Tuesday, 25 March 2014

HUMAN ANATOMY

HUMAN ANATOMY

Human Anatomy is the structure of the human body, its Cells , Tissues, Muscles, Organs, Blood Vessels and Skeleton.

Cells: Cells are the basic atom of our body structure. The cell contains the nucleus and the cytoplasm. This is responsible for the endless chemical processes that occur in our body to keep it functioning. This is referred to as metabolism.

Tissues: Tissue is composed of a group of specialized cells of similar structure that are united for the performance of a particular function.

Muscles: Muscles are the tissues whose cells have the ability to contract, producing movement or force.

Organs: Organs are composed of tissues from the four major tissue groups. Each tissue serves a specialized function within the organ and all tissues work collectively for a common purpose.

Blood Vessels: Blood Vessels are carriers of blood to the various tissues of the body.
Skeleton: The infrastructure and backbone on which various structures are laid down.
PHYSIOLOGY

Physiology is the study of the FUNCTION of the various parts of the body:
  • How the work of one part is interrelated with the work of other structures and systems, and How a structure or organ acts when it is healthy and when it is diseased.


Chapter 2 Anatomy of the Human Body

INTRODUCTION:
Anatomy is the study of the structure of plants, animals, and human beings. The term “anatomy” comes from the Greek words meaning to cut up, because knowledge of anatomy was first obtained through dissection. The bodies of human beings and animals are so complex that scientists divide anatomy into many branches. Gross anatomy is the study of structures that can be seen with the unaided eye. Microscopic anatomy, or histology, is the study of tissues under a microscope. Comparative anatomy compares the structure of different animals. Embryology is the study of the development of plants and animals during their earliest stages.

Human anatomy includes the study of the structure of the skeleton, muscles, nerves, blood vessels, and the various organs of the human body. Knowledge of the structure of the human body is essential for an understanding of its function in health and disease.

To study the human body, the body has been divided into:
Head
Thorax
Abdomen.

HEAD:
The Head in turn includes the Skull containing the brain, the face, the neck & the structures in them.

The Skull: Occupying the skull cavity (cranium), the adult human brain normally weighs from 2 1/4 to 3 1/4 lb. (1-1.5 kg)
By means of electrochemical impulses the brain directly controls conscious or voluntary behavior, such as walking and thinking. It also monitors, through feedback circuitry, most involuntary behavior—connections with the autonomic nervous system enable the brain to adjust heartbeat, blood pressure, fluid balance, posture, and other functions—and influences automatic activities of the internal organs.

ANATOMICALLY THE BRAIN HAS THREE MAJOR PARTS:

  1. The Hindbrain (including the cerebellum and the brain stem ),
  2. The Midbrain, and
  3. The Forebrain (including the diencephalon and the cerebrum).
Every brain area has an associated function, although many functions may involve a number of different areas. The cerebellum coordinates muscular movements and, along with the midbrain, monitors posture.
  • The brain stem, which incorporates the medulla and the pons, monitors involuntary activities such as breathing and vomiting.
  • The thalamus, which forms the major part of the diencephalon, receives incoming sensory impulses and routes them to the appropriate higher centers.
  • The hypothalamus, occupying the rest of the diencephalon, regulates heartbeat, body temperature, and fluid balance.
  • Above the thalamus extends the corpus callosum, a neuron-rich membrane connecting the two hemispheres of the cerebrum.
  • The cerebrum, occupying the topmost portion of the skull, is by far the largest sector of the brain. Split vertically into left and right hemispheres, it appears deeply fissured and grooved.
  • Its upper surface, the cerebral cortex, contains most of the master controls of the body. In the cortex ultimate analysis of sensory data occurs, and motor impulses originate that initiate, reinforce, or inhibit the entire spectrum of muscle and gland activity.
  • The entire brain is enveloped in 3 protective sheets known as the Meninges, continuations of the membranes that wrap the spinal cord.
  • The two inner sheets enclose a shock-absorbing cushion of cerebrospinal fluid.

The Cranial Bones


The bones present in the skull are:
The Facial Bones

The face is extending from the scalp to the jaw. The bones present in the face are:



The Vertebral Column


  • The vertebral column is situated in the median line, as the posterior part of the trunk; its average length in the male is about 71 cm. Of this length the cervical part measures 12.5 cm., the thoracic about 28 cm., the lumbar 18 cm., and the sacrum and coccyx 12.5 cm.
  • The female column is about 61 cm. in length.

The Vertebral Column is sub divided into :




The Thorax

  • In humans, it lies between the neck and abdomen and is also called the chest. The sternum (breastbone) and ribs in front and the dorsal vertebrae in back form the skeletal frame of the thorax. Within the thoracic cavity are the pharynx, larynx, esophagus, trachea, heart covered by pericardium, lungs covered by pleurae, and thoracic vessels & nerves.

  • The Abdomen: Abdomen, in humans and other vertebrates, portion of the trunk between the diaphragm and lower pelvis. In humans the wall of the abdomen is a muscular structure covered by fascia, fat, and skin.

ABDOMEN is divided into NINE QUADRANTS:
They are:
  • Right Hypochondrium
  • Epigastrium
  • Left Hypochondrium
  • Right Lumbar
  • Umblical
  • Left Lumbar
  • Right Inguinal
  • Hypogastrium
  • Left Inguinal.

  • The abdominal cavity is lined with a thin membrane, the peritoneum, which encloses the liver, gall bladder, pancreas, portal vessel & mesenteries, the stomach, intestines, colon, caecum, rectum & anal canal; lower abdomen contains kidneys, ureters & urinary bladder along with urethra & ureathral meatus (pelvic organs), and spleen.


THE UPPER LIMB:

The Bones of Upper Limb include:


The Hand/ The Carpus
  • The Carpus:

  • The skeleton of the hand is subdivided into three segments: the carpus or wrist bones; the metacarpus or bones of the palm; and the phalanges or bones of the digits.

  • The Carpus (OssaCarpi)

    The carpal bones, eight in number, are arranged in two rows. Those of the proximal row, from the radial to the ulnar side, are named the navicular, lunate, triangular, and pisiform; those of the distal row, in the same order, are named the greater multangular, lesser multangular, capitate, and hamate.


THE BONES OF THE LOWER EXTREMITY:

THE KNEE JOINT: containing the upper bone Femur, lower Tibia and fibula with the capsule and membranes:






  • THE FOOT : consists of the ankle joint, the tarsals, metatarsal bone, & phalanges of the foot.

  • The Tarsus :
  • Calcaneous bone.
  • Talus
  • Navicular
  • Cuboid
  • Cuneiform, First
  • Cuneiform second.
  • Cuneiform third



  • Proximal phalange
  • Middle phalange.
  • Distal phalange.










Chapter 3 HUMAN ANATOMY AND PHYSIOLOGICAL SYSTEMS.

To understand the Human functioning and various structures involved in our body, the physiology is divided into broad categories known as Systems.These systems are mainly classified as follows:

  • Skeletal system or the Osseous System:
  • Locomotion system:
  • Musculo- Skeletal System:
  • Integumentary System:
  • Cardiovascular System:
  • Respiratory System:
  • Digestive System:
  • Lymphatic System
  • Immunity System:
  • Nervous System:
  • Reproductive System
  • Endocrine System

SKELETAL SYSTEM OR THE OSSEOUS SYSTEM:
Our body is constituted of 208 bones, which form the basic skeleton of our body, connected by ligaments & tendons to form a strong framework. This is known as the Skeletal System of our body, the crux on which we stand.

LOCOMOTION SYSTEM:
The joints between the bones give the power of movements or locomotion. The System is known as the Locomotion System, which includes the structures of the various types of joints & their respective complex movement mechanics.

MUSCULO- SKELETAL SYSTEM:
These are strengthened by the muscles interconnected by tendons, fascia, cartilages & connective tissues. This constitutes the Musculo- skeletal System of our body. These help in coordination & movements along with reflexes to varied stimulus from the external environment.

INTEGUMENTARY SYSTEM:
A layer of skin or integument that protects our internal body from the external environment covers these in turn. Skin not only helps in the first line of defense, but also functions as a sensory organ due to the fine peripheral nervous innervations on it, as a thermostatic organ, and an excretory organ. This constitutes the Integumentary System of our body.
The Muscles & Skin along with tissues & organs are supplied by complex intricate connections of nerves & blood vessels.

CARDIOVASCULAR SYSTEM:
The blood vessels constitute the Circulatory system, which start & end at the heart, the pumping machine of the body, The Cardiovascular System. This includes the heart as the central pumping machine with branches of vessels, the veins & the arteries to the various organs of the body. The veins carry impure blood from the peripheral parts & other tissues & organs of the body to the heart. The arteries carry pure blood from the heart to various parts of the body.

RESPIRATORY SYSTEM:
The Lungs (Right & Left Lungs) constitute a special role in the purification of the blood in the heart besides the oxygenation of the body cells & tissues for survival. This constitutes the CARDIOPULMONARY SYSTEM.
The Respiratory system includes the Nose, the pharynx, the larynx, the trachea, the lungs, the bronchus & the bronchioles that end up as air sacs known as alveoli.
This system not only helps in breathing but also helps in exchange of gases between external environment & our lungs & tissues.
Two types of respiration: EXTERNAL RESPIRATION also known as breathing, and
INTERNAL RESPIRATION which is the actual diffusion of gases between the lungs and the tissues.

DIGESTIVE SYSTEM:
  • The digestive system consists of the organs of the gastro intestinal tract, which include:The Mouth, tongue, & teeth: Swallowing & mastication: breaking down solid foods to smaller particles.
  • Pharynx & esophagus: Help swallowing & propulsion of food to the hollow organ stomach by peristalsis.
  • Stomach: digestion.
  • Small & large intestines: digestion, absorption & assimilation of food.
  • Rectum & anus: absorption of water & excretion of waste products.
  • The accessory glands & organs that contribute to the digestive process are the
  • Salivary glands: Lubrication & digestion.
  • Liver: the largest gland in the body: digestion, metabolism & detoxification, regulating lipid & cholesterol, synthesis of proteins & carbohydrates, reservoir for blood & produce & store clotting factors, conversion of carbohydrates to glycogen.
  • Gall bladder: bile secretion: secreting bile for digestion & assimilation of fats.
  • Pancreas: Exocrine: pancreatic Juice helps in digestion of fats, proteins & carbohydrates; Endocrine :
  • The digestive system mainly helps to provide nutrition to the cells, the body.

EXCRETORY or THE RENAL SYSTEM or URINARY SYSTEM:
Group of organs that produce & excrete urine.
The most important function is to:
  1. remove the soluble wastes from the body (excretion),
  2. maintain proper water & electrolyte balance in the body (acid- base equilibrium of body fluids) &
  3. maintain blood pressure, regulate blood volume & osmolarity,
  4. Preservation & concentration of vital substances to the body.

