Textbook of Forensic Medicine and Toxicology

612 Pages·2014·7.5 MB·English

by  Krishan Vij

Textbook of

Forensic Medicine
and Toxicology

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Textbook of

Forensic Medicine
Forensic Medicine

and Toxicology
and Toxicology

Principles and Practice

Fifth Edition

Krishan Vij MD LLB
Head
Department of Forensic Medicine and Toxicology
Adesh Institute of Medical Sciences & Research, Bathinda, Punjab

Former Professor and Head
Department of Forensic Medicine and Toxicology
Government Medical College and Hospital, Chandigarh

Counsellor
Torture Medicine

ELSEVIER
A division of
Reed Elsevier India Private Limited

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Textbook of Forensic Medicine and Toxicology, 5/e
Krishan Vij

ELSEVIER
A division of
Reed Elsevier India Private Limited

Mosby, Saunders, Churchill Livingstone, Butterworth-Heinemann and
Hanley & Belfus are the Health Science imprints of Elsevier.

© 2011 Elsevier

First Edition 2001
Second Edition 2002
Third Edition 2005
Fourth Edition 2008
Fifth Edition 2011

All rights are reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the
prior permission of the publisher.

ISBN: 978-81-312-2684-1

Medical knowledge is constantly changing. As new information becomes available, changes in treatment, procedures,
equipment and the use of drugs become necessary. The authors, editors, contributors and the publisher have, as far as
it is possible, taken care to ensure that the information given in this text is accurate and up-to-date. However, readers are
strongly advised to confirm that the information, especially with regard to drug dose/usage, complies with current
legislation and standards of practice.

Published by Elsevier, a division of Reed Elsevier India Private Limited.

Registered Office: 622, Indraprakash Building, 21 Barakhamba Road, New Delhi-110 001.
Corporate Office: 14th Floor, Building No. 10B, DLF Cyber City, Phase-II, Gurgaon-122 002, Haryana, India.

Managing Editor (Development): Shabina Nasim
Development Editor: Shravan Kumar
Manager – Publishing Operations: Sunil Kumar
Manager – Production: NC Pant

Typeset by Olympus Infotech Pvt. Ltd., Chennai, India.

Printed and bound at xxx, India.

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To
the memory of my daughter
Divya Vij

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Foreword

In the present civilised society, every crime ought to be punished and a criminal must be taken to task. Investigators and those who
are engaged in the dispensation of justice require aid of an expert, who, by experience and knowledge, has acquired scientific tem-
perament and skill to unearth the crime. At the same time, with the aid of a forensic expert, an innocent can be saved from the
gallows. Dr. Krishan Vij, in this edition, has put a great effort to notice transformation of medical jurisprudence to clinical foren-
sic medicine. The present edition of Textbook of Forensic Medicine and Toxicology will be of great help not only to the under-graduate
and postgraduate students but to all those who are engaged in investigation of the crime and administration of justice, be it lawyers
or judges, and victims of violence and negligence.
The 5th edition of Textbook of Forensic Medicine and Toxicology by Dr. Vij has summoned the resources of science from all quarters.
Division of contents into segments, viz., (i) Of the Basics, (ii) Of the Dying and the Death, (iii) Of the Injured and the Injuries,
(iv) Clinical Forensic Medicine, (v) Legal and Ethical Aspects of Medical Practice, (vi) Forensic Toxicology, and placement of
illustrations, tables, flowcharts, etc. speak volumes of his experience and expertise spreading over about three decades. Chapters
on brain-stem death vis-à-vis organ donation; sudden and unexpected deaths; custody related torture and/or death; deaths associ-
ated with surgery, anaesthesia and blood transfusion; medicolegal examination of the living; complications of trauma (was wound-
ing responsible for death?); medical negligence; informed consent and refusal; and medicolegal aspects of immuno-deficiency
syndrome deserve extreme applause.
Exceptional features of this ensuing edition have been the presentation of cases clinching to the text and updation of information
in every segment. I am sure that the edition would serve as a guiding light for all concerned.
I wish Dr. Vij all success in his endeavour.

