Journal of Forensic Medicine & Toxicology Vol. 25 No. 1, Jan-June 2008

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008 EPIDEMIOLOGICAL STUDY OF DROWNING DEATHS IN RA...

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Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

EPIDEMIOLOGICAL STUDY OF DROWNING DEATHS IN RAJKOT, GUJARAT Hitesh Rathod1, Akhilesh Pathak2, H. M. Mangal3

ABSTRACT Drowning is a form of asphyxial death in which the access of air to the lungs is obstructed by the submersion of the body in the water or other fluid media. It is a tragedy that happens to many people each day all around the world. Thousands of innocent people drown every year because of lack of awareness of the hazards of water. They go into ponds and rivers without knowing their depth and by one fatal step they sink, never to rise again. Drowning is one of the most common causes of death in Saurashtra region of Gujarat and the incidences are increasing day by day . This study was under taken with the aim to analyze the magnitude of drowning deaths and to provide epidemiological data, so the attention of health and administrative authorities can be drawn towards this neglected scenario of death. Total 100 cases of drowning death were selected for the study during the span of twoyear (From Nov.2004 to Oct.2006), and ever y effort was made to collect all the epidemiological data with a detailed autopsy examination. Keywords: Drowning; Asphyxia; Diatom. INTRODUCTION Panchamahabhuta are the five elements of nature, which include earth, water, fire, air and sky. In the graphical depiction of Panchamahabhuta, water represented by a circle, symbolizes the fullness. Primarily, water is the building block of life and all the living beings are at the mercy of god, for the water. On earth, approximately 70.8 percent of the earth area is covered by water and only 29.2 percent is dry land area. Without understanding the statistics of drowning it is difficult to know the types of safety measures to be taken to reduce the incidence of this mishappening. Even with swimming and safety classes available in many countries, large numbers of people still drown every year, over 400,000 around the world.

2 3

MATERIAL & METHOD The present study was conducted in the Department of Forensic medicine, P.D.U. Medical College Rajkot, (Gujarat) during the period of 2 years- from 1st November 2004 to 31st October 2006. During this period total 2934 autopsies were conducted. Out of these drowning was observed in 100 cases (3.4%). Detailed and complete post mortem examination of the corpses was done, including diatom test and chemical analysis of viscera, which was done at Forensic Science Laboratory, Junagadh. A proforma was prepared to fill up details of the parameters used in the study and conclusions were drawn after comparing and discussing with similar type of the work carried out by foreign and Indian authors. RESULTS Out of total 2934 cases, 100 cases (3.4%) of drowning were selected for the present study. Incidence of drowning was more in second decade (28%) and third decade (32%) as compared to both extremes of life. Males were more prone to death by drowning (73%) as compared to females (27%). Incidence of drowning was more in Hindu people (91%) especially during the months of summer and monsoon e.g. from May to September (55%) as compared to other months of the year. Maximum persons were Un-married (53%) either illiterate (30.68%) or literate upto matric level (43.18%) and from lower socio-economic group (59.09%). We could not detect marital, educational and socioeconomic status in 12 cases, because of their non-identification. Most of the dead bodies were recovered either from pond (51%) or from a well (32%) at some where in urban areas (52%). Most of the corpses (63%) were recovered from water soon after the incidence of drowning and two third of them were having typical drowning froth over mouth and nostrils with other signs of antemortem drowning. The rest 37 % cases were

In India, drowning is a common method of committing suicide especially amongst women, and more particularly 1

in localities nearby the sea, river, dam or canal. Due to increasing stress in life by various reasons the problem of suicidal drowning is getting worse day by day. People also prefer it for the purpose of suicide, as it causes immediate and painless death. In spite of advancement and development in all fields, the incidences of death due to drowning are increasing regularly. Thus, the higher incidences of drowning cases specially in Saurashtra region, has prompted us to undertake this study to know the epidemiological aspects, patterns and other significant features of drowning deaths, and to compare the data with the observations of various authors by scientific discussion.

Tutor, PDU Medical College, Rajkot. Assistant Professor, PDU Medical college, Rajkot. Prof. & Head, PDU Medical College, Rajkot Corresponding Author: Dr. Akhilesh Pathak Assistant Professor, PDU Medical college, Rajkot (Gujarat), E-mail : [email protected] 5

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

recovered in a stage of advanced decomposition without having any sign of antemortem drowning except some blood stained discharge from the nostrils, which was also present in trachea and bronchi. In all these decomposed corpses, viscera were preserved for chemical analysis and intact sternum bone was preserved for diatom test. After receiving the reports only 5.4% cases were found positive for a nonfatal poisoning, while in 94.59% cases the diatom test was found positive. With regard to medicolegal etiology, incidence of suicidal cases was highest in the present study (43%), followed by accidental (36%) cases. This inference is based on history, circumstantial evidences and post mortem findings.

regard to medico-legal etiology we found that maximum cases were suicidal deaths followed by accidental deaths, similar to others [1,7]. Shetty M. [2] observed more accidental cases in his study, which may be because of different sample area. In 20% cases, we could not determine the manner of death by any means, while homicidal drowning was noticed in only one case, which shows its un-common existence, as the murder by drowning is difficult when the victim is an adult or unless he was made first weakened by some other means [2,7]. Table 1: Age and sex wise distribution of drowning cases

DISCUSSION Incidence of drowning varies considerably around the world for a number of reasons. Despite tremendous progress in all fields of life, drowning continues to be one of the major causes of mortality in India. More data and knowledge about drowning can only help in better understanding of drowning and should hence lead to more effective measures to tackle the problem. The incidence of drowning in present study was 3.4%, which is comparable to the other studies [1,2,3,7]. The incidence of drowning was higher in third decade of life, in Hindu married males of lower socio economic class, which is similar to most of the other studies by various authors [1,3,4,5]. This might be because of major Hindu population, stress, tension, family and social problems and due to modern life style. Most of the deaths due to drowning were noticed during the months of summer and monsoon e.g. from May to September as compared to other months of the year, similar to other studies [1,2,4,5] . The higher incidence was also observed either in illiterate people or literate below metric level who were belonging to an urban area. Maximum number of corpses were recovered from ponds or wells as compared to other water sources like river, water-tank, and water-pits, as these are the major water sources in Saurashtra region. In our study no death was reported from bathtub and swimming pool, which may be due to less usage of bathtubs and swimming pools in Rajkot City, a developing city in a developing country. Almost two third (63%) dead bodies were brought to us in fresh condition (without having any signs of decomposition) and most of them were having typical drowning-froth and drowning-lungs showing there antemortem nature. While the rest (37%) corpses were recovered in a stage of decomposition, in which no signs of antemortem drowning were noticed at the time of postmortem examination. In all these cases where decomposition has started, viscera were preserved for chemical analysis and intact sternum was preserved for diatom-test. The diatoms were detected in bone marrow in 94.59% cases, similar to others [6,9,10,11], while only 5.04% cases were found positive for a non-fatal poisoning. Death due to drowning associated with poisoning is suggestive of strong determination for committing suicide by the victim. With

Table 2: Religion wise distribution of drowning cases

Table 3: Month wise distribution of drowning cases

Table 4: Distribution of drowning cases according to marital status

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Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

Table 5: Distribution of drowning cases according to educational status

Table 11: Distributionof drowning cases according to manner of death

CONCLUSION The present study showed a wide range of similarities and dissimilarities in findings and mode of drowning with the works of other authors. Our study shows that the incidences of drowning are more in certain population, at certain time of year and at certain localities. Finally our observations conclude that most of the drowning victims are Hindus in majority, un-married males and people with low socioeconomic class and low literacy level. Such similar studies later on at the other centers as well as at the same center needs to be done to provide a better understanding of the epidemiology of drowning in Saurashtra and how deaths by drowning may further be reduced.

Table 6: Distribution of drowning cases according to socio-economic status

Table 7: Distribution of cases according to place of drowning

SUGGESTIONS Though suicidal drowning was the commonest mode of death in this region, accidental drowning was also common. So various preventive measures of reducing the incidences of drowning based on the present study has been suggested:

Table 8: Area wise distribution of drowning cases

1. Four-sided fencing and lifeguards around the high-risk water bodies such as dams & ponds. 2. Close supervision around dams, especially during the stressful and shocking conditions like various academic results and during marked fall in share-market etc. to decrease the risk of suicidal drowning.

Table 9: Distribution of drowning cases according to condition of the body

3. The family and the near ones should keep a close watch on family members or known ones who are subjected to either any psychological or any severe physiological illness and should not allow them to move all alone at such high risk water places. 4. Intoxicated people should not be allowed to work or move near dangerous site of water. 5. Water reservoirs like wells and water tanks should be properly guarded and covered to reduce the accidental drowning.

Table 10: Distribution of cases according to chemical analysis & diatom-test report

6. Small children should neither be allowed to go near the site of the water nor to swim in any unfamiliar water sources. 7. To encourage people to learn swimming and also to keep themselves aware as to how to deal with any such emergency as and when required. 7

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REFERENCES 1. 2.

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J. of Forensic Medicine & Toxicology 2006: 7(2). 7. Sharma BR, SinghVP, Sharma R & Sumedha. UNnatural deaths in northern India- A profile, JIAFM 2004: 26(4): 140-46. 8. Srivastava AK, Tripathi CB, Das Gupta SM & Gupta RK. A study of fatal drowning cases in Varanasi, Ind. J. Forensic Sci 1987: 1: 127-31. 9. Singh M, Kulshreshta P & Satpathy DK . Synchronous use of maggots and diatoms in decomposed bodies JIAFM 2004: 26(3): 121-24. 10. Timperman J. The detection of diatoms in the bone marrow of sternum as evidence of death by drowning J. of Forensic Medicine1962: 9: 134-36. 11. Pollanen MS. The diagnostic value of the diatom test for drowning, II Validity: Analysis of diatoms in bone marrow and drowning medium. J. of Forensic Sci. 1997: 42(2): 286-90.

Majumdar BC. Study of violent asphyxial deaths, JIAFM, 2002: 24(2): 8-10. Shetty M. Profile of drowning deaths in Mangalore, A coastal city of Karnataka, Medico-legal Update, 200504, 2005-06: 5(2). Chaudhury P . Profile of medico-legal cases in Kasturba hospital of MGIMS, Sewagram, A thesis submitted in Nagpur University, 2001- 2002. Pandey S. A study of violent asphyxial death in the department of Forensic Medicine, Institute of Medical sciences. A thesis submitted in Banaras Hindu University, Varanasi, 1999–2003. Brenner RA, Smith GS. Divergent trends in childhood drowning rates. JAMA 1994: 271: 1606-08. Singh R, Singh R, Kumar S & Thakkar MK . Forensic analysis of diatoms- A review. Anil Agrawal’s Internet

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Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

DIAGNOSIS OF MALARIA AT AUTOPSY: PRELIMINARY OBSERVATIONS WITH IMMUNOCHROMATOGRAPHIC RAPID TEST Rajesh Bardale1

ABSTRACT

autopsy gross findings were recorded and tissues were retained for histopathological examination. The tissues were processed and stained with H & E stains with standard technique.

Traditionally, autopsy diagnosis of malaria is based on microscopic and histological examination but sometimes, the diagnosis remains difficult to establish by these conventional means. The present study describes the preliminary observation of usefulness of immunochromatographic rapid test to confirm postmortem diagnosis of malaria. The result of present study suggests that the test can be served as useful rapid means of diagnosing malaria at autopsy .

At laboratory, the blood sample was subjected for immunochromatographic test with commercial kit (Aspen Laboratories, Baddi, Himachal Pradesh). The commercial kit consists of a test strip, micro-well, and buffer solution. A micro-well was placed in holder and 5 drops of buffer solution were added. Then the test strip was taken from the container and placed on flat surface. 10 ìL of whole blood with micropipette was dropped in the sample-loading window of the test strip (see fig 1). Then the strip was placed in the micro-well and results read at 15 minutes. The result was interpreted as negative if only control line is visible on test strip, positive for Plasmodium vivax – if pink or purple line develops at control and T2 position of strip, positive for Plasmodium falciparum – if pink or purple line develops at control and T1 position of test strip and results was inconclusive if no line, including control line, appears over test strip (see fig 2).

Keywords: Malaria; autopsy; microscopy; immunochromatographic test INTRODUCTION Traditionally, autopsy diagnosis of malaria is based on microscopic and histological examination (1-4). However, at times, the diagnosis remains difficult to establish by these conventional means. Nevertheless, immunopathological examinations (5), DNA detection of malaria by polymerase chain reaction (6), or by electron microscopy (7) have been successfully utilized to confirm postmortem diagnosis of malaria. But these techniques require complex apparatus & expertise and they may not be available at every center. With this background, the present study was undertaken and this paper describes preliminary observation of usefulness of immunochromatographic rapid test to confirm postmortem diagnosis of malaria.

