Essentials of Forensic Medicine and

Toxicology, 1st Edition Suresh Chand

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 TE
AINA

Essentials of

Forensic Medicine
&Toxicology

S.Chand

ELS4158594.

ELSEVIER
 ABBREVIATIONS
Td Increased
Decreased IUL Intrauterine life
Jd IVC
Lead(s) to/results into Inferior vena cava
1/V Intravenous
More than or equal to
JJB Juvenile Justice Board
Less than or equal to
LAMA Left against medical advice
um Micrometer
Airway, breathing and circulation LBW Low birth weight
ABC
Acetylcholine LMP Last menstrual period
Ach
LOC Loss of consciousness
AND Allow natural death
LQ Long question
ASIS Anterior superior iliac spine
LTI Left thumb impression
a/w Associated with
MCI Medical Council of India
BAC Blood alcohol concentration
mg% milligram percent) = mg/dL (milligram
BBB Blood-brain barrier
Body weight per decilitre) = mg per 100 mL
BW
MI Myocardial infarction
CCU Chaudhary Charan Singh University MIP Mentally ill person
CME Continuous medical education MLC Medicolegal case
CNS Central nervous system MLI Medicolegal importance
CO Carbon monoxide MLR Mediclolegal case report
COHb Carboxyhaemoglobin MOA Mechanism of action
COI Constitution of India nm Nanometer
CrPC Criminal Procedure Code, 1973 NREM Nonrapid eye movement
CVS Cardiovascular system N/V Nausea and vomiting
D/D Differential diagnosis OD Once a day
DIC Disseminated intravascular coagulation OIC Officer-in-charge
DMC Delhi Medical Council OT Operation theatre
DNR Do not resuscitate POCSO Protection of Children from Sexual
DU Delhi University Offences Act
D/W Difference between POTA Prevention of Terrorism Act
EDH Extradural haemorrhage PSIS Posterior superior iliac spine
EUL Extrauterine life PVS Persistent vegetative state
FD Fatal dose RMP Registered Medical Practitioner
FP Fatal period RTA Road trafic accident
FSL Subarachnoid haemorrhage
Forensic Science Laboratory SAH
FPs SDH Subdural haemorrhage
Finger prints
GA SIDS Sudden infant death syndrome
General anaestheticCS
h Hour/Hours SMC State Medical Council
Hb Haemoglobin SN Short note
HR Heart rate Sol Solution
HSR SVC
Hyper sensitivity reaction Superior vena cava
MR Indian Council of Medical Research TADA Terrorists and Disruptive Activities Act
ICP TBSA Total body surface area
Intracranial pressure
IEA TCAs Tricyclic antidepressants
Indian Evidence Act, 1872
IHD WMA World Medical Association
Ischaemic heart disease
IM Intramuscular ww-I
IPC and II World War-first and second
Indian Penal Code, 1860
 ABBREVIATIONS

PUNISHMENTS
P=110 rm +F: Punishment is 'imprisonment for
10 years which may extend to lifec' with fine.
P =
I,
or F (Rs 10) or both: Punishment is
mprisonment for 4 years or fine of Rs 10 or both. P RI + F: Punishment is 'rigorous imprison-
P 1, + F: Punishment is 'imprisonment ment' with fine.
for life P Punishment is 'rigorous inmpris.
smenths-2 years
with'fine.
onment extending from 6 months to 2 years.
 CONTENTS
Preface, vii
Acknowledgements, ix 7 Firearm Injury 191
Abbreviations, xi 7P Miscellaneous injuries (electrical
injurics and lightning) 207
8 Mechanical Asphyxia 211
SECTION Forensic Medicine 9 Sexual Jurisprudence 232
9A Impotence and Sterility 232
1 Introduction to Forensic Medicine 9B Virginity, Pregnancy, Delivery
3
2 Legal Procedures and Legitimacy
5 238
3 Medical Jurisprudence 22 9C Abortion 247
3A Code of Medical Ethics, Medical 9D Infanticide 253
Councils, Acts, Medical Records 9E Sexual Offences and Sexual
and Professional Misconduct 22 Perversions 263
3B Consent 33
10 Blood Stains 282
3C Medical Negligence 11 Forensic Psychiatry 289
37
4 Medicolegal Autopsy 12 Miscellaneous Topics 306
(Postmortem Examination) 49 12A Anaesthetic and Surgical Deaths 306
5 Identification 56 12B Torture and Custodial Deaths 308
5A Identification, Age, Race, Sex and 12C Recent Methods of Interrogation 310
Stature 12D Fall From Height 312
56
5B Forensic Osteology 12E Trauma and Disease 313
75
5C Forensic Odontology 12F Medicolegal Importance of
85
AIDS/HIV 314
5D Dactylography (Fingerprinting)
12G Starvation Deaths 315
and Other Prints 93
5E DNA Fingerprinting 97
5F Miscellaneous Methods of SECTIONII Forensic Toxicology
Identification: Forensic Trichology,
Marks and Deformities, 13 General Aspects of Forensic
Toxicology 319
Anthropometry, Superimposition
101 14 Corrosive Poisons 336
and Biometric methods 342
6 Thanatology 106 15 Inorganic Irritant Poisons
16 Organic Irritant Poisons 355
6A Death and Its Causes 106
17 Poisons Acting on Nervous System 368
6B Sudden Death and Unexpected
113 17A CNS Depressants 368
Death 381
115 17B Deliriants
6C Euthanasia 389
117 17C Spinal and Peripheral Nerve Poisons
Postmortem Changes
6D
135 18 Cardiac Poisons
394
7 Injuries 398
135 19 Asphyxiants
7A Medicolegal Aspects of Injuries 404
7B Mechanical Injuries
144 20 Agricultural Poisons 410
163 21 Drug Abuse 417
7C Regional Injuries
7D Thermal Injuries 180 22 Miscellaneous Poisons

xiii
xiv CONTENTS

SECTION I Practicals SECTION IV Appendix

MA Specimens 423 1 Weights and Measurements 491
(For Spotting and Grand Viva) 423 2 Important Sections in CrPC, IPC and IEA 492
IB Injury Examination Report 446 Sample Papers 496
IIC Age Estimation Report 455
IIID Grand Viva in Forensic Medicine 465 Index 499
IIIE Grand Viva in Forensic Toxicology 483
(Except Specimens) 483

Introduction to Forensic
INTRODUCTION TO FORENSIC
MEDICINE
term forensic has come from the Latin word
The
esis which means of the forun' or 'court of
ia. In ancient timmes, 1n Rome, forum was the
meeting place whe civic and legal matters
were
discussed by the conmpetent authorities.
Forensic medicine: It deals with the application
of medical knowledge to aid in administration of
justice; it also deals with the medical aspects of law
It is used by legal authorities to
solve legal prob-
lems.
Medical jurisprudence (Latn, Juris = law; pru-
dentia= knowledge): It deals with the legal aspects
of medicine, that is, the legal principles that guide
the medical personnel. It includes legal rights,
privileges, duties and obligations of a medical
practitioner, doctor-patient relationship, consent,
medical negligence, serious professional miscon-
ducts, medical ethics and so on.
Forensic science: It deals with the application of
scientific knowledge (e.g. physics, chemistry, biol-
ogy, etc.) for the purpose of law and administra-
tion of justice. The laboratory established to carry
out scientific examination and evaluation of evi-
dence for legal purpose is known as the forensic
science laboratory (FSL).
HISTORY OF FORENSIC MEDICINE
Imhotep (2980-2900 BC): He is considered as the
nrstmedicolegal expert. He was the chiet justice and
chief physician to Pharaoh Zoster, the king of Egypt.
Hippocrates (460-377 BC): The father of western
nedicine, Hippocrates was born and practised
medicine in the island of Kos in Greece. He
1
Medicine
discussed the lethality of wounds. Hippocrates was
the first to write the code of medical ethics.
Orfila (1787-1853, France): He is considered as
the founder and father of modern toxicology as
he introduced precise chemical methods into
toxicology.
First autopsy: (1) Outside India-Bartolomeo da
Varignana (AD 1302) performed the first medico-
legal autopsy in Bologna, Italy. Then in AD 1562,
Ambroise Paré performed an autopsy in France on
the dead body of King Henry II. (2) In India-Dr
Edward Bulkley (1693) performed the first med-
icolegal autopsy in Chennai on the dead body of
Mr Wheeler. Dr Hamilton (1725) performed the
first autopsy in Kolkata.
CRIME SCENE INVESTIGATION
Crime scene: It includes the actual location where
the crime was committed. The investigation of a
crime scene done by authorities to help in admin-
istration of justice is known as crime scene inves-
tigation.
Evidence: Anything which helps to support truth
is evidence. Anything which is in the form of an
identifiable object is physical evidence, for exam-
ple, hair, blood stains and so on. When phys-
ical evidence is present in very tiny quantities, it
is known as trace evidence. Trace evidence can
be thought as evidence occurring in such small
amounts that it can be transferred (or exchanged)
between two surfaces (or persons or bodies) with-
out being noticed. The evidence is collected from
crime scene and then preserved and transported to
laboratory or court. It is very important to main-
tain the chain of custody of evidence
Locard's principle of exchange [SN-1]
3
 SECTIONI Forensic Medicine
QUESTIONS-ANSWERS
SN-1: Locard's principle
Drnalist
Edmond Locard (1877-1966), a French crimi-
and
pioneer
in forensic science, described a
principle popularly known as Locard's exchange
principle. This principle constitutes the basis of the
concept of trace evidence and all crime detection.
It states that 'Every contact leaves a trace. It means
Examples:
when any two objects come into contact, there
is always a transfer of material from each object
onto the other.
In crime scene investigation, Locard's principle has
a very important role. The perpetrator after com-
mitting crime leaves the crime scene after destroy-
ing the evidence. But it is the principle of nature
that when a perpetrator touches something dur
ing crime, he leaves some evidence which is either
not visible to him or which he is not aware of. The
evidence left at crime scene may be grossly visible
to the naked eye (e.g. blood) or it may be invisible
(e.g. sweat, epithelial cells, saliva, semen, finger.
prints, etc.).
Nowadays, criminals are more aware about the sci-
entific investigation of crime, so the criminal after
mmitting crime tries to destroy the evidence,
but modern techniques recently developed in the
field of forensic science can detect trace evidence
at microscopic level.
1) Rape: The semen is transferred to the female
genitals, but vaginal cells are transferred to the
penis.
2) Homicide: Blood of the victim sticks to the
dagger and the dagger leaves its metallic traces
at the wound.
3) Fingerprints: The perpetrator touches a glass
by his hands to leave his fingerprint patterns.
4) Shoe marks: A criminal after committing crime
runs away but leaves his footprints on soil. The
soil sticks to the sole of his shoes.
,

INDIAN LEGAL SYSTEM
The Indian legal system was founded by the Colonial Brit-
ish, and after independence it was adopted by India after
making some amendments. The criminal justice in India
isgoverned by the Constitution of India (COI), CrPC,
IPC, IEA and various categories of criminal courts' (c.g.
Supreme Court, High Court, Session Court and so on)
which conduct trials and help incriminal justice.
It
Criminal Procedure Code, 1973 (CrPC): provides
themechanism for punishment of offences against
thesubstantivecriminallaw. It prescribes the proce
dures to be followed by the police in criminal cases,
forexample police duties in arresting.offenders, deal-
ingwith absconders. in production of documents and
investigating offences. It classifies courts and deals
with actual procedure in trial, appeals, references,
revisions and transfer of criminal cases,
Indian Penal Code, 1860 (IPC): It classifies all pos-
sible crimes and prescribes punishments for them.
Chapter XVI is the largest chapter in IPC, which con-
tains 78 sections [S.299-S.377]; it describes offences
affecting the human body, which include some of the
important sections relevant to medical practitioners.
Indian Evidence Act, 1872 (TEA): It deals with law of
evidence and prescribes rules regarding procedures
for tendering evidence in a court of law.
TYPES OF COURTS OF LAW IN INDIA
Ihere are two types of courts: civil courts and crim-
inal courts.
Civil courts: They dealonly with civil matters, for exam-
Ple, land and
property (eg. landlord/tenant disputes),
Industrial, financial, administrative, family matters (e.g.
avorce), etc. Examples include consumer protection
1orum, tribunals
and family courts. The punishment
8ven by these courts is in the form of compensation.
Conduct money is paid to witnesses for attending court.
Legal Procedures
Criminal courts: They deal with criminal offences
codified in IPC, for example, murder, rape, theft,
robbery, etc. and award punishment in the form of
imprisonment or sometimes death penalty with or
without fine. Examples include Supreme Court, High
Court, Session Court and Magistrate Court. Conduct
money is not paid to witnesses for attending the court
but they can get TA/DA.
Supreme Court (SC): It is the highest court of the
country situated in New Delhi.The Supreme Court
has been establishedunder Article 124 of COL It
is presided over by the Chief_Justice of India who
is appointed by the President of India. Article 145
empowers SC to frame its own rules for regulating
thepractice and procedure of the court as and when
required (with the approval of the President).
High Court (HC): It is the highest court of a state
usually located in thecapital of every state. Ithas been
established under Article 214 of COL. It is presided
over bythe Chief lustice of State whois appointed
by the President of India. Some states share a comn
mon HC for example, (1) Guwahati HC caters for all
seven states in the North East (Arunachal Pradesh,
ASsam Manipur Meghalaya, Mizoram, Nagaland
and Tripura), (2) Mumbai HC caters for the states
of Maharastra, Goa, Union Territories of Dadra and
Nagar Haveli and Daman and Diu.
Session Court (or District courts): It is the high:
est court of a district located at district headquar
ters, It is presided over by a "District Session ludge
DS) appointed by High Court. High Court may
LSO appont additional session judge and asSIstanE
Session_judge, to exercise_ jurisdiction in a court or
Session,DSI is also knownas district judge whenhe
when he
presiles over a civil case, and session judge
case, Fast track courts havE
presicles over a griminal are
Session Courts. They
ne_statuS of additional cases and tor ne
established to reduce long pending
speedy disposal of cases.
 SECTIONI Forensic Medicine

First information report (FIR): FIR is the first infor-

Magistrate Courts
are specialised in law mation report about the commission of a'cognisable
1) Judicial magistrate: They
are empow- offence, given either by the victim or any other person
(i.e. have LLB and LLM degree) and
ered to deliver judgment. They are of thrce
types. to the police. It is recorded in writing in FIR regis-
(a) Chiefjudicial magistrate (CJM): In
metropoli- ter by the officer-in-charge of a police station [S.154,
tan cities, CJM is known as Chief Metropolitan CrPC)
Magistrate.
(b) First-class judicial magistrate: In metropolitan INQUEST [SN-2]
cities, first-class judicial nagistrate is known as
Inquest: It is an inquiry by legal authorities into the
Metropolitan Magistrate cause of death in cases of sudden, unnatural and
(c) Second-class judicial magistrate.
suspicious deaths. Types of inquest are shown in
2) Executive magistrate: They are administrative Table 2.2
officials appointed either through a civil service
examination or through promotion. So, they may
have LLB degree but most often do not. They are TABLE 2.2 Types of Inquest [Mnemonic:
not authorised to deliver judgment because their Prime Minister Chief Ministerl
duties are of executive nature. They do not give any Medical
punishment. Examples, District Magistrate (DM), Magistrate Coroner's Examiner
Additional District Magistrate (ADM), Subdivi- Police Inquest Inquest System
Inquest ISN-3] [SN-4] [SN-5]
sional Magistrate (SDM), Collector, Tahsildar.
It It is It is It is
Powers of Various Criminal Courts [SN-1] conducted conducted conducted conducted
by police by by by 'medical
OFFENCE AND FIR magistrate. Coroner examiner

Offence is defined as 'any act or omission made pun-

ishable by law for the time being in force. Depending
on the nature and gravity of an offence, it may be clas- SUMMONS [SN-6]
sified as cognisable and noncognisable (Table 2.1).
Summons (or subpoena): t is a written document
TABLE 2.1 Cognisable Offences Versus issued by the court, compeling the attendance of
a witness in the court of law, to depose evidence,
Noncognisable Offences
Noncognisable Offences
at a particular date and time and purpose under
Cognisable Offences
penalty.
These are offences of such These are offences not
nature and such gravity that of such nature and such Conduct money [SN-7]
immediate arrest of the gravity as is cognisable
offender is necessary and offences and thus the Warrant: If a witness fails to attend the court due
thus the police officer may police officer firstly has to some reason (e.g. illness, emergency and so on),
arrest without warrant. to take warrant from he should convey the message to the court and then
These are serious offences magistrate to arrest the next date of hearing will be issued to him. If the
and so the punishment These are minor offences
for these offences is more and so the punishment for witness has no valid reason for not attending the
than that of noncognisablethese offences is less than court, a warrant for his arrest may be issued to secure
offences. that of cognisable offences. presence of the witness.
Examples: Murder, Examples: Adultery,
sexual offences, sexual bigamy, bribery, causing
harassment, voyeurism, miscarriage, etc. WITNESS [SN-8]
stalking, dowry death,
Kidnapping,etc. Witness: A person who provides evidence about a fact
An FIR can be filed only Here, the police will not file in the cort of law under oath is known as witness.
in the case of cognisable an FIR but it will register
offences
Types of witness (Table 2.3): There are three types of
the complaint in the dally
dlary report/register (DDR). witness: common witness, expert witness and hostile
witness.
 CHAPTER 2 Legal Procedur

