pale body

MLI
1. Mostly accidental
2. Homicidal in case of Burking

13. Burking (North Eastern Hill University, Shillong 2017)

Ans:
• Burking is a combination of homicidal smothering and traumatic asphyxia.
• William Burke and William Hare killed many persons in Scotland and sold their
bodies to Medical College in UK.
• Method: Invited the victim to the house and offered him alcohol. When drunk, he
was thrown on the ground and Burke would sit on the chest and close the nostrils
and mouth with his hands, while Hare used to pull the body by the feet till he is
dead.

14. Paltauf’s hemorrhage (Rajiv Gandhi University, Bengaluru 2015)

Ans:
• Paltauf’s hemorrhages are multiple, large, bluish reddish colored subpleural
hemorrhages of variable size seen in case of wet drowning
• Rupture of alveolar walls produce hemorrhages just below pleura in the lungs
• Mostly occur in the lower lobes on anterior surface of lungs
• On cut section, copious amount of frothy bloodstained discharge comes out due to
presence of water within alveoli and bronchioles.
 78 Exam Preparatory Manual of Forensic Medicine and Toxicology

15. Describe the postmortem findings in death due to drowning (Rajiv Gandhi
University, Bengaluru 2020) (Uttarakhand University 2017, 2016)
Ans: Refer to long question no. 4.

16. Postmortem features of fresh water drowning (Sardar Patel University, Gujarat
2020) (GMC, Chandigarh 2016)
Ans: Refer to long question no. 4.

17. Fractures of the hyoid bone (BFUHS, Punjab 2019) (West Bengal University 2019)
Ans: Refer to long question no. 6.

18. Enumerate types of drowning. Describe autopsy findings of antemortem

drowning. (Sardar Patel University, Gujarat Supple 2019)
Ans: Refer to long question no. 4.

19. Gettler's test (North Eastern Hill University, Shillong 2019) (Adesh, Bathinda Supple
2019)
Ans: Refer to long question no. 4.

20. Describe the ligature mark of typical hanging (Rajiv Gandhi University, Bengaluru
2019) (Sardar Patel University, Gujarat Supple 2016)
Ans: Refer to long question no. 1.

21. Neck finding in manual strangulation (Rajasthan University 2018)

Ans: Refer to long question no. 5.

22. Wet drowning (Uttarakhand University Supple 2018)

Ans: Refer to long question no. 4.

23. Drowning in the sea water (Andhra Pradesh Supple 2016)

Ans: Refer to long question no. 4.

24. Throttling (BFUHS, Punjab 2015)

Ans: Refer to long question no. 6.

25. Internal finding in a case of death due to drowning (KHMS, Tamil Nadu 2017)
Ans: Refer to long question no. 4.
 Asphyxial Deaths 79

DIFFERENTIATIONS

1. Hanging and strangulation (GMC, Chandigarh 2015) (Adesh, Bathinda Supple 2017)
(Uttarakhand University 2018, 2017) (Sher-i-Kashmir Institute, Srinagar Supple 2018)
(Rajasthan University 2016)
Ans:
Hanging Strangulation
Signs of asphyxia Less marked More marked
Protrusion of tongue -do- -do-
Bleeding from nose, ear Rare More common
Ligature mark
• Direction Oblique Horizontal
• Continuity Incomplete Complete
• Level in neck Above the level of thyroid Below the level of thyroid
• Base Hard, dry, parchment-like Soft, reddish base
• Abrasions and bruise around ligature Less common More common
• Tissues beneath ligature mark White, glistening Shows hemorrhage and
ecchymosis
Fracture of thyroid cartilage Less common More common
Fracture of hyoid bone More common Less common
Stains of saliva Common Rare
Discharge of urine and feces Less common More common
Seminal discharge Common Rare
Manner of death Suicidal Homicidal

2. Antemortem and postmortem hanging (Uttarakhand University Supple 2017)

Ans:
Antemortem hanging Postmortem hanging
Ligature mark
• Direction Oblique Circular
• Continuity Noncontinuous Continuous
• Level in neck Above thyroid At/below thyroid
• Base Dry, hard, parchment like No changes seen
Le facie sympathetique Present Absent
Stain of saliva -do- -do-
Fecal/urinary/seminal discharge -do- -do-
Stretching of neck -do- -do-
Signs of asphyxia -do- ±
PM staining Glove and stocking pattern Not specific
Suicide note Present Absent
 80 Exam Preparatory Manual of Forensic Medicine and Toxicology

3. Wet drowning and dry drowning (Rajasthan University 2015)

Ans:
Wet drowning Dry drowning
Definition Type of drowning in which water or Type of drowning in which water or fluid
fluid enter lungs does not enter lungs
Lungs Voluminous, bulky and show Lungs do not contain water (dry)
impressions of ribs
Froth Fine, copious, tenacious froth Not seen
Signs of asphyxia Present ±
Cause of death Heart failure Laryngeal spasm

4. Fresh water drowning and sea water drowning (Rohtak Supple 2020) (Adesh,
Bathinda Supple 2019)
Ans:
Fresh water drowning Sea water drowning
Features in lungs
• Size and weight Ballooned, but light Ballooned and heavy
• Color Pinkish Purplish or bluish
• Consistency Emphysematous Soft, jelly-like
• Shape after removal Retained Not retained, flatten out
• On cut section Crepitus is heard, little froth and No crepitus, copious fluid
no fluid and froth
Blood volume Hypervolemia Hypovolemia
Hemodilution Hemoconcentration
Electrolytes Hyponatremia Hypernatremia
Hyperkalemia
Cause of death Ventricular fibrillations Pulmonary edema
Death Early Late
 5
Injury

LONG QUESTIONS

1. Outline the features of suicide by firearm. What is the appearance of entry

wound caused by revolver shot at a distance of 3 cm and 10 cm? (Adesh,
Bathinda supple 2020) (Uttarakhand University 2017) (Sher-i-Kashmir Institute, Srinagar
supple 2018)
Ans:
Features of Suicide by Firearm
1. Common in males with history of previous psychiatric illness, financial loss
2. Most of the suicidal firearms have shot distance as contact or very close range shot
wound with sites of entry as:
• Temple—the most common site
• Center of forehead
• Mouth
• Midline behind the chin
• Left side or front of chest
• Abdomen
3. The person uses his dominant hand to press the trigger, steadying the muzzle against
the head with the non-dominant hand
4. Presence of powder soot may be seen on hand pressing trigger, as well as on the
non-dominant hand
5. Path of bullets—the gunshot is directed in-upward or backward direction
For example, gunshots to right temple show a front-to-back or upward path in
suicides. Therefore, a downward shot or a back to front should raise suspicion
despite typical shot location. Gunshots to the left chest tend to show a right-to-left
path and in the mouth, an upward trajectory in suicides.
6. Only one entry and one exit wound is present
7. Cadaveric spasm may be seen with the weapon firmly grasped in the hands
8. Presence of suicide note and weapon at the scene (mostly house)
Entry wound caused by revolver shot at a distance of 3 cm and 10 cm: Refer to
long question no. 2.

81
 82 Exam Preparatory Manual of Forensic Medicine and Toxicology

2. Classify firearms. Discuss the findings of entry bones caused by rifled firearm
from various ranges. (BFUHS, Punjab supple 2018) (Delhi University 2017) (North
Eastern Hill University, Shillong 2018) (VNS, Gujarat 2018)
Ans:
Rifled firearms Smooth bored firearm (shotgun)
• Military rifle/assault rifle-AK-47, AK-56 • Single barrel
• Revolver • Double barrel
• Pistol • Cylinder bore
• Submachine gun • Choke bore
• Machine gun • Bolt action
• Single shot pistol • Pump action
• Auto-loading pistol

Findings of entry bones caused by rifled firearm from various ranges

Effects Range
Flame Singeing 8 cm
Smoke Blackening 30 cm
Gun powder Tattooing 60–90 cm

Contact shot Close shot Near/intermediate Distant shot

shot
Distance Hard contact Within range Outside range of Outside range of
over head of flame (<8 cm) flame but within gun powder
range of gun (>90 cm)
powder (>8 cm–
90 cm)
Shape Stellate/cruciate Small, circular Small, circular Small, circular
and inverted and inverted and inverted
Muzzle impression + – – –
Burning and singeing – + – –
(but seen inside
track of wound)
Contd...
 Injury 83

Contact shot Close shot Near/intermediate Distant shot

shot
Blackening – + – –
(but seen inside
track of wound)
Tattooing – + + –
(but seen inside
track of wound)
Abrasion collar +/– + + +
Grease collar +/– + + +

3. Define and classify burns. How will you differentiate antemortem and
postmortem burns? What are the causes of death in case of burns? (Rajiv
Gandhi University, Bengaluru 2019, supple 2017) (University of Health Sciences,
Rohtak supple 2020)
Ans:
Definition of Burns
Burn is an injury caused by heat, or by a chemical or physical agent having an effect
similar to heat.
Classification of Burns
1st Degree 2nd degree 2nd degree deep 3rd and 4th degree
superficial
Depth Involves only Involves epidermis Involves epidermis Till subcutaneous
epidermis and papillary and whole of layer (3rd degree),
dermis dermis muscles
(4th degree)
Color Red Red Red Black and charred
Pain to stimuli Tender Tender Less painful Painless
Blisters Present Present Less in number Absent
Blanching Present Present Varied blanching Absent
Healing Heals Heals within Heals within 3 weeks Difficult to heal,
spontaneously 2 weeks contracture seen
in 3–5 days
Scar Absent Absent Hypertropic scar Hypertropic scar
and keloid formation
Seen in Sun burns Scalds, flash burns Scalds, flash burns Contact with flame,
hot surface, hot
liquids
Treatment Paraffin Silver sulfadiazine Silver sulfadiazine Early excision and
dressing dressing dressing skin grafting

Differences between antemortem and postmortem burns: Refer to difference no. 11.
 84 Exam Preparatory Manual of Forensic Medicine and Toxicology

Causes of Death in Case of Burns

Immediate causes
1. Neurogenic shock Due to severe pain and fear
2. Asphyxia Due to suffocation caused by inhalation of CO and smoke
3. Laryngeal spasm and Glotticedema Caused by smoke, fumes and gases
4. Cardiac arrest
Delayed causes
1. Hypovolemic shock Due to loss of fluids and electrolytes
Causes secondary shock and death within 24–48 hrs
2. Toxemia Due to absorption of toxic products from burnt tissues
3. Acute renal failure Occurs on 3rd–4th day
4. Septicemia Most important cause of death in survived patients
Leads to death of person after ≥ 4 days after burns
Common causative agents: Pseudomonas, Staph aureus
5. Infective complication Bronchitis, bronchopneumonia

4. Classify injuries. Discuss the postmortem findings in case of death due to

antemortem flame burns. (North Eastern Hill University, Shillong Supple 2020)
(Sai Tirupati University, Rajasthan 2018)
Ans:
Classification of Injuries
Refer to long question no. 8.
PM Findings in Case of Death due to Antemortem Burns

External findings Internal findings (3Cs)

1. Clothes 1. Carbon/soot particles
• Found to be burnt • Deposition of cabon and soot particles
• Clothes are removed and examined in airway till terminal bronchioles
for smell of kerosene, petrol • Surest sign of antemortem burns
2. Face 2. Curling ulcers—due to mucosal ischemic acute
• Swollen and tongue protruded out stress ulcers are seen in gastric antrum and 1st
with charred tip part of duodenum
• Froth may be seen due to irritation of 3. COHb levels in the blood raised
the air passages by smoke as a result 4. Spleen—enlarged and congested
of pulmonary edema 5. Adrenals—enlarged and congested
• Crow’s feet sign: Skin around eyes 6. Lungs—congested and edematous
spared 7. Heart—cherry red color blood
3. Skin—AM burns show signs of redness
4. AM blisters
• Contains inflammatory fluid
• Erythemic base
• Edges showing signs of redness
5. Singeing of scalp and body hairs
6. Degloving of skin, particularly hands and feet
7. Pugilistic attitude: The legs are flexed at the hips and knees, arms are flexed at the elbows and the
fingers are bent like claws due to heat stiffening. Can be seen in both AM or PM burns
 Injury 85

5. Classify thermal injuries. Describe the postmortem findings in case of death

due to burn injuries. (North Eastern Hill University, Shillong 2019)
Ans:
Classification of Thermal Injuries

Due to Heat Due to Cold

1. Local effects 1. Local effects
• Burns • Frostbite
• Scalds • Trench foot
2. General effects • Chilblains
• Heat cramps 2. General effects
• Heat exhaustion • Hypothermia
• Heat stroke
• Heat syncope

For PM findings in case of death due to antemortem burns: Refer to long question
no. 4.

6. Define grievous hurt as per Section 320 of IPC. What is dangerous weapon or
means? (BFUHS, Punjab 2019)
Ans:
The grievous hurt is defined under Sec 320 IPC and consists of 8 clauses:
First Emasculation
Second Permanent privation of the sight of either eye
Third Permanent privation of the hearing of either ear
Fourth Privation of any member or joint
Fifth Destruction or permanent impairing of the powers of any member or joint
Sixth Permanent disfiguration of the head or face
Seventh Fracture or dislocation of a bone or tooth
Eighth Any hurt which
a. Endangers life
b. Causes the victim to be in severe bodily pain for 20 days
c. Unable to follow his ordinary pursuits for a period of 20 days.

1. Emasculation
• Means loss of masculine power
• This clause is confined only to males
• Causes of emasculation
i. Castration
ii. Cutting of penis
iii. Injury to penis
iv. Injury to lumbosacral spine leading to impotence
 86 Exam Preparatory Manual of Forensic Medicine and Toxicology

2. Permanent privation of the sight of either eye

• The loss of sight may be partial or complete but it has to be permanent.
• For example: Corneal abrasions heal by leaving a scar leading to partial loss of
vision
3. Permanent privation of the hearing of either ear
• Loss of hearing may be partial or complete but it has to be permanent
• For example: Teacher slaps a student and tympanic membrane of student ruptures
and he cannot hear from that ear. So teacher is guilty of grievous hurt.
4. Privation of any member or joint
• Member means any organ or limb of a subject responsible for performance of
distinct function. It includes eyes, ears, nostrils, mouth, hands, feet, etc
• Joint may be both small or big
• For example: Chopping of an ear or finger
5. Destruction or permanent impairing of the powers of any member or joint
For example: Cutting of a tendon cause deformity, loss of movement and weakness.
6. Permanent disfiguration of the head or face
• Opinion of disfigurement should be given after complete healing
• Chopping of an ear or nose, laceration on face as it leaves a scar on healing
7. Fracture or dislocation of a bone or tooth.
• Fracture includes any type of fracture, cut on bone, hairline fracture, skull fracture,
etc.
• Dislocation: For example, shoulder dislocation
8. Any hurt which
a. Endangers life
b. Causes the victim to be in severe bodily pain for 20 days.
c. Unable to follow his ordinary pursuits for a period of 20 days, for example, not
able to brush his teeth, eat food or take bath.

Dangerous Weapon or Means

Any instrument if used as a weapon of offence is likely to cause death, like weapon
used for shooting, stabbing or cutting; or by means of fire or any heated substance,
poison or any corrosive substance, explosive or any substance which is harmful to
the human body to inhale, to swallow or to receive into blood or by means of any
animal.

Sections which Deal with Dangerous Weapon

Offence Punishment
Sec. 324 IPC Voluntarily causing simple hurt by Imprisonment: Up to 3 years and fine
dangerous weapons
Sec 326 IPC Voluntarily causing grievous hurt by Imprisonment: Up to 7 years and fine
dangerous weapon
 Injury 87

7. Enumerate various skull fractures. Add a note on subdural hemorrhage. (Sher-

i-Kashmir Institute, Srinagar supple 2019)
Ans:
Skull Fractures
Skull Vault Fracture
1. Fissure fracture • Also called linear fracture
• Most common type of skull fracture
• It is produced by:
– Blow with blunt weapon having broad striking surface
– When head strikes a flat surface on ground

2. Depressed fracture • Also called signature fracture

• It is produced by heavy weapon with small striking surface like hammer,
axe, etc.

3. Comminuted fracture • Also called spider web fracture/mosaic fracture

• In this type of fracture, bone is broken into several pieces of different
sizes
• It is caused by:
– Vehicular accidents
– Fall from height on a hard surface
– Blow on head with heavy object

4. Gutter fracture • In this outer part of the skull bone is chipped off by a tangential force so
as to form a gutter
• It is produced by oblique bullet not penetrating the skull
5. Indented fracture • Also called pond’s fracture
• It is seen in case of infants (as elastic skull)
• It is caused by obstetrics forceps delivery
6. Diastatic fracture • Also called sutural fracture
• Fracture lines run across the suture
• Commonly seen in young individuals
 88 Exam Preparatory Manual of Forensic Medicine and Toxicology

Skull Base Fracture

1. Hinge fracture • Also called motorcyclist fracture
• It divides the entire base of skull into two parts
• It is the fracture of middle cranial fossa
• Seen in motorcyclist

2. Ring fracture • Type of fissured fracture encircling foramen of magnum

• It is the fracture of posterior cranial fossa
• It is produced by fall from the height

3. Orbital Blow out fracture • Fracture of medial wall and floor of orbit
• On CT tear drop sign is seen

(Mnemonics—BCDeFGHI)

Subdural hemorrhage
Definition Bleeding in the space between dura and arachnoid matter (i.e. in the
subdural space)
Causes 1. Trauma
2. Intense shaking (in infants/child)
Vessels involved 1. Rupture of bridging or communicating veins
2. Tears in the dural venous sinuses
Site Fronto-temporal region with preservation of contours of cerebral
convolutions
Predisposing factors 1. Age—chronic SDH commonly seen in Children and Elderly
2. Alcoholics
Types of SDH 1. Acute SDH
• Symptoms start immediately or within 3 days after trauma
• Treatment: Burr holes or emergency craniotomy
2. Sub-acute SDH: Symptoms start within 4–21 days after trauma
3. Chronic SDH
• Appear >3 weeks after trauma
• Seen in Infants and elderly
Clinical features 1. Drowsiness
2. Headache
3. Lucid interval: Seen in 30% of cases
4. Confusion
5. Forgetfulness
6. Hemiparesis
Diagnosis On CT scan—concavo convex opacity
MLI 1. In battered baby syndrome—SDH is
the most consistent feature
2. Age of SDH correlates with events
prior to death
 Injury 89

8. Define injury. Write medical, legal and medico-legal classification of injury. How
will you differentiate suicidal cut throat injury from homicidal cut throat injury?
(AIIMS, Patna 2018)
Ans:
Definition of Injury
As per Section 44 IPC, injury is defined as any harm, whatever illegally, caused to any
person in Mind, Reputation, Body or Property. (Mnemonic: MR BP)

Classification of Injury
1. Medical 1. Mechanical injuries
(based on causative factors) Based on blunt force Based on sharp force
• Abrasion • Incised wound
• Bruise • Chop wound
• Laceration • Stab wound
• Fracture
2. Thermal injuries
Based on heat Based on cold
• Burns • Frostbite
• Scalds • Trench foot
• Heat cramps and heat • Hypothermia (systemic effect)
stroke (systemic effects)
3. Chemical injuries
• Irritants—plant and animal irritants
• Corrosives—acid and alkali
4. Other injuries
• Electric injuries
• Blast injuries
• Radiation injuries
2. Legal (based on 1. Simple
severity of injuries) 2. Grievous
3. Medico-legal (based on 1. Suicidal
nature of injuries) 2. Homicidal
3. Accidental
4. Fabricated injuries

Difference between suicidal and homicidal cut throat injury: Refer to difference no. 4.

9. What is the difference between injury, wound and hurt? How can you estimate
age of contusion? (Rajasthan University 2018)
Ans:
Difference Between Injury, Wound and Hurt
1. Injury: Any harm, whatever illegally, caused to any person in body, mind, reputation
or property (Sec. 44 IPC).
2. Wound: Clinically, it means any injury where there is breach of natural continuity
of skin or mucous membrane. In medico-legal practice, the terms ‘wound’ and ‘injury’
are synonymous, but strictly wound will include any lesion, external or internal,
 90 Exam Preparatory Manual of Forensic Medicine and Toxicology

caused by violence, with or without breach of continuity of skin (not defined in any
IPC or CrPC).
3. Hurt: Hurt means any bodily pain, disease or infirmity caused to any person
(Sec. 319 IPC).
It is of two types:
i. Simple
ii. Grievous.
Estimation of age of contusion: Refer to long question no. 11.

10. Define bruise. How can you determine age of bruise? How does parallel bruise
occur? (West Bengal University 2017)
Ans:
Definition of Bruise
It is defined as extravasation of blood in the subcutaneous/subepithelial tissues due
to rupture of blood vessels as a result of blunt force impact.
Age to determine bruise: Refer to long question no. 11.
How does parallel bruise occur?
Parallel bruise (railway line or tram-line type) is caused by blows with a rod, stick or
a whip which produces two parallel, linear hemorrhages with the intervening normal
skin.
Mechanism: When the weapon sinks into the skin, there is little or no damage to the
blood vessels over ridges where it compresses the skin. However, traction causes
marginal dermal vessels to rupture in the skin. The resulting accumulation of a small
amount of blood, near the epidermis causes the formation of the patterned bruise.

11. Define injury. Classify mechanical injuries and explain contusion in detail.
(Uttarakhand University 2018) (Sai Tirupati University, Rajasthan 2019)
Ans:
Definition of Injury
Refer to long question no. 8.
Classification of mechanical injuries: Refer to long question no. 8.
 Injury 91

Contusion/Bruise
Definition of bruise: It is defined as extravasation of blood in the subcutaneous/
subepithelial tissues due to rupture of blood vessels as a result of blunt force impact.
Classification of bruise: Bruise is classified into three types:
i. Intradermal bruise lies in the immediate subepidermal layer. Made by impact with
a patterned object, and hemorrhage is sharply defined.
ii. Subcutaneous bruise is situated in subcutaneous tissue, often in the fatty layer,
and the edges are blurred. Most common type of bruise.
iii. Deep bruise: Bleeding deeper to the subcutaneous tissues. It may take hours to
1–2 days to appear at the surface (delayed bruising).

Factors Affecting Appearance of Bruise

Age Easily produced in children and elderly

Sex More common in females
Site More prominent in bony prominence
More prominent on loose skin (scrotum, eyelids)
Less prominent on thick skin (palms and soles)
Complexion of skin More easily visible in fair skin
Natural disease Bruise occur easily by applying minor trauma in case of: Scurvy, hemophilia, purpura
Clothing Difficult in case of heavy clothing

Various Types of Bruise

Ectopic bruise/migratory bruise Patterned bruise

When extravasated blood at point of impact The bruise which reflects the pattern of the
by a blunt weapon tracks down due to gravity object causing it
along the fascial planes and may appear where
the tissue layers become superficial.
Examples Examples
Ant. cranial Black eye/ Collection of 1. Railway track bruise—hit by a stick
fossa fracture Racoon’s eye blood in peri- 2. Six penny bruise—in throttling
orbital region 3. Steering wheel injury
Mid. cranial Battle sign Collection of
fossa fracture blood in
mastoid region

Black eye Six penny bruise

 92 Exam Preparatory Manual of Forensic Medicine and Toxicology

Age of Bruise
Age of bruise can be estimated by:
1. Colour changes
2. Histological changes
3. Spectrophotometry

Estimation of Age of Contusion

On basis of colour changes (Mnemonic: VIBGYOR)

Duration Colour Reason

Fresh Red Oxyhemoglobin
Few hr to 3 days Violet/ Blue Deoxyhemoglobin
4–5 days Brown Hemosiderin
5–6 days Green Biliverdin
7–12 days Yellow Bilirubin
≥2 weeks Original/ Normal Normal

• In subconjunctival hemorrhage—color changes are not seen.

MLI
1. Age of bruise helps in determining time of infliction of injury
2. Artificial bruise can be produced by applying juices of marking nut or calotropis on
the skin in order to allege somebody of assault
3. Contusions/bruises near genital areas may be due to sexual assault
4. Multiple bruises in various stages of healing in case of child suggest child abuse/
battered baby syndrome
5. Character and manner of injury may be known from its distribution
For example: Six-penny bruises are produced by forcible pressure of fingertips as in
case of throttling
6. Bruises are of lesser value than abrasions as:
a. Their size may not correspond to the size of the weapon
b. Do not indicate the direction in which the force was applied.
c. May take few hrs to develop
d. May appear away from the actual site of injury (ectopic bruise)

12. Classify mechanical wounds. Describe the different types of lacerated wounds
with their medico-legal importance. (North Eastern Hill University, Shillong Supple
2018) (VNS, Gujarat University 2016)

Ans:
Classification of Mechanical Wounds
Refer to long question no. 8.
 Injury 93

Different types of lacerated wounds (Mnemonic: CATSS)

1. Split laceration • When blunt force is applied at the bony prominence, skin gets sandwiched
between bone and object causing split laceration
• Usually seen at: Scalp, forehead, zygomatic process, shin
• As margins look regular, so these lacerated wounds are called incised
looking lacerated wounds (look like Incised wounds) which can be
differentiated from incised wound with magnified lens
2. Stretch laceration • Occurs due to overstretching of skin and subcutaneous tissue
• Caused by heavy forceful impact
• Seen in—run over injuries, compound fractures
3. Avulsion laceration • Produced by a tangential force/shearing force, seen in case of run over by
vehicles in cases of RTA.
• Leading to
– Flaying—due to rotational force of wheel leading to detachment of skin
and subcutaneous tissue over a large area
– Degloving injury—entire skin comes out
– Amputation injury
4. Tear laceration • When objects hit the skin and skin is pulled back in opposite direction
• Seen in case of car door handle
5. Cut laceration • Caused by a heavy cutting weapon like axe, chopper
• Fracture of underlying bone also occurs

MLI
1. Laceration is usually homicidal, accidental but not suicidal
2. Laceration over face can result in extensive scar formation on healing resulting in
disfiguration of face—grievous injury
3. Avulsion laceration/flaying helps in determining the direction of force
4. Type of laceration can suggest shape of the blunt weapon, e.g. crescentic laceration—
hammer head.

13. Classify mechanical injuries. Write down the difference between laceration and
incised wound. On what parts of the body hesitation cuts are seen? (Rajiv
Gandhi University, Bengaluru supple 2015)
Ans:
Classification of Mechanical Injury
Refer to question no. 8.
Differences between laceration and incised wound: Refer to difference no. 3.
Hesitation cuts are tentative cuts seen in suicides. These cuts are multiple, small and
superficial often involving only the skin, and are seen at the beginning of the incised
wound. They are seen over:
1. Front of wrist, chest, groin
2. Front and sides of neck
3. Back of legs
4. Frontal aspect of elbow
 94 Exam Preparatory Manual of Forensic Medicine and Toxicology

14. Classify mechanical injuries. Describe the characteristic features of stab and
incised wound. (Sardar Patel University, Gujarat supple 2016, 2015)
Ans:
Classification of Mechanical Injuries
Refer to long question no. 8.

Characteristic Features of Stab Wound and Incised Wound

Stab wound Incised wound

1. Site Usually over chest, abdomen or neck Anywhere
2. Margins Clean cut Clean cut and everted margins
3. Length Length of the wound is slightly less Length is greatest dimension
than the width of the weapon
4. Width Width is more than the thickness of Width is greater than the width of the
weapon weapon
5. Depth Depth is the greatest dimension Length is greater than its width/depth
6. Shape Spindle-shaped, but depends on Spindle-shaped
weapon
7. Direction It can be vertical, horizontal or Direction is given by the tailing of the
oblique in direction wound.
8. Surrounding May be seen (hilt mark) Absent
abrasion and bruise

15. Define injury. Classify mechanical injuries and describe briefly the different
types of stab wounds. (Adesh, Bathinda supple 2017)
Ans:
Definition of Injury
Refer to long question no. 8.

Classification of Mechanical Injuries

Refer to long question no. 8.

Types of Stab Wound

Concealed punctured wound Penetrating stab wound Perforating stab wound

Puncture wounds on the Punctured wound caused by Punctured wound caused by any
concealed body parts any weapon that enters body weapon that enters from one side of
• Caused by pins, ice picks cavity producing only entry the body and exits from the other
• Usual sites—ear lobes, wound side, i.e. has entry wound and exit
fontanella, genitals, axilla wound
MLI: Needle puncture on MLI—Identification of entry and exit
fontanelle is a common wound
method for infanticide • Entry wound—larger with inverted
edges
• Exit wound—smaller with everted
edges
 Injury 95

16. A 30-year-old male presents to causality with multiple injuries over head
caused allegedly from assault by many people. In such a case: (Sardar Patel
University, Gujarat 2015)
a. What features help you differentiate a lacerated wound from incised wound?
b. What features of any mechanical injury help in indication the nature of
inflicting weapon?
c. What criterion is used to opine an injury as grievous?
Ans:
a. Refer to difference no. 3.
b. The margins and dimensions of the wound help in indicating the nature of inflicting
weapon.
c. Sec. 320 IPC gives the eight clauses of grievous hurt which help in opining the injury.

17. A 20-year-old female domestic maid presents to the emergency with burns
over both lower limbs. Her employer gives a history of spillage of boiling water
over her body parts while she shakes her head in disagreement. The burnt
areas also look suspicious and not consistent with the history given by the
employer. (Sardar Patel University, Gujarat 2015)
a. How will you confirm whether the injury is due to spillage of hot liquid and
not by flame or use of corrosive?
b. If the burns are confirmed to be sure to corrosive, how will you manage it?
c. What shall be your medico-legal duties in such a case?
Ans:
a. A thorough examination of the burnt area will help in identifying the causative
agent. Points which may help in differentiating burns from boiling water vs
corrosives are:
Boiling water Corrosives
1. Site At or below the site of contact At or below the site of contact
2. Splashing Present Present
3. Skin Sodden, bleached Corroded and devitalized
4. Color Bleached Distinctive coloration
5. Vesicles Present Absent
6. Red line —do— —do—
7. Ulceration Absent Present
8. Clothes Wet, not burnt May be burnt, with characteristic stains

Additionally, there will be pain or numbness at the site, irritation, burning, black
dead skin in corrosive.
Refer to difference no. 10 for features of burns due to dry heat and moist heat.
b. Treatment
1. Use of PPE—vital for the treating doctor.
2. Airway, breathing and circulation (ABC): Stabilization of patient is vital.
3. Remove solid debris.
 96 Exam Preparatory Manual of Forensic Medicine and Toxicology

4. Copious irrigation with warm water for surface burns—at least 20–30 mins.
5. Neutralization of chemicals is not indicated.
6. Complete wound evaluation—assessment of depth, debridement of blisters and
non-viable tissue
7. Treatment of acid-base and electrolyte imbalance, and hypothermia.
8. Referral.
c. Since it is corrosive burns and there is suspected foul play; the doctor should inform
the police and treat it as Medico-legal Case (MLC).
• The medical officer should inform the duty constable, giving the name, age, sex
of the patient and the place of occurrence of the incident and should start the
treatment of the patient.
• The treating doctor should record a proper history, examination including general
condition, level of consciousness, vitals, and report of investigations and the other
circumstances of the case and then analyze the injuries. He should document
clearly all injuries observed by him in the MLC after taking due consent from the
patient.
• All the communication in case of MLC should be written.