Fig 1: Diagrammatic representation of strip used and loading window for blood

MATERIAL & METHODS The present study was conducted at Dept. of Forensic Medicine, Govt. Medical College, Nagpur from October 2005 to September 2007. The study consists of 5 cases admitted in ward with suspected malaria. The cases consist of 3 male and 2 female. During autopsy, venous blood sample was drawn from internal jugular vein and 2 ml of blood collected in sterile bottle with EDTA as anticoagulant. Peripheral smears were prepared immediately and the remaining sample was transported to laboratory. The peripheral smears were stained with Leishman’s stain with standard technique. At 1

Fig 2: Diagrammatic representation of results interpreted. Strip A is showing one line at control level & the test is negative. Strip B is showing one line at control level and another thick line (at T2 position in strip) denoting positive forP. vivax. Strip C is showing one line at control level and another thin line (at T1 position in strip) denoting positive forP. falciparum. Strip D is not showing any line eitherat control level or at other level therefore results are inconclusive

Lecturer Dept. of Forensic Medicine, Govt. Medical College Nagpur Address for correspondence: Lecturer Dept. of Forensic Medicine Govt. Medical College & Hospital, Nagpur. E-mail: [email protected] 9

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RESULTS The study consists of five subjects comprising of 3 male and 2 females (see table 1). All cases were admitted cases and their duration of admission ranged from 2 hours to 20 hours (mean 7.4 hours) and postmortem interval ranged from 6 hours to 29 hours (mean 16.3 hours). The first samples for immunochromatographic rapid test were assessed from 8 hours after death to 31 hours (mean 18.4 hours). After analyzing the blood samples, they were kept at room temperature for 72 hours. The kept blood samples were sub-sampled and analyzed for immunochromatographic test at regular interval and positive results were obtained up to 72 hours.

Fig 4: Microphotograph showing liver with pigments (H & E, 10X)

Table 1: Demographic profile of cases, their admission stay and postmortem interval

Amongst 5 cases, histopathological findings suggestive of malaria were obtained in 3 cases (60%) in form of macrophages laden pigments and vessel containing RBCs laden with mature parasites (see table 2 &, fig. 3, 4 & 5), whereas peripheral smear in one case (20%) reveals ring form trophozoites (see fig 6). Immunochromatographic test was positive in all samples and amongst them, Plasmodium falciparum was positive in 4 (80%) and Plasmodium vivax in 1 case (20%) (See fig.7). The comparative descriptions of the three different methods are presented in table 2.

Fig 5: Microphotograph showing spleen with malarial pigments (40X, H & E)

DISCUSSION It is estimated that, worldwide, malaria accounts for 300 to 500 million new cases and between 1.5 and 2.7 million deaths annually (3). Specific epidemiological data provided by the Health & Family Welfare department of India for the year 2003 points out that malaria is not uncommon, affecting

Fig 6: Microphotograph of peripheral smear showing ring form trophozoites (Leishman’s stain, X100)

Fig 3: Microphotograph showing brain with cerebral vessels containing RBCs laden with parasites (H & E, 40X)

Fig 7: Photograph showing immunochromatrographic test strip 10

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

Table 2: Comparative description of three different methods

parasite antigen by using monoclonal antibodies prepared. The capture antibodies applied to test strip of nitrocellulose act as the immobile phase. The preferred targeted antigens are those that are abundant in all asexual and sexual stages of the parasite; currently interest is focused on the detection of histidine-rich protein 2 (HRP-2) or parasite specific lactate dehydrogenase (pLDH) from Plasmodium falciparum or Plasmodium aldolase from the parasite glycolytic pathway found in all species (9, 10). The formation of antigen-antibody complex results in visible coloured line in the test strip. In forensic practice, the precise use of diagnostic method depends on the sensitivity, specificity, the ease of use and stability of said method. The specificity of such test is 99.6% and sensitivity for Pf and Pv is 98.2% & 91.8% respectively in antemortem cases, however, it remains to be elucidated in postmortem sample. Based on this study of limited sample size, the result indicates that the test is sensitive and convenient to use however further research is needed to substantiate such statement. The intent for use of such test at autopsy sample was to provide adjunct to supplement microscopy and histopathological examination as a rapid and reliable means of diagnosing malaria. But by further research it could be possible to establish whether such tests are useful only as screening test (as used in clinical practice) or has capability to be substituted for other established methods.

1.87 million people and causing 1006 deaths. Provisional data for the year 2004 reveals that the largest numbers of cases in the country were reported by Orissa, followed by Gujarat, West Bengal, Jharkhand, Karnataka, Uttar Pradesh and Rajasthan. Delay or failure in the diagnosis &/or therapeutic management of malaria may result in avoidable deaths, often incurring medicolegal investigation because the disorder may appear as sudden death (6). The victim may be referred to forensic pathologist and in such autopsies the role of forensic pathologist becomes important for systemic evaluation of the disease (4).

Utility of such test, as tested in the present series, is up to 72 hours in postmortem period (further studies are under consideration) but it remains to be evaluated in further postmortem interval. Another limitation of present study is that no attempt has been made to study the effect of refrigeration on the corpse and this aspect deserves attention.

In clinical practice, microscopic examination of blood films is accepted as the current universal “gold standard” for diagnosis of malaria. The autopsy diagnosis of malaria has been relied on the microscopy and histopathological examination. However, changing patterns of accepted morphological appearance of malarial species and strain variation have created diagnostic problems. Nevertheless, the advanced postmortem autolytic process and putrefaction may thwart malaria diagnosis by conventional methods (6). Limitation of smear examination is that, it may possiblebe that due to sequestration, no parasite may be visible (8). In addition, in autopsy sample, problem of postmortem degradation of red blood cells causes much distress. It may be possible that no parasite may be noted in the brain or spleen but pigments may be evident. Interpretation of such result requires expertise and multiple sections. Methods such as fluorescence microscopy have helped to improve the sensitivity but not the specificity and this method is unable to distinguish active from prior infections.

CONCLUSION In conclusion it can be said that the test could serve as useful rapid means of diagnosing malaria at autopsy. The advantage of such procedure is that it shifts the process of diagnosing malaria from laboratory setup to autopsy room. However, at present it seems to be possible only against Plasmodium vivax and Plasmodium falciparum. Further research is warranted in order to examine other strains and aspects. ACKNOWLEDGEMENTS The author is indebted to the assistance provided by Dr Amit Aggrawal MD, Lecturer in Pathology and Dr Sashikant Tayade MD, Lecturer in Microbiology, Indira Gandhi Govt. Medical College, Nagpur. REFERENCES

The immunochromatographic method is based on principle of migration of liquid blood across the surface of a nitrocellulose membrane and capturing the malarial

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Yapo EH, Koffi K, Botti K, JouvetA, Effi AB, Honde M. Sudden death caused by parasites: postmortem

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2.

3.

4.

5.

cerebral malaria discoveries in the African endemic zone. Am J Forensic Med Pathol2002; 23: 202-7. Oga A, Sadamitu D, HattoriY, Nakamura Y, Kohno M, Kawauchi S, Sasaki K . Imported malaria in a Japanese male: an autopsy report. Pathol Int 2001 ; 51: 371-5. Stoppacher R,Adams SP. Malaria deaths in the United States: case report and review of deaths, 1979-1998.J Forensic Sci 2003; 48: 404-8. Peoc’h MY, Gyure KA, Morrison AL. Postmortem diagnosis of cerebral malaria. Am J Forensic Med Pathol 2000; 21: 366-9. Boonpucknavig V, Boonpucknavig S, Udomsangpetch R, Nitiyanant P . An immunofluorescence study of cerebral malaria. A correlation with histopathology. Arch Pathol Lab Med 1990; 114: 1028-34.

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Becker K, Ortmann C, BajanowskiT, Brinkmann B, Peters G . Use of polymerase chain reaction for postmortem diagnosis of malaria. Diagn Mol Pathol 1999; 8: 211-5. 7. Pongponratn E, Turner GDH, Day NPJ, Phu NH, Simpson JA, Stepniewska K et al. An ultrastructural study of the brain in fatal plasmodium falciparum malaria. Am J Trop Med Hyg 2003; 69: 345-59. 8. Silamut K, Phu NH,Whitty C,Turner GDH, Louwrier K, Mai TH et al. A quantitative analysis of the microvascular sequestration of malaria parasites in the human brain. Am J Pathol 1999; 155: 395-410. 9. Moody A. Rapid diagnostic tests for malaria parasites. Clinical Microbiological Reviews 2002; 15: 66-78. 10. Malker MT , Piper RC, Milhous W. Lactate dehydrogenase and diagnosis of malaria. Parasitol Today 1998; 14: 376-7.

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Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

DEATH FOLLOWING D & C PROCEDURE: A CASE REPOR T Th. Meera Devi1, Kh. Pradip Kumar Singh 2

ABSTRACT A 35-year old female died shortly after D&C (Dilatation & curettage) for Medical termination of pregnancy by a young doctor at a health centre in Manipur on 11/01/05, and her dead body was br ought to the mortuary of the Regional Institute of Medical Sciences, Imphal for autopsy. On examination, about 2 litres of blood was present in the abdominal cavity and the cervix was found perforated with haematoma formation in the parametrium and surrounding area. D&C is a simple procedure and some of the complications of this procedure include haemorrhage, infection, perforation, shock, etc. However, the incidence of death following such a procedure is very minimal. Most of the time, death is averted by a timely intervention. Lack of experience, improper assessment of the patient’ s condition and avoidance of consultation with an experienced colleague could be some of the important contributing factors. Considering the uncommon occurrence of death following such a procedure, a case of death following D&C is presented in this paper.

present in the abdominal cavity. The uterus was enlarged (10.5 cm x 5.5 cm x 2.5 cm) and the right ovary was also enlarged and cystic, triloculated with jelly like mucoid material. The anterior wall of the cervix was found perforated and the track of the wound was identified extending from cervix to the parametrium with extravasation of blood into the surrounding area (Fig 1).

Fig 1: Showing perforation of uterus

Keywords: Dilatation & curettage; perforation; bleeding; death.

The internal organs were pale and the heart was empty. The histopathological examination of the uterus showed degenerated villi and inflammatory cell exudation. The wall of the perforated track showed vascular congestion and mixed inflammatory cell infiltration; foreign body giant cells & fibrosis (Re-traumatized healed cervical perforation ). Sections from the ovarian cyst showed features of ovarian mucinous cystadenoma.

CASE REPORT A 35-year old female died shortly after D&C for Medical termination of pregnancy by a young doctor at a health centre in Manipur on 11/01/05. She was a third gravida in first trimester with a history of undergoing previous D&C procedures. Her body was brought to the mortuary of the Regional Institute of Medical Sciences, Imphal for autopsy.

The cause of death was opined as to be due to haemorrhagic shock resulting from laceration of uterine vessels produced by perforation of the uterine cervix with blunt elongated object.

On examination, the stature of the body was 5 ft and it weighed 48 kg. Rigor mortis had passed off from the upper limbs but was present in the lower limbs. Post mortem lividity was present on the back and fixed. The abdomen appeared distended and generalised pallor was observed, and blood was seen at the vaginal opening.

DISCUSSION D&C (Dilatation and curettage) is a common surgical procedure to remove tissue or product of conception from inside the uterus. Some of the complications of this procedure include haemorrhage, infection, perforation, shock, etc. Perforation of uterus in D& C procedure may be produced by the uterine sound, dilators or curette. During the procedure, fundus and anterior wall perforations of the uterus are common. In a study by Mittal and Mishra1, it was observed that chances of uterine perforation is higher in multiparous women, and cases with a retroverted uterus had a higher incidence of perforation (59.4%) than those with an anteverted uterus (32.4%). In another study by

On internal examination, about 2 litres of blood was 1

Assistant Professor Demonstrator Department of Forensic Medicine, Regional Institute of Medical Sciences, Imphal - 795004 Correspondence: Assistant Professor Department of Forensic Medicine, Regional Institute of Medical Sciences, Imphal - 795004 e-mail: [email protected] 2

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Berek and Stubblefield2, perforation of the cervix or the lower uterine segment was higher in the pregnant patients than in non-pregnant patients. At the same time, there is an increased risk associated with previous surgery or laceration involving the cervix and previous uterine surgery 3. Interestingly, the risk of perforations in D &C is also higher with trainee operators4.

assessment of the condition of the case and consultation with an experienced colleague or senior is always advisable. It is worth saying that ‘The young man knows the rules, but the old man knows the exceptions’- Oliver W endell Holmes.

The incidence of death following a simple procedure like D & C is very minimal. However, in the management of the present case, there was some noticeable lacunae viz. lack of careful history taking, lack of proper assessment, lack of consultation with an experienced colleague or referral to an expert, mismanagement of the complication i.e. bleeding, etc.

1.

REFERENCES

2.

3.

CONCLUSION Death is uncommon following D&C procedure and it should be remembered that mismanagement of complication in such a case could be a potential problem area with legal liabilities. Operator inexperience seems to be a risk factor in this very common operation. Mishaps or misadventures do occur inspite of our best efforts. However, proper

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Mittal S, Misra SL .Uterine perforation following medical termination of pregnancy by vacuum aspiration. Int J Gynaecol Obstet1985; 23(1):45-50. Berek JS, S tubblefield PG. Anatomic and clinical correlates of uterine perforation. Am J Obstet Gynecol 1979;135(2):181-4. Roche NE, Park SJ,James D. Surgical Management of Abortion. emedicine from WebMD, June 2006: http:/ /www.emedicine.com/med/topic3312.htm. Amarin ZO, Badria LF. A survey of uterine perforation following dilatation and curettage or evacuation of retained products of conception. Arch Gynecol Obstet 2005: 271(3): 203-6.

