Forensic Cerebellum RR

FORENSIC MEDICINE

• Medical Ethics:
  • Moral principles guiding doctors' behavior towards other doctors, patients, and society.
  • Mandatory; failure can lead to infamous conduct.
• Medical Etiquette:
  • Conventional courtesy laws guiding doctor-to-doctor behavior.
  • Not mandatory.
• Infamous Conduct:
  • Disgraceful act by a doctor.
• Medical Negligence:
  • Lack of reasonable care/skill causing patient injury or death.
  • Punishment by State Medical Council or court (civil/criminal).
  • Penalties: warning, erasure, fine, imprisonment (under IPC sections 304A, 337, 338).

MEDICAL RECORDS RETENTION

• Digital records: 10 years.
• OPD Patients: 3 years.
• Indoor patients: 3 years.
• MLC: 10 years.
• Record Provision Time: 72 hours (3 days).

DEFENSE AGAINST MEDICAL NEGLIGENCE

• No duty owed to patient.

• Duty discharged as per standards.

• Therapeutic misadventure (medical maloccurrence): no fault (e.g., anaphylaxis).

• Limitation period: 2 years.

• Error of judgment: Wrong diagnosis of atypical disease.

• Res Judicata (“Doctrine of Double Jeopardy”): No retrial; appeal only.

• Volunti non fit injuria: Voluntary consent for risky procedure after consultation.

• Contributory Negligence: Both doctor & patient at fault.

  • Doctrines related to Contributory Negligence:
    • Last clear chance doctrine: doctor liable if failing to avoid damage in the last clear chance.
    • Avoidable consequences rule: patient liable if they could have avoided the damage but didn't.

CONSENT

• Types of consent:
  • Informed consent: Valid.
  • Blanket consent: Not valid.
  • Implied consent.
  • Expressed consent: Oral/written.
    • General physical examination, sexual assault victim examination: minimum age >12 years.
    • Surgery and invasive procedures: >18 years.
• Consent in Emergency: Not required (92 IPC).
• Consent of Accused: Not required (53 CRPC).
• Consent of Spouse: Required for contraceptive sterilization and artificial insemination, but not for abortion or other operations.
• Consent of Autopsy:
  • Pathological autopsy: Relative's consent required.
  • Medico-Legal autopsy: Relative's consent not required.

COMMON MEDICO LEGAL DOCTRINE

• Profession secrecy:
  • Patient-doctor confidentiality.
• Exception: privileged communication.
• Doctrine of full disclosure:
  • Disclose everything to the patient.
• Therapeutic Privilege:
  • Exception to full disclosure (e.g., cancer).
• Doctrine of Informed Refusal:
  • Patient refusal after being informed.
• Corporate Negligence:
  • Hospital at fault.
• Products Liability:
  • Manufacturer at fault.
• Vicarious Liability:
  • Liable for another's act.
  • Senior/employer punished with junior/employee.
• Novus actus interveniens:
  • New action intervening.
• Res Ipsa Loquitor (Common Knowledge Doctrine):
  • Obvious negligence: “Facts speak for themselves”.

EUTHANASIA

• Active: Lethal injection.
• Passive (Allowed in India): Withdrawing life support.
• Involuntary: Against consent.
• Voluntary: Consent available.
• Non-voluntary: Consent not available (e.g., coma).
• Physician assisted Suicide: Physician helps, patient commits suicide.