The Kidneys are the filter organs that filter the blood fluid & concentrate the filtrate so obtained to from urine.
Besides the Kidneys we have the ureters entering into the Urinary bladder, (a bag where urine is collected) & the urethra, the excretory duct. In males it opens at the urethral meatus at the tip of the penis. In females it opens in front of the vaginal opening.

THE LYMPHATIC SYSTEM:
The Lymphatic system includes a fluid known as lymph which bathes the tissues, the fluid derived form blood and is drained by the lymphatic vessels.
This lymph passes through a series of filters called the Lymph nodes & is ultimately returned to the blood stream via the thoracic duct.

THE IMMUNITY SYSTEM:
Besides lubrication to the tissues, it acts defends the body system by immunological responses.
These immunity & the immunological responses are due to presence of Lymphocytes, the white blood corpuscles; which are the soldiers to fight & evade any foreign agent entry into our body system.

NERVOUS SYSTEM:
The nerves innervate the skin, the muscle spindle, the tissues & organs; joining at the pivot of the body, the spine that has the spinal cord & entering or leaving the brain eventually. This forms the Nervous System of the Body.
  • The CENTRAL NERVOUS SYSTEM is a highly developed & specialized has the brain with the Spinal cord.
  • The PERIPHERAL NERVOUS SYSTEM has the nerves outside the brain & the spinal cord; spinal nerves, cranial nerves & the autonomic nervous system.
  • The AUTONOMIC NERVOUS SYSTEM has the two sympathetic trunks that extend vertically through the neck, thorax, and abdomen, one trunk on either side of the vertebral column. This system prepares for “Fight” or “flight” reaction of an individual.

REPRODUCTIVE SYSTEM:
Reproduction is a process involving Procreation or generation of species of its own kinds.
The male reproductive system organs are the penis, the testes, the epidydymis & vas deferens, the accessory glands including the seminal vesicles & the prostate glands.
  • The Penis is mainly a urinary excretion organ, the major portion being the urethra, through which semen and urine are discharged.
  • Due to excessive vascularisation of the penis, sexual stimulation causes penile erection due to vascular engorgement.
  • The testes situated in the scrotum, produce sperm cells or spermatozoa & semen along with other reproductive gland s like the prostate gland & the seminal vesicles.

The female reproductive organs are the Uterus, Ovaries, & the fallopian tubes (Internal reproductive organs) with vagina & vulva (external genitalia).
  • Uterus a hollow pear shaped muscular organ is mainly for childbearing.
  • The Ovaries are two oval sexual glands in which ova or eggs are formed.
  • The ovaries are located on each side of the uterus, connected by fallopian tubes: which transfer the ova to the Uterus.
  • The vagina is a hollow elastic muscular tube that functions as a birth canal, passageway for menstrual fluid & receptacle for the semen during intercourse.
  • The vulva is the external genitalia having the labia, clitoris & hymen: a protective function along with sexual stimulation.

ENDOCRINE SYSTEM:
The endocrine system is the group of glands and other structures in the body that create hormones and release the hormones directly into the circulatory system.
The various functions of these hormones are:
  1. Salt & water balance in the body.
  2. Blood pressure maintenance.
  3. Metabolism.
  4. Reproduction.
  5. Blood sugar level regulation.
  6. Nerve impulse transmission.
  7. Digestion.
The glands are:
  1. PITUITARY GLAND: rests at the base of the brain: growth hormone secretion.
  2. HYPOTHALAMUS: area at the base of the brain interconnected with the pituitary:
  3. THYROID GLAND: in front of trachea below the Adam’s apple: Right & left lobes connected by isthmus: T3, T4, TSH: tissue & organ metabolism with formation of bones. These hormones stimulate the various target organs, the adrenal glands, the reproductive glands, & organs of nervous system.
  4. PARATHYROID GLANDS: 4 oval discs on the back of Thyroid gland: regulation of blood calcium, phosphates & utilization for bone development, normal nerve & blood vessel functioning.
  5. SUPRARENAL OR ADRENAL GLANDS: flattened cup shaped structures on upper part of each kidney: Steroid production like the glucocorticosteroids (regulate body’s sugar metabolism & other functions) & the mineralocorticosteroids (maintain sodium & potassium levels in body. Also estrogen, and androgens such as testosterone. Adrenaline, another hormone: stress related release.
  6. PANCREAS: Insulin for sugar metabolism. Produced by a collection of cells called as islets of langerhans.



























Chapter 4. Bodily Injuries

Injury or a wound: means a solution or disruption of the anatomical continuity of any tissue of the body.
  • Under section 44 IPC, an injury is defined as any harm whatever illegally caused to any person, in body, mind, reputation or property.
  • Injuries caused by the application of physical violence to the body are known as Mechanical injuries.
SIMPLE INJURY: which is neither extensive nor serious, and which heals rapidly without leaving any permanent deformity or disfiguration.
HURT: under section 319 IPC, any bodily pain, disease or infirmity caused to any person.
GRIEVOUS HURT: Any injury causing physical, mental continuous incapacitating pain for more than 20days during which period the injured person is in severe bodily pain or unable to follow his ordinary pursuits. Defined under section 320 IPC.
INJURIES TO THE BRAIN:

  1. CEREBRAL CONCUSSION: Injury to the brain sometimes resulting in unconsciousness. Sometimes there may be Concussive head injury or Non -Concussive head injury. There is no loss of consciousness in Non- Concussive injury. If cerebral concussion is severe it may lead to Cerebral Edema, means the Swelling of the brain. In cerebral concussion there may be mild swelling.

  2. CEREBRAL CONTUSION OR ODEMA: An injury, which is a direct blow to any part of the brain and this injury is severe than the cerebral concussion. An injury to any part of the brain tissue directly is called Cerebral Contusion. Cerebral contusion always leads to Cerebral Odema & Capillary Hemorrhages (bruises) around the brain region. Sometimes Cerebral Oedema may result in extra dural haematoma, which means collection of the blood within the brain membrane.


  1. CEREBRAL LACERATION: A severe form of cerebral contusion and it may; lead to multiple neurological deficiencies and most of the time it is irreversible.

  1. CEREBRAL COMPRESSION WITH EXTRA DURAL HAEMATOMA:
Injury, which results in collection of blood within the brain membrane.
Sometimes an injury of this nature keeps the patient for confinement for a period of one month.

CLASSIFICATION OF INJURIES:

For convenience, injuries are discussed under the following heads:
  1. Mechanical Injuries.
  2. Firearm injuries.
  3. Traffic injuries.
  4. Thermal injuries including chemical injuries, lightning, electricity, and explosions.

ABRASION: abrasion is defined as injury involving only the skin & the superficial surface of the body. E.g. Scratch, Graze, Imprint and impact abrasion. Heals within a week to 10 days. These are usually blunt trauma related injuries. Example: Hitting against a stone or a hard flat surface causing a bruise or abrasion.

Types of injuries under abrasion are:
  • Imprint abrasion (takes the signature or mark of the object.),
  • Graze abrasion: some hard object just grazing or scratching across the skin surface.



CONTUSION/ BRUISE:
  • A bruise is an infiltartion of blood into the tissues, following the rupture of vessels, usually capillaries, as a result of the application of the blunt force, eg. A stick, astone or a fist.
  • Usually it is subcutaneous, and there is no solution in the continuity of the skin.
  • It varies in size from a pinhead bleeding to a large collection of blood known as Haematoma, e.g. extradural haematoma from injury to the middle meningeal artery.
  • Haematoma is due to rupture of vessels by trauma with subsequent coagulation blood.
  • Bruise is an injury on the surface of the body produced by a sharp blow or fall. Usually the skin is not torn.
  • If the skin breaks and bleeds, the injury is called a laceration. Pain and redness occur with the swelling. Then the bruise becomes black and blue within 1-2 days of injury because blood seeps from injured blood vessels into the flesh. Later, the skin changes to greenish-yellow on the 3rd or 4th day post injury and finally to its normal color as the blood breaks down to pigments that are absorbed gradually into the bloodstream. Ice packs help relieve painful bruises. A doctor should treat a severe bruise. Heals with a scar in 7-15 days depending on the extent of the injury.

CONTUSED LACERATED WOUNDS: along with a tear on the skin, accumulation of blood or fluid around the subcutaneous area of the injured tissue is known as Contused lacerated wound.

LACERATION: a tear or split or stretch on the skin surface causing a linear tear injury with extravasation of blood & fluid around the injured surface. The length is more than the depth of the injury in this type of injury. E.g. Knife cut superficially over the leg or thigh.This can be subdivided into:
Split Laceration/ stretch laceration: truck over any bony part of the body, causing stretch due to pressure on the skin causing stretch or a split tear.

INCISED WOUNDS/ STAB WOUNDS: These are injuries in which the depth is more than the length of the injury. Generally caused by a knife, a sword, etc.

PUNCTURE WOUNDS: wounds caused by pointed objects. The Length of the wound being minimal but depth can vary depending on the force & length of the object or weapon causing injury. Can appear superficially like a punch mark or a needle point mark. At times the injury mark may forgo the observation of the naked eye. E. g. : Snake bite, Needle puncture.

PENETRATING WOUNDS: caused mainly by pointed objects, which have a greater length than the breadth. The injury is generally through and through the entire body length. E.g.: has a capacity to penetrate abdominal viscera or enter through the abdomen & exit through the back.

PERFORATING WOUNDS: The injury causes an abdominal or thoracic or any organ to rupture causing the contents of the sac or the organ to spread & cause infection. E.g. Peritoneum of the abdomen gets ruptured due to injury. This can cause Perforative peritonitis due to extravasation of fluid inside the peritoneum, out into the abdominal cavity causing inflammation & or infection of the contents.

CUT THROAT INJURIES: These are due to injury across the throat either due to assault or due to accident. Death is due to rupture of major blood vessels or vagal shock of nerve Injuries.

FIREARM INJURIES: These are injuries caused due to gunshot or rifle injuries. Depending on the range of bullet shot, or type of weapon used, the injuries can be studied in detail. These can be homicidal, suicidal or accidental.






CHAPTER NO: 4.
FRACTURES

DEFINITION OF FRACTURES: DEFINED AS ANY BREAK IN THE CONTINUITY OF A BONE OR CARTILAGE.

SOME OF THE COMMON TERMINOLOGY USED IN FRACTURES:

  • Avulsion Fracture – occurs when a sudden severe muscle pull that tears the ligaments and muscles from the bone.
  • Buckle fracture - when the bone bends but does not suffer a break. This type of fracture typically occurs in children.
  • Comminuted Fracture - when a bone breaks into two or more fragments, or is crushed.
  • Compound Fracture – The overlying skin and soft tissues are disrupted and parts of the broken bone surfaces penetrate to the outside of the body. May also be called an Open Fracture.
  • Greenstick Fracture - when the bone suffers a crack to only one side, leaving it injured but intact.
  • Hairline Fracture - when the bone is cracked, but the bones are still connected.
  • Single fracture - when the bone is fractured in only one location.
  • Multiple fracture: is a break that involves two or more lines of fracture that are not physically connected each other in the same bone.
  • Colle’s fracture - a fracture in the main bone in the radius or the ulna, both located in the lower arm.
  • Impacted fracture: A break that involves two bone fragments that are firmly driven into each other in the same bone.
  • Crack line fracture: A crack like fracture without any break in the continuity of the bone.
  • Spiral fracture: fracture occurs in a spiral manner around short axis of the bone shaft.
  • Transverse fracture: is one that occurs at a right angle to long axis of the bone.
  • Oblique Fracture: occurs at a slant to the long axis of the bone.
  • Pathologic fracture: occurs when a bone weakened by tumour or disease, breaks during normal daily activities or minor trauma.
  • Fracture with or without displacement: Along with the break in the bone, there could be displacement of the bones.

DEPENDING ON THE EXTENT OF BONE INVOLVEMENT:

  • Simple Fracture - when the bone is cracked and then separates, causing little damage to the soft tissue.
  • Partial fracture: involving only ½ or ¼ th or ¾ th of the shaft of the bone.
  • Total Fracture: Complete through & through fracture of the shaft of the bone.


DEPENDING ON THE INTEGRITY OF THE OVERLYING TISSUE:

  • Open: also known as compound fracture, Along with the break in the bone there is also penetrates or punctures the skin & the bone is exposed on the body surface.

  • Closed: The fracture is limited to the bone without penetration of the bone on the body surface.





OTHER TYPE OF INJURIES:

  • Sprains: Sprain is an injury to a ligament or to the tissue that covers a joint caused by sudden over stretching.
  • Ligaments are bands of stringy fibers that hold the bones of a joint in proper position.
  • The tissue that covers the joint is called the capsule.
  • Most sprains result from a sudden wrench that stretches or tears the tissues of the ligaments or capsule.
  • Sprains of the ankle and wrist are most common, but a person may sprain any joint. As the ligament is not severed it gradually heals, but this may take several months.
  • A sprain is usually extremely painful.
  • The injured part often swells and turns black and blue.
  • Sprains should be treated by cold compresses (ice packs) at the time of injury, and later by restriction of activity Doctors may prescribe rest, elevation of the injured part, or the application of cold compresses or elastic bandages to reduce swelling.
  • Special types of exercise also may help reduce swelling and speed recovery.

  • Strains: Excessive stretching or working of a muscle, resulting in pain and swelling of the muscle. There is no ligament tear.












CHAPTER NO: 5.

BURN INJURIES/THERMAL INJURIES:

Burns and scalds rank among the most serious and painful injuries. Most burns result from contact with burning clothing or other materials or with electricity or chemicals. Burns caused by hot water or other hot liquids or by vapors are called scalds.

Burns can affect all the systems of the body. A serious burn destroys much of the skin. But it also upsets the circulation of the blood, the function of various organs, and the body's ability to fight infection.

RULE OF NINE: This is a rule made to assess or measure the extent of burn on the body. Sections 324 and 326 of the IPC deal with punishments to be awarded for such injuries. The estimation of the surface area of the body involved is usually worked out by the rule of nine:
  1. 9%: For the head and each arm.(total 27% only of the anterior or posterior side)
  2. 18% for the front or back of the trunk.
  3. 9%: for the front or back of each leg.
  4. 1%: for the perineum, thus making a total of 100% for the body.

CLASSIFICATION OF BURNS. Burns are classified as first-degree, second-degree, or third degree, depending on the depth of the burn and the degree of tissue injury.
  • A first-degree burn, such as mild sunburn, affects only the surface of the skin. The burned area is red and tender.
  • A second-degree burn involves blistering and swelling, and a watery liquid may ooze from the wound. Many second-degree burns are caused by deep sunburn or by contact with hot liquids, or with burning oil or other flammable substances.
  • A third-degree burn penetrates the entire thickness of the skin and usually part of the tissue underneath. The skin appears white, very red, or even charred. Most victims have no feeling in the area of a third-degree burn.

FIRST-AID TREATMENT: is vital for a victim of almost any burn.
  • Many burns are more serious than they seem.
  • Therefore, a doctor should examine all burns except the smallest ones.
  • Even small burns on the hands and face should receive medical attention.
  • Any large burn may cause severe shock.
  • To avoid shock, the victim should be kept in a horizontal position.
  • He or she also should be covered to prevent as much loss of body heat as possible.

  • Small or moderate burns should be bathed in cold water to ease the pain.
  • Wrapping the burned area in a dry, sterile bandage will help prevent infection.
  • Burns that cover a large area should not be treated with cold water.
  • Wrap the burned area in a dry, sterile dressing.

  • Burns caused by chemicals should be bathed with cold flowing water.
  • The water dilutes the chemical and washes it away.
  • Electrical burns sometimes cause respiratory failure.
  • If this happens, artificial respiration should be administered.

HOSPITAL TREATMENT:

  • Burns cause plasma (the fluid component of the blood) to leak from the blood vessels.
  • This loss of circulating fluid causes shock.
  • Emergency treatment consists of replacing the lost fluid, preventing infection, and minimizing pain.
  • Victims are given a diet high in protein, calories, and vitamins to help to heal the injuries.
  • However, most large third-degree burns do not heal naturally.
  • Removing destroyed skin and replacing it with skin grafts treats these burn injuries.

  • Victims of severe burns also receive extensive physiotherapy.
  • These injuries cause terrible pain when such parts of the body as the arms and legs are affected. Physiotherapy can help restore the use of these body parts.
  • Treatment also includes activities designed to ensure the victim's emotional well being after he or she returns to an active life.


























CHAPTER NO: 6.
INJURIES DUE TO POISONS:

POISONS are substances or drugs, which in excessive doses cause harmful effects on the body.
CLASSIFICATION OF POISONS:

  1. CORROSIVES:
  1. Organic:
  • Hydrocyanic acid.
  • Carbolic acid.
  • Potassium Cyanide.
  1. Inorganic: Mineral acids like Sulfuric acid, Hydrochloric acid, and Nitric acid.

IRRITANTS:

  1. INORGANIC:
  • (Metallic Poisons): Mercury, lead, arsenic.
  • (Non Metallic poisons): Phosphorus, Iodine & Bromine.

  1. ORGANIC:
  • Plant/ Vegetable Poisons: Capsicum seeds, Abrus precatorus, Semicarpus anacardium known as Bhilawanol causes false Blisters; etc.
  • Animal Poisons: Snake poisons, Scorpion bites, Bees/ Wasp bites.

NEUROTICS:
  • Alcohol,
  • Petrol/ Kerosene,
  • Pesticides,
  • Dhatura,
  • Cocaine, Cannabis,
  • Barbiturates, LSD, and anesthetics, Strychnine, Arrow poisons like Curare & Conium.

RESPIRATORY:
  • Carbon monoxide,
  • Carbon dioxide,
  • Methyl Isocyanate gas (Bhopal Gas Tragedy), And
  • Hydrogen sulfide.

CARDIAC POISONS:
  • Aconite,
  • digoxin,
  • Nicotine (Tobacco).

INJURIES DUE TO POISONS:

  • Vitriolage: is known as throwing of acid or irritant chemicals on the victim with malicious or ill intent.
  • The Chemical burns or irritant burns can also be caused in industrial or chemical plants where workers are working with such hazardous drugs or chemicals.
  • The injuries possible mainly are accidental or suicidal or homicidal or assault.
  • The chemicals thrown commonly are Sulfuric acid, nitric acid, bhilawanol juice, and organic acids.
  • Chemical burn generally involves carbonization and corrosion of the tissues. Irritants cause burns, irritation & infection.
  • Vitriolage falls under Grievous injury and as per IPC 320, it is a punishable offence.
  • Snake bite/ Scorpion bites: This can be mainly accidental, rarely homicidal or suicidal.
  • Insecticide poisons/ Kerosene are mainly suicidal or accidental Injuries.
  • Alcohol or neurotic poisons do not cause any bodily injuries but cause accidents due to loss of muscular coordination after intoxication. Deaths have been reported to be also due to suicidal injections or ingestion of heavy doses of these poisons.
  • Respiratory & cardiac poisons can be accidental or suicidal or homicidal.
  • Irritant Poisons are mainly environmental hazards or industrial hazards.
  • Most ailments fall under Occupational hazards for industrial workers. Phossy jaw, an infection of the bones with suppuration leading to deterioration of the Jaw to the extent of surgical removal, is seen in Phosphorus factory workers.
  • Mercury or lead poison can be an environmental hazard or industrial hazard. Mercury causes a MAD HATTER’S SHAKE disease.
  • The fall of Roman Empire was because of Lead Poisoning.
  • Bangladesh has an epidemic of Arsenic poisoning since the earth levels of Arsenic are more & people use ground water for consumption.skin or inhalation injuries are common.








CHAPTER NO: 7.

DRUNKEN DRIVING


As per the Insurance policies, the injuries or accidents as a result or under the influence of alcohol are exclusion. Let us get an insight into the basic modes for diagnosing a drunken driver/ intoxicated person.

DRUNKENNESS: a condition which results from excessive alcohol and the person concerned is so much under the influence of the alcohol that
  1. He loses control over his mental faculties.
  2. He is unable to perform the duties on which he is engaged at a particular time, and
  3. He may be a source of danger to himself or to others.

WHY THE CRIME OF "DRUNKENNESS:

1. A Moral Hazard: to be or not to be: to delineate and to find a perfect example of how the law reaffirms the moral boundaries of drunkenness.
2. About 40% of all traffic deaths and over 2,000,000 automobile injuries are alcohol-related.
Alcohol abuse, despite signs of decline, is still at epidemic proportions.
3. Family or wife abuse with assault or battery.
4. Physical and moral deterioration.
5. Crimes like Rape/ sexual Murder.

MOTOR VEHICLE ACT:

Under Section 185 of the Motor Vehicle act, Whoever, while driving, or attempting to drive, a motor vehicle-
  1. Has, in his blood, alcohol-exceeding 30mg per 100ml. Of blood detected in a test by a breath analyzer, or
  2. Is under the influence of a drug to such an extent as to be incapable of exercising proper control over the vehicle,
Shall be punishable for the first offence with imprisonment for a term which may extend to 6 months or with fine which may extend to Rs. 20,000/- or with both, and for a second or subsequent offence, if committed within 3 years of the commission of the previous similar offence, with imprisonment for a term which may extend to 2 years, or with fine which may extend to Rs. 3000/- or both.
Explanation: For the purposes of this section, the drug or drugs specified by the Central Government in this behalf by notification in the official Gazette, shall be deemed to render a person incapable of exercising proper control over a motor vehicle.

ALCOHOL INTOXICATION TESTING:

  • Functional Principle: All of these machines were designed to take a deep air sample (breath from the alveolar sacs, the site of gas exchange in the lungs) and calculate the rate or proportion of alcohol-in-blood to alcohol-in-breath.

THE OTHER TESTS BESIDE Drunkometer are CLINICAL TESTS like:

  1. (Horizontal gaze nystagmus) testing / eye gazing/ Eye jerks following an object moved laterally.
  2. Eye jerks trying to use peripheral vision
  3. Point at which jerking first occurs estimates BAC:
  • Other field sobriety tests such as finger-to-nose, walk-and-turn, or the one-leg stand.

Evidentiary tests: Tests that require the suspect to do something:
  1. Blow into a tube,
  2. give blood,
  3. stand on one leg,
  4. walk a line, and
  5. Touch their nose.

Preliminary tests: Test that don't require the suspect to do anything:
  1. Erratic driving
  2. staggering,
  3. Memory,
  4. Reflexes,
  5. slurring,
  6. Erratic Writing.
  7. having bloodshot eyes,
  8. The odors associated with alcohol.

BLOOD TESTS:

The BEST MEDICO-LEGAL SCIENTIFIC METHOD for determining anything close to "impaired judgment" is an estimate of the amount of alcohol that has flowed through the blood vessels of the brain.
  • Blood samples are usually drawn from the arm.
  • The unconsumed amount of dichromate or the chromic sulfate formed is measured which gives the percentage of alcohol in the sample expressed in percent weight per volume, which is exactly the same formula for estimating BAC.

URINE TESTS


  • Urine normally contains about 1.3 times as much alcohol as blood.
  • Higher concentrations of alcohol in urine will occur over a longer period of time than in blood.
  • Law enforcement practice is to take two (2) samples, at 30-minute intervals, preferably the latter sample after the bladder has been emptied.
  • Urinalysis requires a bit more sophisticated laboratory equipment than for blood testing.

  • One of three (3) laboratory methods are used:

(1) Chemical tests;
(2) Biochemical tests; and
(3) Gas chromatography.
Gas chromatography is the most widely used because it can distinguish alcohol from ketones and aldehydes (a problem that exists with diabetics and people with other disorders that blood tests are not capable of controlling for)

DUTIES OF A MEDICAL OFFICER:

  • If a police brings an accused for examination due to alcohol intoxication, the police examines the patient with preliminary details and identification marks, with or without consent.
  • Based on general examination as mentioned in preliminary and evidentiary tests, he makes his diagnosis and interpretation.
  • Blood sample, with urine sample sent to the chemical analyzer for alcohol detection.
  • He retains one copy, another handed over to the investigating officer and third is given to the executive magistrate.








CHAPTER NO: 8.
Snake Bite

"She died because she never knew
These simple little rules and few:
The snake is living still"
- H. Belloc.

OPHITOXAEMIA is the rather exotic term that characterizes the clinical spectrum of snakebite envenomation.
  • Of the 2500-3000 species of snakes distributed worldwide, about 500 are venomous.
  • The major families in the Indian subcontinent are:
  1. Elapidae which includes common cobra, king cobra and krait,
  2. Viperidae which includes Russell's viper, pit viper and saw-scaled viper and
  3. Hydrophidae (the sea snakes).
  • Of the 52 poisonous species in India, majority of bites and consequent mortality is attributable to 5 species viz.

  1. KING COBRA,
  2. COMMON COBRA,
  3. RUSSELL'S VIPER,
  4. KRAIT AND
  5. SAW-SCALED VIPER.
  • Based on the type of effects on the body, the snake poisons are further classifed as:
  1. Neurotoxic,
  2. Vasculotoxic And
  3. Myotoxic.



First Aid For Snakebites:

Many health-care professionals embrace just a few basic first-aid techniques.
  1. Wash the bite with soap and water.
  2. Immobilize the bitten area and keep it lower than the heart.
  3. Get medical help.
  4. If a victim is unable to reach medical care within 30 minutes, a bandage, wrapped two to four inches above the bite, may help slow venom.
  5. A suction device may be placed over the bite to help draw venom out of the wound without making cuts.
  6. Suction instruments often are included in commercial snakebite kits.
  7. Allow bite to bleed freely for 15-30 sec.
  8. Cleanse and rapidly disinfect area with Betadine.If bite on hand, finger, foot or toe, wrap leg/arm rapidly with 3" to 6" Ace or crepe bandage past the knee or elbow joint immobilizing it.
  9. Leave area of fang marks open. Apply Extractor immediately as well. Wrap no tighter than one would for a sprain. Make sure pulses are present.
  10. Apply Sawyer Extractor until there is no more drainage from fang marks.
  11. Extractor can be left in place 30 min or more if necessary.
  12. It also aids in keeping the venom from spreading by applying a negative pressure against the tissue where the venom was initially deposited and creates a gradient, which favors the movement of venom toward the Sawyer's external collection cup.
  13. If extractor not available: Apply hard direct pressure over bite using a 4 x 4-gauze pad folded in half twice.
  14. Tape in place with adhesive tape.
  15. Soak gauze pad in Betadine(tm) solution if available and not allergic to iodine’s
  16. Strap gauze pad tightly in place with adhesive tape
  17. Overwrap dressing above and below bite area with ACE or crepe bandage, but not too tight. No tighter than you would use for a sprain.
  18. A good rule of thumb is to make the band loose enough that a finger can slip under it. Make sure pulses are present.
  19. Immobilize bitten extremity, use splinting if available.
  20. If possible, try and keep bitten extremity at heart level or in a gravity-neutral position. Raising it above heart level can cause antivenom to travel into the body.
  21. Holding it down, below heart level can increase swelling.
  22. Antivenom is the only and best treatment for snakebite and you must get as much as is necessary as soon as possible. Antivenom administration should not be delayed.

What Not to Do if Bitten by a Venomous Snake

  • Contrary to advice given elsewhere DO NOT permit removal of pressure dressings, Sawyer or ACE bandage until you are at a facility ready and able to administer antivenom.
  • As soon as the dressings are released the venom will spread causing the usual expected problems of venomous snakebite.
  • The hospital at this time must be prepared to administer the antidote (antivenom)*
  • Do not eat or drink anything unless Okayed by medical sources
  • Do not engage in strenuous physical activity
  • Do not apply oral (mouth) suction to bite
  • Do not cut into or incise bite marks with a blade
  • Do not drink any alcohol or use any medication
  • Do not apply either hot or cold packs
  • Do not apply a narrow, constrictive tourniquet such as a belt, necktie or cord
  • Do not use a stun gun or electric shock of any kind.
  • Do not remove dressings/elastic wraps until arrival at hospital and antivenom available.
  • Do not waste time or take any risks trying to kill, bag or bring in offending snake
  • Remember ACE or other wide bandaging must not be wrapped so tight as to cut off systemic venous or arterial circulation.
  • Properly applied such bandages will NOT compromise the systemic circulation.
  • No ice or any other type of cooling on the bite. Research has shown this to be potentially harmful.
  • No incisions in the wound. Such measures have not been proven useful and may cause further injury.

TREATMENT:

Medical professionals sometimes disagree about the best way to treat poisonous snakebites.
  • Procedures such as fasciotomy, a surgical treatment of tissue around the bite, have some supporters.
  • But most often, doctors turn to the antidote to snake venom--antivenin--as a reliable treatment for serious snakebites.
  • There are two types of antivenin (sometimes called "antivenom") in use today.
  • They are derived from antibodies created in the blood of a horse or sheep when the animal is injected with snake venom.
  • In humans, antivenin is injected either through the veins or into muscle, and it works by neutralizing snake venom that has entered the body.
  • Because this antivenin is obtained from horses, snakebite victims who are sensitive to horse proteins must be carefully managed.
  • The danger is that they could develop an adverse reaction or even a potentially fatal allergic condition called anaphylactic shock.
  • The enzyme treatment also allows the antivenin to be cleared from the body more rapidly, so that additional treatments may need to be given.







POST MORTEM APPEARANCES:

  • Two bite marks about 1 cm deep in cases of elapids and 2.5 cm deep in case vipers may be found.
  • These should be searched for with a magnifying lens if not visible to the naked eye.
  • There is swelling and cellulitis about the bitten part and in case of viper, the local appearances are more striking due to considerable oozing of blood from the site of puncture.
  • The blood is generally fluid and haemolysed causing early staining of the blood vessels.
  • If the venom is predominantly neurotoxic, there are no definite appearances indicating cause of death except the signs of asphyxia (decreased air/oxygen supply demand to the lungs).
  • If the venom is predominantly vasculotoxic, there are hemorrhages in the lungs and also extravasations of blood in the serous membranes such as pleura and pericardium.
  • Hemorrhages are noted under the cardiac tissue walls (Endocardial) in the left ventricle, septum and papillary muscles.
  • Petechiae are also found within the kidney pelvis and mucosa of the urinary bladder stomach and intestines.
  • The regional lymph nodes are swollen and haemorrhagic.
  • Blood fails to clot normally even after addition of thrombin because of the extremely low level of fibrinogen.
  • Arterioles and capillaries are characterized by blurred walls and swollen endothelial cells.
  • Other findings include necrosis and desquamation of the renal tubules and cloudy swelling and granular changes in the cells of other organs.





PRESERVATION OF VISCERA:

  1. Mainly the skin and subcutaneous tissue at the site of bite is taken 2” x 2” x2”. A Control sample should also be taken from the opposite limb or bite site for comparative study.
  2. Routine viscera as in case of any poisoning or unnatural death.

MEDICOLEGAL ASPECTS:
  • Generally accidental, rarely homicidal and still rarely suicidal (Cleopatra had killed herself by an asp letting her bite the left breast).
  • Sometimes allegations of death due to snakebite are made after killing a person by throttling or poisoning.















CHAPTER NO: 9.
CRITICAL ILLNESSES

SIX MAJOR CRITICAL ILLNESSES ARE:

  1. MYOCARDIAL INFARCTION.
  2. CORONARY ARTERY DISEASE.
  3. STROKE/CVA.
  4. RENAL FAILURE: ACUTE & CHRONIC.
  5. CHRONIC OBSTRUCTIVE PULMONARY DISORDER.
  6. CANCER.

I. MYOCARDIAL INFARCTION:

Commonly called as a HEART ATTACK, is the death or necrosis, of the cardiac muscle tissue resulting from inadequate blood supply.

This is a condition arising due death or necrosis of the cardiac muscles due to insufficiency or lack of blood supply to the cardiac tissue. The main cause for a heart attack or MI is an Ischaemic heart disease.

Ischemic heart disease is caused by an imbalance between the Cardiac blood flow and the metabolic demand of the cardiac muscle. Reduction in heart vessel blood flow is related to progressive fatty plaque formation & thickening of the arteries (atherosclerosis) with increasing occlusion of coronary arteries. Blood flow can be further decreased by superimposed events such as sudden vessel spasms, formation of blood clot in the vessels, or circulatory changes leading to decreased organ perfusion.

Myocardial infarction occurs when a fatty atherosclerotic deposit or a blood clot suddenly blocks one of the coronary arteries cutting off blood supply and oxygen from a section of the heart thus causing death of that portion of heart supplied by that particular artery.

CLINICAL PRESENTATIONS: severe crushing pain in the chest, mainly in the center with or without radiation to the left upper limb, neck, back and the jaw. May also present with severe perspiration, nausea.

DIAGNOSIS:

  • Electro Cardiogram Changes ECG changes.
  • Creatinine-Phosphokinase – MB enzyme levels, CPK-MB in the blood stream.
  • Holter Stress test or TMT (Treadmill Test), after complete recovery from infarction.
  • Cardiac enzyme levels in blood.
  • Echocardiography (color Doppler)
  • Coronary Angiography.

PROGNOSIS:

  • If come out of the first four hours of MI, prognosis is good.
  • If severe/ massive infarction affecting the vital areas of the heart may cause death.
  • If recovered continuous follow up & control of risk factors is a must with diet control.












A BRIEF NOTE ON DIAGNOSTIC TESTS IN HEART FUNCTION EVALUATION:

1. Electrocardiogram: recording of electrical impulses or current generated due to cardiac muscle motion on a graph paper. The changes generally found are:

  • ST-changes correlate best with ischemia
  • Rhythm disturbances (ectopy or block) do not correlate well
  • Abnormal ST-segment response

V. EXERCISE TOLERANCE TESTING - PHYSIOLOGIC RESPONSE TO

EXERCISE:

A Conventional test- Progressive workload until the patient demonstrates ischemia or reaches limiting fatigue. The electrocardiac monitoring done on TV (ultarsonography), Blood pressure and respiratory rate or other parameters are noted.
The various Parameters measured in the test are:

  • Heart rate.
  • Blood pressure.
  • Symptoms.
  • Chest pain.
  • Dyspnea.

ECHOCARDIOGRAPHY: a tool second to ECG. Consists of an ultrasound machine that directs high frequency sound waves into the patient’s body and a mechanism that records the sound waves as they reflect off the patient’s heart walls, chambers, valves, and red blood cells. Viewing the patient’s heart during Echo is done in “real view” on an oscilloscope, and the image is also recorded for further viewing and study. The recorded image is called as Echocardiogram.

SCINTIGRAPHIC EXERCISE TESTING:


Perfusion imaging (e.g. thallium-201)

Thallium is taken up my myocardium in direct proportion to local blood flow. Thus a marker of perfusion. Thallium images allow comparison of relative Cardiac Blood Flow between different segments of the Left Ventricle. Thallium redistributes with time.
Comparing stress and redistribution images allows one to find reversible defects and deduce the heart status and effectivity in it’s functioning. The impaired blood flow is seen as a cold spot on the Radionuclide image.

RADIONUCLIDE TECHNIQUES:

  • Radionuclide Technetium is used to locate abnormal coronary blood flow or damaged heart tissue.
  • The imaging follows an intravenous injection of technetium into the patient.
  • Technetium concentrates in the dead myocardial tissue, a person with Myocardial infraction will have increased accumulation of radioactivity, called a hot-spot in the area of myocardial injury.





CARDIAC CATHETERIZATION:

  • Allows visualization of the lumen of the artery
  • Precise delineation of extent and severity of disease "road map" that helps in planning therapy.
  • More invasive and expensive than exercise stress testing.
  • The cardiac catheter Judgkin’s catheter is inserted through femoral vein into the heart, angiographic dye is injected and the blood flow through the cardiac vessels and walls is visualized on the TV monitor and pictures are taken for further reference.

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA):

  • A form of corrective surgery, Uses balloon catheter to squash plaque against lumen and restore blood flow.
  • Does not require anesthesia or thoracotomy.
  • Here the catheter is used to dilate partially occluded coronary arteries by introducing a balloon tipped catheter into the large artery in the patient’s thigh and advancing the catheter into patient’s aorta and then into the narrowed coronary artery.
  • An elongated balloon at the tip is inflated, pressing the atherosclerotic plaque in the coronary artery against the arterial wall.
  • The widening of the vessel channel allows for an increase in the patient’s blood flow.
  • Greatest drawback is high rate of restenosis.

CORONARY ARTERY BYPASS GRAFTING (CABG):

  • Surgical procedure Indicated for certain groups.
  • Involves incision into the patient’s chest to allow for insertion of a graft, usually consisting of a segment of leg vein, from the ascending aorta to a coronary artery.
  • The graft bypasses a stenotic segment in the coronary artery.
  • Surgeons attempt as much as many bypass grafts as possible, to ensure the optimum revascularisation of the myocardium.

II. STROKE: (Cutting off of blood supply to part of brain.)

A Cerebral Vascular accident (CVA), which is more commonly called a stroke is a leading global health problem and predicted to grow.
  • It is the second most common cause of death and major disability worldwide.
  • Any disease of the cerebral vascular system that results in cerebral, cerebellar, or brain stem anoxic (cessation of oxygen supply) damage.
  • It is characterized by decreased or sudden stoppage of blood supply to the brain causing loss of consciousness with or without paralysis.
  • Deprived of oxygen and nutrients supplied by the blood, brain cells quickly die, the parts of the body controlled by these cells stop working.
  • Thus, A stroke victim may thus lose the ability to speak (Dysarthria) or Understand.
  • He may become paralyzed or stop breathing altogether.
  • The location of the loss of function and its severity depend on the part of the brain that has been injured and how badly it has been damaged.

Aggravating factors or Conditions such as
  • Hypertension,
  • Diabetes mellitus,
  • Elevated blood cholesterol, and
  • Certain type of heart diseases, which produce or aggravate arterial disease, predisposes individuals to CVAs.
  • Hypertension is the greatest contributing factor.

CAUSES: immediate causes are like
  • A CEREBRAL THROMBOSIS which means actual blocking of a blood vessel to the brain.
  • E.g.: a blood clot which breaks in any artery mainly cardiac and then travels to the brain artery, an embolus or a thrombus: a blood clot in the vessels which ruptures.
  • CEREBRAL HEMORRHAGE: break or rupture in the blood vessels due to high blood pressure.

CLINICAL PRESENTATION:
  • Sudden weakness,
  • speech loss,
  • paralysis of one side,
  • blurring of vision or double vision,
  • dizziness,
  • nausea.

DIAGNOSIS: CT SCAN Brain, MRI angiography Brain.

PROGNOSIS:
  • Complete recovery if Transient Ischaemic attack involving only a small brain artery: many a times no manifestations or if present are so mild that patients do not take much notice of it.
  • Partial recovery: paralysis or Permanent partial disability/ Total disability depending on severity and extent of brain damage.
  • Death.












III. CORONARY ARTERY DISEASE:

  • It is a disease that affects the coronary arteries, the vessels that supply the heart itself with blood.
  • There are two coronaries, Right and left which branch out from the aorta (the body’s main artery) as it leaves the heart.
  • In coronary artery disease, these vessels become clogged with fatty deposits. This process is known as atherosclerosis.
  • Such deposits can interfere with, or block, the blood supply to the cardiac muscle, causing angina or a heart attack.

RISK FACTORS:

  • High cholesterol, mainly high levels of “LDL’ (Low density Lipid’) is the bad cholesterol.
  • Smoking.
  • Hypertension.
  • Obesity.
  • Diabetes Mellitus.

DIAGNOSIS:

  • ECG.
  • Echocardiography.
  • Coronary Angiography.
  • Stress test/TMT.

PROGNOSIS:
A sudden myocardial ischaemia or angina can cause death.
Can be controlled by controlling the risk factors.

IV. CHRONIC OBSTRUCTIVE PULMONARY DISEASE:

COPD is a varied group of chronic respiratory disorders that are associated with varying degrees of obstruction to the flow of air during expiration.
COPD results from
  • Chronic bronchitis,
  • emphysema (increased size of alveolar sacs, an irreversible damage due to destruction), or
  • Combination of both, and is closely associated with cigarette smoking.
COPD is a major cause of disability in old people and an important cause of mortality.

FOLLOWING ARE THE DEGREE OF OBSTRUCTIONS SEEN:

  1. LOW DEGREE OF OBSTRUCTION: Increased airway resistance, which results from increased mucus secretions.
  2. HIGHER DEGREE OF OBSTRUCTION: A thickened bronchial wall from edema causing airway obstruction.
  3. SEVERE OBSTRUCTION: A Constricted bronchial wall from chronic inflammation with fibrosis causing airway obstruction.

CLINICAL: PRESENTATION:
  • Laboured breathing/ Dyspnea.
  • Productive Cough.
  • Wheezing.
  • Morning tightness in chest.
  • Difficulty breathing except in an upright position.
  • Weight loss.
  • Recurrent respiratory infections.
  • Right heart failure in end stage COPD.

DIAGNOSIS:
  • Chest X-Ray.
  • Pulmonary Function Tests.

PROGNOSIS:
  • Death In cases of sudden airway obstruction due to acute increase in bronchial secretions.
  • Heart failure causing death/ is a bad prognosis.
  • Progressive Cerebral Oxygen Deficiency, which is manifested by drowsiness, disorientation and Coma.
  • Tachycardia with weight loss is a negative prognostic indicator.



















  1. RENAL FAILURE is a condition in which the kidney is unable to normally excrete the substances produced by metabolism.
IT IS CHARACTERIZED BY:
  • A decrease in the rate of filtration by the glomerulus, manifested by oliguria, which is reduced excretion of urine, and
  • A rise in blood urea levels along with serum creatinine concentrations.
  • Uremia or Azotemia is end stage of renal failure.
1. ACUTE RENAL FAILURE: Sudden development of renal failure within a day or a week is known as Acute Renal failure.
Commonest cause is Acute Tubular Necrosis causing death of the cells of the renal tubules.
This is due to
  • Exposure to toxic drugs.
  • Severe hemorrhage.
  • Septicemia.
  • Crush Injury.
  • Incompatible blood transfusion.
  • malignant hypertension,
  • Glomerulonephritis,
  • vasculitis,
  • bacterial infections,
  • drug reactions, and
  • Metabolic disorders (e.g. hypercalcemia, hyperuricemia).
DIAGNOSIS:
1. Increased Serum Urea & Serum Creatinine levels.
2. Decreased Urine outflows.
PROGNOSIS:
  • Reversible if acute.
  • The nature of severity of any associated illness or injury influences his or her clinical course of treatment.

2. CHRONIC RENAL FAILURE:

The clinical condition resulting from chronic derangement and insufficiency of renal excretory and regulatory function (uremia). Development varies from months to years.

Chronic renal failure (CRF) may result from any major cause of renal dysfunction.
The most common cause of end-stage renal disease is diabetic nephropathy, followed by
  • Hypertensive nephroangiosclerosis and various primary and secondary glomerulopathies.
  • Heart Failure.
  • Edema.
  • Anemia.
  • Diarrhoea.
  • Neuropathies.

DIAGNOSIS:

The functional effects of CRF can be categorized as
  • diminished renal reserve,
  • renal insufficiency (failure), and
  • Uremia.
With diminished renal reserve, there is a measurable loss of renal function, but homeostasis is preserved at the expense of some hormonal adaptations (e.g., secondary hyperparathyroidism, and intrarenal changes in glomerulotubular balance).

PROGNOSIS:
  • End stage renal disease is treated with
  • Hemodialysis.
  • Peritoneal Dialysis.
  • Renal Transplantation.

VI. BRAIN TUMOURS:

  • Tumors are abnormal growths that can cause severe brain damage.
  • The effects of a tumor depend on its size and location.
  • A tumor may destroy brain cells in the area surrounding it.
  • As the tumor grows, it also creates pressure, which may damage other areas of the brain or at least interfere with their normal function.

CLINICAL PRESENTATIONS:

  • Headache,
  • Seizures,
  • Unusual sleepiness,
  • A change in personality, or
  • Disturbances in sense perception or speech.

DIAGNOSIS:

  • CT Scan brain.
  • MRI brain.
  • Anti Nuclear Antibodies level in blood.

PROGNOSIS:

  • Surgery cures some tumors. For cancerous tumors, doctors may combine surgery with drugs or radiation. One type of radiation, called stereotactic radiosurgery, is sometimes used as an alternative to traditional surgery.
  • In stereotactic radiosurgery, doctors use computers and a CT scan or MRI to produce a three-dimensional image of the brain.
  • Beams of radiation are then focused precisely on a target, which may be a tumor or a blood-vessel malformation.
  • The individual beams are either too brief or too weak to harm areas of the brain in the path of the radiation.
  • But their combined effect will destroy the target. These procedures are quick and painless and allow patients to resume moderate activity the same day.

























CHAPTER NO: 10.
INQUEST

Inquest (in = in; quasitus= to seek) means a legal or judicial inquiry to ascertain matter of fact. In forensic, an Inquest generally means an inquiry into the cause of death, which is apparently not due to natural causes. In cases of sudden, unnatural deaths or suspicious deaths, an urgent investigation into the cause of death (inquest) is obviously necessary to apprehend and punish the criminal. The body cannot be disposed as in natural deaths.
The following are the examples of such deaths:
  1. Sudden death, unknown cause.
  2. Suicide, homicide and infanticide.
  3. Custodial death: police, Borstal schools, mental asylums or certified school.
  4. Dowry deaths.
  5. Anesthetic/ Medical negligent deaths.

Types of Inquest:
  1. The Coroner’s Inquest (No longer prevalent in India.)
  2. Police Inquest.
  3. Magistrate’s inquest.
  4. The Medical Examiner System. ( In USA)

POLICE INQUEST: (PANCHNAMA)

  • (Cr. P. C 174) inquiries by an officer in charge of a police station into the cause of any unnatural death.
  • The police officer making the preliminary inquiry is known as the investigating officer.
  • On receipt information of any unnatural or accidental death, the police officer informs about it to the nearest magistrate of the same area and proceeds to the place of offence.
  • Here, he holds inquiry into the cause of death in presence of two or more respectable witnesses of the locality who are panchas, panch witnesses or panchayatdars. He prepares a report about the probable cause of death as judged by him and the panchas from the appearance of the surroundings of the body including the nature of injuries thereon.
  • This report is known as the Panchanama or Inquests report, and is then signed by the witnesses present.
  • In case where no foul play is suspected the dead body is ordered for disposal.
  • In Further enquiry and trail of the case is conducted in the usual manner by the concerned magistrate to whom entire case records are then transferred by the investigating police officer.
  • The Head constable along with the inspector in Chief visits the scene of crime to investigate and make an FIR/ Panchanama.
  • The report is known as PANCHANAMA since in ancient times, the Panchas at the scene of crime recorded the offences in villages, and they were the deciding authority in criminal or civil offences.
  • In Case where foul play is suspected, the dead body sent for autopsy to the nearest medical officer, after performing the autopsy, gives his opinion about the cause of death in the post mortem report which is written in triplicate using carbon copies.
  • One retained by himself, other handed to the police officer in charge & third to the executive magistrate.
  • Further enquiry and trail of the case is conducted in the usual manner by the concerned magistrate to whom entire case records are then transferred by the investigating police officer.
  • The Inspector in Chief records the state at the scene of crime along with 2-3 witnesses’ evidence about the circumstances leading to the particular offence along with their thumbprints or signatures.
  • Of these witnesses at least two should be disinterested witnesses. These witnesses can be called as alibi or hearsay evidences in the court of law.
  • Besides noting down the details present at the scene of crime, any suspicion or suspect if present related to the case can also be noted down.
  • The FIR with these observations, dates, time & address of the incident with his interpretations; duly signed by the constable and the police in charge is filed.
  • In cases of Burns or poisonings or accidents or suicide, if the victim is alive his or her statement is recorded and taken to the hospital immediately.
  • If the victim is about to succumb to the injuries even after utmost care and treatment, a dying declaration is taken.

MAGISTRATE’S INQUEST: This means an inquiry conducted by the magistrate to ascertain certain matters of fact. It is commonly held in the following cases:
  1. Insanity cases before person admitted into asylum.
  2. Death of a convict in jail.
  3. Death of a person in police custody or during police interrogation.
  4. Death in police firing.
  5. Exhumation cases.
Main intention is to ensure:
  • No person is unjustly deprived of his liberty and his rights as citizen.
  • Check the neglect or brutality of Police officers or persons incharge.
  • Already buried body, where doubt lingers regarding identity or cause of death, it will be settled by judicial inquest and not by police inquest.

FIRST INFORMATION REPORT/FIR:

The information given to a police officer and reduced to writing required by the following sections is known as the “First Information”; the corresponding report is understood to mean the First Information Report (FIR).

The FIR is generally done in cases of a crime or an offence.
Section 154 (1) of the code of Criminal Procedure provides that the information relating to the commission of a cognizable offence if given orally to an officer in charge of a police station. Even a telephonic information is recorded as FIR.

  • The police reduces the information in writing.
  • It should be read over to the informant.
  • Every such information whether given in writing or reduced to writing shall be signed by the person giving it, substance thereof shall be entered in a book in a prescribed manner.

S 154 (2) Provides that copy of the information as recorded under the sub section (1) shall be given free of cost to the informant.

S 154 (3) provides that if the information is not recorded by the police officer, the informant can approach the Superintendent of Police by sending him the information by post. In such cases, the officer can carry out the investigation himself or direct an investigation by his subordinate. Where any information disclosing the cognizable offence is laid before the officer-in-charge of a police station, he has no option but to register the case and thereafter start the investigation.

[COGNISABLE OFFENCE: (i.e. an offence for which a person may be arrested without the need of a warrant) examples: - Murder, Rape, red-handed catch amidst robbery/ Theft.]

Th principal object of the FIR from the point of view of the informant is to put the criminal law in motion and from the point of view of the object of the investigating authorities is to obtain information about the alledged criminal activity so as to able to take suitable steps to trace and bring to book the guilty.

DYING DECLARATION is a statement given by the victim before death, of the circumstances leading to his or her present condition, in presence of the Inspector in Chief, the treating doctor and one dis interested witness. Oath is not taken in a dying declaration since in India it is assumed that a dying person always speaks the truth.

Ideally, DYING DEPOSITION is more superior to Dying Declaration. In deposition, an Executive Magistrate or a Magistrate with lawyers for both the accused and the victim along with a dis interested witness, the statements are recorded with a trial at the site itself. The report so recorded is direct evidence in the court of law. If the declarant dies, the Dying declaration report is documentary evidence and carries weightage. If the declarant survives, it becomes corroborative evidence. Dying deposition retains its value even after survival of the victim. A police officer is not allowed during Dying deposition or declaration to avoid intimidation or fear during declaration by the victim.

DUTIES OF A MEDICAL OFFICER IN CASES OF OFFENCE OR POISONING

When a patient comes to a doctor in wounded state, or when there is any suspicion of foul play or assault, the doctor should He should continue with the treatment and Immediately intimate the police for FIR. If the patient is about to die and the police or the magistrate has not reached for the dying declaration, the doctor can record the declaration in presence of a dis interested witness.
The declaration is recorded in the patient’s own language and should be verbatim along with the colloquial words. The statement so recorded should be complete. If the patient is unable to communicate, he should record the gesticulations or signs of the patient. If the patient dies amidst the recording of the statement, the doctor should record the complete statement as per his interpretation of the entire case.
This signed by the declarant if alive or his thumb impression; with the witnesses signature & doctor’s own signature duly stamped shall complete the Dying declaration report.
In medico legal cases, the doctor should arrange for MLC/FIR. A copy of the FIR or MLC should be attached to the case sheet of the injured person.
In cases of death, a death certificate is issued only in case of a natural death. In cases of foul play or suspicion, police should be intimated.



A Medico legal autopsy is conducted only after receipt of the following documents:
  • The Inquest Report.
  • The First Information Report.
  • The Dead body Challan from the police.
  • Authority letter from the Executive Magistrate.
  • Identification of the dead body by the police and or relatives.
  • In cases of poisoning, if it was a suicidal (Killing oneself) case, the doctor may or may not inform the police at his own discretion.
  • If the case was a homicidal (Murder) one, he should treat the patient and simultaneously intimate the police.
  • He should also take due care that another attempt can be made on the victim.
  • Thus, He should take into confidence a nurse or a confidante relative, and should allow food made by the nurse or the relative only.
  • The patient should be isolated and strangers should not be allowed to visit the patient.
  • The first stomach wash along with vomitus, clothes soiled with vomitus or bedsheet soiled with the vomitus should be wrapped and sent to the chemical analyzer.
  • If visits the patient at the scene of crime, should check out for any empty bottle, pills or food remnants near the bed side or the lying patient; collect and send it for Chemical Analyser.

If the patient is dead, in case of autopsy, the following viscera is preserved and sent to the chemical analyzer: (Selection of viscera for Chemical analysis)
  • Since many poisons are ingested and after absorption pass through liver and spleen, and are excreted through the kidneys in the urine, the following material should be routinely preserved in all cases, irrespective of the nature of poison.
  • Whole Stomach with 300ml of stomach contents.
  • Small intestines 100cms in adults, 200cms in children and whole in infants, preferably tied at short lengths.
  • Small intestine contents 100ml. If less, whole quantity.
  • (500 gms ) Part of liver and gall bladder and its contents.
  • Blood about 5-10ml preferably in a plain bulb from the veins.
  • Urine sample 100-200ml if present, or soiled cloth of urine.
  • Spleen half in adults and whole in children.
  • Half of each kidney and both kidneys in children.
  • Brain taken only in cases of Neurotic poisonings.
  • Spinal cord only in case of Neurotic Poisonings.
  • Skin about ½ x ½ inch only in case of snake poisoning.(100gms)
  • Muscle tissue bit near the site of bite only in snake bite or scorpion bite.

These samples are preserved, noted down, numbered and marked off; packed with labels and duly sent to the Chemical analyzer in the FSL.
The Post mortem preliminary report is given with a final report pending after the Chemical analysis. A Copy of the P. M. report is enclosed for the perusal of the analyzer.


















SICKNESS / FITNESS CERTIFICATE

The Sickness or Fitness certificate issued by a Registered medical Practitioner is significant in cases of
  • Leave or Sickness Leave authenticity in employee’s organization.
  • Sickness absenteeism.
  • Attendance of court of law as a witness or any important business meets.
  • In cases of accident or injuries causing temporary total disability.
  • Fitness certificate is crucial in employee’s handling critical job profiles. E.g. a bus driver suffering from color blindness.
  • Recruitment of personnel in Military: e.g. Fitness of a person contesting for Air Force Officer or a pilot.


SICKNESS CERTIFICATE.


Name: Ms. Pallak Shah; Age: 26yrs. Dated: 13/3/04.
Signature of the Patient: XYZ.

This is to certify that Ms. Palak Shah was suffering from Malaria since 12/3/04 to 15/3/04. She is fit to resume her duties from 16/3/04.

Signature: Dr. Sonal Gandhi.
Registration No: 60548.







FITNESS CERTIFICATE.


Name: Mr. Sudip Sen, Age: 25yrs. Dated: 12/3/04.
Signature of the Patient: MNO.

This is to certify in that Mr. Sudip Sen, 25year old male has been completely examined by me and is found to be medically fit to join the Air force. His vitals along with systemic examination were without any clinical findings.

Signature: Dr. Sonal Gandhi.
Registration No: 60548.














DEATH CERTIFICATE


DEATH: is defined as a complete irreversible cessation of important functions as to respiration, cardiac circulation & brain functions. A continuous plain irreversible ECG till 5 minutes is clinically considered to be dead.

Any registered Medical practitioner can issue death Certificate. In a hospital set up, the treating physician issues the certificate. It is issued only when the death is natural & without any suspicion. In case of a suspicion as to suicide or homicide or a case of poisoning, the RMP informs the police and an FIR is lodged along with Post mortem authorization to ascertain the cause of death & any foul play involved. Issuance of Death certificate signifies that there was no doubt of foul play & the person died a natural death. According to Births & Death Registration Act, Death should be registered. Only after getting a Death certificate, a relative of the demised can take custody of the body & take for burial.

Any Death Certificate has the name, age, and sex heading, with complete address of the deceased. Important aspects of the certificate, the cause of death; any morbid or immediate cause of death; and any other morbid cause that is unrelated to the death.
If a female, Pregnancy related death inclusion is a must along with the immediate cause.

Death Certificate is a Standard format prepared by WHO & is statistically very important. Death certificates not only give data as to the common causes of death among various age groups & sexes of the country but also are an indicator of the health services efficiency in a country. The data is used to study & plan for betterment of the health services of a country. Also it has academic significance by way of retrospective or prospective studies of diseases, Prevalence & their etiologies.
Example:



INJURY CERTIFICATE

  • The certificate is issued when a police officer with a FIR report brings a victim/ an accused for examination of his wounds in cases of offence.
  • Besides his age sex, name and address and date and time details,
  • Two identification marks superficially seen on the body should be written. Along with confirmation from the police officer of the identification of the accused or victim is confirmed.
  • After getting the consent of the victim duly signed, the examination of wounds or injuries is carried out.
  • History of the victim or accused noted as per the statement given.
  • Injury/ Injuries noted in serial order, with the site, type of wound length and depth, along with the type of weapon causing the injury, grievous or simple with homicidal, suicidal, defence or fabricated wound opinion.
  • The final opinion given duly signed by the medical officer.
  • A copy of it handed over to the police, another retained by himself and a third sent to the executive magistrate.
  • The significance of the injury certificate is:
  • In cases of assault or battery, becomes documentary evidence by a skilled witness. Here, the skilled witness is the doctor.
  • It helps in justice by proving a person guilty or innocent based upon the facts at time of injury.
  • If the injury was accidental, homicidal; or suicidal.
  • If grievous injury, can get compensation from the accused.









THE MEDICO-LEGAL AUTOPSY

AUTOPSY LITERALLY MEANS “AUTO” IS “TO CUT OPEN” AND “OPIS” IS TO “SEE/VIEW”.

A medicolegal autopsy or postmortem examination is a special type of scientific examination of a dead body carried out under the laws of the state for the protection of its citizens and to assist the identification and prosecution of the guilty.

The objects of a medicolegal autopsy are:
1. Identification of the person
2. Determining the cause of death, whether natural or unnatural, if   unnatural whether suicide, accident or homicide, and if homicide,   any trace of evidence of the accused.
3.Determining time since death.
4. In newborns determining the question of live birth and viability of  a child.
5. Determining whether mutilated or skeletal remains are human and   if human probable case & time of death.
  • An unnatural and sudden Death, with a suspicion for foul play,is an Executive Magistrate’s case, a legal case, if it is unexpected, Sudden & unnatural or if there is any possibility that a law has been broken. Not every death that occurs outside a hospital is an executive’s case.
  • If the deceased had a physician who is reasonably certain of the cause of death and is willing to sign a death certificate, further medical examination may not be required.
  • The time of death or the angle of gunfire may determine whether the person committed suicide or was murdered.
  • The percentage of deaths that are autopsied has been falling for many years. Autopsies benefit society by providing information about hidden pathologies and about the accuracy of medical diagnoses.
  • But they do not benefit the patient, and physicians who do not want the accuracy of their diagnoses challenged sometimes oppose them.
  • Because of these factors, there is little money available to pay for autopsies.
  • Even when it is feasible to do an autopsy, many physicians do not know how to obtain CONSENT.
  • Physicians should be familiar with the state law in their jurisdictions governing the persons who may consent to an autopsy.
  • If there is any question of criminal activity, the autopsy may be ordered by a court, an Executive Magistrate.
AIM: The purposes and administrative aspects of death investigation are dealt with in the lecture notes on Death Investigation. Here, the practical aspects will be considered.
The aims of death investigation are to answer the following questions:
These are the 5 wise men that pave way to all puzzles.
  • Who died? (identification of the deceased)
  • Where? (place of death)
  • When? (time of death)
  • Why? (cause of death)
  • How? (manner & mechanism of death)
  • Autopsy is only one part of death investigation.

BODY, HISTORY AND SCENE are equally important (diagnostic triangle).
Each of the three aspects of the death investigation process are equally important (like a three legged stool, which will fall over if one leg is removed or even shortened!)

SCENE:
  • Attendance by police officers, CID, family doctor, police surgeon, forensic pathologist, forensic scientists.
  • The aim is to collect the maximum of information with the minimum of disturbance.
  • Potential for professional conflicts.
  • Photography, videos, trace evidence.

HISTORY:

  • Social - from relatives, friends, police.
  • Medical - from General Physician, hospital notes. Often indicates the likely cause of death
  • Psychiatric - from General Physician, hospital notes. May indicate possibility of suicide.

THE MEDICO-LEGAL AUTOPSY:

  • Purpose: - What happened? To Who, When, Where, Why, and How.
  • Technique: - The external examination assumes much greater importance, special dissection techniques and examinations, evidential materials, report formulation or commentary.

AUTOPSY AUTHORITY:
Instruction/consent for autopsy is derived from a law officer having jurisdiction, i.e. the Executive Magistrate.
Authority for autopsy is permanently recorded: how received, from whom, and when:
1. Two doctor case if legal proceedings likely {homicide (murder) , road accident}.
2. One doctor examination in most non-suspicious cases (accident, suicide).
3. Autopsy or external examination only (death obviously natural) at the discretion of the pathologist.
IDENTIFICATION OF DECEDENT:
The body must be identified to the Pathologist as the decedent for whom autopsy authority has been given. Identification in 2 doctor autopsies is performed in front of the 2 doctors performing the autopsy.
Initial (provisional) identification may be:
  • Visual (relatives),
  • Circumstantial (address, car, papers, cards, keys, clothes),
  • Medical (scars, teeth, x-rays, DNA).
  • Permanent record is made of the method of formal identification:
  • personal (name, title, address),
  • body tag (record all details),
  • Accompanying documentation.

PERSONAL EFFECTS AND CLOTHING:

  • The examination of personal effects and clothing is an integral part of the medico-legal autopsy providing information on life style, events leading to death, and often the actual cause of death.
  • List of jewelry, valuables, and personal effects.
    Listed description of the clothing: - type of garment, color, fabric type, location, if disarranged, wet/moist/dry, stains (blood, vomit, feces, urine, semen, dirt, oil, soot, etc.), damage (holes, cuts, and tears).
  • Clothing findings are correlated with historical and scene information, e.g. appropriateness of clothing, source of stains, trace materials.
  • Clothing findings must also be correlated with other autopsy data, e.g. injuries, source of bloodstains.

IN A MEDICOLEGAL AUTOPSY THE FOLLOWING POINTS ARE NOTED ON EXTERNAL EXAMINATION

  • Identification data
  • Clothing and whole body examined to find evidence pointing to   cause of death
  • Photographs or sketches of evidence found on examination
  • Data that indicates time since death

EXTERNAL EXAMINATION:

  • This is a detailed head to toe examination of the naked body, documenting stains and soiling, general and specific individualising characteristics, post-mortem changes {temperature, lividity (post mortem staining of the body), rigor mortis ( Contarction of the muscles of the body), and putrefaction (decomposition changes in body), cadaveric spasm}
  • The location, extent and type of staining or soiling of the body are described e.g. dual flow pattern of blood from a wound, high velocity impact blood spatter from gunshot wound, coffee grounds vomitus and melaena (reddish black stools /black stools)(upper gastrointestinal hemorrhage), antiseptic from medical intervention.
  • General body characteristics are recorded, namely:-
  • Racial group, height, weight, head hair (colour, dyed, length, style, balding),
  • eyes (colour, pupil size, conjunctival congestion or petechial haemorrhages, jaundice, prosthesis),
  • nose and ear canals (blood, pus), earlobes (piercing, earlobe creases), face (hirsute woman, clean shaven, beard, moustache),
  • mouth (vomit, blood, tablet debris, teeth, dentures), breasts (normally developed, atrophic, hirsute),
  • Genitalia (pubic hair pattern, circumcised, palpable testes), feet (general hygiene, bunions, ingrowing nails).
  • More specific identifying characteristics are described fully: tattoos (location, design, colour, names), scars (surgical and non-surgical, needle tracks, striae), skin lesions (naevi, senile keratoses, other skin diseases), prosthesis, pacemaker.
  • Post-mortem changes are documented, namely: - body temperature to touch (alternatively state if the body has been refrigerated), rigor mortis (extent and degree), hypostatic lividity (distribution, dual pattern, color, contact pallor), putrefactive changes.

INJURIES (EVIDENCE OF INJURY):
All injuries are described systematically either by grouping them according to anatomical location, e.g. right arm, anterior chest, left leg (as in multiple injuries in vehicular collisions), or in numerical order (e.g. where the number of injuries is few or where each and every injury is particularly important as in multiple stab wounds).
If numbered, it is stated that the order of numbering does not imply sequence of infliction or degree of severity.

INJURIES ARE DESCRIBED AS TO THEIR TYPE, e.g. bruise, abrasion, laceration, incised wound, puncture or stab wound, gunshot wound, burn, fracture.
  • Injuries should be described with regard to their location, size, shape and colour.
  • The location of the wound is given by general description (e.g. on the left side of the face, or over the rib cage, immediately below the left breast) and by precise location in relation to fixed anatomical landmarks (analogous to latitude and longitude).
  • Suitable vertical landmarks are the heel, superior margin of the pubic symphysis, superior anterior iliac crest, supra-sternal notch, orbital ridge, and crown.
  • Suitable horizontal landmarks are any midline structures, e.g. umbilicus, midline of the sternum and glabella.
  • The size of an injury is measured in two dimensions.
  • The shape can be related to a geometric shape or common object, often supplemented with drawings, sketches or by tracing patterned injuries onto acetate sheets.
  • Internal injuries are described in continuity with the related externally apparent injuries, e.g. the bruising and abrasion to the chest, then the fractured ribs, then the lacerated lung and haemothorax.
  • This organisation of the final report frequently does not correspond with the order of dissection and dictation of findings.
  • In the final report remote injuries are segregated from recent injuries under separate subheadings.

SIGNS OF MEDICAL INTERVENTION:
  • Medical intervention is described under a separate heading.
  • This includes all medical equipment attached to, or accompanying, the body, e.g. urinary catheter, endotracheal tube, oral airway, rods for external fixation of fractures, arterial and intravenous lines, intravenous solutions or blood (with details of contents).
  • External surgical incisions are described in continuity with the internal evidence of surgery.

INTERNAL EXAMINATION:
  • After a detailed external examination of the body is done, the three major cavities of the body, viz. skill, thorax (chest) and abdomen are opened and examined.
  • All parts of the body are examined and dissected in detail.
  • The internal examination is systematic description of natural disease and does not include recent injuries, all of which have been previously described under the appropriate heading.
  • A Systematic examination of the various organs & systems of the body is done.

THE HEAD: is opened if accidental or sudden death cause unknown.
  • Head is opened from mastoid to mastoid process by a saw.
  • The skull cut down & brain removed & cut in transverse sections at various levels of the brain and the injuries or blood clot or hemorrhages noted.
  • Extra dural, Subarachnoid, Sub dural hemorrhages can be seen if head injury present. Pathological findings if any are also noted.
  • Tubercular meningeal or edematous changes or congestion may give clues as to nature of disease or injury.

THE THORAX:
  • Chest is opened by an incision from the mid sternum to the xiphisternum.
  • Lungs & heart along with their coverings, the pleurae & the pericardium respectively are checked for any pathology or injury.
  • If any rib fracture noted or not. If haemothorax or pericardial effusion noted.
  • Heart & lungs are dissected separately to see for any pathology or injury.
  • Mainly congestion with or without petechial hemorrhages or pale organs is findings worth noting.
  • These give a clue as to the immediate cause of death. Special importance’s given to lungs & heart in case of drowning, asphyxial deaths like strangulation, hanging, etc.

THE ABDOMEN:
  • Opened up from xiphisternum to pubic symphysis.
  • The stomach & its contents, liver, gall bladder & pancreas are note.
  • Kidney along with spleen is cut open for any injury, congestion or pathological changes.
  • The contents in stomach & intestines tell the time since death.
(P.S.: - The contents of the stomach t6aken in case of ingestional poisoning)

THE SPINAL CORD:
  • The vertebral column is left intact except in cases of neurotic poisonings or neurological pathologies.
  • Negative observations are included, e.g. no pulmonary thrombo-emboli, no significant coronary artery atherosclerosis, no skull fracture, etc.

OTHER EXAMINATIONS:
  • Any special dissections, e.g. neck dissection, or further examination of organs e.g. brain after formalin fixation, together with microscopic, biochemical, and toxicological studies should be described at this point.
  • When naked eye examination fails to determine the cause of death, appropriate samples are taken for laboratory tests and chemical analysis.
  • In cases of suspected poisoning the following things are preserved for further study - whole stomach, 300 ml of stomach contents, part of small intestine, 100 ml of small intestine contents, liver spleen, kidneys, 200 ml of urine and 10 ml or more of blood.
  • In special cases brain, cerebrospinal fluid, blood from the heart, skin, female genital organs, bone marrow lungs, bones, scalp hair, nails, or fatty tissue may also be preserved.
  • After examination is over body is sutured and handed over to police. The history of the case, and visit to the scene of crime can help in arriving at a proper cause of death and manner of death, whether natural, suicide accident or homicide.

CAUSE OF DEATH:
  • The disease process or injuries responsible for initiating the train of events, brief or prolonged, which produces the fatal end result.
  • Mechanism of death: the physiological or biochemical derangement produced by the above cause, which is incompatible with life; i.e. how the disease or injury leads to death
  • Manner of death: the fashion in which the cause of death came into being; i.e. whether natural, accident, suicide, homicide, unclassified (alcohol/drug deaths) or undetermined

Cause
Mechanism
Manner
Atherosclerotic coronary
artery disease
Electrical arrhythmia
or heart failure
Natural
Stab wounds
Internal or external blood loss
Homicide, Suicide or Accident
Stab wounds
Internal or external blood loss
Homicide, Suicide or Accident
Hanging
Asphyxia
Suicide
Strangulation
Asphyxia
Homicide

OPINION (CONCLUSION OR COMMENTARY):

  • This section is interpretative and subjective, It includes the cause of death as appearing on the death certificate.
  • The commentary is in simple English and brings together all the relevant information obtained from examination of the body, the scene of death and the history of the decedent.
  • Information obtained second-hand (hearsay) may be included e.g. from police reports, medical records, fire investigation reports.
  • The relevant issues are addresses i.e. what happened, to whom, when, where, why and how.
  • It may be as brief or as detailed as the need dictates It is directed to the law officer investigating the death and any other legally interested parties who may obtain access to the report subsequently.

SIGNATURE:

  • All medico-legal reports require the original signature of the author. Relevant degrees and other qualifications are given. Occupational titles, e.g. Lecturer in Pathology, Head of Dept. forensic Medicine, Police Surgeon, etc. may be included.
  • A copy of it handed over to the police, another retained by himself and a third sent to the executive magistrate.


















CHAPTER No: 11.

DISABILITIES:

TEMPORARY TOTAL DISABILITY: For a temporary period of time, the patient will be totally disabled. E.g.: Fractures.
TEMPORARY PARTIAL DISABILITY: For a temporary period of time, the patient will be partially disabled from performing usual functions.
PERMANENT PARTIAL DISABILITY: Person is partially able to perform usual activities, but is not expected to ever be completely able to perform his pre injury activities.
A permanent partial disability which results from an accidental bodily Injury to an Insured Person which will probably continue for the rest of their life and certified to that effect by a competent and qualified Physician as appointed by Us. (As per policy wordings)
PERMANENT TOTAL DISABILITY: Patient will never be able to perform his pre- injury vocation.
IMPAIRMENT: Medical factor which is included as part of the disability evaluation. Any abnormality, which remains after the treatment, is concluded and which is not expected to improve.

DISABILITY


When we say a person is disabled, we mean that the person has lost all or some ability to use a part of the body in the same manner as in the past. This use may involve employment as well as other activities. Disabilities are classified as one of the four types:
  • Temporary Total disability.
  • Temporary partial Disability.
  • Permanent partial disability.
  • Permanent Total Disability.

TEMPORARY TOTAL DISABILITY: A temporary total disability means that, for a period of time, the patient will be totally unable to perform any activity, either at work or anywhere else. Temporary Total Disability usually refers to the disability during the recovery period after an accident.E.g. Any fracture of one of the limb bones causes a Temporary total disability for around 4-6 months.

TEMPORARY PARTIAL DISABILITY: With a Temporary partial disability, the patient is, for a temporary period, only partially able to perform usual activities; however, it is expected that the patient will eventually be completely able to perform these activities. This disability classification usually applies to the patient’s occupation. For example, a waiter fractures his radius; while in cast he can perform all his usual duties except carrying a tray. So the disability is Temporary & partial. In addition, he might be only partially able to perform his usual personal activities, such as driving or cleaning his house.

PERMANENT PARTIAL DISABILITY: This type of disability is often found in the lawsuits. This means a person is partially able to perform his usual activities, but is not expected to ever be completely able to resume pre-injury activities. Permanent Partial disability usually involves a patient’s job but not always. For Example, Ten months after his leg is broken, Fred was back at work as a truck mechanic. However, his job duties are limited because his leg permanently lost its mobility and he is no longer able to work underneath the trucks.

PERMANENT TOTAL DISABILITY: In this type of Disability the patient will never be able to perform his or her pre-injury vocation. This type of disability might also involve activities in other areas of the person’s life in addition pursuing a livelihood. An injury that results in a permanent total disability must be extremely severe and will probably involve several parts of the body. Example: a brain surgeon whose fingers are permanently immobilized.

The Civil Surgeon issues a disability certificate after thorough examination of the type and extent of disability caused. The disability certificate is of great significance in Reservation of the Physically disabled for employment and the benefits available to them thereunder.


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