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(BQ) Part 2 book Review of forensic medicine and toxicology has contents: Impotence and sterility, sexual offences, postmortem artifacts, forensic psychiatry, forensic psychiatry, torture and custodial deaths, newer techniques and recent advances,... and other contents.
CHAPTER 23 Impotence and Sterility iii iv ii v Impotence: It is the inability of a person to perform sexual intercourse and achieve gratification (unable to copulate) Erectile dysfunction: Inability to develop and maintain an erection for satisfactory sexual intercourse in the absence of an ejaculatory disorder such as premature ejaculation Quod (impotence quode hanc, ‘as regards’): A male may be impotent with one particular female, but not with another.1 Frigidity (Latin, coldness): It is the inability to initiate or maintain the sexual arousal pattern in female (absence of desire for sexual intercourse or incapacity to achieve orgasm).2 Sterility: It is the absolute inability of either a male or a female to procreate In male, it is inability to make a female conceive, and in females, it is inability to conceive children Fertility: Capacity to reproduce or the state of being fertile Infertility: Failure to conceive (regardless of cause) after year of unprotected and regular intercourse.3 Definitions z Question of impotence and sterility arises in: and believed to be semen), widower syndrome, post-traumatic stress disorder or over-indulgence Excessive masturbation may also lead to impotence Age: Before puberty, boys are usually impotent and sterile with certain exceptions, like precocious puberty Poor physical development of penis is common cause of impotence—examination depends more on its development than the age In advanced age, libido diminishes, but they are not impotent or sterile As long as live spermatozoa are present in seminal fluid, individual is presumed to be fertile Developmental and acquired abnormalities: Absence of penis, intersexuality, malformations, e.g hypospadias, epispadias, absence of testicles, Klinefelter syndrome, retrograde ejaculation and cryptorchidism (Fig 23.1) Local diseases: Priapism, hydrocele, elephantiasis, phimosis, Peyronie disease, adherent prepuce, orchitis following mumps, syphilis and tuberculosis (Fig 23.1) Mumps may cause sterility, not impotence Exposure to X-rays may cause sterility General diseases: Impotence is common during acute illness and in any severe or debilitating illnesses z Neurological conditions, like tabes dorsalis, multiple sclerosis, paraplegia, hemiplegia, syrin gomyelia, temporal lobe damage and 3rd ventricle tumors; endocrine disorders, e.g diabetes, hypothyroidism, hyperprolactinemia and testicular atrophy following renal failure, hemochromatosis or cirrhosis; blood vessel and nerve trauma (e.g long-distance bicycle riding), CVS disorders, e.g Leriche syndrome, and diseases like tuberculosis and nephritis may cause impotence and sterility z Malnutrition, vitamin C and zinc deficiency may cause erectile dysfunction Injuries: Infertility is a significant problem after spinal cord injury The two major causes are poor semen quality and ejaculatory dysfunction Civil cases, like divorce, adultery, nullity of marriage, disputed paternity and legitimacy, claims for damages where loss of sexual function is claimed Criminal cases, like adultery, rape, or unnatural offences where impotence is cited as defense i Psychological: Most important and frequent cause, though transient in nature.4 Absence of desire for sexual intercourse may result from dislike of partner, fear of failure, anxiety or mood disorder, guilt, aversion, low self-esteem, hypochondriacs, childhood sexual abuse, masturbatory anxiety (‘dhat syndrome’—passage of whitish discharge in urine z vi Causes of Impotence and Sterility in Males https://kat.cr/user/Blink99/ 346 Review of Forensic Medicine and Toxicology Fig 23.1: Causes of impotence and sterility in males Causes of Impotence and Sterility in Females z z z z x ix viii z z vii i Age: Being passive partners in intercourse, age has no effect on potency Women are fertile from puberty to menopause, but may become pregnant before menarche and after menopause z Kraurosis vulvae in old women may cause narrowing of the vagina z The occurrence of infertility rises significantly as age increases ii Developmental and acquired abnormalities z Impotence may result from total occlusion of vagina, adhesion of labia, imperforate hymen— can be cured by surgery (Fig 23.2) z Injury or operation of vagina may cause stricture which can lead to impotence z Absence/abnormal uterus, ovaries or fallopian tubes produces sterility, but not impotence z Erectile dysfunction may occur following treatment for lower limb fractures due to perineal neurovascular traction injury acquired during surgery z Fracture of the penis (rupture of both corpora cavernosa with urethral rupture) may result in impotence The commonest causes of fracture of penis are coitus and penile manipulations, especially masturbation Chronic poisoning: Exposure to poisons, e.g lead, arsenic, pesticides or aphrodisiac agents may lead to impotence and/or sterility Medications: Antidepressants (e.g SSRIs), antipsychotics, anti-hypertensives, antiulcer agents (e.g cimetidine), cholesterol-lowering agents and finasteride may cause impotence Behavioral factors: Lifestyle choices—chronic alcoholism, smoking, being overweight and avoiding exercise are possible causes of impotence Tight-fitting underwear causes increase in scrotal temperature that may result in decreased sperm count Addictions: Certain drugs, e.g morphine, heroin, opium, cannabis, cocaine and tobacco (smoking) may cause impotence and sometimes sterility z Penile erection is a complex process involving psychogenic and hormonal input, and a neurovascular nonadrenergic, noncholinergic mechanism Nitric oxide (NO) is considered as the main vasoactive neurotransmitter and chemical mediator of penile erection Impaired NO bioactivity is a major pathogenic mechanism of erectile dysfunction Treatment of erectile dysfunction often requires combinations of psychogenic and medical therapies Oral phosphodiesterase type (PDE-5) inhibitors are useful in this respect https://kat.cr/user/Blink99/ Fig 23.2: Causes of impotence in females Impotence and Sterility A simple way to distinguish between organic and