MBBS MEDICINE (Humanity First)

Urinary System (Embryology)

2011-10-17T18:27:00.000-07:00

Patient Examination Charts in United States

2011-10-14T19:03:00.000-07:00

Patient Examination forms

ECG leads connection Information

Spirometry Test Form

Laboratory Tests Forms

Nuclear Medicine Scan Forms

Breast Examination Findings form

Ankle Brachial Index (ABI)

Cell division

2011-10-12T18:51:00.000-07:00

The phase between two mitoses is called INTERPHASE, during which the nucleus appears as it is normally observed in microscopic preparations.

The PROPHASE of mitosis is characterized by the gradual coiling of nuclear chromatin (uncoiled chromosomes), giving rise to several individual rod-or hairpin-shaped bodies (coiled chromosomes) that stain intensely.

During METAPHASE, chromosomes, due to the activity of microtubules, migrate to the equatorial plane of the cell, where each divides longitudinally to form two chromosomes called sister chromatids. The chromatidsattach to the microtubules of the mitotic spindle.

In ANAPHASE, the sister chromatidsseparate from each other and migrate toward the opposite poles of the cell, pulled by microtubules. Throughout this process, the centromeresmove away from the center, pulling the remainder of the chromosome along. The centromereis the constricted region of a mitotic chromosome that holds the two sister chromatidstogether until the beginning of anaphase.

TELOPHASE is characterized by the reappearance of nuclei in the daughter cells. The chromosomes revert to their semidispersedstate, and the nucleoli, chromatin, and nuclear envelope reappear. While these nuclear alterations are taking place, a constriction develops at the equatorial plane of the parent cell and progresses until the cytoplasm and its organelles are divided in two. This constriction is produced by microfilaments of actinassociated with myosin that accumulate in a beltlikeshape beneath the cell membrane.

G1 PHASE

The first phase within interphase, from the end of the previous M phase until the beginning of DNA synthesis is called G1 (G indicating gap). It is also called the growth phase. During this phase the biosynthetic activities of the cell, which had been considerably slowed down during M phase, resume at a high rate. This phase is marked by synthesis of various enzymes that are required in S phase, mainly those needed for DNA replication. Duration of G1 is highly variable, even among different cells of the same species.

S PHASE

The ensuing S phase starts when DNA synthesis commences; when it is complete, all of the chromosomes have been replicated, i.e., each chromosome has two (sister) chromatids. Thus, during this phase, the amount of DNA in the cell has effectively doubled, though the ploidyof the cell remains the same. Rates of RNA transcription and protein synthesis are very low during this phase. An exception to this is histoneproduction, most of which occurs during the S phase.

G2 PHASE

The cell then enters the G2 phase, which lasts until the cell enters mitosis. Again, significant protein synthesis occurs during this phase, mainly involving the production of microtubules, which are required during the process of mitosis. Inhibition of protein synthesis during G2 phase prevents the cell from undergoing mitosis.

MITOSIS (M PHASE)

The relatively brief M phase consists of nuclear division (karyokinesis) and cytoplasmicdivision (cytokinesis)

G0 PHASE:

In cells that are not continuously dividing, the activities of the cell cycle may be temporarily or permanently suspended. Cells in such a state (eg, muscle, nerve) are referred to as being in the G0phase.

CLINICAL :Growth factors stimulates increase cell cycle rate thus increase the cell production e.g.. Erythropoietin.In Cancers the cell cycle is abnormally increased thus uncontrolled cell production.Some Anticancer drugs act by controlling this uncontrolled rate.

Candidiasis (candidosis)

2011-10-10T18:10:00.000-07:00

Opportunistic Mycosis

is caused by the yeast Candida albicans, and other Candida species, which are normal body flora found in the skin,mouth,vagina, and intestines.

Infections occur when competing bacterial flora are eliminated, for example, by antibacterial antibiotics, allowing the yeast to overgrow.

Oral Candidiasis:

Candida infections have various manifestations depending on the plaques on the oral mucosa, tongue, or gums. The plaques can become confluent and ulcerated and spread to the throat. Most HIV-positive individuals eventually develop oral candidiasis, which often spreads to the esophagus. The latter condition is considered an indicator of full-blown AIDS.

Vaginal Candidiasis:

it presents as itching and burning pain of the vulva and vagina, accompained by a thick or thin white discharge. HIV-positive females often experience recurrent vaginal candidiasis.

Systemic Candidiasis:

is a potentially life-threating infection that occurs in debilitated individuals, cancer patients ( with neutropenia secondary to chemotherapy), individuals on systemic corticosteroids, and patients treated with broad-spectrum antibiotics. Systemic candidiasis may involve the gastrointestinal tract, kidneys, liver, and spleen.

Treatment:

Both oral and vaginal infections are treated topically with nystatin or Clotrimazole. Oral systemic antifungal agents such as ketoconazole, fluconazole, and itraconazole are preferred for ease of administration and increased efficacy.

Amphotericin B by itself or in combination with flucytosine is used in systemic disease.

EPITHELIUM

2011-09-15T13:26:00.000-07:00

EPITHELIAL TISSUE

Despite its complexity, the human body is composed of only four basic types of tissue: EPITHELIAL, CONNECTIVE, MUSCULAR, and NERVOUS. These tissues, which are formed by cells and molecules of the extracellular matrix, exist not as isolated units but rather in association with one another and in variable proportions, forming different organs and systems of the body. Also of great functional importance are the FREE CELLS found in body fluids such as blood and lymph.

Most organs can be divided into two components: parenchyma, which is composed of the cells responsible for the main functions typical of the organ, and stroma (mesenchyma), which is the supporting tissue.

FUNCTIONS:

The principal functions of epithelial (Gr. epi, upon, + thele, nipple) tissues are the covering and lining of surfaces (eg, skin, intestines), absorption (eg, intestines), secretion (eg, glands), sensation (eg, gustative and olfactory neuroepithelium), and contractility (eg, myoepithelial cells). Because epithelial cells line all external and internal surfaces of the body, everything that enters or leaves the body must cross an epithelial sheet.

THE FORMS & CHARACTERISTICS OF EPITHELIAL CELLS:

The forms and dimensions of epithelial cells range from high columnar to cuboidal to low squamous cells.

Epithelial cell nuclei have distinctive shapes, varying from spherical to elongated or elliptic. The form of the nuclei of epithelial cells corresponds roughly to the cell shape; thus, cuboidal cells have spherical nuclei and squamous cells have flattened nuclei. The long axis of the nucleus is always parallel to the main axis of the cell.

Almost all epithelial cells, whether lining a surface or forming gland units, rest on a connective tissue. In the case of epithelia that line the cavity of internal organs (especially the digestive, respiratory, and urinary systems) this layer of connective tissue is often called lamina propria. The lamina propria not only serves to support the epithelium but also provides nutrition and binds it .

The portion of the epithelial cells that faces the connective tissue is called the basal pole, whereas the opposite side, usually facing a space, is called the apical pole. The surface of the apical pole is also called the free surface, whereas the surfaces that are apposed to neighbor cells are called lateral surfaces.

Basal Lamina & Basement Membrane

Most epithelial cells are separated from the connective tissue by a sheet of extracellular material called the basal lamina. This structure is visible only with the electron microscope, where it appears as a dense layer, 20–100 nm thick, consisting of a delicate network of very fine fibrils (lamina densa) .In addition, basal laminae may have an electron-lucent layer on one or both sides of the lamina densa, called lamina rara or lamina lucida. Between cell layers without intervening connective tissue, such as in lung alveoli and in the renal glomerulus ,the basal lamina is thicker as a result of fusion of the basal laminae of each epithelial cell layer.

The main components of basal laminae are type IV collagen, the glycoproteins laminin and entactin, and proteoglycans (eg, the heparan sulfate proteoglycan called perlecan). In some instances, reticular fibers are closely associated with the basal lamina, forming the reticular lamina. The term basement membrane is used to specify a periodic acid–Schiff (PAS)-positive layer, visible with the light microscope, present beneath some epithelia.

Intercellular Adhesion & Intercellular Junctions

Several membrane-associated structures contribute to cohesion and communication between cells. They are present in most tissues but are ,prominent in epithelium. Adhesion is due in part to the binding action of a family of transmembrane glycoproteins called cadherins.

Tight junctions, or zonulae occludens (singular, zonula occludens), are the most apical of the junctions. The Latin terminology gives important information about the geometry of the junction. "Zonula" refers to the fact that the junction forms a band completely encircling the cell , and "occludens" refers to the membrane fusions that close off the intercellular space.

In many epithelia, the next type of junction encountered is the zonula adherens. This junction encircles the cell and provides for the adhesion of one cell to its neighbor. A noteworthy feature of this junction is the insertion of numerous actin filaments into electron-dense plaques of material on the cytoplasmic surfaces of the junctional membranes. The filaments belong to the terminal web, a web of actin filaments, intermediate filaments, and spectrin found close to the free surface.

Gap or communicating junctions can occur almost anywhere along the lateral membranes of epithelial cells. The individual unit of the gap junction is called a connexon. Each connexon is formed by six gap junction proteins called connexins, which join together leaving a hydrophilic pore about 1.5 nm in diameter in the center. Connexons of adjacent cells are aligned to form a hydrophilic channel between the two cells . Each gap junction is formed by tens or hundreds of aligned pairs of connexons. A typical example is heart muscle cells, where gap junctions are, to a great degree, responsible for the heart's coordinated beat.

The final type of junction is the DESMOSOME (Gr. desmos, band, + soma, body), or MACULA ADHERENS. The desmosome is a complex disk-shaped structure at the surface of one cell that is matched with an identical structure at the surface of the adjacent cell. The cell membranes in this region are very straight and are frequently somewhat farther apart (>30 nm) than the usual 20 nm. On the cytosolic side of the membrane of each cell and separated from it by a short distance is a circular plaque of material called an ATTACHMENT PLAQUE, made up of at least 12 different proteins. In epithelial cells, groups of INTERMEDIATE CYTOKERATIN FILAMENTS are inserted into the attachment plaque or make hairpin turns and return to the cytoplasm. Because intermediate filaments of the cytoskeleton are very strong, desmosomes provide a firm adhesion among the cells. In nonepithelial cells, the intermediate filaments attached to desmosomes are made not of cytokeratin but of other proteins, such as desmin or vimentin. Proteins of the cadherin family participate in the adhesion provided by desmosomes

Specializations of the Cell Surface

Microvilli

When viewed in the electron microscope, the majority of cells from several different tissues are seen to have cytoplasmic projections. These projections, the microvilli (Gr. mikros, small, + L. villus, tuft of hair), are fingerlike extensions measuring about 1 m high and 0.08 m wide. They are found mainly on the free cell surface. Hundreds of microvilli are found in absorptive cells, such as the lining epithelium of the small intestine and the cells of the proximal renal tubule In these absorptive cells the glycocalyx is thicker than it is in most other cells. The complex of microvilli and glycocalyx may be seen with the light microscope and is called the brush, or striated, border.

As seen at higher magnification in micrograph, the cytoplasmic core of each microvillus contains actin microfilaments F which insert into the terminal web, a specialisation of the actin cytoskeleton lying immediately beneath the cell surface. At the periphery of the cell the terminal web is anchored to the zonula adherens .At the tip of the microvillus, the filaments attach to an electron-dense part of the plasma membrane. The microfilaments maintain stability of microvilli and may also mediate some contraction and elongation of the microvilli.

STEREOCILIA

Stereocilia are long, nonmotile extensions of cells of the epididymis and ductus deferens that are actually long and branched microvilli and should not be confused with true cilia. Stereocilia increase the cell surface area, facilitating the movement of molecules into and out of the cell.

CILIA & FLAGELLA

Cilia are cylindrical, motile structures on the surface of some epithelial cells, 5–10 m long and 0.2 m in diameter. They are surrounded by the cell membrane and contain a central pair of isolated microtubules surrounded by nine pairs of microtubules. The two microtubules of the peripheral pairs are joined to each other.

Cilia are inserted into BASAL BODIES, which are small cylindrical structures at the apical pole just below the cell membrane .Basal bodies have a structure analogous to that of the centrioles.

In living organisms, cilia have a rapid back-and-forth movement. Ciliary movement is frequently coordinated to permit a current of fluid or particulate matter to be propelled in one direction over the epithelial surface. Adenosine triphosphate (ATP) is the source of energy for ciliary motion. A ciliated cell of the TRACHEA is estimated to have about 250 cilia.

Flagella, present in the human body ONLY IN SPERMATOZOA, are similar in structure to cilia but are much longer and are limited to one flagellum per cell.

ALL BLOOD VESSELS ARE LINED WITH A SIMPLE SQUAMOUS EPITHELIUM CALLED ENDOTHELIUM

THE SIMPLE SQUAMOUS EPITHELIUM THAT COVERS THE BODY CAVITIES (THE ABDOMINAL CAVITY IN THIS CASE) IS CALLED MESOTHELIUM. PT STAIN. MEDIUM MAGNIFICATION

SIMPLE CUBOIDAL EPITHELIUM (ARROW) FROM KIDNEY COLLECTING TUBULES. PT STAIN. LOW MAGNIFICATION

SIMPLE COLUMNAR EPITHELIUM FORMED BY LONG CELLS WITH ELLIPTICAL NUCLEI.

STRATIFIED SQUAMOUS NONKERATINIZED (MOIST) EPITHELIUM OF THE ESOPHAGUS. THE MOST SUPERFICIAL CELLS (ARROW) HAVE THE FORM OF VERY THIN SCALES. PT STAIN. MEDIUM MAGNIFICATION.

STRATIFIED TRANSITIONAL EPITHELIUM OF THE URETHRA. THE RED-STAINED BASEMENT MEMBRANE BETWEEN THE EPITHELIUM AND THE UNDERLYING LOOSE CONNECTIVE TISSUE IS INDICATED BY ARROWS.

PSEUDOSTRATIFIED COLUMNAR EPITHELIUM OF THE TRACHEA, FORMED BY LONG AND SHORT CELLS. AS SOME CELLS DO NOT REACH THE SURFACE OF THE EPITHELIUM THEIR NUCLEI ARE PRESENT IN DIFFERENT HEIGHTS OF THE EPITHELIAL LAYER. MUCUS-SECRETING CELLS, CALLED GOBLET CELLS (ARROW), INTERMINGLE WITH CILIATED LINING CELLS.

GLANDULAR EPITHELIA

Glandular epithelia are formed by cells specialized to produce secretion. The molecules to be secreted are generally stored in the cells in small membrane-bound vesicles called secretary granules.
Glandular epithelial cells may synthesize, store, and secrete proteins (eg, pancreas), lipids (e.g., adrenal, sebaceous glands)
complexes of carbohydrates and proteins (eg, salivary glands).
The mammary glands secrete all three substances.

TYPES OF GLANDULAR EPITHELIA

The epithelia that form the glands of the body can be classified according to various criteria. Unicellular glands consist of isolated glandular cells, and multicellular glands are composed of clusters of cells. An example of a unicellular gland is the GOBLET CELL of the lining of the small intestine, or of the respiratory tract. The term "gland," however, is usually used to designate large, complex aggregates of glandular epithelial cells, such as in the salivary glands and the pancreas.

Section of large intestine showing goblet cells (arrows) secreting mucus to the extracellular space. The mucus precursor stored in the cytoplasm of the goblet cells is also stained in a dark color.

The nucleus of the goblet cell on the right is outside the plane of section, the nucleus N of the other being typically highly condensed showing a goblet cell in horizontal section). The cytoplasm is packed with rough endoplasmic reticulum rER; a few mitochondria M are present. A prominent Golgi apparatus G is found in the supranuclear region although it is barely visible at this magnification.

The protein component of mucigen is synthesised by the rough endoplasmic reticulum and passed to the Golgi apparatus where it is combined with carbohydrate and packaged into membrane-bound, secretory granules containing mucigen Mu

Formation of glands from covering epithelia. Epithelial cells proliferate and penetrate the connective tissue.

Simple tubular glands, LARGE INTESTINE

Simple coiled tubular glands,

Sweat glands are almost the only example of simple coiled tubular glands.

Simple branched tubular glands

mainly in the stomach.

In this example of the mucus-secreting glands of the penile urethra, the secretory cells are pale stained compared to the non-secretory cells lining the urethra U. Note that the term acinus can be used to describe any rounded exocrine secretory unit.

Sebaceous glands provide a good example of simple branched acinar glands. Each gland consists of several secretory acini A that empty into a single excretory duct; the excretory duct E is formed by the stratified epithelium surrounding the hair shaft. The mode of secretion of sebaceous glands is HOLOCRINE, i.e. the secretory product, sebum, accumulates within the secretory cells and is discharged by degeneration of the cells.

Brunner's glands of the duodenum, as shown in this example, are described as compound branched tubular glands. Although difficult to visualise here, the duct system D is branched, thus defining the glands as compound glands and the secretory portions S have a tubular form, which is branched and coiled.

Compound acinar glands are those in which the secretory units are acinar in form and drain into a branched excretory ducts E system. The pancreas .

Compound tubulo-acinar glands have three types of secretory units; namely BRANCHED TUBULAR, BRANCHED ACINAR and branched tubular with acinar end-pieces called DEMILUNES. THE SUBMANDIBULAR SALIVARY GLAND shown here is the classic example. It contains two types of secretory cells, mucus-secreting cells and serous cells; the former are pale but the latter, which have a protein-rich secretion (digestive enzymes), stain strongly due to their large content of rough endoplasmic reticulum. Generally, the mucous cells form tubular components T whereas the serous cells form acinar components A and demilunes D. Part of an excretory duct E is also seen in the lower left corner of the micrograph.

