In such cases of products liability, the manufacturer becomes responsible for injury or death. The doctor must prove that the manufacturer departed from standards of due care, with respect to negligent design, manufacture, assembly, packaging, failure to test and inspect for defects, or failure to warn or give adequate instructions.

If the instrument functioned satisfactorily in previous operations or for several previous years in the hospital’s possession, it is a proof that it was not defective at the time of supplying.

Later, if the instrument develops a defect through ordinary and gradual wear and tear, or if the physician or the hospital misuses the manufacturer’s medical materials, the hospital or physician owner have Products liability for the failure to inspect, test and repair such defects.

But the Products liability is on manufacturer who becomes responsible, if the doctor can prove that the subsequent development of this defect was due to negligent design, structurally inferior component material, or improper assembly. An adequate warning cautions the user to follow directions, and may also notify the risk of disregarding directions.

Products liability

The manufacturer of a drug keeps a “package insert” in the drug carton or attaches it to the label of the immediate container. It bears adequate information for its use, including indications, effects, dosages, routes, methods and frequency and duration of administration, and any relevant side-effects, hazards, contraindications and precautions under which registered practitioners can use the drug safely and for the purposes for which it is intended, including all purposes for which it is advertised or represented. The burden of proving the safety and effectiveness of a new drug or new uses of an approved drug rests with the manufacturer.

The manufacturer of medicines has a legal duty to use care in research and development of drugs. Products liability is on the manufacturer, if a patient is injured due to a drug reaction due to the negligence or breach of warranty on the part of manufacturer; The manufacturer is also liable due to the harm caused by the contamination, adulteration, incorrect dosage or mistaken labeling of a drug.

Once the physician has been warned about possible side-effects (that come in Products liability area), the manufacturer has no duty to ensure that the warning reaches the patient under normal circumstances. From the information received from the manufacturer, and other medical sources, the doctor is required to inform the patient of those reasonably expected side-effects likely to occur in the particular circumstances. The manufacturer is responsible for performing studies of its material when adverse reactions are reported in articles in scientific journals.

The result of these studies must be reported to the physicians. The manufacturer is not responsible for unforeseeable or unknown dangers in case of Products liability, it is unable to discover with reasonable care. If the doctor has or should have information, knowledge, or suspicion from any source that a certain drug is likely to produce serious side-effects, he may become legally liable for prescribing it, if any substituted drug would have been adequate and satisfactory.

The manufacturer, seller or anyone in the chain of sale, may be sued by the buyer (for Products liability), by another user of the material by some third party, whose bodily injury is caused by the product. The patient has to prove that a defect in production and testing in the material existed, before it left the manufacturer’s hands and that the defect was the proximate cause of the patient’s injury.

Evidence will have to be produced as to the drug’s physical and chemical qualities, so as to show a need to warnings. It would be defective, if a drug manufacturer knew or should have known the presence of certain adverse effects and then failed to warn. Causal connection should be established between the lack of warning and resulting harm to avoid Products liability case.

MEDICAL INDEMNITY INSURANCE under products liability

It is a contract under which the insurance company agrees, in exchange for the payment of premiums, to indemnify (reimburse to compensate) the insured doctor as a result of his claimed professional negligence. The objects of Medical Indemnity Insurance are:

(1) To look after and protect the professional interests of the insured doctor.

(2) To arrange, conduct and pay for the defense of such doctors.

(3) To arrange all other professional assistance including pre-litigation advice.

(4) To indemnify the insured doctor in respect of any loss or expense directly arising from actions, claims and demands against him on grounds of professional negligence, misconduct, etc.

When any dispute or allegation of negligence arises, the society must be contacted before any admissions or correspondences are entered into.

EUTHANASIA (mercy killing) as a part of Products liability

It means producing painless death of a person suffering from hopelessly incurable and painful disease.

Types:

(1) Active or positive.

(2) Passive or negative.

Active euthanasia is a positive merciful act (and may come under Products liability), to end useless suffering or a meaningless existence. It is an act of commission, e.g. by giving large doses of drugs to hasten death. Passive euthanasia means discontinuing or not using extraordinary life-sustaining measures to prolong life. This includes acts of omission, such as failure to resuscitate a terminally ill or hopelessly incapacitated patient or a severely defective newborn infant.

It is not using measures that would probably delay death and permits natural death to occur. Voluntary euthanasia means at the will of the person, and involuntary means against the will of the person, i.e., compulsory. Non-voluntary refers to cases of persons incapable of making their wishes known, e.g., in persons with irreversible coma or severely defective infants. Euthanasia advocates the administration of lethal doses of opium or other narcotic drugs. It has no legal sanction and may be charged under Products liability.

Assisted Suicide

A person providing information to another with information, guidance and means to take his own life with the intention that it will be used for this purpose is assisted suicide.

Terminal sedation (that come in Products liability) includes the administration of morphine and similar medications, which has a dual effect of relieving of pain and hastening the death (aid-in-dying). If the patient requests the same medical treatment with its known dual effects, and if the physician knowingly provides that medication by prescription so that patient can end his life, it is considered physician-assisted suicide.

Netherlands and Belgium legalized euthanasia in persons above 12 years. Strict rules govern assisted suicide. Patients must face a future of unbearable, interminable suffering and must make a voluntary, well-considered request to die. Another physician must be consulted first and life must be ended in a medically appropriate way.

IATROGENIC DISEASES: Iatrogenic disease can be defined as a disease that results from administration of a drug, or medical or surgical acts for prophylaxis, diagnosis or treatment.

DEATHS DUE TO MEDICAL CARE (Products liability)

Deaths may occur due to:

(1) Complications of anesthesia.

(2) Complications of surgery.

(3) Nonsocial infections. The use and/or misuse of urinary catheters, techniques and equipment employed in intravenous therapy, hyper-alimentation, and respiratory therapy cause most of these infections.

(4) Therapeutic misadventure.

(5) Professional negligence (that come under Products liability).

• Administration of wrong dose.
• Pharmacist dispensing wrong medicine due to illegibility of the prescription.
• Abbreviations of drugs.
• Confusing patients with similar names and to administer the correct dose to the wrong patient.
• Susceptibility of children to medication errors.
• New approved drugs may result in death from side- effects undetected in the study population.
• Patient or specimen mis-identification in laboratory testing can lead to inappropriate and potentially life-threatening therapy.
• Errors in reporting abnormal values in electrolyte analysis.
• Mismatched blood transfusion.

Contributory negligence is any unreasonable conduct, or absence of ordinary care on the part of the patient, or his personal attendant, which combined with the doctor’s negligence, contributed to the injury complained of, as a direct, proximate cause and without which the injury would not have occurred. These include

(1) failure to give the doctor accurate medical history. If the patient provides incomplete or inadequate information, it could result in misdiagnosis, mistreatment and harm.

(2) failure to cooperate with his doctor in carrying out all reasonable and proper instructions,

(3) refusal to take the suggested treatment,

(4) leaving the hospital against the doctor’s advice,

(5) failure to seek further medical assistance if symptoms persist.

