Forensic Medicine and Toxicology(FMT) - AIM4PG

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Forensic Medicine Notes

Management of Property and Affairs of mentally ill person: If any relative or friend of an alleged mentally ill person possessing property gives an application, the Court may direct inquiry whether the person is of unsound mind and incapable of managing his property and affairs. The medical evidence is given in the form of a certificate, which should state, "that unsoundness of mind is of such a degree as to make him incapable of managing his property and affairs". In case of doubt, it is safer to give an opinion in favour of sanity. If on inquiry, a person is found incapable of managing his property and affairs, but is not dangerous to himself or to others, the Court appoints a manager to look after his property, granting him necessary power. The Court may order the sale or disposal of the property of the mentally ill person for the payment of his debts and expenses. The Court may order a second inquiry, if it is reported that unsoundness of mind had ceased and will order all proceedings in the unsoundness of mind to cease, if it is satisfied that the unsoundness of mind has ceased.

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Discharge of a Mentally Ill Person : ( 1) Voluntary patients should be discharged within twenty-four hours of the receipt of request for discharge made by the patient or the guardian. (2) A mentally ill person who is admitted on an application by a relative or friend can himself, or a relative or friend can apply to the Magistrate for his discharge. The Magistrate after making an enquiry can either allow or dismiss the application. (3) The officer-in-charge of a psychiatric hospital can order in writing discharge of any inpatient (other than voluntary patient), on the recommendation of two medical practitioners, one of whom shall preferably be a psychiatrist. (4) A mentally ill person detained under Reception Order made on application, shall be discharged, if the person on whose application the admission order was made, applies in writing to the officer-in-charge. Such person cannot be discharged if the officer-in-charge certifies in writing that the person is dangerous. (5) If a person detained on Reception Order, is subsequently found by any judicial inquisition to be of sound mind, he is to be discharged.

Reception Order on Production of Mentally Ill Person Before Magistrate : (a) An officer-in-charge of a police station is authorised to arrest a wandering or dangerous mentally ill person, and produce him before a Magistrate. A wandering mentally ill person is one who wanders aimlessly, and a dangerous mentally ill person is one who because of his violent behaviour is dangerous to himself or others. The Magistrate must examine such person, send him to be examined by a medical officer, and make such inquiries as he thinks necessary, and if he is satisfied that such person is mentally ill, he may pass a Reception Order. If a relative or friend executes a bond for the proper care of the mentally ill person, the Magistrate may hand him over to the friend or relative. (b) An officer-in-charge of a police station, or any private person can report to a Magistrate, if he believes that any person is mentally ill, and is not kept under proper care and control, or that he is cruelly treated or neglected by any relative or guardian. The Magistrate may order to produce the mentally ill person before him and summon such relative or guardian. The Magistrate may make an order for the proper care and treatment of the mentally ill person. If there is no one who is legally bound to maintain the mentally ill person and even otherwise, the Magistrate may pass an order for the admission of the mentally ill person.

Admission to psychiatric hospital Reception Order on Application : The officer-in-charge of a psychiatric hospital can make an application to the Magistrate in case of a mentally ill person who is undergoing treatment under a temporary treatment order, if he is satisfied that (a) the treatment is required to be continued for more than six months, or (b) it is necessary in the interest of the health and personal safety of the mentally ill person, or for the protection of others. The husband or wife of the mentally ill person, or any other relative, can make an application in the prescribed form to the Magistrate. The applicant must be a major and must have personally seen the patient within fourteen days of the date of the application. Two medical certificates should be submitted, issued by two medical practitioners, who must have separately examined the patient within ten days of the presentation of the application. On the date fixed, the petition must be considered in private in the presence only of the petitioner, the alleged mentally ill person, a representative of the alleged mentally ill person, and such other persons as the Magistrate thinks should be present. If the Magistrate is satisfied that it is necessary to detain the alleged mentally ill person in a psychiatric hospital, he passes a Reception Order (order for admission and detention), which is valid for 30 days A certified copy of the Reception Order is sent to theofficer-in-charge of the psychiatric hospital.

