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(BQ) Part 1 book Biswas review of forensic medicine and toxicology has contents: Medical jurisprudence and ethics, acts related to medical practice, legal procedure, medico legal autopsy, autopsy room hazards, firearm injuries,... and other contents.
Review of Forensic Medicine and Toxicology Review of Forensic Medicine and Toxicology Including Clinical and Pathological Aspects MCQs of Previous Years PG Entrance Examinations Included Third Edition Gautam Biswas MD (UCMS) Professor and Head Department of Forensic Medicine and Toxicology Dayanand Medical College and Hospital Ludhiana, Punjab, India Forewords George Paul Satish K Verma The Health Sciences Publisher New Delhi | London | Philadelphia | Panama Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: jaypeedhaka@gmail.com Jaypee Brothers Medical Publishers (P) Ltd Bhotahity, Kathmandu, Nepal Phone +977-9741283608 Email: kathmandu@jaypeebrothers.com Jaypee-Highlights Medical Publishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: +1 507-301-0496 Fax: +1 507-301-0499 Email: cservice@jphmedical.com J.P Medical Ltd 83 Victoria Street, London SW1H 0HW (UK) Phone: +44 20 3170 8910 Fax: +44 (0)20 3008 6180 Email: info@jpmedpub.com Jaypee Medical Inc The Bourse 111 South Independence Mall East Suite 835, Philadelphia, PA 19106, USA Phone: +1 267-519-9789 Email: jpmed.us@gmail.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2015, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and not necessarily represent those of editor(s) of the book All rights reserved No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book Medical knowledge and practice change constantly This book is designed to provide accurate, authoritative information about the subject matter in question However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications It is the responsibility of the practitioner to take all appropriate safety precautions Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book This book is sold on the understanding that the publisher is not engaged in providing professional medical services If such advice or services are required, the services of a competent medical professional should be sought Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com Review of Forensic Medicine and Toxicology First Edition: 2010 Second Edition: 2012 Third Edition: 2015 ISBN 978-93-5152-864-7 Printed at With lots of love to my son Gaurav & All my students—past, present and future Foreword This textbook, aimed for the medical undergraduate for preparing him/her for the various long and short questions on the subject of Forensic Medicine and Toxicology as taught to medical undergraduates all over India, as well as MCQs of nearly all the various entrance test exams for postgraduation, is an extensive labor of love, in an attempt to present the subject in a most systematic and organized manner The approach is to make mining down to fine details—either for a long essay question, or to organize one’s answer for a short text answer, easier, and in that sense it has well succeeded All the various headings coming under the broad chapter of Forensic Medicine and Toxicology have been broken down very clearly into sub-topics and subheadings Where the subject leads to some important questions and answers often required of the medical witness, they are presented in addition, at the end of the chapter, as question and answers The author has also put in a lot of effort to cull from all possible sources, MCQs that have been made in the past on the various subjects – itemized them with their source reference listed (i.e the various entrance exams they have been used in), and given the most appropriate answer to the question, based on the construction of the sentences, or the stem or statement However this book, being primarily a resource book for undergraduates and those graduates appearing in various postgraduate and recruiting commission’s exams, is tailored to what is expected of the student from the current set of forensic examiners, rather than updating all users of the textbook to the current concepts and recent advances and norms in practice, of some of these topics And one can hardly blame the author for this, because, looking at the current MCQs listed at the end of chapters of toxicology and other sections, some of these exam setters are still in the practice of forensic medicine and the knowledge of it thereof of the 50’s and 60’s rather than the new millennium Antidotes are still entrenched in outdated clinical concepts of ‘universal antidote’ and burnt toast for activated charcoal, and one cannot blame the author for it, for these various entrance exams extensively feature knowledge of this in their selection MCQs While the chapters on sexual abuse cover the legal and medical features well, the emphasis in the chapter on detection of seminal stains for establishing sexual intercourse with the victim is still stuck with outdated tests, which have been given up in modern countries and replaced by their DNA and forensic labs test such as screening with PSA and Seminogelin jointly and then progress to DNA markers using single-locus-probes or multi-loci probes Technology has advanced and some of it has found their place in Forensic Medicine Forensic radiology—use of radiological techniques (not the ubiquitous ‘virtopsy’) in assisting forensic work has resulted in a quite a few clinical radiologists taking special interest and training in forensic radiology, as there are vast differences between imaging and techniques possible in the living and dead At an undergraduate level, textbooks of quality such as these should incorporate key features where its techniques are now baseline for diagnosis or investigations in some forms of sudden death, identification parameters, deaths from barotraumas—especially diving deaths, etc But I would not be surprised if the inclusion of these would get the candidates into trouble during their exams, as many of the examiners are still anachronistic in their understanding of many of these topics, and have never put any of them to use Modern concepts such as brain death—related to organ harvesting, is an important concept which will feature quite a bit in clinical practice, as it is doing overseas The young medical graduate should be brought onto a sound basis on these by textbooks such as this Some of the well-presented chapters deserve mentioning Thus the chapter on jurisprudence, injuries—their medico-legal importance, firearms, thermal injuries, identification, especially the medico-legal importance of age (which finds great significance in the MCQs—though in fact is just a legal interpretative part), pregnancy viii Review of Forensic Medicine and Toxicology and delivery, sexual offences, forensic psychiatry, toxicological chapters such as mercury, cannabis, cocaine, belladonna, cardiac poisons, carbon monoxide, agricultural poisons, aluminum phosphide, kerosene poisoning and food poisoning are quite adequate for an undergraduate level and are well presented with good coverage for even answering MCQs There are good coverage of general concepts in the chapters on explosions and falls from height, starvation deaths, torture, decompression sickness, infanticide and child abuse, specific topics in toxicology such as corrosives, alcohol, opioids, medicinal drugs, snakebite, cyanide, drug dependence and war gases, such that the candidate has a good overview of these topics All in all, this textbook is well organized The layout makes breaking up and assimilating the various diverse topics that come under its ambit – easy, and systematic, with an approach which makes it easy and effective in organizing one’s