SHORT NOTES

1. Hesitation cuts (Adesh, Bathinda supple 2020)

Ans:
Definition: While attempting suicide, a person undecidedly makes superficial cuts
before attempting a final deeper cut. These are called hesitation cuts.
• They are also called tentative cuts, trial marks.
• It shows hesitation while gaining courage to make a final decisive cut.

Characteristics Usual sites of hesitation cut

• Multiple • Front of wrist
• Parallel • Front of elbow
• Superficial cuts (involving skin) • Front and sides of neck
• Mostly incised wounds
• Seen on accessible parts of body

MLI
• It suggests suicidal tendency
• These are caused by light sharp edged weapons (knife/razor)
• It indicates direction of cut (deeper at the beginning and superficial at end).

2. Section 320 IPC (Adesh, Bathinda supple 2020) (Sardar Patel University, Gujarat 2020,
supple 2016) (Rajiv Gandhi University, Bengaluru 2020, 2015, supple 2015) (AIIMS
Patna 2018) (Uttarakhand University 2017, supple 2016) (North Eastern Hill University,
Shillong 2016) (Himachal Pradesh 2017) (BFUHS, Punjab 2015) (VNS, Gujarat 2016)
Ans: Refer to long question no. 6.
 Injury 97

3. Self-inflicted injury/fabricated Injuries (Rajasthan University 2018) (KHMS, Tamil

Nadu 2018)
Ans:
Definition: These are the wounds produced by a person deliberately on his own body
or by another person with his/her consent.

Types

Self-inflicted injuries: Produced by person on his body

Self-suffered injuries: Produced by another person with his/her consent

Diagnosis
Based on the:
1. Clinical history
2. Features
1. History
• History of assault incompatible with injuries
• No defence injury despite history of assault
2. Features
Type 1. Incised wounds (mostly)—Multiple, superficial, parallel
2. Abrasions
3. Burns
Sites 1. Front of forearm
2. Outer side of upper arm
3. Front of chest and abdomen
4. Top of head, forehead
5. Outer sides of thigh
Clothes 1. Are not cut (usually)
2. If cut—not compatible with nature of injuries
Injuries produced by 1. Knife
2. Razor
3. Glass piece
4. Scissors
5. Ice pick

MLI: These are produced with an intention:

1. To make false charge against another person with assault or attempt of murder
2. To convert simple injuries into grievous injuries
3. By women, to bring a charge of rape
4. By prisoners, to bring charge of beating by officers
5. To avoid hard duties by employees
6. By an assailant to pretend self-defence.
 98 Exam Preparatory Manual of Forensic Medicine and Toxicology

4. Types of skull fractures (BFUHS, Punjab 2020) (KHMS, Tamil Nadu supple 2020)
(University of Health Sciences, Rohtak 2019) (JIPMER supple 2018) (Sai Tirupati
University, Rajasthan 2019)
Ans: Refer to long question no. 7.
(Another Mnemonic: Love can do problem, girls please be serious)
1. Linear fracture
2. Comminuted fracture
3. Depressed fracture
4. Pond fracture
5. Gutter fracture
6. Perforating fracture
7. Basilar fracture
8. Sutural fracture

5. Signature fracture (KHMS, Tamil Nadu supple 2019) (Rajiv Gandhi University,
Bengaluru 2015) (VNS, Gujarat 2018)
Ans:
1. Signature fracture is depressed fracture of skull.
2. They are so called since the shape of the depressed part of the skull corresponds
and resembles the striking surface of the weapon, and it appears as if the weapon
has left its signature on the skull.
3. It is produced by heavy weapon with small striking surface like hammer, axe, etc.
4. The part of the skull which is first struck shows maximum depression.
5. MLI
a. Helps in identifying the causative agent/weapon
b. Helps in determining manner of application of violence
c. Helps in determining the relative position of assailant and victim.

6. Pond Fracture (Andhra Pradesh supple 2016)

Ans:
1. It is just a simple dent seen on the skull which looks like a depression on a ping
pong ball produced by pressing thumb or a finger.
2. It is also called indented fracture/ping-pong fracture.
3. Fractures occur only on the outer table around the periphery of the dent but the
inner table is not fractured.
4. Seen in case of:
1. Infants—due to elastic skull
2. Children—due to incomplete ossification of skull bones
3. Newborns—due to forceps delivery.
 Injury 99

7. Age of contusion (Sher-i-Kashmir Institute supple 2020) (AIIMS Patna 2018) (GMC,
Chandigarh 2016)
Ans: Refer to long question no. 11.

8. Classify mechanical injuries (Pondicherry 2015)

Ans: Refer to long question no. 8.

9. MLI of incised wounds (Pondicherry supple 2017)

Ans:
1. Helps in determining the nature of weapon.
2. Nature of injury can be determined—as incised wounds usually are not fatal as
they do not penetrate deep enough to damage large blood vessels. However, they
are highly fatal if present over the neck, as veins of neck are present superficially.
3. Helps in determining direction of force (tailing present at end of incised wound).
4. Manner of injury can be determined (i.e. whether it is suicidal, homicidal, accidental
or fabricated wounds).
5. Helps in determining age of injury.
6. Relative position of assailant and victim can be determined.

10. Degree of flame burns (Sardar Patel University, Gujarat 2019, supple 2020, supple
2019)
Ans: Refer to long question no. 3.

11. Heat hematoma (Sher-i-Kashmir Institute, Srinagar supple 2015)

Ans:
• Heat hematoma is an artifact and not a vital phenomena. It is seen in exposure of
skull to tremendous heat which results in charring of the skull.
• It resembles extradural hematoma (EDH).

Mechanism of Formation
 100 Exam Preparatory Manual of Forensic Medicine and Toxicology

Features
1. Distribution: Seen diffusely around the brain (commonest site—parieto-temporal
region)
2. Position: Usually bilateral
3. Appearance
• Soft friable clot, light chocolate brown in color, sickle shaped, honeycomb
appearance
• Thickness: 1.5 mm to 1.5 cm
• Contains up to 120 mL of blood
4. There may be eggshell fracture and cross suture lines (in comparison to EDH)
5. Presence of COHb in blood

12. Explain various causes of death in case of flame burns (Sardar Patel University,
Gujarat supple 2018)
Ans: Refer to long question no. 3.

13. Complications of burns (Adesh, Bathinda supple 2017)

Ans:
Complications can occur after a few days to a few months which may lead to death of
the patient.
1. Hypovolemic shock is quite common in burn patients. It occurs within 24–48 h
due to loss of fluid and protein, causing decrease in cardiac output and multiorgan
failure.
2. Acute edema of glottis occurs from inhalation of irritant smoke or hot gases with
or without pulmonary edema.
3. Sepsis is seen after 4–5 days. Septicemia can be caused by burn wound infections
(e.g. Pseudomonas aeruginosa, Staphylococcus aureus), UTI following catheterization,
pneumonia, etc.
4. Infective complications like bronchopneumonia may be seen.
5. Suppurative discharges from infected burn areas lasting for weeks or months may
occur.
6. Gangrene, tetanus, anemia, edema of dependant parts and jaundice.

14. Explain why Wilson’s first degree burns are more painful than third degree
burns. (West Bengal University 2018) (West Bengal University supple 2017)
Ans:
Wilson’s epidermal burns (first degree burns) involve the superficial nerve endings
and is extremely painful and tender. Whereas in deep burns (third degree burns), the
nerve endings are destroyed. Hence, they are painless.
 Injury 101

15. Rule of 9 (BHUHS, Punjab supple 2020) (KHMS, Tamil Nadu supple 2020) (SGRD,
Amritsar 2019) (Sardar Patel University, Gujarat supple 2019) (Delhi University 2018)
(West Bengal University supple 2017) (Adesh, Bathinda supple 2017) (GMC,
Chandigarh 2015) (Uttarakhand University 2015, supple 2016)
Ans:
• It is a method used to estimate percentage of total body surface area (TBSA) that
has burnt.
• It is also called Wallace Rule of 9.
• As per the rule, body is divided into 11 anatomical regions and each represents 9%
of TBSA. Remaining 1% area is perineum.

Region % TBSA
1. Head and neck 9
2. Upper limb: Right side 9
3. Upper limb: Left side 9
4. Chest 9 (Front) + 9 (Back)
5. Abdomen 9 (Front) + 9 (Back)
6. Lower limb: Right side 9 (Front) + 9 (Back)
7. Lower limb: Left side 9 (Front) + 9 (Back)
8. Perineum 1
Total (9 × 11) = 99 + 1 = 100
 102 Exam Preparatory Manual of Forensic Medicine and Toxicology

MLI
1. Gives rough estimate of TBSA involved
2. Helps to know prognosis in case of burns (as >33% TBSA burns has poor prognosis)
3. Helps in calculating amount of fluid required for resuscitation by Parkland formula.

16. Joule Burns/ Endogenous Burns (Rajiv Gandhi University, Bengaluru supple 2020)
(SGRD, Amritsar 2019) (Rajasthan University 2018) (KHMS, Tamil Nadu 2017)
(Uttarakhand University supple 2017) (Sher-i-Kashmir Institute, Srinagar supple 2017)
(Adesh, Bathinda 2017)
Ans:
Definition: The point where electric current enters the body which is usually
characterized by presence of electric mark. This electric mark (entry point) is called
Joule burn.
• It is seen in cases of low voltage current with tight
contact.
Characteristics of Joule Burns
1. Crater
• Central crater with peripherally raised margins
• Chalky white in color
• Floor of crater is pale and lined by flattened skin
2. Hyperemia
• Mild hyperemia of adjacent intact skin
• If contact is prolonged, skin mark becomes brown or charred
3. Metallization
• Due to deposition of metallic ions from the conductor into skin
• May impart fade color to the electric mark
• It is detected by Acro-Reaction test
• It can be demonstrated only in Entry wounds and not in Exit wounds
4. Sites: Seen on exposed parts of body, especially on palmer aspect of hand.
5. Microscopic features
a. Epidermal separation leading to microblisters
b. Palisading appearance of nuclei and nuclear streaming
c. Coagulative necrosis
d. Nuclear elongation of basal layer
6. MLI: The presence of Joule burns is not itself a proof of electrocution as similar
marks can be produced even after death except for the zone of hyperemia.

17. Enumerate injuries caused by hard and blunt object. Describe any one of these
in detail. (Sardar Patel University, Gujarat 2020)
Ans:
Injuries caused by hard and blunt object
1. Abrasion
2. Bruise
3. Laceration
4. Fracture
 Injury 103

For details of bruise: Refer to long question no. 11.

For details of abrasion: Refer to short question no. 18.

18. Abrasion (BFUHS, Punjab supple 2016)

Ans:
Definition: Abrasion is a type of mechanical injury caused by the removal of superficial
epithelial layer of the skin, usually the epidermis by friction against rough surface.

Types of Abrasions

1. Scratch/linear 2. Graze abrasion 3. Pressure abrasion 4. Imprint abrasion

abrasion
Caused by a pointed Caused by horizontal Caused by linear Caused by force applied
object passing across or tangential friction pressure of a rough perpendicular to the skin and
the skin, such as finger- between the skin and object over the skin bears the imprint of the object
nails, thorn or pin the hard rough surface causing it
Fingernail abrasions Seen in road traffic Ligature mark in Tyre-tread mark, imprint of
seen in throttling accidents hanging and bicycle chain
strangulation

• Most common type of abrasions is graze abrasions.

Healing of Abrasion
It produces minimum bleeding, heals rapidly (in 1 week) and leaves no permanent
scarring on healing.
MLI
1. Usually, it is seen in accidents and assaults.
2. Abrasions on the face or body of the victim/assailant indicates struggle.
3. Abrasions give an idea about the site of impact and direction of force.
4. Nature of injury: Abrasions are superficial injuries and simple in nature. Abrasions
over the cornea may cause corneal opacity, which may cause grievous hurt (Sec.
320 IPC).
5. Patterned abrasions are helpful in connecting the wound with the causative weapon.
6. Age of injury can be determined.
7. Character and manner of injury may be known from its distribution. For example,
in throttling, crescentic abrasions made by fingernails are found on the neck.

19. Filigree burns (BFUHS, Punjab supple 2018) (Rajiv Gandhi University, Bengaluru 2018)
(Andhra Pradesh 2016) (VNS, Gujarat supple 2018, supple 2019)
Ans:
• Definition: It is defined as characteristic fern-like pattern seen on the body due to
lightening strike.
• It is also called Arborescent markings, Lichtenberg flowers.
 104 Exam Preparatory Manual of Forensic Medicine and Toxicology

Characteristics
1. Superficial
2. Irregular (tortuous or dendritic)
3. Red markings over the skin
4. Resembles branch of leaf
5. Usual sites: Shoulder, front and back of chest,
abdomen
6. Appear within 1 hr of lightening and disappear
in a day or two
Mechanism/theories Related
1. Static electric discharge along superficial vasculature
2. Hemoglobin staining the tissues due to high current that break down RBCs in the
capillaries
3. Electron showers giving rise to inflammatory reaction
MLI
a. Markings over the skin indicate path taken by discharge and usually takes long axis
of body towards ground.
b. Death is accidental.
c. If anyone can recognize these features, and start immediate resuscitation, then the
person can be saved.

20. Harakiri (AIIMS Patna 2019, 2017, 2015)

Ans:
• It is a method of suicidal disembowelment (cut open the abdomen).
• It is a type of self-inflicted injury.
• Seen in case of Japanese Samurai soldiers.
• Victim with sword produces a stab injury over the abdominal region.
• As a result of sudden evisceration of internal organs, there is decrease intra-
abdominal pressure resulting into circulatory collapse and ultimately leading to
death.

21. Split laceration/incised looking wounds (BFUHS, Punjab 2019, 2015) (North Eastern
Hill University, Shillong Supple 2019) (Adesh, Bathinda supple 2017) (Uttarakhand
University 2015, supple 2016)
Ans:
Refer to long question no. 12.
MLI
1. At the time of preparing MLC report or at time of autopsy. Incised looking lacerated
wounds can be wrongly interpreted as incised wounds. The doctor may opine that
the causative object as “sharp”, whereas it was caused by a “blunt” object.
2. In court of law, doctor will have to explain the reason for misinterpreting it as incised
wound.
 Injury 105

22. Write MLI of Tailing of wound (West Bengal University 2019)

Ans:
1. Incised wounds show “head” and “tail” ends.
2. Tailing of wound is seen on one end due to withdrawal
of the weapon. At beginning, the wound is deeper
(head end) and becomes increasingly shallow till,
finally, cut the skin alone.
3. MLI: Tailing of wound indicates the direction in which
force was applied.

23. Delayed bruise (Rajiv Gandhi University, Bengaluru 2015)

Ans:
1. Definition: Bruise which takes some time to appear at the point of impact.
2. It is also called deep bruise.
3. In this, bleeding occurs deeper to subcutaneous tissues, i.e. either in superficial
muscles or muscular fascial planes.
4. Since it is deeper, it may take hours to 2 days to appear at the surface.
5. Therefore, it is very important to reexamine the person 1–2 days after first
examination.

24. Concealed puncture wounds (Uttarakhand University supple 2017)

Ans: Refer to long question no. 15.

25. Explain why stab injury over auricles is immediately fatal, whereas those over
the ventricles are not (West Bengal University 2018)
Ans: Stab injury over auricles is immediately fatal, whereas those over the (left)
ventricles are not.
1. This is because if ventricles are punctured, the thick muscles may restrict the bleeding,
therefore allowing time for surgical emergency treatment. It may almost completely
seal itself by contraction of the cardiac muscle around the defect. Death will occur
due to cardiac tamponade which may take some time.
2. A stab wound through the left ventricle or through the thin-walled auricles is unlikely
to re-seal itself and will bleed out into the pericardium with fatal results.

26. Chop wound (BFUHS, Punjab 2019)

Ans:
Definition: Chop wounds are large deep gaping
wounds caused by a blow with heavy cutting
weapons when applied with significant degree of
force.
Weapons used: Axe, chopper, hatchet, butcher’s
knife
 106 Exam Preparatory Manual of Forensic Medicine and Toxicology

Characteristics
1. A chop wound is a combination of blunt and sharp force injury.
2. Margins—sharp and may show abrasion, bruise or laceration with severe injury to
underlying tissues
3. Dimensions of the wound correspond to the cross-section of penetrating blade
4. Presence of incised wound with underlying bone fracture
MLI
1. Mostly homicidal in nature
2. Sometimes accidental or suicidal
3. Proper wound examination can give clue about the causative weapon

27. Punch Drunk syndrome (Adesh, Bathinda supple 2019)

Ans:
1. It is seen in boxers or may occur late in their career or years after retirement as a
result of repeated blows to the head resulting in cumulative effect of cerebral
concussions.
2. It was also called
a. Dementia pugilistica
b. Boxer’s encephalopathy
3. Now it is called chronic traumatic encephalopathy (CTE).
4. Clinical features
a. Parkinson-like symptoms
b. Drunken appearance
c. Dementia
d. Others: Delusion, intentional tremors, dysarthria, etc.
(Mnemonic: PD; very common example of Mohammad Ali
P-Parkinson D-Dementia, Drunken gait, Dysarthria, Delusion)
5. On autopsy: Chronic SDH, DAI may be present

28. Heat stroke (BFUHS, Punjab supple 2020) (Rajiv Gandhi University, Bengaluru 2015)
Ans:
Definition: Heat stroke is a life-threatening medical emergency resulting from failure
of thermoregulatory mechanisms.
2. It is also called heat hyperpyrexia or thermic fever.

Predisposing Factors

Environmental factors Non-environmental factors

1. High humidity 1. Obesity
2. High temperature 2. Extremes of age
3. Strenuous exercise 3. Alcohol intoxication
4. Malignant hyperthermia
5. Thyrotoxicosis
 Injury 107

Clinical features
1. High fever with core temperature >41ºC
2. Absence of sweating—leading to dry skin
3. CNS symptoms—delirium, stupor, disorientation, etc.
4. Miosis
5. Tachycardia and hyperventilation
6. Low BP
Treatment
1. Lower the temperature by active cooling (cold bath and sponging) and passive
cooling (removing clothes)
2. Correct dehydration—by oral or IV glucose or saline
3. To control shivering—IV diazepam and IV chlorpromazine
4. Supportive treatment.
Complications
a. Hepatic necrosis
b. DIC
c. Adrenal hemorrhage
d. Myoglobinuria
PM findings
1. PM caloricity
2. Necrosis and edema in Purkinje layers of cerebellum
3. Lungs—congested
4. Heart—subendocardial hemorrhages
5. Rigor mortis sets in early and passes off early.

29. Whiplash injury (BFUHS, Punjab supple 2018) (Pondicherry supple 2017) (North
Eastern Hill University, Shillong 2017) (Delhi University 2015) (VNS, Gujarat 2016,
supple 2019)

Ans:
Definition: Whiplash injury is seen commonly in occupants of front seat in motor
vehicle when a moving car suddenly stops, resulting in acceleration-deceleration
mechanism of transfer of energy to the neck.
Causes
1. Rear end or side impact motor vehicle collisions
2. When a car suddenly stops
3. Blow on the chin
Mechanism
1. Hyperflexion followed by hyperextension—when a car suddenly stops
2. Hyperextension followed by hyperflexion—when a car is hit from behind
 108 Exam Preparatory Manual of Forensic Medicine and Toxicology

Out of hyperflexion and hyperextension injuries, hyperextension is more dangerous

as it leads to tearing of anterior longitudinal ligament resulting in injury to cervical
region of spinal cord (C5-C6 dislocation is more common than C1-C2 dislocation).

Signs and symptoms

1. Pain and stiffness of neck
2. Headache, dizziness
3. Numbness, tingling
4. Pain in arms, legs
5. Blurred vision

Prevention
1. Wear seat belts
2. Presence of head rests in car seats

30. Stab injury (Uttarakhand University 2017, 2016)

Ans:
• Definition: Stab injury is produced by penetration with long narrow instruments
having pointed ends into the depth of the body.
• It is characterized by depth which is more than its length.
Weapons used
1. Sharp: Knife, dagger, scissors, pens, needle
2. Blunt: Screw driver, iron rod, cricket stump
Types of stab wound: Refer to long question no. 15.
 Injury 109

Various Shapes of Stab Wounds

Weapon Shape
1. Single-edged knife Wedge/triangular
Fish tail

2. Double-edged knife Spindle-shaped

3. Arrow Circular

4. Fork Circular wounds

(3–4 in no.)

Characteristics of Stab Wound

1. Depth is the greatest dimension
2. Breadth is more than the thickness of blade due to gaping
3. Length is usually less than the width of stab wound because of stretching of skin
4. Margins are clean cut. But in case of full penetration—patterned abrasion/bruise
can be seen (hilt mark)
MLI
1. Concealed punctured wounds suggest homicide
2. Depth of the wound—suggests amount of force used
3. Foreign material can be seen in the wound
4. Shape of the weapon—suggests type of weapon
5. Manner of production can be determined

31. Lacerated wound (Sardar Patel University, Gujarat 2018) (BFUHS, Punjab 2017)
Ans:
Definition: It is defined as tearing of skin, mucous membrane, muscle or internal
organs caused by blunt force impact producing shearing or crushing force
Weapons used: Blunt weapons (cricket bat, hammer, iron rod, hockey, etc.)
Characteristics
1. Margins: Irregular
2. Bruise and abrasion—present around the
margin
3. Hair bulbs—crushed
4. Blood vessels—crushed
5. Hemorrhage—less (due to crushing of blood
vessels)
6. Tissue bridges—present and is the hallmark
of lacerated injury
 110 Exam Preparatory Manual of Forensic Medicine and Toxicology

Types of laceration: Refer to long question no. 12.

MLI: Refer to long question no. 12.

32. Propellant (Sher-i-Kashmir Institute, Srinagar supple 2019)

Ans:
Definition: Propellant is an explosive substance used to propel (to move forward with
force) the projectile from a gun. They are of following types:
1. Black powder: It produces flame, smoke and heat, and consists of sulphur (10%),
charcoal (15%) and potassium nitrate (75%).
2. Smokeless powder: It is more effective than black powder as it burns more efficiently
and produces much less smoke, resulting in less blackening and tattooing around
the entry wound. It can be:
a. Single base powder consists of nitrocellulose. Most common type of commercial
powder.
b. Double base powder consists of nitrocellulose and nitroglycerin.
c. Triple base powder consists of nitrocellulose, nitroglycerin and nitroguanidine.
3. Semi-smokeless powder: It consists of mixture of 80% black and 20% smokeless
type.

33. Tandem bullet (North Eastern HIll University, Shillong 2019) (Adesh, Bathinda supple
2017) (VNS, Gujarat 2019)
Ans:
1. “Tandem” means two things arranged one in front of the other.
2. When a rifled firearm is fired, bullet gets stuck in the barrel and fails to come out of
the muzzle, so when the gun is fired again, the second bullet hits the first bullet
from behind and forces the first bullet to move forward. Therefore, both the bullets
are seen coming out of the muzzle as a single projectile.
3. It is also called Piggy bank bullet.
4. Seen in case of old unused guns where one bullet follows the other bullet.
5. This phenomena is used practically in “Duplex bullets” wherein there are two bullets
by design so as to hit the target at different points.

34. Abrasion collar (KHMS, Tamil Nadu 2018) (Andhra Pradesh 2016) (GMC, Chandigarh
2016) (Rajiv Gandhi University, Bengaluru 2015) (VNS, Gujarat supple 2019)
Ans:
1. Definition: It is the abrasion of the skin
caused by a bullet around the entry
wound.
2. It is seen in case of rifled firearm.
3. It surrounds the grease collar and itself
can be surrounded by blackening or
tattooing.
 Injury 111

4. Sometimes, contusion is present in place of abrasion collar and is called contusion

collar.
5. Mechanism: As the bullet strikes the skin, it first indents and then stretches the skin
surface and then it penetrates the tense area of skin. So, rubbing of the bullet against
the inverted skin epidermis and heat is responsible for the development of abrasion
collar.
6. MLI
a. It is a proof of entry wound.
b. Abrasion collar is circular in shape—if bullet strikes perpendicular to the body
surface.
c. Abrasion collar is eccentric in shape—if bullet strikes the surface in an oblique
direction to the body surface.
d. Abrasion collar is not seen on palms and soles due to thickness and keratinization
of epidermis.

35. Coup and contrecoup injuries (Andhra Pradesh 2016)

Mechanism of coup and contrecoup injuries and its MLI (Rajiv Gandhi University,
Bengaluru 2018) (Pondicherry 2016)
Ans:
Coup Injury
It occurs immediately beneath the site of impact, and results directly by the impacting
force.
• Caused when the head is fixed and there is violent impact over the skull
• There will be fracture and underlying brain damage (contusion) will be located
beneath the site of impact
Contrecoup Injury
The injury is located in the brain opposite to the site of
impact.
• Caused when the moving head is suddenly
decelerated by hitting a firm surface, e.g. striking on
the wall
• Common in road traffic accidents (RTAs)
• Contrecoup injury is rare in <3 years of age.

Mechanism
1. When head strikes a fixed surface, a momentary
deformation of skull occurs with increase in pressure
which may struck on the underlying brain causing
compression—coup injury.
2. At the same time, opposite area of the skull will bulge
outward to accommodate the deformation—‘struck-hoop’ theory. There is formation
of vacuum as brain lags behind the moving skull. The vacuum exerts a suction
effect that causes shear strain by pulling the brain—contrecoup injury.
 112 Exam Preparatory Manual of Forensic Medicine and Toxicology

Site: Common site for coup injury is the occipital lobe and for contrecoup injury is the
frontal lobe in case of RTAs.
MLI: It is possible to determine if injury resulted from a fall or assault on the basis of
location of the injuries.
1. In assaults, brain shows much larger contusions underlying the area of impact (coup)
than on the site opposite to impact (contrecoup).
2. In head injuries caused by falls (RTAs), the contrecoup injuries are usually located
in inaccessible portions and are larger than the coup contusions (e.g. occipital
lobes).

36. Choking in a firearm (SGRD, Amritsar 2019)

Ans:
Definition: It is defined as the narrowing or constriction of the barrel at its muzzle
end in a shotgun.

Types of Shotguns
1. Cylinder bore: When the entire barrel (from breech to muzzle) is of same diameter
in a shotgun
2. Choke bore: When 7–10 cm of bore near muzzle end is constricted in a shotgun
Degree of choking in ascending
order of choking
1. Cylinder bore
2. Improved cylinder choke
3. Modified choke
4. Full choke

Advantages
1. To decrease dispersion of pellets
2. To increase range of the shotgun by increasing velocity
3. To increase the explosive force

37. Cartridge of shotgun (West Bengal University supple

2017) (BFUHS, Punjab 2016) (VNS, Gujarat 2017)
Ans:
Cartridge of shotgun comprises:
1. Cartridge case with percussion cap containing primer.
Primer: It is highly inflammable that burns into flame and
explodes the gun powder.
2. Gunpowder- it is the explosive material that is burnt by a
spark generated in primer to propel shots.
3. Wad: It is disc-shaped cushion made up of cardboard or
plastic.
It acts as lubricant and functions like a piston by pushing the lead shots out.
4. Lead pellets: These are spherical lead balls used in smooth bored firearm.
 Injury 113

38. Characteristics external features of contact shot wound by rifled firearm.

(Sardar Patel University, Gujarat 2019, 2015)
Ans: Refer to long question no. 2.

39. Entry wound in firearm injury (KHMS, Tamil Nadu supple 2020) (VNS Gujarat,
supple 2018)
Ans: Entry wound is one that results when a projectile enters a body.
Characteristic features are:
1. In skull, entry wound is clean cut on outer table and beveled in the inner table.
2. Smaller than the diameter of the bullet (except contact shot)
3. Edges are inverted
4. Bruising, abrasion and grease
collar, burning, blackening,
tattooing can be seen.
5. Bleeding is less as compared to
exit wounds.
6. Singeing of hair will be there
(close range)
7. Wound track is cherry-red due to
COHb.
8. Fibers of clothes are turned in.

40. Caliber (Andhra Pradesh 2015)

Ans:
In case of rifled firearm In case of smooth bore firearm
• It is defined as the diameter of the interior • It is defined as the number of spherical lead balls of
of the barrel measured between diagonally size fitting the barrel of a shotgun which can be made
opposite lands. from 1 pound of lead.
• It is expressed in mm or inches. • It is also called Bore.

18 bore
 114 Exam Preparatory Manual of Forensic Medicine and Toxicology

41. Bullet fingerprinting (AIIMS Patna 2016)

Ans: Bullet fingerprinting comprises primary marking and secondary markings.
1. Primary markings: It occurs due to rifling, i.e. presence of lands and grooves on the
interior wall of a barrel (parallel shallow spiral grooves from breech end to muzzle
end).
• It is also called “class characteristics”
• Class characteristics in a fired bullet identification would be
a. Number, diameter and width of lands and grooves.
b. Depth of grooves
c. Direction and degree of rifling twist
• Advantage: Helps in identifying the make and model of a gun.
2. Secondary markings
• It is also called “individual characteristics”
• Cause: Produced on the surface of the bullet due to irregularities in the barrel
(occur during manufacturing process)
• Advantage: Helps in identifying the specific gun which was fired.

42. Patterned injuries (University of Health sciences, Rohtak supple 2020)

Ans:
Definition: Pattern injuries are one which has a distinct pattern that may reproduce
the characteristics of the object causing the injury.
• Most common are patterned abrasion and patterned bruise.
• For example: “Railway track bruise”—by stick, “six penny bruise” in throttling,
tyre mark pattern in RTAs, etc.
Patterned injuries can be categorised into type of force involved:
i. Blunt force injuries: These are the most commonly seen group. Caused by abrasions,
bruising and lacerations.
ii. Sharp force injuries: Stab wounds may show characteristics of the blade—hilt guard
mark, or stab wound with screwdrivers or scissors.
iii. Gunshot wounds: Contact entry wounds may produce distinct patterned injuries.
iv. Miscellaneous, e.g. fern-like pattern with lightning strikes.
MLI: Connect a particular weapon or object to an injury, which may connect an assailant
with the crime.

43. Injuries seen in pedestrians in road traffic accidents (KHMS, Tamil Nadu supple
2020)
Ans:
Definition: These are the blunt injuries sustained by person walking or standing on
the ground when hit by a vehicle.
 Injury 115

Types
Primary impact injuries Secondary impact injuries Tertiary impact/secondary injuries
Definition: These are the Definition: These are the injuries Definition: These are the injuries
injuries caused by the first caused by second impact of the caused when the person falls on
impact of the vehicle on body with the vehicle (after the the ground
the victim primary impact)
Cause: Bumper impact Cause: 1. Bonnet impact Cause: 1. Ground impact
2. Windshield impact 2. Run over injuries
Injuries seen: Injuries seen: Injuries seen:
1. Abrasions, contusions and 1. Head injury 1. Abrasions
lacerations on legs, 2. Skeletal fracture 2. Lacerations
thighs/ buttocks 3. Cervical injuries 3. Head Injury
2. Bumper fracture:
It occurs when the victim
is struck by front of vehicle,
(e.g. bumper). Leads to fracture
of tibia which is wedge shaped

44. Primary impact injury (KHMS, Tamil Nadu 2017, supple 2019) (GMC, Chamba 2019)
Ans: Refer to short question no. 43.

45. Close firing may not be evident on examination of gunshot wound (West Bengal
University 2019)
Ans:
1. In contact and close range firing, whole of the discharge containing flame, gases,
powder smoke and metallic particles will be blown under pressure into the track
taken by the bullet through the body, often leaving little evidence that one is dealing
with a contact wound.
2. There is little or no evidence of burning, singeing, blackening and tattooing.
3. Burning, blackening and powder grains deposits will be found in the depths of the
wound.
4. The characteristic features look like that of a distant shot.
 116 Exam Preparatory Manual of Forensic Medicine and Toxicology

46. Intra-cranial hemorrhages (BFUHS, Punjab 2019, 2015) (Uttarakhand University 2015)

Extradural hemorrhage (Delhi University 2017) (BFUHS, Punjab supple 2016)

(Pondicherry 2015)

Sub-arachnoid hemorrhage (Uttarakhand University 2017) (Andhra Pradesh supple

2015)
Ans:
Definition: Intracranial hemorrhages are localized collection of blood in the skull/
brain, usually clotted or partially clotted.
Types: Classified by anatomical location:
1. Extradural
2. Subarachnoid
3. Subdural
4. Intracerebral
• Intracranial hemorrhage is a common complication of head injury, and is the most
common cause of death in patients who experienced a lucid interval.

