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Medico-Legal Aspects

of

Burn & Scald

Under the Delhi Sultanates (circa 1325) permission had to be sought prior to any Sati. In time this check against compulsion became a mere formality. In any case Hindu women from royal families continued to burn unchecked. Humayun tried, but withdrew a royal fiat against Sati. Akbar insisted that no woman could commit Sati without the specific permission of his Kotwals. They were instructed to delay the woman's decision for as long as possible. Pensions, gifts and rehabilitative help was offered to the potential Sati to wean her away from committing the Act. Children were strictly forbidden from the practice. The later Moghuls continued to put obstacles in the way but the practice carried on in the areas outside Agra. In their own sphere of influence the Portuguese, Dutch and French banned Sati but efforts to stamp out Sati were formalised only under Lord William Bentinck after 1829. Finally, within 18 months of having assumed the governorship of Bengal, Lord William Bentinck passed the Sati Regulation, XVII of 1827 on 4 December. The regulation was clear, concise and unequivocal in its condemnation of Sati, declaring it illegal and punishable by the criminal courts. It made zamindars, petty land owners, local agents and officers in charge of revenue collection especially accountable for immediate communication to the officers of their nearest police station of any intended sacrifice of the nature described. In case of wilful neglect the responsible officer was liable to a fine of Rs.200 or 6 months in jail for default. No justification was to be made that the victim desired to sacrificed. The death penalty was specially spelled out for any violence or compulsion or helping or assisting in burning of a widow while she laboured under a state of intoxication or stupefaction or because any other cause impeded her free will. In such cases the court was instructed to show no mercy.

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Burn As Understood to a Medico-legist

Burn is an injury to body by dry heat, radiations, electricity, lightening or corrosive chemicals
Scalds are moist heat injury due to boiling water / milk, steam, heated oils or hot Syrup

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Classification

Surface area of body Burnt- (Wallace) Rule of 9 for Adults

Upper limbs 9x2= 18 %
Both lower limbs front 9x2=18 %
Both lower limbs back side 9x2=18 %
Front of trunk 18 %
Back 18 %
Head & Neck 9 %
Genital area 1 %

Rule of 9's for Children: 9% for each arm, 14% for each leg, 18% for head, 18% for front torso, 18% for back torso.

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Depth of Burn

Dupuytren’s classification

1^st Degree- Erythema of skin
2^nd Degree- Epidermis involved Blister
3^rd Degree- Outer part of dermis also burnt
4^th Degree- Whole of skin burnt
5^th Degree- Subcutaneous tissue also burnt
6^th Degree- Muscle & Bone also burnt

Wilson’s classification- Only 3 Degrees

Epidermal; Dermoepidermal; & Deep burn

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1^st degree- Erythema; 2^nd degree- Epidermal; 3^rd degree- also outer part of dermis; 4^th degree- whole skin; 5^th degree- subcutaneous tissue; 6^th degree- muscles & bones

Burns are caused by flames, highly heated solids, or very cold solids, as solid carbonic acid; scalds, by steam or hot fluids. Burns may cause death from shock, suffocation, œdema glottidis, inflammation of serous surfaces, bronchitis, pneumonia, duodenal ulcer, coma, or exhaustion. A burn of the skin inflicted during life is followed by a bleb containing serum; the edges of this blister are bright red, and the base, seen after removing the cuticle, is red and inflamed; if sustained after death, a bleb, if present, contains but little fluid, and there are no signs of vital reaction. There are six degrees of burns: (1) Superficial inflammation; (2) formation of vesicles; (3) destruction of superficial layer of skin; (4) destruction of cellular tissue; (5) deep parts charred; (6) carbonization of bones.

The larger the area of skin burnt, the more grave is the prognosis. Burns of the abdomen and genital organs are especially dangerous. Young children are specially liable to die after burns.

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Clinical Classification

1. Dermo-epidermal 2. Deep burn
Minor – 1^st & 2^nd Degree of Wilson involving less than 10% of body surface
Moderate- 1^st & 2^nd Degree of Wilson involving less than 15% of body
Severe- 1^st & 2^nd Degree burn involving more than 15% of body surface

or 3^rd Degree of Wilson involving more than 10 % of surface

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Pathology of Burn/ Scald

Destruction of tissue

Frank Charring & Carbonisation
Or Coagulation necrosis

Epithelial cells

elongated, flattened
Stains deeply with haematoxylin

Small haemorrhages may be present in deep layer of skin
Vacuolisation in epidermal & dermal layers

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Characteristics of Burn�As per the Causative Agents

Highly Heated Solid Mass

Applied for a very Short Time

Redding & blister corresponding to the size & shape

Some what prolonged

Skin dark in colour, dry, wrinkled, & Hardened
Heated objects imprint on skin identifiable

Prolonged

Charring & destruction Hair singed

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Cont.