According to S.226 of CrPC, public

TABLE 2.3 Vpes of WitneS prosecutor (PP)
tries to prove, on the basis of witnesses
Expert Witness Hostile Witness and evidence,
Common that the arrested person is an offender (accused)
[SN-9] [SN-10] in
Witness the concerned case.
common A person who A person who If Magistrate finds that there is no specific ground
A is skilled in a purposefully
person wno has (witness or evidence) to take any legal action
or particular field makes statements
actualy seen contrary to the against the accused then he can release the accused
(e.g. law, science
observed the facts IS. 227, CrPC|.
narrates or art) and fact or has some
and he
those facts in who provides
evidence about a
interest or motive
for concealing
If Session Court finds that arrested person is an
the witness
box offender, then court charges the accused [S.228,
common fact in the court truth.
is a
of law under Perjury ISN-11) CrPC). Session Court gives a charge sheet, recites
witness. He is not
allowed to draw oath is known as Wilfully giving it, and asks him whether he admits his guilt or
conclusions from expert witness. false evidence not. If Session Court finds (thinks) that the case
his observations.
under oath.
does not deserve to be heard, then the court sends
(hand-over) the case to the CJM.
According to S.229 of CrPC, if accused confesses
PROCEDURE IN COURT his guilt, then court punishes him, but if he refuses
his guilt, then the court does not admit him as an
When a witness appears in court, the court procedure
offender under S.229 of CrPC but gives another
starts in the following sequence.
date of hearing for statement of witnesses. Accord-
) Oath taking [SN-12]: Before giving evidence in ing to S.231 of CrPC, court proceeds with the testi-
the court, the witness has to take oath because it is
mony (statement) of witnesses on the fixed date of
presumed that after taking oath, witness will speak
hearing. The PP sums-up [presents the point (con-
the truth.
tents)] the case before the court and the accused or
2) Recording of evidence (i.e. examination of a wit-
the counsel of accused shall be entitled to reply. If
ness in the court): According to S.138, IEA, the
the counsel of accused raises any questions regard-
order of examination in the court of law is in the
ing the case, then PP answers those questions. After
following sequence.
that, a final argument takes place between coun-
A. Examination-in-Chief [SN-13] sels of both parties. On the basis of this argument
then and the witnesses and evidence, the judge gives his
B. Cross-examination [SN-14]
decision (judgement) regarding the case.
then
C. Reexamination
EVIDENCE
D. Questions put by the court (note: The court
can ask any question any time during the pro- Evidence: 'Anything which is presented in the court to
cedure.) support the truth' or 'anything presented in support
Summary trial [S.260-265, CrPC]: It means short of an assertion' is called evidence. According to S.3 of
and rapid trials avoiding the regular lengthy proce- IEA, evidence is of two types:
dure. Summary
trial aims at speedy/quick disposal 1) Oral evidence: It means 'all statements (oral or
minor offences. A summary case is one which can verbal) which the court permits or requires to de
tried and disposed made before it by witnesses, in relation to matters
De
of at once. In summary trial,
ence of imprisonment for a term more than
months can be imposed by the magistrate.
of fact under inquiry.
2) Documentary evidence: It means 'all documents
for the
Frocedure of criminal
trial: The proceedings of including electronic records produced
Estigation by the police in criminal offences are inspection of the court. 'acquisition
E udicial magistrate of that area. All offences Classification of evidence on the basis of
Punishable with death,
imprisonment of life or of evidence': directlyY
prisonment for >2 years are tried as warrant cases. evidence: When the witness had
A) Direct his senses, it
l other cases felt it by any of
are tried as summons cases. Seen the crime or had
 SECTIONI Forensic Medicine
is called direct evidence. Example, a street vendor
saw a murder in the street.
(B) Indirect: Witness did not directly see the crime. It
may be of two typeCS:
1) Circumstantial cvidence: The witness dicd
not
see actual crime; but some related act observed
by him indicates strongly the comnmision of
crime. For example, W committed murder of 13
C saw 'A'with knife in hand just bcfore the mur-
der. Here, since 'C' did not see the murder with
his eyes; the evidence of C is a circumstantial
evidence. If'C had actually seen the murder with
his own eyes, it would have been direct evidence.
2) Hearsay evidence: The witnes only heard
about the crime from someonc. Example, 'A
told that B had told him that he has seen 'C
while committing the crime. Here 'B' can give
direct evidence as he has seen C committing
the crime; however, the evidence of 'A will be
hearsay evidence. Generally, hearsay evidence
is not admissible in court.
Classification of evidence on the basis of 'presenta-
tion in the court':
1) Oral evidence (testimony):
All statements (oral or verbal) which the court
permits or requires to be made before it by
witnesses, in relation to matters of fact under
inquiry [S.3, IEA].
Oral evidence must be direct i.e. it must be
evidence of an eyewitness [S.60, IEA]. In other
words, a person must have himself seen or heard
something or perceived by some other sense.
Oral evidence is more important than docu-
mentary evidence because it permits cross-ex-
amination. Documentary evidence is accepted
by the court only after oral testimony by the
person concerned.
Oral evidence by a dumb witness is possible if
in the open court, he tries to do so by writing
by signs, or by an interpreter |[S.119, IEA].
Exceptions to oral evidence: Documentary evi
dence is accepted in the court only on oral tes-
timony (i.e. oral evidence). But in some cases,
documentary evidence is accepted in the court
without y oral testimony. These exceptions to
oral evidence are:
1) Statements of relevant facts made by
a per-
son who is dead (i.e. dying declaration)
or can't be found or is incapable of giving
evidence (S.32, IEA].
2) Evidence given by a witness in a previous
judicial proceeding is admissible in a subse-
quent judicial proceeding when the witness
is dead or can't be foun or is incapable
of
giving evidence [S.33, IEAJ.
3) Expert opinion expressed in a treatise:
Expert opinions printed in standard text.
books are accepted as evidence without oral
evidence of the author [S.60, IEA].
4) Deposition of a mental witness taken in
lower court: Evidence of a doctor recorded
and attested by a Magistrate in the presence
of accused who had an opportunity to cross
examine the witness, may be accepted as evi-
dence in a higher court [S.291, CrPC].
5) Reports of certain government scientific
experts e.g. (A) Chemical examiner, (B) Chief
controller of explosives, (C) Director of Finger
Print Bureau or Director of Haffkeine Insti
tute of Mumbai, (D) Director, Deputy direc
tor or Assistant director of Central or State
FSL, (E) Serologist [S.293(4), CrPC]. The
court may however summon and examine any
such expert if it thinks fit [S.293(2), CrPC].
6) Public records: Birth certificates, Death cer-
tificates, Marriage certificates.
7) Hospital records: Routine entries eg. date
& time of admission, discharge, vitals (e.g.
pulse, temperature, urine output, etc), etc.
2) Documentary evidence: All documents produced
before the court is called documentary evidence.
These may be (1) primary evidence (i.e. original
document itself produced for inspection by the
court) and (2) secondary evidence (i.e. the docu-
ments, which are not original, e.g., certified copies,
photocopies and so on). Documentary evidence
related to medical field are known as medical doc-
uments. Medical documents include (1) medical
certificates, (2) medicolegal case (MLC) reports,
(3) dying declaration [SN-16] and (4) dying
deposition [SN-17].
MEDICAL CERTIFICATES
wwww
They are the simplest form of documentary evi-
ence, issued by a registered medical practitioner
(RMP) at the request of the patient.
Examples: sickness certificate, fitness certificate,
disability certificate, unsoundness of mind certifi-
cate, age certificate, death certificate.
 accepted in the court of law as a piece of evi-
accepted
It is the RMP who has issucd it may be
dence Even
summoncd to the court of law to
l testify the con-
certificate on oath; it needed, cross-exami-
entsof done. So, RMP must take due care
nation can be certificates.
and skill in issuing such
signing false certificates: This is pun-
Issuing or S.193, IPC and the ctor can be
ishable under
atwarded 7 ycars of imprisonment
and fine. The
atient using
such ertificates will also be pun-
ished under S.198, 1PC with
similar punishment.
(DC)
Death Certificate
,According to Registration of Birth and
Death
all births and deaths are to be registered
Act, 1969,
throughout India.
must inspect the body
Before issuing DC, a doctor
and satisfy himself that the
person is dead.
the patient during his last
Ifa doctor has attended
illness, he must issue DC without charging any
fee [S.10(3), RBD Act, 1969]. The Brodrick Com-
mittee says that a doctor should not be allowed to
issue a DC unless he has attended the deceased at
least once during the 7 days preceding death. If the
doctor refuses to issue a DC even if the aforemen-
tioned conditions are satistied, he will be charged
Rs 50 [S.23(3), RBD Act].
A doctor cannot refuse or delay issue of DC. But
ome situations, such as the following, he must
refuse to issue DC and inform police: (1) when he is
not sure about the cause of death, (2) there is suspi-
cion of foul play, that is, doubtful cases, (3) death by
Violent and unnatural cause, drugs, poisoning, etc.
Relative of deceased may plead, persuade, pres-
Surise, offer a price and at times even threaten the
doctor to issue a false certificate.
WHO ([nternational) format of DC is in two parts.
Part I: There are three subsections for the
Sequence of events leading to death.
(a). Immediate cause of death: The disease
or condition directly leading to death.
It should not be the mode of death. 'Car
diopulmonary arrest or cardiorespira-
ory arrest or "cardiac arrest or caraiac
Talure or heart failure' or asphyxia are
Commonly seen written in death certifi-
cates as immediate cause of death, which
1S wrong.
These terms are actually the
modes of death. It is well known to all
medical practitioners that every one dies
of cardiopulmonary arrest or cardiac
failure.
It should be a discase, injury or complica-
tion, which caused death.
I(b). Antecedent cause (or intermediate
cause of death): The morbid condition
that caused the immediate cause of death.
I(c). Antecedent cause (or underlying cause
of death): The basic pathological condi-
tion present before the aforementioned
two causes [i.e. I(a) and I(b)] and lead-
ing to the aforementioned two causes. So,
I(a) must be caused due to I(b), and I(a)
and/or I(b) must be caused due to I(c).
Underlying cause of death is the disease,
which initiated the train of morbid events
leading directly to death.
Features of part I: If the sequence of events
in part I comprised more than three stages,
extra lines may be added in part I. Most
recent condition has to be written in the
top line and the earliest (i.e. the condition
that started the sequence of events between
normal health and death) in the last.
Part II: Contributory cause: The condition,
which contributes to death but not directly
related to the disease or condition causingit.
Conditions in part I should represent a distinct
sequence so that each condition may be regarded as
being the consequence of the condition entered imme
diately below it. Where a condition does not seem to fit
into such a sequence, it may belong to part II.
Examples:
A patient dies from myocardial infarction (MI)
due to coronary artery disease (CAD). Immediate
cause of death is MI; write it in part I(a). Anteced
ent cause of death is CAD; write it in part I(b).
2) A patient died from cerebral haemorrhage due to
hypertension. He had a history of diabetes. Inme-
diate cause of death is cerebral haemorrhage;
Write it in part l{a). Antecedent cause of death
Is
nypertension; write it in part 1(6). Contributory
cause of death is diabetes; write it in part l
days after
3) A man of 65 died of peritonitis a few
pertoration. e
noperation for duodenal duocdenal ulcerations.
had a history of chronic
death is peritonitis;
Here immediate cause of pertora
is duodenal
antecedent cause of death is chronic
contributory cause of death
tion and
duodenal ulceration.
10 SECTIONI Forensic Medicine
MEDICOLEGAL CASE AND
MEDICOLEGAL CASE REPORT
Medicolegal case (MLC): If an attending doctor
(in
casualty or OPD) after taking history and examining the
patient suspects foul play or has doubts about
the case
and/or thinks that some investigations by law enforcing
agencies are essential so as to fix responsibility regard-
ing the case, the case is regarded as medicolegal case.
It
is left to the doctor's judgment to label the case as
MLC
whether patient agrees or not. Sometimes, the patient
or relative may request or conmpel a doctor not to make
MLCbut the doctor has to be firm with his own decision.
Medicolegal case report (MLR): This includes the
legal documents prepared by a doctor at the request
of some investigating authority, for example, police,
magistrate. It is made on both living and dead patients.
Examples are (1) injury report, postmortem report,
vaginal swab report in case of sexual offences, etc.
Who can make MLC ?: A government as well as a pri-
vate practitioner can make MLC. It is very common
for private hospitals and private practitioners to avoid
MLC cases; they generally refer doubtful cases to gov-
ernment hospitals. If condition of such a patient is
serious and he dies on the way to hospital, the private
practitioner as well as the private hospital can be sued
under S.304A.
Following cases are labelled as MLC and the police
must be informed: (1) injury cases, (2) poisoning,
(3) burns, (4) sexual assault, (5) brought dead cases,
(6) brought unconscious, (7) road traffic accidents
(RTA), (8) fall from height, (9) factory accidents, (10)
death in OT during MTP, criminal abortion, delivery
or other surgical procedures, (11) suspected homicide
or suicide.
Precautions while preparing MLC
1) Consent for examination: If a patient is not
arrested, consent is required.
For the purpose of medicolegal examination,
consent can be given by any person of sound
mind and >12 years of age. If the person is
unconscious or insane or <12 years, the con-
sent can be obtained from the guardian.
Signature or left thumb impression (if illiterate) of
patient as well as witness must be taken. Witness
may be the police officer who brought the patient.
The purpose and outcome of such examination
should be explained to the victim before taking
the consent.
If the patient is not arrested, then for the exami-
nation, his or his relative's consent has to be
taken. If patient refuses, then under S.53, CrPC,
the medicolegal examination of accused can
be done at the request of police [not below the
rank of subinspector (SI)J by using reasonably
necessary force.
2) Labelling the case as MLC: It is left to the doctor's
judgment to label the case as MLC, whether patient
agrees or not. The patient or relatives may compel a
doctor not to make MLC but the doctor has to make
his own decision. If doctor delays in labellinga case
as MLC, it can be so labelled at any later date and
time. Consent of the patient/relative is not required
for labelling a case as MLC. Doctor has to decide.
3) Information to police: When there is a doubt
about a case, it is better to inform police. Police
must be informed as early as possible.
If a doctor in casualty does not inform police in
an MLC, he may be punished with month of
1
imprisonment or fine of Rs 500 or both [S.176,
IPC].
If adoctor furnishes information to police
which he knows or believes to be false, he shal
be punished with 6 months of imprisonment or
fine of Rs 1000 or both [S.177, IPC).
4) MLC reports must be made in triplicate and all
copies must be marked 'MLC. Original copy is
handed over to police and his signature must be
taken on an other copy, that is, the doctor's copy.
Doctor's copy is retained in medicolegal register.
The third copy may be given to the patient.
5) Investigation reports (e.g. X-rays/CT requisition
slip, laboratory report slips and so on) must be
marked 'MLC' and then handed over to the police.
They should never be given to patient.
6) MLC has to be attended round the clock without
delay. If delay has occurred initially in labelling a
case as MLC, it can be labelled as MLC at any later
date and time, but not after death of a patient.
What is more important, treatment or completion
of injury report?
It depends on seriousness of a patient. Injury
report can be completed after the enmergency treat-
ment. If the condition of the patient is very serious,
arrangement should be made for dying declaration. If
death occurs during treatment, the police should be
immediately informed and the body handed over only
to police, not relatives.
 CHAPTER 2 Legal Proced

If a case has been labelled as MLC PUNISHMENTS AUTHORISED BY THE

econd MLC: hospital (e.g. H1) but is referred
doctor in one. LAW [S.53, IPC]
byaanothecr hospital (e.g. H2) for proper treat-
to
a resh (i.e. second). MLC report can be made S.53 of IPC mentions five types of punishments:
ment, (1) Death sentence (also known as capital punish-
doctor in H2 at his discretion. The reason is
by the H1 may be MBBS and the findings ment)
doct
that the been explain properly but the doctor (2) Imprisonment for life-Life imprisonment
maynot have (i.e. MD) in forensic medicine means imprisonment for whole of the remain-
H2 may bean expert
in can interpret injuries in a better way. Addition- ing period of a person's natural life i.e. till the last
who
doctor from H2 is summoned in court, he breath of his life i.e. till death.
alls when findings. (3) Imprisonment
has to go
by his own
where a doctor has to wait to give opinion: (1) (i) Simple
Case
If the nature
of injury (simple, dangerous or grievous) (i) Rigorous
immediately apparent, the patient must be kept (4) Forfeiture of property
is not
investigation (e.g. X-ray (5) Fine
under observation. (2) If the
CTor blood) have been
sent and it will take a long time
for these to collect, the doctor
must wait to give opinion. EXHUMATION [SN-18]
Opinion: Opinion must be kept pending
till the
reports are available in cases where
necessary inves-
tigations are required. Negative results should
also be CONDUCT OF DOCTOR IN THE COURT
pointed out in the report.
Subsequent opinion: After observation period is over (1) After receiving summons, the doctor must
and all reports have been collected, the subsequent attend court. He should be punctual, carry all rel-
opinion is given based on the new findings. evant documents and be well prepared about the
MLC reports are produced in the court of law and case. (2) He must be well dressed. (3)) He should
if summoned, the doctor should attend the court. neither be nervous inside court nor lose his temper.
If thedoctor is not available, someone can attend He should remain calm, polite and courteous. (4)
He should address the judge as 'sir' or
your hon-
the court to testify his signature and handwriting as
our. (5) He should not be overconfident. If he does
evidence.
not know the answer, he can simply say 'Sir, don't
I
In poisoning case: Gastric lavage, vomitus, urine or
blood must always be preserved in a case of poison-
know. (6) He should listen and understand the
ing and these samples handed over to the concerned question, then answer. If not clear, he should ask for
police official. If a doctor fails to preserve these, he may the question to be repeated again. He should answer
be sued under S.201 of IPC for causing disappearance only what is asked. (7) He should speak audibly, and
of evidence with the intention to screen the offender
avoid technical terms. (8) He should not try to mem-
Trom legal punishment. The doctor may be punished orise any fact. The law allows the doctor to refresh
according to three situations. If the offence which he his memory from the records and he can consult any
Knows or believes to have been committed is as follows. book to check any point [S.159, IEA]. (9) He should
Punishable with 'death: The doctor will be pun- not leave the court without permission. He should
fine. always greet the judge before leaving the court.
Snea with imprisonment for 7 years and
Example in case of murder.
Funishable with imprisonment for life or>10 years: IMPORTANT QUESTIONS FOR
he doctor will be punished with 3 years of impris EXAMINATION
onment and fine.
Shable with imprisonment for <10 years: The SHORT NOTES (SN)
doctor will be punished with imprisonment for
1. Powers of various criminal courts
/4th of the longest term of imprisonment pro- 2. Inquest [CCU 2005, 2012]
Ided for the offence, or fine, or both. Example in
case of suicide. 3. Magistrate inquest
 Powers of Session Court
4. Coroner's inquest 1) Session Judge or
Additional Session Judge
5. Medical examiner's system pass any sentence authorisedibylaw,but can
Summons/Subpoena the'i
6. sentence' must be confirmed by High Court.
7. Conduct money 2) Assistant Session Judge may pass sentence
17]
8. Witness [DU 2005, CCU 2016, imprisonment for only <10 years. of
9. Expert witness [CCU 2003, 2010]
Powers of Magistrate Court (Table 2.4): Kecutive
10. Hostile witness [DU 2008] |CCU 2012]
magistrates are not authorised to leliver judgnm
11. Perjury (DU 2009, 2011) [CCU 2012] nent
because their duties are of executiv nature. They
12. Oath
Examination-in-clhief (direct examination) do not give any punishment.
13.
14. Cross-cxamination
15. Leading question [DU 2007] [CCU 2005, 2009] TABLE 2.4 Powers of Judicial
16. Dying declaration Magistrate [S.29, CrPC]
17. Dying deposition [CCU 2010]
Magistrate Imprisonment Fine
18. Exhumation [CCU 2003, 2004, 2009, 2010]
Chief Judicial Magistrate (CJM) 7 years Unlimited
DIFFERENCE BETWEEN (D/W) Judicial Magistrate of 3 years 10,000
first-class
inquest and magistrate inquest [DU 2011]
19. Police
Judicial Magistrate of 1
year 5,000
20. Coroner's Court and Magistrate Court second-class
21. Common witness and expert witness
22. Examination-in-chief and cross-examination
DU 2003, 2009] [CCU 2012] SN-2: Inquest
23. Oral evidence and documentary evidence
24. Dying declaration and dying deposition [CCU Inquest: It is an inquiry or investigation by legal
2003, 2004, 2012] authorities into the cause of death in cases of sudden,
unnatural and suspicious deaths. Types of inquest are

L ANSWERS as follows:
1) Police inquest
SN-1: Powers of various criminal 2) Magistrate inquest [SN-3]
3) Coroner's inquest [SN-4]
Courts
4) Medical examiner system [SN-5]
Powers of Supreme Court
1) The law declared by it is binding
on all courts Police Inquest [S.174, CrPC]
(Article 134, COI).
It is the most
common type of inquest in India.
2) It can try both civil as well as criminal
cases. Itis done in the following cases: (1) death due to 'sui-
3) It can pass any sentence including death
sentence. cide' or 'accident, (2) death in 'suspicious
4) It usually considers appeal from
lower courts.
circum-
stances, (3) killing by man
The parties dissatisfied with the or animal or machinery.
decisions Who conducts police inquest? An officer-in-charge
in High Courts may go for an appeal
in the (usually a police officer not below the
Supreme Court. rank of SI) of
Powers of High Court the police station in whose jurisdiction
the death has
1) It can try both civil as well occurred conducts the police inquest.
as criminal cases.
2) It can pass any sentence
authorised by law
What does officer-in-charge do on receipt Or
including death sentence. information? The officer-in-charge immedi-
3) It usually considers appeal ately informs the nearest executive
from lower magistrate
The parties dissatisfied with the decision courts. and then proceeds to the place
where the body
of Ses of such deceased person
sion Courts can appeal in the High Court, is. This police officer
4) Session Judge or Additional Session Judge who reaches the spot is
can now called investigat
pass any sentence authorised by law, but the 'death ing officer (10) who then
starts an inquiry into
sentence' must be confirmed by High Court. the cause of death. This
investigation or inquiry
by the police into
the cause of death is called
 9a OCtuits

