हम देखेंगे लाज़िम है कि हम भी देखेंगे वो दिन कि जिसका वादा है जो लोह-ए-अज़ल में लिखा है जब ज़ुल्म-ओ-सितम के कोह-ए-गरां रुई की तरह उड़ जाएँगे हम महक़ूमों के पाँव तले ये धरती धड़-धड़ धड़केगी और अहल-ए-हक़म के सर ऊपर जब बिजली कड़-कड़ कड़केगी जब अर्ज-ए-ख़ुदा के काबे से सब बुत उठवाए जाएँगे हम अहल-ए-सफ़ा, मरदूद-ए-हरम मसनद पे बिठाए जाएँगे सब ताज उछाले जाएँगे सब तख़्त गिराए जाएँगे बस नाम रहेगा अल्लाह का जो ग़ायब भी है हाज़िर भी जो मंज़र भी है नाज़िर भी उट्ठेगा अन-अल-हक़ का नारा जो मैं भी हूँ और तुम भी हो और राज़ करेगी खुल्क-ए-ख़ुदा जो मैं भी हूँ और तुम भी हो Faiz Ahmed Faiz

हम देखेंगे लाज़िम है के हम भी देखेंगे वो दिन कि जिसका वादा है जो लौहे-अज़ल पे लिखा है जब ज़ुल्मों-सितम के कोहे-गरां रूई की तरह उड़ जाएंगे हम महकूमों के पांव तले ये धरती धड़-धड़ धड़केगी और अहले-हिकम के सर ऊपर जब बिजली कड़-कड़ कड़केगी जब अर्ज़े-खुदा के काबे से सब बुत उठवाए जाएंगे हम अहले-सफा मर्दूदे-हरम मसनद पे बिठाए जाएंगे सब ताज उछाले जाएंगे सब तख्त गिराए जाएंगे बस नाम रहेगा अल्लाह का जो गायब भी है, हाज़िर भी जो मंज़र भी है, नाज़िर भी उठ्ठेगा अनलहक़(*) का नारा जो मैं भी हूं और तुम भी हो और राज़ करेगी खल्क़े-खुदा जो मैं भी हूं और तुम भी हो .

We shall Witness It is certain that we too, shall witness the day that has been promised of which has been written on the slate of eternity When the enormous mountains of tyranny will blow away like cotton. Under our feet- the feet of the oppressed- when the earth will pulsate deafeningly and on the heads of our rulers when lightning will strike. From the abode of God When icons of falsehood will be taken out, When we, the righteous ones, the heretics will be seated on high cushions When the crowns will be tossed, When the thrones will be brought down. Only The name will survive Who is invisible but is also present Who is both the spectacle and the beholder 'I am the Truth'- the cry will rise, Which is I, as well as you And then God’s creation(people) will rule Which is I, as well as you

अनलहक़ - 'मैं सत्य हूँ' , 'मैं ईश्वर हूँ'; ऐसा कहने पर इरानी सूफ़ी संत मंसूर को सरे आम सज़ा-ए-मौत दी गयी थी.

"ज़िन्दान नामा (कारावास का ब्यौरा)" फ़ैज़ अहमद फ़ैज़

बोल कि लब आज़ाद हैं तेरे

बोल, ज़बाँ अब तक तेरी है

तेरा सुतवाँ जिस्म है तेरा

बोल कि जाँ अब तक तेरी है

आईए हाथ उठाएँ हम भी

हम जिन्हें रस्म-ए-दुआ याद नहीं

हम जिन्हें सोज़-ए-मुहब्बत के सिवा

कोई बुत कोई ख़ुदा याद नहीं

लाओ, सुलगाओ कोई जोश-ए-ग़ज़ब का अंगार

तैश की आतिश-ए-ज़र्रार कहाँ है लाओ

वो दहकता हुआ गुलज़ार कहाँ है लाओ

जिस में गर्मी भी है, हरकत भी, तवानाई भी

हो न हो अपने क़बीले का भी कोई लश्कर

मुन्तज़िर होगा अंधेरों के फ़ासिलों के उधर

उनको शोलों के रजाज़ अपना पता तो देंगे

ख़ैर हम तक वो न पहुंचे भी सदा तो देंगे

दूर कितनी है अभी सुबह बता तो देंगे

(क़ैद में अकेलेपन में लिखी हुई)

निसार मैं तेरी गलियों के ऐ वतन

के जहाँ चली है रस्म के कोई न सर उठा के चले

गर कोई चाहने वाला तवाफ़ को निकले

नज़र चुरा के चले, जिस्म-ओ-जाँ बचा के चले

चंद रोज़ और मेरी जाँ, फ़क़त चंद ही रोज़

ज़ुल्म की छाँव में दम लेने पर मजबूर है हम

और कुछ देर सितम सह लें, तड़प लें, रो लें

अपने अजदाद की मीरास हैं, माज़ूर हैं हम

आज बाज़ार में पा-बेजौला चलो

दस्त अफशां चलों, मस्त-ओ-रक़सां चलो

ख़ाक़-बर-सर चलो, खूँ ब दामां चलो

राह तकता है सब, शहर ए जानां चलो

बोल कि होठ स्वतंत्र हैं तेरे

बोल, जीभ अब तक तेरी है

तेरा कसा हुआ शरीर है तेरा

बोल कि प्राण अब तक तेरे है

आईए हाथ उठाएँ हम भी

हम जिन्हें पूजा करने का तरीक़ा याद नहीं

हम जिन्हें प्रेम की भावनाओं (जज़बात) के सिवा

कोई बुत कोई भगवान याद नहीं

लाओ, सुलगाओ कोई ग़ज़ब के उत्साह की ज्वाला

दीवानेपन की आग लाओ

दहकता हुआ गुलज़ार (फूलों से भरपूर) लाओ

जिस में गर्मी भी है, चलन भी, ऊर्जा भी

अवश्य अपने जैसे लोगों का कोई गुट

इस अन्धकार में दूरी पर मेरी प्रतीक्षा कर रहा होगा

मेरी जलाई ज्वाला के शोले बेकार नहीं - वे उन्हें मेरी मौजूदगी के बारे में बताएँगे

वो मुझे बचाने मुझ तक न भी पहुँच पाए, तो मुझे पुकारेंगे ज़रूर

इस रात की प्रभात कितनी देर में होनी है, मुझे ख़बर दे देंगे

(क़ैद में अकेलेपन में लिखी हुई)