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

KILLER BEES: CASE REPOR T OF FATALITIES DUE TO HONEYBEE STINGING Manish Shrigiriwar1, Rajesh Bardale2, Shailendra Dhawane1

ABSTRACT

CASE 2

Death from honeybee envenomation is rare phenomenon. In many cases no specific findings are obvious at necropsy, especially in aller gic reactions that causes rapid onset of shock and death. W e are reporting the autopsy findings in two cases of bee-sting related deaths.

A 59-year-old farmer was resting under a tree colonized by bees where he was stung by swarm of honeybees. The person was brought to Govt. Medical College, Nagpur with history of pain and itching. Subsequently he developed breathlessness. The patient survived for about 3 hours. Autopsy revealed multiple sting marks (~ 350) with beestings in situ . The face was swollen and inflamed with periorbital oedema. The sting areas were swollen and inflamed. Internal examination showed oedema of larynx and glottis. The lungs were congested and oedematous. Adrenal cortex studded with hemorrhages. Brain was congested and oedematous. Other organs were congested.

Keywords: honeybee; death; anaphylaxis. INTRODUCTION Death from honeybee envenomation is rare phenomenon and often death is caused by IgE-mediated Type I anaphylaxis. Less commonly, death may be attributed to the toxic effects of massive envenomation 1. With increased in cultivation of bees for honey, more such incidents will be present to autopsy surgeons in future. Over-reporting of bee-sting-related deaths may occur due to inclusion of deaths unrelated to a reaction to bee venom; whilst under-reporting may be due to unexplained deaths where a history of a bee-sting is not available or apparent at autopsy2. In many cases, no specific findings are obvious at necropsy, especially in allergic reactions that causes rapid onset of shock and death. With this observation, we are reporting the autopsy findings in two cases of bee-sting related deaths.

DISCUSSION Bees inflict painful stings and greatest threat to humans is posed by few species of social-bees – mainly honey and bumble bees. Apis mellifera is used throughout the world by beekeepers and therefore, it is the species most commonly involved in stinging incidents. In Asia, reported incidents occurred due to stinging by A. cerana and A. dorsata. Amongst bees, there are worker bees which are sterile female that lives for 42-56 days. They work to feed others. Queen bee lives for 4 years. Drones are fertile male and lives for about 50 days. Female bees poses sting while male do not have sting. A bee will sting for two reasons to protect its colony and when they are frightened. A sting is delivered by a posterior, tapered, needle like structure designed to inject venom. Bee venom is composed of melittin, phospholipase A2, mast-cell degranulating protein, Hyaluronidase, acid phosphatase, lysophospholipase and Apamin (a neurotoxic peptide). Melittin is the main compound in honeybee venom that causes alteration in the integrity of cell membrane. Phospholipase A 2 in association with melittin causes red cell hemolysis.

CASE 1 A 22-year-old male was attacked by honeybees when he was collecting honey. The patient was brought to Govt. Medical College, Nagpur with history of stinging pain, breathlessness and swelling over face. The patient survived for a period of one hour. Autopsy examination revealed hundreds (~ 300) of sting marks all over the body. The skin was infiltrated by oedema and stung areas were oedematous and inflamed. There was swelling of face with erythema. Internal examination showed evidence of anaphylaxis with oedema of airway with mucous plugging. Adrenal cortex showed multiple hemorrhages. Lungs were congested and hyperinflated with petechial hemorrhages. Other organs were congested.

The stings are strongly barbed and remains imbedded in human flesh. The presence or absence of a detached sting is useful indicator in determining whether bees or wasps cause envenomation. The presence of detached sting indicates envenomation caused by honeybees. In allergic individuals, the venom causes fatal anaphylaxis whereas in non-allergic persons, a localized wheal at the sting site with oedema, erythema and pruritis can be identified. In massive envenomation, the initial symptoms include oedema, fatigue, dizziness, nausea, vomiting, fever and unconsciousness. Dysphagia has also been reported3. Endogenous histamine response can cause

1

Associate Professor 2 Lecturer Dept of Forensic Medicine Indira Gandhi Govt. Medical College Nagpur. Corresponding Author: Dr Manish Shrigiriwar 5,Ayodhya nagar, Nagpur-24 E-mail: [email protected] 15

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

onset of diarrhea and incontinence. Systemic effect usually develops within 24 hours but in rare instances, may be delayed. The systemic effect includes hemolysis, hemoglobinuria, rhabdomyolysis, thrombocytopenia, oliguria, renal failure, muscle aches, hyperkalemia, hyperglycemia and hypertension. There is elevation of serum creatine phosphokinase, lactate dehydrogenase and hepatic enzymes with acidosis may be manifested. Even myocardial infarction has been reported4.5. Early death happens due to anaphylaxis whereas delayed death occurs due to venom toxicity with systemic effects. Thus broadly, the cases may be divided into two groups – cases presenting immediately are due to anaphylactic reaction whereas, the other group with delayed presentation, suggest systemic toxicity caused by venom. The anaphylaxis reaction consists of evidence of oedema of larynx & glottis, bronchial obstruction, mucous plugging of airway, pulmonary oedema, and hemorrhages in adrenal cortex. In systemic reactions, the fatalities are mainly attributed to renal failure due to rhabdomyolysis and breakdown products of hemolysis.

Fig 2 : Face showing signs of inflammation with periorbital oedema and multiple stings with marks

Evaluation of serum tryptase and specific IgE to beevenom on serum obtained at autopsy can assist in confirming anaphylactic reactions to bee venom as the cause of death. Although there are limitations to the usefulness of serum tryptase tests in the postmortem situation, it may still be useful to confirm suspected anaphylaxis in autopsy cases with an undetermined cause of death2. IgE is stable in serum for several weeks and can be measured in postmortem state6.

Fig 3: Recovered bee stings CONCLUSION

Fig 1: Skin showing sting mark with sting insitu with inflammation 16

Death due to bee-sting envenomation is rare phenomenon and poses difficulty for diagnosing at autopsy, especially in absence of stings or history. Obtaining proper history, careful autopsy examination in suspected deaths; presence of detached stings and appropriate use of laboratory method may assist in

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

confirming bee envenomation as cause of death. Broadly, the cases may be divided into two groups – cases presenting immediately are due to anaphylactic reaction whereas, the other group with delayed presentation, suggest systemic toxicity caused by venom.

3. 4. 5.

REFERENCES 1.

2.

Vetter RS, Visscher PK, Camazine S . Mass envenomations by honeybees and wasps. West J Med 1999; 170:223-7. Riches KJ, Gillis D, James RA. An autopsy approach to bee sting-related deaths. Pathology 2002; 34:25762.

6.

17

Shah D, Tsang T. Bee sting dysphagia (letter). Ann Int Medicine 1998; 129:253. Vikrant S, Patial RK. Acute renal failure following honeybee stings. Indian J Med Sci 2006; 60:202-4. Hiran S, Pande TK, Pani S, Gupta R, Vishwanathan KA. Rhabdomyolysis due to multiple honeybee stings. Postgrad Med J 1994; 70: 937. Pumphrey RSH, Roberts SD. Postmortem findings after fatal anaphylactic reactions. J Clin Pathol 2000; 53:273-6.

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

DO’S AND DON’TS FOR SOPHISTICA TED ANALYTICAL INSTRUMENTS VOL - III A. K Jaiswal 1, T Millo2, S. K Mewar3, Mamta Sharma4, D.V Moon5, M Moharana6

ABSTRACT

2. Temperature of NMR room should be 20-220c.

In the present article an attempt has been made for Do’s and Don’ts for sophisticated toxicological analytical instruments which are used in Forensic Chemistry and Forensic Toxicology. Volume-III series of the article consists of Do’s and Don’ts of NMR, Flame Photometer , Mercury analyzer, pH meter and Conductivity meter.

3. Filling of liquid nitrogen once in a week should be done up to over flow in the instrument.

Keywords: NMR; Flame Photometer; Mercury analyzer; pH meter; Conductivity meter.

4. Always good quality NMR tubes should be used. If NMR tube is sealed, make sure it is symmetric and doesn’t wobble. NMR tubes should be uniform in thickness and concentric. 5. NMR tube should be clean from outside to make it absolutely free from dirt, oil, crude, etc. Wipe the lower part of the tube with tissue paper before inserting it in the magnet.

1. NUCLEAR MAGNETIC RESONANCE NMR is a sophisticated instrument. In the modern times as many new developments have been made, it is very useful instrument in chemical and biological field. Literature reveals that NMR spectroscopy has frequently been used in the forensic sciences successfully for the detection purposes. One dimensional and two dimensional NMR techniques have been used for the trace level detection of chemical warfare agents in environmental samples in the proficiency test. In the biological system these chemical warfare agents or military agents form adducts with the macromolecules such as DNA and proteins that reflect the toxicity of agents. NMR is a very unique, reliable, safe and nondestructive method for the analysis of toxicants in the biological systems. NMR analysis should always be done by fully trained and skilled hands. Essential precautions should be taken while working on NMR instrument. NMR instrument requires day to day maintenance. Proper training should be given to the person who is going to operate the system. One should learn carefully, how to shim and how to collect and process data for basic 1H (proton), 13C (carbon),DEPT (Distortionless enhancement by polarization transfer) and other related NMR experiments.1-7

6. NMR tubes should be clean and dried properly to avoid the contamination. 7. Deuterated solvents should be used to record the spectra. Solution of the sample should be filtered before analysis, if this contains small particles of sample to be analysed. It should contains all the essential informations like chemical shift values, integration, expansion required in the interpretation of spectra. Baseline should be even. Peak shapes should be narrow and symmetrical. Small splittings should be clearly visible specially in the 1H NMR spectrum. 8. Toxic or compounds with offensive smell should be taken utmost care responsibly according to their nature. Sample preparation should be done in the fuming chamber and sample should be sealed by electric torch or by wax paper. Exhaust fan should be switched on during analysis. In case of any spill reporting should be done immediately to the head of the division. Always wear gloves and face mask during the toxic sample preparation. 9. Place the standard sample back into the sample box when experiment is finished.

Do’s 1. Always follow the sequence of opening and closing the instrument.

10. Accurately record the instrument use including date, total time used, type of experiment, and comments in the logbook.

1&2.

Deptt. of Forensic Medicine and Toxicology, AIIMS New Delhi -110029 3. Deptt. of NMR,AIIMS, New Delhi-110029 4. Synthetic chimistry division, Defence Research & Development Establishment, Gwalior, M.P-474002 5&6. Indian Bureau of Mines, Bangalore - 560022

11. Always keep the lab clean. Throw out used tissue papers, chemical gloves, scraps of paper, and labels, and any unwanted material 12. After the completion of analysis remove sample from the magnet and switch off the lock.

Corresponding Author: Dr A.K Jaiswal Chemist, Deptt. of F.M.T, AIIMS, New Delhi-29

13. Never lean against the magnet. 14. For VT control, users should know the temperature limitations of their NMR samples and to know how to 18

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

use the spectrometer safely within these limitations, otherwise ‘O’ ring may get damaged.

metallic compound) is aspirated into a flame (e.g. of acetylene burning in air), a vapor which contains atoms of the metal will be formed. Some of these gaseous metal atoms will be raised to an energy level which is sufficiently high to permit the emission of radiation characteristics of the metal e.g. the characteristic yellow color imparted to flames by compounds of sodium. This is the basis of flame emission spectroscopy (FES), formerly known as flame photometry.812 The instrumentation is simple. The solution under analysis is sprayed as a fine mist into a nonluminous flame which becomes colored according to the characteristic emission of the metal. A very narrow band of wavelength corresponding to the element being analyzed is selected by a light filter and allowed to fall on a photo detector. The output of the photo detector, which is a measure of the concentration of the element, is connected to measuring system viz: a galvanometer, a metering unit or digital unit. Once the galvanometer or the metering unit is standardized with solution of known concentration, the system will be ready for analyzing the unknown sample.13-17The flame photometer has got applications in the following areas.

15. Promptly report any instrument problems, including warning messages, to the concerned higher authority. 16. Immediately report any accidents, such as breaking of tube in the magnet, or spills, to the concerned higher authority. Don,ts 1. The magnetic field can erase information from credit cards, electronic access/ID cards and magnetic storage media. Do not take them near the magnet. Keep these items far from magnet. Analog watches or armed watches can also be significantly slowed down once they are magnetized. So remove while working on NMR. 2. Samples containing radioactive nuclides are not allowed in the NMR facility 3. Always check that icing should not be at the out lets of liquid nitrogen.

1. In Food & Agriculture

4. Always check that there should not be sudden decrease in the liquid helium level. This may lead to the quenching of magnet. 5. Gloves should never be worn while operating the computer / spectrometer

-

Na & K content in soils, plant materials, food & beverages

-

Ca in wine

2. In Pathological, Medical, Clinical & Bio-Medical investigations

6. No one should use the NMRs without training. This includes changing nuclei, probe tuning, temperature experiments, etc. 7. Do not change pulse power levels or the lock power level without knowledge.

-

Na, K & Li electrolytes in serum

-

Na & K in body fluids ( blood, urine, perspiration & saliva )

3. In Pharmaceuticals

8. Do not clean the NMR tube depth with gauge in acetone. The gauge is plastic and will dissolve in acetone. 9. Do not put spinner on upside down and then put sample and spinner into the magnet. There will be problems.