It is done in the presence of two

police hauest. The proceedings of the magistrate are not judicial
respectable neighbours called panchas. procecdings; these proceeclings only try to find out
orm IO do?
does
,Whatinspects the cause of death.
the injurie present on the dead body After inqucst, the body is sent for postmortem
1) IO these injuries on paper with suitable
writes cxamination. The inquest papers must be handed
and mention the type of weapon
diagrams. He also Over to the autopsy surgeon for information. Dur-
responsible for these injuries and the anner of ing the investigation, the magistrate shall inform
dath (suicidal, accidental or homicidal). the relatives of the deceased and also allow them to
also writes the brief facts, views and infor- stay during investigation.
2) 1O papers.
mation from panchas on
arranges all these papers to prepare an SN-4: Coroner's inquest
3) Then he
inguest report (also known as panchnama').
panchnama is then signed by 1O himself Coroner's inquest: It is the inquiry into the cause
Thispanchas. of death conducted by coroner.
and
IO forwards this inquest report History:
5) Then,
(panchnama) to the magistrate. This type of inquest was followed earlier in Ko
kata and Mumbai. It was abolished in Kolkata
What does IO.do if any foul play or unnatural
in 1978 and in Mumbai in 1999. It no longer
death is suspected? IO torwards the body for post-
exists in India.
mortem examination (1.e. autopsy) to the near-
papers of Historically, the coroner (Latin, corona means
est government hospital along with the
crown' or 'king) was an officer appointed by
inquest report (panchnama). He then writes an
application requesting postmortem examination
the king to look into the cause of death.
At present, it is followed in countries such as
and attaches this application with the inquest
United Kingdom, United States, Canada and Aus-
papers. Finally, he presents these inquest papers
tralia.
along with application to the autopsy surgeon for
It is similar to magistrate inquest in quality.
conducting the postmortem examination.
Who is a coroner? He is an officer (a lawyer or a
lfpostmortem report confirms the unnatural cause doctor, or both) of the rank of first-class Judicial
of death, then further enquiry and trial of the case
is conducted by magistrate concerned, to whom
Magistrate, appointed by State Government.
the entire records of the case are transferred by 10.
The Coroner's Court is only a court of'inquiry, not
a court for'trial. It means the coroner is authorised
Magistrate Inquest [SN-3] only to conduct inquest; he is not authorised to
conduct trial. So, obviously he is not authorised to
Coroner's Inquest [SN-4J pass judgment on the case and thus has no power
Medical to pass a sentence.
Examiner's System [SN-5
After conducting inquest, if coroner finds ample
evidence against some suspect, he sends the culprit
SN-3:
Magistrate inquest to the judicial magistrate for trial.
If no culprit is identifiable, the coroner returns an
Magistrate inquest (S.176, CrPC]: The inquiry open verdict (i.e. no concliusion).
Ao the cause of death conducted by magistrate.
may be conducted by executive magistrate or SN-5: Medical examiner system
judicial magistrate.
into the
Indications: [Mnemonic. 3Ds Medical examiner system: It is an inquiry
examiner.
Dowry deaths (S.304B, IPC| use or death conducted by medical
Canada and Japan.
2) Death
occurring (1) in prison, jail or police cus- It exists in the United States, United
was first introduced in Massachusetts,
todys (2)
during police firing. (3) during police It
States in 1877.
Erogation/investigation, (4) in reformatories, legally and medically qual-
OTstal school or psychiatric hosplta Medical examiner is a
forensic pathologist.
He
3) especially a
igging out an already buried dead body from ifed expert,
grave lawfully, that is, 'exhumation performs two functions:
 SECTIONI Forensic Medicine
hand the court unless there are valid
valid and
and urgent
crime to get first attending.
1) He visits the scene of circumstances of
for not reas0ns

information regarding the 1) If the witness fails to attend

the cour
death.
conducts postmortem examination
(i.e. valid reason (e.g. ilness), he must
message to the court. A new date
e ey
2) He
after visiting crime
scene. ot hearingthe
autopsy) on dead bodies be issued to him. wi
district attorney for
submits his report to the 2) If the witness fails to attend the court
He further action. any valid reason, then
cour without
system. As a legally and
medi-
It is the best inquest scene of crime himself in civil cases, the court can issuewarrant
cally qualifed expert' visits the his arrest or he may be imposed a fine, of
and then conducts the
postmortem cxamination, he and
findings with the post- in criminal cases, the court can issue a
can correlate the crime scene noti
is no loss to him and asks the reason for nonattendan
mortem findings in a better way and there
is If there was no proper reason for not
of information. Hence, medical examiner system attend.
ing the court, he may De imposed a fine;
the best system and superior to that of other types ora
bailable/nonbailable warrant may be issued
of inquests in which nonmedical personnel (police,
magistrate or coroner) conduct an inquest. In other to procure his attendance in the court.
systems, inquest (including crime scene visit) is done If a witness receives tw0 summonses on the same
by a nonmedical person and the autopsy is done by date from the same type of court, he must attend
a medical professional, so a chain correlating crime the court from which he received the summons
scene findings with autopsy findings breaks and first and should inform the other court.
there are chances to loss information. If a witness receives two summonses on the same
The medical examiner does not have any judicial ate, one from criminal court and the other from
function. civil court, then he must attend the criminal court
first with intimation to the civil court as criminal
SN-6: Summons (or subpoena) courts have priority over civil courts. Similarly, the
higher court has priority over lower court.
Summons: It is a written document issued by the Conduct money [SN-7]: It is a certain amount of
court, compelling the attendance of the witness in money paid to the witness towards his expenses for
the court of law, to depose evidence, attending the court in civil case.
at a particular
date and time and purpose
under penalty. (Singu-
lar is'summons' and plural is
'summonses.)
It is also known as 'subpoena' (Latin, SN-7: Conduct money
poena = penalty). Types: sub = under
(1) subpoena ad testifi-
candum (to testify under It certain amount of money paid to the wit
is a
summoned to give his penalty)--a witness is
evidence. (2) subpoena ness to meet his travelling expenses (from his
tecum (bring with you duces residence to the court and back from the cour
under penalty)--a
is asked to produce
and submit a document. witness for attending the court. It is paid when a witnes
It is issued by the court in attends'civil court.
magistrate and bears duplicate, signed
the seal of the by the In a civil case, the conduct money is paid by tne
It is delivered to the witness court.
cer or an officer from through a police party who calls hinm. Conduct money 1s usu ly
the court or by offi
son specifically authorised any other
per- pad to the witness while serving the summons, Du
On getting the sümmons,for the purpose. at times, the money is paid in the court itsel
carbon copy of summons, the witness signs
relurns it to the If conduct money is insufficient: Even if the witness
not
son who provided the ninks that the amount paid is insufficient n
court) and keeps the
it (1.e, it 18
returned back per- according to the probable status and expenses
original copy. to the
After geting
the summons, then he should not ignore the mons; he shou
appear before the the witness attend the court, he can
time with proper
court on the specified must and before giving evidence,
records, A Witness date and inform the magistrate
must attend been paid that the conduct mone
to him by the party is insufficient. The mag
wOuld decide about the right quantum ot mo ney

conductt money is paid: Witness can ignore
Ifno summons if no conduct money is paid but the
the attend the court in the interest of the
witness must
justice Ifwitness does not attend the ourt,
stateor
charged for contempt of court.
can be
iminalcase: No conduct money is paid at the
summons, but after attending and giving
time f govern
rnment usually pays TA and
evidence, the
the courts [S.312, CrPC]. According
DA to
attend.such
CrPC, any crinminal court, if it thinks
S ofpayment ofreasonable expenses of any
foS.312
fAt, orders
mplainant or witness:attending the court for the
purpose of any inquiry trial or other proceeding.
a government servant, some courts
f a doctor iscertificate
only give a
mentioning that the doctor
had attended the court
and was paid nothing by
the court. On showing
this certihcate, the doctor
wOuld get reimbursement of his travelling and
other incidental expenses from
his institute. Pri-
vate institutes do not reimburse
this money, so
doctors working in a private hospital should
take
this money from the court before leaving the court.
SN-8:Witness
Witness: A witness is a person who provides evi-
dence about a fact in the court of law under oath.
After getting a summons from the court, the per-
son attends the court. He stands inside the witness
box, takes the oath and then gives evidence.
According to S.118, IEA, all persons are considered
competent to testify (i.e. to give evidence in tne
court of law) except when they do not understand
the question or do not give rational answers to the
question due to (1) tender years (e.g. a child of
1ature understanding), or (2) extreme old age
or (3) disease (mental/physical).
ypes of witnesses: Actually, the witnesses are of
WO types(e.g. common witness and expert wit
S but as both of these types of witnesses may
nOstile (i.e. unfavourable), hostile witness
nay be considered
as a third type of witness.
Common (ordinary) witness: A common per
SOn who has
actually seen or observed the facts
4a narrates those facts in the witness box 1s
4 Common
witness. He is not allowed to draw
Conclusions from
his observation.
Xample, Ram (a common man) saw a crim
nal stabbing someone else by a knife. The
CHAPTER 2 Legal Procedures
court asks him about the incidence and Ram
narrates the whole story in the court. The
court does not ask him his opinion or con-
clusion, so Ram is a common witness.
Pirst-hand knowledge rule' applies here, that
is, the common witness must demonstrate that
he actually observed the fact and was capable
of perceiving the facts by one of his senses.
2) Expert witness [SN-9]
3) Hostile witness [SN-10]
SN-9: Expert witness
Expert witness: A person who is skilled in a partic
ular field (e.g. law, science or art) and who provides
evidence about a fact in the court of law under
oath is known as expert witness.
S.45, IEA, deals with opinion of experts.
How does an expert witness help law?
1) Because of his professional training and experi
ence, an expert witness is capable of drawing a con-
clusion on the facts observed by him or by others.
2) He can give his expert opinion. He also gives
expert opinion on hypothetical questions as
well as on matters of common knowledge.
Who can be an expert witness? Doctor/medical
expert (e.g.general surgeon, autopsy surgeon and so
on), fingerprint expert, chemical examiner, hand-
writing expert or ballistic expert. He should give the
answer after understanding the question clearly.
Doctor as an expert witness: A doctor is an expert
witness to the court, not belonging to any party
even though one party has called him.
Paul Broussard (a French medicolegal expert,
1897) said If the law has made you a witness,
remain a man of science.
A doctor has to present his facts in the court
based on the science, which he has learnt in his
professional career.
as an expert
he conduct and duties of a doctor dressed
witness in the witness box: (1) be well
(2) be well prepared with al
doc-
andmodest, address the
uments and details of the case, (3) should be
(4) there
Judge as 'sir' or your honour, and testimonyy
nodiscrepancy between records (6)
anything and
memorise
(5) do not attempttto notlo5e temper.
and polite;do
De honest, pleasant forensic medi-
(i.e. MD in 1s usually
A forensic pathologist in mortuary
autopsy
Clne) who conducts
 SECTIONI Forensic Medicine
has to appear as an
summoned by the court and he
magistrate to give his opinion.
expert witness before
witness
SN-10: Hostile
makes
Hostile witness: A person wlho purposefully
statements contrary to the fact or las some interest
is known as hostilec
or motive for concealing truth
witness. In simple language, a person who knows the
truth but purposefiully does not tell the truth in the
court after taking oath is known as hostile witness.
Usually, these are witnesses who were completely
honest in the beginning but later on turn hostile.
Both the common as well as expert witness can be
hostile witness. The reason for turning hostile may
be bribery or threat.
Perjury [SN-11}: 'Wilfully giving false evidence
under oath or unable to tell what a witness knows
or believes to be the truth is known as perjury.
SN-11: Perjury
Perjury[S.191, IPC]: Wilfully giving false evidence
under oath is known as perjury. It means the wit-
ness knows the truth but does not tell the truth.
A witness has to take oath in the witness box before
giving evidence and it is compulsory. In oath, he
swears in the name of God that he will tell the truth
and only the truth in the court. So, he is legally
bound by an oath to state/speak the truth. Accord-
ing to S.191, IPC, *willfully giving false evidence
under oath or unable to tell what a witness knows
or believes to be the truh is known as perjury.
The term perjury has not been mentioned any-
where in Indian law. Indian law mentions the
terms
false evidence |S.191,IPC] which is synonymous
with the term perjury.
Motives behind perjury: The person intentionally
gives false evidence under oath due
to some rea-
sons, for example, (1) he might have taken
bribe,
or (2) he may be under threat, or (3) he may
biased towards one party due to personal be
relation.
Punishment for perjury [S.193,
IPC] is
P = 1, vars +E (i.e. imprisonment of up to 7
years
with fine).
SN-12: 0ath
[S.51, IPC) is a declaration required by
Oath the
law, which is compulsory for a witness before
he
gives evidence.
witness has to take an oath in the witnes
.
A
ess
before giving evidence and it is compulsory boy
By taking oath, the person becomes legallv
bound
to state/speak the truth«during the evidence
An oath holds the witnesS responsible for
Conse-
quences of his evidence.
Procedure:
While talking an oath, a Hindu usually
puts h
hands on Gita, a Muslim on Koran and a Chri
tian on Bible.
Declaration of oath |S.4 and 6, The Oaths Act
1969]: 'I swear in the name of God, that what
I shell tell, shall be truth, the whole truth
and
nothing but the truth.
Ifa witness is an atheist (1.e. he does not believe
in God), he has to solemnly affirm instead of
swearing in the name of God.
A child of <12 years of age is not required to take
an oath [S.4(1), The Oaths Act, 1969].
Punishment for refusal to take an oath: P = 6 months
or fine of Rs 1000 or both [S.178, IPC].
When a person gives false evidence under oath, it
is known as 'perjury [S.191, IPC). Its punishment
hasbeen given in S.193, IPC as P =I+E.
SN-13: Examination-in-chief
(direct examination)
According to S.138,IEA, the order of examination in
the courtoflaw is in the following sequence: Exanmi-
nation-in-Chief > Cross-examination Reex
amination
Examination-in-chief: After taking an oath, the
examination-in-chief is the first examination ofa
witness in the court of law. The witness is exam
ined by the lawyer of the party that has called him
to give evidence. In a criminal case, the PP first
examines the witness.
The main purpose of examination-in-chief is to
place all the facts known to the witness before the
court.
The doctor is summoned to the court as an exper
witness. He gives evidence from medical reports he
had submitted earlier. He is also testify that the
to
report submitted was prepared by
him and duly
signed by him. He is usually asked
questions such
as the following.
1) When he saw
the body.
2) Time of conduction
of postmortem examination.
3) Description
and/or duration of injuries.

4) Weapon of
offence.
5) Opinion regarding the
cause of death.
What should doctor do before giving evidence?
He should always
go through the previously pre-
nared report. He can even meet the PP and go
through the records.
,No leading questions' are allowed
[S. 142, 11EA] in
examination-in-chict except under two conditions.
1)If the court permits to ask leading question
during examination-in-chief, or
2) when the witness is declared 'hostile' by the
court.
SN-14: GrosS-examination
According to S.138, IEA, the order of examination
in the court of lawthe following sequence:
is in
Examination-in-chief> Cross examination
Reexamination
After examination-in-chiet, the crosS-examination
is the next procedure. The lawyer of the opposite
party, that is defence lawyer examines the witness.
Main objectives of cross-examination:
1) to elicit facts favourable to the cross-examining
party
2) to test the accuracy of the facts told by witness,
3) to find out the weak points in the case, and
4) to discredit the witness and prove that the
report given is not correct and is a biased one.
In cross-examination, the defence lawyer will try
to weaken the evidence given by the witness in
the examination-in-chief. He will elicit points
favourable to the defence side and for this, he
will try to establish that the evidence given by the
witness was conflicting and contradictory. So, the
witness must be very careful in answering ques-
tions during cross-examination.
Leading questions are allowed in cross-examina-
tion [SN-15].
SN-15: Leading
question
Leading question [S.141, IEA]: Any question sug-
gesting the answer, which the person putting it
wIshes or expects to receive. In simple language,
t is a question, which suggests the answer by itselt,
unat 15, the answer lies implied
in the question itsel.
he answer is expected as simply either 'yes' or'no.
Leading questions are asked during 'cross-exami-
nation' (S.143, IEA].
CHAPTER 2 Legal Procedures
Examples: Leading question for an expert witness
(c.g. doctor) may be as follows.
Q.1: Did you carry out postmortem examina-
tion?
Q.2: Did you find a 4 cm laceration on the fore-
head?
Q.3: Was the length of knife 10 cm?
They are not allowed in examination-in-chief
and reexamination [S.143, IEAJ. In 'chief exami-
nation, the leading questions may be asked uncler
two conditions:
1) if the court permits to ask leading question,
or
2) when the witness is declared 'hostile' by the
court.
Why are leading questions asked? To test the
truthfulness, skill and character of the witness.
So, witness must be very careful in answering the
questions.
SN-16: Dying declaration
Dying declaration [S.32(1), IEA] is a written or
verbal statement of a person who is dying as a
result of some unlawful act. If he dies, the docu-
ment containing the statement is produced in the
court as a dying declaration.
It is followed in India, that is, dying declaration is
legally accepted in the courts of law in India.
It is a type of hearsay evidence.
Dying declaration is considered legally relevant
because it is commonly believed that a dying per-
son always speaks the truth.
Who can record dying declaration? If possible,
it should be written by the dying person himself
and then signed by him. If impossible, it can be
recorded by the following.
1) Executive magistrate: The dying declaration
recorded by executive magistrate is preferred
and has more importance as compared to that
recorded by doctor or police officer or any other
person.
2) Other persons, for example, doctor, police ofn-
cer or even any lay person (like Panchayat head
declaration but
or relative) can record dying
It should be in
s evidential value will be less. should sign the
presence of two witnesses who
dying declaration.
of doctor:
Role
1) Stabilise the patient.
 SECTIONT
and then the police wil
2) Inform the police
inform the arca executive
magistrate to record
dying declaration.
if the life of patient
3) Write the dying declaration
delay in the arrival
is in danger or there is much
of magistrate.
state-
4) Compos mentis: Before recording the
ment, the doctor first has to certify that patient
is in perfect mental condition (i.e. compos men-
tis) to make a declaration. The doctor should be
there throughout the declaration to check the
mental condition of the patient.
5) Signature Magistrate signs the written declara-
tion on the paper and then the doctor signs. The
Signature by' the doctor signifies that the patient
was in a sound state of mind and was well ori-
ented in time, space and person while the state-
ment was being recorded.
Procedure:
If posible, it should be written by the dying
person himself and then signed by him. If not
possible, it should preferably be video recorded.
Record word to word: Dying declaration should
be recorded in declarant's own words without
any alteration of terms or phrases. If he is unable
to speak, the signs and gestures are recorded.
No oath and no leading question: The oath is not
administered while recording dying declaration
because of the belief that dying person tells the
truth. Léading questions should not be put.
Reading out and signature. If the statement is
written by declarant himself, it should be signed
by him with date and time. If the
recorded by any other person, it
statement is
should be read
out to the declarant and if he agrees, his
or thumb impressions are taken. It is also
signature
signed
by the magistrate, the doctor
and the witness.
Send declaration to magistrate:
When the dec-
laration is recorded by a person
other than the
magistrate, the declaration is
sent to the mag-
istrate in a sealed cover, The person
the declaration will have to give recording
evidence in the
court to prove it.
.FIR lodged by dying person to police is valid
declaration. dying
The person recording dying declaration should
be
present in the court to certify the fact.
Dying declaration is not admissible under two
conditions:
1) Ifthe person survives after makino.
laration, the dying declarat dying
de
Then he is called to the court
dence. The oral evidence givento give c
by this
by attending the court has
more impoperson
as compared to the dying declaration
carlier. The dying declaration record
recorded
acts as corroborative evidence. earle
If the dying person is not in a
soundstate
mind as certified by the doctor.
In Western countries, the concept of dying
depo
sition |SN-17] is followed.
Difference between dying declaration
and dying
deposition [D/W-24].
SN-17: Dying deposition
Dying deposition: It is a statement of a person
on oath, who is dying as a result of some unla
ful act; it is recorded by magistrate in presence of
accused or his lawyer.
It is followed in Western countries, for example
United States, where there is a provision for the
court to be brought to the dying person, that is a
magistrate comes to the bedside. Here in addition
to the magistrate, accused and his lawyer are alsa
present. Rest of the procedure is exactly the same s
in the court. This is called dying deposition; anda
it is a full-fledged court procedure at the bedside, t
is also known as 'court by the bedside.
In India, the procedure of dying declaration (n0t
dying deposition) is followed in which the stale
some
ment of a person, who is dying as a result of
unlawful act, is recorded [either written or veru
(oral)]. If he dies, the statement is produced in u
court as a dying declaration).
The oath is administered and then
magiStrde
records the evidence.
Unlike dying declaration, which is followed
in Inus
dying deposition is recorded always by a magistrvictim
The lawyer is allowed to eross- S-examine the
and so leading questions are also allowed. retains
t the victim survives, the dying deposition the
its value. If we compare both the statements,with
dying deposition has more value compared
the dying declaration.
Dying deposition is not followed in Inda. and dying
ilference between dying declaration and
deposition [D/W-24].
 CHAPTER 2 Legal Procedures

SN-18: Exhumation E. Identify the spot of buriat: The spot of burial

has to be identified with the help of relatives and
Exhumation S.176{3), CrPC): It is the lawful other persons related with the disposal. Besides,
digging out of an already buried body from the the location of the grave from some fixed objects
grave. (Latin ex= Out ot, humus= ground). such as road, tree, etc. is to be noted.
Scenario in world: In India, the bodics are mainly E. Photography and sketching. Photographs are
disposed of by cremation (i.e. burning), so exhu- taken from very beginning of the procedure till
mation is rarcly done in India. In Western coun cnd. Sketches may be drawn aboutthe position
tries, dead bodies are buried for disposal, so of coffin and body.
exhumation is more common. Digging out of body: (1) Removal of earth in lay-
Purposes: ers, (2) lifting out of bodycarefully to avoid artifacts,
identification (3) identification of body by relatives, (4) noting
2) For second autopsy when the first autopsy report the condition of soil and water, (5) collection of
is doubtful or has not been done properly. soil-about % kg of soil should be collected from
3) When the body has been disposed off without above, lateral sides and below the body for chemical
any autopsy and then after disposal, foul play is analysis in suspected poisoning. The soil from the
Suspected. control site should also be colleçted.
4) To determine cause of death, time since death, Autopsy: If the jintermenthas Been recent, autopsy
manner of death and to establish identity. should be conducted either in the open near thee
Prerequisites: graveyard but screened off from the public, or at
Writfen order of a first class magistrate. the mortuary. Injuries must be noted and inter-
B. Supervision of magistrate: The digging out of preted correctly.
buried dead body has to be done under thesuper- Preservation of viscera in suspected poisoning:
vision of magistrate. The police officer and med- If nothing found, then hair, soil, teeth and bones
is
ical officer also have to be at the spot, should be preserved. About % kg of soil should also
C. Early in the morning: Procedure of exhuma- be collected from the top, sides, bottom of the body
tion should be started early in the morning to and kept in dry clean bottles for toxicological analysis.
avoid publicexposure Time limit: Though there is no time limit for exhu-
D. Screening of the area: The area should be mation in India, the period is restricted to 10 years
screened off from the public. inFrance and 30 years in Germany.
DW-19: Police inquest and magistrate inquest (Table 2.5)
TABLE 2.5 Difference Between Police Inquest and Magistrate Inquest
Sr. No. Features Police Inquest [S.174, CrPC Magistrate Inquest [S.176, CrPC]
Conducted t is done in those cases where a person the following cases:
It is done in
in cases has committed suicide, or 1. Dowry death
2. has been killed by another man/animal 2. Death during police firing or poliço cdstody
machinery, or or prison or interrogation
3. has been killed in an accident,or 3. Death in reformatories, borstal sckod,
4. has died in suspicious circumstances. psychiatrjc hospital
4. Exhumation
Investigating officer Palice officer above the rank of head DM/SDM
constable (HC), that is, SI
Warrant Can not issue Can issuJe
Fine/Punishment Can not impose Can impose
Exhumation Can not allow Can allow
Value Inferior Superior
 SECTIONI Forensic Medicine

D/W-20: Coroner's court and magistrate court (Table 2.6)