EDH SDH SAH

Location Between skull and dura Between dura and Between arachnoid and pia
arachnoid
Cause Always due to head Mostly due to injury Both natural and traumatic
injury but not always
Vessel involved Middle meningeal artery Bridging veins Leakage from vessels on
brain surface
Externally Swelling under the scalp No external sign No external sign
Clinical course • Loss of consciousness • Drowsy or comatose • Sudden onset of severe
due to concussion. (may have lucid headache (‘thunderclap
• Dilation of pupil on interval) from the headache’)
the side of hemorrhage moment of injury • Nausea and vomiting
with conjugate • Unilateral headache, • Neck stiffness, photo-
deviation of eyes to hemiparesis phobia, drowsiness or
opposite side • Enlarged pupil on agitation
• Bilateral fixation of pupils the same side
• Lucid interval—due to
compression of
accumulated blood
Situation Unilateral Unilateral or bilateral Focal, diffuse or bilateral
Space occupying Can be space occupying Space occupying Space occupying, if it is
arterial
Effect on brain Brain surface ironed out Brain compressed, Brain surface not distorted
by dura but less ironed out
Confusion with Can be confused with Seldom confused with Can be artifact from
other condition heat artifact other bleeding opening the skull

Refer to long question no. 7 for details on SDH.

 Injury 117

Intracerebral Hematoma
Hemorrhage found within the cerebral parenchyma that is not in contact with the
surface of the brain.
1. Causes: Hypertension, trauma and cerebral amyloid angiopathy
2. Artery involved: Spontaneous hemorrhage in the region of basal ganglia by rupture
of lenticulo-striate artery
3. Site: Well-demarcated homogenous collection of blood seen most frequently in the
white matter of the frontotemporal lobe
4. Clinical features
i. Abrupt onset of focal neurologic deficit.
ii. Diminished level of consciousness.
iii. Signs of increased intracranial pressure, such as vomiting and headache.
iv. Contralateral hemiparesis.

47. All murders are homicides but all homicides are not murder. (West Bengal Supple
2019)
Ans:
Murder as defined under Sec. 300 IPC is killing of a person with malice aforethought.
If the act by which death is caused:
• With the intention of causing death.
• With the intention of causing such bodily injury which is likely to cause death of the
person or sufficient in ordinary course of nature to cause death.
In murder, the mens rea (guilty mind) should be there, i.e. the mental element of a
person’s intention to commit a crime.
Homicide is the killing of a human being as a result of conduct of the other. It may
be lawful or unlawful.
a. Lawful homicide: It can be justifiable by the circumstances that led to killing of
the person (like judicial execution, self-defence, etc) or excusable and caused
unintentionally (like causing death by accident/misadventure or death following
lawful operation).
b. Unlawful homicide: Implies both, the fact of death and an accompanying state of
mind known as ‘malice aforethought’ on the part of the killer (murder).
Hence, all murders are homicides but all homicides are not murder.

48. Explain why, in extremes of age EDH is rare but SDH is common. (West Bengal
University 2017)
Ans:
1. EDH is rare in extremes of age [elderly and young (<2 years)] due to greater
adherence of dura to the skull in both these age groups, and absence of a bony canal
for the artery in the young.
2. Whereas SDH is common in infants (<6 months) and in the elderly (>60 years)
because of delicate nature of blood vessels, large head-to-torso ratio with less
developed neck muscles to hold the head steady and underdeveloped brain (more
 118 Exam Preparatory Manual of Forensic Medicine and Toxicology

room for the brain to move) in former, and cardiovascular changes, on anticoagulants
and decreased brain weight leading to an increase in extracerebral volume in the
latter.

DIFFERENTIATIONS

1. True bruise and artificial bruise (Adesh, Bathinda supple 2020) (KHMS, Tamil Nadu
Supple 2019) (Sher-i-Kashmir, Srinagar supple 2018)
Ans:
True bruise Artificial bruise
1. Caused by Trauma Juice of marking nut, Calotropis
2. Site Anywhere Accessible parts of body
3. Color changes Seen Only dark brown colour
4. Signs of inflammation At site Surrounding the site
5. Margins Irregular Regular and well defined
6. Blisters and itching Absent Present
7. Content Blood Acid serum

2. Incised and incised looking wounds (BFUHS, Punjab Supple 2020) (Uttarakhand
University 2017)
Ans:
Incised wounds Incised looking wounds
1. Produced by Sharp object Blunt object
2. Seen Anywhere on the body Bony prominence (shin, scalp, forehead)
3. Margins Regular and clean cut Regular (to naked eye) but using hand
lens—Irregular margins
4. Tissue bridging Absent Present
5. Underlying bone fracture Absent Present (may be)
6. Foreign bodies Absent Present (may be)
7. Hair bulb Cut Crushed
8. Blood vessels Cut Crushed

3. Incised and lacerated wound (Jammu and Kashmir 2017) (Rajasthan University
2017) (Sher-i-Kashmir supple 2015) (North Eastern Hill University, Shillong 2015)
(GMC, Chandigarh 2016)
Ans:
Incised wounds Lacerated wound
1. Produced by Sharp object Blunt object
2. Site Anywhere Bony prominences
3. Shape Spindle shaped Irregular
4. Margins Smooth and clean cut Irregular
5. Dimensions Length greater than depth, gaping Variable
6. Abrasion/ bruise Absent Present
around the wound
 Injury 119

7. Tissue bridges Absent Present

8. Foreign matter Absent Present
9. Hair bulbs Clean cut Crushed
10. Blood vessels Clean cut Crushed

4. Suicidal and homicidal cut throat injuries (Rajiv Gandhi University, Bengaluru 2020)
(West Bengal University 2019) (KHMS, Tamil Nadu 2018) (Delhi University 2017)
(Andhra Pradesh 2015) (GMC, Chandigarh 2016)
Ans:

Suicidal cut throat Homicidal cut throat

1. Location Left side of neck On the sides of neck
2. Direction • Oblique from left to right, or • Horizontal, or
• Above downwards • Below upwards
3. Level Above thyroid cartilage Below thyroid cartilage
4. Severity of wound • Superficial (multiple) • Deep (multiple)
• Less severe • More severe
5. Carotid artery Not cut Cut
6. Hesitation cuts Present Absent
7. Defense wounds Present Absent
8. Weapon at crime scene Present Absent
9. Suicidal note Present Present
10. Signs of struggle and Absent Present
foreign materials

5. Contusion and postmortem staining (KHMS, Tamil Nadu 2016, supple 2020)
(Adesh, Bathinda 2017) (North Eastern Hill University, Shillong supple 2017) (Delhi
University Supple 2016) (Sardar Patel University, Gujarat 2016) (University of Health
Sciences, Rohtak 2017) (GMC, Chamba 2019)
Ans:

Contusion Postmortem staining

1. Occurs due to Rupture of vessels Distension of blood vessels
2. Site Anywhere On dependant parts
3. Margins Irregular Regular
4. Blanching Absent Present
5. Color changes Present Absent
6. Extravasations Present Absent
7. Effect of pressure No change Blanch when pressure is applied
8. On incision Blood present in surrounding tissues, Blood present in blood vessels, can
cannot be washed by water be washed easily by pouring water
 120 Exam Preparatory Manual of Forensic Medicine and Toxicology

6. Difference between antemortem and postmortem injuries (Uttarakhand 2015)

(Adesh, Bathinda 2018)
Ans:
Antemortem injuries Postmortem injuries
1. Bleeding Profuse Slight/ Absent
2. Source of bleeding Arterial Venous
3. Extravasation of blood Present Absent
4. Signs of spurting Present Absent
5. Coagulation Present Absent
6. Vital reaction Present Absent
7. Chances of Infection Present Absent
8. Infiltration by cells Present Absent
9. Enzyme activity Present Absent

7. Suicidal and homicidal wounds (GMC, Chandigarh 2016)

Ans:
Suicidal wounds Homicidal wounds
1. Wounds Incised/ Stab Incised/Stab/Lacerated
2. Seen on Accessible parts only Anywhere on the body
3. Number of wounds Single Multiple
4. Hesitation cuts Present Absent
5. Severity of wound Superficial, less severe Deep, more severe
6. Multiple deep wounds Absent Present
7. Signs of struggle Absent Present
8. Clothes Not cut Cut
9. Weapon at crime of scene Present Absent
10. Suicide note Present Absent

8. Exogenous and endogenous burns (Adesh, Bathinda 2019)

Ans:
Exogenous burns Endogenous burns
Cause Burns is produced by the flame Burns produced by the steam due to heating
which produced outside the body. of the tissues (for example, by the electric current)
Mechanism Direct transfer of thermal energy Electrical energy is converted to thermal
to body injury within tissues
E.g. Flash burns Joule burns

9. Coup and contrecoup injuries (KHMS, Tamil Nadu 2017)

Ans:
Coup injury Contrecoup injury
1. Site At side of Impact Opposite to side of Impact
2. Severity of Injury Mild Severe
3. Produced due to Direct impact on brain Vacuum and suction force
4. External injury Present Absent
5. Caused when Head is fixed Moving head strikes
6. Most common site Occipital lobe Frontal lobes
 Injury 121

10. Burns from dry heat and moist heat (Sardar Patel University, Gujarat 2017)
Ans:
Dry heat burns Moist heat burns
1. Produced by Flames Steam or hot liquid
2. Site Below upwards Above downwards
3. Clothes Burnt Wet
4. Splashing Absent Present
5. Singeing Present Absent
6. Charring Present Absent
7. Color Black Bleached
8. Vesicles On the edges All over the affected area
9. Scar Thick Thin

11. Antemortem burns and postmortem burns (University of Health Sciences, Rohtak
2019) (Himachal Pradesh 2017) (Delhi University supple 2016) (GMC, Chandigarh
2015)
Ans:
Antemortem burns Postmortem burns
1. Line of redness Present Absent
2. Blisters Contains inflammatory fluid Contains gas bubbles
3. Base of blister Red, swollen Dry, hard and pale
4. Vital reaction Present Absent
5. Sign of healing Present Absent
6. Soot particles in airway Present Absent
7. Infection Present Absent
8. COHb in blood Present Absent

12. Heat Hematoma and EDH/Heat hematoma and Traumatic Hematoma (Adesh,
Bathinda 2018, Supple 2019) (West Bengal University 2018) (GMC, Chamba 2019)
Ans:
Heat hematoma EDH
1. Cause Heat Blunt trauma
2. Vessels ruptured Venous sinuses and diploic veins Middle meningeal artery
3. Position Bilateral Unilateral
4. COHb in blood Present Absent
5. Appearance Honeycomb like, soft, friable Disc-shaped, rubbery
6. Suture lines Hematoma may cross suture lines Do not cross suture line
7. Fracture Egg shell fracture Linear radiating fracture
8. Injury to brain Absent Present
 122 Exam Preparatory Manual of Forensic Medicine and Toxicology

6
Sexual Jurisprudence
and Infanticide
LONG QUESTIONS

1. Classify sexual offense. Define Rape under Section 375 IPC and 376 IPC. (Sher-
i-Kashmir Institute, Srinagar supple 2017)
Ans:
Classification of Sexual Offenses
Natural Unnatural Sexual perversions
R- Rape Bestiality Fetishism, Frotteurism
I-Incest Buccal coitus Sexual Asphyxia
A-Adultery Lesbianism Masochism, Masturbation
Sodomy Others like:
Urophilia
Sadism
Exhibitionism
Transvestic fetishism
Voyeurism
RIA BCLS FAMOUS EXHIBITION on TV

Definition of rape as per Section 375 IPC:

A man is said to commit rape, if there is:
a. Penetration of penis into vagina, anus, urethra or mouth
b. Insert any object or body part (not being his penis) into mouth, vagina, urethra or anus
c. Applies mouth to vagina, urethra or anus
d. Manipulates any part of victim’s body for penetration into vagina, anus or urethra.
If any of the above act is done:
1. Against her will
2. Without her consent
3. With her consent, if consent is obtained by
• Fear of death or hurt
• Impersonation or fraud
• Insanity or intoxication
4. With or without consent when she is <18 years of age: Statutory rape
5. When she is unable to communicate her consent.
Exception: Any medical intervention shall not constitute rape

122
 Sexual Jurisprudence and Infanticide 123

Punishment of rape is as per Section 376 IPC:

376(1) Rape committed on a girl ≥18 yrs 10 yrs to LI + Fine
376(2) Rape under special circumstances 10 yrs to LI + Fine
1. Custodial rape
2. Rape of pregnant female
3. Rape during communal violence
4. Rape by armed forces
5. Rape on same female repeatedly
376(3) Rape of a girl <16 yrs. ≥20 yrs to LI + Fine
376 A Rape causes persistent vegetative state/ death of the victim ≥20 yrs to LI/death
376AB Rape of a girl <12 yrs. ≥20 yrs to LI + fine/death
376 B Sexual intercourse by husband with his wife during separation 2 yrs to 7 yrs
B = Bride/Biwi
376 C Sexual intercourse by person in authority not amounting to rape 5 yrs to 10 yrs
376 D Gang rape ≥20 yrs to LI + Fine
DA Gang rape of woman <16 yrs LI + Fine
DB Gang rape of woman <12 yrs LI + Fine/death
D= Delhi = Gang rape
376 E Repeat offender LI to death
E = Eat – Repeat
*LI –Life imprisonment

2. Define Rape. How will you proceed for examination of a case of a 14-year-old
girl survivor of sexual offence? Enumerate various evidences to be preserved
in such case. (North Eastern Hill University, Shillong 2017, 2016, supple 2020)
(BFUHS, Punjab 2017, supple 2016) (Sher-i-Kashmir Institute, Srinagar 2015) (Sai
Tirupati University, Rajasthan, 2018, 2019)
Ans: Definition of rape: Refer to long question no. 1.
Examination of Rape Survivor
1. General particulars
• Preliminary particulars: Name, height, weight, brought by, marital status, two
identification marks.
• Informed consent
Age of girl Consent form is signed by
<12 yrs. of age Guardian/parents
≥12 yrs. of age Survivor

• Victim is preferably examined by or under supervision of female doctor.

• Examination is carried out with minimum delay.
2. History
a. Medical and surgical history
b. Sexual history—any history of sexual intercourse, if yes, then date of last
consensual sexual intercourse
c. Menstrual history
d. Obstetric history
e. Physical violence
 124 Exam Preparatory Manual of Forensic Medicine and Toxicology

Specific history about the incident:

• Date, time and place of commencement of act
• Any physical violence
• Details of events—bathing, cleaning, changing clothes, etc.
Examination of victim of rape–under Section 164-A CrPC
Physical examination Local examination
1. General Done in lithotomy position
• Stature • High vaginal swab
• Weight • Low vaginal swab
• Nutritional status • Cervical swab
• Gait • Swabs from introitus and perineum
• Behavior of survivor • Matted pubic hair
2. Clothes of victim Genital Examination
• Should stand over a clean sheet of paper 1. Vulva—assessed for tears, swelling, abrasions, or
and then remove all her clothes herself, discharge
in front of doctor 2. Hymen
• Look for the tears/loss of portion of • Tears at postero-lateral position (most
clothes, torn buttons, foreign hair common), edema
• Examined for stains, soiled areas • An intact hymen does not rule out sexual
• After drying in shade, clothes are packed violence
in paper bag and sent for chemical 3. Vagina
examination • Bruises seen on anterior vaginal wall (lower
1/3) and posterior wall (upper 1/3)
• Look for vaginal discharge
4. Cervix—presence of abrasions (away from external os)
3. Extra-genital injuries Local injuries
 Sexual Jurisprudence and Infanticide 125

Evidences to be preserved
Samples preserved Remarks
Clothes Worn at time of alleged incident to detect blood/ semen
Swabs 1. Soiled areas
2. Anal swab
3. Buccal swab
Hair 1. Loose hairs on the body
2. For comparison—pubic hair
3. Matted pubic hair
Fingernail clippings Tissue sample, blood of the accused
Blood 1. ABO blood grouping
2. Alcohol/drugs
3. HIV/Hepatitis B
Scrapping 1. Dried blood stain
2. Dried seminal stain
Saliva Secretor grouping

3. Define Rape as per S.375 IPC. What is the role of informed consent in
examination of such cases? (BFUHS, Punjab 2019)
Ans: Definition of rape: Refer to long question no. 1.
Informed consent should be obtained before the examination, collection of
specimens, release of information to authorities and taking of photographs.
1. In emergency conditions, the doctor may start the treatment without consent
(Sec. 92 IPC).
2. Informed consent: The survivor is informed about the nature and purpose of
examination:

a. Examination may involve an examination of the mouth, breasts, vagina, anus and rectum.
b. Evidence may be collected like clothing, hair, foreign substances from the body, saliva, samples from the
vagina, anus, rectum, mouth and blood sample.
c. She may refuse examination or collection of evidence or both, but that refusal will not be used to deny
treatment. The refusal should be documented.
d. She has a right for partial examination—whether she wants a physical examination and/or genital
examination, and allow collection of bodily evidence.
e. The doctor is bound to inform the police. However, if she does not wish to, she has the right to refuse to
file FIR and it would not result in denial of medical examination and treatment. At the time of intimation
being sent, a note stating ‘informed refusal for police intimation’ should be made.
f. Any evidence obtained may be used in court, and that she will then be exposed to publicity and cross-
examination.

3. The consent form should be signed by:

Age of girl Consent form is signed by
<12 yrs of age Guardian/parents
≥12 yrs of age Survivor

4. The form should be signed by the survivor, a witness and the examining doctor.
 126 Exam Preparatory Manual of Forensic Medicine and Toxicology

4. Define Rape. What are the precautions to be taken while examining a victim of
rape? (Adesh, Bathinda 2018)
Ans: Definition of rape: Refer to long question no. 1.

Precautions to be taken while Examining A Victim of Rape

1. The doctor should not refuse to examine a rape survivor on the ground that she
was not brought by the police or she came on her own.
2. Even if the rape occurred outside the jurisdiction of the hospital, the survivor must
first be examined and treated, before referring her to the hospital in the appropriate
area.
3. The examination should be conducted without delay (priority case) by a government
doctor or any other doctor with the consent of the patient or guardian, and she
should be sent to a doctor by the police within 24 hrs from the time of receiving the
information relating to the commission of such offence.
4. Senior medical faculty instead of junior doctors should examine the patient.
5. If possible, the survivor is examined by or under the supervision of a female doctor.
If a board of doctors is examining her, at least one doctor must be a female.
Otherwise, a female nurse/attendant should be there, if she is examined by a male
doctor. If the survivor requests, her relative may be present while the examination
is done.
6. Privacy and confidentiality should be maintained.
7. The patient should be informed about the nature and purpose of examination. The
doctor should prepare a detailed report and describe the material taken from the
person of the woman for DNA profiling.
8. Even if there is informed refusal for medico-legal examination, medical treatment
should not be denied.
9. In case of refusal for police intimation, the doctor is duty bound to inform the
police.
10. Per-vagina examination, commonly referred to as ‘two-finger test’, must not be
conducted for establishing rape/sexual violence.
11. A small child survivor must never be held down during examination of the genital
area, this is equivalent to sexually assaulting the child.

5. Define infanticide. Write in detail about battered baby syndrome. (Sher-i-

Kashmir Institute, Srinagar supple 2019)
Ans: Definition: It is killing of an infant at any time from birth up to the age of
12 months.
• It is punishable under Sec. 302 IPC.

Battered Baby Syndrome

• It is also known as Caffey-Kempe syndrome,
• A battered child is one who has received repetitive physical injuries as a result of
non-accidental violence produced by a parent or a guardian.
 Sexual Jurisprudence and Infanticide 127

Features related to:

Child Parent/Guardian
1. Age <3 yrs. 1. Unmarried couple
2. Males > females 2. Young age
3. Illegitimate/unwanted child 3. Low education status
4. Themselves were victims of battering during childhood

Clinical Features

Soft tissue injuries CNS injuries Skeletal injuries (on X-ray) Others
a. Abrasions Triad of injuries
b. Bruise 1. SDH (most common) 1. Long bones 1. Burns-small pitted
c. Slap marks 2. Encephalopathy • Corner’s fracture burns indicate deli-
d. Skin pinch marks 3. Retinal hemorrhage • Bucket handle fracture berate stubbing of
e. Black eye Violent shaking of • Fractures at different cigarette ends on skin
f. Laceration-Torn child leads to intra- stages of healing 2. Scalds
upper lip frenulum cranial hemorrhage 2. Skull 3. Visceral injuries
called shaken baby • Egg shell fracture
syndrome (SBS) • Fissure fracture
3. Ribs
• Knob fractures
Fractured ribs heal by callus
formation leading to a knob
and on X-ray give ‘string
of beads’ appearance in
paravertebral gutter.

Conclusive diagnosis
1. Injuries in different stages of healing
2. Discrepancy between history and findings
3. Delay in seeking advice
MLI: Any suspected child abuse case should be reported to the police.
 128 Exam Preparatory Manual of Forensic Medicine and Toxicology

6. Define infanticide. Describe in brief various acts of omission and commission

in relation to infanticide. (North Eastern hill university, Supple, 2019)
Ans: Definition of infanticide: Refer to long question no. 5.
Acts of commission Acts of omission
These are the acts done positively to cause Intentional failure on part of the mother in providing
death of an infant. the essential care to the newborn that results in death
of the infant.
1. Burning—newborn is burnt alive 1. Not providing proper assistance during labor
2. Smothering to death with use of hand 2. Not tying the cord, after it is being cut
or clothes 3. Not providing food to the child
3. Strangulation—by ligature /umbilical cord 4. Not providing adequate clothes resulting in fetal
4. Concealed punctured wound—caused by hypothermia
nail/needle through fontanelle
5. Poisoning—insecticides are commonly used
as poison
6. Head injury—banging the head of the child
against the wall leading to SDH/EDH
7. Drowning—throwing baby in water
(Mnemonic–BSC PHD)

7. Define infanticide. Discuss signs of live birth. (Sher-i- Kashmir Institute, Srinagar 2015)

Define infanticide. Discuss in detail the postmortem findings of a liveborn

infant. (Delhi University, 2018)

What is infanticide? Write in brief about the signs of live birth. (North Eastern
Hill University Supple 2016) (VNS, Gujarat 2016)
Ans: Definition of infanticide: Refer to long question no. 5.
External changes
1. Changes in skin
• Absence of vernix caseosa
• Skin color changes from bright red to brick-red to yellow and finally normal by 1st week
2. Changes in umbilical cord

Changes Time since birth

Shrunken cord Day-1
Inflammatory line at base of stump Day-2
Mummified changes Day-3
Cord falls Day-5
Scar Day-10
(Mnemonic—SIMFallS)
3. Presence of caput succedaneum and cephalohematoma

Internal findings (from head to toe)

1. Closure of posterior fontanelle at birth
2. Changes in middle ear (Wredin’s test)
 Sexual Jurisprudence and Infanticide 129

• Before birth—presence of gelatin in middle ear

• When baby respires—presence of air in middle ear
3. Closure of fetal channels (umbilical vessels, ductus arteriosus and ductus venosus)
4. Changes in chest
• Color—red/pink, mottled appearance
• Consistency—soft, spongy, elastic
• Level of diaphragm—6–7th rib
• Fodre’s test
– Weight of lungs increases due to increase in vascularity
– Weight of respired lungs (both)—60 g
• Ploucquet’s test
Weight of lungs
Ploucquet test=
Weight of body
Respired lungs = 1:35 (as weight of lungs increases with vascularity)
• Positive hydrostatic test
– Based on the principle of specific gravity
– Specific gravity of respired lungs–0.94
– So lungs float on water
5. Changes in stomach
• Presence of milk in the stomach
• Breslau’s second life test: Stomach and intestines are cut together and placed in a bowl of water
– If floats—baby respired (as when baby respires, air is also swallowed into stomach)
– If sinks—baby not respired
6. Absence of meconium in large intestine

8. What are the positive signs of pregnancy? Discuss the signs of recent delivery.
(North Eastern Hill University, Shillong 2019) (Adesh, Bathinda supple 2017)
Ans: Positive (conclusive) signs of pregnancy are:
1. Fetal heart sounds 1. Most definitive signs of pregnancy
2. Can be heard between 18 and 20th week with a stethoscope
3. FHR—160 beats/min at 5th month and 120–160 beats/min at 9th month
4. Not audible in—fetus <18 weeks, dead fetus, obese females
2. Fetal movements and parts Can be felt by 20–22nd week on abdominal palpation.
3. Fetal RBCs in maternal blood Can be detected by 5th week of pregnancy
(KB test)
4. USG 1. 5th week: TVS can detect cardiac activity
2. 6th week: Gestational sac can be seen
3. 11th–13th week: Sex of baby can be determined
5. X-ray 1. Vertebrae: Series of small dots in a linear arrangement
2. Skull: Crescentic or annular shadows

Signs of recent delivery in living are:

General changes 1. Exhausted
2. Mild fever with tachycardia
Breast 1. Full and prominent
2. Colostrum expressed
 130 Exam Preparatory Manual of Forensic Medicine and Toxicology

3. Montgomery tubercles
4. Dark, pigmented areola and nipples enlarged
Abdomen 1. Flabby with wrinkled skin
2. Stria gravidarum
3. Linea nigra
External genitalia 1. Fourchette ruptured
2. Labia majora and minora—tender, bruised, swollen
Vagina Roomy, loss of rugosity, episiotomy wound
Cervix Soft, dilated
Uterus Involution of uterus
Lochia 1. Lochia rubra (1–4th day)
2. Lochia serosa (5–9th day)
3. Lochia alba (11–15th day)

9. Enumerate and explain findings in a victim of alleged sexual offence of sodomy

(Adesh, Bathinda 2017) (JIPMER supple 2018) (VNS, Gujarat 2016, 2018)
Ans: Sodomy is the anal intercourse between two males (homosexual sodomy) or
between a male and a female (heterosexual sodomy).
Findings seen in victim of sodomy are
Non-habitual passive victim Habitual passive agent
Examination is done in left lateral decubitus position Examination done in knee chest position
1. Pain and tenderness during digital rectal 1. No pain and tenderness during DRE
examination (DRE) 2. No inflammation around anus
2. Substances found in/around anus—fecal matter, 3. Shaving of anal hair may be present
lubricants, semen, loose foreign hair 4. Lateral traction test—external anal sphincter
3. Inflammation around anus relaxes reflexly during bimanual traction of
4. Bleeding due to laceration buttocks
5. Loss of normal anal tone 5. Loose foreign hair and lubricants
6. Injuries 6. Perianal skin—thickened, keratinized due to
• Perianal abrasions—due to frictional shearing constant regular friction
force by penetrating penis 7. Anal sphincter—lax and patulous and dilated anal
• Bruises—may be mistaken for hemorrhoids canal with old, healed fissures
• Laceration 8. Anal opening—deeply situated giving funnel–
• Anal fissures—wedge shaped, present in shaped depression of buttocks
posterior quadrant and radially towards 9. Evidence of venereal disease
the anal canal
7. Swabs taken from inside and outside anus for
microscopic examination

10. Define artificial insemination. What are the types? What are the medico-legal
problems of AID and precautions must be followed by a doctor. (North Eastern
Hill University, Shillong 2017) (Sardar Patel University, Gujarat 2019) (JIPMER supple
2018)
 Sexual Jurisprudence and Infanticide 131

Definition of artificial insemination: It is the artificial introduction of semen of

husband or donor into the reproductive tract of female so as to bring about pregnancy
which is not attained by sexual intercourse.

Types of artificial insemination (AI)

1. AIH (artificial insemination homologous)
2. AID (artificial insemination donor)
Refer to difference no. 4 for AIH and AID.

Precautions to be followed by doctor

1. Donor should be of age less than 40 years and should have completed his family.
2. Donor should be healthy and not suffering from any hereditary disease.
3. Donor’s identity should not be revealed.
4. Consent of wife, husband, donor and donor’s wife should be taken.
5. Donor must not be related to woman or husband.
6. Donor should not know the recipient and the outcome of the technique.
7. Delivery should not be done by the physician who has performed artificial
insemination.
8. Donor should have same blood group and there should be no Rh incompatibility.

Medico-legal Problems
1. Legitimacy: A child born through AID shall be presumed to be legitimate, born
within wedlock, with consent of both the spouses.
2. Adultery: AID used for married woman with the consent of the husband does not
amount to adultery on part of the wife or the donor.
3. Litigation: The doctor may be sued following the birth of a defective child.
4. Nullity of marriage and divorce: It is not a ground for divorce, if AI is done for
sterility. If AI is due to impotency, it is a ground for nullity in favor of the wife due
to non-consummation of marriage.
5. Psychosocial aspect: Problems may arise if it is known that the husband consented
to AID and the husband was not capable of consummating the marriage.
6. Incest: There may be chance of incest among offspring born by AI and children of
donor.

11. Define abortion. Write medical and legal classification of abortion. Write in brief
about MTP Act, 1971. (University of Health Sciences, Rohtak 2019, Supple 2020)
(AIIMS Patna 2018, 2016) (North Eastern Hill University, Shillong supple 2018) (Sardar
Patel University, Gujarat 2017)
Ans:
• Legal definition: Expulsion of products of conception any time before full term is
called abortion.
• Medical definition: Expulsion of products of conception before the period of
viability.
 132 Exam Preparatory Manual of Forensic Medicine and Toxicology

Medical and Legal Classification of Abortion

MTP ACT, 1971

Clauses of MTP
1. Indications of termination of pregnancy
Therapeutic When continuation of pregnancy is a risk to the life of a pregnant female (risk can be in
terms of physical/mental risk to health of female), e.g. toxemia, epilepsy, cervical or
breast cancer, etc.
Eugenic When it is known that child born would be suffering from severe physical or mental
abnormalities, e.g. anencephaly, Down’s syndrome, TORCH infections, chickenpox
Humanitarian Pregnancy occurred due to rape
Social Pregnancy occurred due to failure of contraceptive methods

2. Where can it be done?

Hospitals established/maintained by the Government
Place approved by government/district level committee with CMO/DHO
3. Who can perform it?
Conducting MTP up to <12 weeks Conducting MTP up to 20 weeks
Doctor who has assisted in 25 MTP cases, Any doctor with
out of which at least 5 MTPs should be • Diploma/degree in Obs-Gynae
performed independently • 6 months of house job in Obs-Gynae
• 1 year of experience in Obs-Gynae department

In case of emergency, to save life of a female, even an MBBS doctor can also perform
MTP.
Duration of pregnancy
a. Up to 12 weeks of pregnancy: Opinion of one doctor is required
b. Between 12 and 20 weeks: Opinion of two doctors is required
c. More than 20 weeks of pregnancy: Pregnancy cannot be terminated as per MTP
Act, except in case of emergency when continuation of pregnancy is a risk to life of
the mother.
Consent for termination of pregnancy
• Informed consent is taken from females ≥18 yrs. of age.
• In case female <18 yrs. or mentally ill—consent given by parents/guardian
• Consent of husband is not necessary
 Sexual Jurisprudence and Infanticide 133

12. Define liveborn, stillborn and deadborn. How will you differentiate stillborn and
liveborn infant? (AIIMS, Patna 2015)
Ans: Definition
1. Liveborn: The child which is born after period of viability (i.e. after 28 weeks) and
shows signs of life after birth.
2. Stillborn: The child which is born after period of viability (i.e. after 28 weeks) but
does not show any signs of life after birth.
3. Deadborn: The child which is found to be already dead in the uterus before beginning
of the birth process and shows signs of intrauterine death.
Difference: Refer to difference no. 1.