psychological impotence is to determine whether the patient ‘ever’ had an erection If never, the problem is likely to be organic; if sometimes, it could be organic or psychological Permanent impotence is a ground for nullity of marriage/divorce as he is incapable of fulfilling the rights of consummation of marriage (physical union by coitus), but sterility is not The person is examined only when asked by the court or by the police Informed consent of the person should be taken and the consequences of the examination should be explained History: Complete history of previous illness (including surgery), mental condition and sexual history is taken History of smoking, dietary habits, obesity and the use of various medications are also evaluated Psychosocial examination: A psychosocial examination using an interview and a questionnaire reveals psychological factors A man’s sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse Examination of a Male Complete medical examination including CNS is done, especially if there is history of CNS illness, peripheral neuropathy, diabetes or penile sensory deficit It includes pulse, blood pressure, any abnormal secondary sexual characteristics (hair pattern or breast enlargement), site of urethral meatus, urethral stenosis, sensitivity of the penis to touch or if there is any deformity in the penis itself—whether it is bent or curved when erect, or any other congenital anomalies of the genitalia Testicular size, epididymis, spermatic cord and presence of varicocele are also noted Bulbocavernosus reflex test is done to determine if there is adequate nerve sensation in the penis The doctor squeezes the glans of the penis which immediately causes the anus to contract, if nerve function is intact z z z z z z iii Local diseases z Bartholin cyst, chancre of vulva, stricture due to perineal tear during previous pregnancy, prolapse of uterus/urinary bladder and dyspareunia causes impotence, but not sterility z Pelvic inflammatory disease, peritoneal adhesions secondary to previous pelvic surgery, endometriosis, and ovarian cyst rupture may produce blockage of fallopian tubes and sterility z Diseases of the genital organs (e.g gonorrhea), leukorrhea, acidic vaginal secretions and rectovaginal fistula not cause impotence but may produce sterility iv General disease: General infective, metabolic and hormonal conditions may cause sterility, but not impotence z Physiologic sexual dysfunction can be the result of impaired neurovascular tone to the clitoris and vagina v Chronic poisoning: Exposure to poisons, e.g lead and arsenic may lead to sterility, but not impotence vi Environmental factors and addictions: Occupational exposure to excessive heat, lead, microwave radiation or X-rays lead to sterility Drug dependence (alcohol, opium) may lead to sterility vii Medications: Chemotherapy, cessation of oral contraceptives—hormonal imbalance may remain for some time after stopping the pill viii Psychological: In males, psychological factors lead to non-erection (passive), but in females it is active in nature Fear, pain, disgust or apprehension for intercourse may give rise to vaginismus [severe spasm of the lower one-third of vagina involving the paravaginal muscles (levator ani and adductor femoris muscle)].5 The spastic contraction of vaginal outlet is an involuntary reflex which replaces the rhythmic contraction associated with anticipated or actual attempt of vaginal penetration z It may occur with equal severity in the women who has borne children, as in virgins z Etiological factors: Male sexual dysfunction, psychosexually inhibiting influence due to religious orthodoxy, incidents of prior sexual trauma, secondary to dyspareunia or personal dislike/disgust for coitus Laboratory Examination A sterile person may or may not be impotent and an impotent person may or may not be sterile Examination of a Person in an Alleged Case of Impotence and Sterility It will vary depending upon the history and clinical findings Examination of semen is essential in cases of infertility Tests for systemic diseases include blood counts, blood sugar (evaluation of diabetes), urinalysis, lipid and thyroid profiles, creatinine, liver enzymes and prostate-specific antigen Serum testosterone, LH and serum prolactin https://kat.cr/user/Blink99/ 347 348 Review of Forensic Medicine and Toxicology Laboratory tests: Besides routine blood and urine analysis, HSG, pelvic ultrasonography, hysterosonogram and MRI are required Opinion Other tests Evaluation of penile function can be done by direct injection of PGE1 into the corpora If the penile vasculature is adequate, an erection will develop Duplex ultrasonography: Vascular function within the penis including signs of atherosclerosis and scarring or calcification can be evaluated Ultrasonography of testes: Detect abnormalities in testes and epididymides Transrectal ultrasonography can disclose abnormalities in the prostate and pelvis Nocturnal penile tumescence testing: Normally, a man has 5–6 erections during sleep, especially during REM—their absence may indicate defect in nerve function or blood supply in the penis It may be useful in distinguishing psychogenic from organic impotence.6 Penile biothesiometry: This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glans and shaft of the penis Sterilization Classification: Sterilization can be classified as given in Flow chart 23.1 Compulsory: It is performed on a person, compulsorily by an order of the State, carried out on mentally or physically defective person, or as punishment to sexual criminals, or for the purpose of eugenics It is not done in India Voluntary: It is carried on married persons with consent of both the husband and wife It can be: i Therapeutic: It is done to prevent danger to health or life of women due to future pregnancy ii Eugenic: It is carried out to prevent conception of the children who are likely to be physically or mentally defective iii Contraceptive: It is done as a family planning measure Definition: It is the process to cause a person sterile without affecting his/her potency or sexual functions Gynecologic examination should include an evaluation of hair distribution, clitoris size, Bartholin glands, labia majora and minora, and any lesion that could indicate the existence of venereal disease In case of impotency in females, the defect usually lies in