Difference Between Coroner's Court andMagistrate
Court
TABLE 2.6
Magistrate Court
St. No. Coroner's Court
Presided by magistrate
1 Presided by coroner
It is a 'court of trial'
It is a 'court of inquiry
deaths Magistrate enquires dowry deaths, exhumation, deaths in
3. Coroner enquires into sudden, suspicious, unnatural
police firing/prison/custody
within his jurisdiction
Accused should be present during trial
Accused need not be present during trial
Magistrate can impose fine and give punishment
. Coroner has no power to impose fine or give
punishment
5.
Coroner can punish a person for contempt, committed
if Magistrate can punish whether the offence is committed
within the premises of his court within or outside the premises of court

D/W-21: Common witness and expert witness (Table 2.7)

TABLE 2.7 Difference Between Common Witness and Expert Witness
St. No. Common Witness Expert Witness
Legally defined in S.118, IEA Legally defined in S.45, IEA

2. A common person who has actually seen or observed An expert witness is a person who is skilled in a particular
perceived the facts and narrates those facts in the field (e.g. law, science or art) and he is capable of drawing
witness box is a common witness a conclusion on the facts observed by him or by others

He is not allowed to draw conclusion from his observation He can

He can not express opinion on the observations made by He can
others
Responsibility is less High
5

DW-22: Examination-in-chief and cross-examination (Table 2.8)

TABLE 2.8 Difference Between Examination-in-Chief and Cross-Examination

Sr. No. Examination-in-Chief Cross-Examination
In the order of sequence described in S.138, IEA, it is the 1. In the order described in S.138, IEA, it is the second
first examination ofa witness in the court of law examination of a witness in the court of law; it
means the examination-in-chief is followed by cross
examination
The witness is examined by the lawyer of the party that 2. Here the lawyer of the opposite party, that, is the
has called him lawyer of the accused (defence lawyer) examines the
witness
3 Leading questions must not be asked in chief 3. Leading questions' are asked in cross-examination
examination; however, they can be asked in IS.143, IEAI
chief-examination only
a) if the court permits, or
b) when the court suspects that the witness is a
hostlle
witness
 CHAPTER 2 Legal Procedures 21

Dw-23: Oral evidence and documentary evidence (Table 2.9)

TABLE 2.9 Difference Between Oral Evidence and Documentary Evidence
Oral Evidence Documentary Evidence
St. No.
Alloral/verbal statements under oath made before All documents including electronic records produced for the
the court inspection of the court

Types of oral evidence: Direct, indirect and hearsay Verities of docurnentary evidence: Medical certificate, death
evidencee certificate, medicolegal case (MLC) report, dying declaration,
dying deposition

More important because it permits cross Less impor tant

examination

D/W-24: Dying declaration and dying deposition (Table 2.10)

TABLE 2.10 Difference Between Dying Declaration and Dying Depositíon
Dying Declaration Dying Deposition
St. No.
Followed in India Followed in Western countries, for example United States
It ismerely the recording of a statement of a dying
It is a ful-fledged court procedure at the bedside, so aiso
person known as court by the bedside'

It can be recorded by a magistrate or doctor or Recorded always by a magistrate.

police officer or Panchayat head or relative
The accused and his lawyer need not be present The accused and his lawyer have to be present

Oath: Not administered Oath: Has to be administered

Cross-examination: Not allowed Allowed

Leading questions: Not allowed Allowed

Ifthe victim survives, it loses its value and is not f the victim survives, it retains its value
admissible in the court of law but it acts as
corroborative evidence
More value
Less value
 Medical Jurisprudence

Chapter 3A
Code of Medical Ethics, Medical Councils, Acts,
Medical Records and Professional Misconduct

INTRODUCTION Regulations 2002 (amended and then notified on

amananmanmoa
2009). The text of the code is actually prescribed
Medical jurisprudence (Latin juris = law; pru- in two parts: the declaration and the code proper.
dence = knowledge): It is the study of law in rela- Declaration of Helsinki (1964) prescribes ethical
tion to medical practice. principles for human experimentation.
Medical ethics: It means moral principles (code
of conducts) which should guide the members of
the medical profession in course of their practiceDUTIES OF A DOCTOR
of medicine and their dealings with patients and
other members of the profession. Medical eti- Duties and Responsibilities of Physician
quette means sense of courtesy and mutual respect in General
which should govern the conduct and relationship (1) He should be pure in character and modest and
among the members of the medical profession. pleasing in personality. He should be dedicated to
Hippocratic oath: It is earliest known code provide service to humanity and he should uphold
(4th-5th century BC), the modern version of the dignity and honour of his profession. (2) He
which is the Declaration of Geneva, 1948. should maintain good medical practice by contin-
International Code of Medical Ethics, 1949: uously improving his medical knowledge and skills.
World Medical Association (in 1949) adapted cer- (3) He should participate. in.continuing medical edu-
tain codes of medical ethics (solely based upon cation (CME) for at least 30 h every 5 years. (4) He
Declaration of Geneva), popularly known as Inter- should bea member of medical societies and should
national Code of Medical Ethics. attendtheir meetings.(5) He should maintain med-
Code of Medical Ethics las enumerated by Med- ical records for a period of 3 years fronm_ the date of
ical Council of India (MCI)] in India: It is a set commencement of treatment. He should maintain a
of regulations to maintain the professional con- register of medical certificates issued. (6) He should
duct and etiquette among the members of a sys- display his MCI/State Medical Council (SMC) reg
tem of medicine. It has eight chapters. In S.20A, istration number almost everywhere, for example,
Indian Medical Council Act, 1956, MCI brings in clinic, on prescriptions, money slips, certiicates
out regulations relating to the professional con
and so on. (7) He should use generic names of drugs,
duct, etiquette and ethics for registered medical
not brand names. (8) He should employ only qual
practitiopners (BMPs), but these regulations have
ified medical and paramedical personnels to attend
been now presented in Indian Medical Council
(Professional Conduct, Etiquette and Ethics) patients. (9) He should announce fees before starting
treatment.
22

Duties of Physicians to
Their Patients
exercis a reasonable degree of skill and
1) Duty to
knowledge. (2) Duty to tell about the prognosis of
to give legible prescription and
discase. (3) Duty
aboo the dosage and timing of
proper instruction
drugs. (4) Duty to warn the patient about side effects
to warn paticnt as well as closely
of drugs. (5) Duty
related people in case the paticnt is suffering from
infectious disease. (6) Protessional
secrecy [SN-1].
(7) Duty to immediately respond to any
emergency
(S) Therapeutic privilege lplease refer to Chapter
3B, SN-3].
Duties of Physician in Consultation
should be avoided. (2)
(1) Unnecesary consultation
Consultant should be punctual for consultation. (3)
a
Patient should be reterred to consultant with case
summary. (4) Fees and other charges should be dis-
played on the board of his room and in visiting room.
des-
(5) Prescription letter should contain name and
1gnation.
Duties of Physician Towards Professional
Coworkers
(1) Consultation fees should never be taken. It is
professional courtesy and a doctor should consider
it a pleasure and privilege to render service to all
fellow doctors and their family dependents. (2) An
RMP should never criticise his coworkers in front
of patient. (3) The doctor should always help his fel-
low coworkers, especially in professional matters. (4)
When a doctor requests his coworker to take over his
patients temporarily during his absence, the coworker
should agree only if he has the capacity to discharge
the additional responsibility.
Duties of Physician Towards State
(1) He should cooperate with_authorities in the
administration of sanitary or public health laws and
Tegulations. (2) During epidemic, (a) a doctor should
not.abandon his duty for fear of contracting disease
himself, (b) a doctor is bound to bring every case of
mmunicable disease under his care_to the notice
Opublic health authority. (3) The police should be
med about medicolegal cases brought to him. (4)
births and deaths should be brought to the notice
of authorities.
(5) The physician should respond to
emergen
military service when required.(6) A med
ical
practitioner bound to treat or proVide medical
Is
CHAPTER 3 Medical Jurisprudence
aid to persons wounded or sick in the armed forces,
ship-wrecked persons, prisoners of war or civilians of
cnemy nationality without any discrimination based
On sex, race, religion or nationality. (7) Privileged
communication |SN-2].
RIGHTS AND PRIVILEGES OFA DOCTOR
(1) A doctor has right to choose his patient except
in emergency. A doctor can refuse a patient (a) if
patient is unable to pay doctor's fees and (b) if the
condition of the patient does not belong to the pro-
fessional specialisation of the doctor. The right to
choose patients does not apply in case of emergency.
The doctor must attend every patient in emergency
even if he is not able to pay fees. After the manage-
ment of the case, the doctor can demand fees from
the patient. It is the right of the doctor to recover fees
from his patient. If the patient denies paying doctor's
fees, the doctor can sue the patient in the civil court
for recovery of his fees. (2) He has the right to prac
tice medicine and prescribe medicines. (3) The doc-
tor has the right to possess or prescribe drugs listed
in the Dangerous Drug Act. (4) He has the right to
add professional titles to his name (i.e. doctor) and
qualifications after his name (e.g. MBBS, MD). (5)
The doctor has the right to give evidence as an expert
in the court. (6) He has the right to issue medical
certificates. (7) The doctor has the right for appoint
ment to any public or government hospital.
DUTIES, RIGHTS AND PRIVILEGES
OF PATIENTS
Duties of Patient
(1) He should furnish the doctor with complete infor
mation about the facts and circumstances of his il-
ness. (2) He should strictly follow the instructions ot
the doctor. (3) He should pay reasonable fees to the
doctor. (4) lt a patient wishes to take second constt
tion/opinion, he has to inform the first doctor.
Rights and Privileges of a Patient
facilities and emer
(1) Right to access to healthcare social or
regardless of age, sex, religion,
gCncy services his own doctor
status. (2) Right to choose from another
cOnomic opinion
Right to seek second during consultation
Cly.3) privacy
doctor. (4) Right to have complain and redressal of
treatnnent. (5) Right to
Or
 SECTIONT Forensic Medicine
with dignity, with
grievances. (6) Right to be treated
discrimination. (7) Right of
care and respect without about
confidentiality. (8) Right to get information
treatment, alternatives,
his diagnosis, investigation,
to refuse
complications and sIde ettects. (9) Right
treatment. (10) Right to
any diagnostic procedure or
access his medical records.
UNETHICAL ACTS
1. Advertising: (a) A physician should not use an
unusually large signboard. The contents of his
signboard should be title, name and qualification.
Signboard should not be affixed on a chenmist shop,
tree or in places where he does not reside or work.
(b) Prescription paper should contain title, name,
qualification, address, registration number and
telephone number. (c) Consultation fees should
be clearly exhibited in consulting room or waiting
room. (d) A physician should not publish in press
the reports of cases treated by him. (e) A physi-
cian can announce in press, his starting of prac-
tice, interruption or restarting after a long interval,
a change of his address, temporary absence from
duty and so on.
2. A physician may patent surgical instruments/med-
icines/procedures. But it shall be unethical if the
benefits of such patents/copyrights are not made
available in situations where the interests of large
population are involved.
3. Running an open shop for dispensing of drugs and
appliances by physicians is unethical.
4. Dichotomy (fee-splitting), that is the practice of
sharing (e.g. offering, giving or receiving) fees for
the referral of a patient with professional coworkers,
is also unethical.
5. All drugs prescribed should always carry a propri-
etary formula and clear name. Prescribing a secret
remedy of which he does not know the composi-
tion, the manutacture or promotion of their use is
unethical.
6. Physician should not aid or abet torture.
7. Practicing euthanasia is unethical.
8. Code of conduct for doctors and professional
association of doctors in their relationship with
pharmaceutical and allied health sector indus-
try: Doctors should not take any gifts or mone-"
tary grants or avail any facility or seek any type of
hospitality from any pharmaceutical companies. A
physician may carry out, participate in, or work in
rescarch projects funded by pharmaceutical
allied healthcare industries. Doctors must main
and
tain professional autonomy.
PROFESSIONAL MISCONDUCT
(INFAMOUS CONDUCT) [SN-3]
MEDICAL COUNCIL OF INDIA (MCIY
CI is the statutory body tor establishing and
maintaining uniform standards of medical edu-
cation and recognition of medical qualifications
It grants registration to medical practitioners and
monitors medical practice in India. It was estab-
lished in 1934 under Indian Medical Council Act
1933. In 1956, this Act was repealed and a new Act,
known as Indian Medical Council Act, 1956, was
enacted.
Functions of MCI include (1) maintenance of a
medical register, (2) formulation of medical uni-
form standard of medical education, (3) recog
nition of medical qualifications, (4) registration,
(5) warning notice, (6) appeal against disciplinary
action, (7) CME programmes and (8) formulation
of code of medical ethics.
NITI Aayog has recommended the replacement of
MCI (IMCAct, 1956) with National Medical Com-
mission (NMC), and thus National Medical Com
mission Bill, 2017, has been drafted.
Indian government dissolved MCI and replaced
it with seven-member Board of Governors
(BoG) by bringing an ordinance [Indian Medical
Council (Amendment) Ordinance 2018] dated
26 September 2018.
The BoG has been appointed initially for a period
of 1 year, and will be the sole decision-making
body till the NMC Bill, 2017-meant to replace the
MCl-is cleared in Parliament. A similar BoG was
also appointed in May 2010.
NATIONAL MEDICAL COMMISSION (NMC)
NMC shall consist of total5 persons: a chair
person, 1#ex officio members, 21 part-time mem
bers anedan-ex-efficio member secretary.
A person who is aggrieved by any decision of NM
may preter an appeal to the Central Government
against such decision within 30 days.

Powers and functions of NMC: (1) To lay dowvn
policies for (1) maintaininga high quality and high
standards in medical education, (ii) regulating
medical institutions, medical researches and med-
ical professionals; (2) to assess the requirements
in health care, for example, human resources,
infrastructure; (3) to nmake necessary regulations
for the proper functioning of the Commission,
the Autonomous Boards and the State Medical
Councils; (4) to ensure compliance by the State
Medical Councils; (5) to ensure observance of
professional ethics in medical profession.
Medical Advisory Council (MAC): It shall be the
primary platform through which the states and
union territories nmay put forward their concerns
before the NMC. MAC shall advise the NMC on
the measures to maintain the minimum standards
in medical education, training and research.
National Eigibiity-cum-Entrance Test and
Examination (NEETE): There shall be a uniform
NEET for admission to UG medical education in
all medical institutions There shall be a uniform
National Licentiate Examination (NLE) tor the
studentsgraduating from medical institutions for
granting hcense to practise medicine.
Only the person enrolled in the State Register or
the National Register shall be allowed to practise
medicine and shall be entitled to sign or authenti-
catea medical certificat¢. Any person who contra-
venes shall be punished with fine of Rs 1-5 lakhs.
Autonomous Boards
Autonomous boards, which have been constituted,
are (1) UG-MEB (Undergraduate Medical Education
Board), (2) PG-MEB (Postgraduate Medical Education
Board), (3) MARB (Medical Assessment and Rating
Board) and (4) EMRB (Ethics and Medical Registra-
tion Board). A person who is aggrieved by any decision
o an autonomous board may prefer an appeal to the
Commission against such decision within 60 days.
Functions of UG-MEB: (1) To grant recognition to
a medical
qualification at the UG level; (2) to deter
ne standards of medical education at the UG level
develop competency-based dynamic curricu-
at the UG.level and (ii) for primary medicine
Community medicine to ensure health care; (3)Juvenile Justice(Care and Protection
Irame guidelines
tutione for setting up of medical insti-
tutions for
mparting UG courses; (4) to determine
dards and norms for infrastructure, faculty and
CHAPTER 3 Medical Jurisprudence
quality of education in medical institutions; (5) to
facilitate development and training of faculty mem-
bers teaching UG courses; (6) to specify norms for
compulsory annual disclosures, electronically or
otherwise, by medical institutions, in respect to their
functions.
Functions of PG-MEB: Almost same functions as that
of UG-MEB, but these functions are at the PG and
super-speciality levels.
Functions of MARB: (1) To carry out inspections of
medical institutions for their assessment and rating
(2) to grant permission for the establishment of a
new medical institution; (3) to determine the pro-
cedure for assessing and rating medical institutions
for their compliance with the standards laid down
by the UG-MEB or PG-MEB; (4) to make available
on its website the assessment and ratings of medical
institutions at regular intervals; (5) to impose mon-
etary penalty against a medical institution for failure
to maintain the minimum standards specified by the
UG-MEB or PG-MEB.
Functions of EMRB: (1) To maintain a National Reg-
ister: It should contain name, address and all recogg
nised qualifications possessed by a licensed medical
practitioner. It shall be a public document, and it shall
be made available to the public by placing it on the
website of EMRB. EMRB shall ensure electronic syn-
chronisation of National Register and State Register in
such a manner that any change in one register is auto-
matically reflected in the other registers (2) to regulate
professional conduct and promote medical ethics.
State Medical Council
If a doctor is aggrieved by any action taken by
SMC, he may prefer an appeal to the EMRB. If he
is aggrieved by the decision of EMRB, he may pre-
fer an appeal to the Commission within 60 days of
thedecision. If he is aggrieved by the decision of the
Commission, he may prefer an appeal to the entra
Government within 30 days of the decision.
SOME IMPORTANT ACTS
of Children) Act, 2015 and chil-
in conflict with law
children
addresses and protection.
dren in need of care
 Medicine
SECTIONI Forensic

a person bclow
below MEDICAL RECORDS
'child' as
It defines juvenile' or
years of age.
A medical record is a document containing all
law [S.2(13)] means 'a
18
Child in conflict with offence data regarding patients treatment in chronologi.
have conmitted an cal order. It includes history, consent, examination,
child who is alleged to
ageas on the date of commis- investigations, diagnostic modalities used, treat.
and was 18 ycars of
sion of such offence. consists
It
ment, operation notes, discharge summary and
Juvenile Justice Board ()]B) |S.4]: details of further visits.
first class judicial magis-
of three persons: One There is a Medical Record Department in most
magistrate) with 2 years
trate (or metropolitan hospitals which maintain medical records.
workers at least one
of experience and two social Medical records are actually the property of the
For every district,
of whom should be a woman. hospital but the personal data (i.e. the informa
there will be one or more JJBs. tion) contained in the record is the confidential
Action against the offender:law is apprehended by property of the patient. Thus, the patient has a legal
conflict with
Ifa child insuch child shall be placed under the
right to use that information for his benefit. The
the police,
patient pays for services (i.e. diagnosis and treat-
charge of Special Juvenile Police Unit or Child
Welfare Police Officer, who shall produce the
ment), not for medical records. Due to this reason,
child before JJB within 24 h of apprehending
if the patient requests for the medical records, the
the child. The child shall not be placed in a photocopy of the original medical records (not the
police lockup or jail. original records) can be given to the patient on
payment of cost of reproduction.
If any person of 18-21 yearsoffence of age is aPpre-
when he Medical records are required in case of accidental
hended for committing an
was below the age of 18 years, then, such per- death (e.g. traffic, fall from height), assaults (phys
son shall be treated as a child during the pro- ical or sexual), insurance (life and health) policies,
cess of inquiry. medical negligence and the claims under Work-
any person of >21 years of age is appre- men's Compensation Act.
If
hended for committing any serious or heinous Maintenance of hospital records: (1) Every doctor
offence when he was between the age of 16 should maintain medical records for a period of
and 18 years, then he shall be tried as an adult. 3 years from the date of commencement of treat-
Punishment: ment. (2) If patient asks for his records, it should
If the age of child is <16 years, he will be be supplied within 72 h.
sent to special home (not jail) for maximum Storage of medical records: Under the Directorate
3 years for providing reformative General of Health Services guidelines published in
services, for
example, education, counselling, behaviour hospital manual, OPD records have to be stored for
and psychiatric support. minimum 5 years. IPD records have to be stored
If the age of child is 16-18 years, he will be for minimum 10 years. There is no period men-
tried as adult for following three types of tioned for MLC cases.
offences:
False certification can invite not only criminal and civl
1) For heinous' offence, punishment s action against the doctor, but also disciplinary pro-
imprisonment of >7 years but he cannot ceedings of the medical council. According to S.197,
be sentenced to death or life imprisonment. IPC, issuing or signing false certifcate shall be pun-
2) For 'serious' offence, punishment is
impris- ished in the same nmanner as if he gave false evidence.
onment for 3-7 years.
3) For 'petty' offence, punishment is
impris-
onment for <3 years. SOME IMPORTANT TERMS
The children's court shall ensure
that the child Res judicata: It means once any court takes dec
who is found to be in conflict with law is
sent to a sion in a case, the case cannot be reopened in any
place of safety till he attains the age of
21 years and other court, that is, a person cannot be sued twice
thereafter, the person shall be transferred
to a jail. for the same crime.
 CHAPTER 3 Medical Jurisprudence