न्यौछावर हूँ मैं तेरी गलियों पर ऐ राष्ट्र

कि जहाँ चली है प्रथा के कोई न सिर उठा के चले

अगर कोई चाहने वाला सैर को निकले

नज़र चुरा के चले, तन और प्राण बचा के चले

कुछ दिन और मेरी प्रिय, केवल कुछ ही दिवस

ज़ुल्म की छाँव में दम लेने पर मजबूर है हम

और कुछ देर अत्याचार सह लें, तड़प लें, रो लें

अपने पूर्वजों की देन (करनी का नतीजा) हैं, हम निर्दोष हैं

आज बाज़ार में ज़ंजीरों में जकड़े पाँव के साथ चलो

हाथ हिलाते हुए चलो, मस्त हुए नाचते हुए चलो

धूल से भरा हुआ सिर लेकर चलो, ख़ून से लथपथ दामन लेकर चलो

रास्ता देख रहा है वो, प्रियतमा के शहर चलो

THE LEGAL BASIS OF CONSENT

1.     The element of consent is one of the critical issues in medical treatment. The patient has a legal right to autonomy and self determination enshrined within Article 21 of the Indian Constitution. He can refuse treatment except in an emergency situation where the doctor need not get consent for treatment. The consent obtained should be legally valid. A doctor who treats without valid consent will be liable under the tort and criminal laws. The law presumes the doctor to be in a dominating position, hence the consent should be obtained after providing all the necessary information.

2.    The element of consent is one of the critical issues in the area of medical treatment today. It is well known that the patient must give valid consent to medical treatment; and it is his prerogative to refuse treatment even if the said treatment will save his or her life. No doubt this raises many ethical debates and falls at the heart of medical law today. The earliest expression of this fundamental principle, based on autonomy, is found in the Nuremberg Code of 1947. The Nuremberg Code was adopted immediately after World War II in response to medical and experimental atrocities committed by the German Nazi regime [1947. Neurenberg Code]. The code makes it mandatory to obtain voluntary and informed consent of human subjects. Similarly, the Declaration of Helsinki adopted by the World Medical Association in 1964 emphasizes the importance of obtaining freely given informed consent for medical research by adequately informing the subjects of the aims, methods, anticipated benefits, potential hazards, and discomforts that the study may entail [1964. Declaration of Helsinki]. Several international conventions and declarations have similarly ratified the importance of obtaining consent from patients before testing and treatment. The present paper examines the entire gamut of issues pertaining to consent from the point of view of the legal environment as it exists in India today. The circle of legal development in the area (i.e., consent) appears to be almost complete when the apex court in India recently ruled that, it is not just the ‘consent’ or ‘informed consent’ (as it is known worldwide) but it shall also be ‘prior informed consent’ generally barring some specific cases of emergency. This places a medical professional in a tremendous dilemma. Hence, it is time to revisit the area of ‘consent and medical treatment’ to understand the sensitive and underpinning elements.

THE LEGAL BASIS OF CONSENT

3.    Consent is perhaps the only principle that runs through all aspects of health care provisions today. It also represents the legal and ethical expression of the basic right to have one's autonomy and self-determination. If a medical practitioner attempts to treat a person without valid consent, then he will be liable under both tort and criminal law. Tort is a civil wrong for which the aggrieved party may seek compensation from the wrong doer. The consequences would be payment of compensation (in civil) and imprisonment (in criminal). To commence, the patient may sue the medical practitioner in tort for trespass to person. Alternatively, the health professional may be sued for negligence. In certain extreme cases, there is a theoretical possibility of criminal prosecution for assault or battery. The traditional definition of battery is an act that directly and either intentionally or negligently causes some physical contact with another person without that person's consent. If a person has consented to contact expressedly or by implication, then there is no battery. It is a rare case in which a doctor would be held liable for criminal breach, unless there is gross disrespect to the patient's bodily autonomy, for instance, if a patient's organs are taken without his consent.

4.    In tort law, usage of force against any human body, without proper justification, is actionable irrespective of the quantum of force. If the medical practitioner attempts to treat a patient without obtaining proper consent, he will be held guilty under tort law. Consent for treatment may be expressed or implied. The patient entering the consultation chambers by his own volition may be considered to have given consent for a clinical diagnosis to be carried out. Consent may be inferred from the general submission by a patient to orders given by a doctor during clinical diagnosis. This is an excellent example of implied consent. During the clinical examination, there might arise the need for an intimate examination of the patient, such as a vaginal examination. For such an examination, the medical practitioner must ideally obtain another consent by asking the patient's permission orally. Furthermore, if there is a need to undergo an invasive examination, such as an incision or drawing of samples of body fluids, a written consent of the patient is ideally required.

5.    Often medical practitioners ask for precise prescriptions for the situations when written consent is needed. It is interesting to note that what law demands is mere consent and not written consent and does not prescribe such requirement on a mandatory basis. In fact, the medical practice itself determines the need for written consent. Ideally, where the patient is subjected to anesthesia (either local or general) or where the patient is subjected to severe pain during administration of the treatment, a written consent would be helpful. There is no mandate that a doctor should always obtain written consent and failure of which would hold him liable. However, if there is written consent, the medical practitioner would have greater ease in proving consent in case of litigation. To standardize the practice, the Medical Council of India (MCI) has laid down guidelines that are issued as regulations in which consent is required to be taken in writing before performing an operation [ Regulation 7.16, of Medical Council of India (Professional Conduct, Etiquette and Ethics) Regulations.2002.]. The MCI guidelines are applicable to operations and do not cover other treatments. For other treatments, the following may be noted as general guidelines:

a.     For routine types of treatment, implied consent would suffice

b.    For detailed types of treatment, ideally express oral consent may be needed

c.     For complex types of treatment, written express consent is required

CAPACITY AND INFORMATION WHILE SEEKING CONSENT

6.    There are two more additional aspects to be borne in mind: first, valid consent can be obtained only from a patient who is competent to consent and secondly, such consent must also be informed consent. To be competent to give a legally effective consent, the patient must be endowed with the ability to weigh the risks and benefits of the treatment that is being proposed to him. The law presumes that such an ability is generally acquired with the attainment of the age of maturity. A person who has attained the competent age and who has sound mind can give valid consent to the medical practitioner for any treatment. Persons who have attained the age of 18 are generally considered to have attained the age of maturity and are competent to give consent. The law thus presumes capacity, rationality, autonomy, and freedom if the person has attained the age of so called maturity. On the other hand, where there is reason to believe that a patient is unable to understand the nature of the treatment and its benefits or side effects before making the decision, it is necessary to consider whether an adult presumption of capacity is rebutted in that particular case. If the patient is incompetent to give consent, then the consent may be obtained from the attendant of the patient [ Law Commission. Mental Capacity, Law. Com. 1995;231]. In the UK, there are several ethical issues raised regarding the proxy consent on behalf of such persons. Even the Law Commission Report (Mental Incapacity, 1995) suggests few reforms. Irrespective of the age, for a person who is incompetent due to unsoundness of mind, consent will be obtained from the guardian of the patient. In India, the court has not come across borderline cases of an adult refusing treatment leading to emergency and leaving the doctor in a dilemma, unlike in the west [ Re C (Adult: Refusal of Treatment) [1944] 1 All ER 819, Re T (Adult: Refusal of Treatment), [1992] 4 All ER 649, F v West Berkshire Health Authority, [1989] 2 All ER 545, and Gillick v West Norfolk and Wisbech AHA, [1985] 3 All ER 402.].