Flame

Short Application

Vesication may or may not be present
Singed hair, Blackened skin

Prolonged Application

Underlying tissue, muscles hardened and roasted

Kerosene oil or petrol

Burn Covers large surface area & deep
Sooty blackening of part & smell

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Effect of Intensity of Heat

Burn due to ignition of clothes

Death will not take place on the spot

In house fire

Body never completely consumed

Incineration for 1- 1 ½ hrs at 1100⁰ C

2 to 3 Kg residue human bones still identified

Prolonged exposure to heat

Hardens underlying muscles

Intense heat applied for short duration

Skin charred but muscles soft

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Cont.

Corrosive substances

No blisters, Hairs not singed, Red line absent
Specific colour as per the corrosive
Gradually ulcerates which is slow to heal

X-ray, & Radiations

More often present as dermatitis or eczematous reaction
Ulceration with delayed healing & ill formed scar

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Cont.

Electricity-Joule Burn

Contact with live wires or unprotected electrical outlets can also cause burn injuries. The severity of these types of burns depends on the intensity of the electrical current and the duration of exposure.
Both at the point of entry and exit burn of varying severity is seen from minor hardening of tissue to crater formation with raised borders and ironed floor.
There may be flame burn due to ignition of fire

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Cont.

Lightning- Arborescent or filigree mark

Due to high voltage current
Heated air, flash, or fire
Blast effect

Scalds

Blisters present prominently, hairs not singed
Splashing/spilling/ or dribbling mark present
Overlying cloth not damaged

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Examination of Burnt Person

Clothing

Nature of cloth and extent of clothing
Burning clothing worse than being naked
Presence of cloth or cotton with body which is not part of garment of the person
Presence of K-oil or other fuel oil, Ghee etc.
Residue of brassier, panties & cloth in axillary and inguinal fold should be searched if body covered in fresh clothing and preserved.

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History of Present Illness

To be recorded by the treating doctor in detail which can be used as dying declaration if so needed

Usually the patient is threatened to narrate a concocted story by the tormentor
Pay attention to the demeanour of Pt.

Recording of dying declaration

Talk to the Pt. while he/she is alone

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Associated Other injuries

Heat rupture of skin
Thermal fractures
Heat haematoma
Accidental Injuries

Collapse of burning material, roof wall etc.
Injuries sustained in trying to escape, due to fall or jumping

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Associated Poisoning

Homicidal poisoning
Toxic Gases Produced in burning material

Nitrogen, Oxides of Nitrogen & Methane
Hydrogen Cyanide (HCN)
CO

Smoke Particle Size

5 to 30 micron- Impacted in nasopharyngeal passage
1 to 5micron- up to large airways
Less than 1.5 micron reach alveoli

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Of Complications

Oedema of the glottis
Pulmonary oedema, Patchy pneumonia
Pleural effusion
Curling ulcers with severe gastrointestinal bleeding

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Outcome of treatment

What Result followed or likely to follow

Depends on

Extent of surface burnt- 1/3 or more of body dangerous to life
Part Burnt-
Depth of burn & complications
Age of the Patient

Death-

Burn involving more than 50% of surface area

Scar deformity & Psychiatric disorders
Causa causati

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Causes of Death

Immediate-

Shock, suffocation, CO poisoning.

Delayed

Oedema glottis, inflammation of serous surfaces, bronchitis, pneumonia, duodenal ulcer. multiple organ failure or respiratory distress syndrome.

Late causes of death

Anaemia, hypoproteinaemia, exhaustion, thromboembolism

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Injury Report

Simple injury

1^st & 2^nd degree not extensive

Grievous Injury

50 % or more endangers life
Hospitalisation for more than 20 days
Disfiguration of head or face
Permanent loss of sight
Permanent impairment of a member or joint

Due to cicatrix and contraction

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Age of Burn

Stages of reparative process

Redness immediately
Vesication within an hour
Dry brown crust within 48 to 72 hrs
Pus in 2 to 3 days but not earlier than 36 hrs
Separation of slough

Superficial in 1 week
Deep in 2 weeks

Cicatrix after several weeks or months

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Whether all burnt area of same age

In freshly burnt individual presence of old burnt, healing area, scars or depigmented patches can be identified.
After a week or so depending on the depth of burn areas show different stages of healing though caused on the same time

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Medico-Legal Questions

Is the injury Burn or Scald

How was it caused

Whether Accidental / Suicidal/ Homicidal ?
In case the patient was brought dead to the hospital