knowledge and thoughts on each subject For once, based on the chapters reviewed, I would recommend this book as a good basic reference book for undergraduates, to prepare them both for their university exams and entrance tests I look forward to further amendments which would raise this textbook to one of great current relevance through revisions on some of the small deficiencies that have been observed I wish Prof Gautam Biswas great success in this 3rd edition of the Review of Forensic Medicine and Toxicology— Including Clinical and Pathological Aspects, and congratulate him for single-handedly maintaining great standards and depth of knowledge, as well as keeping up-to-date with the needs of the medical undergraduates all over India, for preparing them for their respective university’s undergraduate and various postgraduate entrance examinations George Paul Senior Consultant Forensic Pathologist and Branch Director-Technical Capabilities Forensic Medicine Division, Applied Sciences Group, Health Sciences Authority, 11 Outram Road, Singapore 169078 and Senior Lecturer-Yong Loo Lin School of Medicine National University of Singapore Foreword It is indeed a moment of immense pleasure and sense of pride to write a foreword for a book authored by one of my most sincere, hardworking and brightest students to whom fortunately I introduced the art and science of the specialty of Forensic Medicine and Toxicology, both as undergraduate and postgraduate at UCMS A teacher or a guide feels special and privileged, when his students excel in the field initiated by him, the words are too timid to describe this feeling The current book is 3rd edition in the series of this title, Review of Forensic Medicine and Toxicology I have no iota of doubt about the success of this title and this will be rather loved more than the earlier versions The current title contains 63 chapters covering the entire MCI undergraduate curriculum, presented in a student friendly fashion I have gone through, some of the chapters of this title and found them even more informative and attractive than previous ones with lots of new information being added Major changes and updates have been provided in chapters such as: Medical jurisprudence and ethics (MCI, Declarations of WMA, informed consent, euthanasia), Acts (POCSO Act, Sexual Harassment of Women at Workplace Act, Protection of Women from Domestic Violence Act); and Identification, etc A special feature of the book is MCQs drawn from various PG entrance and other competitive examinations at the end of each chapter making it more relevant to undergraduates even after passing 2nd Professional MBBS examination By now Gautam (I usually call him by his first name due to my special love) has established himself as a prolific author and I am sure that this edition will add another feather in his success story May God bless him… Satish K Verma Professor Department of Forensic Medicine and Toxicology University College of Medical Sciences Former Head Department of Forensic Medicine (University of Delhi) 322 Review of Forensic Medicine and Toxicology Thorax: Before opening the thorax, the abdomen is opened first and position of diaphragm is noted by passing a finger The whole chest cavity can be opened under water in order to demonstrate a pneumothorax In infants and fetuses, Letulle’s technique of en masse removal is the preferred in most cases so that certain rare malformations can be properly preserved, e.g pulmonary venous connections Note is made of whether there is free blood or fluid, pus or stomach contents present in the thoracic or abdominal cavity, or whether the diaphragm is ruptured or not If there is any fracture of the ribs, it should be noted Any evidence for malformations or birth-injuries should be meticulously searched which may reveal obvious incompatibility with the continuation of life The lungs, stomach, heart, genitalia and other viscera are examined for different parameters as outlined below the gestational age can be made Examination of various organs and its development can also assist an autopsy surgeon in estimating the gestational age of a fetus/ infant (Table 21.1 and Fig 21.2) However, it must be understood that at any time of life, morphological measurements are by no means infallible indicators of chronological age The time of appearance of ossification centers is also no longer regarded uniform, as once thought Neck: This is examined for internal injuries, and the trachea for foreign body, froth, mucus or amniotic fluid Rule of Hasse It is a rough method of calculating the age of fetus.8 The length of fetus is measured from crown to heel in centimeters During first months of pregnancy—square root of length gives approximate age of fetus in months During the last months—length in centimeters divided by gives age in months Limbs and sternum: They are examined for presence of ossification centers to determine the age of the fetus Center of ossification for the calcaneum appears by the 5th month, four divisions of sternum by the 6th month, talus by the 7th month and lower end of femur by the 9th month (36th week) At birth, a center of ossification is usually present for the cuboid and upper end of tibia (Fig 21.2) Conceptus: Any product of conception at any stage of development from fertilization until birth including extra embryonic membranes as well as the embryo or fetus Pre-embryo: Fertilized ovum upto 14 days after conception, until the implantation occurs Embryo: Prefetal product of conception from implantation to the end of 8th week (2nd month or 56 days) Fetus: Unborn young from the end of 8th week after conception till delivery Infant: Child from the time of birth to year of age Neonate: Infant in the first 28 days of extra-uterine life Meconium: Mixture of bile, mucus and shredded-off mucosa Vernix caseosa (Latin vernix: varnish; caseosa: cheese): White, cheesy substance composed of sebum and desqua mated epithelial cells which covers the skin of the fetus Lanugo hair (Latin lanugo: down, like the fine small hairs of plants): Fine, soft, downy, usually unpigmented hair on the body of the fetus and newborn Age of Fetus By weighing the infant and measuring the height (crown-heel length), various other measurements (crown–rump length, head circumference, chest circumference) and the foot length, an approximation of Non-osseous method of estimating maturity: Progressive development of surfactant-producing alveolar Type-II cells in fetal lungs Fig 21.2: Gestational age from size of foot Infanticide and Child Abuse Table 21.1: Determination of age of fetus Weeks of gestation weeks Features Length: cm, weight: 2.5 g.1 Eyes are seen as dark spots and mouth as cleft weeks Length: cm, weight: 10 g.1 Eyes and nose recognizable, hands and feet are webbed Anus is seen as dark spot Placenta is formed 12 weeks Length: cm, weight: 30 g Eyes are closed and pupillary membrane appears, nails appear, neck is formed.2 16 weeks Length: 16 cm, weight: 120 g Sex can be recognized; lanugo hair is visible on body; pupillary membrane is visible and meconium is seen in the upper part of small intestine.3,4 20 weeks Length: 25 cm, weight: 400 g Nails are distinct and soft, vernix caseosa appears on the body Fine hair on scalp, meconium at the beginning of large intestine.4 Center of ossification for calcaneum appears (Fig 21.3A) 24 weeks Length: 30 cm, weight: 700 g, foot length: 4.5 cm Eyebrow and eye lashes appear, eyelids are adherent and pupillary membrane is still present; skin is red and wrinkled for want of fat; testes are close to kidneys and scrotum is empty; meconium is seen in upper part of large intestine.4 28 weeks Length: 35 cm, weight: 900–1200 g, crown-rump: 23–25 cm, foot length: 5.4 cm Eyelids