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FMT Exam Questions & Answers

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1. MECHANICAL ASPHYXIA

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• (a) Impedes access of air to the lungs, or
• (b) Reduces blood supply to the head and neck, or
• (c) Causes sudden cardiac arrest due to stimulation of the carotid sinus resulting in vagal reflex mechanism.

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1. Cyanosis - Blue/purple discolouration; requires at least 5 gm% reduced haemoglobin to become evident. Cutaneous cyanosis depends on absolute amount of reduced haemoglobin, not oxy-haemoglobin. After 24 hours, cyanosis may be entirely due to postmortem changes.
2. Congestion - Visceral congestion due to capillo-venous congestion from hypoxia. Right ventricular dilatation and pulmonary congestion are common but not specific for asphyxia.
3. Petechiae (Tardieu's spots) - Pinpoint haemorrhages, most prominent on visceral pleura and epicardium. Also seen beneath conjunctiva, skin of face and eyelids.
4. Oedema of lungs - Due to increased capillary permeability from hypoxia.
5. Fluidity of blood - Blood remains fluid due to fibrinolysis; does not clot.
6. Engorgement of right side of heart - Right ventricle is dilated; left side is empty.

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• Mode: Judicial, Sexual (autoerotic), Lynching (homicidal)
• Manner: Suicidal, Homicidal, Accidental
• Position of noose: Typical, Atypical
• Position of feet: Complete, Partial (standing/sitting/reclining)

• Ligature strangulation
• Manual strangulation (throttling)
• Mugging, Garroting, Bansdola, Palmer strangulation, Foot strangulation

• Smothering (Overlaying, Burking)
• Gagging, Choking, Cafe Coronary, Traumatic Asphyxia

• Dry drowning, Wet drowning, Secondary drowning, Near drowning

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• Found on visceral pleura, epicardium, conjunctiva, skin of face/eyelids
• Caused by increased venous pressure during asphyxia
• Most prominent in strangulation
• Differential diagnosis: coronary deaths, terminal stage of any asphyxia, diseases (where haemorrhages are more diffuse and numerous)

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• Diatom test: Diatoms (siliceous microalgae) found in lungs, bone marrow, brain confirm ante-mortem drowning (drowning while alive)
• Gettler's test (chloride test): Blood chloride in left heart > right heart in saltwater drowning; left < right in freshwater drowning (now obsolete)
• Freshwater drowning: Water absorbed rapidly into circulation → haemodilution → haemolysis → ventricular fibrillation
• Saltwater drowning: Osmotic effect → pulmonary oedema → haemoconcentration → slower death
• Washerwoman's hands (maceration of skin) indicates body was in water for prolonged time
• Cadaveric spasm (death grip) - hand clutching grass/weeds = ante-mortem drowning

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1. Closing the mouth and nostrils (smothering)
2. Compressing the chest simultaneously

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2. SEXUAL JURISPRUDENCE

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1. Against her will
2. Without her consent
3. With her consent obtained by putting her or any person in fear of death or hurt
4. With her consent when she believes the man is her husband
5. With her consent when she is unsound mind or intoxicated
6. With or without consent when she is under 18 years of age (statutory rape)
7. When she is unable to communicate consent

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• Age estimation
• Signs of struggle: bruises, abrasions on face, wrists, thighs, limbs
• Bite marks
• Mental state, signs of intoxication

• Hymen: Freshness of tears, whether healed or recent, position of tears (usually at 6 o'clock and 3 o'clock)
• Vagina: Lacerations, discharge, semen
• Fourchette: Bruising, laceration

• High vaginal swab for spermatozoa
• Blood group, DNA typing of semen
• Pubic hair combing
• Fingernail scrapings
• Clothing for stains

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• Intact hymen does NOT rule out rape (flexible/elastic hymen, posterior fourchette tears may occur without hymen rupture)
• Torn hymen does NOT prove rape (may be torn by fingers, tampons, accidents, masturbation)
• A freshly torn hymen shows: raw edges, swelling, bleeding
• A healed tear shows smooth edges, granulation tissue formation
• Legal NOTE: The Supreme Court of India (Lillu alias Rajesh vs State of Haryana, 2013) held the two-finger test (virginity test) unconstitutional and violative of dignity.