vagina and can be clearly observed The inspection of the vaginal mucosa may also indicate a deficiency of estrogens or the presence of infection The evaluation of the cervix should include a Papanicolaou test and cultures for sexually transmitted diseases The postcoital test (Sims-Huhner test) consists of evaluating the amount of spermatozoa and its motility within the cervical mucus during the preovulatory period Bimanual examination should be performed to establish the direction of the cervix, and the size and position of the uterus to exclude the presence of uterine fibroids, adnexal masses, tenderness or pelvic nodules indicative of infection or endometriosis Examination of a Female An opinion of impotence (in males) cannot be given, unless there is gross deviation from normal The opinion should be given in double negative form— stating that from examination of the male, there is nothing to suggest that the person is incapable of sexual intercourse In case of infertility, opinion can be given with certainty depending on clinical and laboratory findings Flow chart 23.1: Classification of sterilization https://kat.cr/user/Blink99/ Impotence and Sterility z z z Medico-legal Aspects Methods (Flow chart 23.2) z Flow chart 23.2: Methods of contraception Newer contraceptives Per cutaneous vas occlusion is an effective and reversible method, popular in China Polyurethane elastomere is injected into vas which forms a plug and blocks the sperm passage This plug can be removed under local anesthesia Gossypol, an extract from cotton seed (discovered in China) and GnRH analogues are other male contraceptives In females, centchroman, transdermal delivery system (nestorone), vaginal rings containing levonorgestrel, LNG rod, uniplant (nomegestral), biodegradable injectable contraceptives, LHRH agonist, quinacrine pellet, frameless IUD (GyneFix) and anti hCG vaccine are being tested z Natural contraception—rhythm method, coitus interruptus and breastfeeding z Rhythm period: Observing safe period—abstinence during fertile period of a cycle z Coitus interruptus—withdrawal of penis shortly before ejaculation Barrier contraceptives (spermicidal agents, diaphragm in females, condom in males).7 Intrauterine devices (IUD) or hormone containing IUD (Copper T 200, Cu T 380A, Multiload 250/375, levonorgestrel intrauterine system, progestasert and Lippes loop) z Temporary In males: Vasectomy (dividing the vas deferens) Newer technique uses chemical sclerosing agents, like ethanol, formaldehyde and AgNO3 that can eliminate the need of surgery In females: Tubectomy (Fallopian tubes are ligated), hysteroscopy using electrocoagulation/cauteri zation, laparotomy or minilap (Pomeroy, Madelener, Aldridge methods, Cornual resection, and fimbrectomy), and laparoscopy using clips z Permanent i There is no absolute guarantee to sterility after the operation, and the procedure may prove irreversible z A man is not sterilized immediately after vasectomy Additional protection is needed for about 2–3 months following this operation Condom should be advised for at least 20 ejaculations Impotency may occur which is mostly psychological z Overall failure rate in tubal sterilization is about 0.7%—failure due to fistula formation or due to spontaneous reanastomosis ii Doctor may be implicated, if he performs sterilization without consent and proper indication A written consent of both husband and wife is essential iii It is desirable to sterilize only individuals above 30 years of age and having two children, one of whom is male iv Healthy unmarried or married persons without any issue should not be permanently sterilized, even if they volunteer for the same v Failure of contraceptive measure adopted by males may lead to suspicion of wife having sexual relationship with another man who may initiate litigation—divorce, illegitimacy or disputed paternity Contraception: The term contraception includes all measures (temporary or permanent) designed to prevent pregnancy due to coital act Steroidal contraception z Oral contraceptive pills: Commonly used progestins are levonorgestrel, norethisterone or desogestrel; and estrogens are ethinyl-estradiol or mestranol z Injectable steroids: Depo medroxy progesterone acetate (DMPA), norethisterone enanthate (NETEN) z Implants: Norplant (levonorgestrel), Implanon (desogestrel) Chemical castration involves the administration of antiandrogen cyproterone acetate, contraceptive Depo-Provera or antipsychotic Benperidol Unlike surgical castration, where the testicles are removed, chemical castration does not remove organs, nor is it a form of sterilization These patients experience reductions in frequency and intensity of sexual drive, frequency of masturbation and sexual fantasies This may be a treatment strategy for sex offenders and can be an alternative to life imprisonment or death penalty The Justice Verma committee set up after the Delhi gang rape rejected the Government’s proposal of chemical castration, since it considered such punishments as violation of human rights https://kat.cr/user/Blink99/ 349 350 Review of Forensic Medicine and Toxicology Female infertility accounts for one third of infertility cases, male infertility for another third, combined male and female infertility for another 15%, and the remainder of cases is ‘unexplained’ i AIH (artificial insemination homologous/husband) ii AID (artificial insemination donor) The success rates of AI vary depending on the type of insemination used, but typically the success rate varies between 5–30% The success rate can be affected by factors such as stress, and quality of the egg and sperm Differentiation 23.1: AIH and AID S.No Feature AIH AID Semen used is derived from woman’s husband Semen of person other than husband is used Indications Male factor Impotency Defects of the penis, e.g hypospadias Retrograde ejaculation Decreased sperm counts, motility or quality Female factor Scant/unreceptive mucus Persistent cervicitis Cervical stenosis Consent Needed from both husband and wife Needed from husband, wife, donor and donor’s wife Pre-condition None Donor should have his own child Relation with recipient Husband Must not be a related to either spouses Donor characteristics Nothing specific Must be < 40 years, should resemble closely to the husband in race Medical tests Routine tests Tuberculosis, diabetes, epilepsy, Rh