Based on how the secretory products leave the cell, glands can be classified as merocrine (Gr. meros, part, + krinein) or holocrine (Gr. holos, whole, + krinein). In merocrine glands (eg, the pancreas), the secretory granules leave the cell by exocytosis with no loss of other cellular material. In holocrine glands (eg, sebaceous glands), the product of secretion is shed with the whole cell—a process that involves destruction of the secretion-filled cells. In an intermediate type—the apocrine (Gr. apo, away from, + krinein) gland—the secretory product is discharged together with parts of the apical cytoplasm,mammary gland

General Biology of Epithelial Tissues

POLARITY

In many types of epithelial cells the distribution of organelles and membrane proteins is different when comparing the basal and apical poles of the cell. This differential and stable organization of cell components is called polarity. This means that different parts of the cell may have different functions.

INNERVATION

Most epithelial tissues receive a rich supply of sensory nerve endings from nerve plexuses in the lamina propria. The exquisite sensitivity of the cornea, the epithelium covering the anterior surface of the eye, is due to the great number of sensory nerve fibers that ramify between corneal epithelial cells.

RENEWAL OF EPITHELIAL CELLS

Epithelial tissues are labile and their cells are renewed continuously by means of mitotic activity. The renewal rate is variable; it can be fast in tissues such as the intestinal epithelium, in which cells are replaced every week, or slow, as in the liver and the pancreas. In stratified and pseudostratified epithelial tissues, mitosis takes place within the germinal layer, closest to the basal lamina, which contains the stem cells.

VIRGINITY, PREGNANCY, DELIVERY AND LEGITIMACY

2011-09-11T07:13:00.000-07:00

Definitions:

Virginity: a virgin is a woman who has never had any sexual intercourse.

Defloration: loss of virginity

SIGNS OF VERGINITY

Breasts: hemispherical, firm and rounded.
Nipple: small, undeveloped, areola is pink.
Labia majora: firm, elastic, rounded & completely.
Labia minora: soft, smooth, small, sensitive & pink in color.
Fourchette & posterior commisure: intact.
Vaginal wall: closely approximated.
Vaginal mucosa: rugose, reddish, sensitive to touch.
Hymen: intact, deeply situated in children & superficial after puberty, soft to firm in consistency & usually annular or semilunar in shape.

Different types or shapes of hymen:

Annular or circular (with a central aperture)
Cresentic or semi lunar
Fimbriated or notched
Septate (divided into two openings by a septum)
Cribiform (with several openings)
imperforate

Difference between fimbriate & torn hymen

Fimbriate

Notches are symmetrical
Notches occur anteriorly
Do not extend to vaginal wall
Mucus membrane intact
No signs of inflammation

Torn Hymen

Irregular
Usually posteriorly
Extend to vaginal wall
Damaged
Signs of inflammation present

Signs of defloration:

Carunculae myrtiformes: several small, granular tags or knobs of tissues (remnants of hymen).
Labia majora & vagina: lose of tone and rugosity.
Labia minora: leathery and hard.

Conditions causing ruptured hymen before coitus

Accidents
Masturbation
Instrumentation by doctors
Artificial dilatation of vagina by foreign bodies for prostitution
Passage of large blood clots

True virgin

Hymen is intact & the woman has had no sexual intercourse.
It only admits tip of little finger in vagina.

False virgin

Hymen is intact but the woman has had sexual intercourse
It can easily admit two fingers in vagina.

MLI of Virginity

Divorce
Defamation (chastity)
Rape

Signs of prgenancy in living:

Subjective

Cessation of menstruation
Morning sickness
Sympathetic disturbances (salivation, altered taste, irritable temper)
Quickening (movement of fetus felt by mother) – after 14-18 weeks
Frequency of micturation

Objective

Breast changes
Skin changes
Vaginal changes
Changes in cervix
Hegar’s sign (softening & compressibility of lower uterine segment from 2nd to 5th month)
Progressive enlargement of abdomen
Braxton Hick’s sign: intermittent contraction & relaxation of uterus after 4th month
Uterine souffle (soft blowing murmur heard by 3rd or 4th month)
Ballottment

Breast changes:

2nd month: breast becomes full & tender, increase in size, veins become prominent, nipples enlarged, areola wider & darker, Montgomery’s tubercles (ENLARGED SEBACEOUS GLANDS)appear.
3rd month: colostrum can be squeezed out of the nipples.
6th month: lines like linea albicantes appear on breast due to stretching.

Skin changes:

Pigmentation of abdomen, axillae, pubis & vulva.
A dark line extends from symphysis to umbilicus called linea nigra.

Vaginal changes:

Pressure of the gravid uterus >> increased vascularity >> mucosa becomes purple or bluish purple >> Jacqueimier’s sign.
4th month- pulsation of vaginal arteries is felt by placing a finger in vagina (osiander sign)

Changes in cervix:

4th month- cervix becomes soft like lips (goodell’s sign)

Location of uterine fundus:

4th month- just above symphysis pubis.
5th month- midway b/w symphysis pubis & umbilicus.
6th month- umbilicus.
7th month- midway b/w umbilicus & xiphoid.
8th & early 9th month- at xiphoid process.

Classification of signs of pregnancy in living:

A.Presumptive signs

Suppression of menstruation
Morning sickness
Sympathetic disturbances
Breast changes
Pigmentation of skin
Quickening
Vaginal changes
Urinary disturbances

B.Probable signs

Changes in abdomen
Softening of lower segment and os
Presence of cervical mucus plug
Braxton Hick’s sign
Ballottment
Uterine souffle
Biological tests

C.Positive signs of prgnancy:

Fetal movements (after 5th month,at 24 weeks )
Recognition of fetal parts (by abdominal examination)
Fetal heart sound (160 bpm at 5th month, 120bpm at term),heard between 18-20 wks for first time.
Radiograph of fetus (can be taken after 4th month)
Ultrasound-G.S seen by 6th week

Pseudocyesis

-Spurious or phantom pregnancy

-Seen in women near menopause or those who are much desiring pregnancy

-All subjective symptoms of pregnancy including increase in abdominal size by abnormal fat deposition,or ascites occur

-even lady seen to have started labour like pains

Signs of prgenancy in Dead (on PM examination)

Presence of an ovum or fetus
Uterine changes
Presence of corpus luteum in one of the ovaries

Uterine changes:

Uterus thickened and enlarged
Length, breadth, & weight are increased
Chorionic villi are seen on microscopic examination

Posthumus child

-born after the death of father

MLI of pregnancy:

To escape hard labor or punishment
To avoid court attendance
In cases of property
In divorce cases
Black mailing
If a woman is charged of unchastity
Identification

Superfecundation-fertilisation of two ova which have been discharged by two separate acts of coitus commited at short intervals.

Superfoetation –fertilisation of second ovum in a woman who is already pregnant.

DELIVERY

Signs of recent delivery in living

General appearance- pale, exhausted & ill looking sunken eyes, slight increase in pulse and temperature.
After pains – intermittent contractions of uterus for the first 4-5 days after delivery.
Breasts- enlarged, contain colostrums, surface veins dilated & prominent, striae & Montgomery’s tubercle present
Abdomen- flaccid, wrinkled, striae gravidarum present
Fourchette- ruptured, posterior comissure destroyed
Vulva- bruised, tender & gaping
Vagina- lax, capacious, rugae begin to reappear about the third week

Uterus- enlarged, easily felt, palpate as a cricket ball

Soon after delivery- 2.5cm below umbilicus

10th day- on level with pelvic brim

2-3 weeks- returns to pelvic cavity

6 weeks- returns to normal size and position

Cervix- soft, patulous, may be lacerated. Internal os closes in first 24 hours, external os in two weeks.

Lochia- discharge from uterus and vagina for about 2-3 weeks.

Has a peculiar disaggreable odor
1st 4-5 days- bright red with large clots- lochia rubra
Next 4 days- serous and pale in color- lochia serosa
After 9th day- yellowish grey or turbid- lochia alba until its final disappearance
If the blood or urine gives positive pregnancy test, strong evidence that pregnancy has been terminated recently. (likely to disappear in a week or 10 days)

Signs of recent delivery in dead:

Breast when cut open, may show milk
Uterus flabby and enlarged
Ovaries and fallopian tube congested, on section may show corpus luteum

Animal Poisoning

2011-09-07T18:15:00.000-07:00

Classification of snakes

-Poisonous

Poisonous

A. Colubridae

Elapidae

Kobra

Krait

Mamba

2. Hydrophidae

Viperadae

Rattle snake

Pit vipers

Russel viper

Elapids: (Cobra, Krait)

Secrete neurotoxin- leads to local burning pain, muscular weakness, spreading paralysis, slow labored breathing, death is usually due to respiratory failure
Head is small
Pupils are round
Fangs are short, fixed and grooved
Cobra is found everywhere except Europe
Cardiotoxin found particularly in cobra venom is toxic to heart
Cobra has a hood which on the dorsal side often bears a double or single spectacle mark
Cobra grows to a length about 2 m.
Cobra venom fatal dose- 15 mg
Krait has a single or double white bands across the back and a creamy white belly
Kraits are nocturnal in habit
Kraits venom fatal dose- 6 mg

Vipers

Secrete vasculotoxic venom- intense local pain, swelling, ecchymosis and discoloration of surrounding tissue, oozing of bloody serum rapid feeble pulse, hemorrhage from natural orifice, cold and clammy skin, loss of consciousness, death from shock
Consists of pit vipers and pit less vipers
Pits are situated between the eye and nostrils
Head is big and triangular
Pupil is vertical
Fangs are long, movable and canalized
Can bite through clothes
Pit vipers are seldom dangerous but the russel viper, which is pitless viper, is dangerous.

Sea snake

Secrete myotoxic venom- generalized pain and stiffness, brown colored urine due to myoglobinuria, hyperkalaemic symptom, death due to respiratory failure
Small head and flat tail
Found in the vicinity of sea coast
Most of them do not bite

Difference

Poisonous

Belly scales are large and cover entire belly
Fangs are hollow like hypodermic needles
Tail is compressed
Two long fangs are present
Usually nocturnal
Head scales are small with enlarged central row of scales on back

Non-poisonous

Small, do not cover the entire belly

Fangs are short and solid

Tail is not much compressed
Several small teeth
Not so
Head scales are large

Delirient poison

Dhatura (thorn apple)

Solanaceae family- flowers are bell shaped, fuits are spherical with spinous projections
All parts of plants are poisonous, but seed and fruits are more
Active principle is hyoscine, traces of atropine, so it paralyses the parasympathetic system
S/S- dry mouth, dry face, restlessness, confusion, delirium, patient may become noisy or violent, hallucination (usually visual), amnesia, convulsion and death, tachycardia, dysrrhythmias, raised body temperatures.
Treatment- stomach wash with warm water and KMnO4, oxygen, catheterization for urinary retention, cold water sponging for pyrexia, i/v diazepam for convulsion, physostigmine
MLI- is a stupefying agent used for robbery, rape, and kidnapping; may be accidental, suicidal and homicidal
Fatal dose- 100 to 150 seeds crushed, 60 mg alkaloid
Fatal period within 24 hours

Atropa Balladona:

Also called deadly night shade
All part of plant are poisonous
Contain alkaloids, atropine, and hyoscymine
Treatment, sign and symptoms and postmortem findings same as dhatura
Fatal dose 10-15 berries, 100-125 mg atropine by mouth, 3mg by injection
Fatal period 24 hours

Cannabis indica or sativa

All parts are poisonous
Drug is used as “Bhang” (dry leaves and fruiting shoot, least potent), “Ganja” (flowering top of the female plant), “Charas or Hasis” (exudates obtained from leaves and stem)
First stimulates and depresses the vital centre
never causes death and its dangers are denied by many, though long-term users may develop psychotic states
and there is some evidence of genetic defects in the offspring of users
S/S- anxiety, excitement, euphoria, talkativeness, laughter, increased appetite, hallucinations, unproductive cough, dry mouth, run-amock (homicidal tendency),finally stage of narcosis (drowsiness, staggering gait, dilated pupil, rarely death)
Treatment- stomach wash, saline purgatives, symptomatic treatments
MLI- dangerous when driving, stupefying agent, run-amock, sadhus and pujaris use it
Fatal dose- Charas: 2gm/kg, Ganja: 8gm/kg, Bhang: 10gm/kg
Fatal period: 12hrs to 19 days

Cocaine:

Derived from the dry leaves of cocoa plant
Colorless, odorless, crystalline substance with a bitter taste
Administered through the oral mucus membrane, injection, inhalation
Ulceration of the nasal septum is always recorded as a complication of long-term nasal abuse of cocaine but this is, in fact, a rare phenomenon.
Cocaine produces hypertension, which (like amphetamines) may lead to cerebral bleeding. Dilated pupils hyperpyrexia, marked sweating and confusion may lead to coma and death from either respiratory depression or cardiac arrhythmia.
more potent form of cocaine called ‘crack’ has appeared
S/S- numbness of mouth, pyrexia, dilated pupil, increased sexual desire, happy and euphoric, delirium, tachycardia, tachypnoea, nausea, vomiting, muscular twitching, convulsion, collapse and death.
Treatment- stomach wash with warm water and KMnO4, symptomatic treatment
Postmortem finding- lungs edematous, signs of asphyxia or cardiac failure
MLI- aphrodisiac, used by prostitutes to constrict vagina, accidental, drug of addiction
Fatal dose- 1gm orally,
Fatal period- 2min to 4 hours

FORENSIC TOXICOLOGY

2011-09-06T08:17:00.000-07:00

Definition

Toxicology-science dealing with properties,actions,toxicity ,fatal dose,detection,estimation of and the interpretation of result of toxicological analysis and treatment of poisons
Forensic toxicology deals with medical and legal aspects of harmful aspects of chemicals on human beings
Poison is a substance (solid,liquid or gas)which if introduced into the living body,or brought into contact with any part thereof,will produce ill health or death,by its constitutional or local effect or both.

CORRHOSIVE

Strong acid
Strong alkali

IRRITANT

1.Inorganic:

Non-metallic-phosphoros, chlorine, bromine
Metallic- arsenic, mercury, lead, zinc, copper

2.Organic:

Vegetable- castor seed, croton oil, aloe
Animal- snake bite, insect bite, cantharides

3.Mechanical:

Diamond dust
Powdered glass

SYSTEMIC

1.Cerebral:

Somniferant- opium and other alkaloid
Inibriant- alcohol, ether, chloroform
Deliriant- dhatura, balladona, cannabis

2.Spinal: nuxvomice

3.Cardiac: digitalis, tobacco, aconite

4.Asphyxiant: war gas, coal gas, sui gas

5.Peripheral: curare

Symptom characteristic of a particular poison

Violent convulsant
Quick death
Hallucination and delusion
Drowsiness
Colic and pronounced diarrhoea
Paralysis ,unconsciousness
Coffee brown vomitus with garlic odour
Bluish green vomitus
Black vomitus
Yellow vomitus
Strychinine
Cyanide
Dhatura or atropine
Opium, tranquiliser, hypnotic
Arsenic, lead
Carbolic acid, nicotine
Phosphorus,
Cuso4
Sulphuric acid
Nitric acid, chromic acid

Treatment of poisoning

1.Stop further administration

2.Removal of unabsorbed poison

Emesis
Gastric aspiration and lavage
Whole gut lavage

3.Check further absorption with antidote

Mechanical or physical example- oil, fat, milk, banana
Chemical- to neutralize poison, e.g. weak acid, weak alkali
Universal antidote like activated charcoal, milk of magnesia, tannic acid

4.Prevent further action of absorbed poison with chelating agent

BAL (Bristish, Anti-Lewisite for heavy metal poisoning)
EDTA for lead
Penicillamin for copper, lead and mercury
Dicobalt edetate for cyanide
Desferrioxamine for iron

5.Elimination of absorbed poison

Diuresis,
Sweating
Dialysis
Hemoperfusion, exchange transfusion

6.Treat general symptoms

CORRHOSIVE- H2SO4, HNO3, HCl, oxalic acid, acetic acid, caustic potas, NH4CO3

Suicidal ingestion of a corrosive substance (Lysol). Spillage around the mouth has run down the neck and onto the chest.

The symptoms are obvious and immediate, with pain at the sites of exposure, usually the mouth and on the skin, difficulty in swallowing, chest pain, abdominal pain, vomiting, difficulty in breathing, choking.
If the amount ingested is significant, there will be signs of shock, with collapse, a weak and rapid pulse, hypotension and possibly death, even if treatment is available straightaway.
Avoid gastric lavage

Sulphuric acid:

Colorless, oily liquid, damages the tissue by dehydration
Signs and symptoms- burning pain in mouth, throat down to stomach, nausea, vomiting, dark brown or black vomitus mixed with blood, chalky white teeth, swollen or excoriated lips, difficulty breathing if larynx involved, weakness and collapse
Treatment with- neutralisation with milk of magnesia, milk or lime water, analgesia for pain, corticosteroid, fluid replacement
Gastric lavage is contraindicated
Fatal dose- 10-15 ml, fatal period is 12-24 hours.
MLI- used for suicide, mostly accidental, abortificent,vitriolage(throwing acid)
Cause of death-circulatory collapse,spasm or oedema of glottis,collapse d/t perforation of stomach

Nitric acid/Aqua Fortis:

Yellowish liquid, choking odor, colorless irritating fumes on exposure to air
S/S- like H2SO4 except tissues stained yellow, abdominal distension due to gas formation, lacrimation and conjunctivitis, death may occur d/t pulmonary edema.
MLI- used for suicide, accidental, homicidal (rare).
Fatal dose- 15-20 ml, fatal period- 12-24 hours.

