FORENSIC MEDICINE

By Dr. Naveen

FORENSIC MEDICINE

In absolute terms, the phrase ‘forensic science’ means science that is applied to legal matters. The word ‘forensic’ itself originates from the Latin word ‘forum’ which during the Hellenistic and Roman times was the general assembly where all facts of criminal or disturbing behaviour were discussed in the open and verdicts were reached regarding the suspects involved.

What is forensic medicine

Forensic medicine, which is also known as legal medicine, relates to application of medical knowledge for dispensation of justice in a court of law. Thus this subject teaches a person how to use his knowledge of medicine,biology,chemistry etc, to clarify or solve legal problems or issues

Branches of forensic medicine;
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Forensic pathology Forensic toxicology Forensic ballistic Forensic serology Forensic radiology Forensic dactylography Forensic psychiatry Forensic obstetrics Forensic odontology Forensic Criminology

Why doctors needs knowledge of forensic medicine?  Often doctor is the chief source of evidence

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upon which legal decisions are made.FM prepares the doctors to face such situation with efficiency. A doctor of any speciality may be asked at any time to give medicolegal opinion in case of death.FM helps them in such case Fair knowledge of FM is needed to safeguard a doctor himself from criminal cases. A doctor come to know his own code of conduct what to do and what not through FM.

THE DOCTOR & THE LAW

The legal system:

Civil law : It concerns a dispute between two individual or parties which do not amount to offence. eg.land dispute,divorce case etc. Criminal law : It concerns offence w/c are considered to be against general public’s interest. eg. Murder,theft,rape etc.

Defendant: The accused person is called defendant Plaintiff: The other party bringing the action is called the plaintiff.

Role of a doctor??
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As a defendant As a witness -ordinary witness -professional witness -expert witness

Inquest:

“An inquest is an inquiry or investigation into the cause of unnatural death or sudden and suspicious death.”

Types of inquest
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Police inquest Magistrate inquest Coroner’s inquest

Police inquest:

Here the officer incharge of the police station conducts the inquest. Invastigating officer Should not be below the subinspector

Procedure :
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When officer incharge of the police office recieves the information Inform about the incidence to the nearest executive magistrate Go to the place where the body of such person is Makes an investigation in presense of 2 or more respective persons ( Panchas) Prepare reports ( panchanamas) Signed by the police officer and the witness If no foul play is suspected, dead body will be handed over to the relative & if there is any suspicious about the foul play then will be sent for PM examination. Body should be sent with the copy of inquest report and chalan ,and one report is forwarded to the magistrate.

Magistrate’s inquest

It is conducted by the district magistrate,subdivisional magistrate or any other executive magistrate Done in case of: Death in prison,police custody,death due to police firing ,dowry death,Exhumation etc.

Difference between police inquest and magistrates inquest
Police:  Cannot hold inquest in case of death in prison ,police custody,jail etc.  Gets help from the witness  Have to inform nearest magistrate  Cannot issue warrant  Cannot order exhumation of the dead body

Witness:

“ The person who saw,heard or know the incident and is called upon by the court to give evidence is known as witness.”

Types of witness:

Common witness: “common witness is the person who give evidence about the facts observed by him.” Expert witness: “expert witness is a person who is capable of giving opinion about the cases.” or “Expert witness is a person who has been trained or is skilled in technical or scientific subject.”

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Subpoena or summons: “It is a document compelling the attendance of a witness in a court of law under penalty on a particular day or time for the purpose of giving evidence.”  Conduct money : “It is the fee offered or paid to a witness,in civil cases at the time of serving the summons to meet the expense towards attending the court.”

Medical evidence:

Evidence: “All legal means which will help to prove or disprove any matter in question is called evidence.”

Types of medical evidence:
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1. Oral 2. documentary

Documentary evidence:

“It includes all the documents,written or printed which may be produced for the inspection of the court during the course of trail.” 3 types: 1.medical certificates 2.Medicolegal reports 3.dying declaration

1.medical certificates: - fitness certificates,death certificates,health certificates etc. - NMC / PMDC registered - signature or left thumb impression of the person should be taken - Don’t take fee in case of death certificate.