13. Define infanticide and methods usually adopted for carrying out infanticide.
Add a note on macerated fetus. (Rajiv Gandhi University, Bengaluru 2017)
Definition of infanticide: Refer to long question no. 5.
Methods for carrying out infanticide: Refer to long question no. 6.
Macerated fetus: Refer to short question no. 40.

SHORT NOTES

1. Causes of impotency in males (Adesh, Bathinda supple 2020) (KHMS, Tamil Nadu
2017)
Ans: Causes of impotency in males are:
Medications • SSRIs
• Antipsychotic
Injuries • Fractures—spinal cord, pelvis, penis
Psychological • Fear, anxiety, absence of desire
• Dislike of partner and disgust of act
• Quoad hoc—a person is impotent with a particular woman (wife) but not
with others
Age • Boy is sterile before puberty but not impotent
• ED is usually observed in old age
Poisoning • Chronic lead poisoning
• Arsenic poisoning
Anomalies (congenital • Penis—absent penis, hypospadias, epispadias
and developmental) • Testis—absent, cryptorchidism
Operation • Vasectomy
• Removal of testis
• Amputation of penis
Nutritional deficiencies • Vit C
• Zinc
• Malnutrition
Systemic diseases • Neurological disorders—tabes dorsalis, multiple sclerosis·
Endocrine causes—diabetes, hypothyroidism
Addiction • Alcohol
 134 Exam Preparatory Manual of Forensic Medicine and Toxicology

• Barbiturates
• Opium
Local diseases • Penis—Phimosis, paraphimosis, peyronie disease
• Testis-orchitis, elephantiasis
Exposure to X-rays • Leads to azoospermia
(Mnemonic—MI PAPA ON SALE)

2. Medico-legal Aspects of Impotency (GMC, Chandigarh 2015)

Ans: a. Impotence and sterility cases arises in:
Civil cases 1. Nullity of marriage
2. Disputed paternity and legitimacy
3. Claims for damages resulting in impotency
4. Adoption
Criminal cases 1. Rape
2. Adultery
3. Sodomy
4. Bestiality

b. Marriage versus impotence and sterility:

Marriage is not considered null and void nor 1. If impotence develops after marriage
divorce can be obtained 2. If sterility is present at the time of marriage
3. If sterility develops after marriage
Marriage will be considered null and void 1. Impotence at time of marriage.
2. Permanent impotency is a ground for nullity
of marriage but sterility is not.

3. Examination of a person alleging Impotence (Adesh, Bathinda 2019)

Ans: Examination of a person alleging impotence is done as per the protocol:
Prerequisite 1. Obtain the order of Court/Police.
2. Identification and obtain consent: Informed consent of accused should be obtained.
History 1. History of present illness (including sexual history, Surgical history, Psychological
history, e.g. anxiety, depression)
2. Medical history, e.g., smoking, obesity, diabetes, nocturnal tumescence, peripheral
neuropathy and medication
3. History of previous illness
Examination 1. General physical examination: Pulse, BP, secondary sexual characteristics.
2. Systemic examination: CNS, CVS, respiratory and abdominal.
3. Local examination of penis and testis: Look for deformity in penis such as phimosis,
fibrous plaques, etc. or size of testis, hydrocoele, absence of testis
Bulbocavernosus reflex test: Done to detect nerve sensation in the penis. The doctor
squeezes the glans of the penis which immediately causes the anus to contract if
nerve function is intact.
Lab investigations 1. Blood levels of HbA1c, lipids, thyroid, FSH and testosterone.
2. Examination of semen
3. Nocturnal penile tumescence test: Useful in differentiating psychogenic causes
from organic causes.
 Sexual Jurisprudence and Infanticide 135

4. Duplex USG: To check the atherosclerosis or calcification inside the penile

vasculature.
5. Other tests: Penile biothesiometry, cavernosography.

4. Surrogate motherhood and medico-legal aspects (Rajiv Gandhi University,

Bengaluru 2019) (Adesh, Bathinda 2017)
Ans: Definition of surrogate mother: A woman, supported by a legal agreement,
carries a child for a couple or single person with the intention of giving that child up,
once it is born.
Methods
1. Artificial insemination—here AI of husband’s sperm to the surrogate. So, husband
will be the biological father and surrogate will be biological mother.
2. Implantation of Embryo by IVF—here both husband and wife become biological
parents as embryo is produced by IVF of father’s sperm and wife’s ovum, the
surrogate will act as nonbiological mother.

Medico-legal Aspects
a. Surrogate may be emotionally disturbed on separating from the child
b. In India, surrogate is not considered as legal mother. So, after birth of the child, the
child is returned to its biological father and his wife
c. Paternity of child is proved by the biological father who engaged the surrogate
d. Couple can refuse to adopt the child as the surrogate is biological mother
e. Expenses for diet, medicines are given to surrogate during the entire period of
pregnancy.

5. Virginity (Rajiv Gandhi University, Bengaluru 2020) (Uttarakhand University 2017,

supple 2018) (KHMS, Tamil Nadu 2016) (VNS, Gujarat 2016)
Ans: Definition
1. Virgin: The female who has never experienced sexual intercourse.
2. Virginity: The state of being virgin is called virginity.

Signs of True Virginity

Extra-genital signs
1. Breasts—small, hemispherical, firm
2. Areola—pink
3. Nipples—small, pink
Genital signs
1. Hymen—intact, rigid, inelastic, admits only tip of little finger through the orifice painfully
2. Vagina—narrow, slit like opening, marked rugosity of walls
3. Fourchette—intact
4. Clitoris—small
5. Labia majora—thick, fleshy, completely close the vaginal orifice
6. Labia minora—small, pinkish and covered by labia majora
 136 Exam Preparatory Manual of Forensic Medicine and Toxicology

Types of Hymen
Annular Opening is centrally located
Semilunar or crescentic Opening is placed anteriorly. Most common type
Vertical Opening is vertical
Infantile Small linear opening in the middle.
Septate Two openings occur side by side, separated by thin strip of tissue.
Cribriform Multiple openings
Imperforate No opening

MLI
1. The features of a deflorate woman and a false virgin are same except for the presence
of hymen in the latter.
2. Hymen is completely lost after the birth of the child.
3. State of hymen is not a conclusive state of virginity.

6. False virgin (Rajiv Gandhi University, Bengaluru 2015) (KHMS, Tamil Nadu 2019) (VNS,
Gujarat 2019)
Ans: Definition of false virgin: When even after sexual intercourse, if the hymen
remains intact, the female is called as false virgin.
Hymen may not be ruptured due to:
1. Thick hymen
2. Loose hymen
3. Elastic hymen
The features of a deflorate woman and a false virgin are same except for the presence
of hymen in the latter. For rest, refer to difference no. 3.
 Sexual Jurisprudence and Infanticide 137

7. Hymen and its medico-legal significance (Rajiv Gandhi University, Shillong 2019)
(University of Health Sciences, Rohtak 2017) (Uttarakhand University 2015)

Types of Hymen (AIIMS Patna 2016) (VNS, Gujarat supple 2019)

Ans: Refer to short question no. 5.

8. Precipitate labor (Rajiv Gandhi University, Bengaluru 2015) (Adesh, Bathinda supple
2018) (North Eastern Hill University, Shillong 2018, Supple 2018) (Rajiv Gandhi
University, Bengaluru 2015) (VNS, Gujarat University 2019, supple 2019)
Ans: Definition of precipitate labor: It is the sudden and rapid expulsion of the fetus
due to hyperactive uterine contractions.
1. A labor is called precipitate, when first and second stage of labor has < 2 hours of
duration.
2. It is common in multipara.
3. Typical history: Mother goes to the washroom for defecation and sits on lavatory
pan in an attempt to defecate and due to precipitate labor leads to the birth of the
child.
4. PM findings
a. Placenta is attached to the fetus
b. Premature fetus
c. Death of the fetus due to head injury (when baby hits the floor at time of delivery)
d. Torn/lacerated umbilical cord (more commonly on fetal side) leading to death of
fetus due to bleeding.
5. MLI
a. Death of the newborn due to precipitate labor may be taken as a case of deliberate
infanticide.
b. The mother may claim infanticide (negligence on part of the doctor), but death of
the newborn is due to precipitate labor.

9. Medico-legal Importance of Sterilization (West Bengal University 2018)

Ans: Medico-legal importance of sterilization
1. Doctor may be charged, if he performs sterilization without proper consent and
proper indication.
2. It is desirable to sterilize only individuals above 30 years of age and having two
children, one of whom is male.
3. Healthy unmarried or married persons without any issue should not be permanently
sterilized, even if they volunteer for the same.
4. Failure of contraceptive measure adopted by males may lead to suspicion of wife
having sexual relationship with another man who may initiate litigation—divorce,
illegitimacy or disputed paternity.
5. There is no absolute guarantee to sterility after the operation, and the procedure
may prove irreversible.
6. There may be failure in tubal sterilization—failure due to fistula formation or due
to spontaneous reanastomosis.
 138 Exam Preparatory Manual of Forensic Medicine and Toxicology

10. Lochia. (Adesh, Bathinda 2017) (Rajiv Gandhi University, Bengaluru 2015) (Delhi
University 2018) (VNS Gujarat, 2018)
Ans: Features of lochia are:
1. It is an alkaline discharge from female genital tract for 2–3 weeks after delivery,
with peculiar, disagreeable fishy odor.
2. It is a sign of recent delivery.
3. Types
Lochia Rubra Lochia Serosa Lochia Alba
(1–4) days (5-9 days) (10–15) days
Bright red in color Watery, pale in color Grey-yellowish followed by
whitish color
Consists of Consists of Consists of
• RBCs • WBCs >RBCs • WBCs
• Shreds of fetal membranes • Cervical mucus • Mucus
and decidua • Microorganisms • Cholesterol crystals
• Vernix caseosa • Fatty epithelial cells
• Lanugo hair • Microorganisms

11. Complications of Criminal Abortion. (Rajiv Gandhi University, Bengaluru 2020, 2015)
(Sher-i-Kashmir, Srinagar supple 2018) (Pondicherry 2017) (Delhi University 2017)
Ans: Complications of criminal abortion are:
Immediate complications 1. Vagal inhibition
2. Hemorrhagic shock
3. Fat embolism
4. Air embolism
5. Amniotic fluid embolism
Delayed complications 1. Peritonitis
2. Septicemia
3. Toxemia
4. Salpingitis
5. Tetanus
Late complications 1. Pulmonary embolism
2. Endocarditis
3. Jaundice
4. Renal failure
5. Hepatic failure

12. Presumptive signs of pregnancy. (KHMS, Tamil Nadu 2016) (BFUHS, Punjab Supple
2016) (GMC, Chandigarh 2015)
Ans: Presumptive signs of pregnancy are:
Amenorrhea • Earliest and most important symptom of pregnancy
Morning sickness • Presence of nausea and vomiting
• Starts by 1st month and ends by 3rd month of pregnancy
Breast changes • Mainly seen in primigravidae
 Sexual Jurisprudence and Infanticide 139

• Increase in size, tenderness of breast

• Dark areola, presence of montgomery tubercles
Hyperpigmentation • Cholasma (pigmentation over head and cheeks)
• Linea nigra
• Striae gravidarum (pregnancy stretch marks on abdomen)
Fatigue • Easy fatiguibility
Quickening • Pregnant women feel fetal movements in her abdomen
Sympathetic disturbances • Increased salivation, irritability and increased appetite
Urinary disturbances • Increased frequency and micturition
Changes in vagina (Chadwick’s sign) • Bluish discolouration of vaginal mucous membrane
• Seen after 4th week of pregnancy

13. Positive/Confirmatory signs of pregnancy. (Rajiv Gandhi University, Bengaluru 2020,

2015) (University of Health Sciences, Rohtak 2019, Supple 2020) (SGRD, Amritsar
2019) (KHMS, Tamil Nadu 2015, Supple 2019) (Sardar Patel University, Gujarat Supple
2018, Supple 2016) (BFUHS, Punjab 2017) (Rajasthan University 2015)
Ans: Refer to long question no. 8.

14. Artificial Insemination. (Adesh, Bathinda 2019) (BFUHS, Punjab supple 2018) (North
Eastern Hill University, Shillong Supple 2018)

Ethical and legal issues in relation to Artificial Insemination (Uttarakhand University

supple 2018, supple 2017) (Pondicherry 2016)
Ans: Refer to long question no. 10.

15. MTP ACT (KHMS, Tamil Nadu 2017) (BFUHS, Punjab 2016) (Adesh, Bathinda supple
2017) (Rajasthan University 2018, 2017) (North Eastern Hill University 2018)
(Uttarakhand University 2017, 2015) (VNS Gujarat, supple 2018)

Indications for termination of pregnancy as per MTP ACT, 1971 (Sardar Patel
University, Gujarat 2020, 2019, 2018, supple 2018)
Ans: Refer to long question no. 11.

16. Section 377 IPC. (West Bengal University Supple 2019)

1. Sec. 377 IPC defines punishment for unnatural sexual offence.
2. It includes offences like sodomy, lesbianism, bestiality, buccal coitus.
3. It states that ‘if an individual voluntarily has sexual intercourse against the order of
nature with any man, woman or animal, he is punishable with imprisonment for
life or with imprisonment up to 10 years and fine.’
4. Penetration is sufficient to constitute offence under this section.
5. Consensual anal sex between two consenting adults is not punishable under this section.

17. Sodomy/Buggery. (KHMS, Tamil Nadu supple 2020) (North Eastern Hill University,
Shillong 2018, Supple 2017) (AIIMS Patna 2016) (Uttarakhand University 2016)
(Pondicherry 2015) (Rajiv Gandhi University, Shillong 2015) (VNS Gujarat, 2016)
Ans: Refer to long question no. 9.
 140 Exam Preparatory Manual of Forensic Medicine and Toxicology

18. Local findings expected during examination of habitual active and passive
agents involved in sodomy. (Sardar Patel University, Gujarat Supple 2016) (VNS
Gujarat, 2018)
Ans: Refer to long question no. 9.

19. Sadism. (Delhi University 2015) (VNS Gujarat, supple 2019)

Ans:
1. Definition of sadism: Person gets sexual gratification by infliction of pain or physical
cruelty on the partner in form of beating, biting, cigarette burns or humiliation.
2. It is also called Algolagnia.
3. More common in males.
4. It is usually found in association with Masochism, and the combination of Sadism
and Masochism is called as Bondage/ sadomasochism.
5. MLI
a. Sadomasochism can lead to Autoerotic Asphyxia.
b. In extreme case, it can give rise to Lust murder.

20. Voyeurism. (North Eastern Hill University, Shillong Supple 2019) (Rajiv Gandhi
University, Bengaluru 2015)
Ans.
1. Definition of voyeurism: It is a sexual perversion in which person gets sexual
gratification by watching other person undressing, bathing or doing sexual
intercourse.
2. It is also called Peeping Tom/Scotophilia.
3. It is commonly seen in males.
4. Some voyeurs even prefer to observe their own wives being seduced by other men.
5. MLI: It is punishable under Section 354-C IPC.

For 1st time offence Imprisonment from 1–3 years and fine
For 2nd offence/ more Imprisonment is for 3–7 years and fine

21. Fetishism. (Uttarakhand University 2017)

Ans:
Features of fetishism are:
1. It is a type of sexual perversion in person achieves sexual gratification by using
inanimate objects.
2. There is recurrent intense sexual urges and sexually arousing fantasies involving
specific objects.
3. Fetish objects: Handkerchief, dress, particularly the undergarments—panties, bras,
slips, stockings.
4. The object of interest is called Fetish and the person is called Fetishist.
 Sexual Jurisprudence and Infanticide 141

22. Transvestism. (Adesh, Bathinda 2018, supple 2017)

Ans. Features of transvestism are:
1. It is also called Eonism.
2. The person achieves sexual gratification by wearing the dress of opposite sex (cross
dress)
3. It is usually seen in males. So, he collects items like nightgowns, slips, bras, lingerie,
stockings.
4. Types:
Fetishist transvestism Dual role transvestism
Person achieves sexual gratification with There is no role of sexual arousal
inanimate objects Rather person wants to experience opposite sex
temporarily

23. Munchausen syndrome by proxy (Rajiv Gandhi University, Bengaluru 2015)

Ans: Features of Munchausen Syndrome by Proxy are:
1. It is a type of child abuse involving parent or guardian (usually mothers).
2. Children are brought to doctors by parents with fictitious history.
3. Ways of producing symptoms
i. Mother may prick her finger, and add her blood to the urine sample of child and
take the sample to the doctor.
ii. She may give insulin injection to child. And take him to doctor with hypoglycemia.
iii. Use of laxatives and emetics to produce diarrhoea or vomiting.
4. Diagnosis
a. Parent’s denial of knowledge of cause of symptoms.
b. The child becomes ill or worsens when the parent or guardian is present, while
recovery when separated.
c. Signs and symptoms are not proved by laboratory/radiological investigations.

24. Superfecundation (Adesh, Bathinda 2018) (Rajiv Gandhi University, Bengaluru 2015)
Ans: Features of Superfecundation are:
1. Definition: It is the fertilisation of two ova in the same menstrual cycle by 2 separate
acts of coitus committed at short intervals.
2. Types
Homoparental superfecundation Heteroparental superfecundation
When both the ova are fertilised by the SAME person When result of fertilisation of ova is by
DIFFERENT persons
3. MLI: Babies may born with different complexion and features giving rise to adultery.

25. Adultery (Rajiv Gandhi University, Bengaluru 2018)

Ans: Adultery
1. Definition: It is a sexual intercourse by a man with another married woman without
the consent of her husband.
 142 Exam Preparatory Manual of Forensic Medicine and Toxicology

2. It does not amount to rape.

3. MLI
a. Earlier, Sec. 497 IPC dealt with adultery.
b. But now, it is not punishable in India.
c. It can be a ground for divorce.

26. Section 354 IPC. (Rajiv Gandhi University, Bengaluru 2015)

Ans: Section 354 IPC
1. Section 354 IPC deals with indecent assault.
2. Definition of indecent assault: Any unwanted sexual behaviour towards a person
without her will/consent, with an intention to outrage her modesty.
3. Punishment
354 Deals with Indecent assault (1–5 years ± Fine) India had
354 A Punishment for Sexual harassment (Frotteurism) (up to 3 years ± Fine) Sachin
354 B Punishment for Disrobe (3–7 years ± Fine) Dravid
354 C Punishment for Voyeurism (1–3 years ± Fine –1st offence; 3–7 years ± VVS Lakshman
Fine—2nd offence)
354 D Punishment for Stalking (up to 3 years ± Fine –1st offence; up to Sehwag
5 years ± Fine—2nd offence)

27. Section 375 IPC (Sher-i-Kashmir, Srinagar 2020, Supple 2019, Supple 2018) (AIIMS
Patna 2019, 2017, 2015) (Jammu and Kashmir 2017) (Rajasthan University 2017, 2016)

What constitutes rape? (Sardar Patel University 2020, Supple 2016)

Ans: Refer to long question no. 1.

28. Section 376 IPC (Sher-i-Kashmir, Srinagar 2020) (Sher-i-Kashmir, Srinagar Supple
2017)
Ans: Refer to long question no. 1.

29. Signs of recent delivery in living. (Adesh, Bathinda 2018) (Rajasthan University 2018)
(Andhra Pradesh supple 2015) (BFUHS, Punjab 2016)
Ans: Refer to long question no. 8.

30. Various samples collected in victim of rape (Pondicherry 2019) (BFUHS, Punjab
2015)
Ans: Refer to long question no. 2.

31. Semen Analysis (BFUHS, Punjab 2016) (University of Health Sciences, Rohtak 2017)
(JIPMER 2016)
Ans: Semen examination is done as per the given protocol.
 Sexual Jurisprudence and Infanticide 143

1. Screening tests
1. Physical examination • White/yellow-white in color
• Peculiar smell
• Slightly viscous
2. Examination under UV light Shows bluish white fluorescence
3. Chemical examination • Florence test: Dark brown Rhombic crystals
• Barberio test: Yellow Needle shaped crystals
• Acid phosphatase test: Intense purple colour

2. Confirmatory tests
1. Microscopy • Gold standard test
• Shows presence of sperms under microscope

2. Prostate-specific antigen Presence of p-30 which is derived from prostate and found in
seminal plasma
3. Acid phosphatase test

MLI
Civil cases Criminal cases
1. Disputed paternity 1. Proof of sexual assault
2. Legitimacy 2. Rape
3. Murder with sexual violence

32. Benzidine test. (Adesh, Bathinda 2019) (KHMS, Tamil Nadu 2017) (VNS Gujarat, 2017)
Ans: Features of Benzidine Test
1. It is a screening test for blood stains
2. Principle: Presence of peroxidase in RBCs converts hydrogen peroxide to liberate
nascent oxygen which acts on the reagent to change its color
Hb (Heme with peroxidase) + Hydrogen peroxide + Reagent → Color
3. Procedure
a. A drop of saturated benzidine solution
b. Then add a drop of hydrogen peroxide
 144 Exam Preparatory Manual of Forensic Medicine and Toxicology

4. Observation
Change of color to blue color
5. Benzidine is a known carcinogen, hence seldom used nowadays.

33. Barberio test (Adesh, Bathinda 2019)

Ans: Features of Barberio’s Test
1. It is a presumptive test for semen which must be followed by confirmatory test.
2. Procedure
a. Take dried stain extract of semen on slide
b. Add saturated aqueous or alcoholic solution of picric acid to it
c. Cover it with coverslip
3. Observation: Yellow needle-shaped crystals of spermine picrate

4. Advantage: This test is positive without presence of spermatozoa.

34. Negative findings in medical examination of an alleged victim cannot rule out
rape charges. (West Bengal University supple 2018)
Ans: Although positive findings during examination of an alleged rape victim help in
prosecuting the accused, but there may be situations when there may be negative
findings, i.e. normal examination findings. The report should contain negative, as well
as positive findings.
It should be always kept in mind that normal examination findings neither refute
nor confirm the forceful sexual intercourse. Hence circumstantial/other evidence may
be taken into consideration.
• For example: Complete penetration can occur in deflorate women and leaves no
evidence, except for semen. The absence of injury under certain circumstances,
therefore, does not exclude even complete penetration.
• In a young child, there are few or no signs of general violence, for the child usually
has no idea of what is happening and also incapable of resisting. Moreover, the
penis is placed either within the vulva or between the thighs. As such, the hymen is
usually intact, and there may be little redness and tenderness of the vulva.

35. Autoerotic asphyxia/sexual asphyxia. (Rajasthan University 2016) (KHMS, Tamil

Nadu 2018) (Pondicherry 2017)
Ans: Definition of autoerotic asphyxia: It is a paraphilia, wherein a person develops
partial asphyxia in his own body by means to enhance sexual arousal.
 Sexual Jurisprudence and Infanticide 145

• Degree of asphyxia is produced by mechanical means is controlled (as after

experiencing orgasm, constricting force around the neck is released but death may
occur in some cases).
• It is seen in association with Masochism.
• Partial asphyxia caused by pressure on carotid vessels or obstruction of air passages
cause cerebral ischemia.
• Victims are usually young males, in his own house, bedroom, bathroom and the
door is locked from inside.
Methods of Producing Sexual Asphyxia
1. Hanging: Most frequent method
2. Suffocation by plastic
3. Manual pressure on carotid vessels

36. Battered Baby syndrome/Caffey syndrome. (Rajiv Gandhi University, Bengaluru

2020) (KHMS, Tamil Nadu 2018, supple 2019) (Sardar Patel University, Gujarat 2019)
(Andhra Pradesh 2016)
Ans: Refer to long question no. 5.

37. Sudden Infant Death Syndrome. (Adesh, Bathinda 2019) (North Eastern Hill
University, Bengaluru Supple 2017)
Ans: Definition: It is defined as sudden and unexpected death of a healthy infant
whose death remain unexplained even after complete autopsy.
• It is also known as Crib death.
General features
• Age—2 weeks to 2 years
• Sex—Males >Females
• Time of death—nighttime and early morning
• Twins—common in twins
• Addiction—smoking by pregnant mother increases risk
Causes
a. Prolonged sleep apnea (most imp.)
b. Laryngeal spasm
c. Hypersensitivity of respiratory tract
PM findings
• Negative autopsy findings
• Multiple petechial hemorrhages on heart, lungs
• Milk or blood stained froth at mouth and nostrils

38. Signs of live birth. (Sardar Patel University, Gujarat 2019)

PM findings in case of liveborn infant. (Uttarakhand University 2018)

 146 Exam Preparatory Manual of Forensic Medicine and Toxicology

Tests to determine live birth of infant. (Adesh, Bathinda supple 2017)

Ans: Refer to long question no. 7.

39. Dead born fetus (BFUHS, Punjab supple 2016) (Pondicherry 2017) (VNS Gujarat,
supple 2019)
Ans: Definition: It is death of fetus in the uterus.
Signs of IUD (intrauterine death)
1. Maceration It is aseptic autolysis (refer to short question no. 40)
2. Mummification Occurs due to deficient blood supply
3. Rigor mortis Not seen in child <7 months of IUL
(Mnemonic—MMR)

Radiological Signs of IUD

1. Spaulding sign Overlapping of fetal skull bones due to shrinkage of cerebellum
Seen on 5th day after death
Most important sign of IUD
2. Robert’s sign Earliest radiological sign (within 12 hours)
It is presence of gas shadow in chambers of heart and aorta
3. Hyperflexion of spine Fetus curves like a ball
4. Deuel halo sign Separation of subcutaneous fat in scalp from cranial bones
5. Crowding of ribs
(Mnemonic—SRH v/s DC; SRH = Sun Risers Hyderabad v/s DC= Delhi Capitals)

40. Maceration (KHMS, Tamil Nadu 2016) (BFUHS, Punjab 2017) (VNS Gujarat, 2017)
Ans: Features of maceration are:
1. It is a process of aseptic autolysis
2. It develops when dead fetus remains in uterus for >3 days surrounded with amniotic
fluid
3. Mechanism of maceration: After IUD, cell membranes leak out enzymes into the
extracellular space leading to autolysis of the baby
4. Signs of maceration
a. Skin slippage: Earliest sign of maceration (seen within 12 hours of IUD)
b. Skin blebs
c. Bloating of abdomen
d. Increased mobility of joints.

41. Spaulding sign (AIIMS Patna 2019, 2018, 2017) (Rajiv Gandhi University, Bengaluru
2015) (VNS Gujarat, 2018)
Ans: Refer to short question no. 39.

42. Write medico-legal importance of umbilical cord. (West Bengal University 2019,
2017, supple 2017)
Ans: Assessing the changes in umbilical cord helps in assessing liveborn or still/dead
born and number of days passed after being born alive.
 Sexual Jurisprudence and Infanticide 147

Day-1 Shrunken cord

Day-2 Inflammatory line at base of stump
Day-3 Mummification changes in cord
Day-5 Falling off umbilical cord
Day-10–12 Scar formation (healing)

43. Hydrostatic Test (BFUHS, Punjab 2018, Supple 2019) (West Bengal University
2019) (Uttarakhand University 2017) (Himachal Pradesh 2017) (AIIMS Patna
2015) (Sai Tirupati University, Rajasthan, 2018) (JIPMER 2018) (VNS Gujarat,
supple 2019)
Ans: Features of hydrostatic test
1. Also called Lung Flotation Test/ Raygat’s Test
2. Principle: It is based on the fact that specific gravity of lung before respiration is
more, and becomes less after respiration (less than that of water). This makes the
respired lung to float.
3. Method: Take 3 containers having water:
Container 1 Container 2 Container 3
Place few pieces of the lungs in Lungs are taken out and Liver is placed in this container
this container squeezed and placed in this If Sinks—act as control
If floats—move to next step container. If Floats—then no value of
(container 2) (to check for Residual Air) Hydrostatic test
• If Floats—then test is +ve (as it suggests Putrefaction)
(means baby has respired)
• If Sinks—the test is –ve.

4. MLI
a. Conditions in which baby respired, yet lungs Sink (false negative)
• Atelectasis
• Pulmonary edema
• Pneumonia
b. Conditions in which baby has not respired, yet lungs Float (false positive)
• Putrefaction (therefore we do Control test with liver)
• Artificial respiration

44. Rule of Hassae (Rajiv Gandhi University, Bengaluru 2015) (Sai Tirupati University,
Rajasthan, 2018)
Ans: Rule of Hassae
• It is a method used to determine the age of the fetus by measuring the length of the
fetus in cm (crown-heel length).
For first 5 months of pregnancy For the last 5 months of pregnancy
Age of fetus in months is equal to the Age of fetus in months is equal to length divided by 5
square root of length (CHL)
• For example, if length is 36 cm and has crossed 5 months, then √36 = 6 months.
 148 Exam Preparatory Manual of Forensic Medicine and Toxicology

45. Infanticide (GMC, Chandigarh 2016)

Acts of omission and commission in relation to Infanticide (Sardar Patel University,

Gujarat 2016)
Ans: Refer to long question no. 6.