HCl / Muriatic acid:

Pungent, colourless fuming liquid, less corrosive ,is in stomach. destroys mucosa.
S/S- as H2SO4, HNO3 but milder & more respiratory symptoms being volatile
PM findings- skin and mucus membrane whitened, ashy grey or black; errosive esophagitis; stomach is red, perforation is less common.
Fatal dose- 15-30 ml, fatal period is 18-30 hours.

Oxalic acid:

Although not as corrosive as the mineral acids, oxalic acid and potassium quadroxalate are very toxic, death often occurring within a hour or so if the solid or concentrated solution is taken.
They are used extensively as bleach for stain removal and in many other trades and industries .
Natural constituent of many plants e.g.spinach,cabbage
Colorless, prismatic crystals, rapid poison
S/S- sour taste, burning in throat, stomach
rarely damage skin but readily corrode the mucosa;
purging & tenesmus; stools contain blood; low BP; skin cold & clammy
Treatment- give chalk in water; gastric lavage; gastric purgatives; i/v calcium gluconate and calcium chloride(antidote of any oxalate is calcium which binds and forms,calcium oxalate); i/m morphine for pain; inj. coramine to elevate BP
Fatal dose- 15 gms, fatal period is 1-2 hours.

Carbolic acid/ phenol:

Long, colorless, prismatic needle shaped crystal
Largely used as antiseptic and disfectant
Turns pink on exposure to light and air, intense penetrating odour
S/S- hot burning sensation from mouth to stomach, corroded lip, mouth, tongue; nausea, vomiting; pulse small, BP low; greenish appearance of urine k/a carboluria; death from respiratory paralysis as phenol is a respiratory depressant.
T/t- milk, vegetable oil or any demulcent; stomach wash; inj. morphine for pain; artificial respiration for shock; antibiotic prophylaxis of pneumonia
Fatal dose- 15 gms, fatal period is 3-4 hours.

Aspirin/ Acetyl salicylic acid:

White crystalline powder for headache and pyrexia
S/S- n/v, subconjunctival hemorrhage; petechiae over face and eyelids; gum bleeding, GIT and urethral bleeding; tinnitus and deafness; deep and rapid respiration; pulse rate increased; delirium, agitation, confusion, coma and convulsion; death due to respiratory failure
T/t- gastric lavage; KCl to treat hypokalaemia; milk as demulcent; Vit. K for bleeding; oxygen for cyanosis; hemodialysis in very severe cases
PM findings- petechial hemorrhage on face and neck; frothy fluid from mouth and nose; cyanosed; erosion of GIT

Heavy metal poisoning:

The literature of nineteenth-century European forensic medicine is full of notorious cases of murder by arsenic, antimony and mercury.
Arsenic
Metallic arsenic,black is not toxic
It is the compounds of arsenic, particularly arsenious oxide and the various arsenites of copper, sodium and potassium, that are toxic to humans, inteferes with cellular respiration.
Vascular endothelium appears to be particularly susceptible to the toxic effects of arsenic.
In acute poisoning, if sufficient chemical is ingested, there may be initial burning in the mouth and then, after an interval, signs of intense gastroenteritis develop: abdominal pain, nausea, burning regurgitation and vomiting. Diarrhoea ensues and this, together with the sickness, leads to prostration, mainly from dehydration and electrolyte imbalance. death in 1 to 3 hrs in severe ac. Poisoning due to shock and peripheral vascular failure.
In chronic poisoning, a classic state of ill-health develops, Loss of appetite, mild nausea, some vomiting, jaundice, loss of weight and anaemia are relatively non-specific symptoms.

More specific signs can be seen in the skin, where chronic arsenical poisoning causes hyperkeratosis of the palms of the hands and soles of the feet produce band of opacity in the nail k/a MEES-ALDRICH line.
A speckled pigmentation of the general skin surface sometimes described as a ‘raindrop’ appearance (finely mottled brown change especially over eyelid,temples,and neck).
loss of hair, brittle nails and a peripheral neuritis with itching, tingling and paraesthesia of the extremities
The fatal dose is variable, but 200–300 mg of arsenious oxide are likely to be needed for acute fatal toxicity.
At autopsy, little may be found in acute deaths apart from a haemorrhagic gastritis. The stomach mucosa has been likened to red velvet, due to the bleeding
Subendocardial bleeding may be seen in the left ventricle, though this is not specific to arsenic and can be seen in any death when there has been a precipitous drop in blood pressure due to ‘shock’.
T/T-stomach thoroughly washed with fluid,BAL is given,penicillamine may be used in place of BAL.Demulsant decrease the irritation.glucose –saline helpful to combat shock.

Lead

Lead can be administered by oral,inhalation,through skin,mucous membrane,I.V

Causes spasm of capillaries and arterioles

Toxic effects results from fixation of lead into tissues

S/S-

acute poisoning -sweet,metallic taste,burning in throat,V/N,jaundice,feeble pulse,drowsiness,insomnia,headache,convulsion,numbness.

chronic poisoning- anorexia,metallic taste in mouth,constipation,colic,Burton s line(blue pigmentation on gingival margin),anemia and punctate basophilia,peripheral neuritis(foot drop and wrist drop)arthralgias

Management-EDTA as chelating agent,diazepam for convulsion,morphine and pethidine for pain,physiotherapy for paralysis.

MLI-mostly accidental d/t use in utensils,lead pipes.

FD=20-40mg, fatal period =uncertain,2-3 days

Mercury

Mercury is usually an industrial or environmental poison.
Although historically some deaths occurred from its use in medicine, mercurial diuretics and antiseptics are now almost a thing of the past.
Acute poisoning resembles that of arsenic and antimony: gastrointestinal symptoms are common,
But there are also excessive salivation and signs of renal failure.
Chronic mercury poisoning is almost wholly industrial in nature and
The clinical hallmarks are gingivitis, loose teeth, salivation, black gums, mandibular necrosis, peripheral neuritis, encephalopathy and renal failure.

SEXUAL OFFENSES

2011-09-04T15:49:00.000-07:00

Classification:

Natural offenses- rape, incest, adultery.

Un-natural offenses- sodomy, tribadism, bestiality, buccal coitus.

Sexual perversions- sadism, machochism, necrophilia, transvestism, exhibitionism, masturbation, voyeurism, frotteurism.

RAPE

It is an unlawful sexual intercourse by a man with a woman against her will, without her consent, with her consent by putting in fear of hurt or death, with her consent when at the time of consent she is unable to understand the nature & consequence intoxicated or given any stupefying substance, with or without her consent if she is a minor.

Even if his wife, even with consent, if she is under 13,
Of any woman under 14 years, not his wife, even with consent,
Of any women above 14 years, against her will.
Penetration is sufficient to constitute sexual intercourse necessary to the offence of rape.

Punishment:

1. U/S 376 P.P.C:

It may be imprisonment for 10 years to life imprisonment with or w/o fine (unlimited).

2. Under Islamic Penal Code:

HADD means punishment ordained by Holy Quran or Sunnath.

Muhsan- be stoned to death at public place
Not muhsan- whipping numbering 100 stripes at public place.

3. Zina: If a man & a woman, not husband & wife, both not insane, have sexual intercourse, they said to commit Zina.

4. Tazir: means punishment other than HADD

Examination of Victim:

Includes:

a.Signs of local violence to body

b.Signs of local violence to private parts

c.Presence of spermatozoa

The victim should not be examined w/o requisition from investigating police officer or the magistrate. The court or police has no power of forcing a woman for medical examination against her will.
Consent has to be taken.
Examination should be performed in the presence of a third person (female).
General details of patient with identification marks & statement should be collected.
Examine the clothes for signs of struggle like tears & for stains.
Marks of violence on body like scratches, bruises.

Genitals:

Pubic hair should be sent for chemical exam for semen & blood.
Stains on thighs should be examined.
Examine vulva for swelling, bruising, tenderness.
Examine hymen (ruptured or not, if yes- recent or remote)
Two vaginal swabs should be sent for chemical examination.

Presence of spermatozoa:

Motile sperms in vagina- upto 100 hours.
Non-motile sperms in vagina- upto 17 days.

Rape on children:

Signs of struggle are less marked.
Tearing of vulval & vaginal tissues.
Infections are more common.
Hemorrhage.
Hymen is usually intact.

Accidents following Rape on Children:

Convulsions or epileptic fit.
Mental derangement due to psychic trauma.
Death from shock due to fear & tear.
Syncope due to excessive bleeding.
Death due to septic infection.
Death due to asphyxia.

Examination of Accused:

Should be done as soon as possible.
General development & mental condition of accused.
Signs of struggle of victim, like scratches on face and private parts.
Clothes for signs of struggle, seminal or blood stains.

Local examination of genitals include:

a.Development

b.Potency

c.Any abnormality

d.Blood or seminal stains

e.Vaginal epithelial cells or penis

f.Smegma (absent in uncircumcised men)

g.Any injury to penis.

Pubic hair should be sent for examination.

Incest:

Sexual intercourse b/w close blood relations, b/w whom marriage is prohibited e.g. father, brother or uncle of a woman.
Occurs b/w mental defectives where alcohol removes the natural inhibition etc.

Un-natural Sexual Offenses:

Sexual intercourse against the order of nature with any man, woman or animal.
Types:

A.Sodomy

B.Bestiality

C.Triabadism

A. Sodomy

Sodomy: Un-natural or anal intercourse b/w two men (homosexual sodomy) or b/w a man & a woman (heterosexual sodomy). It was practised in a town called Sodom.

Peaderasty: If the victim is a small or a young girl/boy, it is k/a paederasty. The accused is usually the pedophile.

Catamite: Passive agent is called catamite.

Sodomite: Active agent is called sodomite.

Buccal coitus: Intercourse b/w penis of a man & oral cavity of another man, a woman or a child. It is also known as coitus per os/sin of Gomorrah.

Examination of Passive Agent:

Non-Habitual

Anal orifice dialted, irritable, inflamed & tender to touch.
Abrasions of the skin are seen.
Radial fissure of mucus membrane is seen.
Defecation may be painful
Blood stains may be seen on anus, perineum / clothes.
Lubricant may be present.
Signs of struggle may be present.

Habitual

Usually hijras or eunuchs.
Shaved anal regions.
Funnel shaped anus.
Muscles of anus lose tone.
Loss of rugosity of mucosa or disappearance of radial folds.
Prolapse of rectal mucosa.

Examination of active agent:

Presence of smell transferred by anus.
Traces of feces on penis.
Abrasions & bruises on glans.
Tearing of frenulum of penis.
Stains of semen, blood or feces on penis.
Examine for potency.
Elongated & constricted penis (habitual sodomite).
Presence or absence of smegma indicates time since last intercourse (in uncircumcised).

B. Bestiality:Sexual intercourse b/w a human being with a lower animal, either anus, vagina or any other opening.

Accused

Fecal matter of animal may be seen.
There may be an injury to penis.
Blood, seminal or fecal stains may be seen on body or clothes.

Animal

Semen may be seen in vagina or anus.
Human hair may be seen on animal body.
Injuries may be found on the anus of the animal.

Sexual perversions: are persistently indulged sexual acts or fantasies in which complete satisfaction is sought and obtained w/o sexual intercourse.

1.Tribadism- Homosexual connection b/w two women & consists of mutual friction of external genitals. (Lesbianism)

2.Masturbation- Sexual gratification by a person w/o external help in the form of self-indulgence. Mild masturbatory exercises are common and are of little importance.

3.Sadism- Sexual perversion in which sexual gratification is obtained by inflicting pain on opposite partner. In extreme cases of sadism, murder serves as the stimulus for sexual act leading to erection, ejaculation and orgasm called “Lust Murder”.

4.Masochism- Sexual perversion in which sexual gratification is obtained on receiving a painful stimulus from opposite partner (opposite of sadism). Named after Von Sacher Masoch, an Austrian novelist.

5.Fetichism- It is the sexual gratification produces by the sight of some part of woman’s body or their articles. E.g. shoes, stockings, underclothing.

6.Exhibitionism (Indecent exposure)- Sexual gratification is obtained by exhibition of genitals in presence of opposite sex.

7.Transvestism or eonism- Sexual pleasure is obtained by wearing the dress of the opposite sex.

8.Uranism- Sexual gratification obtained by fingering, folding or licking of genitals.

9.Necrophilia- Desire for sexual intercourse with dead bodies. Said to have sadomasochistic foundation and that decomposition, foul smell, coldness serve as stimulus for intercourse.

10.Voyeurism or scoptophilia- Sexual gratification obtained on watching genitals of other people indulged in sexual act.

11.Frotteurism- A compulsion to rub the genitals against other persons usually in buses etc. to obtain sexual satisfaction. It is punishable under IPC with fine upto Rs. 200.

12.Urolangia (coprophilia)- Sexual excitement is obtained by sight or odor of urine or feces.

MISCARRIAGE OR ABORTION

2011-09-01T08:22:00.000-07:00

Definition:

Expulsion of product of conception at any time before full term.

After a pregnancy is apparent, the loss of the fetus up to 24 weeks is usually called a ‘spontaneous abortion’ or ‘miscarriage’; from 24 weeks to full term, it may be called a ‘premature birth’.

The punishment- 3 years imprisonment to transportation for life.

Classification:

1. Natural:

Spontaneous

Accidental

2. Artificial:

Justifiable

Criminal

Criminal abortion

A criminal abortion is the deliberate ending of a pregnancy outside any legal provisions that have been made by the state for this act. A criminal abortion is a serious criminal offence

Methods of performing illegal abortion:

Drugs and toxins have been used for millennia to try to remove unwanted pregnancies, but most of them are quite ineffective.
In South-East Asia, unripe pineapple is alleged to produce miscarriage. However, none of these substances is known to have any predictable or significant effect on the uterus
Other substances that have a contractile effect on smooth muscle have a better theoretical chance of success and these include ergot, pituitary extracts and quinine.

Other substances normally used in obstetrics, particularly prostaglandins, are also used to induce abortions and are potentially more potent .
Another group of chemicals is the strong purgatives such as colocynth, croton oil or jalap, which simply cause general debility to the woman, but they are highly unlikely to cause an abortion.
Instrumentation is commonly practised, involving a wide variety of devices from surgical probes and bougies to the crudest implements made of metal or wood, as well as bicycle spokes, metal coat-hangers or even twigs from trees.
The dangers of instrumentation are perforation and infection.

The fundus may be perforated and the instrument pushed up into the intestines or even the liver.
General violence in an attempt to induce a ‘spontaneous’ abortion may still be encountered on rare occasions.
Other methods that are thought to be capable of inducing a ‘spontaneous’ abortion include the taking of very hot baths, ingestion of large quantities of alcohol, vaginal douches with many substances, and violent exercise such as skipping, jumping and even riding horses or bicycles over rough ground.
Syringe aspiration is a method used by both legal and criminal abortionists.

Drugs for abortion

Mechanical Violence for Abortion

General:

Violent exercise like jumping, cycling, horse riding, heavy weight lifting, driving on rough roads.
Severe pressure on abdomen- blow, kick, jumping over abdomen.
Cupping on hypogastrium
Hot and cold bath alternatively

Local:

Dilatation of cervix- instrumentation, abortion stick, curettage, electricity.
Local irritation by abortifacient

Legal termination of pregnancy

Many countries now have legal provisions for the medical termination of pregnancy. This is often called ‘therapeutic abortion’,

RULES

The termination must be performed by a registered medical practitioner.
It must be carried out in a Health Service hospital or a place specifically registered for the purpose.
Two registered medical practitioners must examine the woman (not necessarily together) and certify that grounds for termination exist.
Neither of these doctors needs to be the doctor who actually performs the operation.
The termination must be notified to medical officers of the appropriate government department.

Consent to termination of pregnancy

The only consent that is required for termination of pregnancy is from the woman herself, provided she is competent to make that decision.
The consent of a husband or permanent partner (if he accompanies the woman) may be obtained as good clinical practice; however, the woman’s wishes are paramount and a husband’s or partner’s objections are not relevant in English law.
Any competent young girl may seek medial advice and may consent on her own to an abortion, although for girls under 16 the doctor should seek to encourage them to discuss the matter with their parents or carers

A photograph of only historic interest in the UK. This

woman had died of air embolism after attempting to induce an

abortion with a Higginson syringe, which can be seen below her

right foot.

Autopsy appearance of a septic uterus following an

illegal abortion.

Differences b/w criminal & natural abortion

Natural

Cause- natural
Genital tract- not injured
Foreign body in genital tract- not present
Sepsis- not usually
Signs of violence- nil
Toxic drug effect- nil
Fetal injury- nil

Criminal

May be injured
May be present
Frequent
Usually present
May be present
May be present

Complications of criminal abortion

Shock
Haemorrhage
Air or fat embolism
Perforation of uterus
Sepsis
Poisoning by drugs
Sub-involution of uterus
Death

MEDICO-LEGAL AUTOPSY

2011-08-30T18:08:00.000-07:00

Autopsy, necropsy and post-mortem examination are synonymous, although post-mortem examination can have a broader meaning encompassing any examination made after death, including a simple external examination.

In general terms, autopsies can be performed for two reasons: clinical interest and medico-legal purposes.

The clinical autopsy is performed in a hospital mortuary after consent for the examination has been sought from and granted by the relatives of the deceased. The doctors treating the patient should know why their patient has died and be able to complete a death certificate even in the absence of an autopsy.

These examinations have been used in the past for the teaching of medical students etc. and for research.

The medico-legal autopsy is performed on behalf of the state.