-

Alkali & Alkali earth metals in presence of each other

-

Na, K & Ca nutrient solutions for cultivation of antibiotics

4. In Mining & Metallurgy

10. Do not force the tuning/ matching rods to turn further than their maximum or minimum positions, this will cause serious internal damage to the probe and render it immediately useless until repaired.

5. Alkali & Alkali earth metals In Pollution Monitoring & Control -

Na, K & Ca in natural, spring, river, sea, boiler feed & waste water

11. Do not put the sample into the magnet unless the lift air is turned on again, you risk damaging the probe if you put the sample into the magnet.

6. In Research Laboratories & Industries -

Solubility, absorption & corrosion studies

12. One should never stop or remove the sample when another person’s experiment is running

-

Alkali & Alkali earth metals in pastes, soda glass, ceramic & chemicals

13. Do not attempt any repairs on your own and do not bring iron objects near to the magnet.

-

Na, K & Ca in cement and other raw materials

Do’s

2. FLAME PHOTOMETER

01. Give sufficient warm up time to the instrument before using.

If a solution containing a metallic salt (or some other 19

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

02. Do periodic maintenance of the instrument.

09. Don’t use high velocity air blower to clean the instrument.

03. Before cleaning, detach the instrument from the mains supply.

10. Don’t touch the optical components of the instrument by hand.

04. Use soap solution for cleaning.

3. MERCURY ANALYSER

05. Make sure that end clamps of the pressure hoses are tight.

When the sample solution containing mercuric ion is treated with stannous chloride, elemental mercury (Hg) is released. There is phase separation in the process. The liberated mercury is drawn into the absorption cell which is irradiated by a low pressure mercury vapor lamp. Mercury vapor absorbs the radiation at 253.7 nm & causes a change in the transmittance, which can be correlated to the total mercury content in the sample solution. Since no flame is used in this method this technique is usually referred to as “Cold vapor atomic absorption spectroscopy”.The instrumentation part is simple. The mercury analyzer consists of a low pressure mercury lamp emitting 253.7 nm line, an absorption cell, a filter, a detector with associated electronics and vapor generation system. The carrier gas (air free of mercury) bubbles through the vapor generation system, carries elemental mercury from the solution and then passes into the absorption cell.

06. Make sure that correct fuse is installed in the fuse holder of the instrument. 07. Ensure that AC power outlets used for the instrument are properly earthened. 08. Always use well digested sample solutions devoid of any turbidity. 09. Use high grade deionised water for preparation of sample and standard solutions. 10. Maintain correct fuel pressure and air pressure. 11. Always use match stick or lighter to ignite the flame. 12. Feed high grade deionised water in between two solutions without fail. 13. After completion of the measurement, feed deionised water for at least 20 minutes.

The mercury analyzer has got application in the determination of mercury in water, brine, gases like air, nitrogen, oxygen and hydrogen, urine, marine products, biomedical investigations, agricultural products, metals, alloys, ores, minerals, chemicals, photography, geophysical prospecting, river sediments & soils etc.18-19

14. Ensure that there are no leakages in fuel and/or air lines. 15. Check leakages using soap solutions at all the nozzle ends of pressure hoses. 16. Drain the buffer tank periodically by opening the turn screw on the drain nozzle.

Do’s

17. Ensure that all glassware to be used are absolutely clean with no contamination.

01. Give sufficient warm up time to the instrument before using.

Don’ts

02. Do periodic maintenance of the instrument.

01. Don’t expose the instrument to rain, excessive moisture, direct sunlight, dust etc.

03. Before cleaning, detach the instrument from the mains supply.

02. Don’t use power cable without proper grounding.

04. Use soap solution for cleaning.

03. Don’t remove cover; refer servicing to qualified personnel only.

05. Ensure that AC power outlets used for the instrument are properly earthened.

04. Don’t disconnect the gas tube from gas inlet when the cylinder regulator is ON.

06. Ensure that all glassware’s to be used are absolutely clean with no contamination.

05. Don’t open the gas control to fully open before giving air.

07. Use high grade deionised water for preparation of sample and standard solutions.

06. Don’t install the instrument near to RF & EM interferences.

08. Preserve the standard solutions in acidic & oxidizing medium.

07. Don’t allow water or any other solution to enter inside the instrument.

09. Maintain same volume of all standards and sample solutions in the reaction vessel.

08. Don’t use corrosive chemicals petrol, acetone or carbon tetrachloride for cleaning.

10. Wash the absorption cell if any liquid enters into it through the gas inlet nozzle. 20

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

11. Replace the R1 (to purify air) & R5 (to absorb Hg vapor) at least once in 3 days.

2. Environmental pollution and control viz. pH in water and effluent

12. Clean R3 (acid) & R4 (alkali) traps & refill with respective reagents daily.

3. Pharmaceutical industry viz. pH of various formulations 4. Beverage industry viz. pH of beverages

13. Before taking the reading of sample, check the blank for zero absorbance.

5. Research laboratories viz. pH of various solutions Do’s

Don’ts

01. Give sufficient warm up time to the instrument before using.

01. Don’t expose the instrument to rain, excessive moisture, direct sunlight, dust etc.

02. Do periodic maintenance of the instrument.

02. Don’t use power cable without proper grounding.

03. Before cleaning, detach the instrument from the mains supply.

03. Don’t remove cover; refer servicing to qualified personnel only.

04. Use soap solution for cleaning.

04. Don’t install the instrument near to RF & EM interferences.

05. Ensure that AC power outlets used for the instrument are properly earthened.

05. Don’t allow water or any other solution to enter inside the instrument.

06. Ensure that all glassware’s to be used are absolutely clean with no contamination.

06. Don’t use corrosive chemicals, petrol, acetone or carbon tetrachloride for cleaning.

07. Calibrate the instrument with acidic buffer like 4.00 which is more stable.

07. Don’t use high velocity air blower to clean the instrument.

08. Use a mains stabilizer if mains voltage is not within 200V to 270V.

08. Don’t touch the optical components of the instrument by hand.

09. Change to fresh standard buffer solution every fortnight.

09. Don’t fill the traps with more liquid than the specified volume.

10. Always calibrate the instrument before measurement of samples.

10. Don’t take reading of samples until blank is checked for zero absorbance.

11. Follow all precautions for maintaining the electrode. 12. Keep the electrode always in deionised water when not in use.

4. PH METER When a pair of electrodes namely pH sensitive electrode and a reference electrodes are dipped in aqueous solution they generate EMF which is proportional to the pH of the solution. The magnitude of the EMF is also dependent on the temperature of the solution. Instrumentation is simple. The modern day pH meter is an electronic digital voltmeter, scaled to read pH directly. A glass electrode has an asymmetry potential which makes it impossible to relate a measured electrode potential directly to the pH of the solution and makes it necessary to calibrate the electrode. A pH meter therefore always includes a control ( set buffer, standardize or calibrate ) so that with the electrode assembly ( glass plus reference electrode or a combination electrode ) placed in a buffer solution of known pH, the scale reading of the instrument can be adjusted to the correct values.20-21

13. Ensure that the internal buffer solution covers the whole membrane and no air bubbles are entrapped.Wash off any salt present on the exterior of the electrode assembly with deionised water. 14. Thoroughly rinse the electrode with deionised water after each sample measurement. 15. Electrodes which have a slow response due to drying out of the membrane or use under extreme conditions may be reactivated by soaking in 0.1N HCl for several hours. 16. Fill up electrolyte to the height of about 1cm below the filling tube in single rod or combination assemblies. Don’ts

PH meter has got wide application in many industrial laboratories and research laboratories. pH measurements are carried out to determine pH in the following.

01. Don’t expose the instrument to rain, excessive moisture, direct sunlight, dust etc. 02. Don’t use power cable without proper grounding.

1. Bio-medical analysis viz. pH in blood & other body fluids 21

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

are properly earthened.

03. Don’t remove cover; refer servicing to qualified personnel only.

06. Ensure that all glasswares to be used are absolutely clean with no contamination.

04. Don’t install the instrument near to RF & EM interferences.

07. Always calibrate the instrument before measurement of samples

05. Don’t allow water or any other solution to enter inside the instrument.

08. Use a mains stabilizer if mains voltage is not within 200V to 270V.

06. Don’t use corrosive chemicals petrol, acetone or carbon tetrachloride for cleaning.

09. Change to fresh standard solution every fortnight.

07. Don’t use high velocity air blower to clean the instrument.

10. Follow all precautions for maintaining the cell.

08. Don’t touch the electrode assembly with naked hand.

11. Keep the cell always in deionised water even when not in use.

09. Don’t immerse the electrode in corrosive or sticky solutions.

12. Thoroughly rinse the cell with deionised water after each sample measurement.

10. Don’t keep the electrode out of deionised water for a long duration.

13. Before taking reading, rinse the cell with little amount of solution whose conductivity has to be measured

5. CONDUCTIVITY METER

14. Always switch off the instrument when not in use.

Conductivity is the reciprocal of the electrical resistivity of a solution between two parallel plates. If this is an electrically conducting solution, then, there will be an ionic current when these plates are charged with different potentials. The resistance offered to the ion in conduction will bear relation to not only physical dimension of the plates but also to the purity of the aqueous solution. If salt content in the water is more, then less resistance is offered for ion flow and hence conductivity becomes more. The unit of conductivity is mho per centimeter. Instrumentation is simple. If any potential divider employing constant AC source is used in one arm, conducting cell and standard resistor in another, it is possible to get an AC voltage proportional to the conductivity across the later provided the ratio of potential division is at least 100:1. Later AC to DC converter can be used to be followed with a standard digital panel meter to read the conductivity digitally.22-23\

15. Ensure that the cell is dipped in such a way that the plates are fully dipped and there are no air bubbles present between them. Don’ts 01. Don’t expose the instrument to rain, excessive moisture, direct sunlight, dust etc. 02. Don’t use power cable without proper grounding. 03. Don’t remove cover; refer servicing to qualified personnel only. 04. Don’t install the instrument near to RF & EM interferences. 05. Don’t allow water or any other solution to enter inside the instrument. 06. Don’t use corrosive chemicals, petrol, acetone or carbon tetrachloride for cleaning.

Conductivity meter is very widely used in many industrial and research laboratories engaged in areas such as environmental pollution monitoring & control, biomedical investigation, pharmaceutical analysis, mineral processing, metallurgy, physical chemistry measurements and many other areas.

07. Don’t use high velocity air blower to clean the instrument. 08. Don’t touch the cell with naked hand. 09. Don’t immerse the cell in corrosive or sticky solutions.

Do’s

10. Don’t keep the cell out of deionised water for a long duration.

01. Give sufficient warm up time to the instrument before using.

REFERENCES

02. Do periodic maintenance of the instrument.

1.

03. Before cleaning, detach the instrument from the mains supply. 04. Use soap solution for cleaning. 05. Ensure that AC power outlets used for the instrument 22

Cartigny B, Azaroual N, Imbenotte M, Mathieu D, Vermeersh G, Goulle J P, Lhermitte M.Determination of giyphaste in biological fluids by 1H and 31PNMR, Spectroscopy. Forensic Science International 2004;143:141-145.

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

2.

3.

4.

5.

6.

7.

8.

9.

Imbentte M, Azarousal N, Cartigny B,Vermeersch G, Lhemitte M. Identification and Quantitation of Xenobiotics by 1H NMR Spectroscopy in Paisoningcases. Forensic Science International 2003;133:132-135. Westpal F, Junge T, Rosner P, Foitschi G, Klein B, Girreser U. Mass Spectral and NMR Spectral data of Two new designer drugs with an á- Aminophenone structure 4’Methyl –a – pyrralidinohexanophnone and 4’- methyl – á- pyrrolidinobutyrophenone .Forensic Science International 2007;169:32-42. Dal Cason T A, Meyers SA, Lankin D C.Proton and Carbon-13 NMR assignments of 3-4methylenedioxyamphetamine (MDA) and some analogues of MDA, Forensic Science International 1997; 86:15-24. Suryaprakash N, Azoury M, Goren Z, Jelinek R. Identification of heroin in street doses using 1DTOCSY nuclear magnetic resonance. Journal of Forensic Sciences 2000;45:5.5 Lee G S, Brinch KM, Kannangara K, DawsonM, Wilson MA. A Methodology based on NMR spectroscopy for the forensic analysis of condoms, Journal of Forensic Sciences2001;46:13. Costa Conn, Glen Ramsay , Claude Rouk, Chris Lennaro. The effect of metal salt treatment on the phetoluminesence of DFO- treated fingerprints. Forensic Science International2001;116:117-123. Furman N H. (Editor), Standard Methods of Chemical Analysis, Vol 1, The Elements, 6th Edition, Robert E. Krieger, Florida, 1985. Kolthoff IM et.al. Quantitative Chemical analysis, 4th edition, The Macmillan Company, London, 1969.