Res indicata: suit for damages for negligence

A 1) Major patient (i.e. > 18 years of age): In the
filed within 2 years case of a major patient, nothing should be
against the doctor should be
from the date of alleged negligence. A suit filed after disclosed to his parents/relatives and the
2 years from the
date of alleged negligence will be doctor should not answer any query by third
dismissed as being beyond the period of limitation. party (parents/relatives) without the consent
Notifiable diseasc: Any discase that is requircd of patient. A doctor should not disclose any
to government authori- information about the illness of his patient
by law to be reported
intectious in nature and without the consent of the patient even when
ties. These diseases are
the health authori requested by a public/statutory body, except in
a doctor is bound to inform
discascs, for example, the case of notifiable disease.
ties about these notifiable
2) Employer: The medical officer of a firm or
cholera, plaguc, AlDS, dengue, yellow fever and
factory should not disclose the result of his
so on.
protect (i.e. cover up) the activities
To examination of an employee to the employer
Covering:
without the consent of employee.
of unqualified persons either by assisting them or
3) Servant: Doctor should not reveal any secret
taking assistance from them in the professional
field. Taking assistance from medical students,
about nature of illness of a servant to his mas-
midwives and medical technicians does not
fall ter without consent, even though master may
be paying doctor's fees.
under its purview.
is a 4) Husband-wife: Doctor is not to unveil secrets
Registered medical practitioner (RMP): He confided and nature of illness detected in
qualified doctor (minimum qualification
MBBS)
Medical respect of husband to his wife and vice versa,
who has been registered in SMC/Indian
Council.
without the express consent of person con-
cerned.
5) S.53(1), CrPC says that an arrested person may
be examined forcefully by doctor using reason-
L IMPORTANT QUESTIONS
FOR EXAMINATION
ably necessary force at the request of police.
A person in police custody or 'prisoner
under trial' has the right not to permit doc-
SHORT NOTES (SN)
tor to disclose the nature of his illness.
1. Professional secrecy If a person is convicted, he has no such
2. Privileged communication [DU 2007; CCU 2011] right and doctor can disclose results to
3. Infamous conduct or professional misconduct the authority. So the matter relating to
4. Warning notice [DU 2009] the illness of a convicted person may be
5. Penal erasure conveyed to the jailor/superintendent of
6. Professional death sentence [CCU 2011] jail.
7. Malingering 6) Case report: While reporting a case in any
medical journal, the name or photograph ot
his
the patient should not be disclosed without
ANSWERS consent.
facts that attect
7) Autopsy: At autopsy, certain
SN-1: Professional secrecy * relatives should
reputation of deceased and pregnancy dis-
Professional secrecy: When a doctor treats a not be disclosed. For example,
unmarried girl should
patient, the information about the illness of the covered at autopsy of surgeon.
patient becomes secret or confidential between the not be disclosed by the autopsy these cases, no
cases: In
dOctor andthe patient. Keeping this information 8) Divorce and nullity without consent of
or confidential by a doctor in his medical intormation shall be given
ret
profession is known as professional secrecy. concerned person. detected in USG should
child
Sex of unborn
heclosesituations where the doctor should not dis- )
not be disclosed.
information:
28 SECTION Forensic Medicine
10) When a doctor examines a government ser-
vant on behalf of the government, he cannot
disclose the nature of illness to government
without patient's consent.
Punishment for doctors: A doctor should not
disclose any secret information about his patient
or his private life which he lcarns in the course
of his examination to a third party without his
Consent.
A. Doctor is liable for damages if he discloses with-
out valid grounds, any such information which
the patient may reasonably claim as secret or
confidential. The patient can sue the doctor
for damages (e.g. nmental suffering, shame or
humiliation) if (1) the disclosure is voluntary
and without valid groumds, (2) the disclosure
has resulted in harm to the patient and (3) the
disclosure is not in the interest of the public.
B. Punishment for doctor for not maintaining
professional secrecy: Patient may sue the doc-
tor for defamation [S.499, IPC]. Punishment for
defamation is imprisonment for 2 years or fine
S.500, IPC] or both. The patient can also com-
plain to MCI or SMC, which can take disciplin-
ary action against doctor.
Exceptions of professional secrecy: A doctor can
divulge information of his patient to a concerned
authority in two situations:
1) When he is required by the law to divulgeit
(privileged communication), or
2) when the patient has consented to divulge it.
3) Other situations:
i. When patient is a 'minor' (i.e. <18 years) or
mentally ill person' or 'intoxicated person':
In these cases, the information about the
nature of illness may be disclosed to the
guardian of the patient.
ii. Hostel: When treating a minor inmate of a
hostel or a boarding house, the doctor may
reveal the information about the patient
to the warden/superintendent. But if the
patient is major, doctor cannot do so with-
out the consent of the patient, unless the
matter poses risk to other inmates of hostel.
ii. Insurance policy and medical certificate:
When a person comes to an RMP for a
medical certificate to produce it as evidence
to a place (e.g. life insurance), then it may
be taken as implied that the person has the
consent for disclosure of all information abo
his illness to the place of deposing evidence
SN-2: Privileged communication
Privileged communication: The doctor has
the
moral duty to keep the intormation about the
illness of his patienbsecret or confidentia). Mean-
while, the doctor also has a moral duty to protecd
the interests of the community/public. In some
cases, a doctor cannot withhold professional
secretes and he discloses the information to the
concerned publicauthority for thepurposeof pro-
tecting the interest of the community (under legal,
moral and social obligation). This communication
(i.e. disclosure of confidential information) has
been given privilege and so it is knownas privi-
leged communication.
=
Punishment: Not punishable. The doctor will not
be liable to damage because it is in the interest of
the community.
Examples: |Mnemonic IV-NIS-Put Canula
Safely Sister]
1) Infectious diseases: Cook/waiter in a hotel with
enteric infection, a teacher with tuberculosis.
He should be persuaded to take leave from the
job until he becomes noninfectious. If patient
refuses, the doctor can inform the employer.
2) Venereal disease:
a. Marriage: If the person is suffering from
syphilis or HIV infection, it is the duty of the
treating doctor to advise the patient not to
marry till he is cured. If patient refuses, doc-
tor can disclose this information to the other
party going to be married.
b. Employee: If drivers are suffering from epi-
lepsy, hypertension, alcoholism, drug addic
tion or colour blindness, the doctor should
persuade him to change the employment
because of the dangers of his present occu
pation both to himself and to the public.
If patient refuses, doctor can disclose this
information to the concerned authority.
C. Swimming pool: If the person is suftering
from syphilis or gonorrhoea, it is the duty of
the doctor to advise the patient not to enter
the swimming pool till he is cured. If patient
refuses, doctor can disclose this information
to the concerned authority.

d. Hostel: If a student suffering from a vene-
is
real disease, the doctor has to warn the stu-
dent to vacate the hostel immediately. If the
student is not ready to vacate the hostel, the
doctor can inform the warden.
3) Notifiable disenses: Any disease that is
required by the law to be reported to the
government authoritics is known as notifiable
discasc. The disclosure of information about
a notifiable discase allows the authorities to
monitor the discase, provide early warning of
possible outbreaks and take preventive mea
sures, for example, plagues, yellow fever and
$O on.
4) Suspected crimes: According to S.39, CrP
every person (including the doctors) aware of
the commission of, or of the intention of any
other person to commit any offence shall imme-
diately give information to the nearest police
offcer or Magistrate. Sofa doctor treats a per-
son suffering from gunshot or stab wounds due
to criminal assault, he must inform the poliçe.
5) Patient's own interest: In some typical situa-
tions (melancholia, suicidal tendencies, etc.),
the guardian may be informed_and warned
about the nature of the illness of the patient.
6) Self-interest:
In both civil and criminal suits by the patient
against the doctor, the doctor can give evi-
dence about the condition of patient.
Against the negligent suit, a doctor may tes-
tify information related with the patient.
7) Courts of law: In court of law, a doctor cannot
claim the rule of privilege communication con-
cerning the illness of the patient, if it is relevant
to the injury before the court. Doctor has to tell
whatever the court asks from him. If he is asked
to reveal any secret, he should appeal to the court,
and even if the court does not accept his plea, he
may request the court that he may be allowed to
give the answer in writing so that the public may
not know it. At last, if it is denied by the court, the
doctor has to give the answer to avoid the risk of
penalties for contempt of court.
) Staff: A
doctor can disclose and discuss
1nformation of patient with other doctors,
the
paramedical staff (e.g. nurse, radiologist, phys-
1Otnerapist) to provide better service
to the
patient.
CHAPTER 3 Medical Jurisprudence 29
SN-3: Infamous conduct (professional
misconduct)
Infamous conduct: improper conduct (or dis-
It is
gracful act) of the doctors in their medical profes-
sion.
In Chapter 7 of Indian Medical Council (Profes-
sional Conduct, Etiquette and Ethics) Regulation,
2002, the MCI has issued a list of offences which
constitutes infamous conduct. If the doctor's dis-
graceful act falls in any of the enlisted acts, he is
liable for disciplinary action. MCI is also empow-
ered to take action against any other disgraceful
act done by the doctor even if it is not included in
the list.
Warning notice: It is actually a list of offences con-
professional misconduct which is
stituting serious
given at the time of registration with the SMC.
Various oftences constituting serious professional
misconduct are as follows [Mnemonic 6A-Disco].
1) Adultery [S.497, IPC]: Voluntary sexual inter
course between a man (married or unmarried2
does not matter) and a married woman with-
out the consent of her husband.
2) Advertisement: A physician should not (i) use
an unusually large signboard. The contents of
his signboard should be name, qualification,
title and names of his specialties. Signboard
should not be affixed on a chemist shop or
tree; (ii) exhibit publically the scales of fees
except in his consulting or waiting room; (ii)
advertise himself through manufacturing firms
directly or indirectly; (iv) print his photo-
graphs in the letter head/signboard/consulting
room; (v) publish the photograph of patient in
journals without his consent and (vi) use touts
or agents to procure patients.
3) Association with unqualified persons in pro-
fessional matters.
4) Addiction to narcotic drugs and psychotropic
so
substances, for example, cocaine, LSD and
on.
5) Alcoholism: The doctor should not
practise
which interteres
under the influence of alcohol
with skilled perfornmances.
should not pertorm
an
6) Abortion: The doctor
illegal abortion.
(fee-splitting or fee sharing):
)Dichotomy receiving commission
from
giving or
Itis
 SECTIONI Forensic Medicine
fellow doctors, manufacturers or chemists.
For example, an orthopaedic surgeon sends
his patients to a radiologist for radiological
examination (e.g. X-rays, CT scan and so
on) and in return, a part (e.g. 20, 30 or 40%)
of the fees taken by the radiologist from the
patient is given to orthopacdic surgeon as
commission.
8) Issuing a false certificate in connection with
sickness, insurance, passport, public services,
attendance in court and so on.
9) Sex determination test with an intent to teer-
minate the life of the female foetus.
10) Covering: Assisting someone who has no med-
ical qualification to attend, treat or perform an
operation on some person in cases requiring
professional skill.
11) Others: (a) Refusal to treat a patient on reli-
gious grounds, (b) disclosing the secrets of
his patients, (c) use of Red Cross Emblem by
doctors, (d) not informing health authorities
about notifiable diseases, (e) failure to obtain
consent of both husband and wife in an oper-
ation which may result in sterility, (f) writing
prescription in the form of a secret formula
which is known to some particular pharmacy
and (g) running an open shop for the sales of
medicines.
Punishment for serious professional misconduct
is penal erasure, that is, the removal of the name
of a doctor from the State Medical Register (SMR)
either temporarily or permanently as a penalty.
1) Temporary erasure of name of the doctor:
After this, the doctor is not allowed to practise
his medical profession for a specified period
(e.g. 1,2 or 3 years) in which his name remains
removed from the register.
2) Permanent erasure of name (also known as
professional death sentence) [SN-5].
SN-4:Warning notice
Warning notice: It is actually a list of offences
constituting serious professional misconduct
which is given at the time of registration with the
SMC.
.An RMP is expected to follow the ethical norms (or
rules of conduct) contained in the Code of Medical
Ethics, published by MCI and by several SMCs.
For
this purpose, the council issues a list of offences
which constitute serious professional misconduct.
This list of offences constituting serious profes-
sional misconduct' is known as warning notice,
The council also stresses the fact that it is not a
complete list. Some other offences, which are not
included in the list, may be committed by a med.
ical practitioner. If any medical practitioner com-
mits those offences, then the list may be extended
to include those offences.
Before starting their clinical practice, doctors are
self-warned and given a general idea about the list
of offences constituting professional misconduct.
They are also self-warned about the consequences
of disciplinary action by SMC. For example, after
completing internship, MBBS students have to
register themselves in SMC. At the time of regis-
tration, warning notice is issued to these students
to inform them about serious professional miscon-
ducts.
SN-5: Penal erasure
The name of a doctor can be erased from the SMR
in the following cases: (1) If doctor dies, or (2) if
doctor is not traceable, or (3) if doctor's name was
entered by fraud or fault or (4) if doctor is found
guilty of serious professional misconduct (or infa
mous conduct): In this case, the name of the doctor
is removed from the SMR and IMR as a penalty.
This removal of name of a doctor from the register
temporarily or permanently as a penalty is known
as penal erasure.
Penal erasure may be temporary or permanent.
1) Temporary erasure of name: The name can be
temporarily erased from the SMR if doctor is
found guilty of a serious professional miscon
duct (infamous conduct). After this, the doctor
is not allowed to practise his medical profession
for a specified period in which his name
remains removed from the register. If the name
of any doctor has been removed from SMR on
the grounds of professional misconduct, there
may be two cases:
a) Doctor may be dissatisfied with the decl-
sion of SMC: He may appeal to the Central
Government after exhausting all remedies
under the SMC. The doctor should appPY
within 30 days from the date of such

decision along with all relevant documents.
The Central Government consults MCI and
then gives decision which shall be binding
on the SMC.
b) Doctor admits his fault: He may apply
for
restoration of his name at various fixed
intervals.
2) Permanent erasure of iname:
It is also called
professional death sentence' [SN-7].
SN-6: Professional death sentence
.Professional death sentence: Permanent removal
is also called
of name of doctor from the SMR
professional death sentence. It is a type of penal
erasure.
a practitioner
This punishment is given if medical
is found gulty of any of the following serious
pro-
fessional misconduct [Mnemonic 6As]:
1) Adultery: Voluntary sexual intercourse between
a man (married or unmarried, does not matter)
and a married woman without the consent of
her husband.
2) Advertisement: A physician should not use an
unusually large signboard.
3) Association with unqualified persons in profes-
sional matters.
4) Addiction to narcotic drugs and psychotropic
substances, for example, cocaine, LSD and so on.
5) Alcoholism: The doctor should not practise
under the influence of alcohol which interferes
with the skilled performances.
6) Abortion: The doctor should not perform an
illegal
abortion.
This punishment is given when the offence comn
mitted by doctor is confirmed beyond doubt.
After removal of name permanently from register,
the doctor is not allowed to practise his medical
profession for his whole life.
Example:
)if an RMP removes human organ illegally (1.e.
without the permission of authority), his name
will be removed from the register of council
years for first offence but permanently for
1or 3
Subsequent offences [S.18, Transplantation of
Human Organs and Tissues Act, 1994].
a doctor (e.g. gynaecologist or ultrasonol
S discloses the sex of foetus to pregnant
WOman concerned or any other person, the
CHAPTER 3 Medical Jurisprudence
the SMR
name of doctor can be removed from
for a period of 5 years for the first offence
and
[S.23,
permanently for the subsequent offence
PcPnDT Act, 1994.
SN-7: Malingering
Malingering (or shamming) means conscious
for the
planned feigning or pretending a disease
sake of gain or advantage.
Malingering is done by people for following advan-
tages:
1)Soldiers or policemen: To avoid their duties, for
example, to avoid hard postings.
2) Prisoners: To avoid hard work or to avoid capi-
tal punishment.
3) Businessman: To avoid business contracts.
4) Workman: To claim compensation.
5) Students: To avoid classes.
6) Beggers: To attract public sympathy.
7) Criminals: To avoid legal responsibility.
Diseases which may be feigned are dyspepsia,
intestinal colic, ophthalmia, deafness, vertigo, epi-
lepsy, insanity, limb paralysis, bruises, sciatica, back
pain, neck pain, diarrhoea and so on.
The patient can distort or exaggerate their symp-
toms in many ways, for example:
1) The patient may injure his nasopharynx with a
sharp instrument, swallow the blood and regur-
gitate in front of doctor to mimic haematemesis.
2) Anal or vaginal mucosa may be punctured to
produce bleeding.
3) Ingestion of high amount of digitalis may pro0
duce cardiac symptoms.
4) Eating of large amount of carrots may produce
carotinaemia, which may simulate jaundice.
By applying the juice of any irritant plant (eg
calotropis), artificial bruises may be produced.
Putting this into eyes may produce ophtnaina
Howto diagnose a case of malingering?
a) Take history carefully from patient and his rel-
by them
ative or friends. The information given
may differ.
carefully. Usuallys
b) Do physical examination
conform to any
tne signs and symptoms do not with
Known disease. Even signs
do not match
symptoms. observation and watch
under
eep the patient
knowledge.
him without his
 SECTION Forensic Medicine

d) Malingering should be differentiated from fac- MLI: If any person gets a medical certificate y pre-
titious disorders, for example, Munchausen toany advantage, then:
tending a disease and uses it
syndrome. Munchausen syndrome is a psy- 1) according to S.198, IPC, he may be punished
chiatric disorder in which the affected person with P =I, ycars F.
fa
exaggerates or creates symptoms of illnesses 2) according to 417 of IPC, he may be punished
in themselves to gain examination, treatment, cheating with P = I a+ F.

attention, sympathy from medical personnel.


cONSENT (L. CONSENTIREZ= TO FEEL
OR SENSE WITH)
In general, consent meains a voluntary agreement,
compliance or pernmission.
According to S.13, Indian Contract Act, 1872:
When 2 or more persons agree upon the
same thing in the same sese, they are said to
consent.
Types of consent: implied consent and expressed
Consent.
IMPLIEDCONSENT
It is the most common variety of consent in both
general and hospital practice.
It implies consent to medical examination in a
general sense but not to procedures more complex
than inspection, palpation, percussion and aus-
cultation.
The patient conducts himself in a manner which
implies consent. In other words, the implied con-
sent is inherent in patient's behaviour.
Typical examples: () When patient presents at
clinic, it implies that he is agreeable to be exam-
ined, (ü) when a patient proffers his forearm for
examination of radial pulse; (ii) when patient
proffers his arm for venepuncture.
There are some situations in which implied consent
1S readily
apparent, for example, (i) in emergency,
() an unconscious patient, (ii) an intoxicated
patient lacking capacity to reasoning and (iv) a
mentally incompetent patient when a legal guard-
ian is unavailable.
EXPRESSED
CONSENT
Pecifhcally stated by patient in distinct and explicit
language.
t hold the
is also
known as 'real consent in the United
gdom (the elements of consent are defined
wth reference
to the patient) and 'informed con-
ent the United States (it shifts the emphasis to
in
the doctor's
duty).
CHAPTER 3 Medical Jurisprudence
Chapter 3B
Consent
Types:
1) Oral (verbal) consent: It is taken for the major
ity of relatively minor examinations or ther
apeutic procedures. It should preferably be
obtained in the presence of a disinterested party
(c.g. any literate paramedical staff) and not a
person closely related with the patient whose
later testimony may be biased. When properly
witnessed, it is as valid as written consent but
with less advantage as compared to written
consent.
2) Written consent: It is required for all major
diagnostic procedures, surgical operations and
general anaesthesia. It is taken in the presence of
a witness with signature. It includes 'informed
consent [SN-1].
Proxy consent (surrogate consent or substitute
consent): Consent given by some other person
(e.g. relative or friend) on behalf of the patient
in case patient himself cannot give consent, for
example, unconsciousness, intoxication, mentally
ill person or a child of <12 years of age.
DOCTRINE OF EXTENSION AND
BLANKET CONSENT
Doctrine of extension: When a patient gives consent
for a particular surgical procedure, that consent is
valid only for that procedure. If at the time of surger
the surgeon subsequently diagnoses another patho-
logical disease, there may be two situations:
1) When there is emergency: Here, another consent
is not required and the surgeon can operate for the
subsequent diagnosed pathological disease in an
emergency to save the life of the patient. For exam-
section
ple, a doctor was performing a caesarean
Suddenly, uncontrol-
in a case of placenta praevia.
performed an
lable bleeding started. The doctor
the consent or
Cmergency hysterectomy without doctor liable
patient. The court did not necessary to save her
because hysterectomy was
extension applies.
lite. Here, doctrine of Here, another
con-
emergency:
) When there is no
the surgery of
subsequent
for
Sent is required
 SECTIONI Forensic Medicine

example, dur- TABLE 3B.1 S.87 Versus S.88, IPC

diagnosed pathological disease. For
appendectomy, the surgeon Doctors) S.88, IPC (for Doctors)
course of an S.87, IPC (Not for
ing the
discased and he per- years can give A person can give
noticed that the uterus was A person of >18
held the doctor valid consent for an act not
valid consent for an
formed a hysterectomy. The court likely act 'not intended to
removed without the intended or not known to be
liable because uterus was to cause death or grievous hurt
cause death done in
there was no medical
consent of the patient when does not Example: Ram and Shyan (both
good faith for person's
emergency. Here, doctrine of cxtension >18 years of age) agree to
benefit
Example: Surgical
apply fence with each other for
taken is not for a amusement. This agreement operation done by a
Blanket consent: When consent
more than one proce-
surgeon with consent
implies consent of each to suffer
specific procedure and it covers any harm which in the course in good faith for the
For example, doctor
dure, it is called blanket consent. of such fencing may be caused benefit of patient
appendectomy on a female patient. without foul play; if Ram, while
took consent for
When that patient was being
operated for appen playing hurts Shyam, Ram
uterus. Since the commits no offence. It means
dectomy, the doctor noticed fibroid
anaesthesia, the doctor Ram will not be responsible for
patient was under general his act because Shyam (a major
the patient if
thought that it would be to the benefit of being>18 years) is able to give
removed whole
the uterus was removed and so he also a valid consent and he gave
The point of interest Consent to suffer any harm in
uterus (i.e. total hysterectomy).
is that the female patient had given consent
only for this amusement

appendectomy, not for total hysterectomy and the this section, the age has been this section, the
In In

mentioned (i.e. 18 years) age has not been

doctor removed her uterus without her separate prior mentioned
consent. It means her surgery was extended beyond
the scope of her consent. The court said that if there
is no emergency related to subsequently discovered
TABLE 3B.2 S.89, IPC Versus S.92, IPC
pathological condition (e.g. fibroid uterus), a separate
consent must be taken later on to remove it although S.92, IPCc
S.89, IPC
it is more convenient for the doctor to operate at the A child of <12 years or insane Any act done in good
time of surgery for first pathological condition. Only person cannot give a valid faith for the benefit of a
person without consent
in case of emergency related to subsequently dis- consent for an act done in
good faith for its benefit. So is not an offence. It
covered pathological condition, can the surgery be applies in following
here consent of guardian is
extended to save the life of the patient. Most of the required Circumstances
time, the signature of the patient is taken on a printed Example: father
A giving 1) When person is
paper and the patient does not even read thoroughly consent for operation on the incapable of giving
child in good faith and for the consent
because he is convinced that whatever doctor is going
child's benefit, even though 2) When guardian is
to do is for the benefit of the patient. Blanket consent the operation is risky, cannot unavailable to give
s ambiguous and not specific and so legally it is not be held responsible theif Consent
allowed. Hence, the doctor should perform the proce- child dies
dure for which he has taken consent; he should not do
anther procedure at the same time for which he has
S.90, IPC: A consent is not valid in the following fhve
not taken consent.
circumstances: (1) fear, (2) misconception, (3) child
of <12 years, (4) insane person and (5) intoxicateu
CONSENT AND LEGAL PROTECTION TO person. It means that a consent given under fear
or