grouping, psychosis, endocrine dysfunction, hereditary or familial disorders and HIV are ruled out Disclosure of identity Not a problem, wife knows Donor and recipient should not know Outcome of AI Known to the husband Donor should not know 10 Confidentiality None Strictly maintained 11 Doctor’s role May deliver the child who administered the AI Should avoid delivering the child, as it would lead disclosing the identity of father in birth record 12 Legal problems No legal complications, except for divorce Husband sterile Husband suffering from hereditary disease Widows/unmarried women desiring children Rh incompatibility Principle Types (Diff 23.1) Procedure: Semen is obtained by masturbation after a week’s abstinence and ml is deposited by means of a sterile needleless syringe just above the internal os, at the time of ovulation (14th day after menstruation) (Fig 23.3) The semen to be implanted is ‘washed’ in a laboratory and concentrated in Hams F10 media without L-glutamine, warmed to 37°C This ‘washing’ increases the chances of fertilization while removing mucus and non-motile sperms in the semen A more efficient method of AI is to insert semen directly into the woman’s uterus When this method is employed, it is important that only ‘washed’ semen is used and inserted by means of a catheter Definition: It is the process of introduction of semen from the husband or a donor by instruments into the vagina or uterus of a female to bring about pregnancy which is not attainable by sexual intercourse Semen can be introduced into the vagina (intravaginal insemination—IVI), cervix (intracervical— ICI), fallopian tube (intratubal—ITI) or uterine cavity (intrauterine—IUI) of the recipient IUI is the most commonly used method of AI (higher success rate); and IVI (low success rate) and ITI (more invasive, greater risk of infection and higher costs) are the least commonly done AI iii AIHD: ‘Pooled’ donor semen to which semen from husband has been added There is a technical possibility of husband being father of the child Artificial Insemination (AI) Legal problems, like litigation against the doctor, illegitimacy, inheritance claims, divorce, incest and mental trauma may arise https://kat.cr/user/Blink99/ 351 Impotence and Sterility viii Psychosocial aspect: If it is known that the husband consented to AID and the husband was not capable of consummating the marriage, difficulties may arise The identity of the donor is kept secret; nevertheless, it is not uncommon for such secrets to be leaked out with adverse consequences ix Rights of sperm donors are debatable issue nowadays The artificial insemination with donor’s semen has not been legalized in India, and should only be undertaken at infertility centers after appropriate counseling and explanation of its implications to both partners i Danger of litigation: The doctor may be sued following the birth of a defective child To avoid this, the donor must be screened for any genetic defects ii Nullity of marriage and divorce: It is not a ground for divorce, if AI is done for sterility If AI is due to impotence, it is a ground If AID is done without the consent of the husband, then he can file for divorce and sue the doctor (regarded as an act of cruelty for the purpose of divorce) iii Legitimacy: The artificiality of the process would make no difference in legitimacy in case of AIH, and the child would be legitimate child Since, the husband is not the actual father of the child in AID, child is illegitimate and cannot inherit property, but for all practical purpose, the husband is accepted as father of the child and treated as legitimate and can inherit property iv Adultery: Recipient cannot be held guilty of adultery because there is no physical union by coitus Moreover, the Indian law specifically provides that the woman cannot be punished for adultery in any case v Incest: Risk of incestuous relationship between the offspring born by AI and children of donor is possible vi Natural birth: Status remains legitimate, but that of AID remains illegitimate vii Unmarried women or widow: There is no legal bar on an unmarried woman/widow going for AID A child born to a single woman through AID would be deemed to be legitimate However, AID should be performed only on a married woman with the written consent of her husband A child born through AIH with the stored sperms of her deceased husband is considered to be legitimate, despite the existing law of presumptions under the Indian Evidence Act Medico-legal Aspects Assisted reproductive technology (ART) Definition: Any fertility treatment in which the gametes (sperms and eggs) are manipulated outside of the body The gametes or embryos are replaced back into the body to establish pregnancy Surgical removal of eggs is known as egg retrieval In vitro fertilization is the most common ART procedure Types of ART procedures In vitro fertilization: IVF involves controlled ovarian hyperstimulation with exogenous gonadotropins, oocyte retrieval via transvaginal ultrasonographic-guided aspiration, fertilization of oocytes with sperm in culture (or intracytoplasmic injection of sperm into the oocyte), and subsequent transfer of the resultant zygotes (3–5 days later) transcervically under ultrasound guidance into the uterine cavity.8 Gamete intrafallopian transfer (GIFT): This involves ovarian stimulation; egg retrieval, followed by laparoscopically guided transfer of a mixture of unfertilized eggs and sperms into the fallopian tube (fertilization takes place inside the female’s body).9 Zygote intrafallopian transfer (ZIFT): Eggs are removed, day fertilized eggs (zygotes) are laparoscopically transferred into the fallopian tube, rather than uterus Intracytoplasmic sperm injection (ICSI): Indicated in male factor infertility One sperm is directly injected into an egg prior to intrauterine transfer of the fertilized eggs Ovum donation: Donor egg IVF is used for patients with poor egg numbers or quality After inducing super ovulation in an egg donor and followed by egg retrieval; eggs are fertilized by the sperms of the patient’s husband and the embryos transferred to the patient’s uterus Micromanipulation techniques include zona drilling and partial zona drilling Fig 23.3: Artificial insemination (intracervical) Oocyte freezing: This is a technique wherein the ovum from a healthy woman is taken and preserved at -196° C for future