10. Mendham J et.al. VOGEL’S text book of quantitative analysis, 6th edition, Pearson education (Singapore) Pvt. Ltd, Delhi, 2004. 11. Skoog DA. Principles of Instrumental Analysis, 3rd edition, CBS College publishing, Philadelphia, 1985 12. Willard HH et al.Instrumental Methods of Analysis, 6th edition, CBS Publishers & Distributors, Delhi, 1986. 13. Dean JA et al.Flame Emission & Atomic Absorption Spectroscopy, Dekken, New York, 1975. 14. Mavrodineanu R. Analytical Flame Spectroscopy, Selected topics, 1st edition, Macmillan & Co Ltd, London, 1970. 15. Users manual, Flame Photometer, Elico Limited, Hyderabad. 16. Instruction Manual for Flame Photometer, Systronics. 17. Maintenance Manual for Flame Photometer, Elico Limited, Hyderabad. 18. Cotton FA et al. Advanced Inorganic Chemistry, A comprehensive Text, 3 rd Edition, Wiley Eastern Limited, New Delhi, 1992. 19. Instruction Manual, Mercury Analyzer, ECIL, Hyderabad 20. Instruction Manual, Digital pH Meter, Digisun Electronics, Hyderabad. 21. Instruction Manual, pH Meter, Systronics. 22. Glasstone S. Text Book of Physical Chemistry, 2nd Edition, Macmillan India Limited, Chennai, 1991. 23. Instruction Manual, Direct Reading Digital Conductivity Meter, Digisun Electronic, Hyderabad.

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Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

KIDNEY RUPTURE WITHOUT EXTERNALLY VISIBLE TRAUMA Memchoubi PH.1

INTRODUCTION In this paper , a case is being r eported about a man who was beaten to death, presenting with extensive internal injury with minimal external injuries. It is an established fact that some areas of the body bruise less in spite of considerable blunt trauma. However, practically, this is not always the case. If there is no significant external trauma, the internal injury if sustained is not usually much. But in this case, there was fatal internal injury without any externally visible injury . The case is ther efore being reported to highlight this rare finding. Keywords: No external trauma; internal injury. CASE REPORT During the durga puja celebrations of 2007, on 20-1007, at around 3 pm, the deceased who was a 24 year old man went towards the local market with a friend to see a music programme but on 21-10-07 at around 6 am, the dead body of the deceased was found at the local high school ground. . The friend could not be traced, but there was a story that the deceased had gone back early from the function with someone whom he knew but no one knew what happened after that. Suggestions were many-some said it could be a case of drug overdose while some said it could be just a natural death. A lot of hue and cry ensued suspecting foul play. Therefore, an FIR was registered and the body was brought for post-mortem examination.

To sum up, the injuries were confined mainly over the head and neck region without any significant injury over the trunk. Internally, there was scalp haematoma, over both parieto-temporal regions; with diffuse subarachnoid haemorrhage over both cerebral hemispheres and contusion 6cmX5cm over the left occipital lobe; there was fracture of left 4th – 6th and 9th-11th ribs laterally and right 6th – 7th ribs anteriorly with contusion of the underlying muscles. About 500ml of blood was present in the peritoneal cavity; gallbladder and adjoining areas of the liver was contused and there was rupture of the left kidney with capsular haematoma. The death was due to shock and haemorrhage resulting from multiple blunt force injuries to the head and abdomen which was homicidal in nature. DISCUSSION Owing to their deep situation in the abdomen, rupture of the kidneys is rare by direct violence from blows, unless considerable force is applied to the lumbar region over the 12th rib 3.

The body was 5ft 8 inches weighing 50kgs of average build with fair nutrition. The wearing apparel consisted of black full sleeved sweatshirt and black long pants. Rigor mortis was developed all over the body; post-mortem staining was developed on the back and fixed; conjunctival haemorrhage and bleeding from the nose were present.

Injuries to the kidney are not common as they are situated in relatively well protected part of the body. Contusions and lacerations usually result from blunt force applied directly to the posterior or lateral aspect of the kidneys as from blows to loins2.

External injuries consisted of a bruise, 11cmx10cm over the left side of the forehead, left eye and left cheek with rupture of the left eyeball; bruise,12cmx12cm over the right side of the forehead and right eye; abrasion, 2cmx1cm on the forehead; bruise,6cmx6cm over the right ear and mastoid; bruise, 10cmx7cm over the left ear and mastoid; lacerated wound, 1.2cmx0.5cmxmuscle deep just below the left lower eyelid; lacerated wound, 1cmx0.5cmxmuscle deep on the inner aspect of the upper lip; lacerated wound, 3cmx1.5cmxmuscle deep on the inner aspect of the lower

1

lip; bruise, 7cmx2cm on the chin; abrasion, 5cmx2cm on the front of the neck; bruise, 5cmx4cm on the front of the neck; abrasion, 2cmx0.5cm just above the left clavicle; abrasion, 0.3cm x0.2cm on the back at the level of 11th thoracic vertebra 13cm right to midline; abrasion, 7cmx5cm on the left shin; abraded contusion, 4cmx3cm on the medial aspect of right foot.

In traumatic injuries of the kidney, there is usually a visible external trauma overlying the renal region4,5. Direct impact over the loin or abdomen is the commonest cause6. However, in the present case, there was rupture of the left kidney with capsular haematoma without any significant external injury over the loin or the abdomen, not even in any part of the trunk. This rare finding may be due to the following factors: 1. The kidney is encapsulated and filled with blood and urine due to which a severe blow initiates forces which act according to PASCAL’s law, which states that the “force exerted upon any part of enclosed fluid is transmitted equally in all directions “. Violent blows to

Corresponding Author: Demonstrator Dept. of Forensic Medicine, Regional Institute of Medical Sciences, Imphal. 24

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

kidneys can cause bursting injuries with fragmentation or multiple bisections2. 2. There may not be any evidence of bruising under the following conditions: when the offending weapon is yielding in nature and of flat surface; where the body surface to be hit is covered with thick rug, blanket, quilt, etc, there will not be any bruising externally, but deep seated bruising underneath may be evident; where the site of injury is a yielding part such as the anterior abdominal wall, there may not be any external bruising though internally rupture of viscera may be noted; where subcutaneous tissues are thick with no pliable subcutaneous fat, bruising may be absent notwithstanding application of gross violence 1 . In our present case, the injuries were over the areas not prone to bruise as mentioned above. Also, the victim was wearing a sweatshirt which was quite thick. These two factors could also have played a role in the rare presentation of the case.

Fig 3: Figure showing rupture of left kidney with capsular haematoma CONCLUSION Internal injury without visible external trauma is not very common but is a fact. If proper mental orientation is not maintained the diagnosis may be missed leading to the death of the patient in clinical cases or to an obscure or a negative autopsy in post-mortem cases. The above case has been reported to highlight this fact. REFERENCES 1. 2.

3. Fig 1: Figure showing absence of external injuries on the left loin

4.

5.

6.

Fig 2: Figure showing contusion of the intercostals muscles

25

JB Mukherjee. Reginal injuries, in Forensic Medicine and Toxicology. Vol 1, 2nd edn, 1994. KSN Reddy. The Essentials of Forensic Medicine and Toxicology, 16th Edn, K. Suguna Devi: Hyderabad, 1997: 220-223 CA Franklin : Modis Medical Jurisprudence nad Toxocology, 21st Edn, N. M Tripathy Pvt Ltd: Bombay, 7998; 327-336 Salimi J, Nikoobakht M, Zareei M. Epidemiologic study of 284 patients with urogenital trauma in three trauma center in tehran.Trauma and Surgery Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.(PubMed). Brophy RH, Gamradt SC, Barnes RP, Powell JW, Delpizzo JJ, Rodeo SA,Warren RF. Kidney Injuries in Professional American Football: Implications for Management of an Athlete With 1 Functioning Kidney.14532 South Outer Forty Drive, Chesterfield, MO 63107. [email protected]. . (PubMed). Lee YJ, Oh SN, Rha SE, Byun JY . Renal trauma.Department of Diagnostic Radiology, Division of Abdominal Radiology, Kangnam St. Mary’s Hospital, The Catholic University of Korea , 505 Banpo-dong Seocho-gu, Seoul 137-701, Republic of Korea. (PubMed).

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

HOMICIDAL ASPHYXIAL DEATHS IN SOUTH DELHI (1996-2005) C Behera1, Ravi Rautji2, Tabin Millo3

ABSTRACT An increasing death rate as a result of violence constitutes a large group in medico legal autopsies. Specially, deaths due to asphyxia ar e one of the most important causes in violence deaths. During the 10-year period from January 1996 to December 2005, there were 198 homicidal asphyxial deaths autopsied by the Department of Forensic Medicine, All India Institute of Medical Sciences, New Delhi, India which constituted 12.27 % of all violent asphyxial deaths. Males outnumber females in total number of homicidal asphyxial deaths [Males 111 (56%): Females 87 (44%)]. The highest homicidal asphyxial deaths score fell into the age group 20-29 years (26.76%), followed by 30-39 years which contributed another 18.68%. The least common age group was 50- 59 years, which contributed only 5.5% of cases. The most frequently used method was ligature strangulation (67.2%), followed by deaths due to smothering (1 1.6%), combined methods (10.6%), throttling (8.6%) and drowning (2%). Deaths were common in autumn and winter season (37.4%) followed by rainy season (30.3%) and spring and summer (30.3%). Keywords: Homicial Asphyxia; smothcring; Throttling. INTRODUCTION

MATERIAL AND METHODS New Delhi, the capital city of India is divided into seven administrative districts. The department of Forensic Medicine of All India Institute of Medical Sciences (AIIMS) caters to medico-legal cases of South Delhi jurisdiction, home of about 4 million people. A retrospective investigation of deaths due to homicidal asphyxia was carried out to establish the distribution and methods. All autopsy reports and relevant medical and toxicological reports pertaining to the period 1996 – 2005 (10 years) were included in the present study. Of the total 13,207 autopsies carried out at the Department of Forensic medicine and Toxicology of All India Institute of Medical Sciences, New Delhi during the period 1996-2005, 1,663 (12.59%) deaths were found to be asphyxial in nature. Among asphyxial deaths 198 (12.27%), deaths were homicidal in nature. RESULTS

Asphyxial deaths are caused by the failure of cells to receive and/or use oxygen. It is a common incident in forensic practice, and determination of the manner of death is very important. The manners of death can be accidental, suicidal, homicidal, or natural due to many methods of asphyxia. In such deaths, autopsy plays a major role to solve the case; the scene investigation and collection of samples are also of importance1.

Males outnumber females in total number of homicidal asphyxial deaths. Approximately half of cases were male (n=111, 56%) as compare to females (n= 87, 44%).(Fig.1) with male to female ratio of 1.27:1. Year-wise distributions of homicidal asphyxial deaths are shown in Table 1. The youngest victim in the study was a new born baby, while the oldest victim being a 82 years old male. The mean age of victims was 29.53 years with a standard deviation of 19.48. Most common age group in both sexes was 20-29 years (26.76%), followed by 30-39 years (18.68%). The least common age group involved was 50-59 years which contributed 5.5% of the cases. (Fig 2) Ligature strangulation (67.2%) was found to be the most common method followed by deaths due smothering (11.6%), combination of methods (10.6%) and throttling (8.6%) (Table 2) These four common methods combined together, contributed approximately 98% of cases.

Asphyxial deaths are divided into different methods, such as strangulations (hanging, manual, ligature), suffocations (environmental, smothering, choking, mechanical, suffocating gases), chemical asphyxia (carbon monoxide [CO], hydrogen cyanide, hydrogen sulfide), and drownings1. Additionally, in some cases, the victim dies as 1&3.

2.

a result of the combination of different mechanisms of asphyxia. The purpose of this study is to find out the epidemiology of the Homicidal Asphyxial deaths in South Delhi and to compare them with other worldwide studies on the subject.

Department of Forensic Medicine and Toxicology AIIMS, New Delhi-110029, India Department of Forensic Medicine & Toxicology, Armed Forces Medical College, Pune, India Correspondence Author: Dr (Lt Col) Ravi Rautji Department of Forensic Medicine AFMC, Sholapur Road, Pune, 411040, India E-mail: [email protected]

DISCUSSION INCIDENCE In our study, the incidence of violent asphyxial death in South Delhi was 12.21% of all medico-legal autopsies. Out 26

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

AGE AND SEX Majority of the cases 111 (56%) were male as compared to female 87 (44%). Male to female ratio was found out to be 1.27:1, which suggests that male are more common victims of homicidal asphyxial deaths in comparison to famale. Few other studies have shown similar male preponderance.3,4 Commonest age group involved was 20-29 years (26.76%), followed by 30-39 years which contributed another 18.68%. LIGATURE STRANGULATION Death due to ligature strangulation (67.2%) was the commonest method of homicidal asphyxial death. As compared to females (n=50, 37.6%) the majority of the victims were males (n=83, 62.4%) with a male: female ratio of 1.66:1. Similar finding was reported in literature5. However in some other studies females were the most common victims of ligature strangulation with associated sexual assault.6,7 The increased prevelance of male sex was due to overall dominance of male sex in homicidal asphyxial deaths in this part of world. Commonest age group involved was 20-29 years (27.8%) followed by equal number of cases in the age groups of 30-39years and 10-19 years (18%). (Table 3)

Fig 1: Sex wise distribution Table 1: No. of cases in year

Table 3: Methods of asphyxiation according to age-group

MANUAL STRANGULATION (THROTTLING) In this group there were 19 cases which were 9.59% of all homicidal asphyxial deaths. Azmak and Coltu and Durak, in their studies had reported the incidence to be 5.85% and 2.3% of all asphyxial deaths.2,8 There were 9 Male cases (52.9%) and 8 cases of female (47.1%) with male to female ratio 1.12:1, which was similar to a study by Satish K Verma et al.9

Fig 2: Age wise distribution Table 2: Methods of asphyxiation according to sex

SMOTHERING Smothering is a kind of suffocation due to mechanical obstruction or occlusion of the nose and mouth with the hands, a plastic bag, or a smooth cover. Homicidal smothering is a killing method often used by a physically stronger assailant against a weaker victim. In the present study it constituted 23 cases accounting for 11.6 % of all homicidal asphyxial deaths. Female (n=14, 60.86%) outnumbered male (n=9, 39.13%) with male to female ratio of 0.64:1 Maximum number of cases were reported in the age group of 0-9 years (n=7, 30.7%) followed by the age group of >60 years (n=5, 21.4%). Other studies have also

of these cases 11.9% deaths was homicidal in nature, which is similar to the findings reported in literature.1 In another study by Derya Azmak in Edirne2, Turkey total homicidal asphyxial deaths accounted for 9% of all cases. 27

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

reported the children as common victim.10,11 Children, females and elder persons, being not so physically strong are more vulnerable.