A poor autopsy is worse than no autopsy. In medico-legal autopsy, often the history is absent, sketchy, doubtful.

The aims of these examinations are much broader than those of the clinical autopsy and include:

to identity of the body;

• to estimate the time of death;

• to identify and document the nature and number

of injuries;

• to interpret the significance and effect of the injuries;

• to identify the presence of any natural disease;

• to interpret the significance and effect of the natural disease present;

• to identify the presence of poisons; and

• to interpret the effect of any medical or surgical treatment.

Taken at its broadest, autopsies can be performed by any doctor, but ideally they should be performed by a properly trained pathologist in mortuary at day-time, without the presence of any unauthorized person.

Rules for medico-legal autopsy:

The body should be labeled as it arrives the mortuary.
Conducted never in a private room, only in mortuary.
However, autopsy is done at the site when advanced level of putrefaction, causing difficulty in transportation.
Conducted only when official order from police or magistrate.
Done without undue delay after receiving the order.
M.O. should read the inquest report carefully to know the apparent cause and circumstance of the death.
Conducted in day light as far as possible.
The body must be identified by the police constable who accompanies it.
In unidentififed bodies, marks of identification, photographs and finger prints should be taken.
No unauthorized person should be present during autopsy.
The investigating police officar may be present.
The details are noted and sketches are made.
Both positive and negative findings should be recorded.
After autopsy, the body should be handed to the police constable.
The PM report should not be handed to the party.

Autopsy Report:

Consists of

1.The pre-amble: mentions the authority ordering the examination, date and place of the examination, name and sex of the deceased.

2.The body of the report: consists of detailed external and internal examination, focusing nature, direction, exact situation and dimension of the wounds, diagrams are of value.

3.Conclusion: as to the cause of death should be concise in clear language and honest. It should be followed by signature and qualification of the doctor.

External examination:

The clothing should be listed and examined, type of garment, colour, tears, loss of button indicating a struggle is explained as each item is removed from the body. Blood stain, grease, seminal stain, poison, vomit should be kept for analysis. Clothes should be placed in clean separate bags.
Nail scrapping- any visible fiber or other matter at the hand should be removed and placed in envelope. Ten small envelopes are labeled, one for each finger.
Height and weight, general state, body built.
General condition of the skin- rash, petechiae, colour.
General description- age, sex, colour, race, nutrition, hair, scar, tatoo, moles, circumcision, pupils.
Vaginal and anal swaps, pubic hair should be combed through. Matted pubic hair should be cut with scissors and the samples of pubic hair should be taken.

The stain of mud, vomit, faeces, gun powder described.
The presence of signs of disease eg., edema of legs, surgical emphysema, skin disease etc.
The time since death should be noted from rectal temperature, rigor mortis, post-mortem hypostasis, putrefaction.
The face examined for frothy fluid at the mouth and nose, cyanosis, petechiae, pallor etc.
The eyes examined for conjunctiva, opacity of the cornea and the lens, petechiae. The ears for leakage of blood or CSF.
The neck examined for bruises, finger nail abrasion, ligature mark.
The abdomen, thorax, thyroid, breast, back, external genitalia and the natural orifices should be noted.
The position of limbs should be noted. Hands examined for injuries, defense wounds, electric mark etc. and anything grasped in the closed fist.

Internal examination:

Skin incison-

‘I’ shaped from the chin to symphysis pubis.

‘Y’ shaped incision from acromial process down below the breast to xiphoid and down to the symphysis pubis.

Modified ‘Y’ shaped incision- incision made in the midline from supra sternal notch to the symphysis pubis. The incision extends from the suprasternal notch over the clavicle to its centre on both sides and then passes upwards over the neck behind the ear.

Abdomen- The recti muscle of the abdomen are divided about 5cm above the symphysis pubis, peritoneum is cut upto xiphoid, the condition of abdominal cavity and the organs is observed. Blood, pus if seen in the abdominal cavity, should be measured.

Neck- a block should be placed under the shoulder to extend the neck, the skin dissection carried out immediately deep to skin to the lower border of lower jaw, sternomastoid muscle is freed from its attachments, the trachea, larynx, pharynx are pulled away from the pre-vertebral tissue by blunt dissection.
Mouth- a knife inserted under the chin through the floor of mouth, cut along the sides of the mandible, to the angle of mandible dividing the neck muscles attached to the jaw. The soft palate is then cut to include the uvula and tonsils with tongue and neck organs to be removed. The knife is turned backwards and laterally to divide the posterior pharyngeal wall. The larynx and pharynx are pulled down, the dissection is then carried distally through the prevertebral muscles on the anterior surface of the cervical vertebra.

Chest- pneumothorax should be noted by creating a pocket filled with water before the proper chest dissection. The wall is punctured with the knife under the water. The chest is opened by cutting the costal cartilage beginning from the second cartilage near the costo-chondral junction. The pleural cavity should be examined. Note the lumen of the main pulmonary vessels, right atrium and ventricle for embolism, distension or collapse of lungs, pleural cavity for fluid, pus, adhesions. Note the pericardium for cardiac temponade, collect blood sample from the heart for toxicological examination.
Air embolism- in the heart can be found by cutting the pericardium anteriorly and grasping the edge with hemostat on each side. The pericardial sac is filled with water and the heart is punctured with scalpel and twisted few times to release escape of bubbles of gas.

Fat embolism- if suspected the pulmonary artery should be dissected under water and the escape of fat droplets noted.
There are two distinct methods of removing the viscera from the abdominal cavity and thoracic cavity:

1.Virchows method- removing each organ seperately

2.Rokitansky method- removing all the organs ‘en masse’.

The organ should be described based on size, shape, surface, consistency, cohesion, cut surface.

Esophagus: the esophagus is cut open from the posterior surface up to the cardiac end of the stomach. If death occurred due to rupture of esophageal varices, the break in the lower end should be noted.

Lungs: look for thrombi, emboli. The lung organ is crossed across from the apex to the base with a large brain knife, producing an anterio-posterior slice and examined for consolidation, edema, emphysema, tumor, infarction. The smaller bronchi are examined for mucosal thickening, infection and blockage.
Aorta: whole length of aorta is cut on its posterior surface from the iliac vessels, around the arc upto the aortic valve to note chronic aortitis, obstruction of coronary arteries.
Heart: is held at the apex and lifted upwards and the vessels are cut as far away as possible. This isolated heart is opened in the direction of the flow of blood. The right atrium is cut between the opening of superior and inferior venecava. Through the right atrium and through the tricuspid orifice, the right ventricle is opened along the lateral margin.

Note whether the content of right ventricle and auricle is fluid blood, currant jelly clot or chicken-fat clot. The left atrium is cut along the lateral wall, extending through the mitral orifice and passes along the lateral margin of the left ventricle upto the apex. After the blood clots in the cavities are removed, the measurements of the valves, circumference and thickness of ventricles are taken. The coronary arteries are examined by making serial cross sections along the entire course of vessel about 2-3mm apart.
Agonal thrombi: seen in case of persons dying slowly with circulatory failure, a firm tough pale yellow thrombus, usually on the right side of the heart, filling the right auricle and ventricle and pulmonary artery. It branches like a tree like cast. In the left ventricle, agonal thrombi are not so big.

Post mortem clots: 2 types-

Black currant jelly: soft, lumpy, uniformly dark red, moist clot formed when the blood clots rapidly.
Chicken-fat clot: when red cells sediment before the blood coagulates. The red cells produces a clot similar to the first type. Above this a pale or bright yellow layer of serum and fibrin is seen called chicken fat. It is soft, elastic jelly like.
Usually a mixture of the two is found. Post-mortem clots are moist, smooth, shiny, homogenous, rubbery, not attached to the underlying wall, and there are no fine white lines of fibrin (striae of zahn).

Stomach: opened along its greater curvature from the cardiac to pyloric end. The contents are examined for food, digestion, smell, colour. In massive hemorrage, the stomach is filled with large soft clots which may take the form of a task of gastric outline.
Intestine: the superior mesenteric vessels are examined for thrombi, emboli. The small intestine is opened along the line of mesenteric attachment.
Liver: weight, size, colour, injury are noted. It is cut into slices 2cm thick which run in the long axis. Amoebic abscess are usually single large and confined to the right lobe. Pyogenic abscess are multiple. In fatty liver, cut section is greasy. In portal cirrhosis, the liver is sturded with nodules, 1-3mm in diameter (micro nodular).
Spleen: removed by cutting through its pedicle. Note the size, weight, rupture.

Pancreas: sliced by a series of cuts at right angle to the long axis which gives the best exposure of ductal system.
Kidney: renal artery ostia are examined. The capsule of the kidney is stripped, the kidney is sectioned longitudinally to split in half and open the pelvis to see calculi and inflammation.
Female genitalia/uterus: the tube, the ovaries and the uterus are freed from the pelvis and are removed. If the uterus contains a fetus, its age should be determined.
Head: head is fixed by head rest. A coronal incision is made in the scalp from the mastoid process just behind ear and carried over the vertex to the opposite mastoid. The scalp is reflected forwards and backwards. The saw line is made in slightly ‘V’ shaped direction so that the skull cap will fit exactly back into the correct position. The meninges are examined and the brain is examined.

MECHANICAL INJURY

2011-08-27T15:59:00.000-07:00

ML Classification of Injury:

MEDICAL

1.Mechanical

A)DUE TO BLUNT FORCE

Abrasion

Contusion

Laceration

Fracturew and dislocation

B)DUE TO SHARP FORCE

a)Incised wound

b) Chop wound

c)Stab wound

C.FIREARM WOUNDS

a) Firearm wound

2.Thermal

DUE TO COLD-frost bite ,immersion foot

DUE TO HEAT-burns,scald

3.Chemical corrosive acid ,corrosive alkali

4.physical- electricity .lightning,Xray.

5.explosions

LEGAL

1.SIMPLE

2.GREVIOUS

MEDICOLEGAL

1.SUICIDE

2.HOMICIDE

3.ACCIDENT

4.FABRICATED

5.DEFENCE

Contusion:

Surface injury to the skin and sub-cutaneous which leads to an effusion of blood into tissues
usually caused by blunt trauma.
Appears 1-2 hours after injury.
may take the shape of weapon eg railway tract appearance.
Children, old, obese women bruise easily.
Mongolian spot shouldn’t be confused with bruise.
Contusion may be also in the internal organs
Gravity shifting of bruise may occur in late occuring bruises

Color changes in a bruise:

1st day- red
2nd day- 3rd day -bluish
4th day- brown day(haemosiderin)
5th-6th day- green(haematoidin)
7th-12th day- yellow(bilirubin)
13th-15th day ,2 weeks – normal
Subconjunctival Hage donot undrego colour change

ML aspect of contusion:

Patterned bruise-Identification of weapon,ligature,vehicle
Degree of violence from size
Time since injury
Purpose of injury
Homicidal, suicidal, accidental .position of assylant while arms are grasped

Difference between antemortem and postmortem bruise:

Antemortem contusion

Swelling present
Color changes present
Epithelium abraded
Clotted blood in tissue present

Postmortem contusion

Not present
Not present
Not present
Not present

Difference b/n artificial and true bruise

Artificial bruise

By juice of marking nut,calotropis or plumbago
At exposed accessible site
Dark brown colour
Shape irregular
Margins well defined and regular
Itching present
Positive chemical test

True bruise

Trauma
Anywhere
Typical colour changes
Usually rounded
Not well defined,diffuse,no vesicles
Absent
negative

Patterned intradermal bruise on the forehead due to a

fall onto ribbed ceramic tiles.

Bruising of the upper arm. The pattern of these bruises

is typical of forceful gripping. Small abrasions from fingernails are

also seen.

Typical ‘railway-line’ bruises caused by a wooden rod.

Note that the centre of the parallel contusions is unmarked.

Recent bruising of the abdominal wall and scrotum due

to kicking.

Abrasion:

destruction of only superficial layer of epidermis,thickness of skin is 1.6mm.
Bleed very slightly
Heal very rapidly
Leave no scar

Types of abrasions:

Scratch or linear abrasion-has length but no significant width.eg by pin, thorn, nail etc. very sharp objects
Graze(sliding,grinding abrasion)-longitudional parallel lines. by rough surface in contact with a broader surface of skin, eg. RTA
Patterned abrasion (pressure and impact abrasions)- thumb mark in strangulation, ligature mark in hanging, wheel mark of tyre,teethbite mark.

Age of abrasion by color change: exact age cant be determined

Red color- fresh
Red scab- 12-24 hours-by dryind of blood and lymph
Reddish brown scab- 2 to 4 days
Healing from periphery- 4 to 7 days,dark brown
Complete healing- 10 to 14 days
Seperation of scab- 10 to 14 days

ML importance:

Identification of object
Direction of injury
Time since injury
Possibility of internal injury
Somtime erosion by ants look like abrasion.d/d-ants produce abrasion that are brown,irregular margin,commonly at mucocutaneous junction about eyelids,nostril,mouth,axilla,by hand lens show multiple cresent shaped,sand like bite marks

Difference

Antemortem abrasion

has Moist surface
Bleeding present
On drying scab formation,scab slightly raised
Blurred margin
Inflammation present
Intravital reaction and congestion seen

Postmortem abrasion

Dry surface
No bleeding
No scab
Sharply defined margin
Inflammation absent
Not seen

Abrasions from scraping against a rough surface

during a fall.

Extensive abrasions caused by stumbling, drunk and

naked, against furniture. The dark leathery appearance is due to

post-mortem drying of the damaged areas of skin

Incised wound:(cut,slash,slice)

Clean cut through tissues ,usually skin and subcut. By sharp edged or cutting weapon, eg. knife, sword, glass.
Edges are smooth, clean cut and everted.
Broader than the edge of weapon
Length is greater than depth and breadth.
Bleed profusely
Superficial towards the end of wound k/a tailing
Edges may be inverted in case of underlying muscle attached to skin, eg. scrotum.

ML importance:to find homicidal,accidental or suicidal

Homicidal, anywhere in the body, deep
Suicidal- multiple, superficially, usually in the left hand
Accidental- anywhere
Edges of the wound indicate: antemortem or postmortem, sharp or blunt weapon.

Difference between incised wound

Antemortem

Bleed freely and profusely
Arterial spouting present
Blood is clotted
Edges gape
Inflammation present
Serum serotonin and histamine increased

Postmortem

Very slight or no hemorrhage
Not present
Not clotted
Edges closely
Not present
Not raised

Difference between suicidal and homicidal cut-throat wounds

Suicidal

Left side of neck,passing across the throat,usually in rt handed
Level above thyroid cartilage
Multiple no ,superficial,rarely single
Edges usually ragged,due to overlapping
Hesitation cuts present
Defence wound absent
Weapon usually present
Clothes not torn or damaged
Circumstancial evidence, quite place

Homicidal wounds

Usually on both sides
On or below thyroid cartilage
Multiple .cross each other at a deep level
Sharp and clean cut,bevelling may be seen

Incised wound to the flank; it is clearly longer than it

is deep

A complex stab wound where all three injuries are

caused by a single action. The first entry is in the right breast; there

is an exit wound in the middle and a re-entry wound over the centre

of the chest.

Stab or punctured wound:

Type of incised wound whose depth is greatest in dimension.
Eg. Knife wound, dagger

Types of stab wound:

Penetrating wound- has only wound of entry
Perforating wound- has both entry and exit wound

Features of stab wound:

Aperture is usually smaller than the weapon due to elasticity of the skin
Depth is greater than breadth and length.
Very little external hemorrhage but profuse internal hemorrhage

Shape- Wedge shaped with knife, elliptical with dagger, rounded with needle, slit-like opening with screw driver,
Margins of entry wound are clean and inverted,
Margins of exit wound are small and everted
Direction determined by line joining entry and exit wounds or X-ray after radio-opaque dyes.

ML(medical legal ) importance:

Nature of weapon
Direction of wound
to find Suicidal, homicidal or accidental

Lacerated wound:

Wound in which skin and underlying tissue is turned due to blunt force application

Classification:

Split laceration
Stretch laceration
Avulsion
Tears (caused by irregular sharp object)

1.Split laceration (incised looking wound)

Usually found overlying the bones
caused by blunt perpendicular impact
Skin splits between 2 hard objects and simulate an incised wound

2.Stretch laceration:

Overstretching of skin produces a flap
Caused by blunt tangential impact
Also by sudden deformity of bone after a fracture

3. Avulsion:

Caused by horizontal crushing impact
Commonly truck, bus wheel, muscles are crushed
Also known as degloving of skin

Multiple lacerations from a blunt steel bar. These were

initially mistaken by the police for axe wounds. The abraded or

crushed margins can be easily seen.

Laceration of an arm of a pedestrian struck by a car.

The impact has been oblique, causing a flap of skin to tear away

to the right.

Nature of injuries- simple, grievous, dangerous

1.Simple injury:

Neither serious nor extensive
Heals rapidly w/o leaving permanent deformity or disfigurement

2. Grievous injury:

Emasculation
Permanent loss of sight of either eye
Permanent loss of hearing of either ear
Destruction of joint or any member of body eg. Limb
Permanent disfigurement of head or face
Fracture or disfigurement of bone or tooth
Any hurt to be in hospital for 20 days

3. Dangerous injury:

Compound fracture of skull
Injury to vital organ eg. spleen, liver
A wound of large artery eg. radial femoral

INJURY DUE TO HEAT AND ELECTRICITY

2011-08-26T14:02:00.000-07:00

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

Burning

1 first degree – erythema and blistering (vesiculation);

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

3 third degree – destruction down to subdermal tissues

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

Clinical conditions due to high heat exposure

1.Heat cramp- miner’s cramp, fireman’s cramp due to rapid dehydration through loss of water and salt in the sweat, severe and painful paroxysmal cramp of muscles of leg, abdomen, arms.