Kanwaljit Singh Ahluwalia

Judge

Punjab & Haryana High Court

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Preface to the 5th Edition

The rapid exhaustion of the last four editions reflects volumes of wide acceptance and popularity of the book, encouraging me to
bring about the 5th edition. The current edition reflects the meticulous work that has been done to revamp its predecessor. Based
on the feedback received from students, teachers, advocates and the judiciary, both Sections of the book (Forensic Medicine and
Forensic Toxicology) have been extensively revised with consequent deletion of outdated information and incorporation of the
new. Extensive placement of photographs, illustrations, tables and flowcharts has made this edition extremely catchy and easy
to grasp. Appearance of enormous references in the flow of the text is the result of extensive study and the period of toil and
turbulence through which I had to creep in. The integral thread of evidence-based description is seen running through the entire
content. Placement of precise information about the relevant legal provisions and forensic aspects of anatomical structures/findings
at appropriate places promote interdisciplinary understanding of issues.
Cases of extreme medicolegal significance, commensurating with the flow of the text, have been introduced to illustrate medi-
colegal principles and explore solutions to tackle problems usually encountered in day-to-day medicolegal work. And therefore,
the ensuing edition will be of immense help not only to undergraduates and postgraduates (the 'would be' medical practitioners/
experts), but also to wide segments of other professionals engaged in the administration of justice; be it prosecutors, defense
counsels, and of course, the judiciary.
User friendliness of the book is depicted in its lucid style, rational use of various levels of headings, subheadings and boldface
words. Presentation of ‘cases’ is an exceptionally interesting feature of the book helping the user to have an in-depth approach to
the intricacies of medicolegal issues.
Author’s view has always been that the modern time student should not be deprived of the fruits of recent information; therefore,
topics like Sudden and Unexpected Deaths; Deaths due to Asphyxia; Deaths Associated with Surgery, Anaesthesia and Blood
Transfusion; Custody Related Torture and/or Death; Medicolegal Examination of the Living; Injuries by Firearms; Complications
of Trauma: Was Wounding Responsible for Death?; Medical Education via-à-vis Medical Practice; Medical Negligence; Consent
to and Refusal of Treatment, etc., have been thoroughly up-dated with placement of ‘cases’ clinching to the text.
In their effort to add to the learning experience, the publisher, Elsevier, has made use of this book’s companion website
http://www.manthan.info/Vij/web-home.aspx easy for all students. Now any student can use features like Interactive Assessment,
Downloadable Images and Updates by simply logging in into the Website and creating an ID for self.
In essence, the 5th edition has been nurtured with most recent information, which will serve as an excellent resource for the
undergraduates as well as postgraduate students. Teachers will find it as a guiding light. A wide segment of other professionals
like practitioners (medical as well as legal), investigative agencies, and above all, the judicial officers will also be benefited with
far-reaching content of this edition.