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• Recent tears of hymen with raw bleeding edges
• Bruising and laceration of posterior fourchette and vaginal walls
• Presence of spermatozoa in vaginal swab (motile up to 6 hours, non-motile up to 72 hours)
• Presence of seminal acid phosphatase
• DNA match of semen with accused

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• Dilatation and laxity of anal sphincter
• Funnelling of anus
• Old scars or fresh lacerations at anal margin
• Spermatozoa in rectal swab
• Loss of cutaneous reflex around anus
• "Rosebud appearance" (chronic case)

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• Bestiality: Sexual intercourse with an animal (Sec. 377 IPC)
• Incest: Sexual intercourse between persons closely related by blood (not a separate offence in IPC, tried under rape or unnatural offence)
• Indecent Assault: Any act of sexual nature (other than intercourse) on a person without consent, including touching, fondling

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3. REGIONAL INJURIES

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• Incised, lacerated, or contused wounds
• "Signature wound" - contusion showing pattern of weapon

• Linear fracture: Most common, radiate from point of impact
• Depressed fracture: Bone pushed inward; indicates localised force
• Pond fracture: In infants/young skulls, indentation without fragmentation
• Ring fracture: Around foramen magnum from forces transmitted up the spine (fall on feet)
• Contre-coup fracture: Fracture opposite to site of impact

• Extradural haematoma (EDH): Between skull and dura; "talk and die" syndrome; usually from middle meningeal artery tear; lucid interval
• Subdural haematoma (SDH): Between dura and arachnoid; from bridging vein tear; may be acute/chronic
• Subarachnoid haemorrhage: Beneath arachnoid
• Intracerebral haemorrhage

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• Larynx fractures: Occur in throttling and direct blows; thyroid cartilage most often fractured
• Hyoid bone fracture: Seen in throttling/manual strangulation; rarely in hanging (judicial); fracture at greater cornua
• Cervical vertebral fracture: Seen in judicial hanging (hangman's fracture - C2 fracture-dislocation), diving injuries, whiplash

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• Rib fractures: Multiple rib fractures → flail chest → paradoxical breathing
• Haemothorax/Pneumothorax: Blood or air in pleural cavity
• Cardiac tamponade: Blood in pericardium compressing heart
• Traumatic asphyxia: Sudden severe compression of chest → raised intrathoracic pressure → venous stasis → petechiae on face and upper body

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• Solid organ rupture: Liver (most common) and spleen (most fragile); may cause massive haemoperitoneum
• Hollow organ perforation: Stomach, intestine; leads to peritonitis
• Seatbelt sign: Bruising across abdomen from seatbelt in road accidents; associated with intestinal injury and lumbar vertebrae fracture
• Concealed abdominal injuries are a common cause of medicolegal controversy in blunt trauma deaths

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4. ABORTIONS

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• Medical definition: Spontaneous or induced expulsion of products of conception before viability (28 weeks)
• Legal definition: Expulsion of products of conception at any period before full term; law makes no distinction between abortion, miscarriage, and premature labor

• Ovum: 7-10 days of gestation
• Embryo: 10 days to end of 9th week
• Fetus: Beyond 9 weeks until birth

1. Natural: (a) Spontaneous (b) Accidental
2. Artificial/Induced:
   • Justifiable (therapeutic)
   • Criminal
3. Clinical types:
   • Threatened, Inevitable, Incomplete, Complete
   • Missed (carneous/blood mole)
   • Septic
   • Habitual/Recurrent (3 consecutive times)

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• Up to 20 weeks: Single registered medical practitioner (RMP) opinion
• 20-24 weeks: Two RMPs opinion; applicable to special categories: survivors of rape, victims of incest, differently-abled women, minors, change in marital status (widowhood/divorce)
• Beyond 24 weeks: Only by Medical Board (for substantial fetal abnormalities)