DIFFERENTIATIONS

1. Respired lungs and Unrespired lungs. (BFUHS, Punjab 2019, 2015) (University of
Health Sciences, Rohtak 2019, Supple 2020) (West Bengal University 2019, Supple
2017)

Liveborn and stillborn. (Adesh, Bathinda Supple 2018) (JIPMER supple 2018)
Ans:
Respired lungs/liveborn Unrespired lungs/stillborn
Volume of lungs Large Small
Colour Mottled, salmon pink Uniformly bluish red
Consistency Soft, spongy Dense, firm
Margins Rounded Sharp
Level of diaphragm 6–7th rib 4–5th rib
Hydrostatic test Positive (lungs float in water) Negative (sinks in water)
Fodere’s test Weight of lung 60–70 g Around 30–40 g
Ploucquet’s test 1:35 1:70
(wt. of lung: wt. of baby)
Breslau’s second life test Stomach floats in water Stomach sinks in water
(air in stomach)
MLI Indicates live birth Indicates stillbirth/deadborn infant

2. Multiparous uterus and Nulliparous Uterus (Adesh, Bathinda Supple 2020)

Ans:
Multiparous uterus Nulliparous uterus
Size Large Small
Weight 80–100 g 40–50 g
Body: cervix 2:1 1:1
External os Transverse patulous slit Circular, dimple like
Upper surface of fundus Higher level than the line of Same level as broad ligament
broad ligament
Uterine cavity Rounded and spacious Triangular and smaller
Cervix Cylindrical shape Conical shape
Scar for placental attachment Present Absent

3. True virgin and false virgin. (University of Health Sciences, Rohtak 2019 , Supple
2020) (Jammu and Kashmir 2017) (North Eastern Hill University 2015) (GMC,
Chandigarh 2015) (BFUHS, Punjab 2015) (Delhi University Supple 2016)
 Sexual Jurisprudence and Infanticide 149

Ans:
True virgin False virgin/defloration
Definition Woman has never experienced Woman has experienced sexual
sexual intercourse with intact hymen intercourse but her hymen is intact
(ruptured in defloration)
Hymen Admits only tip of little finger Easily admits two fingers through
through orifice orifice
Clitoris Small Enlarged
Labia minora Small, pinkish and covered with Enlarged, pigmented, separated
labia majora from majora
Labia majora Fleshy and completely close Less fleshy, separated
the vaginal orifice
Vagina Narrow with marked rugosity Roomy with less rugosity
Fourchette Intact Ruptured
Posterior commissure -do- -do-
Nipples and areola Small and pink Enlarged and pigmented
Note: In defloration, the hymen is ruptured, rest of the features are same as false virgin

4. Artificial insemination homologous (AIH) and Artificial insemination donor

(AID). (Delhi University Supple, 2016)
Ans:
AIH AID
Indications Erectile dysfunction, hypospadias, Sterile husband, hereditary disease,
cervical stenosis Rh incompatibility
Donor Husband Other person
Donor’s age Not specific Should be <40 years
Disclosure of identity Not an issue Donor and recipient must not know
each other
Doctor who conducted AI May deliver the child Should avoid delivery of child
Outcome of AI Known to husband Donor must not know
Consent From both husband and wife From husband, wife, donor and
donor’s wife
Confidentiality maintained No Yes
MLI No legal issues, except for divorce Litigation against doctor,
illegitimacy, inheritance claims,
(Mnemonic—DOC) divorce, incest and mental trauma

5. Natural abortion and criminal abortion. (Adesh supple 2019, supple 2018)
(University of Health Sciences, Rohtak 2017)
Ans:
Natural abortion Criminal abortion
Cause Predisposing disease In unmarried woman/widow
Marks of violence on abdomen Absent Present
Fetal injuries -do- -do-
Injuries on genital organs -do- -do-
Toxic effects on drugs -do- -do-
Sepsis -do- -do-
Foreign body in genital tract -do- -do-
 150 Exam Preparatory Manual of Forensic Medicine and Toxicology

7
Forensic Psychiatry

LONG QUESTIONS

1. Explain the term “Feigned Insanity”. Mention four salient features to

differentiate true insanity from feigned insanity. Add a note on civil and
criminal responsibility of an insane. (Rajiv Gandhi University, Bengaluru 2018)
Ans:
Feigned Insanity
Definition: It means that the person is pretending to be mentally ill/ insane in order
to deceive and for gain.
The person has some motive behind this act, e.g.,
a. to avoid inquiry
b. to avoid trial
c. to avoid conviction
d. to avoid punishment
e. to avoid going to prison
Hence, it is the duty of the doctor/psychiatrist to distinguish between two.
It is also necessary that no sane person is confined to a psychiatric hospital.
Difference between True and Feigned Insanity: Refer to difference no.1.

Civil responsibility of Insane

Management of self The court may appoint a guardian to take care of the mentally ill, and may
and property appoint a manager to manage the property.
Contracts A contract made by mentally ill person, who does not understand the nature
and quality of the contract will be considered invalid. However, he is liable for
contracts if made during lucid interval.
Marriage and divorce Marriage is invalid, if one of the parties, at the time of ceremony, was suffering
from mental illness.
Adoption Taking/giving adoption of a child is not allowed, if either of the parents is
mentally ill.
Witness A mentally ill person cannot be considered as competent to give evidence in
the court of law. He can be regarded as competent during lucid interval.
Consent The consent given by a mentally ill person is not valid because he is unable to
understand the nature and consequence of that to which he gives the consent.

150
 Forensic Psychiatry 151

Testamentary capacity Will made by mentally ill person is considered invalid because mentally ill
person does not have the capacity to make a valid will. Will is valid made
during lucid interval.
Guardianship A mentally ill person is not considered as a legal guardian of a minor.

Criminal Responsibility of Insane/McNaughton’s Rule

• McNaughton’s rule deals with criminal responsibility of an insane person.
• History: In 1843, Mr. Edward Drummond, the private secretary of the then Prime
Minister of England, Sir Robert Peel, was shot dead by Daniel McNaughton who
was suffering from delusion of persecution and believed that his life was in danger
due to the acts of persecution by the Tory Party on him. He shot dead Mr. Drummond
on the belief that he killed Mr. Peel. Later, it was established that McNaughton
suffered from paranoid delusions and was acquitted on the ground of insanity. The
new rules that were framed for criminal responsibility of the insane were named
after McNaughton.
• According to these rules, it must be proven by the defence that at the time of
committing the act, the accused was laboring under such a defect of reason from
disease of mind (known and nameable disease) as not to know the nature and quality
of the act, or if he did know this, that he did not know what he was doing was
wrong or contrary to law.
• The legal test of insanity is laid down in Sec. 84 of IPC “Nothing is an offence
which is done by a person who, at the time of doing it, by reason of unsoundness of
mind, is incapable of knowing the nature of the act or what he is doing is either
wrong or contrary to the law.”

2. Define McNaughton rule. How is it incorporated in Indian law? Discuss criminal

responsibility of an insane. (Sher-i-Kashmir Institute, Srinagar 2020)
Ans:
McNaughton rule: Refer to long question no. 1.
McNaughton rule is incorporated under Sec. 84 of IPC in Indian law. It states that
“Nothing is an offence which is done by a person who, at the time of doing it, by
reason of unsoundness of mind, is incapable of knowing the nature of the act or what
he is doing is either wrong or contrary to the law.”
Criminal responsibility of an insane: Refer to long question no. 1.

3. Define and classify insanity. What is delusion? Describe various types of

delusions. (Rajiv Gandhi University, Bengaluru Supple 2015) (Sher-i-Kashmir Institute,
Srinagar Supple 2018)
Ans:
Definition of insanity: It is the disease of the mind, which affects the personality,
mental status, critical faculties, emotional processes and interaction with the social
environment.
Mentally-ill person: Any person who is in need of treatment by reason of any mental
disorder other than mental retardation.
 152 Exam Preparatory Manual of Forensic Medicine and Toxicology

ICD-10 Classification of Mental Illness

Classification Types
Organic mental disorders Delirium, dementia
Psychoactive substance use disorders Acute intoxication, withdrawal state
Schizophrenia and delusional disorders Schizophrenia, psychotic disorder
Mood disorders Manic, depressive, bipolar, mood disorders
Neurotic and somatoform disorders Anxiety, phobic disorder, OCD
Behavioral syndromes Eating disorders, sexual dysfunctions
Adult personality and behavior disorders Personality or impulse disorders
Mental retardation Mild, moderate, severe mental retardation
Disorders of psychological development Speech, language, scholastic skills disorders
Behavioral and emotional disorders in children Hyperkinetic, conduct and tic disorders

Definition of Delusion
False but firm belief in something which is not a fact despite proof to the contrary. It is
a disorder of content of thought.

Types of Delusion
Hypochondriacal delusion Patient believes of having some serious disease (like cancer) based on his
own interpretations of physical signs and symptoms.
Delusion of infidelity • Patient believes that his partner is unfaithful to him or her.
(Othello syndrome) • Seen in patients with alcohol dependence
Delusion of Reference Person believes that everyone is looking at him or talking about him. For
example, if patient sees anyone smiling, then says he was laughing at me.
Nihilistic delusion • Patient denies the existence of their body, their mind or even world in
general.
• Seen in patients of depression.
Delusion of Influence Patient complains that his thoughts, feelings and actions are being
influenced and controlled by some outside agency, e.g., radio.
Delusion of Love/Erotomania • Patient believes that a person of higher socioeconomic status is in love
with her/him.
• Usually common in females.
Delusion of Persecution • Most common delusion.
• The person thinks that people around him are trying to kill him/harm
him/making conspiracy against him.
• Commonly seen in schizophrenia.
Delusion of Grandiosity • Person imagines himself to be very rich/powerful, although in reality he
may be poor.
• Seen in patients with mania and schizophrenia.
(Mnemonic—HORN In LPG)

4. Write in detail about Mental Health Act, 2017. (Sher-i-Kashmir Institute, Srinagar
Supple 2019)
Ans:
• The Mental Healthcare Act 2017 provides for mental healthcare and services for
persons with mental illness. It is presumed that all persons have the capacity to
make mental healthcare and treatment decisions.
 Forensic Psychiatry 153

• Under this Act, the person can make an advance directive in writing the way he
wishes to be cared for or not to be cared for and treated for a mental illness and
appoint a nominated representative to take decisions on his behalf when he is
incapable to decide.
• This Act has also decriminalized attempt to commit suicide.

Rights of Persons with Mental Illness

1. Right to access mental healthcare and treatment from mental health services
2. Right to information about proposed treatment and its side effects
3. Right to live in, be part of and not be segregated from society
4. Right to live with dignity
5. A child <3 years of a woman receiving treatment should not be separated from her
during her stay in such hospital.
6. Right to confidentiality in respect of his mental health, care and treatment, and no
release of even a photograph in media.

Admission and Discharge (Restraint of Mentally Ill Patient)

A mentally ill person needs to be restrained for his own safety or for the safety of
others. If the lawful guardian of the patient is unable to keep him under control, or if
there’s no guardian, then the state is legally justified to take charge of the patient and
put him under restraint.
a. Supported admission: Seen in case of minor (age <18 yrs)
• Patient is admitted on the decision of Nominated Representative. Any such
admission shall be informed by medical officer (MO) in-charge to the concerned
board within 72 h.
• Nominated person shall stay with the minor for the entire duration of admission.
When a minor attains the age of 18 yrs, the MO in-charge shall classify him as an
‘independent patient’.
• If nominated representative requests discharge of the minor, the minor shall be
discharged by mental health establishment. Also, any admission of a minor which
continues for a period of 30 days shall be immediately informed to the concerned
board.
b. Independent admission: Any person of ≥18 yrs of age, who considers having a
mental illness and desires to be admitted may request the MO in-charge of the
psychiatric hospital to be admitted as an independent patient for treatment, only
after informed consent. On request, MO in-charge shall discharge the patient
immediately.
Mentally ill person who requires treatment beyond 30 days should be reviewed by
two psychiatrists.
c. Involuntary admission: This is done if the patient:
• Recently threatened/attempted or is threatening/attempting to cause bodily harm
to himself;
• Recently behaved/is behaving violently towards another person or caused bodily
harm to another person
This involuntary admission can be for a period of 30 days. It is only when this
period is to be extended beyond 30 days that the Board must confirm the admission.
 154 Exam Preparatory Manual of Forensic Medicine and Toxicology

Emergency
Any doctor may provide treatment for mental illness of a person with informed consent
of the nominated representative where it is immediately necessary to prevent:
a. Death of the person; or
b. Serious harm to himself/others; or
c. Serious damage to property, which is directly related to his mental illness.

Treatments Prohibited
• Direct ECT without use of muscle relaxants and anaesthesia
• ECT for minors (performed only after taking permission from caretaker and prior
permission from board)
• Psychosurgery (performed only after taking permission from caretaker and prior
permission from board)
• Sterilization as a treatment for medical illness.

Restraints and Seclusion

It is needed only when:
1. It is the only means available to prevent immediate harm to the person or to others,
and
2. It is authorised by the psychiatrist in charge
• The Nominated Representative should be informed of restraint within 24 h, and
concerned Board monthly.
• He shall be kept in a place where he can cause no harm to himself or others.

Offences and Penalties

Any doctor knowingly serves in mental health establishment not registered under
this Act will be fined `25,000.
Anyone contravening any of the provisions/rule/regulation is to be punished:
• First contravention— imprisonment up to 6 months with/without fine up to `10,000.
• For any subsequent contravention—imprisonment up to 2 years with/without fine
`50,000 to `5 lakhs.

SHORT NOTES

1. Hallucination. (Sardar Patel University, Gujarat supple 2018) (North Eastern Hill
University, Shillong supple 2018) (Uttarakhand University 2016, 2015) (Rajasthan
University 2015) (Rajiv Gandhi University, Bengaluru 2015) (Sher-i-Kashmir, Srinagar
supple 2015) (VNS, Gujarat 2017)
Ans:
a. Hallucination is false perception by senses without any external object or stimulus.
b. Seen in insanity, high fever, drug intoxication and during withdrawal from drug
addiction.
 Forensic Psychiatry 155

c. Types
Auditory hallucination • False perception of sound (noises, music) without any source, e.g.,
hearing sound when there is none.
• Seen in schizophrenia
• Most common hallucinations
Visual hallucination • Patient observes something without anything being present.
• Seen in delirium tremens
Olfactory hallucination • False sense of smell (pleasant/unpleasant) without any source.
• Seen in medical disorders (temporal lobe), schizophrenia
Gustatory hallucination • Patient experiences different tastes (sweet/bitter/sour) without any food
or drink.
• Seen in temporal lobe epilepsy
Tactile hallucination (touch) • Patient experiences crawling of insects/rats over his body.
• Seen in cocainism, schizophrenia

d. MLI: Hallucinations are not under voluntary control and a person will not be
responsible if he is incited to commit homicide.

2. Illusion (North Eastern Hill University, Shillong Supple 2019) (Rajiv Gandhi University,
Bengaluru 2018, 2015) (BFUHS, Punjab Supple 2018)
Ans:
a. Illusion is a false interpretation by the senses of an external object or stimulus which
has a real existence.
b. Types
Universal illusions • Found in all individuals and same for all individuals
• For example, the rail tracks appear to be converging to all of us.
Personal illusions • Differ from individual to individual
• For example, a person sees a dog and mistakes it for lion, or imagines a
string hanging in his room to be snake.

c. A sane person may experience illusion, but can correct the false impressions. An
insane person continues to believe in the illusions, even though the real facts are
clearly pointed out.

3. Doctrine of Diminished Responsibility. (Adesh, Bathinda supple 2020)

Ans: The Doctrine of Diminished Responsibility was introduced in UK as a defence to
murder. If this defence is established, it will entitle the offender to be found guilty of
manslaughter (culpable homicide) instead of murder and will be given a lesser
punishment. It states that:
a. Where a person kills someone or is a party to killing, he will not be guilty of murder
if he was suffering from some abnormality of mind and is mentally incapable of
taking responsibility for his acts.
b. A person who would be liable under this section, whether as a principal or as an
accessory, will be convicted of manslaughter instead of being convicted of murder.
In order to prove he was suffering from diminished responsibility a defendant must
show:
 156 Exam Preparatory Manual of Forensic Medicine and Toxicology

1. He was suffering from an abnormality of mental functioning;

2. From a recognised medical condition;
3. Which substantially impaired his ability to understand his conduct, form a rational
judgment or exercise self-control;
4. Which provides an explanation for being party to the killing.

4. Lucid interval (West Bengal University 2017) (Andhra Pradesh Supple 2015) (VNS,
Gujarat 2019) (GMC, Chamba 2019)
Ans:
Lucid interval is seen in two conditions:
1. Insanity
2. Head injury
Lucid interval in insanity Lucid interval in head injury
Definition It’s a period between two episodes of Period of consciousness between two
mental illness in which all the signs phases of unconsciousness
and symptoms of mental illness
completely disappears (i.e., the person
behaves normally)
History Of insanity Of trauma
Seen in Bipolar disorders Head injury (EDH)
MLI Person is responsible for all his civil and If a patient in lucid interval approaches a
criminal acts performed during this doctor and the doctor without examining
period of lucid interval him properly discharges him, the doctor
may be sued for negligence if the patient
dies due to complications

5. Marriage contract with an insane person is not valid. (West Bengal University 2019)
Ans:
a. As per Hindu Marriage Act, if one of the parties at the time of ceremony was suffering
from mental illness, then the marriage is not valid and is considered null and void.
b. But insanity occurring after marriage is not the ground for divorce, but at times
when any of the partners become insane after marriage, then the other sane person
can demand a divorce provided that the insanity is seen to be incurable, even after
his continuous treatment for a period of more than 3 yrs.
c. As per Muslim Marriages Act, a woman can obtain divorce on ground of husband’s
insanity within 2 years of marriage.

6. Impulse. (BFUHS, Punjab supple 2020) (AIIMS Patna 2018) (Adesh, Bathinda Supple
2018) (Andhra Pradesh supple 2016) (VNS, Gujarat 2017)
 Forensic Psychiatry 157

Ans:
Definition
Impulse is an uncontrolled, sudden and irresistible urge which compels the person to
conscious performance of an act. A sane person is capable of controlling an impulse,
but an insane person cannot.

Diagnosis of Impulsive Control Disorder

• Failure to resist the impulse, which is harmful to self or others
• Before the act—feeling of increased tension
• After performing it—person has sense of relief and finally feels guilty

Types
Kleptomania An irresistible desire to steal articles of low value
Pyromania Impulse to set the things on fire
Oniomania Impulse of shopping
Dipsomania An excessive desire to drink alcohol
Mutilomania A desire to maim animals

7. Legal test of insanity (Rajasthan University 2018)

Ans:
The legal test of insanity is also known as the ‘Right or Wrong’ test.
Under this test, a person is not criminally responsible, if at the time of the crime, he
did not know the nature of the act or that it was wrong. It has the following requirements:
i. There should be evidence of mental disease.
ii. This mental disease or defect must exist at the time of commission of crime.
iii. It should be of such degree that the person is unable to understand that the act is
wrong and/or contrary to the law.
It means if a person accused of a crime is found to be a normal, sound person, he
will be punished. But if a person is found to be mentally ill, then the person is not
punished.

8. Phobia (AIIMS Patna 2016)

Ans:
Definition
Phobia is morbid and irrational fear in the presence of stimulus and person tries to
avoid the situation.

Types
Agoraphobia Social phobia Specific (simple) phobia
Morbid fear of places from • Fear of socially demanding • Strong, persistent and irrational
which escape is difficult situations fear of an object or situation
• Fear of embarrassment • Most common type of phobia
E.g., Crowd, market, stores E.g., Stage fear, public speaking E.g., Claustrophobia, hydrophobia,
zoophobia
 158 Exam Preparatory Manual of Forensic Medicine and Toxicology

9. Testamentary capacity (SGRD, Amritsar 2019) (North Eastern Hill University, Shillong
2019, Supple 2017) (University of Health Sciences, Rohtak 2017) (Pondicherry 2017)
(Delhi University Supple 2016) (KHMS, Tamil Nadu 2015) (West Bengal University
2017) (Rajiv Gandhi University, Bengaluru 2015)
Ans:
Testamentary capacity is the capacity of a person to make a valid will. The law defines
it as the possession of a sound disposing mind (compos mentis) which must be certified
by a doctor.
a. Will made by mentally ill person: Considered invalid because mentally ill person
does not have the capacity to make a valid will.
b. Will made in lucid interval: Considered valid because in lucid interval the person
is normal (i.e., of sound mind) and is able to judge and foresee the consequences of
his acts.
c. Will made by drunk person, or under insane delusions: Invalid as the testator is
incapable of understanding the nature and consequences of his own judgements.
Salient features of a valid will
1. Should be executed by a testator
2. Should be sound mind
3. Should be major (age ≥18 years)
4. Should be signed by testator in the presence of at least two witnesses

10. Responsibility of Mentally Ill person (Rajiv Gandhi University, Bengaluru 2020)
(Sardar Patel University, Gujarat 2020) (KHMS, Tamil Nadu 2018) (BFUHS, Punjab 2017,
2016) (Himachal Pradesh 2017) (Pondicherry 2019, 2016, 2015) (Andhra Pradesh
2015) (GMC, Chandigarh 2015) (JIPMER supple 2018)
Ans: Refer to long question no. 1.

11. Delusions (Adesh, Bathinda Supple 2019) (West Bengal University Supple 2019)
(University of Health Sciences, Rohtak 2019, Supple 2020) (AIIMS Patna 2019, 2017,
2015) (Uttarakhand University Supple 2017) (KHMS, Tamil Nadu 2016, supple 2019)
(Rajasthan University 2017) (Sardar Patel University, Gujarat 2018, 2016) (Rajiv Gandhi
University, Bengaluru 2015) (Delhi University 2016) (North Eastern Hill University, Shillong
2017, 2015) (Rajiv Gandhi University, Bengaluru 2015) (VNS, Gujarat supple 2019)
Ans: Refer to long question no. 3.

12. McNaughton’s rule/ Section 84 IPC (KHMS, Tamil Nadu Supple 2020) (Adesh,
Bathinda 2019) (BFUHS, Punjab Supple 2019) (Sher-i-Kashmir, Srinagar Supple 2017)
(Delhi University Supple 2016) (Sardar Patel University Supple 2015) (Uttarakhand
University 2016) (VNS, Gujarat 2017)
Ans: Refer to long question no. 1.
 Forensic Psychiatry 159

13. Feigned insanity (KHMS, Tamil Nadu Supple 2020) (Adesh, Bathinda 2018)
Ans: Refer to long question no. 1.

14. Restraint of insane (Pondicherry Supple 2017) (JIPMER 2016)

Ans: Refer to long question no. 4.

15. Types of Mental Disorders (Rajiv Gandhi University, Bengaluru 2015)

Ans: Refer to long question no. 3.

DIFFERENTIATIONS

1. True insanity and False insanity (West Bengal University 2019) (Delhi University 2018)
(Rajasthan University 2017) (Adesh University, Bathinda Supple 2017) (University of
Health Sciences, Rohtak 2017) (Uttarakhand University 2016)
Ans:
True Insanity False Insanity
Onset of disease Gradual/slow Sudden
Predisposing factor Usually present, h/o insanity Absent
Motive Absent Present (h/o crime)
Facial expression Peculiar vacant/agitated look Normal/exaggerated
Fatigue on exertion Does not get fatigue Easily fatigued
Insomnia Present Absent
Dressing up Poorly dressed/ careless Reasonably dressed up
Habits Dirty and filthy No ill habits
Whether examining or not Features always present Features exaggerate on
examination
Repeated examination Not worried Resists

2. Psychosis and Neurosis (Adesh University, Bathinda 2019) (West Bengal University
2018)
Ans:
Psychosis Neurosis
Insight Absent Present
Empathy -do- -do-
Delusions/hallucinations Present Absent
Dealing with reality Impaired Preserved
Behavior Not within socially acceptable norms Within acceptable norms
Examples Schizophrenia Anxiety, phobia
 160 Exam Preparatory Manual of Forensic Medicine and Toxicology

3. Delusion and hallucination. (Uttarakhand Supple 2018)

Ans:
Delusion Hallucination
Definition False but firm belief in something which is False sense of perception without any
not a fact despite proof to the contrary external stimulus
Disorder Content of thought Perception
Seen in Schizophrenia Schizophrenia
Depression Organic mental disorder
Mania Cocaine, cannabis, LSD intoxication
Alcohol dependence

4. Illusion and delusion. (BFUHS, Punjab Supple 2019)

Ans:
Illusion Delusion
Definition False interpretation of external object False but firm belief in something
which has real existence which is not a fact despite proof to the
contrary
Stimulus External, explicit and distinct Internal, not clear and within the
person
Nature Universally experienced by all Personal experience
Situation Can happen in normal state of mind Happens in abnormal condition
(schizophrenia, mania)
 Toxicology 161

8
Toxicology

LONG QUESTIONS

1. What are the legal responsibilities of a doctor in a suspected case of

poisoning? (Adesh, Bathinda Supple 2020) (Pondicherry supple 2018) (North
Eastern Hill University, Shillong supple 2020) (VNS, Gujarat 2018)
Ans:
Legal Duties of a Doctor in Suspected Case of Poisoning
1. It is the duty of the doctor to inform the police in all cases (in case of government
medical officer).
2. In case of private medical practitioner: He should inform police/magistrate only
in case of homicidal poisoning:
• But he is not bound to inform police in case of suicidal/accidental poisoning
(but should inform all cases for his safety).
3. If doctor does not inform the police, he will be punished under Sec. 176 IPC.
4. Note the preliminary particulars of the patient (name, identification marks, age,
sex, occupation, etc.)
5. History—he should take proper history of poisoning, if it is suicidal, homicidal or
accidental and how much quantity taken.
6. He should inform his senior doctor about the case.
7. Collection of evidence—the doctor should collect gastric lavage, food, vomitus,
blood, urine, feces and preserve and then seal it properly and then send it for
chemical analysis in FSL.
• Failure to do so is punishable under Sec. 201 IPC (destruction of evidence).
8. He should prepare MLC report with consent.
9. If condition of patient is serious and about to die, he should make arrangements
for Dying Declaration.
10. In case the patient dies, he should not issue Death Certificate but instead send the
body for PM examination.
11. Any opinion regarding the nature of poison should be given only after getting the
report from FSL.
161
 162 Exam Preparatory Manual of Forensic Medicine and Toxicology

2. Classify poisons and write briefly about barbiturate poisoning. (Rajiv Gandhi
University, Bengaluru 2020)
Ans:
Classification of Poisons

1. Corrosives a. Strong acids i. Mineral acids—HCl, HNO3, H2SO4

ii. Organic acid—oxalic acid, carbolic acid
b. Strong alkalis NaOH, KOH, NH4OH
c. Metallic salts Zinc chloride, Ferric chloride
2. Irritants a. Inorganic i. Metallic—As, Pb, Hg, Cu
ii. Nonmetallic—phosphorus, iodine
b. Organic i. Plants—Abrus precatorius, castor
ii. Animals—snakes, scorpions
c. Mechanical Powdered glass, diamond dust
3. Neurotics a. Cerebral S: Somniferous—opium
I : Inebriants—alcohol
D: Deliriants—dhatura, cocaine, cannabis
b. Spinal Strychnine
c. Peripheral Curare
4. Cardiac Digitalis, Oleander, Aconite, Hydrocyanic acid
5. Asphyxiants CO, H2S, CO2
6. Miscellaneous a. Agrochemicals
Pesticides Fumigants Herbicides Rodenticides
• OPC • Alphos • Paraquat • Thallium sulfate
• Carbamates • Zinc phosphide
b. Drugs of dependence—antidepressants, hallucinogens
c. Petroleum products—kerosene, petrol
d. Food poisoning—bacterial, chemical

(Mnemonic—CINCAM)

BARBITURATE POISONING
Clinical Features

1. CNS depression • Drowsiness, delirium, excitement, hallucinations, ataxia,

• Coma with positive Babinski sign, loss of superficial and deep reflexes
2. Respiratory system • Respiratory centres are depressed leading to rapid and shallow, or slow and
laboured breathing
3. CVS • Cardiac output decreased leading to hypotensive shock, cyanosis, bradycardia
4. GIT system • In comatose patient – Absence of Bowel sounds (bad prognosis)
5. Renal system • Urine is scanty and suppressed
• Contains albumin and sugar
6. Skin • Barbiturate blisters
7. Body temperature • Decreased (hypothermia)
• Fever—in case of bronchopneumonia

(Mnemonic—when a person goes to BAR, he enjoys and feels relaxed. So all his functions are reduced like
CNS depressed, CO reduced, GIT activity reduced, Resp. reduced, urine decreased and body temperature
decreased)
 Toxicology 163

Management
1. Maintain airway, breathing and circulation (ABC)
2. Gastric lavage is done with 1:1000 KMnO4 solution and activated charcoal
3. Elimination by Forced Alkaline Diuresis—by use of sodium bicarbonate in 5%
dextrose IV slowly
4. Antibiotics to prevent bronchopneumonia
5. Scandinavian method (combination of 1+2+3+4 steps)
6. Hemodialysis
7. Exchange transfusion
8. Supportive care.
PM Findings

External findings Internal findings

1. Signs of asphyxia • Lungs—congested and edematous
2. Cyanosis • Stomach—hemorrhagic, congestion and erosion of mucosa
3. Barbiturate blisters • Kidneys—degeneration of convulated tubules
4. Froth at nose and mouth

3. Define and classify poisons. Discuss the various methods for removal of
absorbed poison from a patient. (BFUHS, Punjab 2020)
Ans:
Definition of Poison
Any substance in any form (solid, liquid, gas) which if introduced into the body through
any route (ingestion, injection, inhalation, contact) will produce ill health or death by
its local or constitutional effects or both.
Classification of Poison
Refer to long question no. 2.
Methods for Removal of Absorbed Poison from Patient
1. Forced diuresis by urine • Urine is made alkaline by use of sodium bicarbonate
alkalinisation • Helps in promoting excretion of acidic drugs through urine
• Done in salicylate, barbiturate poisoning
2. Forced diuresis by urine • Urine is made acidic by use of ammonium chloride
acidification • Helps in promoting excretion of alkaline drugs through urine
• Done in poisoning/overdose of amphetamines, quinine, TCA
3. Whole bowel irrigation Refer to short note no. 4.
4. Hemodialysis • Hemodialysis is done in: (Mnemonic—LABS)
L: Lithium A: Alcohol B: Barbiturates S: Salicylates
5. Hemoperfusion • Blood is circulated extracorporeally from an arterial source through a
filter filled with activated charcoal and then back to patient’s venous blood
• Done in case of poisoning due to caffeine, barbiturates, mushroom
6. Diaphoretics • Increases excretion of drugs by increasing perspiration
• Leading to increased excretion of toxic agents
7. Exchange transfusion • This involves slowly removing the poisoned patient’s blood and replacing
it with fresh donor blood or plasma, useful if antidote is not available.
 164 Exam Preparatory Manual of Forensic Medicine and Toxicology

4. Describe the scientific name, active principle, signs and symptoms, medico-
legal significance/aspects, postmortem findings and treatment in a case of
Dhatura poisoning. (Sher-i- Kashmir Institute, Srinagar, 2020) (Himachal Pradesh,2017)
(North Eastern Hill University, Shillong 2019) (Sai Tirupati University, Rajasthan, 2018)
(VNS, Gujarat supple 2019)

Give the active principles and fatal dose of Dhatura. Enumerate the 10 Ds of
Dhatura poisoning. (BFUHS, Punjab Supple 2019)

A person, whose belongings were stolen, found in semiconscious state in train

with high fever, flushed face and dry mouth. On examination pupil was dilated.
How will you diagnose and manage the case? (AIIMS Patna 2019, 2018, 2017)
Ans:
Scientific name: Datura stramonium
Common name: Thorn apple, Jimson weed, Devil’s trumpet
Active principles
1. Hyoscine
2. Hyoscynamide
3. Atropine
Fatal dose
• 80–120 seeds
• Stupefying dose: 40–60 seeds
Signs and Symptoms (10 Ds)
1. Dryness of mouth
2. Dysphagia—difficulty in swallowing
3. Dysarthria—difficulty in talking
4. Dilatation of cutaneous blood vessels (redness, flushing of face)
5. Dry hot skin (increase in temperature—fever)
6. Drunken gait
7. Diplopia—due to dilated pupil (mydriasis)
8. Drowsiness
9. Delirium, may show pill-rolling movements or pulls imaginary threads from
clothes
10. Dysuria due to retention of urine
Diagnosis
1. Mydriatic test: A drop of the suspected specimen is instilled in the eyes of the rabbit
resulting in dilation of pupils
2. Pilocarpine test
• Instil 2–3 drops of 1% pilocarpine in patient’s eye
• If no constriction of pupil, suggests Dhatura poisoning
3. Atropine can be detected by Radioimmunoassay.
 Toxicology 165

Treatment
1. Maintain airway, breathing and circulation (ABC)
2. Give emetics
3. Perform gastric lavage with tannic acid, KMnO4 or activated charcoal
4. Physiological antidote
Physostigmine is the antidote of choice as it can cross BBB
Dose: 0.5–1 mg slow IV over 5 min with ECG monitoring
5. Purgatives and colonic lavage is done
6. Cold sponging—to control high temperature
7. IV Diazepam—for sedation and seizures
8. Short acting barbiturates—to control delirium
9. Catheterization in case of urinary retention/dysuria.