SCHEDULE OF NMC ACT FOR MEDICAL QUALIFICATIONS

• Schedule I: Medical College in India
• Schedule II: Foreign Medical College degrees recognized in India
• Schedule III: Foreign medical college degrees not defined in schedule II

DECLARATION PURPOSE

• Declaration of Hawaii: Mentally Ill
• Declaration of Helsinki: Human Experimentation
• Declaration of Malta: Hunger Strikes
• Declaration of Oslo: Therapeutic Abortion
• Declaration of Ottawa: Child Health
• Declaration of Sydney: Death
• Declaration of Tokyo: Torture
• Declaration of Geneva, Hippocratic Oath, International Code of Medical Ethics: Medical Ethics

LEGAL PROCEDURES

• Important IPCs: 511 IPCs

FORENSIC MEDICINE IPCs

• Definition of Injury, Life, Death: 44, 45, 46
• Criminal Responsibility: 82-86
• Consent: 87-92
• False Evidence: 191-201
• Murder, Suicide: 299-309
• Criminal abortion, infanticide, child abuse: 312-316, 317,318
• Hurt, grievous hurt etc.: 319-338
• Assault: 351
• Sexual offences:
  • 354 and related IPCs
  • 375,376, 377
• Kidnapping: 359-369 IPCs

IPC DEFINITIONS

• 44: Injury
• 45: Life
• 46: Death

CRIMINAL RESPONSIBILITY (AGE BASED)

• 82: < 7 years, no responsibility
• 83: 7-12 years, +/- responsibility, court decision
• 84: Mental Illness (McNaughten’s)
• 85: Involuntary intoxication
• 86: Voluntary intoxication

CONSENT (IPC SECTIONS)

• 87 - 91
• 92: in Emergency, consent not required

FALSE EVIDENCE (IPC SECTIONS)

• 191: Perjury definition
• 193: Punishment for perjury (7 years)
• 197: Issuing False certificates
• 201: Disappearance of evidence of offence
• 228 A: Disclosing the identity of rape victim
• 269 & 270 IPC: Spreading of dangerous infectious diseases
• 294 IPC: Obscene acts (Exhibitionism)

MURDER AND SUICIDE RELATED IPCs

• 299: Definition Of Culpable homicide
• 300: Definition Of Murder
• 302: Punishment for Murder
• 304: Punishment for Culpable homicide not amounting to murder
• 304 A: Death due to negligence, includes medical negligence (Imprisonment: 2 years)
• 304 B: Dowry Death (Imprisonment: 7 years - life)
• 498 A: Wife subjected to cruelty by husband or in-laws
• 305, 306: Abetment of suicide
• 307: Attempt to murder
• 309: Attempt to commit suicide (No longer an offence)

CRIMINAL ABORTION IPCs

• 312 - 316: Criminal abortion
• 312: Abortion with mother’s consent
• 313: Abortion without mother’s consent
• 314: Death of mother due to abortion
• 315: Act of criminal abortion is punishable
• 316: Quickening has started, Heinous act that could have lead to mother’s death, eg. Hitting abdomen
• 317: Child <12 yrs abandoned by parents
• 318: Newborn death concealment

HURT AND GRIEVOUS HURT IPCs

• 319: Definition Of hurt
• 320: Definition Of grievous hurt
• 321: Definition Of voluntarily causing hurt
• 322: Definition Of voluntarily causing grievous hurt
• 323: Punishment for causing hurt
• 324: Punishment for causing hurt by dangerous weapon
• 325: Punishment for grievous hurt
• 326: Punishment for grievous hurt by dangerous weapon
• 326 A & B: Throwing acid
• 334: Hurt on provocation
• 335: grievous hurt on provocation
• 337: Hurt due to negligence
• 338: Grievous hurt due to negligence
• Death due to negligence: 304 A
• Hurt due to negligence: 337
• Grievous hurt due to negligence: 338

ASSAULT AND KIDNAPPING IPCs

• 351: Assault (Threat)
• 359 - 369: Kidnapping

SEXUAL ASSAULT LAWS (IPC SECTIONS)

• Molestation: 354, 354 A, 354 B, 354 C, 354 D, 509
• Rape: 375, 376, 376 A, 376 AB, 376 B, 376 C, 376 D, 376 D,DA,DB, 376 E
• 377: Unnatural sexual offences
• 497: Adultery (No longer an offence)