1. Continuation would involve risk to life/injury to physical or mental health of the pregnant woman
2. Substantial risk that child would be born with serious physical or mental abnormality

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• Quinine in large doses
• Ergot, Castor oil, Pennyroyal
• Misoprostol (used illegally)

• Introduction of slippery elm, bougies, catheters, knitting needles into cervix
• Syringing with hot water/irritants
• Manual dilatation and curettage (D&C) by unqualified persons

• Hot baths
• Physical violence: jumping, heavy lifting, severe exercise

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• Uterus enlarged, cervix dilated
• Products of conception partly expelled or retained
• Signs of instrumentation: lacerations/perforations of uterus, cervix or vagina
• Septicaemia: features of peritonitis, pelvic infection
• Air embolism (if air syringe was used): foam in right ventricle
• Soap solution/phenol burns of vaginal mucosa
• Ruptured uterus

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5. CORROSIVES

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1. Strong Mineral Acids: Sulphuric acid, Hydrochloric acid, Nitric acid
2. Organic Acids: Carbolic acid (Phenol), Oxalic acid, Acetylsalicylic acid
3. Acid-like corrosives: Dimethyl sulphate, Diethyl sulphate, Ozone
4. Alkalis: Sodium hydroxide (NaOH/Caustic soda), Potassium hydroxide (KOH), Sodium carbonate, Ammonia
5. Metallic salts: Sodium chloride, Potassium cyanide, Ferric chloride, Chromates

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1. Only local action; no remote systemic effects
2. In concentrated form: corrosion and destruction of tissue
3. Extracts water from tissues (dehydration)
4. Fixes, destroys, and erodes tissues
5. Converts haemoglobin to haematin
6. Causes coagulation necrosis by precipitation of proteins
7. Oesophageal mucosa is relatively resistant; pyloric region of stomach most susceptible
8. Complications develop 3 weeks to 3 months after ingestion
9. When diluted, acts as an irritant; when well diluted, acts as a stimulant

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1. Intense burning pain in mouth, throat, oesophagus, stomach
2. Dribbling of acid-saliva from angles of mouth causing brownish discolouration
3. Frothy eructation, retching, vomiting (blood-stained with shreds of mucosa)
4. Oral mucosa: softened, excoriated, corrugated, white necrotic membrane turning brownish-black
5. Tongue: swollen, excoriated, may disorganize into shapeless pulpy mass
6. Teeth: dead chalky white, deprived of polish
7. Lips: swollen, brown/black streaks
8. Intense thirst; attempts to drink water provoke vomiting and dehydration
9. Hoarse, husky voice; painful speech
10. Difficult, noisy breathing (inflammatory oedema of fauces)

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• Staining and corrosion of skin, lips, mouth
• Mucosa of mouth, oesophagus, stomach: dirty white/brown-black necrosis
• Stomach: hardened, parchment-like, leathery (leather-bottle stomach)
• Pyloric region most affected (coagulation necrosis)
• Peritonitis if perforation occurs
• Lungs: pulmonary oedema from fumes

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1. No stomach wash (risk of perforation); however, Levin tube may be carefully used within 30 minutes
2. Emesis is contraindicated (risk of perforation)
3. Neutralisation:
   • For acids: drink water + calcium oxide/magnesium oxide/aluminium hydroxide; demulcents (vegetable oil, soap solution)
   • For alkalis: dilute with water; lemon juice/dilute acetic acid; demulcents
4. Morphine for pain
5. Treat shock, maintain airway
6. Endoscopy after 24-48 hours to assess damage
7. Long-term: oesophageal dilatation for strictures

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• Sulphuric acid attacks most commonly used for grievous hurt (acid attacks), especially against women
• Offence under Sec. 326A & 326B IPC (specific provisions for acid attacks, introduced in 2013 after the Laxmi case)
• Acid attacks are usually homicidal/for revenge; rarely suicidal or accidental
• Nitric acid poisoning: characteristic yellow stain of xanthoproteic reaction on skin
• Hydrochloric acid: white fumes; silver nitrate test positive for chlorides in stomach contents