7.     The law also presumes that the medical practitioner is in a dominating position vis-à-vis the patient; hence, it is his duty to obtain proper consent by providing all the necessary information. Consent without necessary information is no consent at all. Unfortunately, the expression ‘informed consent’ is often used without precision. The “informed consent” doctrine is American in origin and relates to the amount of information that a patient should be provided with to avoid any probable action in negligence. Rarely, a medical practitioner or a hospital administrator can rely upon the consent form signed by the patient, when the contention is that he was made to sign on the dotted lines of such format without proving necessary information. This practice is also developed by the practice of treating the consent form as a one of standard forms of contracts and eliminating all such unfair and sweeping clauses, which will only benefit the medical practitioner. It is rather necessary as the pro-forma is prepared by the medical practitioner/hospital administration, and the patient is left with the choice of either accepting it as whole or rejecting it. Therefore, it is absolute imperative that a medical practitioner provide all relevant information relating to the proposed treatment to the patient in a language understandable to him, while obtaining the much needed consent for the treatment.

8.    However, the nature of the information that a patient must have in order to give informed consent is a debatable question, as the American and English viewpoints differ to some extent. Informed consent from the American sense is often described from the viewpoint of a prudent patient, popularly know as the prudent patient test. In this approach, the highest respect for the patient's right of self-determination about a particular therapy is recognized. This will lead to a so-called objective test of disclosure wherein the doctor will keep in mind the patient and disclose all such information which is required to be given. In other words, there is a presumption that some standard information is required to be disclosed to every patient, and the extent of such disclosure is neither left to the discretion of the doctor (of course leaving out special circumstances where the doctor might have strong reasons for concealing) nor he can rely upon the defense of disclosure like a reasonable medical practice or practitioner [ Canterbury v Spence. 1972. 464 F 2d 772]. In contrast to this, the English approach is doctor centric, which is also popularly narrated as the prudent doctor test of disclosure. Here, the doctor is taken as a professional-man endowed with greater prudence to protect the right interest of the patient and bestowed with the final right to decide what information shall be divulged to the patient considering the circumstances and how much information is to be divulged. Lord Templeman in ‘Sidway’ encapsulated this as follows:

“When the doctor himself is considering the possibility of a major operation, the doctor is able with his medical training, with his knowledge of the patient's medical history, and with his objective position to make a balanced judgment as to whether the operation should be performed or not. The duty of the doctor in these circumstances, subject to his overriding duty to have regard to the best interests of the patient, is to provide the patient with information which will enable the patient to make a balanced judgment if the patient chooses to make a balanced judgment”. [ Sidaway v Board of Governors of the Bethlem Royal Hospital and the Maudsley Hospital and Others [1985] 1 AC 871, HL]

9.    Finally, whatever might be the difference of approach it is evident that a medical practitioner is obligated to provide the necessary information before obtaining consent from a patient. To account for the Indian position, although we do not have much litigation, unlike in the West, it may be concluded that the courts have assigned immense significance to the requirement of informed consent. A medical practitioner in India has a duty to provide all the necessary information to the patient in a language that is understandable to him. Regarding the quantum of information, there are no clear parameters laid down by the courts. Therefore, it is reasonable information which a doctor deems fit considering best practices. Considering the knowledge gap in this regard, the professional regulatory body for medicine can play an important role in establishing standards.

INDIAN LAW ON CONSENT

10.                       The principle of autonomy is enshrined within Art. 21 of the Indian Constitution, which deals with the right to life and personal liberty. The expression personal liberty under Art. 21 is of the widest amplitude and covers a wide variety of rights, including the right to live with human dignity and all that goes along with it, and any act which damages, injures, or interferes with the use of any limb or faculty of a person, either permanently or temporarily [ Maneka Gandhi v Union of India. AIR 1978 SC 597]. However, the common law application of consent is not fully developed in India, although the Indian courts have often referred to these principles. In such situations, obviously one has to refer to the principles of the Indian Contract Act and the Indian Penal Code. The relationship between a medical professional and his patient is a contract by parties competent to contract giving rise to contractual obligations. Parties are generally competent (in accordance with the Indian Majority Act) (i) if they have attained the age of 18, (ii) are of sound mind, and (iii) are not disqualified by any law to which they are subject to. Furthermore, there is a stipulation in the contract law stating that consent of any party (in our case it is the patient) that is obtained by coercion, undue-influence, mistake, misrepresentation or fraud, will render the agreement invalid. However, in England, the General Medical Council guidelines state that the consenting age is 16 years old. A young person can be treated as an adult and can be presumed to have the capacity to decide. If the child is under the age of 16 he or she may have the capacity to decide, depending on his/her ability to understand what is involved. Where a competent child refuses treatment, a person with parental responsibility or the court may authorize investigation or treatment which is in the child's best interests. Interestingly, the position is different in Scotland where those with parental responsibility cannot authorize procedures a competent child has refused.

11. The consent obtained, of course, after getting the relevant information will have its own parameter of operation to render protection to the medical practitioner. If the doctor goes beyond these parameters, he would be treating the patient at his risk, as it is deemed that there is no consent for such treatment at all. A doctor who went ahead in treating a patient, to protect the patient's own interest, was held liable as he was operating without consent [ Ram Bihari Lal v Dr. J. N. Srivastava. AIR 1985 MP 150]. The patient was suspected to have appendicitis. After obtaining due consent, she was subjected to an operation. However, upon incision, it was found that her appendix was normal and not inflamed. To protect the interest of the patient, the doctor removed her gangrenous gall bladder. Later, it was discovered that the kidney of the patient was affected. The doctor was held liable as he was operating without consent. This case law also signifies the traditional notion of paternalism prevalent among the members of the medical fraternity. It is a notion where the doctor takes-up the role of a parent of the patient and starts deciding on behalf of the patient himself. Unfortunately, the law does not accept this notion. The first priority of law is always the right of autonomy of the patient provided he is endowed with necessary capacity. A medical practitioner who believes that a medical procedure is appropriate and necessary for a patient's well being can perhaps be forgiven for believing that the principle of autonomy should be sacrificed in the best interest of the patient. In the present case, had the doctor stopped after realizing that the patient's appendix was normal, he would have been protected as he was working under the valid consent of the patient, and more importantly, mere error of judgment is not culpable. When he proceeded in removing her gall bladder, he was acting sans valid consent, which was an extreme case of professional paternalism and gross disobedience to the right of the patient's autonomy. Hence, some commentators like Mill, et al. have advocated for minimal level of paternalism in the interest of the medical profession and the overall inability of humans in taking rational decisions, during the time of crises [ Mill, J.S., ‘On Liberty’ Harmondsworth: Penguin; 1982. p. 68].