RMPs misconception, or by a child, insane or intoxicateu

person is invalid.
Sections related to consent are S.87, 88,89,90
and 92,
IPC, and out of these, S.88, 89, 90 and
92, IPC provide
legal protection to RMPs. SOME IMPORTANT POINTS
S.87 versus S.88, IPC (Table 3B.1)
hospital
has

S.89 versus S.92, IPC (Table 3B.2)

1) It is unlawful to detain a patient in a
against his wishes.
 CHAPTER 3 Medical Jurisprudence

2)Ifa doctor examines or treats person without his

a
Competency: (1) patient should be >12 years of
consent, the doctor nmay be charged with assault age for general physical examination and >18 years
[S.351, IPC). of age for surgery and (2) mentally sound (i.e. not
LAMA (left against medical advice): If a patient
3)wants to leave against medical advice, then doctor
intoxicated).
Exceptions for informed consent: Informed con-
has to record three things
on a paper in the case sent not required in the following situations:
is
sheet and then the patient
is allowed to leave. (1)
1) Emergency [S.92, IPC]: If patient is 'critically
Write/record patient's wish. (2) Write the dangers ill' or 'unconscious' or 'mentally ill' or "below
and complications clearly in writing if the patient 12 years of age' and there is no close relative
wants to leave against medical advice. The patient with him, no informed consent is required.
will be responsible for complications. (3) Signature Doctrine of Loco parentis [SN-2].
relatives.
of patient or 2) Therapeutic privilege [SN-3].
A child <12 years of age cannot
4)
give consent. 3) Therapeutic waiver: A patient may specifically
ask not to be informed, that is, he may waive of
his right to make an informed consent.
LIST OF IMPORTANT QUESTIONS 4) Others: (i) sensitive, anxious and emotional
FOR EXAMINATION patient; (ii) examination of arrested person; (ii)
treatment of patients suffering from notifiable
SHORTNOTES disease for community interests and (iv) psychi-
atric examination or treatment by court order.
1. Informed consent (or doctrine of informed con-
Informed consent must be written on paper, with
sent)
signature of patient as well as signatures of two
2. Loco parentis
independent witnesses.
3. Therapeutic privilege
Advantages of taking informed consent: Patient
cannot sue the doctor under S.350, IPC and 351,
ANSWERSS IPC.
Informed refusal: Doctor must inform the patient
SN-1:Informed consent (or Doctrine about the risks of refusing a particular treatment
of Informed Consent) (or Rule of Full or procedure and even after getting such informa
tion, a competent person has a right to refuse to
Disclosure) consent for treatment or procedure. Here, the doc-
When the doctor, at the time of
obtaining consent tor cannot force the patient to consent.
of a patient, fully informs the
patient about his
Condition and the procedure or treatment to be
SN-2: Loco parentis
adopted, including the risks involved, the consent
will be considered informed consent. Doctrine of Loco parentis (Latin, in place of a par
emer-
means there is full disclosure of related infor ent) applies when children are in medical
"tmation by the doctor to the patient. It maintains gency and there is a question of consent.
Usually,
children 1s
ransparency in doctor-patient relationship. the consent of the parents of their
procedures as well
The doctor informs the patient about the follow- required tor any routine surgical
emergency situations
ing in the patient's own
language: as emergency procedures. In
parents are not read-
1) Nature
of illness involving children, when their
emergency procedures
4 lreatment/procedure options available and the ly available, the consent for
person accompanying
purpose, costs, risks and benefits can be obtained from the warden of
example, school teacher,
duccess and failure rates: (a) prognoSIs in tne the child, for
and so on.
absence of intervention, (b) informed refusal hostel, neighbour, relative
Examples: away from home
the said procedure/treatment and (c) after
effects on a
Suppose whilefalls
picnic far
and thus
suffers
from height
Risks of not receiving any treatment town, a child
 SECTIONI Forensic Medicine
even refuse treatment in
playing, the teacher to the patient; he may
head injury there while this situation, doctor
spite of minimum risk. In
accompanying the child can give his consent if up to which extent he will
is privileged to decide
emergency treatment is required. (partial
disclose the information to the patient
2) A student in a hostel suddenly becomes uncon- regarding the involvement of the risk.
disclosure)
scious; the warden can take him to a nearby
doctor. If treatment is urgently required to save
LWhen the doctor partialy disclOses intormation to

the patient according to the emotional

the life of the student, the warden can give his
consent for the treatment of student.
SN-3: Therapeutic privilege
Usually the doctor, at the time of obtaining con-
sent of a patient, fully informs the patient about
the relevant facts regarding the procedures being
adopted or to be adopted including the risks
involved. This is the 'rule of full disclosure. At
times, it may not be possible to explain everything
to the patient. The reason is that the patient may
be already emotionally disturbed and he may not
tolerate the information given by the doctor. The
disclosure can cause serious psychological threat
condition
privilege.
of the patient, it is called therapeutic
disclosure (ie.
It is an exception to the rule of full
informed consent).
The doctor may reveal
detailed information
(including risks of treatment) to any of the close
relative of the patient. The doctor may consult
another doctor familiar with the case or he may
discuss it with a senior doctor.
surgery of
For example, a patient is to undergo
mitral valvotomy, but patient is scared of a sur-
gery on his heart, so he may not be informed
about details of it; however, one of the close rela-
tives should be made aware of it. Patient may be
told that it is a minor surgery.
 CHAPTER 3 Medical Jurisprudence

Chapter 3C
Medical Negligence
TYPES OF
NEGLIGENCE of time, a doctor-patient relationship is estab-
lished. Most often, this situation occurs in OPD.
Medical negligence: Negligence rclated to the medical In the case of emergency, it is the already estab-
nrofession is known as medical negligence. Generally,
lished duty of a doctor to treat the patient. In
it is also known as doctors
negligence.
other words, a doctor must treat the patient
the paticnt is inegligent,
Patient negligence: Here only in case of emergency. Moreover, the Supreme
not the doctor.
For example, the patient docs not give Court has declared that doctors cannot refuse to
correct history, or he does not follow
doctor's advice
treat patient who is in an emergency situation.
and/orhe starts alternative formof treatment without The doctor-patient relationship is not estab-
informing doctor, or he discontinues treatment with- lished in three situations:
out infornming doctor,
or he leaves hospital against 1) If a doctor does not agree to treat the patient.
medical advice. The reason may be the non-payment of fee by
Contributory negligence [SN-3|: When the negligence patient at registration counter. So the doctor
of the patient contributes to the negligence of the doc- can refuse a patient on non-payment of his fee.
negligence.
tor to cause harm, it is called contributory Also, the doctor has choice to select his patient.
Composite negligence: When a patient suffers injury For example, a patient comes to a doctor for
as a result of combined negligence of more than two treatment of itch but patient refuses to give fee.
doctors, it is known as composite negligence. So doctor refuses to treat him. After some days,
Corporate negligence: Negligence of a corporation the patient develops complications, for exam-
(eg. a hospital) is called corporate negligence. ple, secondary bacterial infections, fever and
so on. Here, the patient cannot sue the docto.
MEDICAL NEGLIGENCE Why? Because.. duty was not established.
2) When there is no emergency. For example,
Medical negligence (doctor's negligence): The law a patient is brought to a doctor with 50%
assumes that a medical man will always use 'reason- burns. The doctor demands his fees but
able degree of skill and care' in the treatment of
his patient is not able to comply. For this reason,
patient. But when medical man fails to perform
the the doctor refuses treatment and after some
duty to exercise a reasonable degree of skill and care
time, the patient dies. Can the doctor be
in treatment of the patient, negligence
arises which sued? Yes, the doctor can be sued because in
isknown as medical negligence. Medical
negligence the case of emergency,it is the already estab-
has been defined as
Absence of reasonable skill and lished duty of a doctor to treat the patient. A
care in the treatment of
patient which causes bodily doctor cannot refuse to treat the patient in
nyjury or death
ofthe patient or "Willful negligence emergency. The doctor can ask for his fees
f a medical practitioner in the treatment
which causes of patient later and if the patient does not pay doctor's
bodily injury or death of the patient. fees, the doctor can sue the patient.
Components of 3) When a doctor examines the patient for
Medical Negligence
ror a case of Some purpose other than providing treat-
medical negligence to be established, four ment. For example, a doctor conducting
Tions must be present: Duty, Dereliction, Dam- medicolegal examination for insurance.
and Direct causation [mnemonic. to treat the
4D. These Here the doctor does not agree
Dotents apply for only a healer and thus
not apply civil negligence; they do patient and so he is not as
for criminal negligence.
A. Duty no duty of care arises.
(existence duty: It means
of duty of care by the doctor) Dereliction (breach or neglect) ofperforming his
Adoctor starts to owe a duty towards a negligent in
patient the doctor should be a cancer
SOOn as he agrees to treat him. At that point towards his patient. For example,
luties
 SECTIONI Forensic Medicine

The doc-
wound but fails to give the TT (tetanus Oxoid)
patient comes to a doctor for treatment. injection. The patient goes home and applies co
is established) but
tor agrees to treat him (i.e. duty dung over the wound. He develops tetanus and
then fails to give proper and
judicious treatment
patient dies. dics. Can his relatives sue the doctor for not giv
(i.e. there is dereliction). At last, the ing TT injection? No, because although there Was
for dereliction (i.c.
Can his relatives sue the doctor a duty established, as well as dereliction (i.e. not
neglect) of duty? Yes, they can. giving TT injection) and damage (i.e. death), the
a result of der
Damage: The damage must occur as damage(i.c. death) was not a direct cause of doc.
Unless there is
cliction and it must be foresceable. tor's dereliction. The death was due to the applica.
due to ncgligent
damage (either physical or mental) tion of cow dung by the patient
clainm any com
act of the doctor, the patient cannot
a patient
pensation from the doctor. Por example,
comes to a doctor with viral
fever. Doctor treats him TYPES OF MEDICAL NEGLIGENCE [LO-11
occurs). After the
for typhoid fever (i.c. dercliction There are two types of medical negligence: Civil nep
know that the
patient becomes well, he comes to ligence and criminal negligence. suppose a patient
Can the
doctor had given him wrong treatment.
sue was harmed due to the negligent act of a doctor and
patient sue the doctor? No, the patient cannot
he decides to sue the doctor. He is free to take three
the.doctor despite the fact that dereliction was there,
because no damage had occurred as a result.
types of actions (Table 3C.1).
(i.e. 1) If he decides to go to a civil court or consumer
C. Direct causation: It means the dereliction
neglect) of duty must lead to damage or we can court to ask for compensation, then the negligence
say, the damage must result directly from dere- is regarded as civil' negligence. The patient goes to
liction. Patient must show that a reasonably close civil court because either the injury suffered by him
and casual connection exists between the 'negli- is very mild or he is in need of money.
gent act and the 'resulting injury' without any 2) If he decides to report the matter to police, then
intervening cause. It is known as legal cause' or the negligence is regarded as 'criminal' negligence.
proximate cause. Without proximate cause, the In reality, when the injury suffered by a patient is
injury would not have occurred. For example, a very severe or gross (e.g. death) and immediate
patient comes to a doctor with a lacerated wound. action is required, then most often he or a con-
The doctor agrees to treat him. He stitches the cerned person reports the matter to police.

TABLE 3C.1 Types of Negligence

Negligence of doctor

Injury to the patient

Injury is minor in nature Injury is gross in nature

Patient seeks monetary compensation from the doctor Patient wants immediate action' against the doctor

Patient approaches Patient complains to the police and police brings action
against doctor under following sections of IPC
S.336, IPC if no S.337, IPCc S.338, IPC S.304A, IPC
Civil court or consumer forum injury occurred if "hurt' it if 'death
but the doctor was grievous was caused
endangered caused hurt' was
the life of the caused
patient'
This is
civil negligence This is
criminal negligence
 CHAPTER 3 Medical Jurisprudence

may take both of the aforementioned actions Res Ipsa Loquitur [SN-9]
) He
gether, that is, he decides to go to civil court (or Consumer Protection Act, 1986 [SN-10]
onsumer court); he also reports the matter to tlhe
aolice simultaneously. In this situation, the negligence
will be regarded as cIvil negligence as well as crimi-
SOME IMPORTANT TERMS
a case of medical negligence can
nal negligence. Here, Borrowed servant doctrine: If an employer tempo-
in both civil and criminal courts simulta- rarily borrows an employee from another employer,
be fought
neously and the same negligent action of
thhedoctor then the lending employer temporarily surrenders
would be civil as well as criminal in nature. control over his employee and the borrowing
So if the question
arises what is the difference cmployer temporarily takes over his control. Now the
between civil negligence
and criminal negligence, new employer (i.e. borrowing employer) becomes
it is the patient's action
which decides whether the vicariously liable for any negligent act done by the
case falls under civil
negligence or criminal negli- borrowed employee (i.e. borrowed servant) while
gence (Table 3C.2). working under direct supervision of new employer.
It means in case of negligence by such an employee,
DIFFERENCE BETWEEN INFAMOUS the borrowing employer will be held responsible
by virtue of vicarious liability. Borrowed servant
MISCONDUCT AND MEDICAL
doctrine does not work in isolation. It is generally
NEGLIGENCE (TABLE 3C.3) combined with vicarious liability. For example, a
Junior surgeon from a private hospital was borTOwed
PRECAUTIONS AGAINST MEDICAL temporarily by a senior surgeon of a government
NEGLIGENCE [LO-1] hospital to assist in a surgical operation. During a
specific time period, the junior doctor worked under
Negligence [LO-2]
Defences Against Medical the supervision of the senior doctor. While operat-
Vicarious Liability [SN-8] ing, the junior doctor did some negligent act due to

TABLE 3C.2 Difference Between Civil Negligence and CriminalNegligence [D/W-12]

Sr. No. Features Civil Negligence Criminal Negligence

Where does patient go? In a 'Civil court or in Consumer forum' Patient directly complains to police
1
Trial by Civil court Criminal court

3. Litigation Between two parties Between state and doctor (i.e. state
versus.doctor)
4

Negligence Simple absence of care and skill Gross carelessness, inattention and scant
regard for patient's welfare
Offence No specific and clear violence of law There is specific violation of a particular
criminal law

0. Evidence sufficient Guilt should be proved beyond reasonable

Strong evidence is
doubt
was
Generally 'very gross' (e.g. a wrong limo
Damage to the patient Generally, 'minor (e.g. patient was unable
to attend the office for a few days) amputated or death was caused)
Doctor's defence, for Not defence
Good defence
example,
a Consent for act, and
b} Contributory
negligence lS.3044, IPC
imprisonment or fine or both
Punishment Doctor is liable to pay 'monetary
compensation' for the damages medical council
10 No function of
Clon taken by medical Removal of name from state medical
COuncil register either temporarily or
permanently
 SECTIONI Forensic Medicine

SHORT NOTES
TABLE 3C.3 Difference Between
Infamous Misconduct and Medical 3. Contributory negligence [DU 2008]
Negligence [D/W-13 and 14] 4. Medical maloccurrence
Medical 5. Medical misadventure (therapeutic misadventure
Infamous Conduct Negligence 6. Novus actus interveniens
Sr. (Professional (Professional
7. Product liability
No. Features Misconduct) Negligence 8. Vicarious liability (vicarious responsibility) [DU
Offence Violation of code of Absence of care
2009, CCU 2016]
medical ethics and skill, or
wilful negligence 9. Res ipsaloquitur
2. Duty of care Need not be present Should be present
10. Consumer Protection Act, 1986 in relation
to
medical man [CCU 2004]
3. Dereliction Need not be present Should be present
11. Defensive medicine
of duty
4. Damages to Need not be present Should be present
the patient
5. Trial by State Medical court or
Civil DIFFERENCE BETWEEN (D/W)
Council consumer court
or criminal court 12. Civil negligence and criminal negligence [CCU
6. Punishment Warning: erasure According to IPC 2009, 2011, 2012]
of name from imprisonment 13. Professional misconduct and professional negli-
register either and/or
gence [CCU 2012]
temporary or compensation
permanently (fine) 14. Infamous conduct and medical negligence [CCU
7. Appeal To MCI or Central To higher courts
2012]
Government