As such, the doctor’s contributory negligence is not the direct, proximate cause (actual or legal cause) of the injury suffered by the patient. Proximate cause means, that which in natural and continuous sequence unbroken by any efficient intervening cause produces the injury, and without which the result would not have occurred.

If the doctor and the patient are negligent at the same time, it is a good defense for the doctor. The doctor cannot plead contributory negligence, if he fails to give proper instructions. The extent of contributory negligence may vary and with it will vary the doctor’s liability, from complete non-liability to a substantial liability for damages.

Normally, contributory negligence is only a partial defense, and the Court has right to fix liability between the parties (doctrine of comparative negligence), and damages awarded may be reduced accordingly. The burden of proof lies entirely on the doctor.

If a patient consent’s to take the risk of the injurious event actually taking place, he cannot claim damages. If a doctor is not negligent, but if a patient is negligent which results in injury, it is called contributory negligence of the patient.

Good Samaritan doctrine: One who assists another who is in serious danger cannot be charged with contributory negligence, unless the assistance is reckless or rash.

LIMITATIONS TO CONTRIBUTORY NEGLIGENCE:

(a) THE LAST CLEAR CHANCE DOCTRINE: Under this rule, a person who has negligently placed himself in a position of danger may recover damages, if the doctor discovered the danger while there was still time to avoid the injury or failed to do so.

(b) THE AVOIDABLE CONSEQUENCES RULE: This is applicable where the negligence of the injured person occurs after that of the doctor being sued and increases the severity of injury. In such cases, the patient is not guilty of contributory negligence, since his actions were not a cause of the injury.

CASE: A surgeon was sued for not removing a swab from the vagina of patient. The patient complained about pain in the vagina to a nurse some time after the operation. The nurse examined the vagina and removed the swab. The patient did not inform the surgeon about the swab in the vagina. The Court held that the doctor was guilty of contributory negligence.

It is an implied term of contract between the doctor and his patient. The doctor is obliged to keep secret; all that he comes to know concerning the patient in the course of his professional work. Everything said by a patient or his family members to a physician in the context of medical diagnosis and treatment is confidential.

Its disclosure would be a failure of trust and confidence. It assumes that without medical confidentiality, patients will not reveal everything during a consultation, esp. intimate details, due to which the clinical history may be deficient or even misleading.

The patient can sue the doctor for damages (mental suffering, shame or humiliation) if the disclosure is voluntary, has resulted in harm to the patient and is not in the interest of the public.

The following points may be noted in medical confidentiality

(1) A doctor should not discuss the illness of his patient with others without the consent of the patient.

(2) If the patient is major, the doctor should not disclose any facts about the illness without his consent to parents or relatives even though they may be paying the doctors fees thus maintaining medical confidentiality. In the case of a minor or an insane person, guardians or parents should be informed of the nature of the illness.

(3) A doctor should not answer any inquiry by third parties even when inquired by near relatives of the patient, either with regard to the nature of the illness or with regard to any subsequent effect of such illness on the patient without the consent of the patient.

(4) Even in the case of husband and wife, the facts relating to the nature of illness of the one, must not be disclosed to the other, without the consent of the concerned person.

(5) In divorce and nullity cases, no information should be given without getting the consent of the person concerned.

(6) A doctor should not disclose any information about the illness of his patient without the consent of the patient even when requested by a public or statutory body, except in case of notifiable diseases and thus maintain medical confidentiality. If the patient is a minor or insane, consent of the guardian should be taken.

(7) When a domestic servant is examined at the request of the master, the doctor should not disclose any facts about the illness to the master without the consent of the servant, even though the master is paying the fees.

(8) When a doctor examines a Government servant on behalf of the Government, he cannot disclose the nature of illness to the Government without the patient’s consent.

(9) The medical officer of a firm or factory should not disclose the result of his examination of an employee to the employers without the consent of the employee.

(10) Medical officers in Government service are also bound by the code of medical confidentiality, even when the patient is treated free.

(11) A person in police custody as an under trial prisoner has the right not to permit the doctor who has examined him, to disclose the nature of his illness to any person. If a person is convicted, he has no such right and the doctor can disclose the result to the authorities.

(12) The medical examination for taking out life insurance policy is a voluntary act by the examinee, and therefore consent to the disclosure of the finding may be taken as implied. A doctor should not give any information to an insurance company about a person who has consulted him before, without the patient’s consent and hence maintain medical confidentiality. Any information regarding a dead person may be given only after obtaining the consent from the nearest relative.

(13) In reporting a case in any medical journal, care should be taken that patient’s identity is not revealed from the case notes or photographs.

(14) In the examination of a dead body certain facts may be found, the disclosure of which may affect the reputation of the deceased or cause mental suffering to his relatives, and as such, the doctor should maintain medical confidentiality.

Medical Register

The Council maintains a register of medical practitioners, known as the Indian Medical Register. It contains the names of all persons who are enrolled on any State Medical Register. If the name of a person enrolled on a State Medical Register is removed from the Register, the Council also removes such person’s name from the Indian medical council Register.

Medical Education

The Council has the authority to prescribe standards of postgraduate medical education for the guidance of the universities. It may advise the universities in maintaining uniform standards for postgraduate medical education throughout India.

A Postgraduate Medical Education Committee, consisting of nine members is constituted for this purpose. Prior approval of Indian medical association is necessary before starting a new medical college or to increase the number of seats and a new postgraduate medical course in any discipline. If this mandatory regulation is not followed, the qualification will not be recognized by Indian medical association.

The Council maintains the standards of undergraduate medical education. The Council may prescribe the minimum standards of medical education required for granting recognized medical qualifications by universities or medical institutions in India.

It appoints Medical Inspectors to attend at any or all examinations held by universities or institutions in India, for the purpose of recommending to the Central Government, recognition of medical qualifications. The Inspectors have no power to interfere with the conduct of any training or examination.

The Inspectors report to the Council on the adequacy of the standards of medical education, including staff, equipment, accommodation, training, and other facilities prescribed for giving medical education and on the sufficiency of every examination they attended. The Council forwards a copy of any such report to the university or medical institution concerned for its remarks.

A copy with the remarks of the university or institution is sent to the Central Government. If the Council is not satisfied with the standards, it can make a representation to the Central Government to withdraw recognition of any medical qualifications of any College or University.

The Indian medical association on getting assurance for future rectifications of all deficiencies by the institution, can send its recommendation to the Central Government for reconsideration. The Central Government will again refer it to the council, which in turn will send its inspectors to visit the institutions for verifying the implementation of assurances and will send the reports accordingly.

Any university which grants a medical qualification not included in the First Schedule may apply to the Central Government to recognize the qualification. The Central Government, after consulting the Indian medical association, may by notification in the Official Gazette amend the First Schedule so as to include such qualification therein.

Recognition of Foreign Medical Qualifications

If an Indian national obtains a foreign qualification which is not included in part II of the Third Schedule, he can apply to the Central Government. The candidate is required to provide full information with regard to the course of study, syllabus, duration of the course, etc.