are open, pupillary membrane disappears; nails are thick, but not extend to the tips of fingers and toes; skin is dusky-red, thick and fibrous; meconium present in entire large intestine Center of ossification for talus appears (Fig 21.3A).5 32 weeks Length: 40 cm, weight: 1–1.5 kg, foot length: 6.4 cm Scalp hair is thick; nails reach the tips of fingers; skin is not wrinkled; lanugo hair on face; left testes in scrotum, right testes near the external inguinal ring 36 weeks Length: 45 cm, weight: 2.5–3 kg, foot length: cm Scalp is covered with dark hair; lanugo hair is seen only in shoulders; vernix caseosa is present over the flexures of joints and neck folds; scrotum is wrinkled and contains both testes.6 In females, vulval labia close vaginal opening Meconium is near the end of large intestine Ossification centers for lower end of femur (36–37 weeks), cuboid and capitate appear (Fig 21.3A and B).7 40 weeks (Full term) Length: 50–53 cm, weight: 3–3.5 kg, crown-rump: 28–32 cm, foot length: 8.25 cm Lanugo hair is seen only in shoulders; nails project beyond finger tips, but reach only the tip of toes; rectum contains dark green or black meconium; six fontanelles are present Umbilicus is midway between xiphisternum and symphysis pubis Center of ossification for upper end of tibia appears (38–40 weeks) (Fig 21.3B) A B Fig 21.3: Ossification centers in (A) Tarsal bones, (B) Lower end of femur and upper end of tibia 323 324 Review of Forensic Medicine and Toxicology Till date, there is no legally defined cut-off limit of intrauterine development, age or weight at which a baby automatically becomes viable Any newborn infant, whatever is the length of gestation, can be a victim of infanticide, if born alive A premature baby in a rural area in a developing country is unlikely to survive After birth, increase in the length of the child is given in Table 21.2 Length is measured in children before they are able to stand; height is measured once the child can stand Birth weight doubles by about 5–6 months of age, triples by about year.10 Table 21.2: Length/height of infant/child Length (cm) year 75 years9 100 Viability of Fetus/Infant Viability of infant: It means physical ability of fetus to lead a separate existence after birth, apart from its mother by virtue of a certain degree of development which depends on biological, physiological and extrinsic factors The age of viability varies among countries with 24 and 28 weeks being cited as the lower limits of potential survival Medically, the age of viability in India is taken as 28 weeks of gestation In India, live birth means the fetus was alive after complete birth or when at least one part of its body comes out of mother’s womb In the UK, it means the baby should be alive after complete birth Any sign of life after complete birth of child is accepted as proof of live birth Following are considered as signs of live birth: Baby’s cry—Strong evidence in favor of live birth and respiration having taken place Fetus may inhale air and cry when the head is inside the vagina—vagitus vaginalis, or inside the uterus—vagitus uterinus Muscle twitching/movements of limbs Sneezing and yawning Ultrasonography: On ultrasonography, absence of all fetal movements for 10 minutes (min) is taken as evidence of fetal death Signs of Live Birth Diagnosis of Fetal Death The question as to whether or not a fetus/infant was born alive is a contentious issue When decomposition is not present, a variety of features are taken into consideration in attempting to answer this question There are essentially three possibilities: i the baby was born alive ii the baby died in utero iii the baby died during the birth process Postmortem Findings External Findings Live-Born / Dead-Born / Stillborn Sternum: The bone is placed on a wooden board and sectioned in its long axis with a cartilage knife which exposes the centers of ossification Lower end of the femur and the upper end of tibia: The leg is flexed against the thigh and a horizontal incision made into the knee joint and the patella is removed A number of cross-sections are made through the epiphysis starting from the articular surface and continuing until the largest crosssection of the ossification center is reached In the lower end of the femur, this is seen as brownish-red nucleus which is surrounded by a bluish-white cartilage Bones of the foot: The heel of the foot is held by one hand and with the other hand an incision is made through the interspace between the 3rd–4th toes and carried downwards through the sole of the foot and heel Demonstration of Centers of Ossification In the UK, a baby is stillborn, if after 24 weeks of gestation it did not at any time after being completely expelled from its mother, breathe or show any other sign of life Hence, a period of 24 weeks is fixed for the legal age of viability However, there is no law or Section of IPC or CrPC in India which stipulates the age of viability In other developed countries, fetal death occurring ≥ 20 weeks of fetal life or a birth weight of at least 400–500 g is considered as ‘stillbirth.’ 68 50 months At birth Age General findings Changes in the chest, umbilical cord and skin Caput succedaneum and cephalhematoma 325 Table 21.4: Changes in skin color Table 21.3: Time since birth by umbilical cord changes Time since birth Drying up of cut margin 2h Drying up of cord day Inflammatory line at the base of stump days Obliteration and mummification changes days Detach (falls off ) 5–6 days Complete healing (scar) 10–12 days Time since birth Bright red Just born Darker 2–3 days Brick red→yellow→normal week v Cephalhematoma and caput succedaneum (Diff 21.1, Figs 21.4 and 21.5) i Changes in the lungs: They are considered with reference to volume, consistence, color and weight (Diff 21.2) z Volume – Before respiration, the lungs are small with sharp margins, wrinkled loose pleura, lie in the back of the chest on either side of the vertebral column and are hardly seen on opening the chest, as the cavity is filled up by the heart and thymus – After respiration, the lungs increases in volume, thin tense pleura, rounded margins and occupy the cavity, the medial edges overlapping the mediastinum and part of the pericardium, though not as fully as in the older neonate z Consistence – Before respiration, the lungs are dense, uniform, rubbery, firm and liver-like On rubbing a small piece between the fingers close to ear, no crepitation is heard (noncrepitant lungs) z Internal Findings iv Changes in skin: Vernix caseosa is present on axilla, inguinal region, folds of neck and buttocks It is either cleaned or gets removed in 1–2 days Skin of abdomen exfoliates during the first days after birth (Table 21.4) z Changes observed Color of skin i General findings: Presence of clothing and absence of vernix caseosa—suggestive of live birth ii Changes in the chest: Chest is more flat antero posteriorly in still/dead born The circumference of the chest is about 2–3 cm less than that of the abdomen at the level of the umbilicus After respiration, the chest expands and becomes drum-shaped iii Changes in umbilical cord: The appearance of the cut end of the umbilical cord may help to decide whether the birth was one where medical, nursing or midwife, or only amateur person was available The cut end of the cord should be looked for vital reaction Even where early putrefaction renders evaluation of breathing impossible, vital signs in the cord may indicate live birth, if survival reached 24–48 hours (h) (Table 21.3) Infanticide and Child Abuse Differentiation 21.1: Cephalhematoma and caput succedaneum11-14 S.No Feature Cephalhematoma Caput succedaneum Definition Collection of blood in between the periosteum and the skull due to