Krishan Vij

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Acknowledgements

Revision of any book is a gigantic task. The revision of the fourth edition would have not been possible without uninterrupted
encouragement from well-wishers in general and my colleagues in particular. The acutely updated and illustrated fifth edition has
been made possible through rigorous and continued efforts. I am grateful to my friends and colleagues who obliged me through
healthy discussions. While it is not possible to list them all, I record my indebtedness to:
Dr. BBL Aggarwal, Ex-Principal, University College of Medical Sciences and Head of the Department of Forensic Medicine,
New Delhi; for whom my vocabulary fails to locate adequate words of appreciation. An excellent teacher, guide and philosopher,
he has been a source of inspiration and encouragement to me in all walks of my life.
Dr. Gurpreet Inder Singh, Director Principal, AIMS&R, Bathinda (Punjab) and Dean Colleges, Baba Farid University of Health
Sciences, who commands exceptional mention for his constructive and leadership qualities. Hailing from the Army Background,
he has effectively been able to transmit a message of True Army Spirit at the institute as he performs and expects everything in
a scheduled and meticulous manner.
Dr. TD Dogra and Dr. GK Sharma, Head of the Department of Forensic Medicine, All India Institute of Medical Sciences,
and Director Principal, Lady Hardinge Medical College, New Delhi, respectively, distinct and magnanimous personalities in the
field of Forensic Medicine, deserve exclusive appreciation.
Earnest feeling of gratitude are expressed to the authors/writers of various books/journals/articles whose references have
been cited in the text. Dr. JS Dalal, Dr. J Gargi, Dr. RK Gorea, Dr. Dalbir Singh, Dr. AS Thind and Dr. Jagjiv Sharma deserve
thanks for their constructive inputs. Dr. KK Aggarwal, Dr. SS Oberoi, and Dr. DS Bhuller invite appreciation for their interaction.
Dr. Vijay Vij, my brother-in-law, who was instrumental in making me visit various libraries and book centres during my visit to
the United States of America, deserves special appreciation. I was truly amazed by his profound interest in gaining more and more
knowledge and, in fact, I happened to collect rich material from his personal library.
Dr. Parmod Goyal and Dr. Vishal Garg, my colleagues at the Institute, deserve extreme applause for their inputs and
cooperation.
I must confess that I have been highly demanding on quality and accuracy from all staff members of Elsevier, a division of
Reed Elsevier India Pvt. Ltd, sometimes rather impatiently, but all of them have been quite accommodating. In particular, I would
like to pen down my appreciation for Mr. Shravan Kumar, Development Editor, for his pleasant-pitched interaction with an eye
on the market placement.
The users of previous editions are gratefully acknowledged for having brought the textbook at this pedestal. In the past, I have
been benefited from suggestions by colleagues, students, advocates and the judiciary, and I urge them to continue to give their
valuable suggestions.
Before I conclude, I must acknowledge with profound gratitude, the encouragement and inspiration extended to me by wife,
Anu, and my daughter, Divya (during the Herculean exercise of the maiden edition). My wife has been socially bearing the pangs
of loneliness owing to my remaining obsessively occupied. Her contribution, albeit silent, is far-reaching.

Krishan Vij

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Contents

Section 1 Forensic Medicine

PART I
Of the Basics

Chapter 1
Introduction to Forensic Medicine and Indian Legal System

3

Ancient traditional writings describing considerations for regulating human behaviour and providing punishments,
medical ethics, and medical practice for purposes of law | Explanation for the terms forensic, medicine, medical
jurisprudence, legal medicine, forensic pathology, etc. | Police inquest | Magistrate’s inquest | Various Courts in
India | Documentary and oral evidence | Exceptions to oral evidence | Procedure of recording evidence | Dying
declaration and its importance | Kinds of witnesses | Doctor in the witness box

Chapter 2
Medicolegal Autopsy, Exhumation, Obscure Autopsy, Anaphylactic Deaths and Artefacts
17

Clinical and medicolegal autopsy | Precautions for medicolegal autopsy | Objectives of medicolegal autopsy |
Importance of examining clothing | Incisions for the autopsy | Procedure for external and internal exami nation |
Selection, preservation and dispatch of viscera/specimens | Exhumation | Obscure autopsy | Anaphylactic deaths
| Artefacts

Chapter 3
Identification
35

Complete and incomplete identity | Corpus delicti | Identification in the living | Identification in the dead |
Primary and secondary characteristics | Comparative techniques | Importance of dentition in the medicolegal field
| Age from ‘ossification activity’ of bones | Symphyseal surface in estimating age | Skull sutures in estimating age
| Medicolegal importance of age | Morphological and skeletal changes in determining sex | Intersex states |
Stature from the bones | Medicolegal information from hair, scar, tattoo mark(s), etc. | Skeletal indices for
determining sex and race | Dactylography | Medicolegal information from blood/blood stain | Medicolegal
application of blood groups | Mass disaster | Collection, preservation and dispatch of samples for DNA testing |
OJ Simpson case