REFERENCES

DROWNING

2.

1.

Homicidal drowning is a rare phenomenon in forensic practice. Only 4 cases were reported in this category of which two cases were female and two cases were male. Five yrs and eight years old daughters were thrown into a well by father, while body of a 20 yr old male was fished out by police from a pond, which later turned out to be a case of homicidal drowning. In another case a 35 yrs old man was thrown into a water tank after he was made unconscious after being hit by a blunt weapon.

3.

4.

5.

COMBINATION METHOD In these cases the victim died as a result of the combination of different mechanisms of asphyxia. Total 21 cases were reported which constituted 10.6% of all homicidal asphyxial deaths. (Table 4) Male constituted 38%, whereas female 61.9%.The combination of ligature strangulation and smothering accounted for 8 cases, out of which 2 were male and 6 female. The combination of traumatic asphyxia and different methods of mechanical asphyxia has been reported in previous forensic studies12-14. Isolated gagging case was not reported in the present study. It was always combined with other methods of asphyxia like ligature strangulation and smothering. Total 9 cases ware reported in this type of combination of which 5 cases with ligature strangulation and 3 cases with smothering. A couple killed their daughter and son by combination of smothering and gagging method and later committed suicide. Medium sized lemon was found in the upper respiratory tract of both victims. A 4 years female child was strangled and later drowned in waste water drain. A case was reported from Romania 5 where a victim was killed by 3 different mechanisms of asphyxia: smothering with the hand, manual strangulation with the other hand, and traumatic asphyxia by thoracic compression with the knees15.

6.

7. 8.

9.

10. 11.

12.

Table 4: Combination methods ofAsphyxia

13.

14.

15.

28

DiMaio DJ, DiMaio VJM. Asphyxia. In: Forensic Pathology Boca Raton, FL: CRC Press; 1993;207–251. Azmak Derya. Asphyxial deaths: A retrospective study and review of the literature. The American Journal of Forensic medicine and Pathology 2006; 27(2): 134-144. Katk1c1 U . Sivas’ta adli olgular (1990–1993): demografik veriler veotopsiyi yapan hekimin o¨zellikleri. Bull Legal Med Istanbul1997;2:3–7. Salacin S. An analysis of the medicolegal autopsies performed in Adana, Turkey, in 1983–1988. Am J Forensic Med Pathol 1991;12:191–193. Di Maio, Vincent J. M . Homicidal Asphyxia. The American Journal of Forensic Medicine & Pathology 2000; 21(1): 1-4. Srivastava AK, Gupta D,Tripathi CB. A study of fatal strangulation cases in Varanasi (India). Am J Forensic Med Pathol 1987 8:220 –224. Abder-Rahman HA,Abu-Alrageb SY. Killing tools in mechanical asphyxia. Legal Med 1999;1:2–5. Coltu C¸ Durak D. Adli otopsisi yap1lm1p 205 mekanik asfiksi olgusunun retrospective incelenmesi. Adli T1p Derg 1992; 8:45– 48. Verma Satish K, Lal Sone. Strangulation deaths during 1993–2002 in East Delhi (India), Legal Medicine 2006; 8: 1–4. Dolan M, Guly O,Woods P, et al. Child homicide. Med Sci Law 2003;43:153–169. Banaschak S, Schmidt P, Madea B. Smothering of children older than 1 year of age: diagnostic significance of morphological findings.Forensic Sci Int 2003;134:163–168. Wolodzko AA, Taff ML, Ratanaproeska O, et al. An unusual case of compression asphyxia and smothering. Am J Forensic Med Pathol1986;7:354 – 355. Taff ML, Boglioli LR. Homicidal traumatic asphyxia associated with pebble impaction of the upper airway. Am J Forensic Med Pathol1992;13:271–274. Miyaishi S, Yoshitome K, Yamamoto Y, et al. Negligent homicide by traumatic asphyxia. Int J Legal Med 2004;118:106 –110. Lupascu C, Lupascu C, Beldiman D . Mechanical asphyxia by three different mechanisms. Legal Med 2003; 5:110 –111

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

PENETRATING TRACHEAL INJURY - A CASE REPOR T Usman Ghani1, Shafi Muhammad Nizamani1, Rabia Nizamani1

ABSTRACT

CASE REPORT

We pr esent an unusual case of penetrating injury trachea. Tracheal injuries are rare and more so when they are sustained on falling down. Traumatic airway injuries are fortunately rare. Though injuries can be obvious and initial management straightforward, the diagnosis can be difficult. W e pr esent a case of penetrating cervical tracheal injury due to fall on protruding iron bar from a manhole resulting in a stab wound in neck.

A 20year-old male presented to surgical OPD with injury to neck a day ago. He sustained injury one day ago while playing with friends, he fell on a protruding bar from a manhole resulting in stab injury to neck. He had no significant difficulty in breathing and was coughing. On examination, a wound was seen in the anterior neck and air bubbles could be clearly seen in the wound and upon coughing air could be heard gushing from the wound (Figure 1&2). Patient and his attendants were counseled about the nature of injury and the need for surgery was explained to them. Routine pre-operative investigations were carried out and the surgery was performed the same day. Patient was intubated through orotracheal route with no. 7.5 endotracheal tube. Collar cuff incision was made, subplatysmal flaps were raised, sternocleidomastoid was mobilized, strap muscles divided in the midline and were removed from the thyroid (Figure 3). Tracheal puncture was obvious as the tube could be seen clearly from the laceration site. The laceration was found to be 2nd to 4th tracheal ring anteriorly. Posteriorly trachea was intact and no any other injury was seen. The tracheal defect was primarily closed with vicryl 2/0 inturrupted sutures without any tension and the suture line was further covered by detachment of a part of sternocleidomastoid detachment from the mastoid. It was applied over the suture line and secured there with vicryl. The patient was extubated without much difficulty. Patient was nursed postoperatively in intensive care unit with preparation of early intubation and ventilation. He was given parentral antibiotics and steroids. Postoperative course remained smooth and patient did not require any intubation and was subsequently discharged on 3rd postoperative day. Patient came for two months for postoperative follow up (Figure 4).

The young male patient presented in the Outpatient Department with an open neck wound, air bubbles were visible. Planned exploration of the wound was done the same day and a puncture wound was seen in cervical trachea. There was no injury to major vessels or nerves, so the wound was debrided and closed in layers and a sternocleidomastoid flap was placed. Patient was shifted to intensive care. Recovery was uneventful. Initial management can be complicated by associated head, neck and thoracic injuries. Orotracheal intubation or tracheostomy through the tracheal wound can be done initially. Trachea can be r epaired primarily without any tension on suture line. Mortality rates and the incidence of late complications remain high and have been related to delays in diagnosis and definitive treatment. Keywords: Penetrating tracheal injury; orotracheal intubation; sternocleidomastoid flap. INTRODUCTION Penetrating airway injuries in the neck are relatively uncommon, accounting for an average of less than three cases per year per reporting center1. Penetrating injuries of the neck involve the larynx in 5-15% of patients, associated carotid artery or digestive track injuries being twice as likely to have airway injuries2. The prevailing site of tracheal transection is the junction of the cricoid with the trachea, because the connective tissues in this area are weak3. We present a patient who sustained an unusual injury. He had an obvious cervical tracheal injury. Since this type of injury is quite rare, we briefly reviewed the literature and present our views.

1

Department of Surgery, Liaqat University of Medical and Health Sciences Correspondence Address: H. No. 35, Phase-I, Anwar Villas, Near New Wahadat Colony, Hyderabad, Sindh, Pakistan [email protected]

Fig 1: Showing open neck injury 29

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

Gonzalez et al ., in a prospective blinded study, showed that dynamic CT scan in penetrating neck injury was sensitive in diagnosing associated injuries6. They however concluded that the majority of these injuries do not require identification or surgical intervention. Either way, definitive airway management should not be delayed excessively by radiologic studies, since an apparently stable airway can rapidly progress to an acute airway obstruction. This was the reason why we did not subject our patient to radiography or any imaging procedure. Many patients with upper airway injuries may be successfully managed using traditional techniques to establish an airway - intubation through an obvious airway defect or endotracheal/orotracheal intubation or tracheostomy7. When the trachea itself is injured, it is preferable to primarily close the trachea and further support repair with a muscle flap. Though nonsurgical management of tracheal injuries have been reported in the literature but such patients can develop permanent airway or voice impairment and may have increased difficulties protecting the airway from aspiration of pharyngeal contents8. Some of the problems encountered during general anesthesia are anatomical distortion of the neck and tracheal displacement making intubation difficult; intravenous induction agents producing hypotension, which is undesirable for a bleeding patient; and danger of vomiting and aspiration9. Inhalation induction is also difficult, due to partial breathing ‘through the neck’ and uncertain control of airway10. Postoperative care includes fluid balance to prevent dehydration; humidification and aspiration of tracheobronchial secretions; and broadspectrum antibiotics. Medico legal A Points For the medicolegal point of view one has to consider following points in mind.

Fig 2: Showing perforation of trachea

Fig 3: View of trecheal perforation

1. Nature of injury according to Pakistani law? 2. Is it homicidal or accidental injury? 3. How to prevent mishap and compensate in construction industry. Fig 4: Showing healthy wound

Nature of injury as per Qisas and Diyat Act 1997, attracts section 337 L(1) i.e, Other hurts ;Whoever causes hurts, not mentioned here in before, which endangers life or which causes the sufferer to remain in severe bodily pain for 20 days or more or renders him unable to follow his ordinary pursuits for 20 days or more.11

DISCUSSION Only a minority of laryngotracheal injuries are caused by penetrating trauma. In our patient, the injury was unusual, he sustained it when he fell on an iron bar. His presentation was unusual that he never reported to any physician before and came on second day to the OPD. Injuries to other structures include major or minor vessels, nerves, thyroid and esophagus and is the main reason for mortality (15-30%)4. Since our patient fell directly on the object which prevented from injuring major vessels or nerves. Radiography alone is not sufficient for diagnosing cervical airway trauma and the additional use of CT scan of the trachea and larynx and MRI can be very useful in discovering subtle, previously undetected injuries5.

Homicidal or Accidental : It is problem if injury is incompatible with history. The accompanied person should not be relied until it is proved by meticulous examination. Prevention in construction industry: Usually when shuttering of roof is going on then there are chances of accidents by penetrating of iron rods and to prevent this movement should be minimum and especial warning and red cloth should be put on .As far as compensation is concerned it is covered under ‘’Employees Social Security Ordinance 1965" 30

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Grewal H, Rao PM, Mukerji S, Ivatury RR. Management of penetrating laryngotracheal injuries. Head Neck 1995;17:494-502. 5. Rao PM, Novelline RA, Dobins JM. The spherical endotracheal tube cuff: A plain radiographic sign of tracheal injury. Emerg Radiol 1996;3:87-90. 6. Gonzalez RP, Falimirski M, Holevar MR, Turk B. Penetrating zone II neck injury: Does dynamic computed tomographic scan contribute to the diagnostic sensitivity of physical examination for surgically significant injury? A prospective blinded study. J Trauma 2003;54:61-5. 7. Beiderlinden M, Adamzik M, Peters J.Conservative treatment of tracheal injuries. Anesth Analg 2005;100:210-4. 8. Glinjongol C, Pakdirat B. Management of tracheobrochial injuries: A 10-year experience at Ratchaburi hospital. J Med Assoc Thai2005;88:32-40. 9. Rossbach MM, Johnson SB, Gomez MA, Sako EY , Miller OL, Calhoon JH . Management of Major Tracheobronchial Injuries: A 28-Year Experience. Ann Thorac Surg 1998;65:182-6. 10. Hurford WE, Peralta R. Management of tracheal trauma. Can J Anesthesia2003;50:R1-6. 11. Awan NR . Principles and Practice of Forensic Medicine, Sublime Arts Lahore 2002

Injury Benefit: A secured person shall be entitled to receive injury benefit in respect of any day.……. .

4.

CONCLUSION To summarize, penetrating tracheal injuries are rare. The ideal way to establish airway is orotracheal intubation in the awake patient followed by placement of a tracheostomy tube through the transected portion of the trachea. Formal surgical repair when possible should be done in majority of cases. In conclusion, even though these types of penetrating tracheal injuries are not common, managing them successfully is often a challenge REFERENCES 1.

2.

3.