This is forwarded to Indian medical association, which has authority to enter into negotiations with any of the Indian medical associations of the foreign countries, and can recognize such foreign qualifications on reciprocal basis. The Central Government may, by notification in the Official Gazette, amend the part II of the Third Schedule so as to include such qualification therein.

Appeal Against Disciplinary Action

If the name of any person is removed from the State Medical Register, he may appeal to the Central Government, after exhausting all the remedies under the State Medical Council Act.

Every such appeal should state the grounds of the appeal and accompanied by all relevant documents within 30 days from the date of the decision appealed against. The decision of the Central Government, which is given after consulting the Indian medical association, is binding on the State Government and the State Medical Council.

Warning Notice

The Indian medical council may prescribe standards of professional conduct and etiquette and a Code of Ethics for medical practitioners. It can issue Warning Notice containing certain practices which are regarded as falling within the meaning of the term, “serious professional misconduct.”

(1) Adversarial system: It is for the prosecution to prove their case to the Magistrate, beyond reasonable doubt. The defense does not have to prove innocence.

(2) Inquisitorial System : (applied in Europe). Both the prosecution and defense have to make their cases to the court in criminal trial process, which then chooses which is more credible. The proceedings of investigations by the police in criminal offenses are sent to the Judicial Magistrate of the area. All offenses punishable with death, imprisonment for life, or for a term exceeding two years are tried as warrant cases. All other cases are tried as summons cases.

Standard of proof: In criminal trial process, the prosecution must provide evidence of a sufficient quality to convince the Court “beyond reasonable doubt” that the accused is guilty. In civil cases the standard is based on the “balance of probabilities”, so that the Court should be certain of more than 50% of the defendants culpability.

SUMMONS CASES in Criminal trial process

When the accused appears before the Court, he is given the details of the charged offense and asked whether he pleads guilty or not. If the accused pleads guilty, his plea is recorded and he is convicted. If he does not plead guilty, the Magistrate takes all the evidence supporting the prosecution, and takes the evidence produced in defense. On a consideration of all this evidence, he either finds the accused guilty and convicts him, or not guilty, and acquits him.

WARRANT CASES in Criminal trial process

In criminal trial process filed by the police, when the accused is brought before the Court, the Magistrate must make sure that the accused has received all the required documents. The Magistrate considers the documents, examines the accused, and hears the prosecution and defense.

If he finds the charge groundless, he records his reasons and discharges the accused. If there are grounds for believing that an offense has been committed, he frames a written charge against the accused, which is read out and explained to the accused, who is asked to plead.

If he pleads guilty, the plea is recorded and he may be convicted on that plea. If he pleads not guilty, a date is fixed for the examination of the witnesses, and the prosecution evidence is recorded, during which the accused is permitted to cross-examine the prosecution witnesses.

Next, the defense evidence is recorded, during which the prosecution is allowed to cross-examine the defense witnesses. After this, the lawyers for prosecution and defense make oral arguments before the Court in regard to the evidence, and the conclusion therefrom, regarding the guilt or innocence of the accused. If the Magistrate finds the accused guilty, he passes the sentence, otherwise he acquits him.

SESSIONS TRIAL in Criminal trial process

If the Magistrate is of the opinion that the accused should be committed to trial by Sessions Court, he frames a charge of the offense, which is read and explained to the accused, and passes an order committing the accused to trial by Court of Sessions, and records briefly the reasons for such commitment. A warrant is issued to keep the accused in custody.

The Magistrate sends the charge, the record of inquiry and any weapon or other thing which is to be produced in evidence, to the Court of Sessions. The Magistrate has power to take bond from any witness for appearance in his Court or any other Court to which the case may be transferred for criminal trial process.

At the first hearing, the public prosecutor opens the criminal trial process by describing the charge against the accused and stating the evidence by which he proposes to prove the accused guilty of the offense charged. If after going through the record, and hearing the submissions of the defense and the prosecution, the Judge considers that there is no sufficient ground for proceeding against the accused, he discharges him, recording his reasons for doing so.

Otherwise, the Judge frames a charge which is read out and explained to the accused and his plea is recorded. If he pleads guilty, he may be convicted, otherwise a date is fixed for hearing. The prosecution witnesses are called. Each witness is examined by the prosecutor, and may be cross- examined by the defense, and re-examined by the prosecution, as well as questioned by the Court in criminal trial process.

If, after hearing the prosecution evidence, examining the accused, hearing the prosecution and the defense, the Judge considers that there is no evidence that the accused committed the offense, he passes an order of acquittal. If the accused is not acquitted, he is asked to defend himself. Any written statement submitted by the accused is filed with the record. The defense witnesses are then called.

Each witness is examined by the defense, and may be cross- examined by the prosecutor and re-examined by the defense, and as well as questioned by the Judge. The evidence of all the witnesses is recorded in writing either by Judge himself or by his dictation in open Court. At the conclusion of the evidence, the prosecution sums up the criminal trial process and the accused or his lawyer is entitled to reply, and the prosecutor may enter his submissions if permitted by the Judge.

If the accused is found guilty, he is convicted, otherwise he is acquitted. The judgement in every criminal trial process shall be pronounced in open Court. Copy of judgement is given to the accused. Both the prosecution and defense can appeal to a superior Court against an acquittal or conviction in a lower Court.

When the Court of Sessions passes the sentence of death, the proceedings are submitted to the High Court for confirmation of the sentence.

All persons are competent to testify unless they are prevented from understanding the questions put to them, or from giving rational answers to those questions, due to tender years or extreme old age or disease.

Types: Witnesses are of two types:

(1) Common, and

(2) Expert.

Common witness (witness of fact or occurrence witness) is a person who gives evidence about the facts observed or perceived by him. He must show that he was capable of perceiving the fact by one of his own senses, and that he actually observed this fact.

This principle is commonly known as the “first-hand knowledge rule”, which may be used to establish the exact circumstances of the case for the Court, e.g., A has seen B and C, fighting with sticks on a certain road on particular day and time. In a case of traffic accident the person who witnessed the accident becomes a common witness.

Expert witness is a person who has been trained or is skilled or has knowledge, experience or education in technical or scientific subject, and capable of drawing opinions and conclusions from the facts observed by himself, or noticed by others, e.g., doctor, firearms expert, fingerprints expert, handwriting expert, etc.

An expert witness may give his opinion:

(1) upon facts which are either admitted, or proved by him or other witnesses at the trial,

(2) on matters of common knowledge, and

(3) on hypothetical questions (questions based on stated assumptions) based there on.

Hypothetical questions may be asked to extract an opinion from the expert, after he assumes certain facts to be true, describing a specific situation, even though he may not have first-hand knowledge of the actual case. The expert should hesitate for a moment, so as to give the opposing lawyer an opportunity to object to the question.

The answer should be given only after completely understanding the question. The main obligation of an expert is to point out professional facts. But, he may be asked to give professional estimate which his observations seem to justify, e.g., whether or not an injury is caused in the manner alleged or from the causes assumed; the possible consequences; the reasonable estimate of damages, etc.