PM Findings

External Internal
Show signs of asphyxia • GIT—inflamed mucosa containing seeds and its fragments
• Lungs—edematous and congested
• Brain—edematous and congested
• Other organs—edematous and congested

MLI:
1. Rail-road poison: It is mostly used by criminals as stupefying agent for the purpose
of robbery, rape, etc. Therefore also called rail-road poison.
2. Used as abortifacient
3. Accidental poisoning in case of children
4. Resists putrefaction
5. Used as an adulterant in country liquor to enhance kick effect
6. Used in Chinese herbal medicines to treat asthma.

5. Define stupefying agents. Describe clinical features and management of acute

Dhatura poisoning. (Delhi University, 2017)
Ans:
Definition of Stupefying Agents
• Substances which are used to daze a victim or putting the victim in state of
drowsiness or unconsciousness.
• It is used by criminals for the purpose of robbery, kidnapping or rape during travel
in bus, train and railway station. It is usually mixed with food or drink.

Clinical Features and Management of Dhatura Poisoning

Refer to long question no. 4.
 166 Exam Preparatory Manual of Forensic Medicine and Toxicology

6. Classify the organophosphorous compounds. Describe the signs and symp-

toms, management and medico-legal duties in case of organophosphorous
poisoning. (North Eastern Hill University, Shillong 2018, Supple, 2019) (Sardar Patel
University, Gujarat 2020-19) (North Eastern Hill University, Shillong 2015) (Sher-i-
Kashmir Institute, Srinagar 2015, Supple 2017) (Rajiv Gandhi University, Bengaluru
2017, Supple 2015) (West Bengal University 2017) (VNS, Gujarat 2018)

A patient came in the emergency with the complaints of diarrhoea, vomiting,

dyspnea, incontinence of urine after working in agriculture field. On
examination, there is constricted pupil and crepitation in chest. How will you
diagnose and manage the case? (AIIMS Patna 2018, 2015)

A 35 years old farmer brought to your hospital with alleged history of

ingestion of an unknown poisonous substance. Patient has excessive
salivation, lacrimation, urination, defecation and gastric emesis. On examination,
constricted pupils were found contracted. (Sardar Patel University, Gujarat Supple
2016)
a. What is the most likely diagnosis with reason?
b. Which investigations will support your diagnosis?
c. Describe treatment of this poisoning in detail.
Ans:
Classification of OPC Poisoning
On the basis of chemical composition On the basis of toxicity
1. Alkyl phosphates 1. Agricultural insecticides
• HETP • TEPP
• OMPA • Parathion
• TEPP 2. Animal insecticides
• Malathion • Trichloroform
(Mnemonic—HOT MALA) • Ronnel
2. Aryl Phosphates 3. Household insecticides
• Diazinon (Tik-20) • Malathion
• Chlorthion • Tik-20
• Parathion
(Mnemonic—DCP)

Signs and Symptoms in Case of OPC Poisoning

Muscarinic symptoms Nicotinic symptoms CNS symptoms

1. Salivation 1. Muscle fasciculation 1. Muscle weakness
2. Lacrimation- Red Tears (rare) 2. Weakness of muscles 2. Anxiety
3. Urinary incontinence 3. Mydriasis 3. Depression
4. Diarrhea 4. Tachycardia 4. Restlessness
5. GIT distress 5. Hypertension 5. Ataxia
6. Emesis 6. Tremors
7. Spasm of bronchial muscles (Mnemonic—MAD–RAT)
8. Others: Pinpoint pupil/Constricted pupil
(Mnemonic—SLUDGES in OPC)
 Toxicology 167

Lab Diagnosis
1. Acetylcholinesterase level in RBCs and plasma is decreased
In acute poisoning, signs and symptoms generally occur when >50% of cholinesterase
is inhibited
2. Liquid gas chromatography—to detect OPC in blood
3. P-nitrophenol test—in case of parathion poisoning

Treatment
1. Maintain airway, breathing and circulation (ABC)
2. Patient is removed from the source of contamination and
3. Remove clothes and wash body with soap and water—for decontamination
4. Perform gastric lavage with 1:5000 KMnO4
5. Start Atropine

Atropine acts as an antidote for OPC and carbamate poisoning

MOA: Atropine acts by blocking Muscarinic receptors, and no action on Nicotinic receptors, therefore
reversing Muscarinic manifestations but no effect on Nicotinic manifestations
Dose: 2–4 mg IV repeated after every 5 minutes till signs of Atropinization develops and then dose is
adjusted to maintain it for at least 24 hrs.

6. Acetylcholinesterase reactivators—oximes are used to counter Nicotinic effects

a. Pralidoxime (PAM)
b. Diacetyl monoxime (DAM)
• Effective only in case of OPC poisoning
• But contraindicated in carbamate poisoning

MOA:
1. Oximes bind to anionic site of AChE and forms a bond with OPC which is already present/bound to
esteric site of AChE
2. A strong bond is formed between OPC and oximes
3. Ultimately, OPC is removed from esteric site and reactivation of AChE

7. IV diazepam—to control seizures and muscle fasciculations

8. Supportive measurement

Medico-legal Duties in Case of OPC Poisoning

Refer to long question no. 1.

MLI:
1. Hospitalizing all symptomatic patients for at least 4–6 days following resolution of
symptoms is needed, because of the risk of development of respiratory depression
or intermediate syndrome after resolution of acute symptoms.
2. Symptoms of OPC poisoning can imitate other toxidromes and diseases. The clinician
must keep in mind that misdiagnosis may occur.
 168 Exam Preparatory Manual of Forensic Medicine and Toxicology

3. Accidental and occupational poisoning occurs in manufacturers, packers, sprayers

and in children.
4. Suicidal poisoning is common in India, both in rural and urban areas.

7. Write clinical features and management in case of accidental ingestion of

parathion. What are the precautions to be taken to minimize occupational
exposure? (West Bengal University 2017)

Ans:
Clinical Features and Management
Refer to long question no. 6.

Precautions to be Taken to Minimize Occupational Hazard

Occupational exposure occurs in workers involved in the manufacture of pesticides,
users (e.g., exterminators of house pests), farmers and professional applicators of
pesticides. Pesticide application in confined areas (e.g., green houses) also contributes
to high potential for exposure through inhalation.
1. Farmers’ exposure to pesticides can be reduced through less use of pesticides through
alternative cropping systems (like use of natural processes) that are less dependent
on pesticides.
2. Use of personal protective equipment (PPE) can be used to decrease dermal exposure.
Gloves, boots, hats, long sleeve shirts, and chemical-resistant coveralls are among
the most common types of PPE.
a. The use of gloves and boots are the minimum PPE for most pesticide products.
b. Wearing gloves has been found to be the most effective protection method.
c. Protection is better by waterproof polypropylene fabrics compared with cotton
garments.
3. Proper protection of the eyes should also be used when there is a chance of exposure
to spray or dusts. Protective goggles should be used.
4. Respirators and gas masks provide protection from respiratory exposure.
5. One should not re-enter areas of application until after proper interval of time.
Doctor and nurses should be protected with water-impermeable gowns, masks with eyeshields,
and use double gloves while handling the patient.

8. Classify poisons. Discuss clinical features, management and postmortem

findings in acute organophosphate poisoning. What viscera shall you preserve
in such cases? (Delhi University 2019)

Ans:
Classification of poisons: Refer to long question no 2.
Clinical features and management: Refer to long question no 6.
 Toxicology 169

PM Findings in Case of OPC Poisoning

External Internal
1. Smell of kerosene from nostrils and mouth 1. GIT— congested
2. Signs of asphyxia—congestion of face, 2. Lungs—congested and edematous
cyanosis of lips, nails and mucous membrane 3. Brain—congested and edematous
3. Blood tinged froth coming out of mouth 4. Other viscera—congested and edematous
and nostrils

Viscera preservation in OPC poisoning: Refer to short note no 18.

9. Name the major type of poisonous snakes in India. Describe the signs,
symptoms and treatment of snakebite case. (North Eastern Hill University, Shillong
2016, Supple 2020) (VNS, Gujarat 2017)

Ans:
In India, the major types of poisonous snakes are—common cobra, common krait,
Russell’s viper and saw-scaled viper.

Signs and Symptoms

Cobra venom produces both convulsions and paralysis, while krait causes only
paralysis. Whereas hemorrhage from external orifices is seen in viperine bite.
• Puncture marks at the site bite
• Severe pain and tenderness at the site
• Nausea, vomiting, or diarrhea
• Labored breathing
• Rapid heart rate, weak pulse

Neurotoxic (cobra/krait) Vasculotoxic

• Local necrosis causes ‘wet gangrene’ with a • Redness, swelling, bruising, bleeding, or blistering
characteristic putrid smell. around the bite
• Drooping of head, lower lip and eyelids with • Local necrosis is extensive which lead to dry gangrene,
blurring of vision. • More local reaction is seen along with pain and oozing
• Increased salivation and sweating. • Serous and serosanguineous blisters seen.
• Numbness or tingling around face, speech is • Bilateral parotid swelling (‘viper head’).
affected, tongue paralyzed. • Petechial hemorrhages, epistaxis, hemoptysis,
• Muscles of the extremities become weak. hematuria,
Paralysis of limbs, and respiratory muscles. • Acute renal failure, hypotension
[Mnemonic (elapid bites)
5Ds—Dyspnea, Dysphonia, Dysarthria, Diplopia, Dysphagia
2Ps—Ptosis, Paralysis]
 170 Exam Preparatory Manual of Forensic Medicine and Toxicology

Treatment

Prevention of Spread of Venom (First aid)

Dos Don’ts
• Lay or sit down with the bite in a neutral • Do not apply a tourniquet.
position of comfort. • Do not manipulate the wound.
• Remove rings and watches in anticipation • Do not suck out the venom.
of swelling. • Do not apply ice or immerse the wound in water.
• Wash the bite with soap and water. • Do not drink alcohol as a painkiller.
• Cover the bite with a clean, dry dressing. • Do not take pain relievers (aspirin, ibuprofen, etc.).
• Pressure immobilization technique can be • Do not apply electric shock.
used for elapid bites.

Antisnake Venom (ASV)

1. Antivenom is indicated for patients with clinical manifestations with moderate to
severe envenomation.
2. The freeze dried polyvalent antisnake venom (ASV) serum available in India is
effective against common venomous snakes (cobra, common krait, saw-scaled viper
and Russell’s viper).
3. It is less potent, less immunogenic and less effective than monovalent, and has more
adverse effects.
 Toxicology 171

4. Dose: Freeze-dried antivenom serum is dissolved in water. About 80–100 mL serum

should be diluted in 200–500 mL of isotonic saline and given slow IV.
5. The recommended initial dose of ASV is 8–10 vials administered slowly via IV route
over a period of 1 h.

Supportive Treatment
a. Broad spectrum antibiotics.
b. Tetanus toxoid.
c. Surgical excision: Early surgical intervention is done to prevent extension of infection
and development of gangrene.
d.

Neurotoxic bite Vasculotoxic bite

• Patient is nursed in lateral position, and • Fluid resuscitation (for hypotension) with NS, Ringer’s
salivation cleaned to prevent aspiration. lactate, 5% albumin, fresh whole blood or FFP.
• Endotracheal intubation, O2 Dopamine can be given.
supplementation and tracheostomy. • Rehydration, diuretics or dopamine in oliguria.
• Atropine followed by neostigamine • Hemodialysis in acute renal failure.
is given IV. • Fresh blood, FFP or platelet concentrates for
coagulopathy.

10. A male patient is brought to emergency with history of snakebite. Examination

revealed two pinpoint puncture wounds over dorsum of right foot with oozing
of blood and edema around. How will you confirm your diagnosis that it was
vasculotoxic snakebite? Write in short management of vasculotoxic and
neurotoxic snakebite. (West Bengal University 2018)
Ans:
Confirmation of Vasculotoxic Bite (Viperine)
20 min whole blood clotting test (20 WBCT)
1. Place a few ml of venous blood in a clean, dry, glass tube/bottle.
2. Leave it undisturbed for 20 min at room temperature.
3. Tip the tube once.
4. If the blood is still unclotted and runs out, the patient has hypofibrinogenemia
(‘incoagulable blood’) due to venom-induced consumption coagulopathy.
A normal 20 WBCT and clot lysis would exclude viperidae species.

Management of of Vasculotoxic and Neurotoxic Snakebite

Refer to long question no. 9.

11. Which poison is commonly known as ‘road side poison’? Describe clinical
feature of that poison. (West Bengal University 2018)
Ans: Refer to long question no. 4.
 172 Exam Preparatory Manual of Forensic Medicine and Toxicology

12. Discuss in detail mechanism, signs and symptoms, fatal dose, fatal period,
treatment and postmortem findings in case of cyanide poisoning or
hydrocyanic acid poisoning. (Adesh, Bathinda 2019, 2018) (Rajiv Gandhi University,
Bengaluru 2018) (Pondicherry Supple 2017)
Ans:
MOA (in sequence)
1. Cyanide inhibits enzyme cytochrome oxidase/complex IV
2. Cyanide reacts with cytochrome oxidase to form cytochrome-oxidase-cyanide
complex
3. Blocking the final step of oxidative phosphorylation and preventing ATP formation
4. So arrest in aerobic resp. results in histotoxic hypoxia
5. Blood is saturated with O2 and there is O2 supply at tissue level but tissues are not
able to utilize O2
6. Hence, conversion of pyruvate into lactate resulting in lactic acidosis
Fatal dose
• HCN: 50–60 mg
• NaCN/KCN: 200–300 mg
Fatal period
• HCN: 2–10 min
• NaCN/KCN: 30 min

Signs and Symptoms

GIT Burning taste, throat constriction and numbness, salivation, froth at mouth and nostrils
CNS Headache, vertigo, dizziness, coma, anxiety
CVS Initially, hypertension with reflex bradycardia. Later, hypotension with reflex tachycardia
RS Initially, tachypnea and dyspnea. Later, respiratory depression. Smell of bitter almond in breadth
Eyes Prominent eyes. Pupils dilated.

Treatment
1. Stabilization of patient: Maintain airway, breathing and circulation (ABC) by using
assisted ventilation, 100% oxygen and cardiac monitoring.
2. Decontamination: Remove the person from the source of poisoning. Remove
clothing, brush off any powder from the skin and flush the skin with water.
3. In case of ingestion: Gastric lavage is done with 5–10% solution of sodium
thiosulfate, followed by potassium carbonate to form Prussian blue which is inert.
Activated charcoal is ineffective (because of low binding of cyanide)
4. Antidotal therapy: An antidote kit comprises:
i. Amyl nitrite
ii. Sodium nitrite
 Toxicology 173

iii. Sodium thiosulfate

1st step: 0.3 ml ampoule of amyl nitrite pearl is broken in a gauze and the victim
is made to inhale for 30 secs, every minute, and use a new pearl every 3 min.
2nd step: 10 ml of 3% solution (300 mg) of sodium nitrite is injected IV slowly
3rd step: 50 ml of 25% solution (12.5 g) of sodium thiosulfate over 10–20 min, by
the same needle.

5. Hydroxycobalamine/Vitamin B12—introduced by IV route.

As it binds with cyanide to form cyanocobalamine
6. Dicobalt EDTA.

Postmortem Findings

External Internal
1. PM staining—Bright red in color 1. Smell of bitter almonds on opening the body cavity
2. Froth coming out of mouth and nostrils 2. Oral/perioral erosions
3. Smell of bitter almonds from the body 3. Stomach—smell of bitter almonds
4. Lungs—congested and edematous
5. Other viscera—congested and edematous

13. Rohini, a 17-year-old girl was brought to the emergency in an unconscious

state and convulsions with history of consumption of bitter almonds. What is
your probable diagnosis? How does the almond become toxic in the body?
How will you manage the condition of the patient? (West Bengal University
supple 2019)

Ans:
• The probable diagnosis is cyanide poisoning.
• Bitter almonds contain cyanogenic glycoside amygdalin (harmless). Hydrogen
cyanide is released when amygdalin undergoes enzymatic hydrolysis in GIT leading
to poisoning. The toxicity of amygdalin is directly related to the release of HCN.
The enzymes which catalyze the hydrolysis of amygdalin are supplied by the GI
flora.

Management of the Condition (Cyanide Poisoning)

Refer to long question no. 12.
 174 Exam Preparatory Manual of Forensic Medicine and Toxicology

14. Classify irritant poisons. Discuss in detail signs and symptoms, fatal dose, fatal
period, treatment and postmortem findings in case of ALPHOS poisoning.
(Adesh, Bathinda Supple 2019) (Rajasthan University 2018)

Ans:
Classification of Irritants

Inorganic 1. Metallic—As, Pb, Hg, Cu

2. Nonmetallic—phosphorus, chlorine, iodine
Organic 1. Plants—Abrus precatorius, castor, croton, calotropis
2. Animals—snakes, scorpions, spiders
Mechanical Powdered glass, diamond dust

ALPHOS POISONING
Signs and Symptoms

Due to inhalation Due to ingestion

1. Mild: Mucous membrane irritation, 1. GIT: Epigastric pain, retrosternal pain, vomiting
headache, dizziness, resp. distress 2. CVS: Tachycardia and arrhythmias, shock
2. Moderate: Ataxia, numbness, weakness, 3. RS: Tachypnea, dyspnea, crepitations
paralysis, tremors 4. CNS: Restlessness, altered sensorium, convulsions
3. Severe: ARDS, arrhythmias, CHF, Coma, 5. Hepatobiliary system: Jaundice, hepatitis, fever
convulsions

Fatal dose
• Ingestion: 1 tablet
• Inhalation: 400–600 ppm
Fatal period: 1 to 4 days

Treatment
1. In case of inhalation poisoning—remove the patient from source of contamination
into an open area
2. Maintain airway, breathing and circulation (ABC)
3. To reduce absorption of phosphine gas
• Perform gastric lavage with 1:10000 KMnO4 and activated charcoal
• Antacids and liquid paraffin can also be used
4. To enhance excretion of phosphine gas
• IV fluids—to maintain adequate hydration and renal perfusion
• Dialysis—in case of renal failure
5. Treatment of shock
• IV fluids
• Hydrocortisone
• Low dose dopamine
• Extracorporeal membrane oxygenation (ECMO)
 Toxicology 175

6. Treatment of metabolic acidosis

• IV sodium bicarbonate (NaHCO3)
• If fails to correct metabolic acidosis, then hemodialysis is done
7. Treatment of arrhythmias and toxicity
• IV MgSO4 is used to correct hypomagnesemia and arrhythmias
• Anti-arrhythmic agents.

PM Findings
1. Garlic odor from mouth and nostrils
2. Blood tinged froth from mouth and nostrils
3. Stomach—hemorrhage and ulcerations
4. Lungs—congested and edematous
5. All other viscera—congested and edematous.

15. Classify irritant poisons. Describe the clinical features of acute arsenic
poisoning along with laboratory investigation. Add a note on the differences
between arsenic poisoning simulating natural disease condition. (Sher-i-Kashmir
Institute, Srinagar supple, 2019)

Describe the mechanism of action, signs, symptoms, management and

postmortem findings in case of acute arsenic poisoning. (Adesh, Bathinda 2018)
Ans:
Classification of Irritant Poisons
Refer to long question no. 14.
For difference between arsenic poisoning and natural disease—refer to difference
no. 5.
MOA—arsenic affects cellular respiration by binding to the PDH enzyme in
mitochondria
• Inhibits the process of oxidative phosphorylation
• Reduced cellular ATPs
• Apoptosis of cells

Signs and Symptoms

GIT Gastroenteric form of acute poisoning (in sequence)

1. Metallic taste, burning pain in throat, intense thirst, garlic odor in breadth
2. Vomiting: Profuse, projectile, dark brown in colour
3. Purging: Initially stools are bloody, but later becomes rice watery (as seen in cholera)
4. Tenesmus, pain around anus
5. Colicky abdominal pain
CVS Hypotension, ARDS, week pulse, sunken eyes, arrhythmias
Renal Painful micturition, oliguria and uremia
Skin Delayed loss of hair, skin eruptions
Liver Fatty degeneration
 176 Exam Preparatory Manual of Forensic Medicine and Toxicology

Lab Investigations
1. Urine: Excretion of >50 μg/L in 24 hrs urine is indicative of poisoning
2. Blood: 0.9 μg/dL
3. Hairs: 75 μg% of arsenic
4. Nails: 100 μg% of arsenic

Treatment
1. Maintain airway, breathing and circulation (ABC)
2. Perform gastric lavage with 1:5000 KMnO4 to enhance elimination
3. Chelation therapy with BAL
• Antidote of choice
• Given IM only
• Dose of BAL in case of severe cases is 3 mg/kg at
4 hourly For first 2 days
6 hourly For next 4 days
12 hourly For next 6 days until full recovery

4. Whole bowel irrigation

5. Purgatives can be used to remove the unabsorbed poison from the body
6. IV fluids, sodium bicarbonate—to correct shock
7. Hemodialysis can be done.

PM Findings

External Internal
1. Sunken eyeballs 1. Ulceration of mouth, pharynx and esophagous
2. Rigor mortis appears early 2. Stomach
3. Delayed putrefaction • Mucosa: Swollen and edematous
4. Emaciated look due to dehydration • Red velvety appearance
3. Lungs: Congested and edematous
4. Liver: Congested and edematous
5. Other viscera: Congested and edematous
6. Heart: Subendocardial petechial hemorrhages

16. A 34-year-old police officer with no previous relevant medical history suffers
from crampy abdominal pain, intermittent nausea, occasional vomiting, and
persistent diarrhea for several weeks in conjunction with muscular weakness
to his lower legs and exfoliative rash on palmar surface of both hands and
planter of both feet. (Pondicherry 2016)
a. What is the cause of this man’s apparent gastroenteritis and why?
b. What are the other usual signs and symptoms?
c. What studies should be obtained when considering the diagnosis?
d. Which treatment modalities are used for this?
e. What is the medico-legal importance?
f. As a treating physician, what is your role in such case?
 Toxicology 177

Mention briefly the symptoms, signs and management of a case of chronic

arsenical salt poisoning due to consumption of water of well/tube well
contaminated with arsenic salts present in the earth. (West Bengal University
2019) (VNS, Gujarat 2017)

Write clinical features and diagnosis tests of a case of chronic arsenic

poisoning. How will you manage a case of acute arsenic poisoning? (Rajasthan
University 2016)
Ans:
a. The cause of man’s apparent gastroenteritis could be Chronic Arsenic poisoning.
b. Clinical features (signs and symptoms)
GIT Nausea, vomiting, diarrhea, abdominal cramps
Skin • Rain drop pigmentation
• Bilateral hyperkeratosis of palms and soles
Hair Alopecia, golden hair
Nails Aldrich-Mees line—transverse white lines
Bone • Bone marrow depression
• Pancytopenia
Nerves • Affects sensory nerves (mainly)
• Peripheral neuropathy in glove and stocking pattern (i.e. numbness of hands and feet),
polyneuritis, anesthesia.
Blood vessels Vasospasm and thrombosis leading to development of gangrene/Black Foot disease

c. Diagnosis
1. NAA (Neutron Activation Analysis)
2. AAS (Atomic Absorption Spectrometry)
3. Take samples from the hair, nails and bone, soil (arsenic is imbibed from the
surrounding soil after death)
Refer to long question no. 15 for other investigations.
d. Treatment
1. Remove the patient from source of exposure
2. BAL in usual doses
3. Vitamin B complex, mineral supplements
4. Symptomatic treatment
Management of a case of acute arsenic poisoning: Refer to long question no. 15.
e. Medico-legal aspects
1. Homicide was common because it is cheap, colorless, odourless, tasteless, easily
obtainable, symptoms simulate those of cholera and onset of symptoms are
gradual.
2. Suicide is rare.
3. Accidental death may be due to admixture with articles of food, or from its
improper medicinal use.
4. Chronic poisoning results from drinking well water containing arsenic.
 178 Exam Preparatory Manual of Forensic Medicine and Toxicology

5. It is applied on abortion sticks to procure abortion.

6. It may be used as cattle poison.
f. Duties of a doctor with regards to poisoning: First of all, we should treat the patient.
For legal duties refer to long question no. 1.

17. Classify poisons. Describe the signs, symptoms and treatment of a case of
opium poisoning. (North Eastern Hill University, Shillong Supple 2018)
Ans:
Classification of Poisons
Refer to long question no. 2.
Signs and symptoms of opium poisoning can be classified into 3 stages: Triad of
respiratory depression, pinpoint pupils and impairment of sensorium is characteristic
of opium poisoning.
1. Stage of Excitement: Euphoria, feeling of well-being, freedom from anxiety,
talkativeness and laughter. Hallucinations, flushed face, red eyes and rapid heart
rate.
2. Stage of Stupor: Headache, nausea, vomiting, weakness, heaviness in limbs,
giddiness, drowsiness, diminished sensibility and feeling of sleepiness. Pupils are
contracted, and face and lips are cyanosed.
3. Stage of Narcosis/Coma: Patient passes into deep coma. Muscles are flaccid and
relaxed, absent reflexes, congested conjunctiva, secretions are suspended except
perspiration. Non-reacting, pinpoint pupils, hypotension, hypothermia, weak and
feeble pulse, slow and steatorous respiration, coma.
(Mnemonic—ESpN)
Treatment
1. Support vitals through respirator and other emergency procedures (ABC).
2. Stomach wash with 1:5000 KMnO4.
3. Activated charcoal—method of choice for decontamination following ingestion.
4. Enema with 30 g of sodium sulphate twice daily.
5. Whole-bowel irrigation in body packers.
6. Naloxone (dose of 0.4–2 mg IV/IM) repeated every 2–3 min, if no response occurs.

18. What is hooch tragedy? Write the signs, symptoms and management of methyl
alcohol poisoning. (North Eastern Hill University, Shillong Supple 2017)

Discuss the clinical findings, management and medico-legal aspect of methyl

alcohol poisoning. (Adesh, Bathinda Supple 2017, 2016) (North Eastern Hill
University, Shillong supple 2016) (Delhi University, 2018)
Ans:
Hooch Tragedy
It is accidental consumption of liquor containing methyl alcohol by lower
socioeconomic classes. Hooch is spurious alcoholic preparation. Outbreak of hooch
 Toxicology 179

tragedies especially in the villages and slum areas are common because the adulterated
liquors are inexpensive and potent.

Signs and Symptoms (Clinical Findings)

GIT Nausea, vomiting, cramps in abdomen, alcohol odor, dehydration.

Eyes Pupils: Fixed and dilated. Photophobia, blurred or misty vision (snowfield vision), scotoma,
decreased light perception, diminution of visual fields causing blindness due to optic neuritis and
atrophy.
CNS Headache, dizziness, vertigo, restlessness, muscular weakness, hypothermia, delirium, amnesia,
convulsion (terminal event), coma.
RS Dyspnea, cyanosis, respiratory depression.
Renal Acidosis, strongly acidic urine, scant urine.

Treatment
1. Gastric lavage is done with sodium bicarbonate solution to prevent absorption.
2. Sodium bicarbonate in 250 ml of water, 4 hourly orally to treat acidosis.
3. Ethanol is given as competitive antagonist: Dose 0.8–1 ml/kg orally of 95% ethanol
in 200 ml of orange juice or 10 ml/ kg IV of 10% ethanol in D5W over 30 min.
4. Antidote is 4-methylpyrazole (fomepizole): Competitive inhibitor of alcohol
dehydrogenase. It blocks the formation of formaldehyde and formic acid.
5. Calcium folinate IV, thiamine and pyridoxine may be given.
6. Eyes should be kept covered to protect them from light.
7. Hemodialysis in case of severe poisoning.
8. Symptomatic treatment.

19. Classify poison. Describe the signs, symptoms, complications, treatment and
postmortem appearances of sulphuric acid. (Andhra Pradesh Supple, 2016)

Ans:
Classification of Poison
Refer to long question no. 1.

SULPHURIC ACID POISONING

Signs and Symptoms
1. Oropharyngeal burns (blackening) and pain in throat and epigastrium
2. Nausea and vomiting
3. Violent cough, dyspnea and glottic edema
4. Teeth become chalky white
5. Intense thirst, scanty urine
6. Swollen lips and tongue
7. Abdomen: Tender and distended
8. Constipation and tenesmus
 180 Exam Preparatory Manual of Forensic Medicine and Toxicology

Complications
1. Neurogenic shock
2. Perforation of stomach
3. Peritonitis
4. Septicemia
5. Septic shock
6. Glottic edema and asphyxia
7. Esophageal stricture
8. Renal failure

Treatment
1. Maintain airway, breathing and circulation (ABC)
2. In case of glottic edema—tracheostomy is recommended
3. Correct circulatory shock—by IV fluids, glucose
4. Gastric lavage is contraindicated
5. Milk/water should be given immediately to neutralize the acid
6. Avoid sodium bicarbonate
7. Start with steroids—to prevent inflammation and long-term complications
8. IV antibiotics—in case of perforation
9. Painkillers like morphine—to reduce pain
10. Symptomatic treatment
11. In case of skin burns—wash with large amount of water.

PM findings

External Internal
• Erosion of skin, angles of mouth and lips • Corrosion of trachea and larynx
• Chalky white appearance of teeth • Blackish charring of stomach and thinning of stomach
mucosa
• Perforation of stomach
• Toxic swelling of kidneys and liver

20. Classify poisons. Discuss the general principles of treatment of a case of

poisoning. (BFUHS, Punjab 2015) (VNS, Gujarat 2016)
Ans:
Classification of Poison
Refer to long question no. 1.
 Toxicology 181

General Principles of Treatment in Case of Poisoning (Treatment of Unknown Poisoning)

• Immediate resuscitation of the patient and maintain
A—Airway Chin lift, suctioning of secretions to clear airway
B—Breathing O2 supply by bag and mask ventilation, ventilators, ET tube
C—Circulation Measure BP, pulse, continuous ECG monitoring
D—Disability/CNS Depression Corrected by drugs and IV fluids

• Removal of unabsorbed poison

Injected poison 1. Remove the sting in case of bee, wasp
2. Apply tourniquet or ice locally
3. Treat allergy and anaphylaxis
Contact poison 1. Remove clothes
2. Wash the affected area with soap and water
Inhaled poison 1. Remove the patient into fresh air
2. Start O2 supplementation
Ingested poison Gastric lavage with water/KMnO4/activated charcoal is done to
remove the unabsorbed poison from stomach with the help of Ewald
tube or Boas tube.

• Administration of antidotes: Refer to short question no. 12.

• Removal of poison by excretion: Refer to long question no. 3.