PART II
Of the Dying and the Death

Chapter 4
Death and Its Medicolegal Aspects (Forensic Thanatology)
74

Death | Presumption of death and survivorship | Somatic and molecular death | Brain death with its medicolegal
aspects, especially in relation to organ transplantation | Suspended animation | Mode, manner, mechanism and
cause of death | Estimation of ‘time since death’ from the immediate, early and late changes after death, and
factors influencing such changes | Medicolegal aspects of immediate, early and late changes after death |
Differentiation between postmortem staining and bruising, hypostasis and congestion, rigor mortis and cadaveric
spasm, rigor mortis and conditions simulating rigor mortis, etc. | Postmortem damage by predators | Entomology
of the cadaver and postmortem interval

Chapter 5
Sudden and Unexpected Death
100

Concept of ‘sudden’ and ‘unexpected’ death | Morbid anatomy of heart and its blood supply | Types of occlusion
| Sequelae of coronary occlusion | Approaching the cause of death | Postmortem demonstration of myocardial
infarction | Hypertensive heart disease and sudden death | Epilepsy as a cause of unexpected death | Pulmonary
embolism | Vagal inhibition and sudden death | Sudden death in infancy

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Chapter 6
Asphyxial Deaths
110

Asphyxia and its types | Asphyxial stigmata | Suffocation and its types | Medicolegal aspects of carbon monoxide
and carbon dioxide | Medicolegal aspects of smothering, gagging, choking, traumatic asphyxia, burking, etc. |
Mechanism of death by compression of the neck | Types, cause of death, autopsy findings and the circumstances
of hanging | Types, cause of death, autopsy findings and circumstances of strangulation | Mugging, garroting,
bansdola, palmar strangulation, etc. | Types, mechanism of death, cause of death, pathophysiology, and diagnosis of
death in drowning | Floatation of body in water | Circumstances of drowning

Chapter 7
Infanticide and Foeticide
146

Infanticide and the related law | Primary and secondary issues to be resolved in relation to infanticide | Age of
viability and its medicolegal significance | Concept of live birth and separate existence | Proof of live birth |
Hydrostatic test and its importance | Other tests for separate existence | Probable duration of life of the child |
Autopsy | Cause of death, i.e. acts of commission and acts of omission | Foeticide | Abandoning of children and
concealment of birth | Development of foetus

Chapter 8
Thermal Deaths
159

Heat regulation, systemic hyperthermia (heat cramps, heat exhaustion and heat stroke) | Character of burns produced
by various agents | Different classification of burns | Rule of nine | Causes of death in burn | Nature of burn
injury in the absence of death | Age of burn injury | Autopsy findings | Medicolegal aspects of death due to burns
| Antemortem and postmortem differentiation of burns | Some legal provisions in relation to dowry death |
Scalds and their medicolegal aspects | Differentiation of injuries due to dry heat, moist heat and chemicals |
Pathophysiology of hypothermia | Circumstances of injury due to cold | Autopsy findings in death due to cold

Chapter 9
Starvation and Neglect
173

Starvation and its types | Autopsy findings | Circumstances of death | Malnutrition

Chapter 10
Death by Electrocution
175

Types of fatal electrocution | Factors influencing effects of electricity | Mechanism of death | Autopsy findings
in ‘medium-tension’ and ‘high-tension’ currents | Joule burn (endogenous burn) | Circumstances of electrocution
| Iatrogenic electrocution | Judicial electrocution | Lightning and mechanism of injury by it | Circumstances of
lightning

Chapter 11
Deaths Associated with Surgery, Anaesthesia and Blood Transfusion
183

Surgical intervention | Respiratory embarrassment | Cardiac embarrassment | Regional and spinal anaesthesia |
Instruments and instrumentation | Unforeseeable problems | Precautions for autopsy | The autopsy | Medicolegal
considerations | Blood transfusion—hazards and risks | Periprocedural complications, etc.