RESTRAINT OF THE MENTALLY ILL PERSON Restraint may be: (1) Immediate, and (2) Admission to an asylum. (I) Immediate Restraint: This can be done in case of (1) mentally unsound person who is dangerous to himself or to others, or who is likely to injure or wastefully spend his property or that of others, (2) person suffering from delirium due to disease, and (3) delirium tremens. Immediate restraint is done under the personal care of attendants, e.g., by safely locking-up in a room. The consent of the lawful guardian of the mentally unsound person has to be taken, but if there is no time to take the consent and the insane person is dangerous to himself or to others, he can be immediately restrained. Such restaint is lawful only as long as the danger exists

THE MENTAL HEALTH ACT, 1987: It was enacted to consolidate and amend the law relating to the treatment and care of mentally ill persons, to make better provision with respect to their property and affairs, and for matters connected therewith. This Act repeals the Indian Lunacy Act, 1912. The Act has changed the following terms: (a) Psychiatric hospital is used instead of mental hospital, (b) Mentally ill person instead of lunatic, unsoundness of mind instead of insane. (c) Mentally ill prisoner instead of criminal lunatic. Some of the main provisions are: (1) "Mentally ill person" is defined as" a person who is in need of treatment by reason of any mental disorder other than mental retardation." (2) The Central Government and State Governments have to establish an Authority for Mental Health for regulation, development, direction and coordination with respect to Mental Health Services. (3) Establishment and maintenance of psychiatric hospitals or psychiatric nursing homes can be done only with licence, which has to be renewed every five years. The licence can be revoked if the hospital is not being maintained according to the provisions of the Act. If a mentally ill person is received or detained against the provisions of the Act, the punishment is imprisonment up to two years and also fine. (4) For every psychiatric hospital or nursing home, the Government should appoint not les than five visitors, of whom at least one should be a medical officer. Not less than three visitors shall make a joint inspection of hospital or nursing home at least once in every month, and examine every minor patient. and as far as possible all other mentally ill person and the order for the admission of, and the medical certificates, and shall enter their remarks in a book.

EPILEPTIC PSYCHOSIS : Short transitory fits ofuncontrollable mania occur. There is general impairment of the mental faculties with loss of memory and self-control. Auditory and visual hallucinations are followed by delusions of persecution. Moral sensibility is lost and sometimes they are dangerous to themselves and to others. There may be progressive dementia. (A) PRE-EPILEPTIC INSANITY : Instead of epileptic aura, the patient may occasionally develop violent fits of mania or extreme depression of mind. Hallucinations and delusions are common during this stage, and such persons may commit assault or other criminal acts. (B) POST-EPILEPTIC INSANITY : The stupor following epileptic fit is replaced by automatic acts, of which the patient has no recollection. The patient is confused and terrified by visual and auditory hallucinations and delusions of persecution, and may commit crimes like thefts, incendiarism, sexual assaults and murders. These crimes are involuntary, automatic and unpremeditated. The patient never attempts to conceal them at the time of committing, but may try to conceal them on regaining consciousness. Automatic action tends to be of the same type in each attack. The action is usually habitual, e.g., a man walks into a shop, picks up something and walks out again, afterwards being arrested for theft, or one who exposes himself in a public place and is arrested for indecent conduct; or a person cutting something may inflict incised wounds or kill a child; or a person accustomed to firearms may shoot somebody.

Locard's Exchange Principle: When any two objects come into contact, there is always a tran fer of material from each object on the other. Trace from the scene may be carried away on the person or tool of the criminal, and at the same time, traces from all or any of these may be left at the scene. Wherever a criminal goes, whatever he touches, and whatever he leaves will serve as silent evidence against him. e.g., fingerprints, footprints, hair, fibres from clothes. broken glass, tool marks, paints, scratches, blood or seminal stains, etc. It is actual evidence, and its presence is absolute proof of the crime. The evidence of eyewitnesses may be wrong as a result of their partisanship, faulty memory, or defective observation. Physical evidence cannot be wrong and completely absent. Only its interpretation can be wrong. Only human failure to find it, study and understand it, can diminish its value. The laboratory must be devoted to this study and understanding. Large numbers of criminals escape because the physical evidence is not fully understood and utilised. More laboratory failures are due to inadequate collection of existing evidence, than are caused by the failure of the laboratory to examine it properly. All laboratory findings are related to a probability, and a single piece of evidence is rarely sufficient in itself to establish proof of guilt or Innocence.

Method of simulation or production of illnesses in a case of munchausen's syndrome by proxy (1) The mother pricks her finger and adds blood to the urine of the child and takes the sample to the doctor. (2) The child's nose is closed with two fingers and the lower jaw pushed up with the palm to block the airway. (3) A pillow or towel is put over the face of the child and the face is pushed down into bed clothing. (4)The mother gives insulin to the child and takes to hospital with hypoglycaemia. (5) Vomiting: allegation or by ipecacuanha. (6) Diarrhoea: laxatives, salt poisoning. (7) Convulsions: allegation or by theophylline, insulin, psychotropic drugs. (8) Bleeding: anticoagulants, phenolphthalein poisoning, exogenous blood. (9) CNS depression: barbiturates, benzodiazipines. (10) Fever: alleged. (11) Rash: scratching or intoxication.

MUNCHAUSEN'S SYNDROME BY PROXY: This term is used to describe the actions of one person (usually mother) who inflicts harm against another person (usually an infant or small child) in an attempt to gain sympathy and attention for both her own and child's suffering. It is a variation which is a peculiar and dangerous type of child abuse usually involving the mother, in more than 90% cases, in which children are brought to doctors for induced or fabricated signs and symptoms of illnesses with a fictitious history. The sex ratio is almost equal. It has been described in children of few weeks of age to 21 years, but is most common in the first two years of life. More than 50% mothers have personal abnormal illness behaviour in the form of factitious or somatoform disorder. Often the parental illness alternates with that of the child; the self-injurious behaviour of the parent may wax and wane as the factitious illness of the child waxes and wanes. Most mothers have personality disorder. The child is admitted frequently in the hospital for medical evaluation for the non-existent conditions. At the extreme end, life-threatening injuries are masqueraded as being legitimately contracted. Rosenberg (1989) gave four diagnostic criteria: (1) Illness produced alleged, or both by a parent. (2) Repeated requests for medical care of a child, leading to multiple medical procedures. (3) Parental denial of knowledge of the cause of symptoms. ( 4) Regression of symptoms when the child is separated from the parents.

Female Genital Mutilation (circumcision): Female sexual mutilation is done by: (1) Excision of prepuce with or without part of clitoris. (2) Excision of clitoris with partial or total amputation of labia minora. (3) Excision of any part of external genitalia with narrowing of vulval introitus, often through stitching. Typically, it occurs below ten years, but is done in all age groups in sub-saharan Africa and areas of Arabian peninsula. It is performed in Christians, Muslims, Jews and atheists.

BOBBIT SYNDROME: This is a type of perversion in which the female partner amputate - the penis of her male partner with a sharp-cutting weapon. ZOOPHILIA: Sexual satisfaction is obtained from fonding of animals. UNDINISM: In this the sexual pleasure is obtained by witnessing the act of urination by one of the same or opposite sex PYROMANIA: In most cases of pyromania, there is an underlying psychosexual disorder. Some have a latent form of sadism, and others obtain sexual stimulation or satisfaction while seeing the flames and destruction of a building. SCATALOGIA: It is associated with obscene telephone calls. CAPROLALIA: Sexual excitement is obtained by using obscene language. CAPROLAGNIA: Sexual excitement is associated with sight or smell of faeces or defecation. UROLAGNIA: Sexual excitement is associated with the sight or thought of urine or urination. NARCISM (NARCISSISM): Self-love, which may or may not include genital excitation. PYGMALIONISM: It is falling in love with an object made by him. TELEPHONE SCATOLOGIA: Obscene telephone calls are made usually by heterosexual males, who call known or unknown females

HAZARDS OF BLOOD TRANSFUSION: Some type of reaction will occur in about one to 2% of patients who receive blood transfusion. The antigens of the ABO and Rh systems commonly produce transfusion reactions. In the case of other antigens a number of incompatible transfusions may be required to stimulate sufficient antibodies and cause a reaction. (A) IMMUNOLOGICAL REACTIONS: (1) Intravascular haemolysis. (2) Extravascular haemolysis. (3) Sensitivity to white blood cells, platelets and plasma components. (B) NON-IMMUNOLOGICAL REACTIONS: (1) Circulatory overload. (2) Coagulation defects. (3) Hyperkalaemia. (4) Citrate toxicity. (5) Infections and transmission of syphilis, hepatitis, toxoplasmosis, AIDS, etc. ( 6) Air embolism. (7) Hypothermia. (8) Rigors. The commonest mistakes in blood transfusions are: (1) clerical error, (2) confusing terms, such as "group A serum" instead of "anti-B serum", (3) failure of the staff to check the reference on the bottle against the actual laboratory report on compatibility, (4) the presence of similarly named patients in the ward. Samples to be preserved are: (1) Sample of blood transfused. (2) Sample of blood of the receipient before and after transfusion. At autopsy, (1) kidneys (2) Blood (3) Urine