12.                        Regarding proxy consent, when the patient is unable to give consent himself, there are no clear regulations or principles developed in India. If such a situation exists, the medical practitioner may proceed with treatment by taking the consent of any relative of the patient or even an attendant. In one case, the wife of a patient informed the hospital authorities in unambiguous terms that she had no objection to her husband undergoing bypass surgery, her consent was deemed sufficient for the purpose of any formalities with which the hospital was required to comply [ C A Muthu Krishnan v M. Rajyalakshmi. AIR 1999 AP 311].

13.                        Interestingly, in another case the relationship between the patient and his wife were strained. A patient was operated on for sterilization. While giving consent he deposed that he is married and has two baby girls. In fact, he was undergoing an operation only for getting the money as incentive. After the operation, his father contended that the patient was of unstable mind and was not competent to give consent. The court held that if there are no circumstances for a doctor to sense foul play or doubtabout the capacity of the patient, he is protected [ Chandra Shukla v Union of India. AIR 1987 ACJ 628]. These two cases demonstrate that a doctor acting reasonably under normal circumstances is always protected and he is never expected to play the role of an investigative agency.

14.                        Recently, the apex court gave an impacting judgment in the area. Wherein the court observed that “where a surgeon is consulted by a patient and consent of the patient is taken for diagnostic procedure/surgery, such consent can't be considered as authorization or permission to perform therapeutic surgery either conservative or radical (except in a life-threatening emergent situation)” [ Samera Kohli v Dr. Prabha Manchanda and Another. (2008) 2 SCC 1 = AIR 2008 SC 1385 = 2008 (1) SCALE 442]. For the first time in India, the court ruled that however broad consent might be for diagnostic procedure, it can not be used for therapeutic surgery. Furthermore, the court observed that “where the consent by the patient is for a particular operative surgery it can't be treated as consent for an unauthorized additional procedure involving removal of an organ only on the ground that it is beneficial to the patient or is likely to prevent some danger developing in the future, where there is no imminent danger to the life or health of the patient”. This proposition puts fetter upon the role of a “paternal doctor” in the Indian scenario. In one case, a 44-year-old unmarried female consulted her doctor and was advised to undergo a laparoscopy. A few consent forms were taken from her of which one was for admission and another one was for the surgery. The relevant one among such consent forms gave the doctor an allowance to carry out a “diagnostic and operative laparoscopy” and there was an additional endorsement that a “laparotomy may be needed”. When the patient was in the operation theater (and was unconscious), another proxy consent was taken from her attending mother for a hysterectomy. Her uterus, ovaries, and fallopian tubes were removed. Subsequently, when an action was brought, it was held that the operation was conducted without real consent and the doctors were held liable.

15.                        This decision is of very far reaching consequences, pushing the development of consent law to new heights. It is contended that it is not only informed consent which is imperative now, but the same shall be “prior informed consent” unless there is imminent threat to the patient's life. In addition, this decision curtails the scope of proxy consent from the person having parental authority or an attendant.

EMERGENCY SITUATION AND CONSENT

16.                        Interestingly, in India, the entire gamut of laws on consent turns into complex propositions if an emergency medical situation arises. In a few of the milestone decisions, the apex court ruled that a medical practitioner has a duty to treat a patient in an emergency. Emphasizing the paramount duty of any “welfare state“, the Supreme Court stated that Art. 21 imposes an obligation on the State to safeguard the right to life of every person. Preservation of human life is thus of paramount importance. The government hospitals run by the state are bound by duty to extend medical assistance for preserving human life. Failure on the part of a government hospital to provide timely medical treatment to a person in need of such treatment results in the violation of his right to life guaranteed under Art. 21 [ Paschim Banga Khet Mazdoor Samity and Ors v State of West Bengal and Another. 1996. 4 SCC 37]. Proceeding in the same direction, the court emphasized further that every doctor whether at a Government hospital or otherwise has the professional obligation to extend his services with due expertise for protecting life. No law or state action can intervene to avoid or delay the discharge of the paramount obligation cast upon members of the medical profession. The obligation of a doctor is total, absolute, and paramount. Laws of procedure whether in statutes or otherwise that would interfere with the discharge of this obligation cannot be sustained and must, therefore, give way [ Pt. Parmanand Katara v Union of India. AIR 1989 SC 2039]. In one case, the apex court laid down some important guidelines such as (i) The doctor when approached by an injured person, shall render all such help which is possible for him at that time, including referring him to the proper experts, (ii) the doctor treating such persons shall be protected by law, as they are not contravening any procedural laws of the land (regarding jurisdictions etc.), and (iii) all legal bars (either real or perceived by the doctors) are deemed to have been eliminated by the verdict. This is in consonance with the hypocratic oath, which a doctor takes when entering the profession. Hence, a doctor is duty-bound to treat a patient in the case of an emergency, without waiting for any formalities. There are several statutes (like medical institutions regulation acts in various states) imposing this duty upon medical establishments to treat emergency patients, especially accident victims.

17.The initial proposition (and the attempt of the Supreme Court) is quiet understandable as the doctor has to do his best to save life in emergency situations. This is irrespective of complying with any of the formalities, including consent. Hypothetically, if a patient in an emergency resists taking treatment, what shall be the way out? Indian courts are not very clear on that. The above decisions are delivered keeping in mind the accident victims who were denied medical treatment by doctors, terming them as medico-legal cases. Moreover, in the above instances, the patient would go himself, or be taken by someone (due to an unconscious state) to the doctor to seek medical treatment.