A doctor’s testimony that a certain thing is possible is no evidence at all. A doctor’s testimony can only be considered evidence when he states that the conclusion he gives is based on “reasonable medical certainty” (more probable than not in a medical sense) that a fact is true or untrue.

In other words, if the likelihood of an event is more probable than not given the facts, the physician can testify with a reasonable medical certainty. The opinion on a key question must be given in a more guarded manner using terms, such as that the findings are “consistent with” an alleged form of trauma, such as a fall against a hard object or with the striking of the head with a blunt instrument of a particular type or a blow from a fist.

It does not exclude other mechanisms which could reasonably or possibly have caused the same findings. If he is so excessively cautious as to confuse possibilities, probabilities and certainties, his testimony will become ineffective. Conclusions must be based on facts. Conclusions are much more important than opinions.

The expert who inspite of provocation, answers questions with goodwill and accuracy, and who does not make statements that he cannot defend, will be successful under such attack. Clear presentation and ability in expressing a relatively firm opinion are helpful for success of the expert.

The medical evidence does not itself establish the guilt or innocence of the accused. In the majority of cases, it provides expert opinions based upon objective, indisputable facts, which help to evaluate the reliability and credibility of other witnesses. The doctor is not a witness of truth. The expert evidence is of little value, when there is a conflict of opinion between experts. In such cases, the Courts usually accept that opinion which is not in conflict with direct opinion.

If there is difference between medical evidence of two doctors, one of whom examined the injured person and the other conducted the autopsy on the injured person after his death, as to the injuries, or the weapon used, or the time of infliction of injuries, etc., the accused gets the benefit of doubt.

Where the direct evidence is not trustworthy, conviction may result on medical evidence, if that is trustworthy. An expert witness may refer to books to refresh his memory, or to correct or confirm his opinion. Books as such are not evidence, but if an expert refers to specific passages as representing his views, they may be taken down as his own evidence.

A witness may adopt the views of any authority as his own, provided he has an honest belief in them. The opinion of an expert can be proved false by standard books on the subject.

A doctor can be both a common and expert witness. When he describes the wounds on the body, he acts as a common witness. But when he says that the wounds were antemortem or postmortem, or they were suicidal, homicidal, or accidental, or gives opinion regarding the cause of death, he acts as an expert witness.

Hostile witness is one who is supposed to have some interest or motive for concealing part of the truth, or for giving completely false evidence. The Court will declare a witness as hostile on the suggestion of the lawyer of the party who has summoned the witness or prosecution lawyer. On declaration of a witness as hostile, he can be cross-examined by the same side lawyer. Any of the above two types of witness can be hostile.

PERJURY

Perjury means giving willful false evidence. Whoever, being legally bound by an oath, or by an express provision of law to state the truth, or being bound by law to make a declaration upon any subject, makes any statement which is false, and which he either knows or believes to be false or does not believe to be true, is said to give false evidence. The witness is liable to be prosecuted for perjury, and the imprisonment may extend to seven years.

How is witness examined in forensic science?

The medical witness is allowed to sit in the Court if the lawyers of the accused do not object.

RECORD OF EVIDENCE

The evidence of the witness is recorded as follows:

Oath: The witness has to take an oath in the witness box before he gives his evidence. He should take the oath as follow : “I do swear in the name of God, that what I shall state shall be the truth, the whole truth, and nothing but the truth’. If the witness is an atheist, he has to “solemnly affirm” instead of “swearing in the name of God.”

Oath is a declaration required by the law, which is compulsory and holds the witness responsible for consequences of his evidence. A child below 12 years is not required to take an oath.

(1) Examination-in-chief (direct examination)

This is the first examination of a witness. It consists of questions put to him by the lawyer (counsel or advocate) for the side which has summoned him. In criminal acts committed by an individual or group, the State becomes a party instead of the aggrieved person, and starts criminal prosecution, which is titled as “State versus A”.

In a criminal trial, the burden to prove is always on the prosecution (adversarial system of trial), and the accused is presumed to be innocent till the contrary is proved against him. In Government prosecution cases, the public prosecutor, first examines the witness. If witness is called by private party, he is first examined by the lawyer of that party.

The object is to elicit all relevant, convincing medical facts, and the conclusions which the doctor has drawn from the facts. The doctor may have to interpret the findings of non- medical ancillary investigations provided by scientific laboratories, analysts and serologists, in all cases where the medical aspects are at issue.

Before giving evidence, it is advisable that the doctor meets the public prosecutor, and discuss the previously prepared report, the certificate of death, photographs, etc., that the witness intends to show in the Court, and an outline or pattern should be worked out for the best way to elicit his testimony.

If the witness intends to modify any of his findings or conclusions, these should be pointed out to the lawyer. The doctor should help the prosecutor in framing proper questions in proper sequence, so that all essential facts are elicited. The lawyer will be able to advice the doctor, about the anticipated content of cross-examination. In this leading questions are not allowed, except in those cases, where the Judge is satisfied that a witness is hostile.

A leading question is one which suggests to the witness the answer desired, or which includes a material fact, and admits of a conclusive answer by a simple “Yes” or “No”. “Was this injury caused by a sharp weapon?” Was the length of cut 3 cm?”. “Was it on the front of the abdomen?”. They are all leading questions, as they suggest the answer “Yes” or “No”.

The proper questions should be: “What type of weapon would cause this injury?” What was the length of the cut? Where was it seen”? The method of examination is by question and answer. The questions are usually short and demand some specific fact and short answer. But the answer can be given in narrative form, if it would be more informative and convincing. The effect of the questions and answers is recorded indirectly and not in the form of the question and answer.

(2) Cross-examination

In this, the witness is questioned by the lawyer for the opposite party, i.e., lawyer for the accused (defense lawyer), In a murder trial, the defense witness is cross- examined by public prosecutor.

The main objects are

(1) to elicit facts favorable to his case,

(2) to test the accuracy of the statements made by the witness,

(3) to modify, or explain what has been said,

(4) to develop new or old facts,

(5) to discredit the witness, and

(6) to remove any undue or excessive emphasis which may have been given to any of them.

In doing this, the lawyer may try to weaken the evidence by showing that the evidence given is inconsistent, inaccurate, ill- founded, contradictory, and untrustworthy. The cross-examination need not be confined to the facts to which the witness testified in his examination in-chief.

The competence and credibility of the witness is tested by questioning his qualifications, experience and the number of cases of the kind under consideration he has personally observed, and by testing his memory or powers of observation. When material is available, the lawyer may attack the character of the witness.

The witness may be asked questions on his bias or impartiality, his previous conviction, his reputation for untruthfulness and on any handicap he may have which would affect the reliability of his evidence. The Court will decide whether the witness should answer any particular question, when asked for a ruling.

The Court may forbid any questions which it regards as indecent or scandalous, unless they relate to facts in issue. The Court also has the power to disallow questions which are intended to insult or harass or offensive in form, but if they are relevant to the facts in issue, the Court cannot disallow them.

The witness has to answer any question relevant to the matter in issue, even though the answer will expose or prove his guilt directly or indirectly, e.g., which would reveal that he has committed an illegal operation. If a witness is forced to give an answer admitting his guilt, he cannot be arrested or prosecuted for it, and also it is not taken as proof against him in any criminal proceeding. A witness is completely immune from actions for defamation (libel or slander), for anything he says in the witness box.