use The process takes 2–4 weeks from injecting hormones to stimulate ovulation and egg retrieval This is being used by working women— both single and married, who wants to delay pregnancy and focus on their careers Initially, egg freezing was used for medical reasons where women suffering from diseases like cancer used to freeze their eggs before chemotherapy Surrogate Mother Definition: A surrogate (Latin subrõgare: to substitute) mother is a woman who carries a child for a couple or a single person with the intention of giving that child up, once it is born (also called surrogate pregnancy) https://kat.cr/user/Blink99/ 352 Review of Forensic Medicine and Toxicology gestational surrogacy The responsibility of finding a surrogate mother rests completely with the couple The surrogate mother should be < 45 years of age It is the responsibility of the ART clinic to ensure that the candidate chosen for surrogacy passes all treatable criteria to ensure full-term pregnancy No individual can be a surrogate mother more than thrice in a lifetime Since there are no laws to protect the couples seeking surrogacy, the ART clinic is responsible for guiding the couples through the processes of egg and embryo donation, and surrogacy The surrogate mother may be the baby’s biological mother (traditional surrogacy) or she may be implanted with someone else’s fertilized egg (gestational surrogacy) She accepts pregnancy either by AI or by implantation of in vitro fertilized ova at the blastocyst stage, till delivery, for the woman who is incapable to bear child Salient features of the Indian Council of Medical Research Guidelines Surrogate mother can be known, unknown or a relative of the couple In the case of a relative, she should belong to the same generation as the woman desiring the surrogate Surrogacy should normally be considered only for parents for whom it would be physically or medically impossible or undesirable to carry a baby to term The genetic (biological) parents must adopt a child born through surrogacy The payment provided to the surrogate mother must include all expenses related to the pregnancy which must be documented through an agreement between the two The ART clinic cannot advertise to find a surrogate mother or be a party to any commercial dealing in Surrogate parenting involves a woman bearing the child of another woman, who is not in a position to bear children as a result of blocked Fallopian tubes or lack of a uterus It is the reverse of donor insemination The most common reason for using a surrogate mother is infertility Gay male couples have also used surrogate mothers in order to have children that at least one partner is biologically related to Surrogacy and posthumous reproduction are the extensions and ramifications arising out of ART However ethical, legal, religious and social issues surrounding these procedures need to be clarified and understood These are gray areas to be cautious about https://kat.cr/user/Blink99/ C B B C A C A Test to differentiate between psychological and organic erectile dysfunction: NEET 13 A Pharmacologically induced penile erection therapy B Nocturnal penile tumescence C Sildenafil induced erection D Squeeze technique Barrier method is: JIPMER 13 A Oral contraceptive pill B Intrauterine devices C Spermicidal D Tubectomy Homologous sperm in IVF is: AFMC 12 A Between donor and wife B Between husband and wife C Between husband and surrogate D Between donor and surrogate All are steps of GIFT, except: NIMHANS 11 A Ovulation stimulation B Oocyte retrieval C Fertilization of oocyte in lab D Transfer of unfertilized egg into the fallopian tube D Quod hanc means: NEET 14 A Medically impotent B Legally impotent C Impotent towards all women D Impotent towards a particular woman Frigidity is: NEET 13 A Inability to initiate sexual arousal in female B Inability to initiate sexual arousal in male C Ejaculation occurring immediately after penetration D Inability to conceive with particular male Infertility can be defined as: UP 11; KCET 13 A Not conceiving after years of marriage B Not conceiving after years of unprotected intercourse C Not conceiving after year of unprotected intercourse D Not conceiving after year of marriage Most common cause of erectile dysfunction: FMGE 10 A Psychological B Drug induced C Alcohol D Diabetes Impotent female is having: NEET 14 A Gonadal dysgenesis B Hermaphrodite C Vaginismus D Absence of ovary MULTIPLE CHOICE QUESTIONS C CHAPTER 24 Virginity, Pregnancy and Delivery Definitions Questions of virginity and defloration arises in: Nullity of marriage/divorce Defamation Rape Fig 24.1: Normal female genitalia (Vulva) i Annular: Opening is situated centrally ii Semilunar or crescentic: Opening is placed anteriorly iii Infantile: Small linear opening in the middle iv Septate: Two openings occur side by side, separated by thin hymenal tissue v Cribriform: Multiple openings vi Vertical: Opening is vertical vii Imperforate: No opening Types of Hymen (Fig 24.2) Hymen: The hymen is a fold of mucous membrane, about mm thick, situated at the vaginal outlet It is usually a thin transparent membrane, but it may be tough, fleshy or cartilaginous In infants, a small swab can be passed through the hymenal orifice into the vagina At ten years of age, the tip of the small finger and at puberty, one finger may be passed into the vagina Vulva includes female genitalia visible externally— the mons veneris (pad of fat lying in front of the pubis), labia majora and minora, clitoris, vestibule, hymen and urethral opening Perineum is the wedge-shaped area between the lower end of posterior wall of vagina and the anterior anal wall Labia majora are the two elongated folds of skin projecting downwards and backwards from the mons veneris—homologous with the scrotum in males Normal Female Anatomy (in Virgins) (Fig 24.1) Virgin (Latin virgo: maiden, intacta: untouched): A female who has not experienced sexual intercourse Defloration: The act of depriving a woman of her virginity Marriage: Legally, marriage is a contract between a man and a woman which implies physical union by coitus Divorce: Dissolution of previously valid marriage They meet in front to form the anterior commissure, and in back, the posterior commissure, in front of the anus Labia minora are two pinkish, thin folds of skin just within the labia majora Anteriorly, they divide to