Symbas PN, Hatcher CR Jr , Boehm GA. Acute penetrating tracheal trauma. Ann Thorac Surg 1976;22:473-7. Rao BK, Singh VK, Ray S, Mehra M. Airway management in trauma. Indian J Crit Care Med 2004;8:98-105. Cicala RS, Kudsk KA, ButtsA, Nguyen H, Fabian TC. Initial evaluation and management of upper airway injuries in trauma patients. J Clin Anesth 1991;3:91-8.

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Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

ASSESSMENT OF AGE BY CLINICAL ERUPTION OF 2 ND MOLAR IN THE 12-14 YEARS K.D Chavan1, S. R Umesh2, Prakash Babladi2, Basavarja Patel3, Singi Yatiraj4

ABSTRACT

MATERIALS ANDMETHODS

The Study was undertaken in the age group of 12 – 14 years in the Gulbarga region to determine the age in school going children by clinical eruption of 2 nd molar teeth. 50 boys and 50 girls studying in 7th to 10th standard in higher secondary schools of Gulbarga city were selected randomly and examined for clinical eruption of 2nd molar teeth after obtaining informed consent and all relevant existence of a co-relation between the stages of eruption of tooth that the oral hygiene and mixed diet promoted eruption of teeth. The socio-economic class II subjects showed early eruption compared to socio-economic class I.

The study was carried out between September 2005 to August 2007 in the Department of Forensic Medicine, M.R. Medical College, Gulbarga. The subjects for the present study consist of 50 boys and 50 girls, studying in 7th to 10th standard in various higher secondary schools of Gulgarga city from the period July 2006 to July 2007. The study subjects were bonafide residents of the region with known birth dates and were apparently healthy at the time of study. The subjects were selected by random sampling. All the selected subjects were broadly classified in the 2 groups of equal strength and equal male to female ratio.

Keywords: age estimation, second molar.

Group 1: Age between 12 years to 12 years + 364 days

INTRODUCTION

Group II: Age between 13 years to 13 years + 364 days For conduction of the study, a proforma was devised to collect all relevant information like their age, sex, socioeconomic status, diet, habits etc. form the subject. The information regarding eruption of teeth was directly entered in to the master chart. The subjects were examined after obtaining informed consent.

The determination of age of 12-14 years is very important in medico-legal work and comes up frequently in connection with the questions of criminal responsibility, rape, kidnapping, child labour, etc. Many workers from India and abroad have undertaken studies to estimate the age from eruption of teeth and they have observed that factors like race, geography, climate, diet, heredity and endocrine factors do affect the physiological changes occurring at puberty, especially in a vast multiethnic county like ours.

The oral cavity was examined with the help of a torch light and a dental mirror with mouth widely open with a tongue depressor. Detailed dental examination was done and details noted in the form of number of teeth erupted and stage of eruption. Dental charting was done according to F.D.I (Federation Dentaile Internationale) system, as follows:

In this context, it was felt that there should be a local data involving local population. Hence, this study of estimation of age based on dental examination of 100 school going children in the age group of 12-14 years in the Gulbarga city was undertaken with an attempt to study the following.

The staging of tooth eruption was done in the following manner1

1. Determine the age in school going children aged between 12-14 years by dental examination.

Stage O: Non-eruption of temporary tooth/fall out of temporary tooth and non-eruption of corresponding permanent tooth.

2. To find out the variation between the findings of other workers in India and abroad with the present study if any.

Stage 1: When tip of crown of tooth penetrated the gum margin. (Positive clinical eruption)

3. To evaluate the factors that affect the eruption of teeth.

Stage 2 : When this crown has grown into oral cavit beyond gum margins but not yet reached the occlusal plane. Stage 3: When the colossal surface came in contact with its counterpart and the bite was complete.

1

. Professor & head (Corresponding Author) Associate Professor 3 . Assistant Professor 4 . Post graduate Dept. of Forensic Medicine, M.R Medical College, Sedam Road Gulbarga – 5885105 2

The finding obtained was tabulated and statistically analysed by comparing other similar studies in India and abroad. 32

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

RESULTS

Table 2: Stages of eruption of 2nd molar

Table 1 describes the age and sex wise distribution of the study subject. For comparing and analysis, the study subjects were taken in equal proportion i.e. 25 females in age group of 12-13 years, and 25 males and and 25 females in age group of 13-14 years were selected. Table 1: Age and sex wise distrubution of study subjects Age Group

Male (No.= 50) Number

%

Female (No.= 50) Number

%

12-13 Years

25

50.00

25

50.00

13-14 Years

25

50.00

25

50.00

Total

50

100.00

50

100.00

Table 2 shows the stages of eruption of the 4 second molar teeth numbered as per the FDI system. In age group 12-13 years, most of the children i.e. more than 40% had more or the other 2nd molar teeth not erupted whereas their countersex had 2nd molar in stage 2 or 3. In age group 13-14 years the contrast in eruption stages between male and female was blurred. Thus, it is evident from the table that in females the dental eruption is quite earlier than males. Similarly from the stages of eruption, it can also be stated that the 2nd molars of the lower jaw appear earlier than those of upper jaw. However there was no difference in eruption of 2nd molars of left and right side in the same jaw.

DISCUSSION In the present study, it was observed that there is significant difference in eruption pattern of 2nd molar in both sexes, the females showing early eruption. This finding is in consistency with shourie(2), Kaul(3), Laxmi Kumar(4), Mishra5, Kishore(6), Agarwal(7), Halikis(8), Knott(9), Carr(10), Hagg(11), Eskeli(12), Parner(13), Diamanti(14) and Wedi(15), but not with Kamalnathan(16). This could be due to the hormonal effect that cause difference in steroid, adrenocortical and gonadotrophin levels between the two sexes. (Table No.4)

Table 3 shows the influence of external factors like diet, oral hygiene and socio-economic status on eruption of 2nd molar. One can infer from the that the mixed diet and good oral hygiene has status, the study subjects belonging to class II showed early eruption of 2nd molar.

However like many authors this study could not establish that there is any time difference between eruption of mandibular and maxillary 2nd molar.

Table 3: Influence of external factors on eruption of 2nd molar

33

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

Table 4: Comparison of eruption of 2nd molarwith other authors

3. The 2nd molar erupts earlier in girls than boys by 4 months. 4. The mandibular 2 nd molar erupts earlier than its counterpart in maxilla by 1 month in males and by 1-2 months in females. 5. There is no significant difference between the eruption of 2nd molar of right and left side in the same jaw. 6. The eruption of teeth is promoted by good oral hygiene. The vegetarians lack behind the individuals with mixed diet and study subjects belonging to class II of socioeconomic status that study subjects belonging to class I of socio-economic status in terms of eruption of teeth. 7. In dental evaluation, emphasis should be given to the stages of eruption rather than mere eruption of 2nd molar to correctly calculate the age. REFERENCES

Moreover the mean age of eruption of 2nd molar is quite high in the present study when compared to other studies. This could be because of the prescribed age limitation taken for this study i.e. between the ages of 12-14 years thus removing the slightest possibility of having mean age below 12 years. There are some variations between the present study and studies of Mishra1, Hurme17, and Knight18, which could be due to limited age period of 12-14 years and limited sample size of eruption between the two sex. (Table No.5) Table 5: Comparison of stages of eruption of 2nd molar with other authors Maxillary Male 1

II

III

I

Mandibular

Female II

III

Male I

II

Female III

I

II III

INDIAN STUDIES Mishra 12.0 12.6 13.4 11.5 12.0 12.8 11.9 12.4 13.2 11.3 11.9 12.7 (H.P.) Present 12.4 13.4 12.5 12.7 12.11 13.9 12.8 13.4 13.2 12.10 12.10 12.11 Study

FOREIGN STUDIES Hurme 12.4 12.38 14.1 10.11 12.27 13.8 10.9 12.12 13.6 10.4 11.66 13 USA Knight 11 UK

13

14

11

12

14

11

12

13

10

12

Mishra VK, Rao CM.Age from Eruption of Permanent Teeth in Himachal Pradesh. Journal of For ensic Medicine & Toxicology 1990; 7 (182) : 24-28. 2. Shourie KL. Eruption Age of Teeth in India. Indian Journal of Medical Research1946; 34 : 105-118. 3. Kaul S, Saini S, Saxena B.Emergence of permanent teeth in school children in Chandigarh, India. Archives of Oral Biology 1950; 28 (4) : 70-81. 4. Kumar CL, Shridhar MS. Estimation of the Age of Individual Based on times of Eruption of Premanent Teeth. Forensic Science International 1990 ; 48 (1) : 1-7. 5. Mishra VK, Swami D.Rao CM.Age & Stage of Dental Eruption. Journal of Forensic Medicine & Toxicology 1994; 11 (182) : 8-14. 6. Upender Kishore, Verma SK. Sharma GK. Estimation of Age Based on the Stages of Eruption of permanent 2nd and 3rd Molar Teeth. Indian Internet Journal of Forensic Medicine & Toxicology 2003; 1 (1) : 32-36. 7. Agarwal KN, Gupta R, Faridi MMA, Kalra N. Permanent Dentition in Delhi Boys of Age 5-14 Years. Indian pediatrics 2004; 41:1031-1035. 8. Halikis SE. The variability of eruption of the permanent teeth. Australian Dental Journal 1961; 6 : 137-140. 9. Knott VB, Meredith HV. Statistics on Eruption of the Permanent Dentition from Serial Data for North American White Children. The Angle Orthodontist 1966; 36 (1) : 68-79. 10. Carr LM. Eruption ages of permanent teeth. Australian Dental Journal 1962; 7 : 367-373. 11. Hagg U, Tarangger J. A Longitudinal Study of the Timing of Tooth Emergence in Swedish Children from Birth to 18 years. The Angle Orthodontist 1985 21 (3): 1.

13

CONCLUSION The following conclusions are derived from the present study of age estimation of 100 children aged between 12-14 years by clinical eruption of 2nd molar. 1. The age range of eruption of 2nd molar is 12 years 10 months to 13 years 4 months. 2. There exists a co-relation between the stages of eruption of tooth and chronological age. 34

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

15. Dedl JS, Schoder V, Blake FAS, Schmelzle R Friedrich RE. Eruption Times of Permanent Teeth in Teenage Boys and Girls in Izmir (Turkey). Journal of Clinical Forensic Medicine 2004; 11 : 299-302. 16. Kamalnathan GS, Hauch HM, Kittiveja C.Dental Development of Children in a Siamese Children. Journal of Dental Research1960; 39 (3) : 455-461. 17. Hurme (1949) As cited in Gradwohl’s Legal Medicine, 2nd Edition (1968); John Wrigh & Sons Ltd.Bristol. 18. Knight B, Saukko P. Knight’s Forensic Pathology, 3rd Edition (2004), Arnold publishing, London.

93-107. 12. Eskeli R, Laine-Alava MT , Hausen, pahkala R . Standards for permanent tooth emergence in Finnish children. The Angle Orthodontist 1999; 69 : 529-533. 13. Parner ET, Heidmann JM, Vaeth M, Poulsen S. A Longitudinal Study of Time Trends in the Eruption of Permanent Teeth in Danish Children. Archives of Oral Biology 2001; 46 : 425-431. 14. Diamanti J, Townsend GC. New Standards for Permanent Tooth Emergence in Australian Children. Australian Dental Journal 2003; 48 (1) : 39-42.

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Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

UNCERTAINTY MEASUREMENT IN QUANTIT ATIVE ESTIMATION OF STREET SAMPLE OF HEROIN (DAM) AND ITS IMPOR TANCE R.S.Verma1, R.M.Tripathi1, A.K.Dalela1

ABSTRACT Quantitative measurement of active constituents has legal importance in narcotic drugs like Opium, Cocaine, Heroin etc. In marginal cases of quantitation, the uncertainty in measurement will have significant effect. On the basis of analysis, product has to be declared under NDPS act and also small or commercial quantities. Accurate quantitation is also required for reward to investigating agencies. Thus uncertainty in measurement with relation to true value of the contraband substance is very essential. In present study, an attempt has been made to quantify the contribution of systematic and random error for arriving at correct results for estimation of Diacetylmorphine in street sample of heroin. Keywords: Uncertainty; Quantitative Analysis; Heroin (DAM); Street Samples of Heroin; Expanded uncertainty. INTRODUCTION

Opium or its products covered under NDPS Act should contain more than 0.2% morphine. Similarly, for preparation of coca derivatives, all preparations should contain more than 0.1% of cocaine. For other contraband substances, grading of punishment is according to quantity of drug. For heroin, its quantity up to 5 gm is treated as small quantity where as 250 gm or more than 250 gm substance comes under the category of commercial quantity. For the present study, attention has been focused on uncertainty measurement for quantitation of heroin with the reason that many laboratories in the country are receiving a large number of cases for analysis. When reporting the result of an analysis in DAM cases it is essential to give some quantitative indication of this uncertainty. Without such an indication it is not possible to assess the reliability of the result and the confidence that can be placed in any decision based on its uncertainty. This is particularly true in the case of DAM because of the importance of many of the decisions that are made on the basis of quantitative results. Also, sometimes, the results from some other forensic laboratory have to be taken into account and trends have to be assessed. Thus, it is important to know the significance of any difference between results and this can not be achieved if the uncertainty on the result is not available.