ANSWERS
which the patient suffered injury. The senior doctor
was held responsible for the negligent act of junior LO-1: Define medical negligence.
doctor by virtue of vicarious liability.
Damage: he term 'damage refers to the injury
Discuss different types of medical
or 'disability' suffered by the patient. negligence? Discuss the precautions
Damages: The term damages' refers to 'monetary thata physician should take to prevent
compensation' that is intended to make up for the the suits of medical negligence
person's injury.
o Medical negligence: It has been defined as
Failure to perform the duty to erercise a rea:
LIST OF IMPORTANT QUESTIONS sonable degree of skill and care in treatment o
FOR EXAMINATION patient.
Types of medical negligence:
LONG QUESTIONS A. Civil negligence:
Question of civil negligence arises in two sil
1. Define medical negligence. Discuss different uations: (1) When patient demands 'mone
types of medical negligence? Discuss the precau- tary compensation' for the damage that he
tions that a physician should take to prevent suitsS has suffered due to doctor's negligence.
of medical negligence [DU 2004, 2006]. When doctor demands for recovery ot n
2. Discuss the defences that a physician can puy
take tee from a patient who has refused to
when he gets a suit of medical negligence. What doctor's fee.
are different forums where action can be taken erally
The damage to the patient is gener
against a negligent doctor and discuss the penal- cour
minor' so the case goes either to civil
ties awarded by these forums.
or consumer forum.
 CHAPTER 3
The patient has to engage a lawyer, that law-
ver takes the fee and presents the case before
the court.
v.
The civil case is Cited as Patient doctor.
The four components (i.e. 4Ds) of nmedical
negligence apply to civil negligence.
Standard of proof rests on 'preponder-
ance of evidence (or balance of prob-
abilities), that is, there should be > 50%
probability of the doctor being negligent
in his conduct.
Burden of proof of negligence: It is the duty
of the complainant to prove negligence.
Punishment: The doctor has to pay the
compensation decided by the court to
the patient. There is no criminal liability
for the doctor and so he cannot be sent
to jail for his negligence. However, if the
patient complains to the medical council
also, the council can take action against
doctor, for example, removal of name from
medical register either temporarily or even
permanently.
Defences: Informed consent, contributory
negligence, res judicata and res indicata.
B. Criminal negligence:
Question of criminal negligence arises when
patient complains to the police regarding the
negligence of doctor. The police then register
the case against the negligent doctor.
Damage to the patient is generally very gross
(e.g. amputation of wrong limb or death),
so the patient informs police for immediate
action.
'Here the complainant is the State (1.e. gov
ernment) which fights the case on behalf of
the patient against the negligent doctor. The
government provides a lawyer called PP (i.e.
public prosecutor) which presents the case
before the court.
The criminal case is cited as State v. Name of
doctor.
"Burden of proof of negligence: The burden to
collect evidence of criminal liability and thus
prove negligence is upon the complainant
Standard of proof: beyond reasonable doubt,
at is, there should be >99% probability of
doctor being guilty. Otherwise accused per
SOn will be
presumed to be innocent.
Medical Jurisprudence
Punishment for doctor: Imprisonment as
well as fine.
Classification of cases of criminal negli-
gence:
1) When 'no injury' occurs due to negligence:
Since there is no damage, the patient can-
not claim compensation in civil court or
consumer court. But patient can still go to
criminal court where according to S.336,
IPC, the negligent doctor will be punished
with P = I, mnh Or F (Rs 250) or both.
For examnple: A doctor conducts a deliv-
ery under influence of alcohol but for-
tunately the delivery occurs safely. Later
the patient becomes aware of the fact and
she goes to civil court to ask for mone-
tary compensation. Will she get com-
pensation? No, because delivery was safe
and there was no damage. Still she has
another option. She can go to criminal
court where the doctor will be punished
according to S.336, IPC.
2) When 'injury' occurs due to negligence:
a) When hur is caused to the patient
due to negligence of doctor: The
doctor will be punished according to
S.337, IPC with P = I month Or F (Rs
500) or both. For example, a doctor
gives penicillin injection without test-
ing sensitivity and the patient develops
anaphylaxis. By treatment, the anaph-
ylaxis was controlled by the doctor.
Although the patient is alright now,
he can stil sue the doctor according to
S.337, IPC.
b) When grievous hurt is caused to the
patient due to negligence of doctor:
The doctor will be punished according
to S.338, IPC with I,.or
years
F (Rs 1000)
or both. For example, a doctor ampu
tates a wrong leg.
negligence
3) When 'death' occurs due to
punished according
The doctor will be
example, a doctor
to S.304A, IPC. For testing8
injection without ana-
gives penicillin develops
sensitivity and the patient patient
The relatives of
phylaxis and dies. according to S.304A,
can sue the
doctor
IPC.
 SECTIONT Forensic Medicine
Precautions against negligence: A doctor should
be very careful while treating a paticnt because a
slight mistake done by the doctor can be a cause
of negligence and the patient who suffered dam-
age can suce the doctor; thus the doctor should kecp
some important points in his mind and take some
precautions to avoid these consequences [Mne-
monic TEST-TLC For MI].
1) Take informed consent.
2) Examination of a female patient should be
done in the presence of a third party which
should be a female, for example, female nurse.
3) Sensitive tests should be done before injecting
some drugs which are likely to produce anaphy-
laxis, for example, penicillin.
4) Tetanus injection has to be given in every case
of injury which is bleeding.
5) Telephone: Do not prescribe drugs on telephone.
6) Labour: Do not leave the patient unattended
during labour.
7) Confirm a diagnosis by proper investigations.
8) Frequently check the conditions of the equip-
ment.
9) Maintain accurate medical records.
10) Inform police if death occurs during anaesthe-
sia or during operation.
LO-2: Discuss the defences that a
physician can take when he gets a
Suit of medical negligence.What are
different forums where action can
be taken against a negligent doctor,
and discuss the penalties awarded by
these forums
Defences against medical negligence [Mnemonic
New Low Cost PCM, Now Vanishes RMP]
1) No duty owed towards the patient: The doc-
tor did not agree to treat the patient; therefore,
no duty exists.
2) Law of limitation: It prescribes the time-limit
for different suits within which an aggrieved
person can approach the court for redress or
justice. For example, in relation to Consumer
Protection Act, a complaint has to be filed by an
aggrieved patient within 2 years from the date
of cause of action (i.e. negligence). After 2 years,
no complaint will be entertained [S.24A,Co
sumer Protection Act, 1986). It means that
if
patient brings the claim tothe consumer forum
after 2 years of alleged negligence, that person
cannot claim compensation and the doctor can
use the concept of law of limitation' as a defenca
3) Calculated risk doctrine: If a physician
chooses for his patient a course of treatment
which is potentially dangerous to life, yet has
a
proven record of saving the lives of patients in
scveral cases, the doctor is said to have taken
a
calculated risk. If the patient suffers any harm
due to such a procedure, the doctor would be
protected by the calculated risk doctrine.
4) Patient negligence: When only the patient ag
is negligent, the doctor can take a defence of
patient negligence.
5) Contributory negligence: It is not necessary
that only the doctor is negligent; patient may
also be negligent. When the negligence of the
doctor is combined with the negligence of the
patient, the doctor can take this defence.
6) Medical maloccurance [SN-4] and Medical
misadventures [SN-5].
7) Novus actus interveniens [SN-6].
8) Volenti non fit injuria (voluntary assumption
of risk in the United States): In Latin, it means
to a willing person, injury is not done. The doc
tor explained the risks of a particular treatment
to a patient and clearly warned him. The patient
willingly consented for that treatment even after
doctor's warning. If injury occurs to the patient
the doctor will not be responsible and the patient
will not be able to bring a claim against the doc
tor. In a sense, the patient consented to waive all
claims for damages. For this, the doctor must
show that an informed consent had been taken
and all side effects had been explained clearly to
the patient. The doctor can use the concept ot
volenti fit non injuria' as a defence. For exampls
65 patient sustains radiation burns during ther
apy and he had earlier been explained about the
risks; he cannot claim damages.
9) Res Judicata (or Doctrine of Double Jeop
ardy): According to S.300, CrPC, person once
convicted or acquitted cannot be tried for tne
same offence
10) Medical indemnity insurance: Insurance
companies have been providing 'Medical
Another random document with
no related content on Scribd:
to produce marked symptoms of poisoning. In this direction a
number of experiments have been performed with arsenic,
particularly those of Cloetta[1], who found that the dose of arsenic for
dogs could be gradually raised, if given by the mouth, to many times
the ordinary fatal dose, but that if at this point a subminimal fatal
dose was injected beneath the skin acute symptoms of arsenic
poisoning followed.
We show in a later chapter that the excretion of lead in persons
tolerant of the metal takes place through the medium of the bowel,
and that probably those individuals who are engaged in what are
recognized as dangerous processes in lead industries, and yet show
no signs of illness, have established a kind of balance between the
intake of the poison and its excretion by the bowel. It is rarely
possible in such persons to find any lead excreted through the
kidney. Occasionally, however, such persons, after working a
considerable time in a dangerous lead process, become suddenly
poisoned, and inquiry frequently discloses the fact that some
disturbing factor, either intercurrent illness, alcoholic excess, etc.,
has occurred, or that the breathing of a big dose of dust has
precipitated the symptoms of general lead poisoning. On the other
hand, the experience of all persons engaged in the routine
examination of lead workers is that, although a worker may show
signs of lead absorption as distinguished from definite lead poisoning
during the earlier period of his employment, he later shows less and
less signs of the influence of the poisonous substance; even a mild
degree of definite poisoning in the early stages of work in a lead
process does not seriously militate against this gradually acquired
tolerance, whilst careful treatment during such a time as the man is
acquiring tolerance to the poison frequently tides him over the
period, and enables him to withstand the ordinary dangers attached
to his work.
The earliest symptom of lead absorption is anæmia. The anæmia
is not very profound, and the diminution in the red blood-cells rarely
reaches as low as 2,000,000 per c.c., the hæmoglobin remaining
somewhere between 75 and 80 per cent. Some loss of orbital fat, as
well as fat in the other parts of the body, occurs, but beyond this no
obvious clinical signs of poisoning exist. Should such persons
possess unhealthy gums, a blue line rapidly makes its appearance,
but where the gums are healthy it is unusual to see any sign of
deposit in this prodromal stage.
Persons who gradually acquire tolerance go through the stage of
anæmia without exhibiting any symptoms of colic or paresis, and
without any treatment the hæmoglobin and the number of red cells
gradually pass back to a more or less normal condition. During this
period—that is, whilst the blood shows signs of a diminution in its
corpuscular and colour content—basophile granules may always be
found if sought for, but disappear as a rule when the blood-count has
returned to about 4,000,000 per c.c. and an 80 per cent.
hæmoglobin. Such a man has now developed tolerance to the
poisonous influence of lead, a tolerance which may be described as
a partial immunity produced by recurrent subminimal toxic doses. On
the other hand, in a number of persons who show definite
susceptibility, the blood-changes are progressive, and do not show
signs of automatic regeneration. In such persons, even after so short
time as four to six weeks’ exposure to lead absorption, definite
symptoms of colic may make their appearance. The removal of such
an individual from the poisonous influence of lead generally clears
up the symptoms in a short time, but the symptoms may occasionally
continue for several months after removal from the influence of the
poison. An individual of this type is to be looked upon as showing
peculiar susceptibility, and should not be employed in any lead
process where there is risk.
Such statistics as are available on this point show that an
increased tolerance to the poisonous influence of lead is gradually
acquired during periods of work, in that the number of attacks of
poisoning diminish in frequency very considerably in relation to the
number of years worked. As will be seen on reference to the chapter
dealing with the statistics of lead poisoning (p. 46), the greatest
number of cases occur in persons who have only worked a short
time in lead. On the other hand, the sequelæ of lead poisoning only
make their appearance, as a rule, after long-continued exposure. It is
important to bear in mind that the various forms of paresis rarely
make their appearance unless the subject has been exposed to
long-continued absorption of lead, and, further, that the blood of such
persons will as a rule show, on careful examination, evidences of the
long-continued intoxication. If measures, therefore, were taken to
determine the presence of such continued intoxication, and to
diminish the amount of poison absorbed (subjecting the individual at
the same time to a proper course of treatment), a large number of
the cases of paralysis, encephalopathy, and death, incidental to the
handling and manufacture of lead, could be eliminated.
Susceptibility may at times be shown by several members of one
family. Oliver[2] says that he has known many members of one family
suffer from and die of lead poisoning. In our experience several
instances of this susceptibility have been noticed. In one case two
brothers, working in one shift of men, developed poisoning, although
no other persons in that shift showed any signs of it. A third brother,
who came into the works after the other two had left, and who was
placed under special supervision on account of the susceptibility
exhibited by his two brothers, although given work which exposed
him to the minimal degree of lead absorption, developed signs of
poisoning six weeks after his entrance into the factory. In another
factory, three sons, two daughters, and the father, all suffered from
lead poisoning within a period of four years: the father had three
attacks of colic, ultimately wrist-drop in both hands; one daughter
had one attack of colic, and the other three attacks; whilst the three
brothers all suffered from colic and anæmia, and one had early signs
of weakness of the wrist. There was no evidence at all to show that
these persons were more careless, or had been more exposed to
lead dust, than any other of the persons with whom they worked, or
that the work they were engaged upon was more likely to have
caused illness to them than to other workers. Persons with a fresh
complexion and red hair have been noted to be more susceptible to
lead poisoning than dark-haired persons.
In one factory with which we are familiar, a number of Italian
workmen are employed; these show considerably less susceptibility
to lead poisoning than do their English comrades as long as they
adhere to their own national diet. When, however, they give this up,
and particularly if they become addicted to alcohol, they rapidly show
diminished resistance; in fact, all the cases of plumbism occurring
among the Italians in this factory during the last ten years have been
complicated with alcohol. It is possible that the relatively large
quantity of vegetables in the diet of these Italians influences the
elimination of absorbed lead. There is some reason to suppose,
however, that there may be racial immunity to lead poisoning.
The following case in the same factory illustrates a point already
mentioned—namely, the gradually acquired tolerance to poisoning,
and the unstable equilibrium existing. The individual was a man of
twenty years of age. He commenced work on August 2, 1905. Six
weeks later he was under treatment for seven weeks, for lead
absorption, and had a peculiarly deep blue line round his gums, and
a diminished hæmoglobin of 75 per cent. The symptoms
disappeared with ordinary routine treatment, and his work was
shifted to a position in the factory where he was exposed to the
minimum amount of lead absorption, at which work he continued
during the rest of the time he remained in the factory. He continued
quite well until June, 1906, when he was again under treatment for
two weeks, with the same blue line and anæmia, and his blood
showed the presence of basophile granules. He was under treatment
again in January and February, 1909, for five weeks, had again a
deep blue line and basophile staining of his blood. On November 7,
1911, having had no anæmia and no blue line, he had a slight attack
of colic. During this period of work his blood had been examined on
eight occasions, and on each occasion it had shown basophile
granules. The attack of colic was an exceedingly mild one. There is
no reason to suppose that he had indulged in alcoholic excess, but
there was some reason to think that for about a month he had been
subjected to increased lung absorption. No other persons working in
the same shift at the same work developed poisoning during the
whole of this period. This case illustrates initial susceptibility, partial
tolerance, and ultimate breaking down of such partially established
tolerance.
During the experimental inquiry on lead poisoning by one of us [K.
W. G.[3]], the question of the subminimal toxic dose and the minimal
toxic dose was under consideration. Animals subjected to inhalation
of lead dust invariably succumbed to the effects of the poison when
the dose given represented from 0·0001 to 0·0003 gramme per litre
of air inhaled, the period of inhalation being half an hour three times
a week. On the other hand, when the lead content of the air was as
low as 0·00001 gramme per litre, the symptoms of poisoning were
long delayed, and in more than one instance, after an early
diminution in weight, recovery of the lost weight took place, and the
animals, whilst showing apparent symptoms of absorption, had no
definite symptoms of paresis. These observations tend to confirm
such clinically observed facts as are given in the case cited above,
but they, of course, do not form a criterion as to the amount of lead
dust which may be regarded as innocuous to man.
Lead is peculiarly a cumulative poison, and post-mortem analyses
of viscera show that it may be stored up in certain parts of the body,
more especially in the bone and red bone marrow and brain, and to
some extent in the liver, spleen, and kidneys. Any circumstance,
therefore, that temporarily interferes with the ordinary channels
through which lead is excreted may determine the presence of a
much larger quantity than usual of the metal in circulation in the
body; and if in addition an increased quantity of the poison be
inhaled, more or less acute symptoms follow. The localization of the
deposit of lead is therefore of some importance.
Meillère and Richer[4] give an analysis of various organs of the
body, but their results are not in accord with the majority of other
observers. They found that the hair particularly contains a large
quantity of lead. They do not seem to have examined the bones.
Next to the hair, the liver seems to have contained the largest
amount. Wynter Blyth[5] found 117·1 milligrammes of lead in the
brain of a person who died of encephalopathy. In another case he
found 0·6 gramme in the liver, 0·003 in the kidney, and 0·072 in the
brain. Hougounencq[6] examined the organs of a person who died
from lead poisoning, and found the largest amount of lead in the
large intestine.
Large intestine 0·2150 gramme.
Small intestine 0·0430 „
Liver 0·0050 „
Brain 0·0008 „