Answers favorable to the defense side should be given as promptly as those given on examination- in-chief. There are few observations in medicine which are capable of only one explanation. If the defense puts points to the doctor which must be conceded, the doctor should reply that alternative explanations were considered, and on balance he prefers the conclusions already expressed.

Admit omissions, e.g. an examination of a drunken person may not require the use of all tests described in a treatise. This can be explained to the Court. Objectivity and impartiality are important against destructive cross-examination.

If a question is not audible, the witness should ask the lawyer to repeat the question. If the question is not understood, the witness should ask the lawyer to explain it better. If a question contains several different questions, each requiring a separate answer, the medical witness should ask the lawyer to break the question into individual components. The medical practitioner should not be dogmatic about his opinion and the lawyer should not expect him to be so. The witness should be clear, direct and precise in his answer, as far as possible.

He should not volunteer unrelated information. The defense lawyer may ask the witness, whether he talked about this case with anyone. The answer should be “Yes’. If asked with whom he talked, he should give the name of the lawyer by whom he was called to give evidence. If a further question is put, “What did you talk about?”, the most effective answer would be: “He told me to tell the truth”.

Sometimes, a previously published statement of his own, which may be in disagreement with what he is now stating is quoted against him. The effective answer should be, “medicine advances with the times, and I try to advance with its progress”.

If the defense succeeds in embarrassing or humiliating the witness, he may become tense, frightened, angry, hostile or aggressive, due to which his intellectual faculties suffer, and he will not be able to think clearly and effectively. When the reply to a question appears to damage the defense case, the lawyer may attempt to interrupt doctor’s answer by asking a new question.

The witness should say that he has not yet completed his answer to the preceding question. If the Judge rules in favor of the new question, the lawyer for the prosecution side will usually make a note of the question and its answer and will give the doctor an opportunity to complete his reply in re-examination.

The witness must answer a hypothetical question, but he cannot be compelled to answer a question that is based wholly or in part upon a subject, regarding which he cannot conscientiously reply. Leading questions are permissible during cross- examination. Cross-examination has no time limit, and may last for hours or even days. The Judge can always disallow irrelevant questions.

Objection to Testimony

When a question is asked of a witness, the opposing lawyer may say, “I object”, and give his reasons for the same. The witness should not answer the question until the Court gives a ruling on the objection. If the Judge says, ‘Objection overruled”, the answer has to be given.

The defense lawyer should not ask a question to which he does not know the answer, for the reply may strengthen the case of the opposite side and seriously hurt his own. Sometimes, cross-examination may act as a double-edged sword, i.e., it may damage the defense as much as the prosecution, especially if lawyer is not familiar with the subject and the witness is efficient and honest.

(3) Re-examination (Re-direct examination)

This is conducted by the lawyer for the side which has called the witness. The object is to correct any mistake or to clarify or add details to the statements the witness has made in cross-examination. It is an opportunity for the witness to explain more fully some answer which might appear damaging to his direct evidence, because of skilful questioning or tactics by the cross-examiner. The witness should not bring in any new matter at this stage. The opposing lawyer has right of re-cross-examination on the new point raised. Leading questions are not allowed.

(4) Questions by Judge

The Judge may ask any question, in any form, about any fact, relevant or irrelevant, at any stage of the examination to clear up doubts. The Court is also empowered to recall and re-examine any witness already examined, if his evidence appears to the Court to be essential to the just decision of the Court.

The deposition of the witness is handed over to him. The witness after carefully going through it, is required to sign at the bottom of each page, and on the last page immediately below the last paragraph, and to initial any corrections. The witness should not leave the Court without taking permission of the Judge.

Doctor as a Witness in Forensic science

The following rules help a doctor in the witness box:

(1) Be well prepared with the details of your evidence before entering the box; anticipate certain likely questions on it and be prepared to answer these in advance. It may be necessary to study the literature on the subject about which he is likely to be cross-examined.

(2) Take all records, and relevant reports that may have to be quoted in the box, e.g., original notes, autopsy report, photographs, X-rays, toxicology and blood grouping reports, copy of the death certificate, drawings or diagrams, special reports on swabs or smears, culture studies, serology and various receipts to prove the chain of custody of the items of evidence. The photographs are useful in the Court: to refresh memory of the findings, to establish the identity of the deceased, to explain the findings conveniently, and to provide true-to-life picture of the investigative findings.The records should be in chronological order, and the doctor should have full knowledge of the contents of his file.

(3) Do not discuss the case with anyone in the Court, except the lawyer by whom you were asked to testify.

(4) Be well dressed and modest.

(5) Stand up straight.

(6) Be relaxed and calm and not frightened or nervous.

(7) Never attempt to memorize. The law allows to refresh your memory from copies of reports already submitted or from case notes and similar records made at the time of examination. An expert may refresh his memory by reference to professional treatises (S.161, I.E.A.). A writing which is used to refresh the memory of a witness must be shown to the opposite party, if he requires it. Such party may cross-examine the witness thereupon (S.161, I.E.A.).

(8) Speak slowly, distinctly, and audibly so that the Judge can record your evidence. It is advisable to watch the pen of the Judge so that the Judge is able to record all the evidence, without asking the witness to pause.

(9) Look people in the eye when you speak, for it gives the impression of honesty.

(10) Speak with assurance. Be confident but not over-confident or arrogant.

(11) Use simple language, avoiding technical terms to the best of your ability. Practice this in advance.

(12) Avoid superlatives and exaggerations, e.g., very large bruise, frightful injury, savage blow, most agonizing pain, etc.

(13) Do not fumble in referring to case notes, records, etc. The less you fumble, the more the Court is likely to be impressed by you.

(14) Address the Judge by his proper title, such as “Sir” or “Your honor”.

(15) Avoid difference between your record and your testimony. If an error or slight contradiction has been made in the testimony, admit and correct it.

(16) Do not underestimate the medical knowledge of the lawyers.

(17) Be pleasant, polite and courteous to the lawyer. Appearance, professional manner, and general behavior are important.

(18) Do not avoid a question. Say I do not know, if it is so, for no one can be expected to know everything. It indicates honesty.

(19) Never become hostile, angry, rude or sarcastic during questioning.

(20) Do not lose your temper. An angry witness is often a poor witness, and the effectiveness of his testimony is diminished or destroyed.

(21) Defence lawyer may irritate the witness into anger by unfair questions, abuse and unfair remarks. The witness should remain calm and keep his temper. Do not argue, just disagree if you do not agree; disagree firmly and repeatedly.

(22) Don’t be too anxious to please or too eager to fight.

(23) Retain independence of your mind. Be honest, impartial, unbiased and truthful. A biased expert is a useless expert. Be frank to admit any points in favour of the accused if that is the truth. Speak only of facts which come within your personal knowledge.

(24) Do not alter your findings to what is said in statements to be the facts. The doctor should “tell it as it is”, and should not choose sides.