enclose the clitoris, and unite with each other in front and behind the clitoris to form the prepuce and frenulum respectively The lower portions of labia minora fuse in midline to form a fold called fourchette The depression between fourchette and the vaginal orifice is called fossa navicularis Vestibule is the triangular space bounded anteriorly by clitoris, posteriorly by fourchette and laterally by labia minora The clitoris is small, and the vestibule is narrow in virgins Vagina is narrow and tight, the mucosa is rugose, reddish in color and its walls are approximated After frequent sexual intercourse, the rugae become less marked, and the vagina lengthens into the posterior fornix https://kat.cr/user/Blink99/ 354 Review of Forensic Medicine and Toxicology Fig 24.2: Types of hymen Causes of Rupture of Hymen When a virgin is placed in lithotomy position with legs wide apart, the vagina remains closed and only the edges of labia minora are seen slightly protruding from between the closed labia majora A single intercourse does not alter the parts much, except rupture of the hymen.1 Principal signs of virginity i An intact hymen ii Normal condition of fourchette and posterior commissure iii Narrow vagina with rugose walls i Sexual intercourse: Commonest cause of defloration ii Masturbation, especially with some large foreign body Hymen is not injured in most cases, as manipulation is usually limited to parts anterior to the hymen iii An accident, like fall on a projecting substance or by slipping on the furniture or fence It does not rupture by jumping, riding, vigorous exercise and dancing iv Gynecological examination or surgical operation v Foreign body insertion for rendering minors fit for sexual intercourse vi Sanitary tampons After the birth of a child, hymen is completely lost and the remnants are represented by cicatrized nodules of varying sizes called the carunculae hymenales or myrtiformes On both sides, it is lined by stratified squamous epithelium The margin of the hymen is sometimes fimbriated and shows multiple notches which may be mistaken for artificial tears.* Medico-legal Aspects PREGNANCY Definition: It is a condition which occurs in the female when she carries a fertilized ovum within the uterus Presence of intact hymen is a presumption, but is not an absolute proof of virginity With an intact hymen, there can be true and false virgins (Diff 24.1) The features will be same for a deflorate woman and a false virgin with the exception of presence of hymen in the latter Diagnosis of Pregnancy in the Living (Flow chart 24.1) * The notches are usually symmetrical, occur anteriorly, not extend to the vaginal wall, mucous membrane over the notches is intact, and with no signs of inflammation https://kat.cr/user/Blink99/ 654 Review of Forensic Medicine and Toxicology L https://kat.cr/user/Blink99/ iv venom 479, 527 metalloproteases 532 ophthalmia 529, 532 Sniffing 622 Snowfield vision 555 Socio-familial factors 331 Sodium amytal 456 Sodium and potassium arsenate 489 Sodium bicarbonate 600 Sodium formal-dehyde sulfoxylate 496 Sodium nitrite 511 Sodomy 388 examination of active agent of 390 passive agent of 388 Soiling of wound 196 Solid 591 blasts 289 Somatic death 126, 136 and molecular death 126 Somatoform disorders 413 Somnambulism (sleep walking) 414 Somniferous poisons active principles 537 detection 539 differential diagnosis 539 narcotic 537 opiate 537 opioids 537 postmortem findings 539 body packers 540 chasing dragon 540 external 539 internal 540 medico-legal aspects 540 signs 538 symptoms 538 toxidrome 537 treatment 539 Somniloquy (sleep-talking) 414 Somnolentia 414 Sonti 543 Soot tattooing 623 Souvenir bullet 213 Spacing of jaw 69 Spalding’s sign 328, 358 Spanish fly See Cantharides Spark burns 276 Sparrow foot marks 285 Spasm of larynx 329 Species identification 425, 532 Species origin, identification of 435 Spectacle hematoma 233 Spectra of hemoglobin and derivatives 423 Spectroscopic examination 423 Speech 549 Speedball 621 Sperm donors, rights of 351 Spermatozoa under light microscope 434f Spermatozoon, morphological appearance of 434f Spermine picrate crystals See Barberio’s test Sphenoid sinuses 182 g Shotgun weapons 212 Shotgun wounds 218f Shotguns 222, 226 Sickle cell crisis 131 Silver nitrate impregnated paper test 607 Sims-Huhner test 348 Sin of omorrah 392 Singeing, cause of 270 Single base powder 215 Single bullet theory 224 Single cell gel electrophoresis 155 Sinsemilla 566 Six-penny bruises 195 Skeletal injuries 332 Skeletal muscle 126 electrical excitability of 126 Skeletal remains, dating of 119 Skeletonization of body 149 Skin 101, 113, 270, 311, 559 and mucous membrane to poisoning, color changes in 468t applied on 518, 520, 521 autofluorescence 155 burns 483 changes in 325 color of 192 color, changes in 325t destruction of superficial 268 dry hot (hot as a hare) 563 exposure of 506 incisions 102 marbling of 147 of lower limbs, marbling of 148f pigmentation of 356 slippage 147 Skull 57, 108, 271 cap, removal of 108f deformation 242 fracture, compound 237 fractures 232, 234, 258t complications of 237 suture closure 73 X-rays 237 Sleep disorders 414 Sleep-drunkenness 414 Sleeping beauty syndrome See Kleine- evin syndrome Sleep-terrors 414 Slippery elm bark (ulmus fulva) 340 SMC, functions of Smell, poisioning in dead 469 Smokeless powder 215 Snake 524 bite envenomation severity scale 530 bite poisoning, management of 530 bite, clinical spectrum of 527 bite, external features of 533f bite, history of 529 classification of 524 nomenclature 524 non-poisonous 526f postmortem findings 532 Seminal stains, examination of 432 Seminal stains, individualization of 435 Semi-smokeless powder 215 Semisomnolence See Somnolentia Sensory functions 413 Sepsis 269 cause of 341 Septic shock 300 Serotonin reuptake inhibitors, selective 614 Serum glutamic oxaloacetic transaminase 607 Serum glutamic pyruvic transaminase 607 Serum iron level 612 Serum strontium 181 Severity of brain injury stratification 238t Severity of concussion 238 Sex 58, 149 chromatin 58, 59 determination of 12, 59, 71 verification tests 58 Sex-linked offences 366 Sexual abuse 333 indicators of 383 victim of 123 Sexual asphyxia 184 Sexual assault 38, 94, 191, 366, 436 forensic evidence (safe) 371 forensic evidence kit 371 suspected seminal stain in 432 Sexual battery 368 Sexual characters, secondary 