MOLESTATION

• 354: Sexual assault
• 354 A: Sexual harassment
• 354 B: Removal of clothes of woman
• 354 C: Voyeurism
• 354 D: Stalking
• 509: Word, gesture or act intended to insult the modesty of a woman (Eve-teasing)

RAPE (IPC SECTIONS)

• 375: Definition Of Rape
• 376: Punishment for rape
  • > 16 yrs of girl (min. 10 years)
  • < 16 yrs of girl ( min. 20 years)
• Minimum age of girl for consent for sex: 18 yrs
• 376 A: Causing death/ vegetative state of victim while committing rape( 20 yrs- life)
• 376 AB: Rape of girl < 12 yrs (20 yrs- life)
• 376 B: Sex by husband during separation (2-7 yrs)
• 376 C: Sex by person in authority (5-10 yrs)
• 376 D: Gang rape ( 20yrs - life)
• 376 DA: Gang rape < 16 yrs girl (Life)
• 376 DB: Gang rape < 12 yrs girl (Life- death)
• 376 E: Repeat offender (Life- death)
• 377: Unnatural sexual offences
• 497: Adultery (No longer an offence)

IMPORTANT CRIMINAL PROCEDURE CODES (CrPC)

• Definitions of all offences: 2 CrPC
• Crime information to police: 39 CrPC
• Med Exam of arrested person: 53 CrPC (forceful), 54 CrPC (himself requests)
• Summons: 61-69 CrPC
• Inquest: 174 CrPC (Police inquest), 176 CrPC (Magistrate inquest)
• Preg. Women death sentence converted to LI: 416 CrPC (Life)

2 CrPCs

• Cognizable offence: 2(C) CrPC, (Murder, Rape, Dowry Death)- Police can arrest without arrest warrant
• Non- cognizable: 2(C) CrPC, (Simple Offences)- Arrest warrant needed
• Bailable: Police can grant bail
• Non-bailable: Only court can grant bail
• Warrant Case: punishment > 2 years
• Summon Case: punishment < 2 years

CRIME INFORMATION TO POLICE

• 39 CrPC: Any major crime to be informed to police or magistrate

MEDICAL EXAMINATION OF ARRESTED PERSON

• 53 CrPC: forceful
• 54 CrPC: Voluntary, requests himself

SUMMONS

• 61-69 CrPC

  • Types of Summons:
    • Subpeona ad testficandum: oral testimony
    • Subpeona duces tecum: Document required

INQUEST

• 174 CrPC: Police inquest, Min. Rank - Head constable
• 176 CrPC: Magistrate inquest
  • Judicial Magistrate: Custodial Death
  • Executive Magistrate: A) Dowry death, B) Exhumation

PREGNANT WOMAN DEATH SENTENCE

• 416 CrPC: Postponed till 6 months of delivery or converted to life imprisonment by high court order

INDIAN EVIDENCE ACT (IEA) SUMMARY

• Dying declaration: 32 IEA

DYING DECLARATION - DYING DEPOSITION

WITNESS TYPES

• 45 IEA: Expert Witness eg. Doctor
• 118 IEA: Common Witness, tells just facts
• Hostile Witness: says False/ hides truth
• Onus to proof in Rape- according to 114-A IEA: lies on Accused
• Onus to Proof (Civil & Criminal case) - Usually lies with the victim’s lawyer
  • Exceptions: lies on Accused in 114-A IEA, Res ipsa Loquitur, Contributory negligence

LEADING QUESTIONS

• 141 IEA: Def. of Leading questions
• 142 IEA: Leading questions cannot be asked (Dying declaration, Examination in Chief, Re- examination)
• 143 IEA: Leading questions can be asked (Dying Deposition, Cross-examination

TYPES OF EVIDENCE

Oral

• Mostly required
• Medical evidence eg, post-mortem report, injury certificate, age certificate

Documentary

• Allowed in Few exceptions eg. Toxicology report, fingerprint report, dying declaration, book of author