21. Classify poisons. Discuss clinical features, management and autopsy findings
in a case of phenol poisoning. What viscera will you preserve in such a case?
(Delhi University 2015)
Ans:
Classification of Poisons
Refer to long question no. 2.

Signs and Symptoms

Acute Phenol Poisoning—also called Carbolism

Systemic effects
1. Eyes—Pupils constricted
2. Skin is cold and clammy
3. GIT—Burning and tingling sensation, and later on anesthesia. Diarrhea, pain in abdomen, but vomiting
is rare.
4. CNS—CNS depression (like headache, giddiness)
5. Kidneys—Renal failure
6. RS—Laryngeal edema and pulmonary edema
7. CVS—Pulse is rapid, feeble and irregular. Unconsciousness and coma.
8. Carboluria—after 36–48 hrs of ingestion of carbolic acid, the urine is scanty and suppressed with greenish
hue.
Local effects: Damage to nerve endings → Tingling sensation → Numbness → Painless white eschar
 182 Exam Preparatory Manual of Forensic Medicine and Toxicology

PM Findings

External Internal
• Corrosion of mouth, tongue and chin • Stomach—hardening of stomach mucosa giving rise to
• Smell of phenol at the mouth brown leathery stomach
• Kidneys—hemorrhagic nephritis

Management of Phenol Poisoning

1. Maintain airway, breathing and circulation (ABC)
2. Gastric lavage with water containing charcoal, olive oil (only corrosive acid
poisoning in which gastric lavage is indicated)
3. Normal saline containing sodium bicarbonate IV
4. In case of renal failure: Hemodialysis is performed.
Viscera to be Preserved in the Case
Refer to short note no. 18.

22. A 19-year-old female presents to your emergency department after ingesting

poison following a fight with her boyfriend. She was found unconscious near
lavatory. She was brought to emergency. On examination, her lips were
swollen, she had respiratory alkalosis and metabolic acidosis. The treating
physician collected the urine for the laboratory investigations, during which
the urine turned green on exposure to air. The patient died on 6th day during
treatment. She was subjected to postmortem examination next day. No
previous suicide attempts or history of depression. (Pondicherry 2019)
a. What substance or poison did the patient ingest?
b. What is the mechanism for the color change of urine?
c. What are the routine viscera will you collect and preserve the same for
chemical analysis?
d. As a treating physician, what is your role in such case of suspected
poisoning?
Ans:
a. She may have ingested phenol (carbolic acid).
b. Mechanism for color change—refer to long question no. 21.
c. Routine viscera collected and persevered for chemical analysis—refer to Short
No. 18.
d. Duties of a doctor with regards to poisoning: First of all, we should treat the patient.
For legal duties refer to long question no. 1.
 Toxicology 183

23. Classify poisons according to signs and symptoms which they produce. Discuss
about ideal homicidal poison. (Pondicherry 2015) (VNS, Gujarat 2017)
Ans:
Signs/symptoms Causative agents
Hypothermia Ethanol, opioids, barbiturates, sedatives, hypnotics, CO, benzodiazepines (BZDs)
Hyperpyrexia Amphetamines, atropine, cocaine, salicylates, strychnine, marking nut, dhatura,
cocaine, aspirin
Miosis Opioids, phenol, OPC, carbamates, ethanol, nicotine, barbiturates, BZDs
Mydriasis Dhatura, atropine, cannabis, strychnine, HCN, anticholinergics, amphetamine,
cocaine, methanol
Diarrhea Arsenic, boric acid
Hematemesis Corrosives, salicylates
Hypotension Narcotics, barbiturates, antidepressants, cyanide, CO, H2S, arsenic
Hypertension Antihistaminics, amphetamines, LSD, cocaine
Brachypnea Alcohol, barbiturates, narcotics, elapid venom, strychnine, sedatives
Tachypnea Methanol, cocaine, salicylates, CO, cyanide, amphetamine
Coma Antihistamines, barbiturates, BZDs, ethanol, opioids, CO, cyanide, OPC, lead,
antidepressants.
Seizures Amphetamines, antidepressants, cocaine, withdrawal from alcohol

Ideal Homicidal Poison

Definition: The poison because of its characteristics favour the accused in committing
homicide.

Criteria for an Ideal Homicidal Poison

1. Should be easily available (cost immaterial)
2. Should be colorless, odorless and tasteless
3. Can be easily administered with food, drink without arousing any suspicion
4. Symptoms should mimic natural disease process
5. Should be highly toxic
6. Signs and symptoms should appear late giving enough time for the culprit to escape
7. Should not produce any specific signs and symptoms
8. Should not be detected by routine tests
9. Should not produce any specific PM findings
10. No proper antidote should be available
11. Will be destroyed in body easily
Example
1. Thallium: Most ideal homicidal poison
2. Arsenic: Most common homicidal poison
3. Others: Insulin, aconite, etc.
 184 Exam Preparatory Manual of Forensic Medicine and Toxicology

SHORT NOTES

1. Classify neurotoxic poisons with examples of one poison in each sub-category.

(Sher-i-Kashmir Institute, Srinagar 2020)
Ans:
Neurotoxic Poisons
These are the poisons which act mainly on the CNS.
1. Cerebral 2. Spinal 3. Peripheral
• Somniferous—Opioids • Strychnine (Nux vomica) • Curare
• Inebriants—Alcohol, ether • Gelsemium • Hemlock
• Deliriants—Dhatura, Cocaine
(Mnemonic—SID)

2. Duties of a doctor in case of poisoning (Jammu and Kashmir 2017) (Sher-i-Kashmir

Institute, Srinagar supple 2017) (West Bengal University 2017) (North Eastern Hill
University, Shillong 2016) (Rajasthan University 2016) (Andhra Pradesh University 2016)

Ans: Refer to long question no. 1

3. Barbiturate blisters (West Bengal University supple 2019) (VNS, Gujarat supple 2018)
Ans:
• These are tense subepidermal blisters found on the skin which occurs due to
barbiturate poisoning.
• Blisters contain clear serous fluid that on rupture leaves a red, raw surface which
dries to a brown parchment like area.
• These are found most commonly on friction areas such as axilla, buttocks, inner
aspect of knee, etc.
• Sometimes may be mistaken for burns by hot water bottle.

4. Whole bowel irrigation (West Bengal University supple 2019)

Ans:
1. It is a method of removal of absorbed poison from GIT by excretion.
2. In this method, PEG (polyethylene glyocol) solution is given via NG tube at a rate
of 2 liters/min.
3. While performing this, patient has to sit on the toilet seat.
4. This method can flush out our entire GIT within 5 hours.
5. Criteria for its use:
a. When activated charcoal is not able to adsorb the ingested poison (or)
b. When enteric coated drugs have been ingested (or)
c. When some drug is ingested by body packers for illegal transport.
 Toxicology 185

5. Toxalbumin (Adesh, Bathinda supple 2020) (VNS, Gujarat 2016, 2017)

Ans:
• Toxalbumin (also called Phytotoxin) is a toxic plant protein which is present in
plants like Abrus (rati), Castor, Croton, etc.
• It inhibits protein synthesis by inactivating ribosomes
• Structure of toxalbumin is similar to those of bacterial toxins (cholera, diphtheria,
botulinium and tetanus)
• Toxalbumins are antigenic in nature and cause agglutination of RBCs leading to
hemolysis
• Examples: Ricin, Abrin, Crotin, etc.
• MLI: As they are also cytotoxic and vasculotoxic, physiological and toxic properties
are similar to Viper snake venom.

6. Gastric Lavage (University of Health Sciences, Rohtak supple 2020) (Sher-i-Kashmir

Institute, Srinagar supple 2018) (BFUHS, Punjab supple 2016) (Rajiv Gandhi University,
Bengaluru 2015)
Ans:
• Gastric lavage is a method used for removal of unabsorbed poison from stomach
(also called stomach wash).
• Most effective—if done within 3 hrs of ingestion of poison
• Tubes used for gastric lavage
Ryle’s tube Children
Ewald/Boas tube Most commonly used in adults

• Agents used for gastric lavage

In case of children Normal saline
In case of adults • Tap water
• 1: 5000 KMnO4
• 4% Tannic acid

• Procedure
Position of the patient Left lateral position/Trendelenberg position (to reduce the chances of
aspiration)
Insertion of tube Till 50 cm mark (in case of adults) and 25 cm mark (in case of children)
Checking position of tube Little air in a syringe is forced down the tube
• Gurgling sounds heard through stethoscope placed over the stomach
• Hissing sounds heard on other end—means tube has entered trachea
Pouring of fluid • After confirmation of tip of tube, 250 ml of warm water is poured
through the funnel
• The first wash is preserved for chemical analysis
 186 Exam Preparatory Manual of Forensic Medicine and Toxicology

• Contraindications of gastric lavage

Absolute contraindications Relative contraindications
Corrosive poisoning—as risk of perforation 1. Convulsant poison (strychnine)
(except carbolic acid poisoning) 2. Comatose patient
3. Compromised unprotected airway
4. Kerosene/ volatile poisons
5. Esophageal varices
(Mnemonic: Cs as in “Contraindications”)

7. Contraindications of gastric lavage (Sher-i-Kashmir Institute, Srinagar supple 2019)

(VNS, Gujarat supple 2019) (Sai Tirupati University, Rajasthan 2019)
Ans:
Refer to short question no. 6.

8. Stomach wash tube (KHMS, Tamil Nadu Supple 2020)

Ans:
• It is also called Ewald tube or Boas tube.
Parts of the tube
Material used Made up of soft rubber
Length 1.5 Metres
Diameter 1 cm
Proximal end Has funnel
Distal end Is rounded with two lateral openings
Middle point Suction bulb—to pump out stomach contents
Marking At 50 cm from the lower end; mouth gag is present near it

• MLI: Used for removal of unabsorbed poison

 Toxicology 187

9. Factors affecting action of poison in the body. (Pondicherry 2017)

Ans:
The various factors affecting the action of poison in the body are:
1. Quantity: Toxic effects of drugs increase with increase in dosage of the drugs
2. Form
Physical state On the basis of onset of action
Gases and vapors > liquid form > solid form
Mechanical combination Alteration in the action of poison when combined mechanically with
inert substance, e.g. corrosive when mixed with water act as irritant

3. Mode of administration
Order of rapidity of action-
Inhaled in gaseous/vapour form > IV > IM > SC/ID > application to wound > ingestion
> introduction to natural orifices
4. Condition of the patient
Age Toxic effects of poison are more in extremes of the age
State of health Healthy person tolerates poison better than the diseased
Tolerance A dose of a poison which is toxic for someone may not be so in other which is
because of the development of tolerance, e.g. alcohol, amphetamines,
barbiturates
Idiosyncrasy Even a small dose of the substance leads to toxic effects which is due to
hypersensitivity towards the drug, e.g. penicillin, cocaine, mushroom
State of stomach Presence of food in stomach delays the action of poison
Sleep and intoxication Action of poison gets delayed:
• If person goes to sleep soon after its intake (or)
• If person takes poison in intoxicated state

10. Mention agents causing miosis. (Sher-i-Kashmir Institute, Srinagar supple 2019)
Ans:
Miosis is constriction of pupils. The agents causing miosis are:
Opioids (opium, morphine, heroine)
Organophosphates
Carbamates
Caffeine
Phenol
Pilocarpine
Barbiturates
Benzodiazepines
Neostigmine
Physostigmine

(Mnemonic—OCP & BNP)

 188 Exam Preparatory Manual of Forensic Medicine and Toxicology

11. Ideal suicidal poison. (Sher-i-Kashmir Institute, Srinagar supple 2015)

Ans:
Definition
The poison characteristics which are in favor of person committing suicide.
Criteria for an Ideal Suicidal Poison
1. It should be cheap and easily available
2. It should have a pleasant taste
3. It must be odorless
4. Can be easily mixed with food or drink
5. It should be highly toxic
6. It should produce painless death
Examples: Cyanide, Barbiturates, OPC, Alphos

12. Antidotes (Sher-i-Kashmir Institute, Srinagar supple 2018, supple 2017) (BFUHS,
Punjab 2017) (Sardar Patel University, Gujarat 2018) (Jammu and Kashmir University
2017) (KHMS, Tamil Nadu 2017) (Uttarakhand University supple 2016) (VNS, Gujarat
2017)

Ans:
Definition
Antidotes are substances that act specifically to counteract the action or poisonous
effects of a toxic agent.
The various types of antidotes are:

1. Physical antidotes They neutralise the poison either by its mechanical action or by
preventing its absorption.
• Activated charcoal: It acts by adsorbing the poison on its surface;
dose—1 g/kg body wt.
• Demulcents: Forms a protective layer over the gastric mucosa, thus
preventing absorption of poison, e.g. aluminium hydroxide,
magnesium hydroxide, milk
2. Chemical antidotes They neutralise the poisons by reacting with it and forming a harmless
compound.
• KMnO4 (1:5000) oxidises the poison and reduces itself (losing pink
color). Effective against most of the alkaloids (opioids, barbiturates)
• Tannic acid—used in lead, mercury, zinc poisoning
• Albumin—used in mercury chloride and copper poisoning
• Tincture Iodine—used in lead, mercury poisoning
3. Physiological/pharmacological Antidotes act on the target cell and produce pharmacological effects
antidotes exactly opposite to the action to those produced by poison, e.g.
atropine for OPC poisoning
4. Chelating agents They inactivate the metallic ions by forming a complex with the
metallic poison which is soluble in water and excreted through urine,
e.g. BAL, EDTA, Desferrioxamine, Penicillamine, etc.
 Toxicology 189

13. Universal antidote (Pondicherry supple 2017) (Delhi University 2015) (Rajiv Gandhi
University, Bengaluru 2015) (VNS, Gujarat supple 2018, 2019)
Ans:
• It was earlier used when the exact nature of the poison consumed was not known.
• It is a mixture of 3 antidotes (2 physical and 1 chemical antidotes) in a specific ratio.
Activated charcoal 2 Adsorbs alkaloids
Tannic acid 1 Precipitates alkaloids, glycosides and metals
Magnesium hydroxide 1 Neutralizes acid

(Mnemonic—ATM)

• It is ineffective and not used nowadays.

14. Chemical antidotes (Sardar Patel University, Gujarat supple 2018)

Ans:
Refer to short question no. 12.

15. Chelating Agents (Rajiv Gandhi University, Bengaluru 2020) (BFUHS, Punjab supple
2019) (Rajasthan University 2018) (AIIMS, Patna 2017) (Himachal Pradesh 2017)
(University of Health Sciences, Rohtak 2017) (Uttarakhand University 2016) (GMC,
Chandigarh 2015)
Ans:
1. Chelating agents are specific antidotes against heavy metal poisoning.
2. These chelating agents have free sulfhydryl (–SH) groups which compete with the
thiol groups of enzymes for binding with heavy metals to form a stable metal—
chelate complex. The formed complex is then excreted from the body through urine.
3. They thus prevent the union of the metal with the –SH group of the respiratory
enzyme system.
Some examples of chelating agents are:
a. BAL is used in (mnemonic-BAL CM) bismuth, arsenic, lead, copper, mercury and
other heavy metal poisoning. It is given IM. Contraindicated in liver damage, G-6-
PD deficient individuals, and cadmium and iron poisoning. BAL has two unsaturated
–SH groups which combine with the metal and prevents the union of the metal
with the –SH group of the respiratory enzyme system.
– Dose: 10% solution in oil, 3–5 mg/kg IM 4 hourly for 2 days, 6 hourly on 3rd day
and then 12 hourly for next 10 days.
– Side effects: Nausea, vomiting, headache and hypertension.
b. EDTA is useful in lead, copper, cobalt, cadmium, iron and nickel poisoning; better
than BAL for treatment of arsenic and mercury poisoning. It is given IV;
contraindicated in renal failure.
c. Penicillamine is used for treatment of copper, lead and mercury poisoning. It is
given orally.
d. Desferrioxamine is useful in acute iron poisoning. It is given IV.
(Mnemonic—Ferric/Fe3+)
 190 Exam Preparatory Manual of Forensic Medicine and Toxicology

16. BAL is not injected by intravenous route (West Bengal University 2019)
Ans:
BAL is given by deep IM route not by IV route as the preparation contains oil which
can cause fat/oil embolism. BAL is available in ampoules in combination with benzyl
benzoate (20%) in peanut oil.

17. BAL antidote (Rajasthan University 2015)

Ans: Refer to short question no. 15.

18. Viscera preservation for chemical analysis in case of suspected poisoning after
PM examination (Sher-i-Kashmir Institute, Srinagar supple 2019, 2017, 2015) (Jammu
and Kashmir 2017) (Uttarakhand University 2017) (Rajiv Gandhi University, Bengaluru
2015)
Ans:
a. Viscera preservation (in routine)
Bottle 1 Stomach along its contents and upper part of small intestine (30 cm) along with its
contents
Bottle 2 Liver—300 gm along with gall bladder
Kidneys—half of each kidney
Bottle 3 (vial) Blood—10 ml
Bottle 4 Urine—100 ml
Bottle 5 Sample of the preservative

b. Additional viscera preservation (in certain poisoning)

Brain Cerebral poison

Heart Aconite
CSF Alcohol
Bile (Mnemonic—GOBI) G—Glutathione
O—Opium
Bi—Barbiturates (as secreted in Bile)
Hair, nails, bone Metallic poisons
Spinal cord Strychnine

c. Preservatives used
Saturated solution of NaCl 1. Most commonly used
2. C/I in corrosive poisoning (except carbolic acid)
Rectified Spirit 1. Best preservative
2. Used in corrosive poisoning
3. C/I in carbolic acid poisoning
Formalin For histopathological examination
Sodium fluoride (NaF) (Mnemonic—COCA) CO—Cocaine,
C—Cyanide
A—Alcohol
 Toxicology 191

19. Vitriolage (North Eastern Hill University, Shillong supple 2020) (Adesh, Bathinda 2018)
(Sher-i-Kashmir supple 2018, supple 2017) (KHMS, Tamil Nadu supple 2019) (Delhi
University 2018) (Uttarakhand University 2017) (BFUHS, Punjab 2016) (Rajiv Gandhi
University, Bengaluru 2015)
Ans:
Definition
Vitriolage is defined as throwing of any corrosive agent (acid or alkali) on another person
with an intention of injuring him or for the purpose of disfiguring him out of jealousy
1. Substances used for vitriolage: Sulphuric acid, nitric acid, carbolic acid, caustic
soda, marking nut juice
2. Characteristics of burns
• Discoloration and staining of the skin and clothing (brown-black in sulphuric
acid, and yellow in nitric acid).
• Trickle marks
• Scar tissue causes contractures.
3. Treatment

For skin burns For eye burns

a. Wash the affected area with plenty of water and soap a. Wash eyes with plenty of water
b. Apply thick paste of MgO over the skin b. Topical anesthetic drop
c. Apply antibiotics over the raw surface

4. MLI: It leads to Grievous hurt (Sec. 320 IPC) by causing:

• Permanent disfigurement of face (6th clause)
• Permanent privation of sight of either eye (2nd clause)

Punishment

Section Punishment
Sec. 326 A IPC 10 years to life imprisonment ± Fine
Sec. 326 B IPC 5–7 years of imprisonment ± Fine

20. Clinical manifestations and treatment of phenol poisoning (BFUHS, Punjab 2019)
Ans: Refer to long question no. 21.

21. Carboluria (AIIMS, Patna 2019, 2017) (Sardar Patel University, Gujarat 2019, supple
2019) (BFUHS, Punjab supple 2018) (Sher-i-Kashmir Institute, Srinagar supple 2015)
(Uttarakhand University 2015)

Ans:
It is seen in acute carbolic acid poisoning/phenol poisoning after 36–48 hrs of ingestion
of carbolic acid.
 192 Exam Preparatory Manual of Forensic Medicine and Toxicology

Mechanism
• After absorption through GIT, it is metabolised in the liver giving rise to the toxic
metabolites of Phenol, i.e. Pyrocatechol, Hydroquinone (mnemonic—Phenol)
• These metabolites are then excreted into urine, which gets further oxidised on
exposure to air giving rise to Green colour urine.
• So, the urine is scanty and suppressed with greenish hue—called Carboluria.

22. PM findings in case of sulphuric acid poisoning. (Rajasthan University 2018)

Ans: Refer to long question no. 19.

23. Internal findings at autopsy in case of inorganic acid poisoning. (Sardar Patel
University, Gujarat 2016)
Ans:
Common inorganic acids include sulphuric acid, nitric acid and hydrochloric acid
Internal findings at autopsy in case of inorganic acid poisoning are:

Sulphuric acid Nitric acid Hydrochloric acid

• Erosion of skin, angles of mouth, • Yellow discoloration of skin • Brownish parchmentization
lips with blackening • Corrosion of skin • Inflammation and edema of
• Corrosion of the trachea and larynx • Congestion of larynx and respiratory passages
• Blackish charring of the stomach, trachea • Stomach contains brownish
peppery feel • Stomach wall is soft, friable fluid
• Stomach perforation and ulcerated
• Peritonitis

24. Drug automatism. (Adesh, Bathinda supple 2017) (VNS, Gujarat 2018)
1. Definition drug automatism: It is taking of a drug (usually barbiturates) repeatedly,
forgetting each time that one has already taken the dose, because of mental confusion.
This can lead to a cumulative overdose.
2. The drug-automatism hypothesis implies a medication-induced absence of
intentionality for self-poisoning and a relative amnesia for repeated or single
overdosage.
3. Cause: The patient develops a state of amnesia after ingestion of one or several
doses of drug, and in the automatism state, takes additional doses of drug in
order to get to sleep without any intention to commit suicide and without realizing
it.
4. MLI: Such deaths should be considered “accidental” and not suicidal.

25. PM findings in case of chronic arsenic poisoning. (Uttarakhand University 2016)

Ans: Refer to long question no. 16
 Toxicology 193

26. Chronic Mercury Poisoning/Hydragyrism (Sher-i-Kashmir Institute, Srinagar 2020)

(Adesh. Bathinda supple 2020) (Uttarakhand University 2018) (Andhra Pradesh 2015)
(Pondicherry supple 2017) (Delhi University 2017) (VNS, Gujarat 2016, 2017)
Ans: Chronic poisoning occurs due to:
a. Continuous accidental absorption by workers.
b. Excessive therapeutic use.
c. Recovery from a large dose.
d. If an ointment is used as an external application for a long time.
Specific Signs Seen in Case of Chronic Mercury Poisoning
A. Due to Inorganic Mercury Poisoning

1. Mercuria Lentis a. It occurs due to exposure to mercury vapors

b. Brownish deposit of mercury on anterior lens capsule
c. On slit lamp examination: Malt brown reflex
2. Acrodynia or pink disease a. It is seen mostly in case of children
b. C/F: Hands and feet become puffy, pinkish and painful with
peeling of skin, excessive salivation or perspiration
3. Intentional Tremors a. It is also known as Danbury’s tremors or Hatter’s shake or
Glass blower’s shake or Mercurial tremors
b. Classical feature of chronic mercury poisoning
c. Tremors start from hands → lips and tongue → arms and legs
4. Mercury Erythism a. It refers to the neuropsychiatric manifestations seen in case
of chronic mercury poisoning.
b. Also called Mad Hatters
c. C/F: Insomnia, anxiety, depression, shyness, blushing,
embarrassment, hallucinations, loss of memory, etc.
(Mnemonic—LATE)

B. Due to Organic Mercury Poisoning

Minamata disease • Occurs due to consumption of contaminated fish

• C/F: Disturbances in hand coordination, gait and speech, chewing and
swallowing difficulties, visual blurring, tremors, seizures, rigidity

Management
1. Remove the patient from source of exposure
2. Chelation therapy—BAL, penicillamine
3. Oral hygiene
4. Demulcents
MLI:
1. Accidental ingestion may occur from broken thermometers
2. Metallic mercury is used in dentistry
3. Mercury chloride is used for criminal abortion
4. Suicidal and homicidal poisoning is rare.
 194 Exam Preparatory Manual of Forensic Medicine and Toxicology

27. Hatters shake (Sher-i-Kashmir Institute, Srinagar supple 2019, supple 2015)
Ans:
• It is also known as Danbury’s tremors or intentional tremors or glass blower’s
shake or Mercurial tremors
• It is a classical feature of chronic inorganic mercury poisoning
• Common in workers in hat making, glass blowing factories
• Characteristics of tremors
Tremors start from hands → lips and tongue → arms and legs
Associated with shabby and shaky handwriting, stammering and hesitation
inspeech, finally, the person is not able to write legibly or dress himself or walk
properly
• The most severe form is called Concussion Mercurialis, where no activity is
possible.

28. Mercury Erythism (Rajasthan University 2018) (Adesh, Bathinda supple 2017)
Ans:
Refer to short question no. 26.

29. Metal Fume Fever (West Bengal University 2019) (Adesh, Bathinda 2017)
Ans:
Definition: Metal fume fever is a self-limiting acute febrile illness occurs due to
inhalation of metal oxide fumes.
1. Also called smelter’s shakes, brass chills or Monday morning fever.
2. Metals involved: It is caused by acute exposure zinc oxide fumes, copper,
magnesium, nickel, mercury, lead, etc when heated above their melting point.
3. Seen in: Workers involved in welding, melting or flame cutting galvanized metal
or in brass industries
4. S/s: Flu-like symptoms (headache, fever, chills, cough, dyspnea, cyanosis, myalgia,
salivation, sweating and tachycardia) start within 4–8 hrs after exposure of fumes.
Finally, the symptoms subside within 24–36 hrs.
5. Treatment
a. Oxygen supplementation
b. Bronchodilators
c. Symptomatic treatment.

30. Phossy Jaw/ Lucifer’s Jaw. (Adesh, Bathinda supple 2019) (Rajasthan University
2018) (Uttarakhand University supple 2016) (North Eastern Hill University, Shillong
2017) (VNS, Gujarat 2017)
Ans:
Definition: Phossy jaw is a type of osteomyelitis of the lower jaw near the decayed
tooth seen in case of chronic phosphorous poisoning
1. It is also called glass jaw.
 Toxicology 195

2. Cause: Exposure to vapors of phosphorous for a long period of time

3. Clinical features:
Constitutional symptoms Specific Lesion (in order of sequence)
a. Nausea a. At first, there’s complaint of Toothache
b. Vomiting b. Followed by swelling of jaw
c. Anorexia c. Multiple sinuses, discharging foul smelling pus with loosening of
d. Pain abdomen teeth and necrosis of gum (Osteomyelitis)
e. Joint pain d. Finally, osteonecrosis of mandible develops.
f. Loss of weight

4. Treatment
a. Regular mouthwash
b. Surgical excision of the affected bone

31. Treatment of HCN Poisoning. (Rajasthan University 2018)

Ans: Refer to long question no. 12.

32. Plumbism (Sardar Patel University 2019, supple 2019) (Rajiv Gandhi University,
Bengaluru 2019, 2015) (Pondicherry 2017) (GMC, Chandigarh 2015) (Sher-i-Kashmir
Institute, Srinagar supple 2015)
Ans: Chronic lead poisoning is called plumbism.

Clinical Features
1. Anemia: There is anemia with karyorrhexis and dyserythropoiesis (punctate
basophilia, reticulocytosis, poikilocytosis, anisocytosis), nucleated red cells and increase
in mononuclear cells in peripheral blood.
2. Burtonian line: A stippled blue line is seen on the upper gum due to subepithelial
deposit of lead sulphide (by the H2S formed from decomposed protein) at the
junction of dirty or carious teeth.
3. Colic and Constipation: Colic involves both large and small intestines, ureters
and blood vessels. Pain is spasmodic, paroxysmal, occurs at night and may be
very severe. Constipation usually precedes colic.
4. Lead palsy (Drops): Common in adults than in children, and males are particularly
affected. It occurs due to degeneration of nerves and atrophy of muscles. The
extensor muscles of wrist (wrist drop) and anterior tibial (foot drop) are affected.
5. Lead Encephalopathy: Involvement of brain function, commonly in children is
present in all cases. Symptoms include changes in personality, restlessness,
hyperkinetic and aggressive behavior, fatigability, mental dullness, learning
disorders, refusal to play, etc.
6. Effects on reproductive system: It may cause sterility in both male and female
patients. In males, there may be loss of libido and impotence. In females, there
may be inFertility, menstrual irregularities.
 196 Exam Preparatory Manual of Forensic Medicine and Toxicology

7. Retinal stippling is noticed by ophthalmoscope with presence of grayish glistening

lead particles in the early phase of chronic lead poisoning.
8. Lead osteopathy: In children and young adults, lead is deposited beyond the
epiphysis of growing long bones which may lead to their abnormal development.
9. Effects on circulatory system: It causes vascular constriction leading to
hypertension and arteriolar degeneration.
10. Effect on kidneys: Acute nephropathy in form of Fanconi’s syndrome. Chronic
nephropathy causes hypertension and hyperuricemia.
(Mnemonic—ABCDEF)

Laboratory Tests
i. Microcytic, hypochromic anemia may be seen.
ii. Punctate basophilia: >200 cells/cu mm.
iii. Blood lead levels >70 μg/dL (severe toxicity) [10 μg/dL (cut-off level)].
iv. Urine lead level >80 μg/dL (in 24 h sample).
v. Coproporphyrin in urine >15 μg/dL.
vi. δ-amino levulinic acid in urine > 5 mg/L.
vii. X-ray: Radio-opaque bands or ‘lead lines’ at the metaphyseal plate of long bones
are seen in children.

Treatment
1. Remove the patient from the source of exposure.
2. Potassium or sodium iodide 1–2 g TDS orally
3. Sodium bicarbonate 20–30 g in 4 or 5 divided doses orally.
4. MgSO4 or sodium sulfate 8–12 g orally.
5. CaNa2EDTA IV in usual doses.
6. BAL: Chelator of choice in case of renal impairment.
7. Give iron, calcium, magnesium and zinc, and vitamins.

33. Brutonian line (Delhi University 2018) (Rajiv Gandhi University, Bengaluru 2015)
(Andhra Pradesh 2015) (VNS, Gujarat supple 2018)
Ans:
1. Burtonian line is seen in chronic lead poisoning.
2. A stippled blue line on the upper gum is seen in most cases.
3. Cause: Due to subepithelial deposit of granules at the junction of teeth, especially
near dirty or carious teeth of the upper jaw due to formation of lead sulphide by the
H2S formed from decomposed protein in the mouth.
4. A similar blue line may be seen in cases of poisoning with other heavy metals like
mercury, iron, copper, etc.
 Toxicology 197

34. Blood Picture in Chronic Lead poisoning (West Bengal University supple 2017)

Anemia and Basophilic Stippling occurring in Chronic lead poisoning (West

Bengal University 2017) (VNS, Gujarat 2018)
Ans:
In chronic lead poisoning, there is anemia with karyorrhexis and dyserythropoiesis
(punctate basophilia, Cabot’s rings, reticulocytosis, poikilocytosis, anisocytosis),
nucleated red cells and increase in mononuclear cells in peripheral blood and
ringed sideroblasts in bone marrow. However, polymorphonuclear cells and platelets
are decreased. RBC count comes down to 3.5 million/dL and hemoglobin level
to 6.5 g%.

Cause of Anemia
a. Impairment in heme synthesis from protoporphyrin.
b. Increased fragility of RBCs due to loss of intracellular potassium.

Punctate Basophilia
1. Punctate basophilia/basophilic stippling is seen in
chronic lead poisoning.
2. There is presence of dark blue colored pinhead sized
spots in the cytoplasm of the RBCs representing
aggregated ribosomes.
3. Cause—toxic action of lead on porphyrin metabolism.