(25) Listen carefully to the questions. Do not hesitate to ask to have the question repeated, if you do not understand it. If still it is not clear, say so frankly, for the lawyer to reframe the question. Give yourself time to think.

(26) Avoid long discussion. Answer should be brief and precise and in the form of “Yes” or “No”. Never nod your head to indicate “Yes” or “No”. In many medical matters, the answer requires an explanation and the doctor should resist to answer with a simple ‘Yes’ or ‘No’. The witness is not bound simply to answer yes or no, but may qualify his answer if it is necessary for accuracy and completeness, even though the lawyer may try to demand a yes or no answer. The Court usually rules that the doctor may explain his reply.

(27) Consider all aspects of the question before answering it. Answer only what is asked.

(28) If you believe the question is unfair or that the lawyer is teasing you excessively, look at your lawyer before answering. If he fails to object, turn to the Judge and ask whether you should answer the question.

(29) Do not over emphasize replies to questions from the cross-examining lawyer.

(30) You may use an opportunity to insert a positive point that you have omitted during your chief-examination; but be careful not to provoke a new line to questioning.

(31) Watch for double question and questions that include an assumption of facts which have not been proven. The answer to each part of the double question may be different. This should be emphasized by the witness. He should also state that the assumed facts are not necessarily true.

(32) You are an authority in this particular case, as you have examined the patient or the dead body and have specific medical knowledge about it. What applies to many cases in general may not apply to this particular case.

(33) Express an opinion from your own knowledge and experience. Say, “In my opinion ….“ Do not use phrase such as “I think”, or “I imagine”. Be prepared to give reasons for your opinion if asked. Never express an opinion on the merits of the case.

(34) When the opinion relates to quantity or number, it should be stated within certain limits, unless an exact answer can be given, e.g., the age of an individual. Keep the opinions within the limits of reasonable medical certainty.

(35) Do not be drawn outside your particular field of competence. Avoid speaking on a subject in which you have little or no practical experience, e.g, pathologist is not the right person to give evidence on clinical problems or dispensing. A general practitioner is not qualified to give evidence on the pathology of a tumor or on blood group inheritance. In such cases, he should explain that this is not a matter in which he has particular knowledge, and that he is not qualified to answer it.

(36) When asked to comment upon the competence of a colleague, avoid any insulting remarks. If he is competent, say so but without superlatives. If you do not wish to make any statement, say that you have “no opinion”.

(37) An expert may adopt the published opinion of the writers on the subject as his own opinion. The published work need not be produced in the Court.

(38) When lawyer quotes a passage from a textbook, and asks the witness whether he agrees with it, the doctor must always take the precaution before answering, of reading the portion which is quoted to him and also of reading a paragraph before and after the quoted passage since it may be taken out of context, and he should satisfy himself that the edition of the book is recent and the views expressed by the author are current. There is no need to accept everything that is written; do not hesitate to disagree.

(39) Textbooks of established repute can be produced in evidence, even though the witness refuses to recognize the authority, or to acknowledge familiarity with its contents.

(40) A medical witness has no professional privilege, and therefore he must answer any question. He must first obtain a ruling from the Judge and if directed to answer, he must do so without further delay.

(41) Volunteering of information: Information should not be volunteered beyond that asked for in the question. The answer should also be limited to the expert’s knowledge. Volunteered information is often not well prepared, and is liable to cross-examination. As an expert witness, a medical practitioner may volunteer a statement, if he thinks that injustice will result if he fails to make the statement.

(1) any thing, state of things, or relation of things, capable of being perceived by the senses,

(2) any mental condition of which any person is conscious (Section.3, TEA.).

In all cases, oral evidence must be direct(Section.60,I.E.A). It must be evidence of a person who saw, heard, or perceived it by that sense or in that manner. If it refers to an opinion or to the grounds on which the opinion is held, it must be the evidence of the person who holds that opinion on those grounds.

If oral evidence refers to any material thing, the Court may require the production of such a thing for its inspection, e.g. a bloodstained weapon or article of clothing, a portion of eliminated poison, etc. (Section.60, I.E.A.). All facts, except the contents of documents, may be proved by oral evidence (Section.59, I.E.A.).

A deaf and mute witness may testify by signs, by writing or through an interpreter (Section.119, I.E.A.). Oral evidence is more important than documentary evidence, as it permits cross-examination. Documentary evidence is accepted by the Court only on oral testimony by the person concerned.

Exceptions to Oral Evidence

(1) Dying declaration (Section. 32 & 157, I.E.A.). Statements, verbal or written, of relevant facts made by a person who is dead, who cannot be found, who has become incapable of giving evidence, or whose attendance cannot be procured without unreasonable delay and expenditure, is admissible as evidence (Section. 32, I.E.A.).

(2) Expert opinion expressed in a treatise may be proved in Court by producing such book if the author is dead or cannot be found or cannot be called as a witness without unreasonable delay or expense (Section. 60, I.E.A.).

(3) Oral Evidence of a doctor recorded in a lower Court is accepted in a higher Court, provided it is recorded and attested by Magistrate in the presence of the accused. But he is liable to be summoned, if the evidence is deficient or needs further explanation (Section. 291, Cr.P.C.).

(4) Oral Evidence given by a witness in a previous judicial proceeding is admissible in subsequent judicial proceeding, when the witness is dead or cannot be found, or is incapable of giving evidence, or cannot be called without undue delay or unreasonable expense (Section. 33, I.E.A. & Section.291 Cr.P.C.).

(5) Oral Evidence of Mint officers or an officer of the India Security Press (Section. 292, Cr.P.C.).

(6) Reports of certain Government scientific experts becomes part of Oral evidence: (a) Chemical Examiner or Assistant Chemical Examiner. (b) Chief Inspector of Explosives. (c) Director Fingerprint Bureau. (d) Director, Central Forensic Science Laboratories or State Forensic Science Laboratories. (e) Director, Haffkine Institute, Mumbai. (f) Serologist to the Government (5. 293(1), Cr. P.C.). The Court has the power to summon and examine any such expert. The prosecution and defence has also a right to demand the Court to summon and examine any such expert (Section.293 (2) Cr.P.C.).

(7) Public records: A record kept in a public office, e.g., birth and death, certificates of marriage, etc., is admissible in evidence without oral testimony (Section. 35, 74, 76 and 78, I.E.A.).

(8) Hospital records: Routine entries, such as dates of admission and discharge, pulse, temperature, treatment given, etc., are admissible without oral evidence. But the cause of the disease or diagnosis are not accepted without oral testimony.

Chain of Custody of Evidence: It is a method to verify the actual possession of an object from the time it was first identified until it is offered as evidence in the Court. Each specimen when obtained, should be labelled with the victim’s name, the time and date, the nature of the specimen, identification number, and signed by the doctor.

This information must be documented each time the material is handled by another person, and that person must give receipt for the material and be included in the chain of custody. The evidence must not be damaged, contaminated, or altered in any significant way. The shorter the chain the better.

(1) all statements which the Court permits or requires to be made before it by witnesses, in relation to matters of fact under inquiry.

(2) All documents produced for inspection of the Court.