rupture of a small emissary vein from the skull, and may be caused by forceps delivery Swelling due to stagnation of fluid between the layers of scalp beneath the girdle of contact (dilated cervix or vulval ring) Situation Usually unilateral, and present over parietal bone May be bilateral Impulse on crying No impulse No impulse Limitation by suture line Yes Not limited Underlying pathology May be associated with fracture of skull bone Not pathological Occurrence It is never present at birth It is present at birth Development and disappearance Develops 12–24 h after birth and decreases in 6–8 weeks Disappears spontaneously within 24 h Medico-legal importance Regression process help to conclude about the separate existence and how many days the infant survived after birth Definite evidence of fetus being alive in uterus But in prolonged labor, the fetus may die before birth 326 Review of Forensic Medicine and Toxicology Fig 21.5: Caput succedaneum Fig 21.4: Cephalhematoma Differentiation 21.2: Unrespired and respired lung (stillborn and live-born) S No Feature A Gross Color Volume Thoracic cavity Pleura Margins Surface Consistency Weight Ploucquet’s test Fodere’s (static) test Diaphragm B Cut section 10 Blood oozing 11 Floatation (Hydrostatic) test 12 Alveoli 13 Microscopically Unrespired lung Respired lung Bluish red Small Not full Loose, wrinkled Sharp Smooth Dense, firm, non-crepitant (liver-like) Mottled Large, covers heart Occupies fully Taut, stretched Rounded Uneven Soft, spongy, elastic, crepitant 1/70 of body weight 30–40 g 4th–5th rib level 1/35 of body weight 60–70 g 6th–7th rib level Little frothless blood Whole and parts sink in water Abundant frothy blood Floats in water Not expanded Alveolar sacs closed, lined with cuboidal/columnar cells Medico-legal importance Indicates still/dead born infant z z z z appearance with circumscribed rose-colored patches This is due to the blood vessels being filled with blood, and is characteristic of the lungs that have breathed On section, frothy blood exudes from the cut-surfaces on the application of slight pressure Weight – Fodere’s/Static test: The blood flow in lung beds increases after breathing, weight becomes double after respiration, but it is not constant.15,16 Weight of the lungs may increase in the stillborn due to: a Edema of lungs b Congenital pneumonitis c Inhalation of amniotic fluid – After respiration, they are spongy, elastic and resemble the adult tissue On rubbing a piece close to the ear, crepitance is heard (crepitant lungs) Color – Before respiration, the color is uniformly reddish-brown, like the liver The surface of the lobules is marked with shallow furrows, but without a mottled appearance On section, it is uniform in texture, being moist and resembling stiff strawberry jelly Froth-less blood exudes on pressing the cut surfaces – After respiration, lungs are salmon-pink in color The air cells are mottled/marbled in 14 Expanded, rise above the surface Sacs dilated, lined with flat squamous cells with prominent vascularity Indicates live birth 327 Infanticide and Child Abuse membrane, edema, feeble respiration, pneumonia and congenital syphilis.19 Hydrostatic test is not necessary if: i Fetus shows congenital anomaly, like anencephaly ii Fetus is macerated or mummified iii Umbilical cord has separated and a scar has formed iv Stomach contains milk v Bruises on lungs indicating efforts to artificially respirate the child vi Fetus is born before 180 days of gestation.* * Not a criteria in India, since there is no legally defined cut-off limit of viability z z iv Histology z Unrespired lung looks like the parotid gland with closed alveolar sacs lined with cuboidal/ columnar cells, and less vascularity z Respired lung cells get flattened with dilatation— pavement (squamous) epithelium with increased vascularization v Changes in middle ear (Wreden’s test): Absence of gelatinous embryonic connective tissue which was present during fetal life and presence of air in middle ear is seen after live birth.20 It is also called Wreden-Wendt tympanic cavity or middle ear test vi Changes in stomach and intestines: Live born infant swallows air into the stomach during respiration, and if present in small intestine it further confirms live birth But air may be present in the stomach after decomposition, or in the stillborn attempting to free the air passages of fluid obstruction Demonstration: The stomach and intestines are removed after tying double ligatures at each end They are kept under water and incision is given between the ligatures Air bubbles will come out, if respiration has taken place—Breslau’s second life test or stomach bowel test.21 If milk is present in the stomach, it is a positive evidence of live birth vii Meconium: In case of live birth, the large intestine is completely free of meconium within 24 h after birth, but in stillbirths it will be present in the intestine In case of breech presentation and hypoxia, meconium may be completely expelled before birth, and thus may be absent even in such stillborn fetuses viii Changes in the blood vessels: Umbilical arteries are obliterated within 12 h to days Obliteration of umbilical vein and ductus venosus is complete by 4th day The ductus arteriosus obliterates in about 10 days z z z z z z z z z – Ploucquet’s test: This test helps to demonstrate establishment of respiration The ratio of the weight of the lungs and the whole body is reduced to half (1/35 of body weight) as compared to the said ratio before respiration (1/70 of body weight).16,17 ii Position of the diaphragm: The position of the diaphragm is at the level of the 4th–5th rib, if respiration has not taken place The arch becomes flattened and depressed, and descends to 6th–7th rib after respiration The position of the diaphragm may be affected by pressure of the gases of putrefaction iii Hydrostatic test Hydrostatic test is also called floatation test or Raygat’s test.16,18 Principle: It is based on the fact that specific gravity of lung before respiration is 1040–1050 and becomes 940-950 after respiration which is less than that of water This makes the respired lung to float Procedure: Dissect out the fetal lungs Put both the lungs (tied at their hilar region) into a trough of water and observe Inference z If they sink—unrespired lung z If they float—remove them from water, cut into small pieces and then squeeze or compress firmly between sponges, and again put into water z If they sink—unrespired lung z If they float—respired lung Explanation: Floatation observed for second time is because of residual air that remains in the lungs which cannot be squeezed out by pressing, if the fetus has breathed after birth z The test is of limited value and it can at best be a suggestive pointer, but never a definitive test in itself z The slightest degree of putrefaction immediately negates any interpretation of this test In such cases, the lungs will float in water, but so are the solid organs, such as the liver z However, assuming body is fresh, the floating of lungs and heart en bloc increases the sensitivity of the test Fallacies z False positive is seen in accumulation of putrefying gases or artificial inflation (by intubation and forced air insufflation expanding the lungs with air after delivery) z False negative is seen in atelectasis (nonexpansion of lungs), obstruction by alveolar duct 328 Review of Forensic Medicine and Toxicology Robert’s sign: Appearance of gas shadow in chambers of heart and great vessels, may appear by 12 h, but difficult to interpret.26 Hyperflexion of spine is more common Crowding of the ribs shadow with loss of normal parallelism Two cardinal signs to identify a dead born fetus are the presence of maceration along with