It must be remembered that Dr. Jhala was not out to discover whether any offence had been committed. He was making a postmortem examination of a body which, under the Coroner's order, had been handed over to the medical authorities with a certificate from a hospital that death was due to diabetic coma. It was not then a medico-legal case; the need for postmortem had arisen, because the peon had noticed certain marks on the neck, which had caused some suspicion. After discovering that the mark on the neck was a postmortem injury, all that he had to do was to verify whether the diagnosis made by the G.T. Hospital that death was due to diabetic coma was admissible. He examined the body, found no other cause of death, and the Chemical Analyser not having reported the administration of poison, he accepted the diagnosis of the G. T. Hospital as correct. Dr. Jhala, however, stated that there were numerous poisons which could 487 not be detected on chemical analysis even in the case of normal, healthy and undecomposed viscera. He admitted that his opinion that death could have occurred due to diabetic coma was an inaccurate way of expressing his opinion.
According to him, the proper way would have been to have given the opinion death by diabetes with complications.” As we have said, all these papers were placed before Dr. H.
S. Mehta for his expert opinion. It is to his evidence we now turn to find out what was the cause of death of Laxmibai. In the middle of March 1958, Dr. Mehta was consulted about this case, and he was handed over copies of all the documents we have referred to in connection with the medical evidence, together with the proceedings of the Coroner's inquest at Bombay. According to Dr. Mehta, opinion was sought from him about the cause of death of 'Indumati Paunshe' and whether it was from diabetic coma, any other disease or the administration of a poison. Dr.
Mehta was categorical that it was not due to diabetic coma.
He was also of the opinion that no natural cause for the death was disclosed by the autopsy, and according to him, it was probably due to the administration of some unrecognisable poison or a recognisable poison which, due to the lapse of time, was incapable of being detected by analysis. He gave several reasons for coming to the conclusion that Laxmibai did not suffer from diabetic coma.
Each of his reasons is supported by citations from numerous standard medical authorities on the subject, but it is unnecessary to cite them once again. According to him, the following reasons existed for holding that Laxmibai did not suffer from diabetic coma:
(1) Convulsion never occur in diabetic coma per se.
According to Dr. Mehta, the involuntary movements described by Dr. Ugale must be treated as convulsions or tremors. We are of opinion that Dr. Ugale would not have made this note on the case papers if he had not seen the involuntary movements. No doubt, these involuntary movements had ceased by the time the patient was carried to Ward No. 12, because Dr. Miss Aneeja made a note that they were not observed in 488 the Ward. But Dr. Ugale was a much more experienced doctor than Dr. Miss Aneeja, and it, is possible that Dr. Miss Aneeja did not notice the symptoms as minutely as the Casualty Medical Officer.
(2) Diabetic coma never occurs all of a sudden and without a warning. There are premonitary signs and symptons of prodromata. In the case, there is no evidence to show how Laxmibai became unconscious. We have, however, the statement of the appellant made both to Dr. Ugale and Dr.
Miss Aneeja that the onset was sudden. Dr. Mehta was crossexamined with a view to eliciting that a sudden onset of diabetic coma was possible if there was an infection of any kind. A suggestion was put to him that if the patient suffered from Otitis Media, then sometimes the unconciousness came on suddenly. It may be pointed out that the appellant in his examination stated that on the day in question, Laxmibai had a temperature of 100 degrees, laryngitis, pharyngitis, and complained of pain in the ear.
That statement was made to bring his defence in line with this suggestion. Dr. Mehta pointed out that Dr. Jhala had opened the skull and had examined the interior organs but found no pathological lesion there. According to Dr. Mehta, Dr. Jhala would have detected pus in the middle ear if Otitis Media had existed. The fact that no question suggesting this was put to Dr. Jhala shows that the defence is an afterthought to induce the Court to hold that death was due to diabetic coma, or, in other words, to natural causes. We are inclined to accept the evidence of Dr. Jhala that he and his assistants did not discover any pathological lesion in the head or the brain. Otitis Media would have caused inflammation of the Eustachian tube, and pus would have been present. No such question having been put, we must hold that there was no septic focus which might have induced the sudden onset of diabetic coma. It was also suggested to Dr. Mehta that there was a tubercular infection and sometimes in the case of tubercular infection diabetic coma suddenly supervened. The tuberculosis in this case was not of such severity as to have caused this. Dr. Jhala referred 489 to the septic focus in the apex of the left lung, but he stated that it was riot sufficient to have caused the death of Laxmibai. Illustrative cases of sudden diabetic coma as a result of tubercular infection were not shown, and the condition of Laxmibai, as deposed to by witnesses right up to 9 p.m. on the night of November 12, 1956, does not warrant- the inference that she had diabetic coma suddenly as a result of this infection.
(3) Dr. Mehta also stated from the case papers maintained by the appellant from February 15, 1956, to November 12, 1956, that during that time, Laxmibai did not appear to have suffered from any severe type of acidosis. The appellant in his examination in Court stated that Laxmibai was prone to suffer from acidosis, and that he had treated her by the administration of Soda Bi-carb. In the case papers, Soda Bicarb has been administered only in about 8 to 10 doses varying between 15 grains to a dram. It is significant that on most of the occasions it was part of a Carminative mixture. The acidosis, if any, could not have been so severe as to have been corrected by such a small administration of Soda Bi-carb, because the acidosis of diabetes is not the acidity of the stomach but the formation of fatty acids in the system. Such a condition, as the books show, may be treated by the administration of Soda Bicarb but in addition to some other specific treatment.
(Joslin, Root & White, Treatment of Diabetes Mellitus, p.
(4) A patient in diabetic coma is severely dehydrated.
(Root & White-Diabetes Mellitus p. 118). We have already pointed out that there was no dehydration, because the skin was soft and elastic and the tongue was pink. The eye balls were also normal and were not soft, as is invariably the case in diabetic coma. Dr. Mehta has referred to all these points.
(5) Nausea and vomiting are always present in true diabetic coma. There is nothing to show either from her clothes or from the smell of vomit in the mouth or from any other evidence that Laxmibai had vomitted in the train. Dr. Jhala who performed the 490 postmortem examination had stated that Laxmibai could not have vomitted because in her stomach 4 oz. of pasty meal was found. The same fact is also emphasised by Dr. Mehta.
(6) In diabetic coma, there will befall of blood pressure, rapid pulse; there will be Kussmaul breathing or air hunger. The respiration of Laxmibai was found by Dr.
Ugale and Dr. Miss Aneeja to be normal. The temperature chart in the case, Ex. 129, gives in parallel columns the respiration corresponding to a particular temperature, and the temperature of 99.5 degrees (Fahrenheit) found by Dr.
Miss Aneeja corresponds to respiration at 20 times per minute. Dr. Variava, Dr. Ugale or Dr. Miss Aneeja also did not say anything about the Kussmaul breathing, and the pulse of 100 per minute according to Dr. Mehta was justified by the temperature which Laxmibai then had. Indeed, according to Dr. Mehta, in diabetic coma the skin is cold, and there was no reason why there should be temperature. According to Dr. Mehta, there was no evidence of any gastric disturbance, because the condition of the tongue was healthy. Dr. Mehta also pointed out that the Extensor reflex called the, Babinsky sign was not present in diabetic coma, while according to Dr. Miss Aneeja it was present in this case.
Dr. Mehta then referred to the examination of the urine for sugar and acetone, and stated that the examination for sugar was insufficient to determine the presence of Ketonuria, which is another name for the acidosis which results in coma. We have already found that the examination for acetone was not made and there was no mention of acetone breath either by Dr. Ugale or by Dr. Miss Aneeja, which would have been present if the acidosis was so advanced.
(Root & WhiteDiabetes Mellitus, p. 118).
(8) Lastly, the examination of cerebro-spinal fluid did not show any increase of sugar and no affection in the categories of meningial irritation was disclosed by the chemical analysis of the fluid. (Physician's Hand. book, 4th Edn., pp. 115-120). The neck rigidity which was noticed by Dr. Miss Aneeja did not have, therefore, 491 any connection with such irritation, and it is a question whether such a slight neck rigidity existed at all.
These reasons of Dr. Mehta are prefectly valid. They have the support of a large number of medical treatises to which he has referred and of even more. which were referred to us during the arguments, all which we find it unnecessary to quote. We accept Dr. Mehta's testimony that diabetic coma did not cause the death of Laxmibai. It is significant that the case of the appellant also has changed, and he has ceased to insist now that Laxmibai died of diabetic coma.
The treatment which was given to Laxmibai would have, if diabetic coma had existed, at least improved her condition during the 5 hours that she was at the hospital. Far from showing the slightest improvement, Laxmibai died within 5 hours -of her admission in the hospital, and in view of the contra indications catalogued by Dr. Mehta and accepted by us on an examination of the medical authorities, we are firmly of opinion that death was not due diabetic coma.
We now deal with events that took place immediately after Laxmibai expired. We have already shown that at that time Dr. Variava was present and was questioning Dr. Miss Aneeja about her diagnosis of diabetic coma. Before Dr. Variava left the Ward, he told Dr. Miss Aneeja that he was not satisfied about the diagnosis, and that a postmortem examination should be asked for. This endorsement was, in fact, made by Dr. Miss Aneeja on the case papers, and the final diagnosis was left blank. Dr. Miss Aneejia says that she left the Ward at about 11-30 a.m. and was absent on her rounds for an hour, then she returned to the Ward from her quarters at about 1 p.m. and went to the office of Dr.' Mouskar, the Resident Medical Officer. According to her, she met Dr. Saify, the Registrar, at the door, and he had the case papers in his hands. Dr. Saify told her that the Resident Medical Officer thought that there was no need for a postmortem examination, as the patient was treated in the hospital for diabetic coma. Dr. Saify ordered Dr. Miss Aneeja to cancel the endorserment about 492 postmortem and to write diabetic coma as the cause of death, which she did, in Dr. Saify's presence. This is Dr. Miss Aneeja's explanation why the postmortem was not made, though ordered by Dr. Variava.
Dr. Mouskar's version is quite different. According to him, the case papers arrived in his office at 1 p.m. He had seen the endorsement about the postmortem and the fact that the final diagnosis had not been entered in the appropriate column. Dr. Mouskar admitted that he did not proceed to make arrangements for the postmortem examination. According to him, the permission of the relatives and the Coroner was necessary. He also admitted that he did not enquire from the Honorary Physician about the need for postmortem examination. He was thinking, he said, of consulting the relatives and the person who had brought Laxmibai to the hospital. Dr. Mouskar sent a telegram at 2 p.m. to the appellant, which we have quoted earlier. He explained that he did not mention the postmortem examination, because he was waiting for the arrival of some person connected with Laxmibai. He further stated that between 4 and 5 p.m. he asked the police to remove the body to the J. J. Hospital morgue and to preserve it, and sent a copy of his requisition to the Coroner. According to him, on the 15th the Coroner's office asked the hospital for the final diagnosis in the case. He stated that he asked one out of the three: Honorary Physician, the Registrar or the House Pbysician,-about the final diagnosis, though he could not say which one. He had sent the papers through the call-boy for writing the final diagnosis, and he received the case papers from the Unit, with the two corrections, namely, the cancellation of the requisition for postmortem examination and the entry of diabetic coma as the final diagnosis. He denied that he had any talk with Dr. Saify regarding the postmortem examination.
It,would appear from this that there are vital differences in the versions of Dr. Miss Aneeja and Dr. Mouskar. The first contradiction is the date on which the case papers were corrected and the second, about Dr. SaifY's intervention in the matter. Dr. SaifY, 493 fortunately for him, had obtained leave orders and had left Bombay on November 8, 1956, for Indore, where his father was seriously ill. He was, in fact, detained at Indore, because his father suffered from an attack of coronary thrombosis, and he had to extend his leave. All the relevant papers connected with his leave have been produced, and it seems that Dr. Saify's name was introduced by Dr. Miss Aneeja either to avoid taking responsibility for correction, on her own, of the papers, or to shield some other person, who had caused her to make the corrections. Here, the only other person, who could possibly have ordered her was the Resident Medical Officer, Dr. Mouskar, who at 1 p.m. had received the papers and had seen the endorsement about the postmortem examination. Dr. Mouskar's explanation that he sent the telegram to the appellant for the removal of the body without informing him about the postmortem examination is too ingenious to be accepted by any reasonable person. Dr.