2.Heat prostration- heat exhaustion, heat syncope, heat collapse.

Is a condition of collapse without increasing body temperature, which follows exposure to excessive heat.
Precipitated by muscular work and unsuitable clothing
Patient usually recovers if placed at rest but death may occur from heart failure.

3.Heat hyperpyrexia or stroke- characterized by rectal temperature more than 41 degree centigrade and neurological disturbance as psychosis occurs.

Term sunstroke used when direct exposure to sun is there.
High temperature, increased humidity, muscular activity and lack of acclimatization are the principle factors in initiation of stroke.
Failure of cutaneous blood flow and sweating, the factors which control the body temperature, lead to breakdown of heat regulating centre of hypothalamus.

Burns in a victim of a house fire.

Scalds:

Runs or dribbles of hot fluid will leave characteristic areas of scalding – these runs or dribbles will generally flow under the influence of gravity and this can provide a marker to the orientation of the victim at the time the fluid was moving.
Scalding is seen in industrial accidents where steam pipes or boilers burst and it is also seen in children who pull kettles and cooking pots down upon themselves.

The examination of bodies recovered from fires

The findings of soot in the airways and carbon monoxide in the blood indicate that the person was breathing after the fire began.

Post mortem findings

A.External:

Burnt fabrics
Smell of kerosene, petrol over fabrics
Postmortem hypostasis and rigor mortis can not be assessed
Face is swollen and distorted,
Tongue protruded and swollen and may be burnt
Froth at mouth and nostril due to pulmonary edema due to heat irritation of air passage and lungs
Pugilistic attitude (boxing, defense attitude)- characteristic of great heat exposure; the flexor muscles being bulkier than extensor contract more.
Heat rupture in severe burning or charring, skin contracts and heat ruptures occur
Flash burn due to sudden ignition or explosion of gases

B.Internal:

1.Heat hematoma- has the appearance of extra dural hemorrhage

Clot has honey comb appearance
Parieto-temporal region is the most common site of such hemorrhage

2.Thermal fracture of skull-

3.Laryngeal edema

Scalds of the buttocks and feet on a child who had been dipped into a bath of extremely hot water as a punishment.

Trachea showing soot and mucus following inhalation of fire fumes and smoke.

Skin splits in the victim of a house fire. These splits were initially thought to be incised wounds.

ELECTRICAL INJURY

Usually, the entry point is a hand that touches an electrical appliance or live conductor,
The exit is to earth (or ‘ground’), often via the other hand or the feet.
In either case, the current will cross the thorax, the most dangerous area for a shock because of the risks of cardiac arrest or respiratory paralysis.
When a live metal conductor is gripped by the hand, pain and muscle twitching will occur if the current reaches about 10 mA.
If the current in the arm exceeds about 30 mA, the muscles will go into spasm, which cannot be voluntarily released because the flexor muscles are stronger than the extensors; the result is for the hand to grip or to ‘hold on’.
This ‘hold on’ effect is very dangerous as it may allow the circuit to be maintained for long enough to cause cardiac arrhythmia, whereas the normal response would have been to let go so as to stop the pain.

If the current across the chest is 50 mA or more, even for only a few seconds, fatal ventricular fibrillation is likely to occur.
The victims of such an arrhythmia will be pale.
Even more rare are the instances in which the current has entered the head and caused primary brainstem paralysis, which has resulted in failure of respiration.

The electrical lesion

Where the skin is wet, there may be no signs at all, as the entrance and exit of the current may be spread over such a wide area that no focal lesion exists.
Usually, however, there is a discrete focal point of entry.
The focal electrical lesion is usually a blister, which occurs when the conductor is in firm contact with the skin and which usually collapses soon after infliction, forming a raised rim with a concave centre.

The skin is pale, often white, and an areola of pallor (due to local vasoconstriction) is a characteristic feature. The blister may vary from a few millimetres to several centimetres.
The skin often peels off the large blisters leaving a red base.
The other type of electrical mark is a ‘spark burn’, where there is an air gap between metal and skin.
Here, a central nodule of fused keratin, brown or yellow in colour, is surrounded by the typical areola of pale skin.

The electric mark (Joule burn):

It is specific and diagnostic of contact with electricity
It is found at the entry point.
These are round or oval, shallow craters, 1-3cm in diameter, and have a ridge of skin of about 1-3 mm height.
The crater floor is lined by pale flattened skin
When the contact is prolonged, there may be charring.
Produced by conversion of electricity into heat within the tissue.

Exit mark:

Variable feature, but have some of the features of entrance mark
May be more damage of tissue
Often seen as splits in the skin, continuous or interrupted
Ante mortem electric burns can not be distinguished from postmortem electric burns

Multiple minute electrical marks on the hand caused by contact with a faulty electrical drill.

Extensive electrical burns with scorching and blistering.

Electrical mark from a mains wire wrapped around the neck. There is marked hyperaemia and adjacent pallor, with evidence of blistering.

Hyperaemia from a defibrillator paddle, caused during

attempted resuscitation.

IMPOTENCE AND STERILITY

2011-08-25T10:30:00.000-07:00

Definitions:

Impotence:

Physical inability of either sex to perform sexual act.

Sterility:

Inability to procreate,

Inability to impregnate in case of males,

Inability to conceive in case of females.

Causes of impotency

1. Pathological

Organic causes,

General diseases.

2. Psychological

Organic causes:

Congenital developmental malformations:

In males:

Absence of penis

Infantile penis

Double penis

Hypospadias & Epispadias

In females:

Absence of vagina

Ill developed or small vagina

Imperforated hymen

Female pseudo hermaphroditism

Acquired conditions:

In males:

Acute diseases of penis

Injuries to penis

Adhesions of penis

Hydrocele, scrotal hernia

Elephantiasis

In females:

Vaginal obstruction

Vaginal strictures

UV prolapse

General diseases

In males:

Heart disease

Acute febrile illness

Chronic general disease

Drug addiction

Masturbation

Neurological diseases

Vit. B deficiency

In females: no general disease renders impotence

Psychological causes:

In males:

Stress

Fear

Guilt

Homosexuality

In females:

Vaginismus (reflex spasm of vaginal orifice & all the muscles of pelvis)

MLI of impotency and sterility:

Divorce

Disputed paternity

Legitimacy

Adoption

Adultery

Rape

Un-natural sexual offences

Forensic Ballistic

2011-08-24T12:49:00.000-07:00

Definitions:

Ballistics: Forensic ballistics is the science dealing with the investigation of the firearms, ammunitions and the problems arising from the use.

Firearm: A firearm is an instrument which discharges a missile by the expansive force of the gases produced by the combustion of the propellant in a closed space.

Types of Firearm:

Smooth bored weapon (shot gun)- eg. musket, shotgun.
Rifled weapon/groove bored firearms- eg. rifle, revolver, pistol, automatic pistols, machine guns.

General make up of firearm:

A barrel- hollow cylinder closed at the back end called breech end, open at the end called muzzle end
Inside of barrel consists 3 parts- 1. chamber at the breech end for the cartridge, 2. the taper in rifled arm and chamber cone in smooth bore, connects the chamber to the bore 3. the bore which lies between the taper and the muzzle
A bolt or block can be opened to insert a fresh cartridge into the chamber

Smooth bored firearm:

Bore is perfectly smooth from end to end
They fire round pellets
The hitting range is quite small
Muskets- smooth, bored guns used by constables, has a long fore stuck and usually takes a bayonet at the muzzle (military gun)
Barrel- steel tube, as long as 40-48 inches and as short as 24-30 inches
May be full-choke (muzzle end is 40/1000inch, less in diameter than the breech end), half-choke (muzzle end is 20/1000 inch less) and unchoked (muzzle end and breech end equal in diameter)
The function of choking is to decrease the spread of shot.
May be single barreled or double barreled.
Are effective upto 30-35meters.

Shot gun cartridge:

Consists of a case of short metal cylinder which is continuous with a card board or a plastic cylinder
The case is rimmed to keep cartridge in correct position in chamber
Length of cartridge= 5-7cm
The cartridge is filled from base to above with percussion cap, gun powder, a thick felt wad with card board disc lying in front and behind it, the shot and finally the retaining card board disc, over which the edges of the cartridge cylinder walls are pressed.
The cartridges are numbered according to the size of the shot they contain

Groove bored/rifled firearms:

Spiral grooves (2-20, usually 6) inside the barrel to impart spin movement to bullet, to keep the bullet in straight line to target.
Rifles have firing range of 1000m.
Striking range is small in case of pistol and revolver.
Rifled firearms are divided into

Low velocity <360 m/s
Medium velocity 360-750 m/s
High velocity >900 m/s
The caliber or gauze of rifle is measured between lands, not grooves made by the spirals inside the rifles.

Rifle may be single shot, repeating, semi-automatic, automatic.
Revolvers are so called because the cartridge chambers revolve before each shot to bring the next cartridge opposite the barrel
Revolver has a cylindrical megazine at the back of barrel and can accommodate 5-6 cartridge each in a separate chamber.
Effective range is 100 m.muzzle velocity is 150 m/s.

Bullet (of Rifle/revolver/pistol)

Traditionally made of lead with antimony added for hardness, k/a round nose soft bullet.
Jacketed bullets are of 2 types:

Full metal jacket bullet
Semi jacketed bullet with nose fully or partly exposed

Air rifles and air pistols

Compressed air supplies the propulsion power instead of ignition powder

Small velocity,80 to 100 metre per second

Striking range about 40 metres

Causes only minor injuries

Muzzle velocity:

Shot gun: 800-1000 ft/sec (240-300 m/s)

Rifles: 2000-3000 ft/sec

Pistol: 1200 ft/sec

Revolver: 600 ft/sec (150-180 m/s)

Air rifle: 400-700 ft/sec

Musket: 1150-1950 ft/sec (350-600 m/s)

Types of projectiles/bullet

Lead shot: Present in shot gun cartridge, are of different sizes
Jacketed conical bullets: fully or partially encased with copper or copper nickel, used in rifles.
Hardened lead bullets: in pistol and revolver
Tracer bullet: barium peroxide and magnesium are enclosed in base, give light as they pass.
Incendiary bullet: contains phosphorus, burn the tissue.
Tandem bullet: two bullets together entering into single entrance wound, when an old rusty weapon’s first bullet comes out only after the second fire.
Dumdum bullet: expands or mushrooms on striking and produces a large hole
Plastic bullet: baton round, used for riot control, effective upto 50-70 m, not fired to a person under 20 meter range.

Gun powder: 3 types

Black powder

Contains carbon 15%, sulphur 10%, potassium nitrate 75%

Only 44% of black powder is burnt into gas

The powder grains are black, coarse or fine, burns with production of much heat, flame and smoke

Fine grains travel 60-90 cm or more.

Smokeless powder

Contains nitrocellulose alone or with nitro glycerin

100% smokeless powder is burnt

Produces much less smoke and are more completely burnt than black powder

Semi smokeless powder

Mix of 85% black and 15% smokeless powder

Following things come out of a gun when fired

Projectile
Blast of highly compressed gases
Particle of unburnt /partly burnt powder
Smoke
Flame
Wads (in shotguns)
Fine lead fragments (in lead bullets )
Grease from the weapon
Empty cartridge (smtm in shotgun

Wounds of entrance

In distant shots ,it s usually smaller than the projectile d/t the elasticity of skin
Rounded if bullet hits the body at right angles ,oval if obliquely and gutter shaped if tangentially
Entrance wound is smaller than the exit
Edges are inverted (except in fat and decomposed)
Characteristic of wound of entrance found at all ranges is ring of greese and gun powder surrounded by collar of abrasion or contusion
It may contain wads

Wounds of exit

Bigger than entrance wounds
Very irregular and torn, stellate
Edges everted
No collar of contusion or abrasion
No tattooing or scorching or blackening

If a bullet hits bone,

a clean purched out hole seen in spongy bone,
It is shattered to small bits d/t great velocity, spin and tailing in compact bone
Rebound or deviate after striking a hard bone(wound of ricochette)

Typical stellate exit wound with everted margins.

Shot gun wounds in detail based on distance:

contact wound

results in a circular entrance wound that is about the size of the muzzle.
The wound edge will be regular and often has a clean-cut appearance with no individual pellet marks apparent.
There will commonly be smoke soiling of at least some of the margin of the wound.
There may be a narrow, circular rim of abrasion around some or all of the entrance wound, caused when the gases of the discharge enter through the wound and balloon the tissues upwards so that the skin is pressed against the muzzle.

If the discharge was over an area supported by bone, the gases cannot disperse as quickly as they would in soft areas such as the abdomen, and the greater ballooning of the skin results in splits of the skin, which often have a radial pattern.
The wads or plastic cup will usually be recovered along the wound track. The tissues along the wound track will be blackened and the surrounding tissues are said to be pinker than normal as a result of the carbon monoxide contained within the discharge gases.

close discharge,

within a few cm of the surface, will also produce a wound with a similar appearance, but as there is now room for gas escape, there will be no muzzle mark.

More smoke soiling of wound can occur, and burning of skin with singeing and clubbing of melted hairs can be seen around the wound.

There is also, very commonly, powder ‘tattooing’ of the skin around the entry wound. This tattooing is due to burnt and burning flakes of propellant causing tiny burns on the skin and cannot be washed off.

Wads will commonly be found in the wound.

intermediate ranges,

between 20 cm and 1m, there will be diminishing smoke soiling and burning of the skin, but powder tattooing may persist.

The spread of shot will begin, first causing an irregular rim to the wound. Often called a ‘rat-hole’ in the USA because of the nibbled edges, the same appearance is called ‘scalloping’ in the UK.

Separate injuries caused by the wads or plastic shot containers may be seen.

At a range of over 1 m, smoke damage and tattooing do not occur.

With a normal shotgun, satellite pellet holes begin to be seen around the main central wound at a range of about 2–3 m.

important to measure the spread of the shot to establish the range at which a particular spread of shot will occur.
Estimates based on generalizations about the ratio of the diameter of this spread to the range should no longer be used.

long ranges,

as 20–50 m, there is uniform peppering of shot,rarely fatal.

Shotguns rarely produce an exit wound.
Exit wounds seen when fired into the head, neck or mouth. The exit wound in these cases may be a huge ragged aperture, especially in the head, where the skull may virtually explode.
The spread of shot will begin, Often called a ‘rat-hole’ because of the nibbled edges, the same appearance is also called ‘scalloping’ .
Separate injuries m/b caused by the wads or plastic shot
satellite pellet holes begin to be seen around the main central wound at a range of about 2–3 m.

Close discharge of a 12-bore shotgun to the chest.

There is a large hole, partly due to disruption by gas, and no

evidence of pellet scatter is seen.

spread of the shot can be seen.

Wounds from rifled weapons in details based on distance

Bullets fired from rifled weapons will commonly cause both an entry and an exit wound.

However, exceptions to this rule are numerous and many bullets are retained within the body.

Entrance wounds in detail

Contact wounds from a rifled weapon are generally circular, unless over a bony area such as the head, where splitting caused by the propellant gas is common.

There may be a muzzle mark if the gun is pressed hard against the skin.
There may be slight escape of smoke with some local burning of skin and hair if the gun is not pressed tightly.
Bruising around the entry wound is not uncommon.

close range up to about 20 cm, there will be some smoke soiling and powder burns, and skin and hair may be burnt, although this is very variable and depends upon both the gun and the ammunition used.

The shape of the entry wound gives a guide to the angle that the gun made with that area of skin: a circular hole indicates that the discharge was at right angles to the skin, whereas an oval hole, perhaps with visible undercutting, indicates a more acute angle.
Examination of the entry wound will show that the skin is inverted; the defect is commonly slightly smaller than the diameter of the missile due to the elasticity of the skin.
Very commonly, there is an ‘abrasion collar’ or ‘abrasion rim’ around the hole, which is caused by the friction, heating and dirt effect of the missile when it indents the skin during penetration.
Bruising may or may not be associated with the wound.

Over 1 m or so, there can be no smoke soiling, burning or powder tattooing.

At longer ranges (which may be up to several kilometres with a high-powered rifle), the entrance hole will have the same features of a round or oval defect with an abrasion collar.

Suicidal pistol contact entry wound in the temple.

The skin is burnt and split due to the gases of the discharge.

Pistol entry wound through the eyebrow with adjacent

powder tattooing. The bruising of the eyelid is due to the fractured

skull.

Deaths and Injury in Infancy

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Infant- <1 year
Infanticide means the unlawful destruction of a child under the age of 1 year.
Stillbirth and sudden infant death syndrome, which have important medico-legal aspects.

Still birth

It is the child (born after 28 weeks)which did not breathe or show any sign of life at any time after being expelled from the mother.
Common causes are prematurity, anoxia, birth trauma especially intracranial hemorrhage due to excess moulding, placental abnormality.

Dead birth:

Is a child which has died in the utero and shows one of the following signs after complete birth:
Rigor mortis at delivery
Maceration (aseptic autolysis after 3-4 days in uterus filled with amniotic fluid and no air). The earliest sign of maceration is skin slippage, which can be seen in 12 hours after death in utero. The body of the macerated fetus is soft, flaccid, and flattens out when placed on a level surface. It has a sweetish disagreeable odor. Spalding’s sign is the loss of alignment and overriding of the bones of the cranial vault.
Mummification: is the condition in which the fetus dries up, shriveled in the uterus. It occurs when fetus dies from deficient supply of blood, when the liqor amni is scanty and when no air enters the uterus.