In the lung, stomach, kidney, and heart, only traces were found.
 Dixon Mann[7] describes some experiments in which potassium
iodide was given in cases of chronic poisoning, and during the whole
of the experiments the fæces and urine were analyzed three times a
week. He found by this means that a considerable amount of lead
was being eliminated by the intestine. He therefore administered 2
grammes of lead acetate three times a day for five days to a patient,
and he found that the fæces contained 0·1762 gramme the first day,
0·17411 gramme the second day; the fourth day it had fallen to
0·0053 gramme, and on the sixth day to 0·0006 gramme. The
largest amount at any one time in a day obtained from the urine was
only just over 0·001 gramme; the average amount found in the case
of chronic poisoning was about 3 milligrammes, whereas the
greatest amount at any one time in the urine was only 0·9
milligramme.
The quantity of lead present in the brain necessary to determine
acute poisoning is not known, and it is probable that an extremely
minute quantity will produce very serious effects; and in support of
this may be quoted a number of observations in which search has
been made for the metal in persons who have died of diseases
affecting the brain associated with other symptoms of poisoning, and
yet post-mortem examination of the brain by chemical methods has
not revealed the presence of any lead whatever. In the case reported
by Mott (see p. 71), no lead at all was recognized in the brain.
There are no reasons, therefore, for supposing that the immunity
to lead poisoning depends on the fixation and storing up of the
poisonous metal in a non-poisonous form in some special situation in
the body, and, further, the particular situation in the body richest in
lead in any given case of poisoning will depend rather on (1) the type
of compound causing the poisoning, and (2) the portal through which
such poisoning occurs.
The question of the detection of lead in the body is referred to in
the chapter dealing with Chemical Examination. It is as well to point
out in this connection that chemical investigation of the amount of
lead present in the organs of persons dying from lead poisoning
should, if possible, always be made where there is any doubt as to
the diagnosis.
 Certain observers—amongst them Gautier[8]—are of opinion that
traces of lead may be found in normal persons. Thus, in a rat (Mus
decumanus) Gautier found 2 milligrammes of lead in 60 grammes of
liver. He considers that in many persons at least 0·5 milligramme of
lead may be swallowed daily incorporated with the food, as a
number of foods are liable to contamination by lead. Tinned foods,
particularly those which are soldered up after the materials have
been placed in the tin, certain tinned fruits with acid juices, often
contain small masses of solder loose in the tins; in the case
particularly of fruits the natural acid may slowly dissolve the lead
from the solder. The amount of so-called “normal” lead, if it is to be
found at all, must be very small, and would certainly be much smaller
in the case of a normal person than in one who had been subject to
definite lead poisoning. Such experimental evidence as is
forthcoming supports the clinical observations that persons exposed
to small doses of lead eventually develop tolerance of the metal, so
that they may ultimately withstand many times the dose sufficient in
the first instance to produce poisoning.
Such circumstances are the natural factors in the prevention of
poisoning, and if due care be given to their significance, the surgeon
in charge of any lead works may by judicious treatment and
alternation of employment so assist and strengthen the natural
defensive forces that susceptibility may be diminished, and the
degree of tolerance increased to a very considerable extent. We do
not imply that efficiency in the exhaust ventilation can be in any way
relaxed; all we desire to emphasize is that certain natural defensive
forces of the body do undoubtedly exist by which susceptible
persons ultimately become less susceptible, and that by appropriate
means these defensive forces may be augmented.
Susceptibility and immunity to poisoning by lead may be
considered, according to the type of lead compound absorbed,
further in its relation to age and sex. All compounds of lead are not
poisonous in the same degree; the more easily soluble compounds
are more poisonous than the less soluble. On the other hand,
compounds which appear at first sight unlikely to produce poisoning
may do so; for instance, fritted lead or lead silicate, a substance
largely used in the potteries as a glaze, and manufactured by fusing
together litharge and a silicate, would appear at first sight to be quite
an innocuous substance. Owing to its method of preparation,
however, it is not a pure compound of lead and silica, but contains
lead oxide, metallic lead, etc., entangled in its meshes, and
experimentally one of us (K. W. G.) has demonstrated that such a
compound may be acted on by the tissues of the body, both when
injected subcutaneously and even when inhaled, and so gradually
produce definite symptoms of lead poisoning, but at a much slower
rate than the more poisonous lead compounds. The fineness of
division in which the compound of lead exists is another factor
affecting its poisonous nature; the more finely divided particles find
their way into the lung more easily than the coarser particles. Various
subsidiary matters may also determine the susceptibility in a given
individual, and of these a certain number require mention, as they
probably act as definite predisposing factors. Age and sex may be
regarded as predisposing factors to lead poisoning, and certain
diseases also.
Age.—Young persons are regarded as more liable to lead
poisoning than adults, although it is difficult to obtain definite figures
on the point, the duration of employment acting as a disturbing factor
in estimating the susceptibility of young persons. They may have
worked in a lead works for a year or more without showing any signs
of poisoning, but develop them later in adult life, although it is very
likely that absorption had taken place during the earlier period. In the
Report of the Departmental Committee on the Use of Lead in the
Potteries (Appendix XII.), the attack rate for the period 1899 to 1909
for young persons is 19·3 per 1,000, and for adults 18·8 for the same
period, but the figures upon which these attack rates are based are
too small to build any conclusion. The general clinical conclusions of
appointed surgeons and certifying surgeons in the various lead
factories would be, we believe, that the susceptibility of young
persons is at least twice that of adults, and there is some ground for
supposing that the tissues of an adult when growth has ceased more
readily adapt themselves to deal with the absorption and elimination
of poisonous doses of lead than do the tissues of a young person.
Sex.—Women are more susceptible to poisoning by lead than
men, and in lead poisoning from drinking water the proportion of
women (especially pregnant women) and children attacked is stated
to be higher than in men, and one such epidemic is quoted by Oliver
where the rise in the number of miscarriages and premature births
led to the discovery of the fact that the water-supply was
contaminated with lead. The close relationship of lead poisoning to
miscarriage has been repeatedly made out, especially by Oliver, in
the white lead industry as carried on twenty years ago. Oliver also
quotes the effect upon rabbits[9], Glibert upon guinea-pigs[10], and in
the experiments of one of us (K. W. G.), referred to on p. 99, all the
animals to which lead was given during pregnancy aborted; and,
further, with one exception out of eight animals, all died of lead
poisoning, not as the result of the abortion, but some time later,
although no further administration of lead was made. This confirms
the well-known abortifacient effect of diachylon, and there is no
doubt that the lead circulating in the maternal blood determines the
abortion. Further, observers who have examined the fœtus in such
cases have demonstrated the presence of lead in the fœtus itself.
Oliver[11] found that eggs painted with lead nitrate did not hatch out,
and on opening the eggs the embryos were found to have reached
only a limited stage of development, and to have then died, whereas
control eggs painted with lime produced live chicks. From what is
stated later with regard to the curious action of lead upon the blood,
the mechanism of abortion is easily understood; it is probable that
placental hæmorrhages are produced, as in other organs of the
body. But the effect of lead on the female is not only apparent during
pregnancy. A considerable number of women working in lead
processes suffer from amenorrhœa, and often from periods of
menorrhagia and dysmenorrhœa, which as a rule is the more striking
symptom. The effect of lead on the uterine functions, however, only
exists so long as the constant intake of the poison is taking place,
and many cases are recorded where women, after having had
successive abortions while working in lead factories, have ultimately
gone through a normal pregnancy and given birth to a living child.
This circumstance bears a strong analogy to the similar train of
events in syphilis.
In the Report of the Committee on the Use of Lead in the
Potteries, some inquiry was made with regard to the possible
association of lead absorption on the male side as a predisposing
cause of infant mortality and premature birth. The tables given are
not very conclusive, and from our own observations there seems to
be very little evidence for supposing that a male lead worker is less
likely to beget children, or that his children are more likely to be
unhealthy than those of men working in any other industrial process.
We are here speaking of the effect of lead under the conditions of its
general use in this country now. In the absence of any precautions
whatever as to daily absorption of dangerous dust, the effect on the
offspring, even in the case of male lead workers, may well be
evident, as has been shown by Chyzer[12] in the manufacture of
pottery as a home industry in Hungary. One greatly disturbing factor
in estimating the greater susceptibility of the female than the male in
many lead industries is that the more dangerous work is performed
by the women, such, for instance, in the Potteries, as the process of
colour-blowing and ware-cleaning.
Predisposing Causes of Lead Poisoning.—In lead poisoning,
as in many other diseases, a number of predisposing and
contributory causes may be cited which tend to lower the
susceptibility of the individual to the poisonous effect of the metal
and its compounds, or to so modify the functions of the body that a
smaller dose of poison may produce more profound changes than
would otherwise be the case.
Certain diseases may be regarded as predisposing causes by
lowering the general resistance of the body tissues to the influence
of lead, and a consideration of the chapter on Pathology will at once
demonstrate how seriously certain diseases may contribute in this
way.
The peculiar effect of lead is upon the blood and the walls of the
bloodvessels, and it will therefore follow that any disease which may
affect the intima of the bloodvessels may predispose to lead
poisoning; and, further, as the elimination of lead takes place to a
certain extent through the kidney, any disease which affects either
the renal epithelium or the general maintenance of the excretory
function of the kidney may predispose that organ to the irritative
effects of the lead circulating in the blood. In the same way, the
condition of lead absorption in which the balance of absorption and
elimination of lead remains in such a ratio that no definite symptoms
of lead poisoning appear may have that delicate balance easily
upset by the introduction of some secondary cause, which, when
operating in association with lead absorption, may precipitate
symptoms attributable to poisoning by that metal. Chronic alcoholism
especially, producing as it does definite changes in the kidney of
itself—changes which it is impossible to distinguish by the naked eye
from the effects of lead poisoning—must clearly act as a
predisposing, if not even an exciting, cause of lead kidney infection.
In experiments upon animals, it was found that the addition of
alcohol to the diet of an animal which was the subject of chronic lead
absorption precipitated the attack of definite poisoning; in other
words, the latent period of lead poisoning—that is to say, the
resistance exhibited by the tissues to the toxic influence of lead—
was considerably diminished by this addition of a second irritant,
alcohol. In several experiments, also, where the form of lead
experimented with was one of the least toxic of the lead compounds,
the animals subjected to such a compound alone did not become
poisoned, but succumbed if alcohol were added to their diet. This
experimental work is amply borne out by the clinical evidence of all
persons who have had experience of industrial lead poisoning, as
cases of colic and wrist-drop are frequently observed in lead workers
shortly after alcoholic excesses. Individuals, therefore, who are
suspected of the alcoholic habit should not be employed in any
process where they are likely to run risk of absorption of lead dust.
Such diseases as syphilis and gout, by causing a heightened
arterial tension or definite disease of the intima of the bloodvessels
themselves, tend to weaken the arteries in much the same manner
as does lead circulating in the blood, and must on that account act
as predisposing causes.
In persons employed in lead trades some species of tolerance is
generally developed, and if the functions of the body progress in the
normal way the balance of elimination and absorption are equal,
and, as will be seen later, the chief channel for the elimination of lead
from the body is through the bowel. It follows, therefore, that any
disease which tends to produce constipation or chronic inactivity of
the normal intestinal functions will also tend to lower the resistance
of the individual to lead poisoning.
Of the various types of intestinal disease of a chronic nature—
such, for instance, as chronic dysentery, colitis, and the like—little
need be said; but the predisposing effect of diseased conditions of
the upper portion of the alimentary canal must not be overlooked,
more particularly affections of the oral cavity itself. This special type
of infection, often included under the term of “oral sepsis,” besides
producing anæmia, is also a constant cause of intestinal
disturbance, and as such operates as a particular predisposing
cause of lead poisoning.
With regard to gout the evidence is not so clear. It was pointed out
by Garrod[13] that gout was common among house-painters, and it
has been generally stated that lead poisoning predisposes to this
complaint. In the opinion of a considerable number of observers,
however, gout is by no means common among persons working in
white lead factories or lead-smelting works, but there seems to be
some reason to suppose that it is somewhat common among those
persons employed in the painting trades, but not among those
employed in the manufacture of paints and colours. From the
experiments carried out by one of us [K. W. G.[13]]. it seems probable
that the occurrence of gout among painters may be associated with
the use of turpentine, largely employed in the ordinary processes of
painting, as this substance in particular is not one that is used by
workers in other lead trades, and, from experiments performed on
animals, the inhalation of turpentine vapour was found to produce
very definite changes both in the kidney and the general metabolism
of the body.
Malnutrition.—Malnutrition is recognized as a predisposing
cause of practically all forms of disease, and with a chronic
intoxication, such as lead poisoning, malnutrition and starvation, with
its attendant depression of all the vital forces of the body, is
essentially a predisposing cause of poisoning, so much so that even
the fact of commencing work without previously partaking of food
may operate directly as a cause of poisoning. It has been found,
moreover, experimentally by one of us [K. W. G.[14]] that an animal
fed with milk containing lead nitrate did not develop poisoning,
though the control animal developed well-marked symptoms of
poisoning with a much smaller dose given in water.
Anæmia.—Anæmia has already been referred to as occurring
with great frequency in persons who are absorbing lead, and it
usually forms one of the chief factors in the symptom-complex of
lead cachexia. As the action of lead is particularly upon the blood
and the hæmopoietic organs, diminishing the number of red cells
and the amount of hæmoglobin, and impairing the organs from which
fresh blood-cells are produced, a disease or state associated with
anæmia other than of lead origin acts as a definite predisposing
cause in the development of toxic symptoms in a worker in an
industrial lead process.
Among the anæmias, two particular types may be referred to as of
chief importance. In the first place, chlorosis, the anæmia occurring
particularly in young women, is often associated with intestinal
stasis. Lead anæmia occurring in a chlorotic person is always more
severe than simple lead anæmia. Young persons suffering from
chlorosis, therefore, should not be employed in a dangerous lead
process until the anæmia has been treated. The second type of
anæmia, which, from its frequency, may be also regarded as a
predisposing cause of lead poisoning, is chronic secondary septic
anæmia. Anæmias of this type, as was pointed out by William
Hunter[15], resemble in many points the original idiopathic or
Addisonian anæmia, often termed “pernicious anæmia,” and one of
us has had occasion to inquire into the curious type of secondary
anæmia associated with septic affections of the upper respiratory
tract, particularly those related to chronic suppurative affections of
the accessory sinuses of the nose, of the gums, of the mucous
membrane of the mouth and the throat. The commonest forms of this
secondary anæmia are those due to chronic post-nasal discharge,
and to chronic infections of the gums and alveolus of the jaws, the
latter often classed together under the term “pyorrhœa alveolaris.”
This term is an exceedingly clumsy one, indicating a discharge of
pus from the gum edges and sockets of the teeth, which are often
loose. The disease commences as an infective gingivitis along the
edges of the gum, and progresses to rarefying osteitis of the alveolar
process, and often of the body of the bone. The affection rarely gives
rise to pain, and as a rule the individual is entirely unaware that any
chronic suppuration is present, and little or no notice is therefore
taken of the disease. Progressive anæmia may thus be set up
without any knowledge of its cause, partly by absorption of the actual
bacteria and their products through the alveolar bloodvessels, and
partly by the fact of the constant swallowing of pus and bacterial
products, which set up various forms of chronic gastro-intestinal
incompetence. From the discharges of the mouth, and issuing from
the gum edges, numerous bacteria have been isolated, and in more
recent work one of us [K. W. G.[16]] has succeeded in isolating and
identifying certain bacteria as a direct cause of arthritis deformans, a
malady occasionally, but without sufficient grounds, ascribed to lead
poisoning. Arthritis of various types may occur in persons engaged in
lead trades, but in all such cases we have had the opportunity of
examining there has been some obvious source of septic infection,
and no evidence that the arthritis was due to the action of lead. It is
most important to draw the attention of those engaged in the
protection of lead workers from the dangers of their occupation to
these chronic septic conditions of the mouth, and it may be taken as
a general rule that, wherever the blue line makes its appearance
along the gums, such gums are in a state of chronic infection, and
the appearance of the blue line is merely a secondary effect. It is
exceedingly rare to find the blue line in persons with intact gums and
clean teeth; and although attention is frequently drawn to the fact
that a lead line exists in a person whose teeth are normal, little or no
notice is taken of the presence or absence of a suppurative condition
of the gum margins. Moreover, such a suppurative condition does
not always result in obvious inflammation of the gum edges, and
very considerable destruction of the alveolus and the interdental
bone may exist without any obvious signs of its presence, unless the
case be examined carefully with a fine probe. This particular point
has been the subject of experiment by one of us. Animals exposed
to the influence of air laden with lead dust never develop a blue line,
although all the usual symptoms of lead poisoning make their
appearance. When, however, some slight suppurative lesion of the
gums was produced by an inoculation into the gum tissue of
organisms isolated from a case of infective gingivitis in a human
being, the site of inoculation and any suppurative lesion that resulted
locally at once allowed the development of a blue line, and it was
only in animals so treated that it was possible to produce
experimentally the Burtonian line.
There is no doubt that any chronic septic infection may predispose
to lead poisoning through the production of a secondary anæmia,
and it is therefore inadvisable to pass for work in a lead process of a
dangerous nature any persons suffering from an infected condition of
the mouth. It follows also that the care of the mouth and gums
should be rigorously enforced upon all persons employed in lead
trades, as the mere mechanical facilities for the accumulation of
débris around the individual teeth tends to increase the quantity of
lead dust that may be retained in the mouth. This is gradually
rendered soluble and absorbed, through the action of the bacterial
acids which are always produced along the gum margins when any
entangled food is retained in the interdental spaces.
One further point of importance attaches to the infections of the
upper respiratory tract—namely, the constant ingestion of bacteria of
a fermentative type. By this means the contents of the stomach may
be maintained in a state of hyperacidity, and any small quantities of
lead which become swallowed are thereby at once rendered soluble
in the intermeal periods.
Of the other types of anæmia which may act as predisposing
causes of lead poisoning, little need be said, as they are either
associated with other grave symptoms or are rare in this country. But
as all forms of anæmia, particularly septic anæmia, malarial fever,
etc., are associated with destruction of the blood-cells, the presence
of basophile staining granules in the red corpuscles of such persons
is a constant feature, and must not be confounded with the basophile
staining owing its origin to the effect of lead.
In addition to the diseases mentioned which may be said to
predispose to lead poisoning, certain other diseases have been
stated to be predisposed to by the action of lead. It is no doubt a fact
that where chronic anæmia, wasting, loss of subcutaneous fat,
decreased muscular power, and general lowering of the metabolic
activity of the body, are produced, an individual so affected may be
supposed to be more susceptible to certain infectious diseases, and
among these stress has been laid on the alleged association of
phthisis with lead absorption. This point is discussed in the next
chapter.
In summing up the difficult question of predisposition to lead
poisoning, together with the correlated questions of susceptibility and
immunity, certain facts may at any rate be clearly stated:
1. Undoubted individual susceptibility and immunity exist with
regard to lead poisoning in exactly the same way as individual
susceptibility and immunity may be shown to exist towards poisoning
by many other metals and drugs. Therefore, given the same
opportunities for infection, a person showing early signs of lead
absorption may be regarded as susceptible.
2. Females are at least twice, and probably three times, as
susceptible to lead poisoning as are males. Much of this
susceptibility is determined by the extra stress thrown upon the
female generative organs.
3. Certain diseases predispose to lead poisoning mainly by nature
of the alterations in metabolism produced—chiefly anæmia.
4. Many persons engaged in lead industries become gradually
tolerant of the absorption of lead, and in time resist much larger
doses than would have been possible at the commencement of
exposure, but in such persons the balance between absorption and
excretion upon which that tolerance depends may become easily
disturbed by intercurrent disease or sudden increase in absorption.

REFERENCES.
[1] Cloetta: Dixon Mann’s Forensic Medicine and Toxicology, p. 463.
[2] Oliver, Sir T.: Diseases of Occupation, p. 142.
[3] Goadby, K. W.: Departmental Committee on Lead Poisoning, etc., in
China and Earthenware Manufacture, Appendix No. XXV.
[4] Meillère and Richer: Meillère’s Le Saturnisme. Paris, 1903.
[5] Blyth: Abstract of Proc. Chem. Soc., 1887-88.
[6] Hougounencq: Meillère’s Le Saturnisme, p. 73.
[7] Dixon Mann: British Medical Journal, 1893.
[8] Gautier: Société de Biologie, April, 1903.
[9] Oliver, Sir T.: British Medical Journal, May 13, 1911, p. 1096.
[10] Glibert, D. J.: Le Saturnisme Expérimental. Extrait des Rapports
Annuels de l’Inspection du Travail. Bruxelles, 1906.
[11] Oliver, Sir T.: Diseases of Occupation, p. 139.
[12] Chyzer, A.: Des Intoxications par le Plomb se présentant dans la
Céramique en Hongrie. Budapest, 1908.
[13] Garrod: The Lancet, 1870.
[14] Goadby, K. W.: Departmental Committee on Lead Poisoning, etc., in
China and Earthenware Manufacture, Appendix XXV.
[15] Hunter, William: Severest Anæmias.
[16] Goadby, K. W.: The Lancet, March 11, 1911.
 CHAPTER IV
STATISTICS OF PLUMBISM[A]
[A] Based mainly on reports received from certifying factory surgeons during the ten years 1900-1909.

Classification of notified cases of lead poisoning was carried out on practically the same
lines between the years 1900 and 1909, and comparison of the data so collected has
interest, in view of their large number—nearly 7,000—in respect of (1) increase or decrease
in recorded amount in each one of eighteen classes of industries; (2) severity and number
of attack—i.e., whether first, second, third, or chronic; and (3) main symptoms.
Notification was first enjoined by Section 29 of the Factory and Workshop Act, 1895,
which subsequently, on consolidation of the Factory Acts, became Section 73 of the Act of
1901. This enactment requires every medical practitioner, attending on, or called in to visit,
a patient whom he believes to be suffering from lead poisoning contracted in a factory or
workshop, to notify the case forthwith to the Chief Inspector of Factories at the Home Office;
and a similar obligation is imposed on the occupier of a factory or workshop to send written
notice of every such case to the certifying surgeon and inspector of factories for the district.
In form there is close similarity between this section and that requiring notification under the
Infectious Diseases (Notification) Act; but whereas the symptoms of these diseases are,
within well-recognized limits, precise, in lead poisoning the differential diagnosis has not
infrequently to be made from a variety of common ailments—headache, anæmia,
rheumatism, abdominal pain; and there is no precise standard of what constitutes lead
poisoning.
The notification of the practitioner as a rule gives no information beyond the belief that the
case is one of lead poisoning. As a matter of routine the notification is followed up by an
inquiry by the certifying surgeon and inspector to see whether regulations already in force
have been infringed in the particular work-place or not, and as to how far there may have
been contributory negligence on the part of the sufferer. The data supplied on the surgeon’s
report form the basis of the tabulation[1]. Brief explanation is wanted of the method adopted
in classification. Cases represent all attacks reported within a year, and not previously
reported within the preceding twelve months, so as to make the number of persons and
cases in a year the same. Where the interval between two reports on the same person was
more than twelve months, the fresh attack was again included. The number of such second
reports on persons already included in a return numbered 284 (4·2 per cent.), and a portion
of these certainly, probably not more than 100, have been included twice or thrice in the
total 6,638 cases. Cases in which there was obvious error in diagnosis, or in which the
opinion of the certifying surgeon was very strongly against the diagnosis (especially when
the report had been made in the first instance by the occupier alone, and not by a medical
practitioner), were excluded from the return. These numbered 458 (6·8 per cent.). Others,
again, where there was a strong element of doubt, but not to be regarded as more than a
difference of opinion between two medical men, were marked doubtful and included. Of
these there were 424 (6·3 per cent.).
The classification of industries was designed to represent the way in which the poisoning
may be supposed to originate from (a) lead fumes (1 to 4), (b) handling metallic lead (5 and
6), (c) dust from lead compounds (7 to 14), and (d) lead paint (15 to 17). We attach now
only slight importance to this attempt to define causation, as it will appear from our survey
that we regard almost all cases as the result of inhalation either of fumes or dust.
The reports describe not only the particular attack, but also the general condition of the
patient at the time of the attack. Very frequently a combination of symptoms—colic,
anæmia, and varying degree of paralysis—are described as present, and when this is the
case each one of them has been entered under the appropriate heading. The total number
of symptoms, therefore, greatly exceeds the number of cases, but this does not affect the
correctness of the estimate of each one as a proportion on the total number reported. The
reports do not give detailed information such as can be gained from hospital records.
Especially is this the case with the symptoms of paralysis and encephalopathy.
Table III. shows the number of reported cases included in returns for each of the years
1900 to 1909. On the total figures there has been a reduction of 47·7 per cent. In the
several industries the salient feature is that the considerable diminution achieved is limited
to industries—notably white lead, earthenware and china, litho-transfers, and paints and
colours—in which, under regulations or special rules, locally applied exhaust ventilation for
the removal of dust, and periodical medical examination of the workers, have been required.
Where, owing to the nature of the processes carried on, it has been found impracticable, in
the present state of knowledge, to apply local exhaust ventilation, and where periodical
examination of the workers is lacking, as in smelting of metals[A] and industries using paint,
there has been tendency to increase in the number of cases. In coach-building the increase
is in part due to activity in the motor-car industry.
[A] This is now required by the regulations dated August 12, 1911.

TABLE III.—NOTIFICATION OF POISONING BY LEAD (under S. 73, 1901), 1900-1909.

Reported Cases.
Total
Industry. 1900-09. 1909. 1908. 1907. 1906. 1905. 1904. 1903. 1902. 1901. 1900.
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)
Lead poisoning 6,762 275 553 646 578 632 592 597 614 629 863 1,05838
30 32 26 33 23 26 19 14 34

1. Smelting of
metals 41218 665 702 282 381 241 331 372 28 543 341
2. Brass works 754 5 6 91 11 51 101 15 5 61 3
3. Sheet lead and
lead piping 1093 92 14 6 7 9 7 11 12 17 171
4. Plumbing and
soldering 21712 28 27 202 164 242 213 26 231 23 9
5. Printing 20017 211 302 263 162 194 15 132 19 231 182
6. File-cutting 21119 8 92 10 15 12 204 242 271 467 403
7. Tinning and
enamelling 1382 21 10 25 181 141 10 14 11 10 5
8. White lead 1,29531 322 793 71 1087 901 1162 1092 1431 1897 3586
9. Red lead 108 10 12 7 6 10 11 6 13 14 19
10. China and
earthenware 1,06557 585 11712 1038 1074 843 1064 973 874 1065 2008
10a. Litho-transfers 48 1 2 10 5 5 3 3 2 7 10
11. Glass cutting
and polishing 489 42 31 4 41 3 — 4 82 113 7
12. Enamelling iron
plates 521 3 7 6 4 2 3 4 31 9 11
13. Electric 2856 272 251 21 26 271 33 28 161 491 33
 accumulators
14. Paints and
colours 4227 392 25 351 37 571 321 391 46 56 561
15. Coach-building 69741 956 703 703 857 563 494 745 631 654 705
16. Ship-building 26910 271 15 221 261 322 48 241 151 281 322
17. Paint used in
other
industries 45218 42 471 492 373 492 273 461 441 61 505
18. Other
industries 65920 572 785 562 662 701 533 40 64 891 864

The principal figures are those of the cases, fatal and non-fatal; the small figures relate to fatal cases only.
For the sake of completeness the figures for the years 1910 and 1911 are given below. The grand totals are
comparable with those for each of the years 1900 to 1909, but not the total for all of the several groups of
industries. Thus, the name of heading No. 7 is altered to “Tinning of metals,” and No. 12 to “Vitreous
enamelling,” because of regulations widening their scope, and now including cases which previously figured in
No. 18, “Other industries.”

Industry. 1911. 1910.

Lead poisoning 66937 50538
Smelting of metals 483 345
Brass works 91 7
Sheet lead and lead piping 12 4
Plumbing and soldering 372 251
Printing 322 334
File-cutting 182 91
Tinning of metals 13 17
Vitreous enamelling 191 17
White lead 412 341
Red lead 131 10
China and earthenware 926 7711
Litho-transfers 1 1
Glass cutting and polishing 5 —
Electric accumulators 241 31
Paints and colours 21 171
Coach and car painting 1045 706
Ship-building 366 212
Use of paint in other industries 561 513
Other industries 884 473

TABLE IV.—ANALYSIS OF REPORTS ON LEAD POISONING BY CERTIFYING

SURGEONS FROM JANUARY 1, 1900, TO DECEMBER 31, 1909.

Severity of Symptoms. Number of Attack.

Third,
No. Occupation. Total. Severe. Moderate. Slight. First. Second. Chron
(1) (2) (3) (4) (5) (6) (7) (8) (9)
M. F. M. F. M. F. M. F. M. F. M. F. M.
1 Smelting of
metals:
Cases 411 — 104 — 105 — 197 — 276 — 65 — 64 —
Per cent. 100 — 25·3 — 25·6 — 47·9 — 67·2 — 16·8 — 15·6 —
2 Brass works: