Introduction of Forensic medicine | Branches |Aim | Medical jurisprudence | Bioinformatics| Short notes| Viva | MCQ | PDF|

FORENSIC MEDICINE

 INTRODUCTION: -

Medicine & law have been related from the earliest times & the bonds which united them were religion, superstition & magic. Law medicine problems were found in the written records in Egypt, Sumer, Babylon, India & China dating back 4000 to 3000 B.C. A Chinese Materia medica of about 3000 B.C. gives information on poisons. Imhotep (27th century B.C.), Grand Vizir, Chief Justice & chief physician of King Zoser of Egypt, enacted rules for medical practice, which was brought under law. The code of Hammurabi, King of Babylon (about 2200 B.C.), is the oldest known medico-legal code. In fourth century, B.C., Manu (King & lawgiver) in his treatise, Manusmriti, laid down various laws including punishment for various sexual offences, & recognized mental incapacity due to intoxication, illness & age. Hippocrates (460 to 377 B.C.), the "Father of Western Medicine" was born & practiced in the island of Kos in Greece, discussed the lethality of wounds. His contribution to medical ethics is by far greatest in our field. Later, Greek & Roman jurists & medical men collaborated in the development of the principles of forensic medicine. In the sixth century A.D. the Justinian Code (Roman emperor) & Institutes regulated the practice of medicine & surgery & established the function of the medical expert for legal procedure. The first medico-legal autopsy was done in Bologna (Italy) in 1302, by Barolomeo De Varignana. In the thirteenth century, a manual was prepared to aid in the investigation of death in China. The 'Constitutio Criminalis Carolina', published in Germany in 1532, recognized that there were several types of homicide which were not punishable under certain conditions, one of which was an offender who was 'deprived of his understanding.' The first book on Forensic Medicine was published in 1602 by an Italian physician, Fortunato Fedele. The greatest of all works was the "Questions Medico-legalis", written by Paulus Zacchias, who was principal physician to Pope Innocent X, & Alexander VII, & an expert before the Rota Romana, the Court of Appeal. This was published in seven volumes from 1621 to 1635 & two additional volumes in 1666, at Amsterdam. Paulus Zacchias is considered the Father of Legal Medicine as well as Father of Forensic Psychiatry. Around the end of the sixteenth century, autopsies in medico-legal cases began to be generally practiced. In the eighteenth century, professorships in legal medicine were founded by the State in Germany. Orfila (1787 to 1853), professor of chemistry & legal medicine at Paris introduced precise chemical methods into toxicology. He is considered the founder of modern toxicology. 

👉What is Forensic Medicine And its branches

Forensic"- Forums of or used in Courts of law 

Forensic medicine may be defined as the branch of science, which embraces all those aspects of medical science including its fundamental, e.g. physical, chemical or biological principles as well as its specialties such as forensic toxicology, or forensic pathology and participate in partnership with the process of law both civil & criminal. 

Or, 

Forensic medicine or legal medicine is the branch of science which deals with the application of medical & paramedical knowledge to aid in the administration of justice. It is used by the legal authorities for the solution of legal problems. In short, it deals with medical aspects of law. 

Or, 

Forensic medicine relates to application of medical knowledge for dispensation of justice in a court of law.

👉Branches of Forensic medicine: - 

1. Forensic pathology: Deals with the study & application of pathological principles in determining the cause & manner of death
2. Forensic toxicology: Deals with the comprehensive study of poisons.
3. Forensic odontology: Deals with the medico-legal aspects of study of teeth.
4. Forensic gynecology & obstetrics: Deals with the gynecological & obstetrical principles in relation to the law of forensic medicine.
5. Forensic psychiatry: It deals with the psychiatric aspects of law in relation to the law of forensic medicine.
6. Forensic chemistry: Deals with the application of chemistry in forensic science.
7. Forensic haematology: Deals with the study of blood & blood products in relation to law.
8. Forensic serology: Deals with the various activity & antigen-antibody reaction in relation to the forensic science.
9. Forensic anthropology: Deals with the origin & development of human being.
10. Forensic anthropometry: Deals with the measurement of different parts of the body in relation to the forensic science.
11. Forensic radiology and Imaging: Deals with the determination of age & foreign particle in relation to the crime & criminal.
12. Medical ethics: Deals with the character, behavior & activities of persons related with medical profession or death.
13. Forensic dactylography: Deals with the fingerprint system for identification of the individual.
14. Forensic thanatology: Deals with the medical & legal aspects of death.
15. Forensic cytogenetics: Deals with the study of genetics of cells in relation to law.
16. Forensic ballistics: Deals with the investigation of firearms, ammunition & the problems arising from their use.
17. Forensic osteology: Deals with the study of bones.
18. Clinical forensic medicine
19. Forensic cyber technology.
20. Forensic osteology.

👉Aim & Objective of Forensic medicine: -

• Application of medical & paramedical knowledge to aid in the administration of justice.
• Solution of legal problems by legal authorities. Some examples are: Applying the medical knowledge in deciding cases of injuries, murder, suicide, accidents, sexual offences, poisoning, etc. 
• Ethical aspect of medical science 
• Legal aspect of medical science

👉 Doctors of all categories should have a fair knowledge about forensic medicine for the following reasons: 

• For professional safeguard: Fair knowledge of forensic medicine helps a doctor to safeguard himself from some legal problems arising during the treatment of victims of criminal act, like a patient of stab injury, during performing criminal abortion, during treating a poisonous case.
• For giving opinions in court of law: A doctor may be asked by the court for his opinion on matter of science as an expert. Forensic medicine helps them in such cases.
• To know about the code of conduct: By knowing forensic medicine a medical man comes to know his own code of conduct that is what to do & what not to do. 

👉Scopes/Uses of forensic medicine: 

1. Application of medical & paramedical knowledge in legal matters, both in civil & criminal cases.
2. Helps in investigation of sudden, unexpected, suspicious or frankly criminal deaths. 
3. Examination of various trauma, injury, dead body, etc. & giving medico-legal opinion regarding the cause & nature of injuries & death.
4. Identification of person by different examinations using medical knowledge & thus helps in crime investigations. 

👉Requirements of medico-legal practice: 

Medico-legal practice requires knowledge, skills & attitude. The skills needed are: 

1. Clinical: The ability to elicit a history, to examine for injuries & to perform the appropriate investigations.
2. Precision in recording the findings. 
3. The ability to present the findings in a clear, concise, correct & meaningful manner.
4. Attitude: (a)Proper respect to the patient.

                  (b)Maintain objectivity in recording the findings.

  MEDICAL JURISPRUDENCE

  "Juris "- Law & "Prudentia"-Knowledge. 

Medical jurisprudence may be defined as the science, concerned with the legal responsibilities of the physician with particular reference to those arising from physician-patient relationship, such as medical negligence cases, consent, rights & duties of doctors, serious professional misconduct, medical ethics, etc. In short, it deals with legal aspects of practice of medicine.

Or. 

Medical jurisprudence may be defined as the science, concerned with the application of rules & regulations for the guidance of medical profession. It deals with those relationships which are generally recognized as having legal consequences, e.g.,

1. Doctor-patient relationship. 
2. Doctor-doctor relationship.
3. Doctor-state relationship.

👉Role of medical jurisprudence during practice of medicine: 

Medical jurisprudence deals with the legal responsibilities of the physician with particular reference to those arising from the doctor-patient relationship, doctor-doctor relationship & door-state relationship, such as- 

• Medical negligence cases. 
• Consent, rights & duties of doctor 
• Serious professional misconduct, medical ethics volante
• It is the subject conducted with knowledge & law of the practice of medicine.

👉Role of anatomy over forensic medicine: 

1. Autopsy: Anatomical knowledge is must to perform the medico-legal autopsy.
2. Toxicology: Preservation of different viscera is essential & helpful to identify the poisonous agent.
3. Identification: Knowledge of anatomy is essential to identify the persons of different races.

👉Different between Forensic medicine & Medical jurisprudence: -

Different between forensic medicine & medical jurisprudence

Short notes

💥Forensic Radiology: -

Forensic radiology may be defined as the branch of forensic medicine which deals with the X- ray examinations, USG, CT, MRI etc for various legal purposes. 

Uses/Role: It is used in- 

• Determining the age, sex, race & stature of a person.
• Diagnosis of pregnancy (Detection of fetus in the uterus).
• Detection of foreign body (bullet) in the body. 
• Diagnosis of live birth. 
• Examination of bone fracture, e.g., In head injury, dislocation of joints.
• It is done in some autopsies (Virtual autopsies). 
• Homicidal cases. 

💥Forensic Pathology: -

Forensic pathology is the branch of forensic medicine which deals with the study & application of the effects of violence or unnatural diseases in its various forms in or on the human body, in determining the cause & manner of death in case of violence, suspicious, unexplained, unexpected, sudden & medically unattended deaths.

Or.

Forensic medicine is the branch of forensic medicine which deals with the study & application of pathological principles in determining the cause and manner of death for medico-legal purposes.

 

Uses: It deals with- 

1. Interpretation of autopsy findings in a medico-legal investigation of deaths! 1910.
2. Study & application of the effects of violence & unnatural diseases on human body.
3. Determination of cause of death & manner of death in unnatural, suspicious, unexplained, unexpected, sudden & medically unattended death. 

💥Clinical forensic medicine (CFM): 

CFM is is the branch of forensic medicine which deals with those who are still alive and on whom a medico-legal opinion is required. It is the interaction of clinical medicine and the law. 

Or.

Clinical Forensic Medicine (CFM) is a medical specialty which deals with the interaction of clinical medicine and the law. 

Or.

It deals with those who are still livened on whom a medico-legal opinions required. This includes those who have been traumatized physically and/or sexually, but who have not succumbed to their injuries, those who are under the influence of alcohol and/or drugs in relation to such matters as driving, human rights abuse etc.

Or. 

Clinical Forensic Medicine is that area of medical practice whereby medicine and law overlaps.

Scopes of CFM: -

• It deals physical trauma, sexual assault, pregnancy, abortion, delivery, age dispute. 
• It deals traffic medicine 

(i) Influence of Alcohol and/or drugs in relation to such matters as driving, human right abuse. (ii) fitness to drive 

(iii) Medical aspects of crash analysis 

• It deals Custodial medicine, i.e. 

(i) examine the treatment of police detainees. 

(ii) fitness for interview assessments of police detainers. 

💥Forensic Thanatology: -

"Thanatos" (Greek word) -Death

"Logia" (Greek word) -Speaking

Forensic thanatology is the branch of forensic medicine which deals with the scientific study of death, types of death, the various events or changes that occur in the cadaver & their medico-legal significance. 

Or.

Forensic thanatology is the branch of forensic medicine which deals with all legal & medical aspects of death.

💥Medical etiquette: -

Medical etiquette means the sense of courtesy & respect which should govern the conduct & relationship between the members of medical profession.

Or.

Medical etiquette deals with the conventional laws of courtesy observed between members of the medical profession. Ethical behavior is a self-imposed duty upon each doctor.

Example: -  

1. A doctor should behave with his colleagues as he would have them behave wih himself.
2. A doctors should not criticize or denigrate the professional ability of another doctor, while dealing with a patient. 

💥Bioinformatics: -

Bioinformatics is a field of study that uses computation to extract knowledge from biological data. It includes the collection, storage, retrieval, manipulation and modeling of data for analysis, visualization or prediction through the development of algorithm and software. 

Function: -

1. DNA sequencing 
2. Genome annotation 
3. Genetics of disease
4. Analysis of gene expression 

Viva Question 

1. What do you mean by forensic medicine?
2. What do you mean by forensic dactylography?
3. What do you mean by forensic anthropometry?
4. What is the role of medical jurisprudence during practice of medicine? 
5. What is bioinformatics?

Multiple choice Question (MCQ)

𝙌Branches of forensic medicine- 

a. Forensic odontology (T)

b. Forensic hematology (F)

c. Forensic serography (F)

d. Forensic chromatography (F)

e. Forensic obstetrics (T)

𝙌 Forensic medicine deals with- a. Legal aspects of practice of medicine (T) b. medical aspects of law (F) c. Investigation of law (F)

d. Post-mortem examination (T) e. Solution of legal problems (T)

𝙌First ML autopsy performed in:

a. Italy (T)

b. France (F) c. Denmark (F)

d. Japan (F

e. Sweden (F)

𝙌Clinical forensic medicine deals To detect foreign body (T) a. Post-mortem examination (F)

b. Rape case examination (T) c. Injury patient examination (T) d. Chemical analysis (F) e. Age determination (F)

𝙌Forensic medicine deals with: -

a. Legal aspect of medical practice. (T)

b. medical aspect of law. (F)

c. Investigations of law (F)

d. PM examination. (T)

e. Used for solution of legal problem. (T)

💥Reference: -

⟥Reddy 35th 1, Nandy 3rd- 1

Q F

Blood: plasma and formed element

 Blood 

Blood performs several vital functions of the blood; hence it has been frequently referred to as the seat of the soul. It distributes nutrients, oxygen, detoxicating compounds, and maintains a uniforms body temperature. It is a carrier of hormones which control and integrate the activities of the various organs. It conveys antibodies and cells that protect the body from invading pathogens and also transport drugs administered to the body so that they may produce their therapeutic effects on specific sites of ailment. 

The blood also collects the waste material generated by the body's metabolic activities. The blood can carry out its functions efficiently only if it is kept circulating in the body. This is affected by the heart which acts as a pump, and an intricate system of distributing pipes the blood vessels, viz, arteries, veins and capillaries. The heart and the blood vessels together form the cardio-vascular system.

Blood as a fluid Tissue: -

In human beings there is about 90 ml of blood per kilogram of body weight. However, this volume depends on the age and health of the Individual. Blood has a specific gravity of 1.05 to 1.06, and a pH of 7.4. It is made up of a fluid matrix called Plasma, and several types of cells termed formed elements. These two components separate when blood is centrifuged. The plasma forms 54% of the blood volume and the cells 45%. The latter is reffered to as the hematocrit or packed cell volume(PCV). The plasma contains many inorganic and organic substances. The formed elements consist of red blood cells(RBC) or erythrocytes, white blood cells(WBC) or leucocytes, and platelets or thrombocytes.

PLASMA

Blood plasma is the straw colored fluid obtained when all formed element are removed from blood. The ratio of plasma to formed elements is held relatively constant by the homeostatic controls of the body. The plasma contains inorganic salts with a dominance of chloride (Cl), sodium (Na+), and calcium (Ca++) ions, and lesser quantities of potassium(K+) and magnesium (Mg++) ions. Smaller concentrations of bicarbonate, sulphate, and phosphate, and traces of iron, copper, and iodine are also present.

The Plasma also contain glucose which is used as a principal energy source in cellular metabolism. A variety of other substances, such as amino acid, vitamins, lipids (neutral fats and cholesterol), hormones, urea, uric acid, and other metabolite waste produces are also present in the plasma. In addition, it contains dissolved oxygen, carbon dioxide, and nitrogen. Plasma also reflects certain abnormal conditions occurring in cells and tissue of the body. For example, within few hours following a heart attack, there is a noticeable increase in the level of the enzymes transaminase and lactic dehydrogenase in the plasma arising from the affected heart muscles. This has proved to be of significant value to a clinician is the diagnosis of heart attacks.

The plasma of a man contains about 70g proteins/L. Some of these proteins possess enzymic activity (e.g., phosphatases), While other function shows no activity at all. The function of the plasma proteins can be summarized as follow: -

1. Lipoproteins carry lipids and also transport lipid soluble vitamins and steroids hormones.
2. They are amphoteric compound because they act both as acids and bases. At the pH of human blood (pH- 7.4) proteins behave as acids and combines with cations such as Na+ and form a buffer, they are however, weak buffers.
3. Being macromolecules plasma proteins create a colloidal osmotic pressure in the blood which is higher than the colloidal osmotic pressure in the blood which is higher than the colloidal osmotic pressure in the interstitial fluid. This favors the passage of interstitial fluid into the plasma Finally (4) plasma, proteins, prothrombin and fibrinogen participate in blood clotting. 

FORMED ELEMENT 

The formed elements consist of the erythrocytes, leucocytes, and the thrombocytes.

ERYTHROCYTES: -

The red blood cells or erythrocytes are small (diameter: -7.5 in man and 9.0 in elephant) biconcave dices. Mammalian erythrocyte, except for the camel does mot possess a nucleus. In contrast, other vertebrates possess a nucleus. The erythrocytes are immobile and move with the flow of blood stream. The average concentration of erythrocytes is approximately 5000000/mm3 of blood in the adult human female. The erythrocytes are reddish in colour due to the presence of a respiratory pigment hemoglobin. Each erythrocyte contains an estimated 200 to 300 million molecules of hemoglobin. The latter serves to transport oxygen and, do some extent carbon dioxide, to and form the lungs. Hemoglobin is easily removed when the cell is broken (or lysed) by exposure to a hypotonic medium, or water. the resulting structure of the erythrocyte is called a "ghost" which consists of a network of protein and lipids.

The average life span of an erythrocyte in man is about 120days the old erythrocytes are continuously breaking down and new once are formed. The erythrocytes are destroyed by the phagocytic macrophages found in the reticulo-endothelial system (in bone marrow, spleen, liver, etc.). The porphyrin section of the hemoglobin is catabolized and formed bile pigment (bilirubin and biliverdin). However, most of the iron is retained in the bone marrow to be again incorporated into new erythrocytes.

LEUCOCYTES: -

The leucocytes are nucleated cells and are somewhat larger than the erythrocytes the white blood cells are also less abundant than the red blood cells. There are 5000 to 9000 leucocytes/mm3 of blood. An increase in the number of leucocytes above 10000/mm3 of blood is known as leukocytosis is caused by violent exercise, infection, hemorrhage, and a high protein diet. Leucopenia results from malnutrition, deficiency of vitamin B12, folic acid, and pyridoxine. 

The leucocytes are classified into granulocytes and agranulocytes depending on the presence or absence of granules in the cytoplasm.

Granulocytes are divided into three basic types, viz., neutrophils, eosinophils, and basophils. This classification of the granulocytes is based on the nuclear structure and affinity of the cytoplasmic granules to dyes (acid or base). In the neutrophils the cytoplasm is filled with fine uniformly distributed granules which do not show any affinity to either acid or basic dyes, and hence the name neutrophil. The nucleus is polymorphic divided unequally in 3-5 lobes and separated by deep indentations or by narrow strands of chromatin, therefore neutrophils are also referred to as polymorphocytes. These form 65-75% of the total leucocytes. The size of each neutrophil range from 10-12u. The eosinophils are loaded with granules which are relatively bigger in size than in the neutrophils. The granules show affinity to the acid dyes such as eosin the latter imparts them an intense red colour, and hence the name eosinophils. These are also referred to as acidophils. The nucleus is bilobed and the two lobes are connected by a thin stand of chromatin. The eosinophils form 2-4% of the total number of leucocytes. In the basophil, the cytoplasm takes an intense blue colored with basic dyes. The nucleus in the basophil is irregularly polymorphic. The basophils have the least representation in the total leucocyte count the normal percentage is only 0.15.

Agranulocytes are of two types, viz, lymphocytes and monocytes. The structure of the nucleus of agranulocytes is not polymorphic and is therefore, different form that of the granulocytes. Lymphocytes fall into two categories- small and large lymphocytes. The nucleus of the small lymphocyte is larger and it almost occupied the entire cell leaving only a peripheral cytoplasm, whereas the largest lymphocytes have relatively more cytoplasm. The lymphocytes form the second largest group of leucocytes; the small lymphocytes constitute about 25% and largest lymphocytes about 3% of the total leucocytes. The size of the small lymphocyte is about 7u, Whereas it is 10-12u in the large lymphocytes.

In monocytes the cytoplasm is more abundant in relation to the nucleus; the nucleus is ovoid, kidney shaped or with  many indentations. Moreover, characteristically, the nucleus is always placed eccentrically in the cells. The monocytes form 5-7% of total leucocytes. There size range from 10-15u. 

The average life span of leucocytes is two days. All leucocytes defend the body against invasion by microorganism which are engulfed and digested by the leucocytes by a process known as phagocytosis. Additionally, the lymphocytes form antibodies against proteinaceous matter gaining entry into the body. The relative ratio of the leucocytes changes during many diseases. This phenomenon is of great use to pathologists in diagnosis of diseases. For example, the concentration of eosinophils increases significantly during infection by worms, and in allergic conditions such as asthma and hay fever. 

Leukemia is very serious disorder of the body. This is a form of blood cancer and is characterized by an uncontrolled increase in the number of leucocytes (up to 1000000/mm3 of blood), with the appearance of immature forms in the blood stream. Leukemia is accompanied by anemia and is eventually fatal because the bone marrow cells that normally produce erythrocytes are displaced by leukemia cells. 

Thrombocytes or platelets: - In addition to the erythrocytes and the leucocytes, thrombocytes or platelets are another group of a formed the leucocytes, thrombocytes or platelets are another group of formed elements observed in the blood. These are small fragments (2-5u) of cells which lake nuclei, and function in blood clotting. They are oval in shape and have the capability of amoeboid movements. There are 250000 platelets/mm3  of blood. The life span of the thrombocytes is also very short perhaps only a few days in duration.