A newborn infant showing marked maceration due toan intrauterine death. The cord around the neck is significant, buta full autopsy is required to establish the cause of death.

Signs of live birth:

Shape of chest- flat, circumference

The position of diaphragm- found at the level of 4th or 5th rib if no respiration, 6th or 7th rib after breathing.

Lungs- After respiration, volume is increased, margins become rounded, consistency becomes soft, spongy, elastic and crepitant. The hydrostatic test by placing the lung tied at bronchi into water- if floats suggests respiration but an unexpanded lung may float from putrifaction and the expanded lung may sink from disease like acute edema, pneumonia.

Stomach- air is swallowed into the stomach during respiration.

Other signs of live birth- caput succedaneum, cephalhematoma, air in GI tract, clothed body, vernix caseosa washed.

How long did the child survive?

Caput succedaneum disappears within 7 days.
Changes in umbilical cord:

1)Clotting at cut end- 2hours

2)Shrinks and dries- 1st day

3)Cord mummified- 3 to 4 days

4)Cord falls- 5 to 6 days

5)Ulcers heals by scar- 10 to 12 days

Skin changes:

1)Vernix caseosa- persists for a day or 2

2)Color bright red at birth, becomes dark at 2nd or 3rd day

3)Original color 7 to 10 days.

Cause of death:

Natural- Immaturity; malformation; disease of heart, lungs or brain; meconium aspiration; Rh incompatibility.
Accidental- cord prolapse; prolonged labor; cord round the neck; placenta previa; death of mother; aspiration of blood or liquor; precipitate labor.
Criminal- suffocation, strangulation with cord, drowning in milk or water, throttling, failure to tie the cord, removal of child from mother’s charge, omission to feed.

Abrasion of the neck of a baby. These marks weresaid to have been caused by traction of the neck of the baby bythe mother during self-delivery. Similar marks could be causedby strangulation.

Battered baby syndrome/ child abuse syndrome

Also called maltreatment syndrome in children

A child who has received repetitive physical injuries as a result of non-accidental violence produced by a parent or a guardian.

In addition to physical injuries, there may be deprivation of nutrition, care and affection.

The classical discrepancy between the nature of the injuries and explanation offered by parents, and delay between the injury and medication is clear.

Constant repetition of injuries at different dates.

Munchausen’s syndrome by proxy

Is feigning illness or injury and going from hospital to hospital for unnecessary investigations and treatment.

Children are brought to doctors for induced or fabricated signs or symptoms of illness.

Child is frequently admitted to hospital for illness, non existing in real.

These patients appear to be compulsively driven to make the complaints. The parent is aware that he is acting an illness but he can not stop the act.

Method of production of illness- mother pricks her finger and adds blood to the urine sample of her child, a pillow or towel is put over the face of the child and the face is pushed down into bed clothing, mother gives insulin to the child and takes to hospital with hypoglycemia, drugs for diarrhea, vomiting given to the child.

DROWNING (MECHANICAL ASPHYXIA)

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Drowning:

Is a form of asphyxia due to aspiration of fluid into the air passage, due to submersion in fluid or water.
Complete submersion is not necessary, that of mouth and nose alone for a sufficient period can cause death from drowning.

Bodies recovered from water may have:

died of natural causes before entering the water; while in the water
died from exposure and hypothermia in the water;
died of injuries or other unnatural cause before entering the water; after entering the water;
died from submersion, but not drowning; or
died from true drowning as a result of aspiration of water into the lungs.

SIGNS OF IMMERSION

the skin becomes somewhat opaque and wrinkled. known as ‘washerwoman’s fingers’, develop after a few hours in cold water.
After a few days, this macerated skin will begin to separate and,
usually within 1–2 weeks the skin will peel off the hands and feet.
another early sign of immersion is cutis anserina or ‘gooseflesh’, d/t contraction of the erector pili muscles.
However, this is partly due to cold (and may be seen in refrigerated bodies) and partly due to rigor mortis.
Cutis anserina is not a specific sign of immersion.
in average temperate conditions a body immersed in water will decompose at about half the speed of one left in air.
After about a week, the body will be bloated and the face, abdomen and genitals will be distended with gas
As the body is moved by the flow of the water, contact with rocks, piers and many other underwater obstructions can cause damage.

TYPES OF DROWNING:

Wet drowning- water inhaled into lungs, death within minutes of submersion, secondary to cardiac arrest.

Dry drowning- water doesn’t enter the lungs, but death results from immediate laryngeal spasm due to inrush of water into larynx; thick mucus, foam and froth may develop producing a plug; usu. in children and alcoholics.

Secondary drowning- also called ‘near drowning’; refers to a submersion victim who is resuscitated and survives for 24 hrs

Immersion syndrome- also called hydrocution; death results from cardiac arrest due to vagal inhibition from

Cold water stimulating skin,

Cold water striking epigastrium,

Cold water entering ear drum, pharynx, larynx.

Seen in 1-2% of drowning.

Pathophysiology of drowning

The mechanism of death in true drowning is not one of simple hypoxia but differ according to the type of water: hypotonic or hypertonic.

If a dead body is thrown into water, due to hydrostatic pressure, water passes into lungs. This hydrostatic lung will simulate drowning lung; but a fluidy lung with frothy fluid is diagnostic of drowning.

FRESH WATER DROWNING:

Fresh water is hypotonic compared to plasma, so, a rapid transfer of fluid takes place from the alveoli into the vascular system because of the osmotic difference between the water in the lungs and the plasma.

may increase the blood volume by as much as 50% within a minute and this hypervolaemia will place a great strain on the heart.

The lungs are ballooned but light in weight.

The rapid influx of water will render the plasma hypotonic, which will result in haemolysis of RBC.

It was once thought that severe hyperkalaemia caused from the haemolysed RBC contributed significantly to rapid myocardial failure, but more recent work has shown this to be only a relatively minor factor in death in fresh-water drowning.

SEA WATER DROWNING:

Seawater is hypertonic (3% NaCl), so that water is withdrawn by osmosis from the plasma into alveolar spaces in the lungs.

There is also electrolyte transfer, with mainly sodium and chloride passing from the hypertonic inhaled fluid into the blood.

The lack of hypervolaemia, with the consequent absence of strain on the heart, probably accounts for the longer survival times in salt-water submersion.

POST MORTEM FINDING:

Drowning is one of the most difficult modes of death to prove at post mortem.

Post mortem lividity is found on face, hands, upper part of chest, lower arms, feet and the calves.

Weed, grass, leaves etc. present in the water may be firmly grasped in the hands due to cadaveric spasm.

Classically, there will be a plume of froth at the mouth and nostrils, which may sometimes be tinged with blood.

This froth fills the air passages and exudes on to the face. It is composed of water containing plasma protein and surfactant that has been whipped into a froth by the violent terminal respiratory actions..

Externally this may be the only sign, but it is absent more often than it is present, especially when the body has been dead for some time.

The lungs may have a ‘doughy’ texture and remain inflated and spongy to the touch.

Dissection of the lung may show generalized pulmonary oedema, but where any water in the air spaces has been absorbed into the pulmonary circulation, the oedema will be absent – this is the so-called ‘dry-lung drowning’.

In a significant proportion of cases, the person dies quickly, sometimes within seconds of entering the water.

Sometime,The mode of death of these cases is considered to be cardiac arrest, which is most likely to be due to a vagal inhibitory reflex triggered by a sudden stimulation of sensitive areas like larynx, pharynx, skin of the heavily drunk alcoholics.

Profuse blood-tinged froth around the mouth and nose in drowning.

LABORATORY TESTS FOR DROWNING

Microscopic algae, called diatoms, which are often, but not always, present in seawater and unpolluted natural fresh water.

All have an almost indestructible silicaceous capsule.

The theory behind the test is that normal people do not have significant numbers of diatoms in the kidneys, brain, marrow etc., but if a person drowns in diatom-containing water, the algae in that water will reach the lungs and some of them will penetrate the alveolar walls. If the heart is still beating, the diatoms that have entered the bloodstream will be transported around the body in the circulation and may lodge in distant organs such as the kidney, brain and bone marrow before death.

An increase in the number of diatoms in the internal organs was thought to confirm that the body had drowned and, if a sample of the water was also taken at the presumed site of drowning.

The similarity of different species of diatom in the water and the body could be compared.

On the other hand, if a dead body was dropped into water, although diatoms could reach the lung by passive percolation, no circulatory transfer could occur and so (theoretically) no diatoms would be present in the distant organs.

The advantages- could be used even in the presence of putrefaction, if protected tissue such as bone marrow was examined.

Unfortunately, the diatom test is often negative, even in undoubted cases of drowning in waterways full of diatoms, and there have been numerous false positive results.

All in all, this test is now so unreliable that it should only be used, and the results interpreted, with great circumspection.

Diatoms from lake water.

ASPHYXIAL DEATHS

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Asphyxia:

Condition in which supply of oxygen to blood and tissues has been reduced below the normal level by some interference with respiration.

1. Disease of circulatory or respiratory system

2. Interferance with respirations

Breathing in atmosphere deficient in oxygen.

Inhalation of irrespirable gases like CO.

Poisoning with respiratory center depression like narcotics & anesthetics.

Mechanical interference with reapiration.

Signs of Asphyxia:

Cyanosis (due to stasis and congestion)

Increased capillary permeability (causing tissue edema)

Petechial hemorrhage

Persistant fluidity of blood (due to fibrinolysis)

Cardiac dilatation.

POST MORTEM FINDING IN DEATH FROM ASPHYXIA

1. Internal findings:

Blood- dark in color, more fluid, coagulate slowly.

Right sided heart-distended with blood

Left- empty

Lungs- Engorged, congested, emphysematous, edematous, exudes copious frothy fluid on cut section.

2.External findings:

Face- Swollen, cyanosed, marked with petechial hemorrhage

Eyes- Open, prominent, pupils dilated, injected conjunctiva

Sub-conjunctival heamorrhage may be present

Lips, ears, finger nails- Deeply cyanosed

Neck veins- Prominent

Mouth & nostrils- Oozing

Hands- Clenched

Hypostasis- Purple in color

Semen may be voided

Urine and feces incontinence

Trachea & bronchi- Congested, contain blood stained frothy fluid

Petechial hemorrhages- can be found on lungs, heart & brain

Abdominal viscera, brain, meninges- Congested

Suffocation:

It includes-

Smothering (obstruction to air passages from outside)

Choking (obstruction to air passages from inside)

Traumatic asphyxia (pressure on chest obstructing respiratory movements)

Smothering:

It is a form of asphyxia caused by mechanical occlusion of external air passage.

Post-mortem findings:

Site of distribution of lividity

Suggestive of suffocation

Bruises & abrasions over mouth & nostrils

Nasal septum may be fractured

Signs of struggle may be present

ML Aspect:

Homicidal (difficult in healthy young adults)

Commoner method for infanticide

Accidental (in children during sleep & breast feeding; may occur in alcoholics or epileptics)

Suicidal (almost impossible, extremely rare)

Choking:

It is a form of asphyxia caused by mechanical occlusion within air passage by a solid object.

Post-mortem findings:

Object responsible for choking is found in respiratory passages,

Other signs of asphyxial death.

ML Aspects of Choking:

Mostly accidental-

Impaction of food, false teeth & other foreign bodies,

Inhalation of vomitus in alcoholics,

Regurgitation of food in infants,

Impaction of coin, pea, grape, or nut,

Tumors of larynx

Diptheria,

T.B. Laryngitis

Homicidal (common for infanticide)

Suicidal (extremely rare)

Traumatic Asphyxia or Crush Asphyxia

It is a form of asphyxia, which results from prevention of respiratory movements by means of mechanical compression.

Post-mortem findings:

Well defined demarcation line between upper (discolored) and lower (normal colored) body part,

Face and neck deeply cyanosed,

Numerous petechiae found over scalp, face, neck and shoulders,

Bilateral, multiple rib fractures (usually at their angles),

Injuries to lungs and heart,

Other signs of asphyxial death.

Traumatic asphyxia due to pressure on the chestfrom an overturned tractor. The extensive congestion and petechial haemorrhages in the head and neck are typical of this type of asphyxia.

ML Aspects of traumatic asphyxia:

Mainly accidental-

Run over by a car

Fall of a tree

Collapse of a house

In crowds (during Haj)

Bansdola (homicidal compression of chest by means of bamboos)

Hanging:

It is a form of asphyxial death brought about by suspension of the body and constriction of neck by a ligature around it.

Partial hanging- when the feet touch ground

Complete hanging- when feet don’t touch ground

Causes of death in Hanging:

Asphyxia

Cerebral congestion or congestive suboxia

Vasovagal inhibition or shock

Injury to spinal cord

Combination of the above causes.

The spiral weave of the rope can be seen in this

horizontal ligature mark caused by hanging

Suicidal hanging: the rope rises to a point, leaving a

gap in the ligature mark – the suspension point – on the neck.

Post-mortem findings:

1. Nature of ligature:

Time, the body has remained suspended

Intervention of clothes, beard, skull hair etc.

2. Position:

Above thyroid cartilage- 80%

On the thyroid cartilage- in cases of partial

Below thyroid cartilage- very rare

3. Course of direction:

Oblique & interrupted at place-usually of knot

Circular- if suspension is in front

Oblique & circular- if ligature is passed around the neck more than once.

4. Color:

Pale in early period-later on becomes yellowish & brown then dark brown or chocolate colored.

5.External appearances other than ligature mark:

Neck- stretched & elongated, bend to side opposite the knot

Face- swollen & blue

Eyes- protruded, dilated pupils, conjuctivae congested

Tongue- protruded, saliva dribbling from the corner of mouth

Head & neck- petechial hemorrhage

Nails- blue

Sometimes face become pale & eyes and tongue less protruded in case of arteries and veins are compressed together

Genitals- swollen & congested

Rigor mortis- slow and longer

PM lividity- on dependent parts e.g. extremities, breasts, penis & testicles.

6.Abrasions and bruises:

May be found when ligature is hard & tough.

7.Number: 1-suicidal, >1- homicidal

8.Internal appearance:

Spinal cord injuries
Transverse tear of the intima of the carotid arteries & extravasation of blood within the wall
Pons and medulla may be injured
Sternocleidomastoid and platysma may be ruptured
Thyroid cartilage may be fractured
Heart, right side full of dark blood & left empty
Abdominal organs congested and bladder empty
Hyoid bone may be fractured in above 40 age group.

Signs of antemortem hanging:

A suspension mark with signs of vital reaction e.g. hyperemia, ecchymosis, abrasions & bruises.

Ligature mark can be produced 2 hours after death but without vital reaction.

ML Aspects:

Most commonly, it is suicidal

More common in females than males

Direction of ligature mark

Oblique-suicidal

Circular- homicidal

Presence of poison in body suggest suicide

Signs of struggle suggest homicide.

Strangulation:

It is a form of asphyxia caused by constricting the neck by any means other than body weight.

Constricting force being hands- in throttling; elbow- in mugging; knee, foot- bansdola; some hard object.

Causes of death in strangulation:

Asphyxia

Vasovagal inhibition

Cerebral congestion

Combination of above factors

It is well accepted that in some cases of strangulation,and in rather more cases of hanging, the sudden application of pressure onto one or other carotid sinus can initiate rapid death, through the vagally mediated cardiac bradycardia described above, before any congestive or petechial signs have time to appear –and so the victim dies with a pale face and no petechiae.

For congestion and petechae,hypoxia of min 15-30 s is reqd

PM Findings

1. External findings

Neck findings

External findings other than neck

2. Internal findings

External findings

Neck findings

Strangulation by Ligature:

Fragments of epidermis on suspected ligature material, if found.

Usually on or below thyroid cartilage.

Encircle the neck completely

Bruising & ulceration at the site of knot

Throttling or Manual Strangulation:

Marks of fingers & thumb on either side of neck

Look like bruises soon after death

There may be bruises on mouth, nose, cheeks, forehead and lower jaw.

Strangulation by means of a Stick:

Bruises in front of the center of the neck

Similar mark will be present on nape of neck if two sticks are used.

B. External findings other than in neck

Signs of asphyxia.
Face- swollen, cyanosed & marked with petechial haemorrhages.
Eyes- prominent, conjunctiva injected and pupils dilated.
Lips- blue.
Bloody froth from mouth, nose & ears.
Tongue- swollen, bruised & bitten by teeth.
Hands- clenched.
Urine, feces and semen may be discharged.
There may be injuries on chest

Petechial haemorrhages on the eyelid in a case ofmanual strangulation.

Conjunctival haemorrhages in manual strangulation

Bruising of the neck in manual strangulation.

Homicidal strangulation with a soft silk ligature. Thefolding of the material has caused the deep grooved mark and thefainter red mark above it.

2. Internal findings

Extravasation of blood into subcutaneous tissue above and below the ligature mark.
Laceration of the superficial muscles of neck.
Fracture of hyoid bone, tracheal rings and cervical vertebrae.
Lungs- dark, frothy blood on section
Heart- right side full of dark blood and left empty
All abdominal organs are congested.

DEATH AND ITS CAUSES

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DEFINITION OF DEATH

Death is the cessation of life in a previously living organism

Medically and scientifically, death is not an event, it is a process. Historically death meant heart and respiration death but heart-lung bypass machine favored new concept ‘brain death’.

There are two aspects of death:

Clinical death

Cellular death

CELLULAR DEATH

means the cessation of respiration (the utilization of oxygen) and the normal metabolic activity in the body tissues and cells.