2. Medicolegal reports: “these reports are prepared by a medical man in response to a requesition from a magistrate or a police officer.” eg.post mortem report,injury certificate,certificate in response to sexual offence- rape etc.

3.Dying declaration: “it is the oral or written statement of a person,who is dying as a result of some unlawful act.” -magistrate should be called if there is time -oath is not administered. ‘dying persons tells the truth.’

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Dying deposition: “It is a statement made by a dying person on oath in a sound state of mind and recorded by the magistrate in the presence of the accused or his lawyer who has an opportunity to cross examine the dying person.” - In other word called “bed side court.”

Oral evidence:

Here the doctor has to attend the court when summoned.

Procedure:
Summon  Conduct money  When turn comes stand inside the witness box  Take oath  Now the question will be asked in the following manner: i) Examination in chief- done by the lawyer on behalf of that party or who called him ii) Cross examination- question is put by the lawyer of the opposite party iii) Re-examination- again done by the laywer of the same side to correct any mistakes iv) Question by the judge- can ask in any stage in case of doubt

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During cross examination_ Opposite lawyer may say“I object yr honour”, “objection over ruled” – doctor has to answer. “Ruling on the object”

Roles/duties of doctor in a witness box
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Should be well prepared Take all reports,relevent records Be well dressed and modest Do not discuss the case with anyone in court except the lawyer of yr own Stand up straight Be relaxed and calm Speak slowly,distinctly and audibly Be confident but not over confident Use simple language Address the judge by his proper title Say ‘In my oponion’ don’t say I think Never attempts to memorize

IDENTIFICATION OF THE LIVING AND DEAD

Identification:
“Identification means establishment of exact individuality of a person - living or dead.”  Types : - Complete or absolute - Incomplete or partial

Complete Identification: “It means the absolute fixation of the personality of an individual and determination of the exact position occupied by him in the society.”  Incomplete Identification: “It means certain data have been ascertained about a person but,other relevant particles necessary for the establishment of his personality are unknown.”

When a doctor should identify a living person??

Marriage ,Passport,Admission into the institute,Insurance,pension claims,missing person Assault, rape, sodomy,murder,interchange of newborn babies in hospital

Dead body???
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Sudden and unexpected death Railway,RTA,aircraft accident Hidden dead bodies Skeleton of isolated bones Partially burned dead bodies

Identification data:
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1.Race 2.Religion 3.Age 4.Sex 5.General configuration- height/wt 6.Hair 7.Finger prints and foot prints 8.External pecularities eg.moles,scars,tattoo marks 9.Teeth 10.Handwriting 11.Speech and voice 12.Gait,trick of manner and habit 13.Memory and education 14.Personal effects – clothes,pocket contents,jewellery etc.

1.Race:

“It may be defined as the biological concept denoting the different breeding of origin of human being ( living in different or same zone with different characteristics) united by common hereditary.” Mainly 3 types: - Caucasion- europeans, part of US,australia - Mongolian- east asia ( china,japan, indonesia) - Negro- Africa,US,

Distinguishing Points between 3 races:
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Skin Hair Eyes Forehead Face clothes

2.Religion :

Hindu/ Muslim

Why you are a Hindu or a Muslim??
Male :  Circumcision  Callosities : a thickened hard mass of a skin occurs in the area w/c undergoes excessive use  Clothes Female:  Vermilion mark  Artificial spot  Tattoo marks  Position of nose ring aperture

3.Sex:
3 methods: - Physical examination - Gonadal biopsy - Sex Chromatin ( Nuclear sexing)  3 types of body: - fresh body - Decomposed body - Mutilated fragments

1.Fresh body: - quite easy - by doing local and physical examination

2.Decomposed body: - see for the presence of prostate or uterus - resists long after decomposition - If you can’t find it histological examination of the suspected t/s.

3.Mutilated fragments: - study in details in class of “Autopsy”.

Histologically how we determine the sex??