lack of lung aeration (‘primary atelectasis’) Signs of Stillborn Fetus z z z Maceration: It is a process of aseptic autolysis.22 This occurs when the dead child remains in the uterus for about 3–4 days surrounded with liquor amnii with exclusion of air z Earliest sign of maceration is skin slippage of face, back or abdomen which may be seen in 12 h after death in utero By 24 h, skin is brown or purplish in color z The dead fetus is soft, flaccid with emission of sweetish disagreeable smell, but no gases are formed z Internal organs show autolytic decomposition, but the lungs and uterus remain unchanged for a long time z Cranial compression is seen in > 36 h, desquamation over 75% of body surface is seen in 72 h, overlapping of cranial sutures in > 96 h and the mouth is widely open in > week Putrefaction is characterized by an unpleasant odor, greenish discoloration of skin and formation of foul smelling gases Rarely, the fetus may show adipocere formation.23 Spalding’s sign: A pathogonomic sign of intra-uterine death There is loss of alignment and overlapping of fetal skull bones on X-ray, occurs due to liquefaction of cerebrum and softening of ligamentous structures supporting the vault It appears in about days after death.24,25 Rigor mortis: It may be seen in dead-born fetus Mummification: It results from deficient supply of blood or scanty liquor amnii Fetus is dried up and shriveled in ≥ weeks z Signs of Dead-Born Fetus Another possibility for deaths occurring in infants whose births are unattended or complicated is that the fetus/infant died during the birth process The findings which suggest that a death is an intrapartum death are lack of maceration and lack of lung aeration.27 The difference between stillborn and dead-born fetus is given in Diff 21.3 In most instances, it is not possible by autopsy alone to differentiate these cases from deaths that occur prior to birth but have not yet developed maceration or from deaths that occur after birth where there is little or no aeration of the lungs When a precipitate birth occurs, air can enter the lungs, via the chest compression followed by rapid chest expansion that occurs during passage through the birth canal, even if the infant does not actively inhale Iatrogenic deaths may result from improper body positioning of the mother, use of medications (such as epidurals), use of various maneuvers, instrumentation, and surgical interventions which can result in prolongation of the labor and birth process Prolongation of labor might contribute to birth asphyxia Question on negligence: Charges for wrongful or negligent act may be brought against the medical practitioner if the act results in a miscarriage or stillbirth of the fetus The medical practitioner become liable to pay damages, if the harm suffered is the result of his/her tortious conduct ix Changes in heart: Closure of foramen ovale occurs by 2–3 months after birth In few cases, the foramen may not completely close x Changes in the blood: Nucleated RBCs are absent in peripheral circulation within 24 h after live birth Fetal hemoglobin may be present in the blood upto months or more xi Incremental line in enamel of teeth: Neonatal incremental line in the enamel of the teeth is formed at birth which is one of the surest sign of live birth xii Ossification centers: Presence of ossification centers at the lower end of radius, heads of humerus and femur and capitulum of humerus may also be taken as signs of separate existence for few months xiii Closure of fontanelle: Closure of different fontanelle occurs at different periods after birth Closure of posterior fontanelle may occur at birth The law in the US and the UK presumes that every newborn child found dead was born dead, until the contrary is proved When a woman is charged with infanticide, the burden of proof is upon the prosecution to demonstrate that the child had a separate existence Unless the autopsy surgeon has absolute reasons to document post-natal survival, for e.g., well-expanded lungs or food in the stomach, he is legally bound not to diagnose live birth 329 Infanticide and Child Abuse Differentiation 21.3: Stillborn and dead-born fetus Dead-born fetus Fetus which has died in utero Dead in utero No such predominance Maceration Spalding’s sign Robert’s sign Rigor mortis at delivery Mummification Congenital anomaly, ABO and Rh incompatibility Stillborn fetus Fetus which is born after 28 weeks of pregnancy (24 weeks in the UK), and which did not breath or show any other signs of life at any time after being completely born (WHO) Condition in utero Fetus was alive in utero, but dies during the process of delivery Predominance Seen mostly among illegitimate and immature male children in primiparae Findings Signs of prolonged labor, like edema, bleeding into scalp, caput succedaneum and severe moulding of head may be seen Feature Definition S No Anoxia, prematurity, birth trauma or toxemia Infant Death (Flow chart 21.1) a Natural Causes Prematurity Congenital malformation Birth trauma Intrapartum asphyxia Neonatal infection ABO and Rhincompatibility Post-maturity Early separation of placenta Preeclamptic toxemia Sudden infant death syndrome (SIDS) Some common causes are: Immaturity: A prematurely born child generally dies immediately after birth In the case of the premature birth of a child, the question may arise as to whether the birth was criminally induced or not, for under the IPC, the criminal induction of premature labour is an offence Debility: Due to lack of general development, even a full term child may die after birth from debility In these cases, no disease, except atelectasis of some portions of the lungs due to feeble respiration is detected Flow chart 21.1: Causes of infant death Congenital diseases and malformations: Syphilis and some fevers may cause death from the toxaemic condition Of the diseases of the internal organs, pulmonary infections and hyaline membrane of the lungs are seen Certain conditions such as anencephaly, spina bifida and congenital diaphragmatic hernia are readily identifiable, although subtle cardiovascular or metabolic abnormalities may be difficult to diagnose It is, however, unsafe to assume that actual live birth could not have taken place Moreover, monstrosity or malformation is no justification for taking the life of an infant Spasm of the larynx may occur from mucus or meconium being aspirated into the larynx, or from the enlargement of thymus gland Erythroblastosis fetalis due to iso-immunization, when an Rh-negative woman is carrying an Rhpositive fetus may result in death of the fetus Birth asphyxia can occur in preeclampsia/eclampsia, placenta abruption, cephalo-pelvic disproportion and shoulder dystocia Evidence of asphyxia at autopsy includes thymic, pleural and epicardial petechiae with intra-alveolar hemorrhage, and meconium on the skin, and shed fetal skin within distal air passages b Unnatural Causes I Accidental causes Perinatal i Injuries to the mother: It may cause premature separation of the placenta or injury to the fetus (concussion of brain/fracture/rupture of blood vessels) and lead to death of the baby ii Prolonged labor: It causes death of the fetus due to injury to the brain because of compression of the head or due to asphyxia Cause 330 z z z Blunt force Present anywhere on the scalp May be present Comminuted/ depressed fracture, may involve all the bones Contusions, lacerations and hemorrhage may be seen z S No Feature Precipitate labor Contusion Present on presenting part of scalp Laceration Absent Fracture Fissured fracture involving the parietal bones Brain Usually not injured z Differentiation 21.4: Head injury due to precipitate labor and blunt force z II Criminal causes Where the