Cessation of respiration is soon followed by autolysis and decay

Skin and bone will remain metabolically active and thus be ‘alive’ for many hours

The cortical neuron, on the other hand, will die after only 3–7 minutes of complete oxygen deprivation.

SOMATIC DEATH/ CLINICAL DEATH:

The complete and irreversible stoppage of circulation, respiration and brain function.

No legal definition of death.

A person who can not survive upon withdrawal of artificial maintenance is dead.

The individual is irreversibly unconscious and unaware of both the world and his own existence.

The question of death is important in resuscitation and organ transplantation.

Cornea can be removed from the dead body within 6 hours, skin 24 hours, bone 48 hours, kidney and heart obtained soon after circulation has stopped.

Brain death is of 3 types:

Cortical or cerebral death with intact brain-stem, vegetative state.
Brain stem death- where the cerebrum will be intact, though cut off functionally.
Whole brain death (1+2)

VEGETATIVE STATE:

If the cortex alone is damaged, patient passes into coma but the brain stem will function to maintain spontaneous respiration.

Death may occur months or year later.

They are not in need of life sustaining treatment but require nutrition and hydration.

Has stable circulation and shows cycles of eye opening and closing but is unaware of the self and environment.

BRAIN STEM DEATH:

1.The patient must be in deep coma.

2.Treatable causes such as depressant drugs, metabolic or

endocrine disorders (diabetic or myxoedema coma)

or hypothermia must be excluded.

3. The patient must be on mechanical ventilation, no movement and no spontaneous breathing.

4. Cessation of spontaneous cardiac rhythm.

5. No brain stem reflexes- corneal, vestibulo-occular, pupillary, grimacing, gag reflex.

6. Bilateral fixed dilated pupil.

DEATH CERTIFICATION

The format of certifying the cause of death is now defined by the World Health Organization (WHO) and is an international standard that is now used in most countries.

The system divides the cause of death into two parts:

Part I describes the condition(s) that led directly to death;

Part II is for other conditions, not related to those listed in Part I, that have also contributed to death.

The pathologist, forensic medical examiner and seniorpolice officer at the scene of a sudden death.

Mode of death:

According to Bichat, there are 3 modes of death based on death begins in which of the 3 systems: (irrespective of what the remote cause of death may be)

Coma

Syncope

Asphyxia

According to Gordon (1994), the stoppage of vital functions depend upon tissue anoxia. It may be anoxic anoxia (strangulation, choking, drowning, hanging), anaemic anoxia (acute massive hemorrhage, CO), stagnant anoxia (heart failure, shock) and histotoxic anoxia (acute cyanide poisoning).

Anoxic anoxia due to lack of oxygen in the inspired air or mechanical obstruction to respiration is k/a asphyxia.

Coma:

State of unarousable unconsciousness.
Clinical symptom and not a cause of death.
Causes of coma are compression of brain, drugs like opium, cocaine, alcohol; metabolic disorders like uraemia, diabetes.
At autopsy, the lungs, brain and the meninges are conjusted, injuries of the brain or the disease may be present.

Syncope:

Sudden stoppage of the action of heart, may be fatal.
Is due to vaso-vagal attack from reflex para-sympathetic action
Blood pressure falls suddenly causing cerebral anemia and rapid unconsciousness, recovery is common.
Autopsy of syncope:
Heart is contracted and the chambers are empty when d/t anemia,
Chambers contain blood when d/t weakness of heart muscles,
The lungs, brain and abdominal organs are pale, capillaries conjusted.

Asphyxia:

Lack of oxygen in respired air or mechanical obstruction due to which the organs and tissues are deprived of oxygen.
Is a mode of death rather than a cause of death.
The rule of thumb is : breathing stops within 20 seconds of cardiac arrest and heart stops within 20 minutes of stopping of breathing.

Types of asphyxia:

Mechanical- closing of the nose and mouth with hand or mouth, hanging, drowning,
Pathological- entry of oxygen is prevented by the disease of URT or lungs eg. bronchitis, acute epiglotitis,
Toxic- eg. CO poisoning, opium paralysing respiratory center.
Environmental- eg. enclosed places, CO, CO2, high altitude
Traumatic- eg. pulmonary embolism,
Postural- eg. alcoholic lying down with upper half of the body lower than the remainder
Iatrogenic- associated with anaesthesia.

The ‘classical’ features of asphyxia are found where the air passages are obstructed by pressure applied to the neck or to the chest and where there has been a struggle to breathe. The classical features of ‘asphyxia’ are:

1.congestion of the face;

2. oedema of the face;

3.cyanosis (blueness) of the skin of the face;

4.petechial haemorrhages in the skin of the face and the eyes.

5.A fifth feature – increased fluidity of the blood – is now not accepted.

Petechial haemorrhages on the eyelid, conjunctiva in a case ofmanual strangulation.

Causes of death:

Disease or injury responsible for starting the sequence of events, which are brief or prolonged and which produce death.

Divided into:

Immediate cause- terminal events eg. trauma, peritonitis etc.

Basic cause- pathological process responsible for death at the time of terminal event eg. gunshot wound

Contributory cause- pathological process involved in or complicating but not causing the terminal event.

Manner of death:

Way in which the cause of death was produced.

May be natural or unnatural, violent.

Violence may be of suicidal, homicidal, accidental or undetermined origin.

Mechanism of death:

Congestion is the red appearance of the skin of the face and head, due to the filling of the venous system

Oedema is the swelling of the tissues due to transudation of fluid from the veins caused by the increased venous pressure as a result of obstruction of venous return to the heart.

Cyanosis is the blue colour imparted to the skin by the presence of deoxygenated blood in the congested veins.

Petechial haemorrhages (petechiae) are tiny, pinpoint haemorrhages, most commonly seen in the skin of the head and face and especially in the lax tissues of the eyelids. They are also seen in the conjunctivae and sclera of the eye.

Physiological or biochemical disturbance produced by the cause of death which is incompatible with life eg. shock, sepsis, fibrillation, respiratory paralysis, severe metabolic alkalosis/acidosis.

NEGATIVE AUTOPSY:

When gross and microscopic examination, toxicological analysis and lab investigation fail to reveal the cause of death.

2-5% of all autopsies are neagtive.

SUDDEN DEATH:

When a person not known to have suffering from any dangerous disease, injury or poisoning is found dead, or dies within 24 hours after the onset of terminal illness (WHO)

Some authors call sudden death as occuring instantaneously or within 1 hour of onset of symptoms. Causes are disease of CVS-50%, resp. system-20%, CNS-15%, GI system- 7%, miscellaneous- 5 to 10% eg. DM.

POST-MORTEM CHANGES

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IMPORTANCE OF PM FINDINGS

Doctor needs to know the normal progress of decomposition so that he does not misinterpret these normal changes for signs of an unnatural death and,

Secondly, because they can be used in determining how long the individual has been dead.

EARLY CHANGES

Immediate fall in bl. pressure & supply of oxygen ceases.

With loss of neuronal activity, all nervous activity ceases, the reflexes are lost and breathing stops.

In eye,corneal reflex ceases and pupils stop reacting to light.Opacity of cornea d/t drying.

If eyelids open after death, in few hours a film cell debris and mucous form two yellow triangles on scelera on either side of iris, which become brown and then black called ‘tache noir’ within 3-4 hours.

The retinal vessels, viewed with an ophthalmoscope, show the fragmentation of the columns of blood,called ‘trucking’ as it suggests the movement of railway wagons.

The eyes lose their intraocular tension.

The muscles rapidly become flaccid (primary flaccidity), but may respond to touch and other forms of stimulation for some hours after cardiac arrest.

Discharges of the dying motor neurons may stimulate small groups of muscle cells and lead to focal twitching.

The fall in blood pressure and cessation of circulation usually render the skin, conjunctivae and mucous membranes pale. The skin of the face and the lips may remain red or blue in colour in hypoxic/congestive deaths.

Loss of muscle tone in the sphincters may result in voiding of urine; this is such a common finding that no relationship with deaths from epilepsy or asphyxia can be established.

Emission of semen is also found in some deaths; the presence of semen cannot be used as an indicator of sexual activity shortly before death.

Regurgitation is a very common feature of terminal collapse and it is a common complication of resuscitation.

RIGOR MORTIS

occurs within muscle cells as a result of lack of oxygen

In the face of low ATP and high acidity, the actin and myosin fibres bind together and form a gel.

If muscle glycogen levels are low or if the muscle cells are acidic at the time of death as a result of exercise, the process of rigor will develop faster.

Electrocution is also associated with rapidly developing rigor and this may be due to the repeated stimulation of the muscles.

Conversely, in the young, the old or the emaciated, rigor may be extremely hard to detect because of the low muscle bulk.

First detectable in the smaller muscle groups such as those around the eyes and mouth, the jaw and the fingers.

It appears to ‘spread’ down the body from the head to the legs as larger and larger muscle groups are rendered stiff.

Rigor mortis is a chemical process enhanced by heat, so colder the temperature the slower the reactions and vice versa. In a cold body, the onset of rigor will be delayed.

body lying in front of a fire or in a bath of hot water will develop rigor quickly.

In temperate conditions rigor can be first detected (begins)in the face between 1 and 4 hours and in the limbs between 4 and 6 hours after death, and the strength of the rigor increases for the next 6–12 hours. Once established, rigor will remain static until decomposition.

The secondary flaccidity becomes apparent from 24 to 50 hours after death with the onset of putrefaction.

It is best to test for rigor across a joint using very gentle pressure from one or two fingers only.or at eyelids.

A crude but useful aide-memoire is:

Body feels warm and flaccid – dead less than 3 hours.

Body feels warm and stiff – dead 3–8 hours.

Body feels cold and stiff – dead 8–36 hours.

Body feels cold and flaccid – dead more than 36 hours.

CADAVERIC RIGIDITY OR SPASM:

the stiffness of muscles that is said to have its onset immediately at death

Most cases are said to be related to individuals who are at high levels of emotional or physical stress immediately before death

the mechanism for this phenomenon is possibly neurogenic

Cadaveric rigidity – a rare condition. This victimgrasped at some ivy as he fell into water.

POST-MORTEM HYPOSTASIS:

The passive settling of red blood cells under the influence of gravity to the blood vessels in lowest areas of the body is important forensically. It produces a pink or bluish colour and it is this colour change that is called post-mortem hypostasis. also called post-mortem lividity and also suggilation.

Hypostasis is not always seen in a body and it may be absent in the young, the old and the clinically anaemic or in those who have died from severe blood loss.

It may be masked by dark skin colours, by jaundice or by some dermatological conditions.

However, hypostasis occurs only where the superficial blood vessels can be distended.

However, compressed areas will remain pale called blanching.

Blanching may also be caused by pressure of clothing or by contact of one area of the body with another

A body left suspended after hanging will develop deep hypostasis of the lower legs and arms, with none visible on the torso, whereas a body that has partially fallen head first out of bed will have the most prominent hypostatic changes of the head and upper chest.the drowning body has different pm lividity.

IMPORTANCE OF LIVIDITY

The cherry pink colour of carbon monoxide poisoning, the dark red or brick red colour associated with cyanide poisoning, and infection by Clostridium perfringens, which is said to result in bronze hypostasis.

The time taken for hypostasis to appear is so variable that it has no significant role in determining the time of death.

Movement of a body will have an effect on hypostasis

Normal distribution of post-mortem hypostasis in abody which lay on its back after death. The white areas are dueto pressure upon the ground.

Post-mortem hypostasis on a body found face downon a bed. The linear marks are formed by pressure from creasesin the blanket. The pale areas around the mouth and nose are notnecessarily signs of suffocation.

COOLING OF THE BODY AFTER DEATH:

Aka algor mortis, is a complex process, not at the same rate through out the body.

Exchange of heat to surrounding occurs only by conduction.

For about half to one hour about death, rectal temperature falls little or not at all. Then, the cooling rate is relatively uniform till 4 degree centigrade.

Postmortem caloricity:

Body temp raised for the 1st 2hrs or so after death, eg. In sunstroke, tetanus, convulsion, septicaemia

Thermometer used to measure rectal temperature is 25 cm long, with a range of 0-50 degree, inserted 8-10cm in rectum for 2mins. The temperature can also be recorded making the hole in the peritoneum and the peritoneal cavity, external auditory meatus, cribiform plate through the nose.

Time since death=normal body temp-rectal temp/rate of temp fall for hours. However, for the formula, we must assume 37 degree rectal temp at the time of death, uniform rate of cooling of whole body.

The rectal temp of an average size naked body reaches the env in about 20hours.

ESTIMATION OF THE TIME OF DEATH:

Of the three historic pathological features that were used to estimate death, only the fall in body temperature has withstood the test of science;

the others – rigor mortis and hypostasis – have now been shown to be utterly unreliable and will not be considered further.

IDENTIFICATION

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Identification:

The determination of the individuality of a person based on physical characteristics.

Necessary in living person, recently dead, decomposed body, mutilated body and skeleton.

Necessary in criminal cases like physical assault, murder, rape etc. or in civil cases like marriage, passport, insurance claim, missing person.

At least two identification mark should be noted by the doctor in all ML cases.

The police has to establish the identity of the person. In some cases doctor may be able to supply identification marks of the person, dead body or fragmentary remains.

The corpus delicti: the body of offense, the fact of any criminal offense. The corpus delicti of murder is the fact that the person died from unlawful violence. Clothing with weapon mark, photographs of deceased showing injuries etc. are included in this term.

The main part of corpus delicti is establishment of identification of dead body.

It includes the body of the victim and other facts which are conclusive of dead by foul play, eg bullet or a broken knife found in the body.

Identification Data:

Race determined by

complexion,

eyes (european-blue/gray),

hair (european-fair, brown, straight, wavy; negros-elongated, oval on crosssection with dense pigment; negros have wooly hair; mongolian hair is coarse and dark, usually circular in cross section)

Clothes

Skeleton- the cephalic index=max breadth of skull/ max length*100

dolicocephalic (CI 70-75) aryans, negros,

mesaticephalic (CI 75-80) europeans and chinese

brachycephalic (CI 80-85) mongolian

Sex

In female, barr body present in the buccal mucosa smear, neutrophil content small nuclear attachment of drumstick form (davidson body) in 6%.

Sex determination is difficult in hermaphroditism, concealed sex, advanced decomposition, skeleton.

Males have square orbits, prominent supra-orbital ridges, sub-pubic angle ‘V’ shaped (70-75 degree), pelvic inlet heart shaped, less movable coccyx.

Religion

Hindu males are not circumcised, sacred thread, cast mark on forehead, tuft of hair on the back of head

Hindu females: vermillion in head, silver toe ornaments, nose ring aperture in the left nostril

Muslim females: may have nose ring in septum only, several openings in the ear

Muslim males: circumcised

Age

Can be determined from teeth, ossification of bones, secondary sex characters and general development in case of children.

Temporary and permanent teeth can be seperated. Temporary are smaller, lighter, china-white colored crown, smaller and more divergent roots.

Tooth eruption dates help identify the date

Gustafsons method is used for estimation of age of adults over 21 years. It is based on attrition (wear and tear of occlusal surface upto pulp), paradentosis (regression of gums and periodontal tissues in advancing age or pathology), cementum aposition (secondary cementum slowly and continuously deposited throughout life forming lines appearing as cross striation in the enamel of teeth and used to count to know the age), root resorption, transparency of the root.

Individual bones ossification centre also used to calculate age eg, symphysis pubis, sternum, hyoid bone, skull, sacrum, vertebra. First bone to ossify is clavicle.

General development and stature

Varies at different time of day by 1 &half to 2 cm.

Malnutrition and old age reduces stature.

On an average body lengthens by 2cm after death.

If the body has dismembered, stature may be determined by length of tip of the middle finger to the tip of opposite middle finger, twice the length of one arm with 30cm added for 2clavicles and 4 cm for sternum

Anthropometric measurement

Includes color of hair, eyes, shape of nose

Body marks as moles, scar, tataoos

Body measurement as height, AP diameter of head, the span of outstretched hands

Complexion

External pecularity eg. mole, birth mark, scar, tatoo mark

Age of scar- 5-6 days, reddish or bluish angry scar; by end of 14 days, scar becomes pale; in 2-6 months, the scar becomes white and glistening, tough and may wrinkle

ML importance of scar is mark for identification, age of scar, shape of scar may identify the weapon.

Superimposition is the technique applied to determine whether the skull is that of person in the photograph

Finger print and foot print

Classification of fingerprints:

Loops (67%) may be radial or ulnar

Whorls (25%)

Arch (6-7%)

Composite

Poroscopy is further study of finger prints which studies microscopic pores on the ridges on fingers formed by sweat glands.

Foot prints (podogram) are also used

Lip print (cheiloscopy) also used

Teeth

Personal effect eg. Cloth, jewellery, pocket content

Handwriting (calligraphy is characteristic of the individual, esp if written rapidly

Speech and voice: certain pecularities of speech eg, stammering, stuttering, lisping may be more evident when talking excitedly

Gait

Memory and education (sometimes useful, esp. incase of imposture)

Liver Ultrasound

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Scan Planes:- Upper abdominal transverse scan (to demonstrate the left lobe)

- Right subcostal oblique

- high and extended right intercostal scans.

- paramedian upper abdominal longitudinal scans.

Sonographic Anatomy and Normal Findings:

- The liver exhibits a diaphragmatic surface and a visceral surface.

- Both surfaces meet anteroinferiorly at the sharp inferior hepatic border and posterosuperiorly at the fixed part of the diaphragm.

- The liver is divided anatomically into the right and left lobes, the falciform ligament separating the larger right lobe from the smaller left lobe. The quadrate lobe (segment IV) and the caudate lobe (segment I) belong physiologically to the left lobe.