INDIAN COURT SYSTEM

RECORDING OF EVIDENCE IN COURT

• Oath: not required < 12 years of age
• Examination in chief: by lawyer who summons the witness, usually public prosecutor - government lawyer for victim
• Cross- examination: done by lawyer of opposing party, usually defence lawyer
• Re-examination: lawer same as examination in chief
• Questions by Judge at any time

CONDUCT MONEY

• Money for travelling expenses
• Given in Civil cases only; money given at time of serving summon
• Party will pay who calls the witness
• Amount is fixed by the court

STAINS

• Species: Human or some other species - Precipitin Tests
• If human: Semen/Blood - Presumptive Tests(More Sensitive), Confirmatory Tests(More Specific)
• If blood: Blood group

TESTS FOR SEMINAL STAINS

A) Presumptive tests for seminal stain

• Fluorescence under UV light
• Microchemical Test (Presumptive):
  1. Florence Test
     • Dark brown rhombic crystals of Choline Iodide
     • Resembles hemin crystal test
     • Choline is a component of seminal vesicle
  2. Barberio’s Test
     • Yellow needle-shaped crystals of spermine picrate
     • Spermine is component of prostate gland
     • In Azoospermia, positive due to being a component of prostate gland

B) Confirmatory tests for seminal stain

• Semen detection (Best)
• Acid phosphatase test- 2nd best, component of prostate
• Creatinine phosphokinase test- component of sperm, negative in case of azoospermia
• Prostate specific antigen or PSA(p30)- component of prostate

TESTS FOR BLOOD STAINS

A) Presumptive tests for blood stain

• Macro-chemical tests (for Visible blood stain):
  • Guaiacum test
  • Orthotoludine test
  • Amidopyrine test
  • Leucomalachite green test
  • Benzidine test - Greeenish blue
  • Phenolphthalein test (Kastle Myere Test)
• Luminal Spray Test: Bluish Luminescence, used for invisible blood stains

B) Confirmatory Tests for Blood stain

• Microscopic examination of RBCs
• Spectroscopy (Most reliable)
• Microchemical Tests for Blood (Confirmatory):
  1. Hemin (Teichmann’s) Test
     • Brownish-black rhombic crystals of hematin chloride
  2. Hemochromogen (Takayama) Test
     • Pink feathery crystals of Haemochromogen

SECRETORS VS NON SECRETORS

• Secretors: blood grouping can be done in Body fluids, eg,
  • Tears
  • Saliva
  • Breastmilk
  • Urine
  • Semen
• Non secretors: blood grouping can be done in blood only

METHODS OF ABO GROUPING IN STAINS

• Agglutinogens detection
  • Absorption-elution
  • Absorption inhibition
  • Mixed agglutination
  • ELISA method
• Agglutinins detetction: Lattes Crust method

PATERNITY CONFIRMATION

• RBC Antigen: AB, MNS, Rh etc.
• WBC Antigen: HLA typing
• DNA fingerprinting (Absolute confirmation)- best

THANATOLOGY

• Study of Death

TYPES OF AUTOPSY

1. Pathological:

• for Academic purpose, consent from relative required

2. Medicolegal:

• consent by law

3. Virtopsy:

• No dissection

4. Psychological Autopsy:

• No dissection, in case of suicide, interviews relatives and friends, to know the mental state of disease before death

5. Partial Autopsy:

• Not done

6. Obscure Autopsy:

• Cause of death found with microscopy examination

7. Negative Autopsy:

• Cause of death not found with gross or microscopic examination.