autopsy surgeon proves separate existence and live birth, he/she has an additional burden i Suffocation: Due to non-availability of nursing care, the neonate may die due to smothering or choking due to inhalation of amniotic fluid or blood immediately after birth ii Precipitate labor (in this condition, all the three stages of labor occur in very quick succession so that delivery occurs suddenly, commonly seen in multipara): It may cause death of the newborn due to head injury (Diff 21.4), suffocation or drowning, or occasionally due to bleeding from torn end of attached umbilical cord Medico-legal aspects z Death of the newborn due to precipitate labor may be taken as a case of deliberate infanticide z The mother may claim infanticide (negligence on part of the doctor), but death of the newborn is due to precipitate labor z Postnatal to document that death occurred from an act of commission or omission The ‘wilful’ aspect is a matter for the prosecution, but it is for the autopsy surgeon to demonstrate fatal injuries or to prove that some lack of care led to the death which is often an impossible task a Acts of commission: These acts are done positively to cause death of infant i Strangulation by a ligature material or the umbilical cord (to simulate natural twisting of cord round the neck) or by throttling ii Poisoning: Earlier, opium was used for the purpose (ideal infanticidal poison) Nowadays, acids and insecticides are used iii Smothering the baby to death with the help of hand or clothes iv Head injury: The head of the fetus may be struck against a wall or on the floor by holding its legs, this may leave an impression on the legs also v Concealed punctured wound may be caused by a nail or a needle through the fontanelle, nape of the neck or inner canthus of eye vi Twisting the neck: Death occurs due fracture dislocation of the cervical vertebrae and injury to the medulla vii Burning the newborn alive or disposing the living newborn inside an oven viii Drowning which also serves the purpose of disposal of the unwanted child ix Cut throat injury Deaths are mostly due to airway obstruction from smothering or strangulation Injuries: Strangulation marks around the neck with bruising from hands, or parchmented abrasions from ligatures that may have been left in situ; bruising with subgaleal, extradural and subdural hemorrhages, skull fractures and cerebral lacerations, and contusions from blows to the head with blunt objects may be seen Drowning and smothering may leave minimal findings b Act of omission or neglect: Intentional failure on the part of the mother to extend care to the newborn leading to its death; this may amount to infanticide It may be failure to: z Provide proper assistance during labor z Clear air passages which may be obstructed by amniotic fluid/mucus z Tie the cord after it is cut z Protect the child from exposure to heat/cold Failure to adequately clothe or place an infant in a warm environment may result in fatal hypothermia z Supply the child with proper food iii Prolapsed cord or pressure on cord: It may cause stoppage of fetal circulation during birth, and death of the newborn may occur during or just after birth iv Twisting of cord around the neck or knots of the cord: It causes death of the fetus during birth or immediately after birth from asphyxia due to strangulation v Death of the mother: When the mother dies during the delivery, the question arises as to how long a child may live in utero after her death The time depends upon the cause of the mother’s death If death occurs slowly from hemorrhage, there is little chance of saving the child, but it may be saved if an attempt is made to extract it within 25 after sudden death from accident of the previously healthy mother Review of Forensic Medicine and Toxicology 331 Infanticide and Child Abuse Abandoning of Children Precipitating factors i Act of disobedience by the child ii Frequent crying may create annoyance iii Refusal to take food iv Soiling of napkin or bedclothes v At times, any trifle act of the child may annoy the mentally challenged father or mother Features Arising Suspicion of Abuse Battered Baby Syndrome Any person who secretly buries or disposes of the dead body of a child and intentionally conceals the birth of such child is punished with imprisonment of years and with/without fine (Sec 318 IPC).28 It does not matter whether the child died before or after or during its birth In a case where infanticide is not proved, the person is usually charged under this section Sec 317 IPC deals with abandoning by the father or mother of the child under the age of 12 years with imprisonment upto years and with/without fine Concealment of Birth by Secret Disposal of Dead Body Socio-familial factors i Low social background ii Lack of equality between members of the family with lack of family harmony iii Long-standing emotional problem iv Financial hardship v Trouble at the place of work Features Parents give vague history of accident to be the cause of the injuries, like fall from stairs or cot which does not appear consistent with the type of injuries or time narrated by the parents (Fig 21.6) Often the parents’ gives a history of tendency of the child to bruise easily The parents of the child seek medical aid rather late or when the condition of the children becomes serious Often injuries in different stages of healing are found in the child i Age: The majority is below years of age ii Sex: More common with male children (M:F ratio 2:1) iii Status of the child: Usually, illegitimate and unwanted children—pregnancy before marriage or failure of contraception iv Position in family: Commonly, the eldest or the youngest The child may be a mentally abnormal one Related to the Child Definition: 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 It is also called Caffey syndrome, Caffey-Kempe syndrome, maltreatment syndrome or parent-infant traumatic stress syndrome i Marital status: Unmarried couple, commonly seen in some Western societies ii Age of parents: Usually, the parents are young iii Educational status: Lower level of education iv Addiction: Reckless life style, often indulging in drugs v Childhood history: Often the parents themselves were the victims of battering during their childhood vi Psychological factors: Low tolerance threshold, impulsive nature, aggressive personality and imbalanced temperament Related to the Parent/Guardian Fig 21.6: Sites of non-accidental injury 332 Review of Forensic Medicine and Toxicology In many cases, the parents later admit to have assaulted their children, but ‘only mildly’ for punishment A strong suspicion of child abuse should be made in a child presenting with altered mental status, unresponsiveness, coma, convulsions or with focal neurologic deficit z Shaken baby syndrome can occur from as little as seconds of shaking z The triad of injuries includes encephalopathy, retinal hemorrhages and SDH.29,30 SDH is the most consistent component of the triad and may be the first clinical sign identified on CT scan Additional traumatic injuries of the cord, brainstem and even skull may be produced Eyes: Retinal hemorrhages and lens displacement may be seen Visceral injuries: Injury to spleen, liver or hollow viscera can occur resulting in massive hemorrhage, shock and death of the child Burns: Small circular pitted burns may indicate deliberate stubbing of cigarette ends on skin Scalds are also common (Fig 21.7) Skeletal injuries: Bony injuries include transverse fractures, impacted fractures, spiral fractures, metaphyseal chip fractures, subperiosteal hematoma, and multiple deformities of the long bones and rib cage of the body due to multiple healed fractures and callus formation z z z z Accidental