64, 74 Sexual contact 436 Sexual development classification of disorders of 61, 61t disorder of 60 Sexual harassment 38, 366 of women at workplace (prevention, prohibition and redressal) Act, 2013 38 Sexual intercourse 354 Sexual natural offences 366 Sexual offence, unnatural 366, 388 Sexual offences I 366, 460 Sexual offences II 388, 460 Sexual offences III 394, 461 Sexual offences, classification of 366t Sexual offences, natural 366 Sexual perversions 366 Sexual torture 448 Sexual unnatural offences 366 Sexual violence 366 Sexually active woman 381 Shaken baby syndrome 333 Shallow water drowning 179 Shamming 25 Sharia Islamic law 385 Sheehan syndrome 80 Sheehan’s hemorrhages 108 Shigella 629, 630 Shock 128, 131, 299 types of 299 Shotgun cartridge, parts of 214f Shotgun pellets 211 655 Index L Strychnine, medico-legal aspects 574 Strychnine, metabolism 572 Strychnine, postmortem findings 574 Strychnine, properties of 572 Strychnine, signs 572 Strychnine, symptoms 572 Strychnine, treatment 573 Strychnine—alkaloid 572 Strychnos nux-vomica family loganiaceae 572 kuchila 572 seeds 572f Stryker saw 100 Stud guns 211 Stupor 406 stage of 539 Sturner’s formula 155 Subacute SDH 245 Subarachnoid hematoma 246 Subarachnoid hemorrhage 131 Subcapsular laceration 256 Subconjunctival hemorrhage 164, 194 Subcutaneous bruise 192 Subdural hematoma 244, 246t age of 246 Subdural hygroma 246 Subendocardial hemorrhages 108 Subendocardial infarcts 132 Submersion inhibition 178 Succimer or DMSA 476 Suction bruise 193f Sudden death 131 Sudden infant death syndrome 144, 175 Sudden withdrawal of steroids 131 Sudorifics See Diaphoretics Suicidal and homicidal cut-throat wounds 199 Suicidal burns 273 Suicidal lacerations 197 Suicidal poisoning, common mode of 588 Suicidal strangulation 169 Suicidal, accidental and homicidal firearm injury 228 Suicide 183, 199, 203 Suicide See Homicide Suicide attempted 406 Sulphmethemoglobin 147 Sulphuric acid 468 Super-added permanent teeth 69 Superfecundation 359 Superfetation 359 Superficial perforating wound 224 Superglue fuming 86, 87 Supplice de baguettes 447 Supportive therapy 612 Supposititious child 360 Surest sign of antemortem burns 271 Surrogacy, traditional 352 Surrogate mother 351 Surrogate parenting 352 Surrogate pregnancy 351 Sutures 111 https://kat.cr/user/Blink99/ Swabs 384 Sweet almonds 582f Swelling 194 Swiss cheese appearance 276 Swollen, cyanosed face 164 Swyer syndrome 62 Sympathomimetic 538 Symphyseal surface of pubis 73 Symphysis pubis 103f Symptomatic patient, emergency management of 471 Syncope 130 Syndrome, compartment 532 Syndrome, dependence 618 Syndrome, intermediate (type II paralysis) 600 Syndrome, second impact 239 Synovial fluid 155 Systemic disorders 130 Systemic reactions 311 t Tactile hallucination 571 Tactile/haptic hallucination 404 Tail 524 Tailing of wound 198 Takayama test 424, 425f Talunex 606 Talus, center of ossification for 323 Tandem bullet 213 Tangential entrance wounds 221 Tannic acid 475 Tardieu’s spots 130, 165, 181 Tarsal bones 323f Taste 514 Tattoo marks 78 Tattoos, classification of 79 Tattoos, professional 79 Teardrop sign 236 Tears 196 Teeth, charting of 95 Teeth, eruption of deciduous 69f, 69t Teeth, eruption of permanent 69t Teeth, pink 148 Teeth, successional permanent 69 Teeth, temporary 68 and permanent 68 Teichmann test 424, 424f Tension pneumothorax 254 Terminal ballistics 209 Tertiary impact injuries 283 Testamentary capacity 77, 407 Testicular feminization syndrome 63 Testimony 51 Testing of rigor mortis 143, 143f Tête de négre’ appearance 180 Tetramethylbenzidine 423 Tetrathiomolybdate 507 Textiloma 19 Thallium acetate 508 Thallium stress test 509 Spill burns 274 Spinal anesthesia 317 Spinal cord 110, 251 concussion of 253 Spine, hyperflexion of 328 Spiral fracture 258 Spirit, proof of 542 Spirit, surgical 542 Spirits (whisky, brandy, rum, gin, vodka) 542t Spleen 104, 148, 182, 256, 264, 293, 491, 509, 624 Split lacerations 195 Split transplants 128 Spontaneous cerebral hemorrhage 249 Spontaneous hemorrhage 299 Spontaneous pneumothorax 254 Spotted hemlock 575 Stab wounds, classification of 201f Stack’s method 70 Staphylococcus aureus 122, 269 Starvation deaths 313, 460 Starvation acute 313 chronic 313, 314 State Medical Council composition of Statutory rape 76 Steam burns 274 Steering wheel impact abrasions 287 Steering wheel impact injury 284 Sterilization 348 classification of 348 medico-legal aspects 349 methods 349 permanent 349 temporary 349 Sternal index 67 Sternal notch 103f Sternum 254 Stillborn and dead-born fetus 329 Stomach 104, 114, 148, 153, 181, 264, 486, 492, 506, 509, 515, 520, 561, 609, 616, 624 agent in 484f and intestines, changes in 327 bowel test See Breslau’s second life test contents 154 damage in empty 484 poisioning in dead 469 poisons 595 wash 509, 518 washing See Gastric lavage Stone baby See ithopedion Strangulated hernia 131 Strangulation 167, 169, 170 accidental 170 Streak gonads 60 Streptococcus pyogenes 123 Stretch lacerations 195 Striking velocity 210 Struck hoop theory 242 Strychnine poisoning and tetanus 574t Strychnine, action 572 656 Review of Forensic Medicine and Toxicology Tumor 131 of kidney/bladder 131 Turkey skin 623 Turner syndrome 61, 62 Twin syndrome, vanishing 360 Twins, fraternal 360 Twins, identical 360 Two-digit system 95 Two-finger test 377 Typhoid 144 Torture, sequelae of 448 Torture, sequelae of management 448 Torture, types of 446 Toxalbumin 517 Toxemia 269 Toxic agent 479 Toxic compounds 494, 499 and uses 499t, 505, 508 Toxic principles 523, 527 Toxicity 514 by inhalation 510 of aconitine 576 of copper, action 505 Toxicological analysis, samples preserved for 477 Toxicological artifacts 401 Toxicology 463 clinical 465 general 465 Toxidromes 538 clinical 538t Toxin type 629 Toxinology 465 Tracer bullet 213 Trachea 148, 181, 264, 271 and bronchi 509 Tracheal reflexes 127 Transcapsular laceration 256 Translational acceleration 233 Transmissible spongiform encephalopathies 123 Transmitted wave theory 242 Transmural infarcts 132 Transplantation of human organs 31 Act, (amendment 2011, 2014) 30 Transplants, types of 128 Transportation injuries 281 Transverse fracture 236 Transvestic fetishism/eonism 395 Trauma 295, 304 and abortion 343 and nervous system 305 Traumatic and nontraumatic ICH 249 Traumatic brain injury 232 Traumatic cardiac rupture, common sites