18.                       In Dr. T.T. Thomas vs. Elisa, (  TT Thomas (Dr.) vs Elisa. AIR 1987 Ker. 52) the patient was admitted into the hospital on March 11, 1974. Upon admission, the patient was diagnosed as a case of perforated appendix with peritonitis requiring an operation. But, unfortunately no operation was done until his death on March 13, 1974. The contention of the doctor was that no surgery could be adhered to, albeit the suggestion, because the patient did not consent for the surgery. Therefore, other measures were taken to ameliorate the condition of the patient, which grew worse by the next day. Although the patient was then willing to undergo the operation, his condition did not permit it. On the other hand, the version of the respondent (i.e., the Plaintiff) was that the doctor demanded money for performing the surgery. Furthermore, the doctor was attending to some chores in an outside private nursing home to conduct operations on the other patients and that the appellant doctor came back only after the death of the patient. The two versions before the court were: 1) the plaintiff (the deceased patient's wife) said that the doctors concerned demanded a bribe, hence the operation was delayed until it proved fatal and 2) the version of denial for consent. Finally, the court delivered a verdict in favor of the plaintiffs stating that consent under such an emergent situation is not mandatory[  TT Thomas (Dr.) vs Elisa. AIR 1987 Ker. 52]. It is interesting to note the following observations:

“The consent factor may be important very often in cases of selective operations, which may not be imminently necessary to save the patient's life. But there can be instances where a surgeon is not expected to say that ‘I did not operate on him because, I did not get his consent’. Such cases very often include emergency operations where a doctor cannot wait for the consent of his patient or where the patient is not in a fit state of mind to give or not to give a conscious answer regarding consent. Even if he is in a fit condition to give a voluntary answer, the surgeon has a duty to inform him of the dangers ahead of the risks involved by going without an operation at the earliest time possible”.

“When a surgeon or medical man advances a plea that the patient did not give his consent for the surgery or the course of treatment advised by him, the burden is on him to prove that the non-performance of the surgery or the non-administration of the treatment was on account of the refusal of the patient to give consent thereto. This is especially so in a case where the patient is not alive to give evidence. Consent is implicit in the case of a patient who submits to the doctor and the absence of consent must be made out by the patient alleging it”.

19.                        Finally, as stated above, before holding the doctor liable, the court said that “we also hold that the failure to perform an emergency operation on the deceased on 11-3-1974 amounts to negligence and the death of the deceased was on account of that failure”. This decision makes the entire discussion of consent law more complex. Although this case law can't be given more accent (because it is a High Court decision), the viewpoint is an interesting one to note. In light of all these developments, it may be concluded that there are many grey areas in this field of consent law in India, which can be eliminated by pro-active intervention by the concerned professional regulatory body.

20.                      This legal opinion shall not be used in Court of Law, as same is confidential document u/s 129 of the Indian Evidence Act. It be also taken note of that legal opinion is only a guiding factor but shall not be used as a document in the Court of Law.

CARPAL TUNNEL SYNDROME

CARPAL TUNNEL SYNDROME

1.     Carpal tunnel syndrome (CTS) is a medical condition due to compression of the median nerve as it travels through the wrist at the carpal tunnel. The main symptoms are pain, numbness and tingling in the thumb, index finger, middle finger and the thumb side of the ring fingers. Symptoms typically start gradually and during the night. Pain may extend up the arm. Weak grip strength may occur, and after a long period of time the muscles at the base of the thumb may waste away. In more than half of cases, both sides are affected.

2.    Risk factors include obesity, repetitive wrist work, pregnancy and rheumatoid arthritis. There is tentative evidence that hypothyroidism increases the risk. Diabetes mellitus is weakly associated with CTS. The use of birth control pills does not affect the risk. Types of work that are associated include computer work, work with vibrating tools and work that requires a strong grip. Diagnosis is suspected based on signs, symptoms and specific physical tests and may be confirmed with electrodiagnostic tests. If muscle wasting at the base of the thumb is present, the diagnosis is likely.

3.    Being physically active can decrease the risk of developing CTS. Symptoms can be improved by wearing a wrist splint or with corticosteroid injections. Taking NSAIDs or gabapentin does not appear to be useful. Surgery to cut the transverse carpal ligament is effective with better results at a year compared to non surgical options. Further splinting after surgery is not needed. Evidence does not support magnet therapy.

4.    About 5% of people in the United States have carpal tunnel syndrome. It usually begins in adulthood, and women are more commonly affected than men. Up to 33% of people may improve without specific treatment over approximately a year. Carpal tunnel syndrome was first fully described after World War II.

Signs and symptoms

5.    People with CTS experience numbness, tingling, or burning sensations in the thumb and fingers, in particular the index and middle fingers and radial half of the ring finger, because these receive their sensory and motor function (muscle control) from the median nerve. Ache and discomfort can possibly be felt more proximally in the forearm or even the upper arm. Less-specific symptoms may include pain in the wrists or hands, loss of grip strength, and loss of manual dexterity.

6.    Some suggest that median nerve symptoms can arise from compression at the level of the thoracic outlet or the area where the median nerve passes between the two heads of the pronator teres in the forearm, although this is debated.

7.     Numbness and paresthesias in the median nerve distribution are the hallmark neuropathic symptoms (NS) of carpal tunnel entrapment syndrome. Weakness and atrophy of the thumb muscles may occur if the condition remains untreated, because the muscles are not receiving sufficient nerve stimulation. Discomfort is usually worse at night and in the morning.

Causes

8.    Most cases of CTS are of unknown cause. Carpal tunnel syndrome can be associated with any condition that causes pressure on the median nerve at the wrist. Some common conditions that can lead to CTS include obesity, hypothyroidism, arthritis, diabetes, prediabetes (impaired glucose tolerance), and trauma. Genetics play a role. The use of birth control pills does not affect the risk. Carpal tunnel is a feature of a form of Charcot-Marie-Tooth syndrome type 1 called hereditary neuropathy with susceptibility to pressure palsies.

9.    Other causes of this condition include intrinsic factors that exert pressure within the tunnel, and extrinsic factors (pressure exerted from outside the tunnel), which include benign tumors such as lipomas, ganglion, and vascular malformation. Severe carpal tunnel syndrome often is a symptom of transthyretin amyloidosis-associated polyneuropathy and prior carpal tunnel syndrome surgery is very common in individuals who later present with transthyretin amyloid-associated cardiomyopathy, suggesting that transthyretin amyloid deposition may cause carpal tunnel syndrome in these people.

10.                       The median nerve can usually move up to 9.6 mm to allow the wrist to flex, and to a lesser extent during extension. Long-term compression of the median nerve can inhibit nerve gliding, which may lead to injury and scarring. When scarring occurs, the nerve will adhere to the tissue around it and become locked into a fixed position, so that less movement is apparent.

11. Normal pressure of the carpal tunnel has been defined as a range of 2–10 mm, and wrist flexion increases this pressure 8-fold, while extension increases it 10-fold. Repetitive flexion and extension in the wrist significantly increase the fluid pressure in the tunnel through thickening of the synovial tissue that lines the tendons within the carpal tunnel.

Work related

12.                        The international debate regarding the relationship between CTS and repetitive motion in work is ongoing. The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding cumulative trauma disorders. Occupational risk factors of repetitive tasks, force, posture, and vibration have been cited. The relationship between work and CTS is controversial; in many locations, workers diagnosed with carpal tunnel syndrome are entitled to time off and compensation.