injuries typically involve bony prominences [head (forehead, occipital or parietal region), nose, chin, palm, elbows, knees and shin], match the history given by the parents and are keeping with the development of the child Injuries iii iv v vi The injuries may be caused by hand, foot, teeth, stick, belt, shoe, hot water, lighted cigarette, hot frying pan or any household article i Surface injuries: Bruises, abrasions and lacerations may be seen Laceration of the oral mucosa along with labial frenulum of the lower lip is a characteristic lesion Slap marks, lash mark, knuckle punches, pinch mark [butterfly-shaped bruise with one wing (caused by thumb) larger than other], bald patches on scalp due to pulling out the hair (traumatic alopecia) may be seen (Fig 21.7) ii CNS: Injuries are inflicted by throwing the child, striking the child with fist or object or against a wall, dropping the child or vigorous shaking of the infant (shaken baby syndrome or infantile whiplash syndrome) leading to intracranial hemorrhage (Fig 21.8) Fig 21.7: Surface injuries 333 Infanticide and Child Abuse Differential diagnosis of childhood fractures should be made from the several ‘brittle bone diseases’ that can cause abnormal skeletal fragility—congenital syphilis, rickets, scurvy, leukemia, osteogenesis imperfecta, copper deficiency, Menke’s syndrome, infantile cortical hyperostosis (Caffey’s disease) and juvenile osteoporosis It can be defense in a criminal trial of alleged child abuse on the grounds that such fractures can be observed within normal parental handling or spontaneous movements of the child Shaken baby syndrome: Infants are susceptible to subdural/ subarachnoid hematoma and retinal hemorrhages due to vigorous shaking of the baby as a method of punishment Predisposing factors: Infant’s relatively large head, weak neck muscles and delicate subarachnoid bridging vessels Signs and symptoms: Seizures, irritability, meningismus and focal or general neurologic deficit Diagnosis: Confirmation by CT/MRI scan, bloody spinal or subdural fluid and normal skull X-rays Reporting of suspected child abuse: It is mandatory to report any suspected child abuse case in the US, Argentina, Finland, Israel, Korea and Spain In other countries such as Croatia, Japan, Netherlands and Romania reporting is voluntary In India, it is mandatory to report to the police about sexual abuse under the Protection of Children from Sexual Offences Act, 2012 Nature of injuries Delay in seeking medical treatment Recurrent injuries Radiological manifestations, especially those involving the ribs, metaphyseal-epiphyseal injuries, and avulsive fractures of the clavicle and acromium process Head injury with or without skull fracture is the leading cause of death in child abuse followed by rupture of an abdominal viscus i ii iii iv z z z z Diagnosis Child abuse can be defined as causing or permitting of any harmful or offensive contact to a child’s body and/or any communication or transaction which humiliates, shames, or frightens a child Major types of abuse i Physical abuse ii Sexual abuse iii Emotional abuse iv Neglect i Physical abuse of children includes any non-accidental physical injury caused by the child’s caretaker It can be beating or battering of a child, and has been described above ii Sexual abuse refers to inappropriate sexual behavior with a child It includes fondling a child’s genitals, making the child fondle the adult’s genitals, intercourse, incest, rape, sodomy, exhibitionism, indecent exposure and commercial exploitation through prostitution or the production of pornographic materials iii Emotional abuse (verbal/mental abuse or psychological maltreatment): Acts of commission and omission which can be potentially damaging psychologically This can include parents/ caretakers using extreme and/or bizarre forms of punishment, such as confinement in a closet or dark room or being tied to a chair for long periods iv Neglect is the failure to provide for the child’s basic needs Neglect can be physical, educational or emotional In general, neglect is an act of omission Fractures of long bones, ribs, skull and vertebral bodies are highly suggestive of abuse z Antero-posterior compression of chest causes fractures in midaxillary line (Fig 21.8) z Multiple rib fractures also occur along posterior angle of ribs on side-to-side squeezing (Fig 21.8) The fractured ribs heal by callus formation in 1–2 weeks, giving characteristic appearance of a knob (knob fractures), and on X-ray ‘string of beads’ appearance is seen in paravertebral gutter z In whiplash movement of arms and legs, typical ‘corner’ or ‘bucket-handle’ fractures in the metaphyseal region may be seen (Fig 21.8) vii CVS: Blunt trauma to chest may cause multiple rib fractures leading to lung and heart contusions, pneumothorax, hemothorax, rupture of diaphragm and cardiac tamponade viii Genitourinary system: Physical and sexual abuse should be considered in a child presenting with hematuria, dysuria, increased frequency of urination and enuresis z Sudden Infant Death Syndrome [SIDS, Cot Death (UK) or Crib Death (US)] Fig 21.8: Internal injuries Definition: Sudden and unexpected death of seemingly healthy infant whose death remains unexplained even after complete autopsy It is an autopsy diagnosis, and not a clinical diagnosis 334 Review of Forensic Medicine and Toxicology Features SIDS is a natural death in which the parents may be wrongfully linked for having criminal involvement or negligence Some infanticide cases may be presented as cot death cases Munchausen syndrome by proxy [MSBP or Factitious disorder (Latin facticious: made by art)]:31 MSBP is a form of abuse in which parent or guardian fabricates or produces symptoms of an illness in a child in order to gain sympathy or attention for themselves The parents frequently have abnormal or borderline personality disorder Diagnosis may require a high level of suspicion and may be met with considerable resistance from family Features i The child may be brought with vague complaints such as vomiting, diarrhea, fever or seizures inflicted by the parent intentionally and repeatively, for e.g bleeding may be caused by anticoagulants and simulated by exogenous blood, seizures can be caused by suffocations, shaking or intoxications, vomiting can be caused by giving ipecac syrup and fever triggered by injecting contaminants into IV lines while the child is in the hospital ii The parent or guardian derives some non-economic benefit at the expense of the victim iii Some perpetrators ‘doctor shop’ while some maintain a constant relationship with one or more health care providers iv When confronted, the parent or guardian usually denies any allegations of causing the victim’s condition.32 Diagnosis i The illness does not conform to the expected presentation or follow the usual course ii Signs and symptoms are not substantiated by laboratory or imaging findings iii Failure of wounds to heal iv The child becomes ill or worsens when the parent or guardian is present, with recovery when separated v Positive drug or toxicological analysis for something not prescribed for the patient vi Finding that the patient has been admitted to multiple hospitals and has been seen by multiple physicians Medico-legal Aspects No definite cause is known i Prolonged sleep apnea is presently accepted as the most acceptable of the suggested causes A periodic failure to breath during sleep makes them susceptible to hypoxia Hypoxic state may be promoted by many allied factors, e.g some infective condition of the respiratory tract ii Respiratory infection may cause viremia which leads to sleep depression of respiratory center and death iii Nasal edema and mucus secretion may narrow upper respiratory