Chapter 12
Custody Related Torture and/or Death
191

Meaning of custody and torture | Methods of torture | Circumstances of death | Related cases | Role of autopsy
surgeon | Incisions at autopsy

PART III
Of the Injured and the Injuries

Chapter 13
Injuries: Medicolegal Considerations and Types
197

Wound, trauma, injury, etc. | Mechanism of production of mechanical injuries | Differentiation between
antemortem and postmortem wounds | Wound healing | Important Sections of IPC relating to offences against
the human body | Simple, grievous and dangerous injuries | Classification of injuries

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Contents

Chapter 14
Injuries by Blunt Force
213

Forensic aspects of the anatomy of skin | Abrasion and its types | Patterned abrasions | Fate of an abrasion |
Differentiation between antemortem and postmortem abrasions | Medicolegal aspects of abrasions | Bruise
(contusion) and factors influencing its production | Migratory/ectopic bruising | Fate of a bruise | Patterned
bruising | Differentiation between antemortem and postmortem bruising | Medicolegal aspects of bruising |
Lacerations and its types | Incise-looking wounds | Features of lacerations | Differentiation between antemortem
and postmortem lacerations | Medicolegal aspects of laceration

Chapter 15
Injuries by Sharp Force
225

Incision/cut/slash, etc. | Features of incised wounds | Bevelled cuts | Hesitation cuts | Chopping wounds |
Types and features of stab wounds | Factors influencing size, shape and configuration of stab wounds | Injuries
by blunt penetrating/dull instruments | Wounds by glass | Pointers towards suicide/accident/homicide

Chapter 16
Injuries by Firearms
234

Types of firearms | Types of ammunition | Parts of cartridge and their functions | Mechanism of bullet wound
production | Characters of wounds produced by rifled and smoothbore firearms | Exit wounds by rifled and
smoothbore weapons | Direction of fire | Unusual circumstances in firearm injuries | Various tests for firearm
residues | Autopsy in firearm fatalities | Suicide, accident or homicide

Chapter 17
Injuries by Explosives
266

Mechanism of production of injuries by bomb blast | Autopsy in explosion fatalities | Medicolegal considerations
in explosion injuries

Chapter 18
Regional Injuries
270

Injuries of the scalp including forensic aspects of anatomy of the scalp | Fractures of the skull including forensic
aspects of anatomy of the skull | Mechanism of production of skull fractures | Meningeal haemorrhages with
their medicolegal aspects | Mechanism of production of cerebral injuries | Medicolegal aspects of coup and
contrecoup injuries | Concussion | Head injuries in boxers | Spinal injuries with their medicolegal aspects | Facial,
cervical, thoracic and abdominal trauma

Chapter 19
Transportation Injuries
296

Mechanism of vehicular injury | Pattern of injuries to the driver, front-seat occupants and rear-seat occupants of
a motor car | Pattern of injuries to the pedestrians, motor cyclists and pedal cyclists, etc. | Aircraft accidents,
railway accidents and vehicular conflagration | Medicolegal aspects of transportation injuries

PART IV
Clinical Forensic Medicine

Chapter 20
Medicolegal Examination of the Living
304

Clinical forensic medicine | Medicolegal examination of the victim of assault and extending opinion | Classification of
sexual offences | Meaning and scope of the offence of ‘rape’ with particular emphasis on implications of consent/
nonconsent | Medicolegal examination of the victim and of the alleged accused of rape and extending opinion in either
case | Medicolegal examination in ‘unnatural sexual offences’ and extending opinion | Medicolegal aspects of ‘semen’
| Acid phosphatase test and its medicolegal importance | Medicolegal importance of pregnancy | Presumptive,
probable and positive signs of pregnancy | Differential diagnosis of pregnancy | Surrogate motherhood | Child abuse