13.                        Some speculate that carpal tunnel syndrome is provoked by repetitive movement and manipulating activities and that the exposure can be cumulative. It has also been stated that symptoms are commonly exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations, but it is unclear as to whether this refers to pain (which may not be due to carpal tunnel syndrome) or the more typical numbness symptoms.

14.                        A review of available scientific data by the National Institute for Occupational Safety and Health (NIOSH) indicated that job tasks that involve highly repetitive manual acts or specific wrist postures were associated with incidents of CTS, but causation was not established, and the distinction from work-related arm pains that are not carpal tunnel syndrome was not clear. It has been proposed that repetitive use of the arm can affect the biomechanics of the upper limb or cause damage to tissues. It has also been proposed that postural and spinal assessment along with ergonomic assessments should be included in the overall determination of the condition. Addressing these factors has been found to improve comfort in some studies. A 2010 survey by NIOSH showed that 2/3 of the 5 million carpal tunnel cases in the US that year were related to work. Women have more work-related carpal tunnel syndrome than men.

15.                        Speculation that CTS is work-related is based on claims such as CTS being found mostly in the working adult population, though evidence is lacking for this. For instance, in one recent representative series of a consecutive experience, most patients were older and not working. Based on the claimed increased incidence in the workplace, arm use is implicated, but the weight of evidence suggests that this is an inherent, genetic, slowly but inevitably progressive idiopathic peripheral mononeuropathy.

Associated conditions

16.                        A variety of patient factors can lead to CTS, including heredity, size of the carpal tunnel, associated local and systematic diseases, and certain habits. Non-traumatic causes generally happen over a period of time, and are not triggered by one certain event. Many of these factors are manifestations of physiologic aging. Examples include:

A.   Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons.

B.   With hypothyroidism, generalized myxedema causes deposition of mucopolysaccharides within both the perineurium of the median nerve, as well as the tendons passing through the carpal tunnel.

C.   During pregnancy women experience CTS due to hormonal changes (high progesterone levels) and water retention (which swells the synovium), which are common during pregnancy.

D.  Previous injuries including fractures of the wrist.

E.   Medical disorders that lead to fluid retention or are associated with inflammation such as: inflammatory arthritis, Colles' fracture, amyloidosis, hypothyroidism, diabetes mellitus, acromegaly, and use of corticosteroids and estrogens.

F.    Carpal tunnel syndrome is also associated with repetitive activities of the hand and wrist, in particular with a combination of forceful and repetitive activities.

G.  Acromegaly causes excessive secretion of growth hormones. This causes the soft tissues and bones around the carpel tunnel to grow and compress the median nerve.

H.  Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal tunnel, reducing the amount of space. This is exceedingly rare (less than 1%).

I.      Obesity also increases the risk of CTS: individuals classified as obese (BMI > 29) are 2.5 times more likely than slender individuals (BMI < 20) to be diagnosed with CTS.

J.     Double-crush syndrome is a debated hypothesis that compression or irritation of nerve branches contributing to the median nerve in the neck, or anywhere above the wrist, increases sensitivity of the nerve to compression in the wrist. There is little evidence, however, that this syndrome really exists.

K.   Heterozygous mutations in the gene SH3TC2, associated with Charcot-Marie-Tooth, confer susceptibility to neuropathy, including the carpal tunnel syndrome.

Pathophysiology

17.The carpal tunnel is an anatomical compartment located at the base of the palm. Nine flexor tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides by the carpal bones that form an arch. The median nerve provides feeling or sensation to the thumb, index finger, long finger, and half of the ring finger. At the level of the wrist, the median nerve supplies the muscles at the base of the thumb that allow it to abduct, move away from the other four fingers, as well as move out of the plane of the palm. The carpal tunnel is located at the middle third of the base of the palm, bounded by the bony prominence of the scaphoid tubercle and trapezium at the base of the thumb, and the hamate hook that can be palpated along the axis of the ring finger. From the anatomical position, the carpal tunnel is bordered on the anterior surface by the transverse carpal ligament, also known as the flexor retinaculum. The flexor retinaculum is a strong, fibrous band that attaches to the pisiform and the hamulus of the hamate. The proximal boundary is the distal wrist skin crease, and the distal boundary is approximated by a line known as Kaplan's cardinal line. This line uses surface landmarks, and is drawn between the apex of the skin fold between the thumb and index finger to the palpated hamate hook. The median nerve can be compressed by a decrease in the size of the canal, an increase in the size of the contents (such as the swelling of lubrication tissue around the flexor tendons), or both. Since the carpal tunnel is bordered by carpal bones on one side and a ligament on the other, when the pressure builds up inside the tunnel, there is nowhere for it to escape and thus it ends up pressing up against and damaging the median nerve. Simply flexing the wrist to 90 degrees will decrease the size of the canal.

18.                       Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causes atrophy of the thenar eminence, weakness of the flexor pollicis brevis, opponens pollicis, abductor pollicis brevis, as well as sensory loss in the digits supplied by the median nerve. The superficial sensory branch of the median nerve, which provides sensation to the base of the palm, branches proximal to the TCL and travels superficial to it. Thus, this branch spared in carpal tunnel syndrome, and there is no loss of palmar sensation.

Diagnosis

19.                        There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. A combination of described symptoms, clinical findings, and electrophysiological testing may be used. Correct diagnosis involves identifying if symptoms matches the distribution pattern of the median nerve (which does not normally include the 5th digit).

20.                      CTS work up is the most common referral to the electrodiagnostic lab. Historically, diagnosis has been made with the combination of a thorough history and physical examination in conjunction with the use of electrodiagnostic (EDX) testing for confirmation. Additionally, evolving technology has included the use of ultrasonography in the diagnosis of CTS. However, it is well established that physical exam provocative maneuvers lack both sensitivity and specificity. Furthermore, EDX cannot fully exclude the diagnosis of CTS due to the lack of sensitivity. A Joint report published by the American Association of Neuromuscular and Electrodiagostic Medicine (AANEM), the American Academy of Physical Medicine and Rehabilitation (AAPM&R) and the American Academy of Neurology defines practice parameters, standards and guidelines for EDX studies of CTS based on an extensive critical literature review. This joint review concluded median and sensory nerve conduction studies are valid and reproducible in a clinical laboratory setting and a clinical diagnosis of CTS can be made with a sensitivity greater than 85% and specificity greater than 95%. Given the key role of electrodiagnostic testing in the diagnosis of CTS, The American Association of Neuromuscular & Electrodiagnostic Medicine has issued evidence-based practice guidelines, both for the diagnosis of carpal tunnel syndrome.