passages, a flaccid pharynx and neck posture may reduce airway iv Local hypersensitivity of the respiratory tract lumen to cow’s milk was thought to cause laryngeal spasm v Bedclothes and pillow falling accidentally over the nose and mouth by the movement of the child vi Overlying of the baby by a sleeping or intoxicated mother Infants placed to sleep prone or on their side increases the risk of SIDS vii Miscellaneous causes: Conduction system anomalies; hypoparathyroidism; deficiency of selenium, antibodies, calcium, magnesium and vitamins B, C, D and E; house-mite allergy; sodium overload in feeds and hypothermia Postmortem findings are negative Trachea contains milky vomit, sometimes bloodstained with shed epithelial cells Multiple petechial hemorrhages on heart (posterior epi cardial surface), lungs and thymus—agonal in nature Pulmonary edema is common Milk or bloodstained froth on child’s mouth or bedding Hands are often clenched around fibers from bedclothes Cause Postmortem Findings i Incidence: 0.2–0.4% of all live births ii Geographical distribution: Worldwide iii Age: Between weeks to years Mid infancy is the most vulnerable age (peak 2–4 months) iv Sex: Male infants have a proportionately higher death rate (M:F ratio 3:2) v Socio-economic status: Low and middle class family with poor housing condition, large family and lack of health consciousness vi Time of death: In most cases, the infant is discovered dead, either in the early morning (death possibly occurring at late night) or sometime after first feed in the morning vii Season: In most occasions, deaths are seen to occur commonly in rainy and winter seasons in temperate zones, but no clear pattern in tropical zones viii Twins: More among twins (two-fold) as opposed to singletons Prematurity and low birth weights which are often present in twins increases the risk of SIDS ix Addiction: Smoking (pre-or postnatal) and drug abuse by pregnant women increases risk There is an increased risk of SIDS as well as other causes of death in families that have one SIDS death 335 Infanticide and Child Abuse MULTIPLE CHOICE QUESTIONS 10 B 20 A D 19 A A 18 B A 17 C C 16 C C 15 B D 14 C C 13 B A 12 D D 11 A 11 Not true about cephalhematoma: AP 08; Kerala 08 A Not limited by sutures B Swelling develops in 12–24 h after birth C Swelling subsides in 2–3 months D Caused by periosteal injury of skull 12 Consider the following statements regarding a cephalhematoma: UPSC 08, 14 Present at birth It can occur after a normal delivery The commonest site is over the parietal bone The bleeding is sub-periosteal Which of the statements given above are correct? A and B and only C 1, and D 2, and 13 Caput succedaneum in a newborn is: Karnataka 07 A Collection of blood under the pericranium B Collection of sero-sanguineous fluid in the scalp C Edema of the scalp due to grip of the forceps D Varicose veins in the scalp 14 The following are the characteristics of caput succe daneum, except: AFMC 12 A It is present at birth B It does not cause jaundice in newborn C It is limited to individual bone D It disappears within a few hours of birth 15 The test based on lung weight useful in the diagnosis of live birth is: KCET 12 A Hydrostatic test B Static test C Wredin’s test D Breslau’s second life test 16 All tests are used to detect live birth, except: NEET 14 A Ploucquet’s test B Fodere’s test C Gettler’s test D Raygat’s test 17 Test in which weight of lung is compared to body weight: PGI 08, 09 A Fodere’s test B Cavett test C Ploucquet’s test D Precipitin test 18 Raygat’s test is based on: NEET 14 A Weight of lung B Specific gravity of lung C Consistency of lung D Volume of lungs 19 False negative hydrostatic test in live born: AI 08 A Atelectasis B Meconium aspiration C Emphysema D Congenital heart disease 20 Wreden’s test is to demonstrate: MP 09; NEET 15 A Live birth B Insanity C Putrefaction D Assault A conceptus material is brought by the police It is cm in length and 10 g in weight Probable age is: AIIMS 12 A weeks B weeks C weeks D weeks In a month fetus, characteristic feature seen is: NEET 13 A Nails are visible B Limbs well formed C Anus is seen as dark spot D Meconium is found in duodenum Lanugo hair first appears in a fetus at: UP 07 A 2nd month B 3rd month C 4th month D 5th month Consider the following four events of development of fetus: UPSC 08; COMEDK 15 Development of external genitalia Appearance of scalp hair Centers of ossification in bones Formation of eyelashes and eye brows What is the order in which they appear from lower to higher gestation? A 1, 3, 2, B 1, 3, 4, C 3, 1, 4, D 3, 1, 2, The center of ossification used as medico-legal evidence for fetal viability: COMEDK 07; Punjab 08 A Head of femur B Distal end of femur C Talus D Calcaneum Testes completely descend in the scrotum by the: DNB 09 A End of 7th month B End of 8th month C End of 9th month D After birth Center of ossification of femur appears at: PGI 07 A 36 weeks B 38 weeks C 40 weeks D 28 weeks Rule of Hasse is used to determine: DNB 09; Punjab 10; NEET 13 A Age of fetus B Height of an adult C Race of a person D Identification At what age, does the birth length doubles: UPSC 07; FMGE 10, 11 A year B years C years D years 10 Birth weight triples at: Odisha 11 A months of age B year of age C years of age D 2.5 years of age 336 29 A 28 D 27 B 26 C 25 C 24 A 23 B NEET 13 A Sec 320 IPC B Sec 312 IPC C Sec 317 IPC D Sec 318 IPC 29 Not the signs of accidental injury in a child: CMC (Vellore) 10 A Subdural hematoma B Abrasion on the knees C Swelling in the occiput D Bleeding from the nose 30 An infant is brought to casualty with reports of violent shaking by parents Most characteristic injury is: AI 11 A Long bone fracture B Ruptured spleen C Subdural hematoma D Skull bone fracture 31 Munchausen syndrome by proxy is: NIMHANS 10 A Factitious disorder B Malingering C Hysteria D Conversion disorder 32 Munchausen by proxy includes all, except: Maharashtra 11 A Admission of abuse by parents B Illness does not suggest particular disease C Child becomes ill in presence of the caregiver D Laboratory and X-ray findings are negative 32 A 22 B 31 A 21 B 28 Concealment of birth is punishable under: 21 Breslau’s second life test utilizes: MAHE 09; AIIMS 12 A Liver B Stomach C Ear D Lungs 22 Aseptic autolysis is seen in: AP 08 A Adipocere B Maceration C Putrefaction D Mummification 23 Dead-born fetus does not show: Kerala 11 A Rigor mortis at birth B Adipocere formation C Maceration D Mummification 24 Spalding sign is seen in: AI 07; BHU 09; AFMC 11; CMC (Vellore) 14 A Maceration B Mummification C Putrefaction D Saponification 25 Spalding sign is seen in: AI 06; CMC (Ludhiana) 10 A Abortion B Stillbirth C Intrauterine death D Infanticide 26 Presence of gas shadow in the heart and great vessels suggestive of intrauterine death This is called: KCET 12 A Chadwick’s sign B Osiander’s sign C Robert’s sign D Spalding sign 27 All are true about stillbirth, except: Maharashtra 08, 09, 11 A Fetus was alive in utero B Birth weight < 1000 g C Diaphragm at 4–5th rib level D Hydrostatic test is negative Review of Forensic Medicine and Toxicology 30 C ... Methods 10 3 Examination Proper 10 4 Chest 10 5 Heart 10 6 Neck 10 8 Skull and Brain 10 8 Description of an Organ 11 0 Report 11 1 Demonstration of Pneumothorax 11 1 Demonstration of Air Embolus 11 2 Collection... Collection of Samples 11 2 Preservation of Viscera 11 3 Preservation of Samples 11 4 Samples for Laboratory Investigations 11 5 Obscure and Negative Autopsy 11 6 Second Autopsy 11 6 Examination of Decomposed,... Injuries and Fall from Height Medico-legal Aspects of Injuries Decompression, Radiation and Altitude Sickness 10 11 12 13 14 15 16 17 18 Jurisprudence and Forensic Medicine