Here we examine the suspected ovarian or testicular t/s microscopically in case of decomposed body. In cells of a women: -“Barr body” tiny nodules of chromatin attached to the inner surface of the nuclear membrane -“Davidson’s body” small drum stick like nuclear attachment in WBC

Inter-sex
“This is the condition in which male and female characteristics coexist in varying propertion in same individual.” --True Hermophrodism: internal sex organ of both sex present -- False Hermophrodism:external genitalia is of opposite sex

4.Age:

Medicolegal Aspects: - Identification of an individual both in the living and dead. - Rape, Kidnapping,prostitution,Criminal abortion - others: Employment,marriage contract

Age determining factors:
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Examination of teeth General development Ossifications of bones and joints Secondary sexual characteristics

Medicolegal aspects:
7 years : child below 7 years of age cannot be convinced to crime.  15 years: sexual intercourse with one’s wife below the age of 15 – rape - can work in a factory  16 years: age of consent of sexual intercourse in female - offenders under 16 – juvenile offenders - taking away a boy under 16- kidnapping  18 years: marriageable age of female - age of entering into government service - Taking away a girl under 18 – kidnapping  21 years: - attainment of majority - marriagable age of male

5.Dactylography:

“It is the system for taking the impressions of the bulbs of the fingers and thumbs with pointed ink on an unglazed white paper which is examined by the magnifying lens.” Characteristics: -Present from birth -Remains constant for whole life -Absolutely different from individual

Classifications:
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Loops : 67% Whorls: 25% Arches: 6-7% Composite: 1-2% “LWAK”

Medicolegal Importance:
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100% individuality denotes by dactylography To established the identity of criminal by detecting chance impression left on the scene of the crimes eg.weapons,glasses. To maintain identity record Useful in banks,other finantial institutes Identification of servants,soldiers,sailors. ‘1 in 64 thousand millions’

6.External Pecularities:

Deformities: congenital: cleft lip,cleft palate,supernumery fingers acquired: malunited # bones,unilateral wasting of muscles

Scars : These are simply the fibrous t/s covered by epithelium without hair follicles, pigments or sweat glands. Medicolegal importance: 1.Identification of person living or dead 2. shape of scar nature of weapon used 3. Linea albicans : previous pregnancy

Occupational marks: - Dye in dye workers - Depression in lower part of the sternum shoe makers Medicolegal importance: Identity social position

Tattoo marks: “These are the designs imprinted in the skin of some individuals by multiple puncture wounds in the true skin with needles or similar penetrating tools dipped in a dye.”  Dyes commonly used: Indigo/ cobalt/ carbon/ Vermilion/ prussion blue/ indian ink etc

Medicolegal importance: - May help in identity by special design - may indicate religion or god of worship - may indicate social status - may indicate behavioral characteristics Natural disappearance?? vermilion,cinnabar,ultramarine disappears after a minimum of 10 years. carbon never disappears

Artificial procedure to remove tattoo marks:
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Surgery Applying chemical subs,carbon dioxide snow,silver tannate Galvanocautery Lesser beam

7.Handwriting :

“It is the characteristic of individual speciality,if it is written rapidly.” May be changed in : -Gradual increasing in age -some mental or nervous disease -when person becomes insane -before the time of death

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A criminal removed his tattoo surgically

Forensic Pathology

By dr. Naveen

DEATH:

Death:
Extinction of life  “The permanent cessation of all the vital functions of the living body is known as death”  Medicolegal defination: “Death is permanent and irreversible cessation of functions of the 3 interlinked vital systems of the body ( the tripod of life), namely the nervous, circulatory and the respiratory systems.”

Crucial situation : “consult” Ordinary circumstances: -wait for 10 minutes - no evidence of function of the tripods> declare death.

Types of Death:
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1.Somatic Death ( systemic death) 2.Cellular death ( Molecular death)

1.Somatic Death: it is permanent and irreversible cessation of the functions of nervous, circulatory and respiratory systems, also known as clinical or systemic death. 2.Cellular death: means the cessation of respiration and metabolism of body t/s which is soon followed by autolysis and decay. Brain cells: 10 minutes blood cells/cornea: more than hrs more the organ needs blood supply ~ more quickly they die

Brain death:
“Brain death means that the patient is dead, whether or not the function of some organs, such as a heart beat is maintained by artificial means, and all the function of the brain must have permanently and irreversibly ceased.”  Medicolegal importance: Brain death = legal death

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For applied purposes, brain death has been classified into three types i) Cortical death ii) Brain-stem death iii) Both cortical and brain stem death.