TYPES OF INCISION

1. “I” incision

• Starting from chin to pubic symphysis
• Most commonly used

2. “T” incision

3. “Y” incision

• Starting from shoulders on both sites reaching Xiphi sternum and it comes down to the pubic symphysis

4. Modified “Y” incision

• Starts from mastoid comes down the lateral side of neck and then from suprasternal notch to pubic symphysis
• Good for neck dissection
• Preferred in Asphyxial deaths

EVISCERATION (ORGAN REMOVAL) METHODS DURING AUTOPSY

1. Letulle’s method

• En-mass removal
• Rapid method
• Also used to study anatomical relation
• Preferred in infant deaths
• Removal of the attachment of tongue, then removal of all the thoraco-abdominal organs together as a single mass

2. Ghon’s Method

• En-block method
• Targets only one particular area
  • Ex. In sexual offence - only pelvic organs are removed
  • Ex. In thoracic pathology/trauma - only thoracic organs are removed

3. Virchow’s method

• One by one removal of organs
• M/C method used

4. Rokitansky method

• In-situ method
• Organs not removed outside of the body to avoid spillage & exposure
• Used for infectious diseases
• Ex. HIV, Hepatitis patient, Covid

ANTEMORTEM VS POSTMORTEM CLOTS AT AUTOPSY

SOMATIC DEATH VS MOLECULAR DEATH

• Somatic Death: Clinical dead, Bishop’s Triad = Atria Mortis = Gateway of death
• Molecular/Cellular Death: Death at cellular level, 1-2 hrs after somatic death
  • Neurons die within few minutes
  • Muscles upto 1-4 hrs after death

MANNER VS CAUSE VS MECHANISM VS MODE OF DEATH

1. Manner of Death

• Natural
• Unnatural
  • Suicide,Accident, Homicide

2. Cause of Death

• Main injury or disease which results in fatal physiological derangement in body

3. Mechanism of Death

• Fatal physiological derangement produced by cause of death

4. Mode of Death (Bichat’s Criteria)

• Heart - Syncope
• Respiratory - Asphyxia
• Brain - Coma

CHANGES AFTER DEATH

1. Immediate (Somatic Death)

• Insensibilty
• No spontaneous respiration
• No cardiac activity

2. Early (Molecular Death)

• Changes in skin
• Changes in eyes
• Algor Mortis
• Livor Mortis
• Rigor Mortis

3. Late (Molecular Death)

• Decomposition (Putrefaction)
• Adipocere
• Mummification

TESTS FOR RESPIRATION AFTER DEATH

• Feather test
• Mirror test- mirror kept near the mouth
• Winslow’s test- mirror kept near the chest

TESTS FOR CIRCULATION AFTER DEATH

• Diaphanous test
• I-card test
• Magnus test
• Pressure test

SUSPENDED ANIMATION CONDITIONS

• After anaesthesia
• Newborn, barbiturate poisoning
• Cholera, coma, cerebral concussion
• Drowning
• Electrocution
• Frozen state(Hypothermia)
• Sunstroke, shock, insanity
• Yoga practitioners

EARLY CHANGES AFTER DEATH

• Skin color - Pale
• Skin elasticity - Lost
• Cattle trucking or Kevorkian sign - Fragmentation of blood in columns in Retinal blood vessels, starts in few minutes upto 1 hr

CHANGES IN EYES

• Corneal opacity - Takes 2 hrs, permanent in 12 hrs
• Tachenoire - Two triangle shaped opacities on sclera, in 3-4 hrs
• Intraocular tension – becomes zero in 6 hrs
• Vitreous humor - Increased $K+$ & Hypoxanthine conc. till 100 hrs, resists putrefaction

COMPARISON OF TIMELINES

5. Algor Mortis

• Best place to record temperature: Sub-hepatic > rectal
• Rate of fall
  • Temperate countries: 1.5⁰F/hr, 1⁰C/hr
  • Tropical countries: 0.75⁰F/hr, 0.5⁰C/hr
• Body temp reaches atmospheric temp: 18 hrs
• Most imp. for time since death in first 24 hrs: Algor Mortis

6. PM Caloricity

• Body remains warm after death (1-2 hrs)
• Prolonged raised temperature seen in
  • Nux vomica( due to convulsions)
  • Tetanus
  • Heatstroke
• This phenomenon is not seen in burn cases
• Causes:
  • Heat regulation is disturbed before death
    • Heatstroke
    • Pontine hemorrhage
  • Heat production due to convulsions
    • Tetanus
    • Strychnine
  • Heat production due to bacterial activity
    • Sepsis
  • Very high environmental temperature

7. PM Staining

Occurs only on dependent parts, both internally & externally, does not occur on pressure areas

• Hypostasis
• Livor Mortis
• Vibices
• Suggillation
• Postmortem Lividity
• Cadaveric Lividity
• Darkening of death

8. Rigor Mortis

• Due to actin-myosin fusion when ↓↓ ATP occurs

• at 85% of normal ATP level,onset of RM occurs

  • Nysten’s rule: Sequence of RM progression Order of appearance and disappearance → Proximal to distal/ descending pattern: Eyelids → Neck → Jaw → Facial muscles → Thorax → UL → Abdomen → LL → Fingers & toes
  • Rule of 12: Starts in 60 minutes, reaches max. In 12 hrs, stays in body for 12 hrs & disappears from body in 12 hrs Max in 12hrs, persists for 12hrs, disappears in 12 hrs

CONDITIONS SIMULATING RM

• Heat stiffening (Pugilistic/ Boxer’s attitude)
• Cold stiffening
• Gas stiffening
• Cadaveric spasm

LATE CHANGES

• Decomposition/ Putrefaction (Common): Mechanism of putrefaction
  • Autolysis: Due to body enzymes
  • Microorganisms: Gut bacteria (Clostridium Welchii- lecithinase)
• Adipocere (Rare)
• Mummification (Rare)
• Casper’s Dictum: The rate of putrefaction in different medium- Air: Water: Earth= 1:2:8

TIMELINES OF PUTREFACTION SUMMER/AIR

• First 12 hrs due to SulphmetHb:
  • Reddish brown discoloration of aorta (1st internal sign/ 1st sign of putrefaction)
  • Greenish discoloration of under surface of liver- 2nd internal sign
  • 1st External sign is greenish discoloration of right iliac fossa
• 12- 24 hrs: Greenish discoloration spreads, gases ↑↑
• 24-48 hrs: “Greenish Foamy Purge on Marble in 2 days”- Whole body greenish, post mortem purge, foamy liver, marbling (36 hrs)
• 48-72 hrs/2-3 days: Black and stiff, loose hair & nail in 3 days- whole body blackish, gas stiffening, prolapse of rectum and uterus, fish mouth appearance, hair and nails become loose.
• 72-120 hrs/3-5 days: Skull, teeth, skin becomes loose, maggots enter, Skull sutures separate, degloving of skins
  *Degloving: Heavy infestation with maggots
• 5-10 days: liquefaction
  • 1st organ: Larynx & Trachea
  • L,B,H,K: Lungs, liver, Brain, Heart, Kidney
  • Late to putrefy- Prostate/testes, non-gravid uterus/ovaries
• At least 1 month- skin, muscles and tendons (k/a skeletonisation)
• In 10 yrs- bone and teeth

MLI FOR ADIPOCERE & MUMMIFICATION

• Injuries can be identified
• Time since death can be known to an extent
• Face may or may not be preserved

IDENTIFICATION RACE (Indices for Race Identification)

• CBCHI

  • Cephalic Index (Max. Breadth of skull/ max. Length of skull) x 100Brachial Index (Length of Radius/ Length of Humerus) x 100Crural Index (Length of Tibia/Length of Femur) x 100Humero-femoral Index (Length of Humerus/ Length of Femur) x 100Intermembral Index (Radius+ humerus/ Tibia+ Femur) x 100

• Race - CBCHI (Skull + Limbs)

• Sex - Pelvis/ Sternum

• Age - No indices

• Stature - Formulas

CEPHALIC INDEX (CI)