Segmental anatomy of the liver, diaphragmatic surface. A line between the gallbladder and inferior vena cava divides the liver into right (Segment V–VIII) and left physiologic lobes (Segment I–IV)

Segmental anatomy of the liver, visceral surface. Boundaries of the caudate lobe: upper hepatic border, falciform ligament, portal vein, and vena cava. Boundaries of the

quadrate lobe: lower hepatic border,

falciform ligament, gallbladder,

and portal vein

Scanning Protocol

- Transducer: 2.5–5.0 MHz (depending on the abdominal circumference)

- Right subcostal oblique scan: Ask the patient to take a deep breath and hold it.

- Define the dome of the liver with the diaphragm, hepatic veins, portal venous branches (common hepatic duct), the intrahepatic bile ducts, the gallbladder, and the hepatic parenchyma.

Subcostal oblique scans. Scan through the porta hepatis into the upper part of the liver. PV = right and left branch of the portal vein. V = inferior vena cava, arrow = ligamentum venosum.

Scan directed from the inferior hepatic border (at top of image) to the fixed part (at bottom of image) demonstrates

the quadrate lobe (QL) and caudate lobe (CL) anterior to the vena cava (VC). L = right lobe of liver, PV = portal vein

Schmidt, Ultrasound

Upper abdominal longitudinal scan of the subdiaphragmatic vena cava and the termination of the hepatic veins (arrow). QL = quadrate lobe, PV = portal vein, CL = caudate lobe, VC = inferior vena cava, L = liver

High intercostal scan on the right side demonstrates the costophrenic angle (CA), posterior portions of the diaphragm (DIA) and the entry echo of the lung (L)

Overview of Findings, Classification:

Changes in the liver: Sonographic abnormalities of the liver may consist of diffuse or circumscribed changes in the normal hepatic architecture:

Diffuse changes: These refer to a general alteration of normal liver architecture with regard to size, echogenicity, contours, vasculature, and tubular tracts. Changes in echo texture and contours are particularly significant.

Circumscribed changes:focal alterations in the normal echo texture of the liver. Their detectability depends on the difference in acoustic impedance between the change and normal surrounding liver (anechoic lesions such as cysts are easily recognized). A lesion that is isoechoic to surrounding liver can be distinguished only by the presence of a hypoechoic rim or vascular displacement

Changes in the portal veins: Abnormalities of the portal vein and its tributaries may produce changes identical to those found in the systemic veins.

Diffuse changes in hepatic echogenicity or contours

Circumscribed hepatic changes

1) Fatty Liver

Slight coarsening of the parenchymal echo pattern, increased echogenicity, distal acoustic shadowing, and organ enlargement

2) Chronic Hepatitis

Very slight coarsening of the parenchymal echo pattern and

increased sonodensity with faint acoustic shadowing.

Right subcostal scan

Congestive cirrhosis

Congestive cirrhosis. The liver still has a near normal parenchymal

Echo pattern, but note the curved, bulging inferior border and the tiny

breaks in the capsule (arrows). A = ascites

Very Pronounced changes in echogenicity and contour

1) Sarcoidosis

Sarcoidosis of the liver: coarse parenchymal echo pattern, nonvisualization of

the vessels, and multiple small hypoechoic foci (arrows)

2) Micronodular abscesses or metastases

Micronodular infiltrates in the liver

Anechoic Changes

1) Liver cysts

Solitary Cyst in Liver

Septated Cysts in Liver

Cystic Echinococcosis

Hypoechoic Changes on Liver Ultrasound

1) Focal Sparing in Fatty Infiltration of Liver

Hypoechoic quadrate lobe (segment IV, arrows) adjacent to the gallbladder (GB) in an otherwise fatty liver

2) Regenerative Nodules

Regenerative nodule in severe alcoholic toxic cirrhosis (arrow), confirmed cytologically

3) Hemorrhagic Liver Cyst

4) Liver abscess

Hypoechoic, sharply circumscribed mass with a faintly Echogenic wall

Hyperechoic pyogenic membrane is often present

5) Adenoma

Isoechoic tumor with focal anechoic necrosis / hemorrhage.

Isoechoic Changes in Liver

1) Liver Metastases

The lesions are demarcated from normal liver tissue only by a hypoechoic rim (this accounts for a certain percentage of sonographically occult metastases that are detectable by other modalities).

Echogenic and Hyperechoic Changes

Hemangioma (H) of the liver (L): typical Echogenic, round to oval mass with smooth margins.

Metastasis from colon carcinoma: echogenic round mass with a less echogenic center.

Calcifying metastasis from colorectal carcinoma

Changes in the Portal Venous System

1)Changes in Portal Vein Lumen – Dilatation.

Commonest finding of Portal Hypertension.

But the diagnosis also relies on CDS(colour doppler) and flow patterns across the portal vein lumen

Common causes of Portal Hypertension are:Pre Hepatic – Portal Vein Thrombosis

Intra Hepatic – Cirrhosis

Post Hepatic – Budd Chiari Syndrome

Increased portal vein diameter, indirect signs:- > 11mm intrahepatic, > 13–15mm in the hepatoduodenal ligament

- Caliber variations I 2mm or 50–100 % with respirations

- Detection of hepatic cirrhosis

- Splenomegaly

- Possible ascites

- Wall thickening of the gallbladder and stomach

Incipient portal hypertension. The portal vein (PV) is marginally dilated: 12.9mm intrahepatic

2) Flow Changes and Collaterals:

- Associated with increased portal hypertension.

- Detected on CDS of portal vessels.

Flow velocity is slowed to < 10 cm/s (normal = 15–20 cm/s)

Luminal diameter > 15 mm, does not vary with respirations

Bidirectional, absent or reverse flow in the portal vein or its tributaries

Portal hypertension in liver cirrhosis. CDS: decreased flow velocity

with absence of flow in the portal vein. Flow is in the normal direction (encoded in red), but its velocity is slowed to 9 cm/s. Absence of flow in the portal vein (PV). Additional sign: large-caliber hepatic artery (A), arterial waveform

3) Intraluminal Changes

1)Acute portal or mesenteric vein thrombosis:

- Patient presents with clinical picture of Acute abdomen.

Echogenic filling defect

Vascular dilatation

Absence of color Doppler flow signals

Acute portal vein thrombosis. Mass in the portal vein (VP) is iso echoic to liver tissue (arrows). CDS shows no evidence of flow

2) Chronic Portal Vein Thrombosis

Chronic portal vein thrombosis (PVT) in the setting of a paraneoplastic syndrome. Hepatic metastases: very little increase in luminal diameter, intraluminal echoes in thrombosed portal vein segments. Intrahepatic portal vein is clear

Ultrasound of Gallbladder

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Ultrasonic anatomy Located inferior to rt. Lobe of liver

Long axis 6-12 cm , short axis 3-5 cm (4*10cm usually at fasting )

Contracted < 5 cm

Distended > 12 cm when the patient is fasting

Max normal diameter of CBD=4 to 7 mm

Wall Thickness:

Measured in the side in contact with the liver.usually < 3 mm.

From 3-5 mm >>> suspect thick wall

More than 5 mm >>> It is a thick wall gall bladder which is seen in:

Cholecystitis (acute-chronic).

Hepatitis ( viral).

Common Bile Duct is anterior to portal vein.this is the position of porta hapatis

Imaging technique

-overnight fast(6-12hr) to distent GB and remove gas shadow

Short focal length transducer is better as GB is anteriorly located organ.

Supine ,LPO position for imaging

Ganarally dilated bile duct seen in longitudional scan.portal vein ant. To IVC

Contents

Stones:

seen inside, mobile except at the neck they appear white with posterior shadow.

Thick bile.

Called sludge.Change with changing position. The picture occurs in the presence of thick bile in patients on IV fluids for 3-4 days and in inflammation.

Parasite:

Fasciola appears pearl shape.

Move as a whole.

Cancer & polyps:

Polypoidal or heterogeneous mass.

Pathologies

CHOLELITHIASIS-gall stone have high reflictive echo with prominent acoustic posterior shadow

Gravity dependent movement confirms diagnosis

Wall thickening as a hypoechoeic region b/n two echoeic lines,suggest chr.cholecystitis,alcoholism.

Sludge

No acoustic shadow

Low to mild level echoes

Moves very sluggishly

Acute cholecystitis

Associated with cholelithiasis in most cases

Gall stone with focal GB tenderness,usg MURPHY s sign

Pericholecystic edema

Wall edema or wall hypoechoeic

Sometime stone may not be present ,called acalculus cholecystitis eg.burns,old age,after major trauma,and fasting patient

Intrahepatic bile duct

If bile duct are >2mm dia

Second ultrasonic feature of bile duct dilatation is irregularity of bile duct dilatation

Extrahapatic bile duct

Normally 4mm at age 40,5mm at 50

Common site at head of pancrease when double duct sign may be seen

Cbd seen by parasagittal scan

Other facts

Fluid filled colon may appear like GB,wait and watch peristalsis.

In bed ridden ,numerous mass,sludge is not pathological

Polyps donot produce posterior shadow

In obese,difficult to see GB from subcostal approach

Male Reproductive System (histology)

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The seminiferous tubules are lined with a complex stratified epithelium called germinal or seminiferous epithelium. Their outer wall is surrounded by a well-defined basal lamina and a fibrous connective tissue consisting of several layers of fibroblasts The innermost layer, adhering to the basal lamina, consists of flattened myoid cells which have characteristics of smooth muscle. Interstitial (Leydig) cells occupy much of the space between the seminiferous tubules .

SPERMATOGENESIS

Spermatogenesis is the process by which spermatozoids are formed. It begins with a primitive germ cell, the spermatogonium (Gr. sperma + gone, generation), which is a relatively small cell, about 12 m in diameter, situated next to the basal lamina of the epithelium. At sexual maturity, spermatogonia begin dividing by mitosis, producing successive generations of cells.

The newly formed cells can follow one of two paths: they can continue dividing as stem cells, also called type A spermatogonia, or they can differentiate during progressive mitotic cycles to become type B spermatogonia Type B spermatogonia are progenitor cells that will differentiate into primary spermatocytes. The primary spermatocyte has 46 (44 + XY) chromosomes and 4N of DNA.

From this first meiotic division arise smaller cells called secondary spermatocytes with only 23 chromosomes (22 + X or 22 + Y). This decrease in number (from 46 to 23) is accompanied by a reduction in the amount of DNA per cell (from 4N to 2N). Secondary spermatocytes are difficult to observe in sections of the testis because they are short-lived cells that remain in interphase very briefly and quickly enter into the second meiotic division.

Division of each secondary spermatocyte results in two cells that contain 23 chromosomes, the spermatids. Because no S phase (DNA synthesis) occurs between the first and second meiotic divisions of the spermatocytes, the amount of DNA per cell in this second division is reduced by half, forming haploid (1N) cells. The meiotic process therefore results in the formation of cells with a haploid number of chromosomes. With fertilization, the normal diploid number is again attained.

SPERMIOGENESIS

The Golgi Phase

The cytoplasm of spermatids contains a prominent Golgi complex near the nucleus, mitochondria, a pair of centrioles, free ribosomes, and tubules of smooth endoplasmic reticulum .Small periodic acid chiff (PAS)-positive granules called proacrosomal granules accumulate in the Golgi complex. They subsequently coalesce to form a single acrosomal granule within a membrane-limited acrosomal vesicle .The centrioles migrate to a position near the cell surface and opposite the forming acrosome. The flagellar axoneme begins to form, and the centrioles migrate back toward the nucleus, spinning out the axonemal components as they move.

The Acrosomal Phase

The acrosomal vesicle spreads to cover the anterior half of the condensing nucleus and is then known as the acrosome .The acrosome contains several hydrolytic enzymes, such as hyaluronidase, neuraminidase, acid phosphatase, and a protease that has trypsin-like activity. The acrosome thus serves as a specialized type of lysosome. These enzymes are known to dissociate cells of the corona radiata and to digest the zona pellucida, structures that surround the oocytes. When spermatozoa encounter an oocyte, the outer membrane of the acrosome fuses with the plasma membrane of a spermatozoon at several sites, liberating the acrosomal enzymes to the extracellular space. This process, the acrosomal reaction, is one of the first steps in fertilization.

THE MATURATION PHASE

Residual cytoplasm is shed and phagocytosed by Sertoli cells, and the spermatozoa are released into the lumen of the tubule.

Sertoli Cells

The Sertoli cells are important for the function of the testes. These cells are elongated pyramidal cells that partially envelop cells of the spermatogenic lineage. Sertoli cells have several functions:

1:Support, protection, and nutritional regulation of the developing spermatozoa,

2:Phagocytosis.

3:Secretion. Production of the anti-mullerian hormone. Anti- mullerian hormone (AMH, also called mullerian-inhibiting hormone),

4:The blood testis barrier.

5:Production of inhibin B, Inhibin B inhibits the production of FSH by the hypophysis.

INTERSTITIAL, or LEYDIG, CELLS

The connective tissue consists of various cell types, including fibroblasts, undifferentiated connective cells, mast cells, and macrophages. During puberty, an additional cell type becomes apparent; it is either rounded or polygonal in shape and has a central nucleus and an eosinophilic cytoplasm rich in small lipid droplets .These are the interstitial, or Leydig, cells of the testis, and they have the characteristics of steroid-secreting cells.

Electron micrograph of a section of an interstitial cell

The highly coiled ductus epididymidis, sectioned several times. Its wall is made of a pseudostratified columnar epithelium surrounded by connective tissue and smooth muscle. PSH stain. Medium magnification. Inset: Higher magnification of the epithelial cells with their long microvilli (stereocilia).

Abdominal USG

2011-08-09T16:28:00.000-07:00

Upper Abdominal Transverse Scan:

The upper abdominal transverse scan displays the following

structures from anterior to posterior:

liver (L), splenic vein (SV), pancreas (P), aorta (AO)

Right Subcostal Oblique Scan:

The probe is placed below the right costal arch and angled laterally upward. The beam is directed posterolaterally and superiorly.

The beam passes through the liver (L) and gives a longitudinal view of the hepatic veins, which open posteriorly into the vena cava. RHV = right hepatic vein, MHV = middle hepatic vein, LHV = left hepatic vein

Right Intercostal Scan:

The intercostal scan is placed on an imaginary line between the right

shoulder and the umbilicus. From this point the beam can be swept across the liver (L) in a fan-shaped pattern. The kidney (K) is posterior

Extended Right Intercostal Scan:

The probe can be slightly angled and rotated to demonstrate the bile duct (BD), vena cava (Vc), and portal vein (Vp) in approximate longitudinal sections. These structures are easier to define in left lateral decubitus at full inspiration

Right longitudinal Paramedian Scan:

The probe is oriented longitudinally and is placed lateral to the midline

in an intercostal space or below the costal arch. The liver (L) is displayed in

longitudinal section, and the shape of the (normally acute) inferior hepatic angle can be evaluated. The fundus of the gallbladder (Gb) projects past the inferior border of the liver. The vena cava (Vc) is displayed in longitudinal section and is posterior to the liver. Vena cava filling can be evaluated in this plane

Right Flank Scan:

The flank scan is done by moving the probe laterally from the paramedian

position. It is used to evaluate the pleural angle distal to the diaphragm (D)

and displays a longitudinal section of the kidney (K) posterior to the liver (L)

Right midabdominal transverse scan:

The kidney (K) is displayed in cross-section posterior to the liver (L). The vascular pedicle with the renal vein (Vr) and renal artery (Ar) can be identified from anterior to posterior at the level of the renal hilum. In thin patients, one section may display the termination of the renal vein at the vena cava (Vc), the origin of the renal artery from the aorta (Ao), and the gallbladder (Gb) at the inferior border of the liver.

High lateral intercostal scan (high left flank scan):

The probe is placed in an intercostal space cranial to the left flank to demonstrate the spleen (S) in longitudinal section. The upper pole of the spleen appears on the left side of the image. The probe is rotated, slid, and angled until the longest diameter is visualized. The length of the spleen and its thickness at the level of the splenic hilum are measured

Left flank scan:

As the probe is moved caudal from the high flank scan, the kidney (K) appears in longitudinal section posterior to the spleen (S). The orientation of the kidney, its posteriorly placed upper pole, and its anteriorly directed lower pole can be clearly identified.

Left midabdominal transverse scan:

While still over the kidney, the probe is rotated to a transverse position

and is angled, rotated, and slid to a midabdominal transverse scan that displays the renal hilum with its vascular pedicle and may define the proximal ureter. The probe is then moved slowly down the kidney (K) from its upper to lower pole to survey the organ in transverse sections. Vr = renal vein

Left Subcostal Oblique Scan:

From the midabdominal transverse scan, the probe is slid to a position

below the left costal arch to obtain a left subcostal oblique scan. The liver (L) is visible on the left side of the image. The spleen (S) appears posterolaterally on the right side of the image, displaying its true width and a foreshortened longitudinal diameter

Upper Abdominal Longitudinal Scan:

The following structures can be identified from anterior to posterior:

liver (L), pancreas (P), superior mesenteric vein (Vms), celiac trunk

(Tc), and superior mesenteric artery (Ams), the latter two arising from the aorta (AO). The spinal column (Sc) is visible

Lower abdominal transverse scan:

The following structures are defined from anterior to posterior: abdominal

wall, bladder (B), and uterus (U), which is flanked by the fallopian tubes (T)

Lower abdominal longitudinal scan:

From anterior to posterior: abdominal wall, bladder (B), and uterus

(U), which is bounded by the fundus above and the vagina (V) below