21.                        Numbness in the distribution of the median nerve, nocturnal symptoms, thenar muscle weakness/atrophy, positive Tinel's sign at the carpal tunnel, and abnormal sensory testing such as two-point discrimination have been standardized as clinical diagnostic criteria by consensus panels of experts. Pain may also be a presenting symptom, although less common than sensory disturbances.

22.                       Electrodiagnostic testing (electromyography and nerve conduction velocity) can objectively verify the median nerve dysfunction. Normal nerve conduction studies, however, do not exclude the diagnosis of CTS. Clinical assessment by history taking and physical examination can support a diagnosis of CTS. If clinical suspicion of CTS is high, treatment should be initiated despite normal electrodiagnostic testing.

Physical exam

23.                       Although widely used, the presence of a positive Phalen test, Tinel sign, Flick sign, or upper limb nerve test alone is not sufficient for diagnosis.

a.     Phalen's maneuver is performed by flexing the wrist gently as far as possible, then holding this position and awaiting symptoms. A positive test is one that results in numbness in the median nerve distribution when holding the wrist in acute flexion position within sixty seconds. The quicker the numbness starts, the more advanced the condition. Phalen's sign is defined as pain or paresthesias in the median-innervated fingers with one minute of wrist flexion. Only this test has been shown to correlate with CTS severity when studied prospectively. The test characteristics of Phalen's maneuver have varied across studies ranging from 42–85% sensitivity and 54–98% specificity.

b.    Tinel's sign is a classic test to detect median nerve irritation. Tinel's sign is performed by lightly tapping the skin over the flexor retinaculum to elicit a sensation of tingling or "pins and needles" in the median nerve distribution. Tinel's sign (pain or paresthesias of the median-innervated fingers with percussion over the median nerve), depending on the study, has 38–100% sensitivity and 55–100% specificity for the diagnosis of CTS.

c.     Durkan test, carpal compression test, or applying firm pressure to the palm over the nerve for up to 30 seconds to elicit symptoms has also been proposed.

d.    Hand elevation test The hand elevation test is performed by lifting both hands above the head, and if symptoms are reproduced in the median nerve distribution within 2 minutes, considered positive. The hand elevation test has higher sensitivity and specificity than Tinel's test, Phalen's test, and carpal compression test. Chi-square statistical analysis has shown the hand elevation test to be as effective, if not better than, Tinel's test, Phalen's test, and carpal compression test.

24.                       As a note, a person with true carpal tunnel syndrome (entrapment of the median nerve within the carpal tunnel) will not have any sensory loss over the thenar eminence (bulge of muscles in the palm of hand and at the base of the thumb). This is because the palmar branch of the median nerve, which innervates that area of the palm, branches off of the median nerve and passes over the carpal tunnel. This feature of the median nerve can help separate carpal tunnel syndrome from thoracic outlet syndrome, or pronator teres syndrome.

25.                       Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and physical examination suggest CTS, patients will sometimes be tested electrodiagnostically with nerve conduction studies and electromyography. The role of confirmatory nerve conduction studies is controversial. The goal of electrodiagnostic testing is to compare the speed of conduction in the median nerve with conduction in other nerves supplying the hand. When the median nerve is compressed, as in CTS, it will conduct more slowly than normal and more slowly than other nerves. There are many electrodiagnostic tests used to make a diagnosis of CTS, but the most sensitive, specific, and reliable test is the Combined Sensory Index (also known as the Robinson index). Electrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in context of normal conduction elsewhere. Compression results in damage to the myelin sheath and manifests as delayed latencies and slowed conduction velocities.  However, normal electrodiagnostic studies do not preclude the presence of carpal tunnel syndrome, as a threshold of nerve injury must be reached before study results become abnormal and cut-off values for abnormality are variable. Carpal tunnel syndrome with normal electrodiagnostic tests is very, very mild at worst.

26.                       The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear. Their routine use is not recommended.

Differential diagnosis

27.                       There are few disorders on the differential diagnosis for carpal tunnel syndrome. Cervical radiculopathy can be mistaken for carpal tunnel syndrome since it can also cause abnormal or painful sensations in the hands and wrist. In contrast to carpal tunnel syndrome, the symptoms of cervical radiculopathy usually begins in the neck and travels down the affected arm and may be worsened by neck movement. Electromyography and imaging of the cervical spine can help to differentiate cervical radiculopathy from carpal tunnel syndrome if the diagnosis is unclear. Carpal tunnel syndrome is sometimes applied as a label to anyone with pain, numbness, swelling, or burning in the radial side of the hands or wrists. When pain is the primary symptom, carpal tunnel syndrome is unlikely to be the source of the symptoms. As a whole, the medical community is not currently embracing or accepting trigger point theories due to lack of scientific evidence supporting their effectiveness.

Prevention

28.                      Suggested healthy habits such as avoiding repetitive stress, work modification through use of ergonomic equipment (mouse pad, taking proper breaks, using keyboard alternatives (digital pen, voice recognition, and dictation), and have been proposed as methods to help prevent carpal tunnel syndrome. The potential role of B-vitamins in preventing or treating carpal tunnel syndrome has not been proven.

29.                       There is little or no data to support the concept that activity adjustment prevents carpal tunnel syndrome. The evidence for wrist rest is debated.

30.                      There is also little research supporting that ergonomics is related to CTS. Due to risk factors for hand and wrist dysfunction being multifactorial and very complex it is difficult to assess the true physical factors of CTS.

31.                        Stretches and isometric exercises will aid in prevention for persons at risk. Stretching before the activity and during breaks will aid in alleviating tension at the wrist. Place the hand firmly on a flat surface and gently press for a few seconds to stretch the wrist and fingers. An example for an isometric exercise of the wrist is done by clenching the fist tightly, releasing and fanning out fingers. None of these stretches or exercises should cause pain or discomfort.

32.                       Biological factors such as genetic predisposition and anthropometric features had significantly stronger causal association with carpal tunnel syndrome than occupational/environmental factors such as repetitive hand use and stressful manual work. This suggests that carpal tunnel syndrome might not be preventable simply by avoiding certain activities or types of work/activities.

Treatment

33.                       Generally accepted treatments include: physiotherapy, steroids either orally or injected locally, splinting, and surgical release of the transverse carpal ligament. Limited evidence suggests that gabapentin is no more effective than placebo for CTS treatment. There is insufficient evidence for therapeutic ultrasound, yoga, acupuncture, low level laser therapy, vitamin B6, and exercise. Change in activity may include avoiding activities that worsen symptoms.