Mouskar could not ordinarily countermand what the Honorary Physician had said without at least consulting him, which he admits he did not do. This is more so, if it was only a matter of the hospital's reputation. Whether the corrections were made by Dr. Miss Aneeja in the wards when the call-boy took the papers to her (a most unusal course for Dr. Mouskar to have adopted) or whether they were made by Dr. Miss Aneeja in the office of Dr. Mouskar, to the door of which, she admits she had gone, the position remains the same. Dr. Miss Aneeja no doubt told lies, but she did so in her own interest. She could not cancel the requisition about postmortem examination on her own without facing a grave charge in which Dr. Mouskar would have played a considerable part. The fact that this correction did not trouble Dr. Mouskar and that his dealings with the body were most unusual points clearly to its being made at his instance. Dr. Miss Aneeja invented the story about Dr.
Saify as a last resort knowing that unless she named somebody the responsibility would be hers. The corrections were made at the instance of Dr. Mouskar, because Dr.
Mouskar admits that he sent the papers to the 63 494 Ward for final diagnosis in the face of the endorsement for postmortem examination, and Dr. Miss Aneeja admits making the corrections at the door of Dr. Mouskar's office.
In our opinion, both of them are partly correct. Dr.
Mouskar made the first move in getting the papers corrected, and Dr. Miss Aneeja corrected them not at the door of the office, because there was no Dr. Saify there but in the office, though she had not the courage to name Dr. Mouskar as the person who had ordered the correction. Dr. Mouskar's telegram and his sending the body to another morgue without the postmortem examination show only too clearly that it was he who caused the change to be made. It is also a question whether the correction about 'acetone + + 'was not also made simultaneously. We do not believe that the corrections were made as late as November 15, because his telegram for the removal of the dead body and its further removal to the J.
J. Hospital would not fit in with the endorsement for postmortem examination on the case papers.
Now, the question is not whether Dr. Mouskar made the correction or Dr. Miss Aneeja, but whether the appellant had anything to do with it. Dr. Miss Aneeja stated that the appellant was present till the visit of Dr. Variava was over and this is borne out by the reply of the appellant, because in the inland letter he mentioned the time of the death which the telegram did not convey to him and which he could have only known if he was present in the hospital. We believe Dr. Miss Aneeja when she says that the appellant was present at the hospital, and the circumstances of the case unerringly point to the conclusion that he knew of the demand for a postmortem examination. Though Dr. Mouskar and the appellant denied that they met, there is reason to believe that the appellant knowing of the postmortem examination would not go away without seeing that the postmortem examination was duly carried out or was given up.
Dr. Mouskar and the appellant both admitted that they were together in the same class in 1934 in the S P. College, Poona, though both of them denied that 495 they were acquainted with each other. Dr. Mouskar stayed in Poona from 1922 to 1926, 1931 to 1936 and 1948 to 1951. The appellant was practising at Poona as a doctor, and it is improbable that they did not get acquainted during Dr.
Mouskar's stay, belonging, as they do, to the same profession. Dr. Mouskar further tried to support the appellant by saying that at 1 p.m. when he saw the case papers the entry about acetone was read by him. He forgot that in the examinationin-chief he had stated very definitely that he had not read the case papers fully and had only seen the top page. When he was asked for his explanation, he could not account for his conduct in the witness-box, and admitted his mistake. There are two other circumstances connected with Dr. Mouskar, which excite considerable suspicion. The first is that he mentioned hysterical fits as the illness from which Laxmibai suffered when Dr. Ugale had questioned it and postmortem had been asked for to establish the cause of death. The next is that the call book of the hospital for the period was not produced by him as long as he was in office. When he retired, the call book was brought in by his successor, and it established the very important fact that it was not Dr.
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