Chapter 21
Complications of Trauma: Was Wounding Responsible for Death?
335

Immediate causes of death—primary or neurogenic shock; injury to vital organ(s); haemorrhage; air embolism |
Delayed causes of death—secondary shock; wound infection; pulmonary thromboembolism; fat and bone marrow

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embolism; crush syndrome; exacerbation of pre-existing disease | Trauma and operation/anaesthesia | Weapon
and its implications

PART V
Legal and Ethical Aspects of Medical Practice

Chapter 22
Medical Education vis-à-vis Medical Practice
346

Ethics and moral in relation to medical practice | Various ‘codes’ of medical ethics | Constitution and powers of
the Indian Medical Council | Constitution and powers of the State Medical Council | Code of ethics by Medical
Council of India | Duties of doctors towards patients and towards each other | Duties of doctors towards the state
| Professional secrecy and privileged communication | Professional misconduct/infamous conduct/malpractice |
Difference between unethical conduct and misconduct | Red Cross emblem policy

Chapter 23
Medical Negligence
361

Negligence and its various components | Medical negligence—differentiation from negligence in other fields |
Mistaken diagnosis/errors of clinical judgement whether amount to negligence | Defensive medicine | Proof of
negligence with particular emphasis on the doctrine of ‘res ipsa loquitur’ | Contributory negligence | Vicarious
liability | Medical product liability | Criminalisation of negligence | Failure to take X-ray—whether amounts to
negligence | Consumer Protection Act and medical negligence

Chapter 24
Consent to and Refusal of Treatment
370

Types of consent | Scope of consent | Doctrine of informed consent and its components | Hospital’s role | Ability
to consent | Exceptions to material disclosure | Evidentiary proof of adequate disclosure | Decision-making for
the patient without capacity | Sections 53, 53A and 164A CrPC in relation to consent | Doctor-assisted suicide and
euthanasia

Chapter 25
Acquired Immunodeficiency Syndrome: Medical, Social, Ethical and Legal Implications
376

Healthcare worker(s) with HIV infection | Criminalisation of HIV transmission | AIDS and autopsies | Universal
blood and body fluid precautions

Chapter 26
Abortion and Delivery
380

Abortion and its classification | Grounds for justifiable abortion | Rules of the MTP Act | Methods of inducing
abortion under the MTP Act | Methods used in criminal abortion | Unskilled, semi-skilled and skilled interference
for inducing abortion | Abortion stick and its hazards | Enema syringe and its hazards | Complications of criminal
abortion | Examination of a woman who has allegedly aborted | Differentiation between nulliparous and parous
uterus | Penal provisions relating to criminal abortion

Chapter 27
Impotence, Sterility, Sterilisation and Artificial Insemination
393

Impotence and sterility | Examination of a case of impotency and sterility and expressing opinion | Causes of
impotence and sterility in the male and female | Medicolegal aspects of sterilisation | Types, procedures, guiding
principles and legal status of artificial insemination | Test tube baby | Concept of ‘wrongful pregnancy’, ‘wrongful
birth’ and ‘wrongful life’ cases

Chapter 28
Nullity of Marriage, Divorce and Legitimacy
400

Circumstances for void and voidable marriage | Legitimacy of children of void and voidable marriages | Grounds
for divorce | Alternate relief in divorce proceedings | Medicolegal issues relating to legitimacy | Some important
considerations

Chapter 29
Forensic Psychiatry
405

Forensic psychiatry | Various ‘terms’ in the Mental Health Act | Signs/symptoms of mental disturbance with their
medicolegal importance | Mental retardation | Psychosis and neurosis | Association of cerebral tumours,
pregnancy and epilepsy with psychosis | Personality disorders | Diagnosis of mental illness | True and feigned

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