34.                       The American Academy of Orthopedic Surgeons recommends proceeding conservatively with a course of nonsurgical therapies tried before release surgery is considered. A different treatment should be tried if the current treatment fails to resolve the symptoms within 2 to 7 weeks. Early surgery with carpal tunnel release is indicated where there is evidence of median nerve denervation or a person elects to proceed directly to surgical treatment. Recommendations may differ when carpal tunnel syndrome is found in association with the following conditions: diabetes mellitus, coexistent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid arthritis, and carpal tunnel syndrome in the workplace.

Splints

35.                       The importance of wrist braces and splints in the carpal tunnel syndrome therapy is known, but many people are unwilling to use braces. In 1993, The American Academy of Neurology recommend a non-invasive treatment for the CTS at the beginning (except for sensitive or motor deficit or grave report at EMG/ENG): a therapy using splints was indicated for light and moderate pathology. Current recommendations generally don't suggest immobilizing braces, but instead activity modification and non-steroidal anti-inflammatory drugs as initial therapy, followed by more aggressive options or specialist referral if symptoms do not improve.

36.                       Many health professionals suggest that, for the best results, one should wear braces at night and, if possible, during the activity primarily causing stress on the wrists.

Corticosteroids

37.                       Corticosteroid injections can be effective for temporary relief from symptoms while a person develops a long-term strategy that fits their lifestyle. This form of treatment is thought to reduce discomfort in those with CTS due to its ability to decrease median nerve swelling. The use of ultrasound while performing the injection is more expensive but leads to faster resolution of CTS symptoms. The injections are done under local anesthesia. This treatment is not appropriate for extended periods, however. In general, local steroid injections are only used until more definitive treatment options can be used. Corticosteroid injections do not appear to be very effective for slowing disease progression.

Surgery

38.                      Release of the transverse carpal ligament is known as "carpal tunnel release" surgery. It is recommended when there is static (constant, not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting or other conservative interventions no longer control intermittent symptoms. The surgery may be done with local or regional anesthesia with or without sedation, or under general anesthesia. In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment.

39.                       Surgery is more beneficial in the short term to alleviate symptoms (up to six months) than wearing an orthosis for a minimum of 6 weeks. However, surgery and wearing a brace resulted in similar symptom relief in the long term (12–18 month outcomes).

Physical therapy

40.                      A recent evidence based guideline produced by the American Academy of Orthopedic Surgeons assigned various grades of recommendation to physiotherapy (also called physical therapy) and other nonsurgical treatments. One of the primary issues with physiotherapy is that it attempts to reverse (often) years of pathology inside the carpal tunnel. Practitioners caution that any physiotherapy such as myofascial release may take weeks of persistent application to effectively manage carpal tunnel syndrome.

41.                        Again, some claim that pro-active ways to reduce stress on the wrists, which alleviates wrist pain and strain, involve adopting a more ergonomic work and life environment. For example, some have claimed that switching from a QWERTY computer keyboard layout to a more optimised ergonomic layout such as Dvorak was commonly cited as beneficial in early CTS studies; however, some meta-analyses of these studies claim that the evidence that they present is limited.

42.                    Prognosis

43.                       Most people relieved of their carpal tunnel symptoms with conservative or surgical management find minimal residual or "nerve damage". Long-term chronic carpal tunnel syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e. irreversible numbness, muscle wasting, and weakness. Those that undergo a carpal tunnel release are nearly twice as likely as those not having surgery to develop trigger thumb in the months following the procedure.

44.                       While outcomes are generally good, certain factors can contribute to poorer results that have little to do with nerves, anatomy, or surgery type. One study showed that mental status parameters or alcohol use yields much poorer overall results of treatment.

45.                       Recurrence of carpal tunnel syndrome after successful surgery is rare.

Epidemiology

46.                       Carpal tunnel syndrome is estimated to affect one out of ten people during their lifetime and is the most common nerve compression syndrome. It accounts for about 90% of all nerve compression syndromes. In the U.S., 5% of people have the effects of carpal tunnel syndrome. Caucasians have the highest risk of CTS compared with other races such as non-white South Africans. Women suffer more from CTS than men with a ratio of 3:1 between the ages of 45–60 years. Only 10% of reported cases of CTS are younger than 30 years. Increasing age is a risk factor. CTS is also common in pregnancy.

Occupational

47.                       As of 2010, 8% of U.S. workers reported ever having carpal tunnel syndrome and 4% reported carpal tunnel syndrome in the past 12 months. Prevalence rates for carpal tunnel syndrome in the past 12 months were higher among females than among males; among workers aged 45–64 than among those aged 18–44. Overall, 67% of current carpal tunnel syndrome cases among current/recent workers were reportedly attributed to work by health professionals, indicating that the prevalence rate of work-related carpal tunnel syndrome among workers was 2%, and that there were approximately 3.1 million cases of work-related carpal tunnel syndrome among U.S. workers in 2010. Among current carpal tunnel syndrome cases attributed to specific jobs, 24% were attributed to jobs in the manufacturing industry, a proportion 2.5 times higher than the proportion of current/recent workers employed in the manufacturing industry, suggesting that jobs in this industry are associated with an increased risk of work-related carpal tunnel syndrome.

History

48.                      The condition known as carpal tunnel syndrome had major appearances throughout the years but it was most commonly heard of in the years following World War II. Individuals who had suffered from this condition have been depicted in surgical literature for the mid-19th century. In 1854, Sir James Paget was the first to report median nerve compression at the wrist in two cases.

49.                       The first to notice the association between the carpal ligament pathology and median nerve compression appear to have been Pierre Marie and Charles Foix in 1913. They described the results of a postmortem of an 80-year-old man with bilateral carpal tunnel syndrome. They suggested that division of the carpal ligament would be curative in such cases. Putman had previously described a series of 37 patients and suggested a vasomotor origin. The association between the thenar muscle atrophy and compression was noted in 1914. The name 'carpal tunnel syndrome' appears to have been coined by Moersch in 1938.

50.                      In the early 20th century there were various cases of median nerve compression underneath the transverse carpal ligament. Physician Dr. George S. Phalen of the Cleveland Clinic identified the pathology after working with a group of patients in the 1950s and 1960s.

Treatment

51.                        Paget described two cases of carpal tunnel syndrome. The first was due to an injury where a cord had been wrapped around a man's wrist. The second was due to a distal radial fracture. For the first case Paget performed an amputation of the hand. For the second case Paget recommended a wrist splint – a treatment that is still in use today. Surgery for this condition initially involved the removal of cervical ribs despite Marie and Foix's suggested treatment. In 1933 Sir James Learmonth outlined a method of decompression of the nerve at the wrist. This procedure appears to have been pioneered by the Canadian surgeons Herbert Galloway and Andrew MacKinnon in 1924 in Winnipeg but was not published. Endoscopic release was described in 1988.