Diagnostic test for brain death:
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Absence of corneal reflex,fixed pupils unreactive to light Absence of vestibulocochlear reflex when ice and water is introduced into ears. Painful stimuli – no motor response Gag reflex - absent when a catheter introduced into the larynx and trachea. No respiratory movements when the patient is disconnected from the ventilator

Death certification:

Should certify if: you are registered medical practitioner you know the cause of death

Issuing the certificate:

‘WHO’ system: 1st part: condition which led directly to the death 2nd part : other condition which also contributes to the death

Modes of death:
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1.Coma: failure of nervous system 2.Syncope: failure of circulatory system 3.Asphyxia: Failure of respiratory system

1.Coma:
“It means insensibility resulting in death from different causes which involves the vital centres of the brain stem.”  Causes: Head injury, encephalitis, meningitis, certain poisoning like opium,barbiturates etc.  C/F: .Initially person in a condition from where he/she can be aroused .Reflex still present .complete unconsiousness .pupils dilated, insensible to light .pulse full and bounding but usually slow .Breathing slow/irregular .Perspiration occurs

2.Syncope :
“It is sudden cessation of action of the heart leading to death.”  Cause : - any heart disease - Anaemia - over exercise or exertion - severe hypoxia  C/F: .pallor of face, lips, finger nails .Dilated pupil .skin cold and clammy .nausea, vomitting .hypotension .pulse slow and weak

3.Asphyxia:
“It may be defined as a state in which body lacks oxygen because of some mechanical interference with the process of breathing.”  May be due to hypoxia or hypercapnia  Cause: mechanical obstruction : hanging ,strangulation disease; pulm.oedema,pneumonia,COPD poisons  C/F: congestion of face cyanosis oedema of face

Stages of asphyxia:
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Total duration : 3 – 5 minutes 1. Stage of Dyspnoea 2.Stage of convultion 3.stage of exhaustion

Death trance/Suspended animation:

It is the condition in which all signs of life or vitality are seems to be absent although the individual still remains alive which can be detected by ECG

Even, the functions of the nervous system, circulatory system or the respiratory system may not be perceived by conventional methods, though the person may actually not be dead and the functions of these systems “return “ after sometime, either as such or after proper resuscitation. Such a death-like state is known as suspended animation or apparent death.

The state of suspended animation or apparent death is said to be practicable . Its practice is popular among the Indian “yogies’ (persons who follow lives of strict principles with physical and mental exercise and restraint). Such people demonstrate their outfit by being, Voluntarily buried alive, under the earth for hours.

Actually, the circulation etc. do not completely stop but is being maintained in their minimum. When it is practiced voluntarily as by yogis, it is called voluntary suspended animation and when it occurs spontaneously as in cases of drowning or electrocution , it is called involuntary suspended animation.

Possibilities:
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A new born infant Drowned person Electrocutation Thunder Snake bite Head injury Anaesthetic shock Severe narcosis Severe hypothermia Prolonged starvation Practitiener of YOGA “”ECG””

postmortem appearance

CHANCES AFTER DEATH OR DIFFERENT SIGNS OF DEATH

Some of the changes which occur after death are related to somatic death and some are related to molecular death. Accordingly, some of them are conspicuous immediately, some come early and the rest appear late

Immediate changes
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(a) Stoppage of function of nervous system (b) Stoppage of respiration (c) Stoppage of circulation

Early changes 

(a) Facial pallor (b) Loss of elasticity of the skin with decrease in the facial crease (c) Primary relaxation of the muscles

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(d) Contact pallor and contact flattening (e) Changes in the eye (f) Cooling of the body (g) Postmortem staining (h) Rigor mortis or postmortem rigidity

Late changes
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(a) Putrefaction or ordinary decomposition (b) Adepocere change- a modified form of decomposition (c) Mummification- another form of modified decomposition

Immediate changes
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Stoppage of function of nervous systemWith death all functions of the nervous system ceased. The subject has no sense. There loss of both sensory and motor functions. There is loss of reflaxes, no response and no tonicity of the muscles. Pupils are widely dilated.