For the evidence to be accepted by the Courts, it must be properly identified as to what it is, and where it was found. The evidence of eyewitnesses is positive and that of doctor or an expert is only an opinion which is corroborative.

Type of medical evidence

(1) Documentary medical evidence

It includes all documents produced for the inspection of the Court. Document means any matter expressed or described upon any substance by means of letters, figures or marks, which may be used for the purpose of recording that matter (Section.29, I.P.C.). Sections 61 to 90 of Indian Evidence Act, 1872, deal with documentary evidence.

The contents of the documents may be proved either by primary or by secondary evidence (Section.61, I.E.A.). Primary medical evidence means the document itself produced for inspection of the Court (Section.62, I.E.A.). Documents must be proved by primary proof except in certain cases (Section.64, 1.E.A.).

Secondary evidence means, certified copies, copies made from the original by mechanical processes, copies made from or compared with the original, oral account of the contents of a document (Section.63, I.E.A.). Proof must conform to the matters in issue, and is admitted on the basis of relevance and admissibility.

(2) Oral medical evidence.

(3) Direct medical evidence

Proof of a fact which is actually in issue, e.g., an electric blanket that has caused injury, prescription, or a consent form.

(4) Indirect or Circumstantial medical evidence

It is not the direct testimony of an eye witness, but has a bearing upon the fact of the other and subsidiary facts which are relied upon as consistent (Section.6. I.E.A.), e.g., in case of alleged murder of A by B at certain place on a particular day and time, the circumstantial proof would be that C saw B with a knife on that day at that place, a few minutes before the murder. Circumstantial evidence requires the Court to draw logical or reasonable inferences from the information presented.

(5) Hearsay medical evidence

It is any statement made by any person about what he did not personally witness, or proof he obtained from a third party, which is presented in the Court in order to assert that the facts contained in the statement are true, e.g., A gives evidence in the witness box stating that B had informed him that he had seen C committing a crime. In such case direct evidence can be given only by B that he had seen C committing a crime.

Medical Certificates

They refer to ill- health, insanity, age, death, etc. They are accepted in a Court of law, only when they are issued by a qualified registered medical practitioner. The certificate of ill-health should contain exact nature of illness, and probable period of expected absence. This is one of the documentary evidence.

The signature or left thumb impression of the patient should be taken at the bottom of the certificate. A medical practitioner is legally bound to give a death certificate, stating the cause of death without charging fee, if a person whom he has been attending during his last illness dies (Registration of Births and Deaths Act, 1970).

Death certificate should not be issued by a doctor without inspecting the body and satisfying himself that person is really dead. The certificate should not be delayed, even if the doctor’s fees is not paid. The certificate should not be given if the doctor is not sure of the cause of death, or if there is the least suspicion of foul play.

In such cases, the matter should be reported to the police. Issuing or signing a false certificate is punishable under Section. 197, I.P.C. This kind of documentary evidence is quite vital.

The Medical Certification of Death

In India, the International Statistical Classification of Diseases, Injuries and Causes of Death is used. The cause of death is divided into two main sections. (1) Immediate cause. This is subdivided into three parts, namely (a), (b), (c). If a single morbid condition completely explains death, this will be written on line (a) of part I, and nothing more need be written in the rest of Part I or in Part II, e.g. lobar pneumonia. The documentary evidence here is helpful for the case.

Next consider whether the immediate cause is a complication or delayed result of some other cause. If so, enter the antecedent cause in Part I line (b). Sometimes there will be three stages in the course of events leading to death. If so line (c) will be completed. The underlying cause to be tabulated is always written last in Part I. (II) Other significant conditions contributing to the death but not related to the disease or condition causing it. This kind of documentary evidence plays vital role.

Medico-legal Report Documentary evidence

They are reports prepared by a doctor on the request of the investigating officer, usually in criminal cases, e.g., assault, rape, murder, etc. The examination of an injured person or a dead body is made, when there is a requisition from a police officer or Magistrate.

These reports consist of two parts:

(1) the facts observed on examination (all relevant, objective descriptions including important negative findings),

(2) the opinion drawn from the facts.

These reports will be attached to the file relating to the case and the file is produced in the Court. The report, which will form the documentary evidence, will be open to the scrutiny of the defense lawyer. It will not be admitted as evidence, unless the doctor attends the Court and testifies to the facts under oath.

Great care should be taken in writing the reports to avoid any loose wording or careless statement. This gives a chance to the defense lawyer to use them to his own advantage. The report should give the date, time and place of examination and the name of individuals who identified the person or the dead body. Exaggerated terms, superlatives, etc. should not be used.

The opinion should be based on the facts observed by himself, and not on information obtained from other sources. In an injury case, if it is not possible to give an opinion immediately, the person should be kept under observation, and necessary investigations should be done before giving the report, which becomes a part of documentary evidence.

The report should show competence, lack of bias and offer concrete professional advice. The report should be made soon after the examination. It should be clear, concise, complete, legible and it should avoid technical terms as far as possible. Relevant negative information should also be given. The doctor should sign or initial at the bottom of each page, if the report exceeds one page in length.

Exhibits: Clothing, weapons, etc., sent for medical examination should be described in detail, sealed and returned to the police, after obtaining a receipt. This also is included in documentary evidence.

DYING DECLARATION

It is a written or oral statement of a person, who is dying as a result of some unlawful act, relating to the material facts of cause of his death or bearing on the circumstances (Section.32, I.E.A.). If there is time, Executive Magistrate should be called to record the declaration.

Before recording the statement, the doctor should certify that the person is conscious and his mental faculties are normal (compos mentis). If the condition of the victim is serious, and there is no time to call a Magistrate, the doctor should take the declaration in the presence of two witnesses. The statement can also be recorded by the village headman, police or any other person, but its evidential value will be less in documentary evidence.

While recording the dying declaration, oath is not administered, because of the belief that the dying person tells the truth. The statement should be recorded in the man’s own words, without any alteration of terms or phrases. Leading questions should not be put. The declarant should be permitted to give his statement without any undue influence, outside prompting or assistance.

If a point is not clear, question may be asked to make it clear, but the actual question and the answer received should be recorded. It should then be read over to the declarant, and his signature or thumb impression is taken. The statement made must be of fact and not opinion as opinions don’t play any role in documentary evidence.

If the declaration is made in the form of an opinion or conclusion, questions should be asked by the recorder to bring out the facts that are the basis for the conclusion. While recording the statement, if the declarant becomes unconscious, the person recording it must record as much information as he has obtained and sign it. If the dying person is unable to speak, but is able to make signs in answer to questions put to him, this can be recorded and it is considered as a “verbal statement” of documentary evidence.

The doctor and the witness should also sign the declaration. If the statement is written by the declarant himself, it should be signed by him, the doctor and the witnesses. The declaration is admissible not only against an accused who killed the declarant, but also against all other persons involved in the same incident which resulted in his death.

In India, if the declarant is in a sound state of mind at the time of making the declaration, it is admissible in Court as evidence, even if the declarant was not under expectation of death at that time. The declaration is sent to the Magistrate in a sealed cover as documentary evidence.