of 255 Traumatic epilepsy 237, 305 Traumatic hemorrhage 299 Traumatic shock 299 Traumatic tattoos 79 Tree bark appearance 106 Trendelenburg position 474 Tricyclic antidepressants 614 signs 614 symptoms 614 treatment 614 Trimetazidine 609 Triphasic withdrawal syndrome 620 Triphenyl tetrazolium chloride 133 Tropical anhidrotic asthenia 267 Tuberculosis 123, 144 of kidney 131 Tug fracture 173 u https://kat.cr/user/Blink99/ U U U U U U U U U U U U U U U U U U U U U U U ndertaker’s fracture 402 ndinism 397 nfavorable witness 51 niversal (Cunningham) system 95 niversal illusions or permanent illusions 405 nlawful homicide 295 nrespired and respired lung (stillborn and live-born) 326 pper limb 72 pper respiratory tract 176 ranism 396 rinary bladder 105, 153, 154 rinary disturbances 356 rine 436, 490, 554 alcohol 553 alkalization of 616 sample 378 robilin 436 rolagnia 397 rophilia 397 sefulness of X-rays 224 -shaped incision 103 terine cavity in nulliparous, shape of 362f parous woman, shape of 362f terine hemorrhage 131 terine perforation with small bowel prolapse 340f Uterine soufflé 357 terine wall 362 terus 105, 148 after delivery, size of 362t nulliparous and parous 362 postdelivery (in days), level of upper border of 361f v Vacuum metal deposition 86 Vagal inhibition 130, 134, 171, 174, 179 Vagal inhibitory phenomenon 136 Vagal stimulation 179 Vagina 105, 353, 355, 362 Vaginal discharge 380 Valve 108 Valvular heart disease 131 van Gogh syndrome 411 Vascular injury 232 Vasovagal shock 134, 299 Vegetative signs 407 Thallium sulfate 508 Thallium, absorption and excretion 508 Thallium, action 508 Thallium, acute poisoning signs 508 symptoms 508 Thallium, diagnosis 509 Thallium, laboratory investigations 508 Thallium, postmortem findings 509 medico-legal aspects 509 Thallium, treatment 509 Thanatopraxia 156 Tharra 542 Thelarche 74 Therapeutic artifacts 400 Therapeutic privilege 23 Therapeutic waiver 23 Thermal injuries 263, 459 classification of 263 Thermogenic anhidrosis 267 Thin layer chromatography 423 Thiopentone sodium See Sodium amytal Thioxanthenes 613 Thoracic blood vessels 293 Thorax 102 Thought and speech disorders 410 Throat, poisioning in dead 469 Thrombosis 301 Throttling 171, 172 accidental 172 Thumb pressure 140 Thunderclap headache 248 Time of assault 381 Time since death 93, 101, 152 Tincture iodine 475 Tinnitus 252 Tissue injury, soft 233 Tissue paper scars 624 Tissue, deep 193 Tobacco smoke 489 Toddy 542 Tongue 168, 179, 549 protrusion of 164 Tonic contractions 573 Tooth dislocation 258t Tooth, parts of 68f Toothed forceps 100 Tooth-grinding See Bruxism Torture and custodial deaths 446, 461 Torture bell (campana) 447 Torture branks 447 Torture chepuwa 447 Torture flying airplane 447 Torture helicopter trip 447 Torture interrogation chair 447 Torture iron maiden 447 Torture judas cradle 447 Torture methods, specific physical 448t Torture torment of sticks 447 Torture, forms of 447 Torture, pharmacological 448 Torture, psychological 448 Torture, reasons for 446 657 Index Waddell’s triad 282, 283f Walk and turn test 551 Wallace rule of nines 268, 268f Wandering bullet 229 War gases 591 and biological weapons 591 chemical warfare 591 Warrant case 47 Washburn/ischiopubic index 67 Washerwomen’s hand 180 Wasting diseases 144 Water 514 current 150 Wax drippings 276 Weapon, types of 203 Weedol 603 Welding of shot 211 Wernicke’s encephalopathy 548 signs 548 symptoms 548 Wernicke-Korsakoff syndrome 548 Wet drowning 181 Whiplash injury 252 Whole-bowel irrigation 477 Widmark’s formula 553 Wife syndrome, symptoms of battered 384 Wine 542t Winslow’s test 136 Wischnewsky spots 264 Witness torture 448 Witness, types of 50 Woman with alleged history of abortion, examination of 341 Wood’s lamp, examination with 374 Workmen’s Compensation Act, 1923 34 Wound 276 accidental 199 w x https://kat.cr/user/Blink99/ Xenograft 128 Xtracorporeal membrane oxygenation 608 y Yaw 223 z N Y-shaped incision 103 modified 103, 164f Ziehl- eelsen’s method 434 Zinc 512 action 512 chloride 468, 512 medico-legal aspects 512 oxide fumes 512 oxide, inhalation of 512 phosphide 512 postmortem findings 512 shakes 512 signs 512 stearate, inhalation of 512 sulfate 512 symptoms 512 treatment 512 uses 512 Zip guns 210 Zsako’s phenomenon 126 Zygote intrafallopian transfer 351 age of 303f ballistics 209, 216 contact 218, 220f dating of incised 198, 198t defense 199, 205, 205f entry 221 and exit 222 exit 221, 222 healing of lacerated 197t of entry 201 of exit 201 shape of stab 202f sharp 197, 198f types of 206 Wreden’s test 327 Wrist drop 502f Vitriolage treatment 484 Voluntary breath holding 136 Voluntary euthanasia 26 Vomiting and salivation, signs of 549 Voyeurism/scoptophilia 395 Vulva 353 carcinoma of 131 Venom, prevention of spread of 529 Venom, spread of avoid manipulation 530 immobilization 529 pressure-immobilization 530 reassurance 529 Venous air embolus 112 Venous bleeding 430, 430f Venous congestion 163 combined asphyxia and 163 Venous thrombosis, deep 301 Ventricular fibrillation 179 Ventricular hypertrophy 108 Verbal/mental abuse 333 Vernix caseosa absence of 321 presence of 321 Vertical compression fracture 258 Vertigo 252 Vesicles, formation of 533 Vessels, dissection of 105 Vessels, staining of 532 Vibrating saw 100 Victim or offenders, identification of 428 Vin rose 612 Vineyard sprayer’s lung 507 Violence, degree of 194 Viper 525t, 527f, 528 head 529 Viperine bite 532 Viral hemorrhagic fever 594 Virchow’s method 103 Virgin 353 true and false 355 Virginity, pregnancy and delivery 353, 460 Virginity, principal signs of 354 Virilizing ovarian tumor 80 Virtopsy 98 Viscera containment 111 Viscera, preservation of 113 Visceral injuries 332 Vision, protection of 580 Visual hallucination 404 Vitamin D 510 Vitamin K 515, 611 Vitreous humor 112, 114, 138, 155 Vitreous potassium and hypoxanthine 138 Vitriol throwing ... https://kat.cr/user/Blink99/ 26 A 27 B 25 A 24 A 23 C 22 C 21 C 30 C 20 A 29 A & C 19 B 28 A 18 C 24 Immediately after delivery, uterus is at the level of: MP... marked, and the vagina lengthens into the posterior fornix https://kat.cr/user/Blink99/ 354 Review of Forensic Medicine and Toxicology Fig 24 .2: Types of hymen Causes of Rupture of Hymen...346 Review of Forensic Medicine and Toxicology Fig 23 .1: Causes of impotence and sterility in males Causes of Impotence and Sterility in Females z z z z