Stoppage of respiration

Stoppage of circulation

Early Chances after death

1 Facial pallor- After death, due to stoppage of circulation, blood drains from the capillaries and small vessels to big ones. This is why, generally the face appears pale and bloodless, but in case of agonising death and where there is obstruction of venous return due to compression over the neck or below, as in case of strangulations etc., the face is congested and cyanotic.

2 Loss of elasticity of the skin with ironing of the facial creases – these occur due to loss of tonicity of the skin muscles including those of the face. The face looks younger.

3 Primary relaxation of flaccidity of the muscles After death muscles loose their tonicity and become flaccid. Joints are loose and the chest wall flattens .During this stage of relaxation the muscular tissues are still alive; their chemical reaction is still alkaline and they still respond to electrical stimuli.

4 Contact flattening and pallor –During the stage of primary relaxation of muscles of the body, the areas which remain in contact with the ground, become flat and the blood from vessels of these areas are pressed out. During the stage of rigor mortis, the areas continue to be flat, as rigor appears in those muscles in their flattened state and the drainage of blood from the vessels of the areas make the areas pale which continue to be so even after formation of postmortem staining in the surrounding areas.

Medicolegal importance

From the contact flattening and pallor, the position of the body in which it stayed for some time after death can be understood.

5 Changes in the eye

(a) With death, the corneal and pupillary reflexes are lost. (b) With death, the eyelids usually close due to loss of tone of the muscles of the eyelids. (c) Haziness of the cornea

(d) Shape of the pupils – Ordinarily, they are circular. But ,as after death, there is loss of tone and elasticity of the ciliary muscles, the shape of the pupil can be changed which may persist during the stage of rigor mortis of the muscles.

As the nervous control over the pupils is lost after death, the sizes and shapes of the pupils of the two sides may be different. The pupils respond to the application of the miotic and mydriatic agents for an hour or two after death.

(e)

Loss of ocular tension

Somatic and molecular deaths

Death commonly refereed to with the cessation of the functions of nervous, circulatory and respiratory systems , are also known as somatic deaths or clinical or systemic deaths.

With somatic death further supply of oxygen to different organs stop. Due to lack of oxygen supply, individual cells of the different tissues or organs die. This death of the individual cells is known as cellular or molecular death .

In the absence of circulation and respiration, molecular death occurs in a series, death of brain cells stand first.

Within five minutes of stoppage of circulation and respiration, brain cells are to die. Molecular death in muscles starts by the end of the first hour of somatic death and it takes some more hours for all muscle tissues to die.

Blood cells and cornea may remain alive for more than 5 hours. organs like , liver, kidneys and heart die comparatively early. Death of the fibrous tissue occurs late . As a general rule, organs which receive or need more blood supply during life, die early in absence of circulation .

organ transplantation from dead bodies
This gap between the somatic and the molecular deaths has helped the process of organ transplantation from dead bodies . For the purpose., tissues like blood or cornea may be removed form a body soon after somatic death. But those organs which are highly vascular, cannot be left, till circulation and respiration stop, as lack of oxygenated blood-supply will soon make them unsuitable for the purpose of transplantation.

Thus , for transplantation purposes, heats, liver and kidney have to be removed before stoppage of circulation i.e., before occurrence of the “ somatic death”, The organ of brain can not be used for transplantation , where cells die within a few minutes of stoppage of circulation or respiration , even though their stoppage may be taken as to have occurred permanently before brain death.

Further, if the brain can be kept transplantable or alive by maintaining circulation and respiration , there is no reason why the subject should be taken as going to face inevitable death . But if it becomes certain that brain has stopped functioning permanently and irreversible, then by maintaining circulation and respiration artificially, transplantable organs can be suitably removed from such a donor. This possibility gave rise to the necessity of understanding the conception of “ brain death”