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6. HEAT INJURIES

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1. Heat cramps - Painful muscle spasms due to salt and water loss
2. Heat syncope (Heat collapse) - Fainting due to peripheral vasodilation and pooling of blood
3. Heat exhaustion - Profuse sweating, weakness, normal body temperature; due to salt/water depletion
4. Heat hyperpyrexia (Heat stroke) - Complete absence of sweating + body temperature >106°F (41°C); a medical emergency
5. Prickly heat (Miliaria) - Blockage of sweat ducts
6. Chilblains - Cold-related condition (frost injury at mild temperatures)

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• Complete absence of sweating
• Temperature raised to 106°F (41°C) or above
• Can occur at 32°C with 100% humidity
• Features:
  • Hot, dry skin
  • Increased depth of respiration
  • Pulse 160-180/min
  • Severe asthenia (weakness)
  • Cerebral deficit: convulsions, delirium, stupor, coma
• Bad prognosis: Hypotension + increased blood urea + raised serum potassium
• Urine: proteinuria, casts
• Raised serum bilirubin and SGOT (liver and muscle damage)
• First 24 hours are critical; death usually within a week

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1. Similar to cardiac failure findings
2. Visceral haemorrhages and congestion in heart, liver, lungs, kidneys (due to thrombocytopenia, decreased fibrinogen, decreased prothrombin)
3. Haemorrhages from increased capillary fragility (anoxia + circulatory collapse)
4. Survivors >24 hours: lobar pneumonia, acute tubular necrosis, centrilobular necrosis, adrenal necrosis and haemorrhages
5. Heart: subendocardial haemorrhages, muscle fibre changes, dilated chambers
6. Brain: congested and oedematous; convolutions flattened; patches in walls of 3rd ventricle and floor of 4th ventricle
7. Cerebellum: oedema of Purkinje layer, swelling and degeneration of Purkinje cells
8. Long-term survivors: rarefaction of granular layer + oedema of hypothalamic nuclei
9. Heat dissipation centre (preoptic nucleus of hypothalamus) shows destruction

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• 1st degree: Only epidermis; erythema
• 2nd degree (superficial): Epidermis + superficial dermis; blistering
• 2nd degree (deep): Deep dermis
• 3rd degree: Full thickness; skin destruction, no pain (nerve ends destroyed)
• 4th degree: Down to bone

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• HbCO found in blood indicates the person was alive during the fire and inhaled carbon monoxide
• CO binds haemoglobin with 200-250x greater affinity than O2
• Cherry-red colouration of skin and blood
• Fatal level: HbCO >50-60%
• Medicolegal significance: Proves death was due to CO inhalation (antemortem), not that the body was burnt after death (to conceal murder)

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• Electric mark (Joule burn): Punched out, crater-like wound with parchment-like dry base at entry point; surrounded by a pale halo of macerated skin
• Exit wound: usually larger, irregular
• Lightning injury: Lichtenberg figures (arborescent/fern-like branching burns on skin)
• Cause of death in electrocution: ventricular fibrillation
• Low voltage (<240V) - domestic accidents; High voltage - industrial accidents, lightning
• Crocodile clips and wire marks help identify the type of current source

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Summary of Topics Covered

• 5 gm% reduced Hb needed for cyanosis
• Diatom test confirms ante-mortem drowning
• Lucid interval = EDH (middle meningeal artery)
• MTP 2021: 20 weeks (1 doctor), 24 weeks (2 doctors), >24 weeks (Medical Board)
• Acids cause coagulation necrosis; Alkalis cause liquefaction necrosis
• Heat stroke: >106°F/41°C + NO sweating
• Pugilistic attitude = post-mortem heat artifact (NOT ante-mortem)
• HbCO cherry-red colour = person was alive in fire