35. Dhatura Poisoning/ Ideal Roadside Poison/ Thorn apple poisoning (Rajasthan
University 2018) (Sher-i-Kashmir Institute, Srinagar supple 2017) (Rajiv Gandhi
University, Bengaluru 2015) (Sardar Patel University, Gujarat 2016)

Ans: Refer to long question no. 4.

36. Stupefying Agents. (GMC, Chandigarh 2015, 2016)

Ans:
Definition
• Substances which are used to daze a victim or putting the victim in state of
drowsiness or unconsciousness.
• It is used by criminals for the purpose of robbery, kidnapping or rape during travel
in bus, train and railway station.
• It is usually mixed with food or drink
• Poisons used as stupefying agents are Dhatura, Cannabis, and Chloral Hydrate.
 198 Exam Preparatory Manual of Forensic Medicine and Toxicology

37. Carbon Monoxide Poisoning (Uttarakhand University Supple 2018) (VNS, Gujarat
2019)
Ans:
Signs and Symptoms
Depends on the concentration of CO in the blood (COHb%)
Severity COHb% Symptoms
Mild 10–30 Mild headache to throbbing headache, irritability, buzzing in ears,
breathlessness
Moderate 30–40 Severe headache, nausea, vomiting, dizziness, dim vision, impaired
judgement, poor concentration
Severe >40 CNS: Increasing confusion, hallucinations, convulsions, coma and death,
staggering and incoordination
RS: Rapid and irregular respiration
CVS: Weak thready pulse, hypotension, arrhythmias
>80 Rapid death from respiratory arrest

Lab Investigations
1. Conc. of COHb by spectroscopy
2. Kunkel’s test
3. CT scan: Symmetric low density areas in the region of globus pallidus, putamen
and caudate nuclei frequently seen within 12 hrs of CO exposure.
Treatment
1. Remove the patient from source of exposure
2. Maintain airway, breathing and circulation (ABC)
3. Oxygen is given by tight-fitting high-flow reservoir face mask or endotracheal tube.
4. Use of hyperbaric oxygen—to reduce neurological sequelae.
5. Gastric lavage—to prevent aspiration pneumonia
6. IV mannitol—to prevent cerebral edema
7. Antibiotics and supportive treatment.
PM Findings

External Internal
1. Cherry red discolouration of PM staining 1. Lungs: Edema and congestion
2. Fine froth at nostrils and mouth’ 2. Heart: Petechial hemorrhage
3. Skin blisters over bony pressure areas 3. CNS: Edema and congestion
(buttocks, calves, wrist)

MLI:
a. Accidental cases are common in India from cooking gas leakage, and incomplete
combustion of wood, charcoal or coal in ill-ventilated rooms.
b. Common method of suicidal poisoning in the West.
c. Homicide is uncommon.
d. Masochistic sexual asphyxia may be due to CO.
 Toxicology 199

38. Treatment of CO poisoning (Pondicherry 2017)

Ans: Refer to short question no. 37.

39. Explain the treatment of Cyanide Poisoning (Rajiv Gandhi University, Bengaluru
2019) (Rajasthan University 2016)
Ans: Refer to short question no. 12.

40. Suis (AIIMS Patna 2016) (VNS, Gujarat 2019, supple 2019)
Ans:
1. Suis are small needles prepared from rati.
2. Preparation of suis—seeds of Abrus precatorius (rati) are crushed into powdered
form, mixed with Dhatura, Opium, onion, water and made into a paste which is
then shaped into sharp needles or spikes about 2.5 cm long and then allowed to
dry.

Clinical Features of Poisoning with Suis

Local features Systemic features

1. The wounds caused by two suis resembles viperine snakebite 1. Weakness
(fangs in snakebite) 2. Faintness
2. At site of injection—painful edema, inflammation, necrosis with 3. Vertigo
oozing of blood 4. Anorexia
5. Drowsiness
6. Coma

Treatment
1. Suis should be dissected out
2. IV fluids
3. Symptomatic treatment.

MLI:
1. Used as abortifacient
2. Used as cattle poison
3. Used as arrow poison
4. For homicidal purposes—by keeping two suis needles in between two fingers of
hand with pointed needles facing ventral aspect of the hand. These are then struck
with force into the flesh of other person resembling Viper snake bites.

41. Marking nut (Sher-i-Kashmir Institute, Srinagar supple 2018)

Ans:
1. It is also called “bhilawa” or “oriental cashew nut”. Scientific name is Semecarpus
Anacardium
2. It is an organic irritant poison.
 200 Exam Preparatory Manual of Forensic Medicine and Toxicology

3. Active principles
i. Semecarpol
ii. Bhilawanol
4. Signs and symptoms
Local lesions Systemic features
Artificial bruise • Vomiting
• When juice of marking nut is applied on the skin • Diarrhoea
• Lesions are raised, blackish, painful and itchy blisters • Hypotension
• On scratching—similar lesions seen on the tips of fingers • Tachycardia

5. Fatal dose: 5–8 seeds

6. Treatment
i. Wash the area with soap and water—in case of contact with skin
ii. Demulscents
iii. Activated charcoal
iv. IV fluids—to correct hypotension
v. Symptomatic management
7. MLI
i. Used as abortifacient
ii. Juice is used to produce artificial bruises
iii. Juice is thrown on face—used as vitriolage
iv. Used by washerman (dhobis)—to mark identification number on clothes.

42. Clinical features of opium/morphine poisoning (Adesh, Bathinda supple 2020)

(VNS, Gujarat 2016, supple 2018)
Ans: Refer to long question no. 17.

43. Treatment of opium poisoning (Sardar Patel University, Gujarat supple 2018)
Ans: Refer to long question no. 17.

44. Brown sugar (West Bengal University supple 2019)

Ans:
1. It is semi-synthetic preparation of opium
2. Most dangerous and popular among drug of addiction
3. It is 2–4 times more toxic than morphine
4. Routes of administration
a. Sniffing
b. Smoking
c. Dragon chasing
d. Skin popping—subcutaneous injection
e. Intravenous injections
 Toxicology 201

5. Signs and symptoms (in order of presentation)

i. Stage of excitement
ii. Stage of euphoria
iii. Feeling of well-being
iv. Hallucinations and intense pleasure
v. Drowsiness and stupor
6. Treatment
i. Maintain airway, breathing and circulation (ABC)
ii. Perform gastric lavage with KMnO4
iii. Naloxone IV is given in acute poisoning—act as antidote
iv. Symptomatic treatment
v. Methadone—to prevent withdrawal symptoms and to drug addicts to reduce
euphoria.

45. Body packers (Adesh, Bathinda 2017, supple 2019) (Rajiv Gandhi University,
Bengaluru 2019) (Rajasthan University 2017) (Pondicherry 2016, supple 2017) (VNS,
Gujarat 2018, supple 2019)
Ans:
1. Definition of body packers: The person who swallows illicit/ illegal drugs for the
purpose of smuggling across countries by ingesting or inserting them into body
cavities.
2. They are also called Mule, Courier.
3. For smuggling, drugs of high quality are packed commonly in condoms, foils,
balloons. After reaching destination, smuggler takes laxatives, defecates and then
retrieves the packets from feces to deliver them to drug dealers.
4. The body packers are usually detected and arrested at the airports and sent for the
custody.
5. In case of suspicion—detection by:
a. Physical examination of body cavities like rectum, vagina
b. Abdominal X-ray and CT scan
6. MLI:
i. Risk of toxicity in case drug packets rupture
ii. Acute intestinal obstruction

46. Delirium tremens (Rajasthan University 2018) (Uttarakhand University supple 2016)
(BFUHS, Punjab 2015) (GMC, Chandigarh 2015) (Sher-i-Kashmir Institute, Srinagar
supple 2015)
Ans:
1. Definition delirium tremens: It is defined as acute episode of delirium which is
seen 2–4 days after sudden withdrawal of alcohol in chronic alcoholics.
2. Most severe alcohol withdrawal syndrome.
 202 Exam Preparatory Manual of Forensic Medicine and Toxicology

3. Causes
a. Sudden withdrawal of alcohol
b. On excessive intake of alcohol
c. Shock after receiving severe trauma, e.g. fracture of bone
d. Acute infection like pneumonia
4. Signs and symptoms
i. Clouding of consciousness with disorientation to time, place and person
ii. Hallucinations—visual, auditory and tactile hallucinations
iii. Tremors of face, tongue and hands
iv. Tendency to commit suicide
v. Autonomic disturbances and hyperactivity of CNS
5. Treatment
i. Diazepam—for sedation
ii. Oral multi-B vitamins and thiamine
iii. Haloperidol—can be added
iv. Symptomatic treatment
6. MLI: If a person commits any crime in delirium tremens, he is not held responsible
for his criminal acts as he is mentally unsound, as per Sec. 84 IPC.

47. Food Poisoning (Sher-i-Kashmir Institute, Srinagar 2020)

Ans:
1. Definition: Illnesses which result from ingestion of food containing bacterial or non-
bacterial products including viruses, toxins present within the food itself. But the term
is usually used for acute gastroenteritis due to the bacterial infection of food or drink.
2. Causes
a. Poisoning due to bacteria and toxins.
b. Poisons of vegetable origin: Lathyrus sativus, poisonous mushrooms and Argemone
mexicana.
c. Poisons of animal origin: Poisonous fish and mussel.
d. Chemical: Intentionally or accidentally added, products of food processing.
3. Bacterial food poisoning results from the ingestion of contaminated food, uncooked
food or imperfectly cooked food. It is divided into two groups:
i. Infection type results from multiplication of pathogenic organisms within body
contained in the food. Organisms belong mainly to the Salmonella group.
S/s: Sudden onset of nausea, vomiting, abdominal pain and foul smelling watery
diarrhea stained with blood and/or mucus.
ii. Toxin type results from ingestion of preformed toxins (exotoxins) from bacterial
proliferation in canned or preserved food, e.g. enterotoxin of Staphylococci,
Clostridium perfringens or Bacillus cereus.
S/s: Salivation, diarrhea, nausea, abdominal cramps and vomiting.
4. Treatment
a. Gastric lavage and purgatives are given.
b. Glucose-saline infusion should be given to promote elimination of the toxins from
the system.
c. Antibiotics are given depending upon the causative organism.
 Toxicology 203

5. Postmortem findings
i. GIT: Mucosa swollen and congested with minute ulcers
ii. Liver: Fatty degeneration
iii. Causative organism can be isolated from the blood and viscera.

48. Truth Serum (Adesh, Bathinda 2019)

1. Barbiturates are used for narco-analysis as ‘truth serum’ or ‘truth drug’.
2. Narco-analysis is a scientific procedure to obtain information from an individual in
a natural sleep-like state.
3. The individual is put to trance-like state and loses all his inhibitions by administering
amytal sodium or sodium thiopental in 2.5–5% solution, slow IV.
4. The dose is dependent on the person’s sex, age, health and physical condition. A
wrong dose can result in a person going into a coma or even death.
5. A person is able to lie by using his imagination. The subject’s imagination is
neutralized by using the drug. In this state, it becomes difficult for him to lie, and
his answers would be restricted to facts he is already aware of.

49. Drunkenness (Adesh, Bathinda supple 2019, supple 2018) (Rajiv Gandhi University,
Bengaluru 2015) (VNS, Gujarat supple 2018)
Ans:
1. Definition: Drunkenness is a consequence of drinking intoxicating liquors to such
extent so as to reduce his capacity for rational action and conduct and can be
dangerous to himself or to others.
2. Exclusion of injuries and pathological conditions: Head injury, hypoglycemia,
diabetic coma, uremia, overdose of insulin, barbiturates, antihistamines, cocaine,
morphine, and CO poisoning.
3. Clinical examination
a. Preliminary data such as name, age, sex, address, time of examination, two
identification marks and person escorting the patient should be noted.
b. Consent: Under Sec. 53 (1) CrPC, an accused can be examined by a doctor at the
request of the police, even without his consent and by use of force, if necessary.
c. History: The history of relevant events should be obtained from the person while
observing him.
d. General appearance: Manner of dressing—properly dressed or not, and soiling
of clothes. Posture—whether over-erect and over smart, can stand steady or not,
and can stand without support or not.
e. General examination: Scalp inspected and palpated for evidence of any head
injury.
f. Specific physical examination
i. Gait is observed for any unsteadiness, staggering, bumping into people or
furniture. Gait on turning (normal, unsteady, stumbling) is also noted.
ii. Orientation and memory: Ask him about incidents which have occurred
few hours prior to examination to check his memory. Ask him about the
date, time and place where he is at present.
 204 Exam Preparatory Manual of Forensic Medicine and Toxicology

iii. Behavior: Whether noisy, jovial, boastful, rude, emotional, talkative, excited
or uncontrollable.
iv. Face: Whether normal, flushed or pale. Redness of the face is indicative of
alcohol intake.
v. Speech: Whether normal, thick and slurred, stuttering, confused,
unintelligible, offensive or over precise.
vi. Tongue: Whether dry, moist and clean or furred. Dry tongue is seen in thirst,
and waning phase of BAC.
vii. Signs of vomiting and salivation: Vomitus may be on clothes. Salivation
and drooling may be found in the severely intoxicated.
viii. Smell of alcohol: Strong, moderate, faint or none. The smell of the breath
may confirm that alcohol has been taken and the type of drink.
ix. Handwriting: The person can be asked to sign his name and compared with
his driving license. Drawing simple patterns, such as triangle and diamond
may be preferable, if the person is illiterate.
x. Eyes: Examine the eyes, noting the conjunctiva (normal or congested),
pupillary size (normal, equal, unequal, mydriasis or miosis), response to
light (normal, delayed or non-reacting), visual fields and acuity (reading the
time on a clock across a room), and the presence of nystagmus (coarse, fine,
continuous or absent). In drunkenness, there is drooping and swollen eyelids,
congestion of conjunctiva and nystagmus may be seen, and convergence
test is negative.
xi. Tests to determine in-coordination: Watch the patient unbutton his shirt,
dressing, undressing or handling objects like picking up a pen. Carry out
standardized field impairment tests (FITs) to check muscle coordination. These
consist of Romberg test, Walk and Turn test, One Leg Stand test and Finger
Nose test.
xii. Knee reflexes are elicited to check whether normal, exaggerated or depressed.
Reflexes are equally depressed in intoxication.
Opinion
The opinion can be drafted with any one of the following statements:
i. He/she has not consumed alcohol.
ii. He/she has consumed alcohol, but is not under the influence of it.
iii. He/she has consumed alcohol and is under its influence.

50. Preservation of blood sample in case of drunkenness (West Bengal University

supple 2017)
Ans:
The Blood Alcohol Concentration (BAC) is the most useful measure, as there is rapid
equilibration across the blood–brain barrier; BAC reflects the concentration of alcohol
currently affecting the brain.

Blood Sample Preservation

1. Soap and water (instead of spirit swab) is used to clean the site to be venepunctured.
2. The blood is collected from antecubital or femoral vein using a disposable syringe.
 Toxicology 205

3. Blood container should be tightly stoppered to prevent loss of alcohol by evaporation,

and labeled with name, date, time of taking the specimen and signature of the medical
officer.

51. Magnan Syndrome (Uttarakhand University supple 2016)

Ans:
1. It is also called Cocaine Bugs/Formication
2. It is a type of tactile hallucination in which the person feels crawling or creeping of
an insect on or under the skin giving rise to itching sensation
3. Presence of excessive scratching marks on the skin
4. Seen in:
i. Cocaine addicts
ii. Methamphetamines intoxication
5. Treatment
• Stop the drug
• Supportive treatment

52. Run amok (Adesh, Bathinda supple 2018) (BFUHS, Punjab supple 2018) (Uttarakhand
University supple 2016) (Rajasthan University 2015) (VNS, Gujarat 2018)
Ans:
1. Definition run amok: It is defined as an acute psychotic disorder which occurs due
to consumption of cannabis.
2. Cause:
i. Sudden consumption of cannabis
ii. Chronic consumption of cannabis
3. It comprises 3 phases (in sequence)
i. Phase of depression
ii. Phase of homicidal mania/impulse murder
iii. Phase of depression
Soon after intake, the person develops phase of depression which is then followed
by killing a person against whom he has real rivalry or imaginary because of
Delusion of Persecution and then kills anyone who comes in his way until the
homicidal tendency stops.
And finally after this phase, the person again enters the phase of depression in
which either he commits suicide or surrender himself to the police.
4. MLI:
1. As per Section 85 IPC: The person will not be responsible for his acts in case of
involuntary intoxication.
2. As per Section 86 IPC: The person will be held responsible for all his acts in case
of voluntary intoxication.

53. Methyl alcohol Poisoning (Uttarakhand University supple 2018, 2016) (Delhi
University 2015) (Rajasthan University 2015) (Sai Tirupati University, Rajasthan 2019)
Ans: Refer to long question no. 18.
 206 Exam Preparatory Manual of Forensic Medicine and Toxicology

54. Treatment of Methanol poisoning/ Methyl alcohol poisoning (Sardar Patel

University, Gujarat 2020, 2019, supple 2019) (Adesh, Bathinda supple 2019) (KHMS,
Tamil Nadu 2018)
Ans: Refer to long question no. 18.

55. Management of OPC poisoning (Adesh, Bathinda supple 2018, supple 2017)
(Sardar Patel University, Gujarat 2018, supple 2015) (Jammu and Kashmir 2017) (VNS,
Gujarat supple 2019)
Ans: Refer to long question no. 6.

56. Atropinization (AIIMS, Patna 2019, 2017)

Ans:
1. Atropine acts as an antidote for OPC and Carbamate poisoning
2. MOA: Atropine acts by blocking Muscarinic receptors, and no action on Nicotinic
receptors, therefore reversing Muscarinic manifestations but no effect on Nicotinic
manifestations
3. It occurs because of the repeated dose of atropine
4. Signs of atropinization
a. Mydriasis—most common sign
b. Heart rate—more than 100 beats/min (Tachycardia)
c. Decreased oropharyngeal and bronchial secretions
• Most specific or consistent sign
• Considered as therapeutic endpoint
5. Dose required for atropinization: 2–4 mg IV repeatedly after every 5–10 min
till secretions is reduced, then maintenance dose to maintain this effect for next
24 hrs.

57. Management of Aluminium Phosphide poisoning (Pondicherry 2019) (Sardar Patel

University, Gujarat 2019) (Adesh, Bathinda 2018) (Sher-i-Kashmir Institute, Srinagar
supple 2018) (VNS, Gujarat 2016)
Ans: Refer to long question no. 14.

58. McEwan sign (AIIMS Patna 2018) (VNS, Gujarat 2019)

Ans:
1. McEwan’s sign: In alcohol intoxication, during the stage of coma, the pupils are
contracted, but on stimulation of the person, e.g., by pinching or slapping causes
them to dilate with slow return.
2. This is rarely seen.

59. Signs and Symptoms of Strychnine Poisoning (Adesh, Bathinda supple 2018)
Ans: A ‘conscious’ seizure is the characteristic of strychnine poisoning.
 Toxicology 207

Signs and Symptoms

1. Bitter taste.
2. Stiffness of neck and face.
3. Restlessness, increased acuity of perception, muscular twitchings.
4. Cyanosed face, eyeballs are prominent and staring, pupils are dilated. Mouth is
filled with bloodstained froth.
5. Convulsions: Any sensory stimulus (light, pain, touch) may produce violent
seizures. Initially, clonic but eventually become tonic, and affect all the muscles at
the same time.
• Risus sardonicus results from raising of patient’s eyebrows, bulging of eyes and
contraction of facial muscles in which the corners of the mouth are drawn back
leading to a grin.
• Convulsions are most marked in anti-gravity muscles resulting in hyperextension
(opisthotonus).
• During convulsions, the patient remains conscious and aware of surroundings.
In between convulsions, muscles are completely relaxed and breathing is resumed.
• After 5–15 min, on the slightest impulse, another convulsion occurs with increased
intensity.
• Death occurs within 4–5 convulsions as the patient cannot breathe.

60. Desribe various positional changes in strychnine poisoning. (Sardar Patel

University, Gujarat supple 2015)
Ans:
1. Opisthotonus: Contraction of the paravertebral muscles on back of trunk resulting
in arch shape of back. Legs are extended, head is bent backwards and arms are
flexed over the chest and hands clenched with heels touching the ground.
2. Emprosthotonus due to spasm of abdominal muscles, body may bend forwards
(bending in front of emperor).
3. Pleurosthotonus: Body may bend to sides (bending along the pleura).

61. Treatment of strychnine poisoning (Sardar Patel University, Gujarat 2018)

Ans:
Control Convulsions
1. Keep patient in dark room, noise free room as any sort of sensory stimulus can start
the convulsions
2. Start with diazepam IV followed by phenobarbital IV to control convulsions
3. If not effective—start muscle relaxants
4. Last resort—general anaesthetic agents (if all other measures fail)

After Controlling Convulsions

1. Gastric lavage with 1:5000 KMnO4 and activated charcoal (cautiously)
2. Forced alkali diuresis—to enhance excretion of strychnine in urine
3. Symptomatic treatment.
 208 Exam Preparatory Manual of Forensic Medicine and Toxicology

62. Snakebite (Sher-i-Kashmir Institute, Srinagar supple 2017) (AIIMS Patna 2016) (BFUHS,
Punjab supple 2016)

Neurotoxic snakebite (BFUHS, Punjab 2017)

Ans: Refer to long question no. 9.

63. Treatment of snakebite (SGRD, Amritsar 2019) (Uttarakhand University supple 2017)
(Adesh, Bathinda supple 2017)
Ans: Refer to long question no. 9.

64. Polyvalent Antisnake venom used in India (West Bengal University supple 2017)
(Sardar Patel University, Gujarat supple 2015)
Ans:
Polyvalent Antivenom
1. It neutralizes the venoms of several different species of snakes, usually the most
prevalent in a particular geographical area.
2. It is less potent, less immunogenic and less effective than monovalent, and has more
adverse effects (caused particularly by non-neutralized part of the polyvalent ASV).
3. In India, polyvalent ASV is raised in horses using the venoms of the four most
important venomous species (cobra, krait, Russell’s viper and saw-scaled viper).
4. Antivenom is indicated for patients with clinical manifestations with moderate to
severe envenomation.
5. Dose: Freeze-dried (lyophilized) antivenom serum is dissolved in water. About
80–100 mL serum should be diluted in 200–500 mL of isotonic saline and given
slow IV.
6. The recommended initial dose of ASV is 8–10 vials administered slowly via IV route
over a period of 1 h.

65. Various forms of Cannabis Indica (Adesh, Bathinda 2017) (Sai Tirupati Univesity,
Rajasthan 2019)
Ans:
Various Preparations of Cannabis
1. Bhang is the mildest of cannabis preparations (2–5% of active principle). It consists
of dried cannabis leaves that are ground to a fine paste and taken as beverage.
2. Majum: Sweetmeat made with bhang.
3. Ganja: Obtained from flowering tops of female plant. Moderately potent (5–8%). It
is mixed with tobacco and smoked in hukka/pipe.
4. Hashish is highly potent, concentrated cannabis resin that has been collected, dried
and pressed into bricks.
5. Charas is a resinous exudate and handmade form of hashish. It is potent (10–20%)
and is mixed with tobacco and smoked in hukka/pipe.
6. Marijuana refers to tobacco-like preparations of dried leaves and flowers. It is usually
smoked, although it is occasionally baked into foods such as brownies or brewed as
tea for drinking.
 Toxicology 209

66. Classify Pesticides. Discuss signs and symptoms of OPC poisoning. (Jammu and
Kashmir 2017)
Ans: Refer to long question no. 6.

67. Describe alcohol intoxication. (Sher-i-Kashmir Institute, Srinagar supple 2017)

(Uttarakhand University 2017)
Ans:
Definition: It is a condition associated with drinking of too much of alcohol in a short
interval of time. This may result in poisoning. The following signs and symptoms
may be seen:
1. Stage of excitement (Blood level: 50–150 mg%)
Euphoria, unrestrained behavior, alteration of time and space perception, might
disclose secrets, show increased confidence, lack self-control, lowering of visual
acuity, poor concentration and attention, and impaired judgment.
2. Stage of in-coordination (Blood level: 150–250 mg%)
Person may be cheerful/irritable/sleepy—depending on the dominant impulses
released. Nausea and vomiting, clumsiness, in-coordination of fine movements, and
alterations in speech and fine. Flushed face, rapid pulse. Sense of touch, taste, smell
and hearing are diminished, prolonged reaction time, hypothermia, breath smells
of alcohol. Pupils are dilated and react sluggishly to light.
3. Stage of coma (Blood level >250 mg%)
Thick and slurred speech, incoordination, rapid pulse, hypothermia, amnesia,
diplopia, pupils are contracted. Patient passes into coma with steatorous breathing.
Fatal dose: 150–250 ml of absolute alcohol consumed in 1 h (BAC >300 mg/dl).

Treatment
1. Maintain airway, breathing and circulation (ABC).
2. Patient is kept warm, and made to lie on the side to minimize risk of aspiration.
3. In comatose and extremely intoxicated patient, endotracheal intubation and
ventilator is useful.
4. Gastric lavage with alkaline solution within 2 h of ingestion.
5. Normal saline with 10% glucose and 15 units of insulin or 50% dextrose (50 in
100 ml) is given IV.
6. Thiamine 100 mg in 500 ml glucose solution IV. Multivitamins with folate and
magnesium may be added to it.
7. Hemodialysis may be used.
8. In case of aggressive behavior, sedation may be given.

68. Differential diagnosis of opium poisoning. (Adesh, Bathinda supple 2019, 2017)
Ans:
Differential Diagnosis of Opium Poisoning
1. Intracranial hemorrhage: Stroke and brain trauma.
2. Poisoning: Alcohol, barbiturates, benzodiazepine, carbolic acid, CO and OPC.
 210 Exam Preparatory Manual of Forensic Medicine and Toxicology

3. Metabolic conditions: Diabetic and uremic coma.

4. CNS infections: Meningitis, encephalitis, encephalopathy and cerebral malaria.
5. Others: Epileptic and hysterical coma, and heat stroke.

DIFFERENTIATIONS

1. Poisonous and non-poisonous snakebite (Sardar Patel University, Gujarat 2020)

(Sher-i-Kashmir Institute supple 2017) (GMC, Chandigarh 2015)

Poisonous snakebite Non-poisonous snakebite

Fang marks Bite leaves two fang marks Leave a semicircular set of teeth marks
Bite site Discoloration, swelling, cellulitis and Redness and slight swelling
hemorrhage
Treatment Wound care, antisnake venom, tetanus Wound care, tetanus

Poisonous snake Non-poisonous snake

Head scales Small Large
Belly scales Large and cover the entire breadth of belly Small, and do not cover the entire
breadth
Fangs Long and canalized Short and solid
Tail Compressed Not so
Habits Nocturnal —do—

2. Russell viper and cobra (Andhra Pradesh, supple 2016)

Russell Viper Cobra

Venom Vasculotoxic Neurotoxic
Pupils Vertical Circular
Reproduction Viviparous Oviparous
Head Large, triangular, covered by small scales Small, covered by large scales
Body Short, stout Long, Cylindrical
Tail Tapering Round
Fangs Long, mobile, canalised Short, fixed, grooved
Maxillary bone Only fangs Fangs and other teeth
 Toxicology 211

3. Dhatura and chilli seeds (BFUHS, Punjab supple 2020) (Adesh, Bathinda supple
2019, 2016) (Rajasthan University 2017)

Dhatura seeds Chilli seeds

Size Large Small
Appearance Kidney-shaped Round
Color Dark brown Yellow
Taste Bitter Pungent
Smell Odorless Pungent
Convex border Double edged Single edged
Cut section Embryo curved outwards Embryo curved inwards

4. Ideal homicidal and ideal suicidal poisoning (Adesh, Bathinda supple 2016)

Ideal homicidal poisoning Ideal suicidal poisoning

Symptoms Should mimic natural death Should cause easy,
painless, quick death
Characteristics Colorless, odorless, tasteless Does not matter
Onset of signs and symptoms Should be slow (to avoid suspicion) Should be very quick
Toxicity Highly toxic Highly toxic
PM changes There should be no PM signs of its poisoning Does not matter
Detectability Should not be detected on chemical tests Does not matter
Example Arsenic, insulin, thallium Opium, OPC, alphos,
barbiturates
 212 Exam Preparatory Manual of Forensic Medicine and Toxicology

5. Arsenic poison and cholera (Adesh, Bathinda 2019) (BFUHS, Punjab 2015, supple
2019) (AIIMS Patna 2015) (Uttarakhand University 2015) (Delhi university 2015) (Sardar
Patel University, Gujarat 2015, Supple 2015)

Arsenic poison Cholera

Symptoms 1. Pain in throat 1. Purging
(in order of appearance) 2. Vomiting 2. Vomiting
3. Purging 3. Pain in throat
Vomitus Contains mucus, bile and blood Watery without mucus and bile
Stools Rice watery; ± blood Rice watery without blood
Tenesmus and anal pain Present Absent
Voice changes Absent Present
Lab investigation Presence of arsenic in chemical analysis Vibrio cholera present
Manner Homicidal > accidental No such thing

6. Strychnine poisoning and tetanus (BFUHS, Punjab 2019) (KHMS, Tamil Nadu 2015)
(Uttarakhand University 2017). (Rajasthan University 2017) (Rajiv Gandhi University,
Bengaluru 2015)

Strychnine poisoning Tetanus

Onset of symptoms Sudden Gradual
Site of action Postsynaptic membrane Presynaptic membrane
Convulsions Generalised Localised
Lock jaw No preference Seen predominantly
Fatal period <2 hrs >24 hrs
State in between convulsions Relaxed Rigid
Lab diagnosis Strychnine can be found Clostridium tetani found
in lab culture
Exam Preparatory Manual of
Forensic Medicine and Toxicology
Questions and Answers
Salient Features
• The book is meant for Last Minute Revision
• Fully colored book with solved questions and answers
• Based on the last 5 years university professional and supplementary
examination papers
• There are more than 90 Long Questions, 280 Short Notes and 40 Differentiations
• Includes examination papers from more than 20 universities in India
• Specially designed as per professional examinations
• To the point answer for easy understanding and easy to remember in a single
reading
• Answers are in bullet format or in numbering form
• Easy mnemonics will help in better learning and retaining
• Color codes also used for easy understanding and retaining
• Contains line diagrams for easy reproduction during the examination
• Contents in 8 chapters covering the entire syllabus
• The chapters are structured into Long Questions, Short Notes and
Differentiations as being asked in examinations of different universities
• Year-wise mention of the questions asked in different universities.
Gautam Biswas MD(ForensicMedicine)
is currently Professor and Head, Department of Forensic Medicine and
Toxicology, Dayanand Medical College and Hospital, Ludhiana, Punjab. He is
author of Review of Forensic Medicine and Toxicology' and Manual of Practical
Forensic Medicine and Toxicology; and is the editor of Recent Advances in '--------""""-"'----'
Forensic Medicine and Toxicology, volumes l and 2.
Tejpreet Singh MBBs
is currently Junior Resident, Department of Forensic Medicine and Toxicology, Dayanand
Medical College, Ludhiana. He enjoys teaching by nurturing inquisitiveness and
creativity in students, and has keen interest in making the subject easy, relatable and
palpable for the students.

ill
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