It is produced at the trial and accepted as evidence in case of death of the victim in all criminal and civil cases, where the cause of death is under inquiry. The person recording the declaration will have to give evidence in the Court to prove it. If the declarant survives, the declaration is not admitted but has corroborative value, and the person is called to give oral evidence. The statement is important to identify the offender or to clear innocent persons.

DYING DEPOSITION

It is a statement of a person on oath, recorded by the Magistrate in the presence of the accused or his lawyer, who is allowed to cross-examine the witness. This procedure is not followed in India, hence is not a part of documentary evidence.

Partly the metabolic effects of glucocorticoids may be due to increased synthesis of cAMP dependent kinase. Certain glucocorticoids stabilize lysosomal membranes and thereby inhibit the release of inflammatory mediators like eicosanoids, histamine, and cytosine or increase the generation of anti-inflammatory mediators.

• Glucocorticoids have a negative feedback action on hypothalamus and anterior pituitary. Due to this, the release of endogenous glucocorticoids is reduced.

• Glucocorticoids reduce vasodilatation and decrease fluid exudation.

• They cause decreased influx and activity of leucocytes in areas of acute inflammation.

• There occurs decreased activity of mononuclear cells, decreased proliferation of blood vessels and less fibrosis in areas of chronic inflammation.

• In lymphoid areas, glucocorticoids decrease clonal expansion of T and B cells and decrease action of cytokine secreting T cells.

• Clucocorticoids have significant effect on inflammatory and immune mediators such as:

— Decreased production and action of cytokines including many interleukins, tumor necrosis factor-r, and granulocytemacrophage colony-stimulating factor.

— Reduced generation of eicosanoids

— Decreased generation of IgG

Decreased in compliment components in the blood.

• So the overall effects of glucocorticoids are reduction in chronic inflammation and autoimmune reactions. However, they also cause decreased healing and diminution in the protective aspects of the inflammatory response.

Other Effects of glucocorticoids

• They inhibit growth and cell division.

• They increase haemoglobulin synthesis.

• Euphoria occurs commonly. Sometimes there will be increased motor activity, insomnia, anxiety, or depression. Some patients treated with glucocorticoids become anxious, depressed or overtly psychotic.

• Glucocorticoids play a vital role in adaptation to stress.

• They cause feedback inhibition of CRU, ACTH and TSH while secretion of growth hormone is increased.

Disorders of corticosteroid secretion

Adrenocortical insufficiency leads to Addison’s disease and hypoaldosteronism. Similarly adrenocortical hypersecretion leads to Cushing’s syndrome and hyperaldosteronism.

Synthetic analogues of corticosteroids are betamethasone, dexamethasone, prednisolone, prednisone, and triamcinolone. All of them have more potent glucocorticoid activity. Fludrocortisone is the most potent mineralocorticoid.

Therapeutic Uses of Glucocorticoids

1. Replacement therapy: Addison’s disease and hypopituitarism are treated by hydrocortisone which has some mineralocorticoid activity or by a combination of a synthetic glucocorticoid with fludrocortisone. Deoxycorticosterone (DOCA) is also occasionally used as a replacement therapy for aldosterone deficiency.

2. Glucocorticoids are very useful in the treatment of rheumatoid arthritis, osteoarthritis, and other form of chronic arthritis.

3. Collagen diseases: Glucocorticoids therapy may prove life saving in diseases like systemic lupus erythematosus, polyarteritis nodosa, dermatomyositis, and nephrotic syndrome.

4. Hypersensitivity and allergic disorders:

Glucocorticoids are very useful in the treatment of anaphylactic shock, angioneurotic oedema, and serum sickness. Beclomethasone and budesonide are available as inhalation aerosol preparations. They are employed in chronic obstructive pulmonary disease including chronic bronchial asthma in order to minimize systemic adverse effects of glucocorticoids.

5. Glucocorticoids are also used to treat diseases having autoimmune aetiology such as haemolytic anaemia, idiopathic thrombocytopenia, ulcerative colitis and myasthenia gravis.

6. Ocular conditions: Glucocorticoids are used topically in the treatment of conjunctivitis, iritis, iridocyclitis, and keratitis. Retrobulbar or systemic therapy is employed for retinitis, uveitis and optic neuritis.

7. Clobetasol (a glucocorticoid) is used topically in pruritic skin conditions, active acute dermatoses and chronic dermatitis. To treat pemphigus, exfoliative dermatitis and Stevens-Johnson syndrome glucocorticoids are given systemically.

8. Since glucocorticoids cause lympholysis, they are used to treat acute lymphatic leukemia, lymphomas and Hodgkin’s disease.

9. Other uses: They are also used in the treatment of:

• Cerebral oedema

• Rheumatic fever (not responding to salicylates)

• Acute gout (intolerant to colchicine)

• Acute/chronic hepatitis

• Sarcoidosis

• Mountain sickness

10. Diagnostic uses:

a. Dexamethasone suppression test: If dexamethasone fails to decrease cortisol release (+ve test), the patient is having Cushing’s syndrome due to anterior pituitary cause. Test is negative (decreases cortisol release), if patient is suffering from adrenocortical tumours.

b. This test is also used to diagnose endogenous depression.

11. Uses of steroids in dentistry: The Glucocorticoids are used to treat following diseases:

• Oral ulceration and oral mucosal lesions:

For this they may be used topically or systemically depending on need, e.g.

(a) use of short course of systemic corticoids in moderate to severe erythema multiformis;

(b) use of a high potency topical steroid preparation such as fluocinonide, betamethasone, or clobetasol in severe cases of recurrent aphthous stomatitis;

(c) use of systemic corticosteroid therapy in oral manifestation of pemphigus;

(d) use of topical medication with 0.05% fluocinonide and 0.05% clobetasol in oral lichen planus;

(e) rarely use of systemic corticosteroid for brief treatment of severe exacerbations or for short period of treatment of recalcitrant cases of oral lichen planus that fail to respond to topical steroids (prednisolone 40—50 mg. daily for 10 days without tapering).

For topical application, Glucocorticoids are used in the form of paste so that they adhere to mucosa for a longer duration to have greater benefit.

• Pulp inflammation: A combination of triamcinolone plus tetracycline is used locally over exposed dental pulp. This will reduce the pain and hypersensitivity of pulp.

• Tempormandibular joint pain is treated by giving intra-articular injection of hydrocortisone or prednisolone.

• Bell’s palsy: Administer Glucocorticoids prednisolone systemically.

• Postoperative pain and swelling after surgery, e.g. after removal of impacted third molar and after orthognathic surgery. So give i.m. injection of methyl prednisolone or betamethasone just before surgery.

• For prophylactic purpose, hydrocortisone is used before any operative dental procedure in patients who are taking steroids for a month or more or who have taken them for a month or more during the previous year in order to avoid precipitation of adrenal crisis— a state of profound shock.

• A preoperative antibiotic may be indicated during dental procedures in patients on large doses of glucocorticoids for longer periods because such patients are liable to have delayed wound healing and a decreased resistance to infections.