Was the Burn injury Ante-mortem Or post-mortem

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Whether Accidental

Burns are mostly accidental

In India 7165 died in 1998 due to Stove Accident 1280 among them were male
In USA, Burn injuries are second to motor vehicle accidents as the leading cause of accidental death

2.4 million burn injuries are reported per year.
650,000 are treated by doctors
75,000 are hospitalized.
Of those hospitalized,

20,000 have major burns involving at least 25% of body surface.
8000 and 12,000 of patients with burns die,
Significant number suffer permanent disability

Burn injuries are second to motor vehicle accidents as the leading cause of accidental death in the United States. R. B. Ahuja, a surgeon who is secretary of the National Academy of Burns in India, an association of burn doctors, estimates that perhaps a quarter of the injuries he sees are a result of accidents with kerosene pump stoves. Others consider that vast majority are suicide or murder

R. B. Ahuja, a surgeon who is secretary of the National Academy of Burns in India, an association of burn doctors, estimates that perhaps a quarter of the injuries he sees are a result of accidents with kerosene pump stoves.Cheap pump-action kerosene stoves, used mainly by the urban poor, are the most dangerous, say surgeons and experts.

Burn injuries, which have reached epidemic proportions in recent years, are considered a health care problem which is more serious than the polio epidemic was at its peak. It has only been in the past several years that the medical profession has begun to recognize and understand the problems associated with burns. In the 1950s there were less than 10 hospitals in the United States that specialized in burns. Since that time, there has been significant advancement in understanding the problem of burn injuries and there are now about 200 special burn care centers in the United States.

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Accidental Cont.

For people above 75 years

Most frequent place of burn- Kitchen
followed by Outdoor fire accidents

From ages 5 to 74 years,

Most burn injuries occur outdoors- Deepawali
Next most frequent area being the kitchen.

Children ages newborn to four years-old,

Are most frequently admitted for emergency burn care in a hospital.
The kitchen is the most frequent area in the home
The next most frequent area is in the bathroom

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Suicidal Burn

Is preternatural/ spontaneous combustibility possible?

Alcohol, Gases formed in the living, gases formed after death may be influencing factor
Some ignited object was nearby but was inadequate to burn the body
Body was more burnt than clothing or surrounding
The body was fat

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By extension from the mythic Sati, the term is also used for the death, voluntary or involuntary, of widows on the funeral pyres of their husbands in India. The term is also extended to refer to the widow herself. For this usage, the term is often written using the old English spelling of suttee. Though supposed to be voluntary, it is believed to have been often enforced on the widow by various social pressures, or by the use of drugs. In medival periods, due to widespread Islamic invasions and rampage that follows, Sati must have served as the best way to protect the widowed women from the invading armies. This practice when performed in large numbers by women of royal families was called Jauhar. after the death of Dasharatha Kausalya, Sumitra, Kaikeyi do not perform Sati. While Tara, wife of Vali, the monkey king performs Sati Madri, second wife of Pandu performs Sati while Kunti, the first wife does not. if any person commits sati, whoever abets the commission of such sati, either directly or indirectly, shall be punishable with death or imprisonment for life and shall also be liable to fine.

(2) If any person attempts to commit sati, whoever abets such attempt, either directly or indirectly, shall be punishable with imprisonment for life and shall also be liable to fine.THE COMMISSION OF SATI (PREVENTION) ACT, 1987 (No. 3of 1988)

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Suicidal Burn

Popularity of fire
Easy availability- K-Oil + Match Box
Self Immolation

On Social injustice- More by males
Domestic quarrels- More in females

Cruelty & torture by in laws

Failure in love or examination ?
On some social or political issue

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Homicidal Burn

Evidence of tying to a post
Evidence of tying of hands and/ or feet
Evidence of assault

and/ or poisoning present

6975 dowry death in 1998
4648 dowry death in 1995

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Dowry Death

When death of a woman occurs due to burn or other bodily injury or in circumstances other than normal within 7 years of marriage and it is seen that she was subjected to cruelty or harassment by her husband or any relative of the husband for or in connection with any demand for dowry, such death shall be called “dowry death” and the husband or his relative shall be deemed to have caused her death. (Sec. 304 B IPC)

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Punishment for Non-fatal Homicidal Burn

Simple Hurt- I year with fine

If caused by fire – 3 years with fine( Sec. 324 IPC)

Grievous Hurt- 7 years with fine

If caused by fire – 10 years with fine (Sec. 326 IPC)

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Ethical Aspects

Expenses in Treatment

Burns are one of the most expensive injuries to treat.

Patient /Care taker relationship

Economical, physical, & mental strain

What the patient wants

Informed consent

Futility of Treatment

Doctor to question the moral basis for treatment

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