No result derived out of measurement process can be stated with absolute certainty. Measurement is basically an estimation process in which the point estimate of the parameter is arrived at, based on statistical analysis. The estimated value may be slightly less or more than the true value of the physical quantity. Therefore, quantifying a measurable quantity through measurement process is meaningful only if the quantity measured is accompanied by an overall uncertainty of measurement. In case of quantitative estimation of contraband substances covered under NDPS Act, one of the first problems faced by forensic chemists is whether they have the methodology to provide a result that is fit for its intended purpose, whether it will produce a result of the required accuracy. However, when reporting the result of an analysis, it is very unused for indication of the ‘accuracy’ of the result to be given. This means that the user of the result is unable to make any judgment buased on the confidence to be placed in the result . It is also not possible to compare in a rational way the results of an independent of the same sample.

MATERIAL & METHOD INSTRUMENT High Performance Liquid Chromatograph Model Varian – 5560 equipped with bondapak 4 mm x 25 cm column with 5 m silica particles with monomeric coating of Octadecylsilane. Solvent system Acetonitrile: Amm. Acetate Buffer (0.75%) 65:35

It is now becoming recognized that a statement of a result is not complete without including in it information

1.

about the “accuracy” or the “uacertainty of the result. Indeed time is not far away when many customers will insist that the uncertainty” be given, and also is thus requirement of accreditation standards for quantitative measurements that is being given more attention by the accreditation agencies.

Central Forensic Science Laboratory Directorate of Forensic Science, Ministry of Home Affairs, Govt. of India, Plot No.2, Dakshin Marg, Sector 36-A, Chandigarh. 36

Flow rate

1 ml/min.

Detector

282 nm UV detector

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RESULT & DISCUSSION Standard DAM

Sample of smack

Area obtained x1

2897724

2302403

Area obtained x2

2892134

2292390

Area obtained x3

2857601

2356288

Area obtained x4

2910401

2368290

Area obtained x5

2917341

2315207

Mean area x

2895040

2326916

Standard dev.

23187.4

33557.99

Std. Dev. Of mean

13387.25

19374.71

%age of DAM in sample =

Calculation for uncertainty of standard working DAM solution

Therefore, total combined uncertainty for standard working DAM

2326916x 0.982 x 99

=

10-3 √{(0.05)2 + (57.70)2 + (4.09)2 + (4.09)2}

2895040 x 1.1

=

57.99 x 10-3

= 71.04% (a) Sources of uncertainty and its estimation in standard diacetylmorphine solution.

(b) Source of uncertainty and its estimation in street sample of DAM 1. Weight about 10 mg std. DAM by Mettler Balance Uncertainty in weighing 10 mg = 5 x 10-4

1. Weight about 10 mg std. DAM by Mettler Balance Uncertainty in the weighing 10 mg = 5 x 10-4

2. Uncertainty due to volumetric flask A 10 µl Volumetric flask was used for this purpose. This flask was calibrated at 27oC and its calibration uncertainty was 0.1 ml.

2. Purity of Diacetylmorphine is 99%. Therefore, 99 ± 1%. Uncertainty is taken as having rectangular distribution = 1/√3 = 0.577 3. Uncertainty due to volumetric flask A 10 ml Volumetric flask was used for this purpose. This flask was calibrated at 27oC and its calibration uncertainty was 0.1 ml.

Therefore, the combined uncertainty due to micro syringe

10-2 √{(0.214)2 + (4.08)2}

=

4.09 x 10-2

10-2 √{(0.214)2 + (4.08)2}

=

4.09 x 10-2

5. Uncertainty due to the injection of solution of street sample of DAM by micro syringe

Therefore, the combined uncertainty due to volumetric flask =

=

A 10 µ1 micro syringe used for this purpose. Its calibration uncertainty was 0.1 m1 at 27oC.

4. Uncertainty due to the injection of working standard DAM by micro syringe A 10 m1 micro syringe used for this purpose. Its calibration uncertainty was 0.1 m1 at 27oC.

Therefore, the combined uncertainty due to micro syringe Therefore, the combined uncertainty due to micro syringe = =

10 √{(0.214) + (4.08) } 4.09 x 10-2 -2

2

2

37

=

10-2 √{(0.214)2 + (4.08)2}

=

4.09 x 10-2

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

Calculation for combined uncertainty of street sample of DAM

CONCLUSION Therefore, the uncertainty in the measurement of street sample of heroin has been estimated 0.17% for 71.04% if diacetylmorphine. The above described method for measurement of uncertainty in quantitative analysis can be applied for any substance including narcotic drugs and explosive substance quantified by HPLC. REFERENCES

Total combined uncertainty for street sample of DAM = 10-3 √{(0.05)2 + (57.70)2 + (4.09)2 + (4.09)2 + (4.6)2 + (81.8)2 + (5.8)2} =

1. 2.

0.084

Expanded Uncertainty

3.

At 95% confidence level, the expanded uncertainty in the estimation process of street sample of DAM is = =

2 x 0.084 ±0.17%

38

Narcotic Drugs and Psychotropic Substance Act, 1985. “Recommended Methods for Testing Heroin” Manual used by National Laboratories, United Nations, New York. NABL Guidelines for Estimation and Expression of Uncertainty in Measurement, April 2001.

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HUMAN RIGHTS, TORTURE AND MEDICAL PROFESSIONAL E. J. Rodrigues1

ABSTRACT One of modern civilization’ s achievement is the realization and dissemination of the knowledge that the rights to life, liber ty and security of person ar e primary, inherent and inalienable to every human being, irrespective of race, nationality, economic status or other man-made discriminations. The Universal Declaration of Human Rights article 3 of 1948 and article 21 of the Indian Constitution recognize these rights as fundamental rights. Torture deals with medical, legal and ethical issues in relation to the barbaric practice of torture in various situations. Today, torture in any form is condemned by civilized societies, and is not acceptable in any situation. Y et, clandestinely torture is prevalent in some form or the other all over the world. Only the methods of torture have changed and have become more “sophisticated” and consequently more “effective” and difficult to detect medically. Keywords: Human rights; Custodial death; T orture; Doctor. INTRODUCTION According to Amnesty International, the world- wide organization that monitors human rights violations, torture is practiced even by Governments in authority in 65 out of 144 countries, on those considered inimical to the state. (1)

In India, the military, intelligence agencies, and the civil police have all been put in the dock for human rights violations on various occasions. In many such instances, the autopsy appearances of fatal abuse are no different from those by any other homicide, and the confirmation of lethal torture must depend on circumstantial and other corroborative evidence. Medical professionals must realize that prompting and protecting human rights is essential for promoting and protecting health. NATIONAL AND INTERNATIONAL LEGISLATION ON CUSTODIAL TORTURE The Webster dictionary defines torture as “anguish of body or mind; something that causes agony or pain, to punish, coerce or afford sadistic pleasure”. The oppression of the Nazi regime during the Second World War prompted the United Nations Organisation (UNO) to come out with the Universal Declaration of Human Rights (1948), followed by an International Agreement of Civil and Political Rights (1966) and a Declaration on the Protection of all Persons from Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (1975). In the same year, the World Medical Association adopted a declaration called the Declaration of Tokyo (1975). According to this, torture is defined as “a deliberate, systemic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority to force another person to yield information, to make confession or for any other reason.”

In article 5 of the Universal Declaration of Human Rights, it is stated that no one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. Today in five out of the six countries including Europe, torture is prevalent.

In 1976, the World Medical Association drafted the Tokyo Declaration, which dealt with the role of physicians in treating the prisoners and victims of custodial violence.

With increasing incidences and awareness, the medical profession has also taken up this challenge and is trying to understand the various aspects of this problem from the medical viewpoint.

The primary source outlawing torture in International law is the United Nation’s Convention against Torture (CAT) that was signed in 1984 and entered into force in 1987. Article 11 of CAT requires that State Parties review periodically the rules and practices related to detention and imprisonment of individuals so as to prevent cases of torture in custody. Any evidence that has been proven to be obtained under conditions of torture should be inadmissible in any proceedings (Article 15 of CAT ).

Custodial torture is a matter of great concern to the Champions of Human Rights because torture, in some way or the other, is aimed at not only to silence the tortured but also to others who may be frightened to passivity. Due to public awareness Human Rights Commissions have been constituted. The latest developments necessitating reporting of Custodial Deaths within 24 hours 1.

and conducting a postmortem by a panel of doctors including video filming of the procedure, speak of the gravity of concern of the Commission.

Further, the UN General Assembly in December 1989 endorsed resolution No 1989/65 adopted by United Nation’s Economic and Social Council, on the prevention of extra

Assoc.Professor Dept. of Forensic Medicine, Goa Medical College, Panaji, Goa-403001 39

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

judicial executions and adequate investigations of such executions. This manual is also known as the Model Minnesota Protocol for a legal Investigation of Extra-legal, Arbitrary and Summary Executions and Model Autopsy Protocol. In 1997, World Medical Association adopted the declaration of Hamburg concerning support for medical doctors refusing to participate in, or to condone, the use of torture or other forms of cruel , inhuman or degrading treatment.

(e) Pain and suffering arising from lawful sanctions however does not constitute torture under the Statute. Article 1 of the United Nations Convention against torture 1984 defines it as any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.

Till date, 144 countries have ratified the treaty. India however has signed the treaty in 1997 but not yet ratified it, without which India cannot be held liable under International law for any acts of torture committed by the of agencies of the State. However since the prohibition of torture has now been largely considered to be a norm of jus cogens or “ a peremptory norm of general international law” India is legally obligated under general international law to uphold the prohibition of torture. The principle of jus cogens entails that no State can derogate from (legally justify the non-adherence to) the practice of the norm, in this case, the prohibition of torture. (2)

Considering the ethical value of a doctor it is imperative on part of one self to protect the individuals from such treatment by effective investigations and documentations to provide evidence of torture and ill treatment so that torturers are made accountable for their actions. The reason behind torturing an individual has not changed much but the methods employed for torturing have changed.

In 1999, World Medical Association at Tel Aviv, Israel passed a resolution on the inclusion of Medical Ethics and Human Rights in the curriculum of medical schools worldwide. According to Code of Medical Ethics issued by the Medical Council of India, violation of human rights by a medical practitioner is an unethical act. Code of Medical ethics states as follows: The physician shall not aid or abet torture nor shall he be a party to either infliction of mental or physical trauma or concealment of torture inflicted by some other person or agency in clear violation of human rights. (3).

AIMS OF TORTURE 1. To obtain information It depends on the case and its gravity. If the suspect has indulged in anti-national activity, or terrorist activity, governmental organizations are often involved in the infliction of torture. Such torture will usually continue till the desired information is obtained. 2. To force a confession A person may be tortured in order to force confession saying that he has committed the crime. Invariably the person eventually signs the confessional document under such threat and force even though he may have not committed the crime, only to avoid further torture.

Other International treaties that prohibit torture are the International Covenant on Civil and Political Rights 1966 ( Articles 7 and 10 ), The American Convention on Human Rights ( Article 5 ), Inter-American Convention to Prevent and Punish Torture, The African Charter on Human and People‘s Rights ( Article 5 ), The European Convention for the Prevention of Torture and Rights 1950 ( Article 3 ) and the European Convention for the Prevention of Torture and Inhuman degrading Treatment or Punishment 1987. States party to the regional conventions that is the InterAmerican, African and European Conventions can be brought to account by individuals and groups for violations of the prohibition of torture in their respective regional human rights courts and commissions.

3. To obtain testimony incriminating others Many a time the victims are forced into signing documents incriminating other people, whether they are involved or not, to build up a case against them. 4. To take revenge Sometimes a victim is tortured merely to take revenge, which may be not only be against the individual concerned, but also the family member or even an entire community. e.g. Raping an enemy’s wife, sister or daughter, kidnapping family members especially small children, aged persons, etc.

TORTURE AS A GRAVE VIOLATION OF HUMAN RIGHTS The Rome Statute of the International Criminal Court terms torture of civilians as a crime against humanity (Article 7). It defines torture as the intentional infliction of severe pain or suffering, whether physical or mental, upon a person in custody or under the control of the accused Article 7 (2)

5. To spread terror in the community This is very common in dictatorial regimes. Anybody who dares to raise voice against the regime may be tortured mercilessly. If the victim dies, his body is openly displayed 40

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

passed, causing shock all over the body.

to the community with overt evidence of torture. This creates terror in the minds of people and nobody would then dare to rise up against the regime. The dictator thus manages to continue his dictatorial rule in the country.

b. Sham Execution—Victim is sometimes blindfolded and asked to stand before a wall, and then threatened that a vehicle is going to hit him. The victim hears the sound of a vehicle very near to him, and coming towards him, causing fear and shock.

6. To destroy the personality There are always some people with leadership qualities in every community. These people are most likely to raise their voices against dictatorial rule or oppression in the society. They are capable of mobilizing people in the community against tyrants or dictators. Such persons are sometimes identified by the dictatorial regime, arrested, kidnapped, and tortured, so that they are transformed into a kind of “living dead”. Their behaviour, thoughts, and feelings are suppressed, and they loose their self confidence. There is often feeling of hopelessness and worthlessness in the society. The main purpose of torture is to deliberately disturb not only the physical and emotional well-being of individuals, but degrading the dignity and will of the community as a whole.

3. Physical torture that cause extreme exhaustion: a. Physical exhaustion—the victim is asked to stand in hot sun on one leg for a long time. Or he may be asked to stretch out both his hands holding heavy bricks or stones. b. Forced labour—the victim is made to work very hard without food and water. 4. Physical torture that causes disfiguration, mutilation or permanent disability: a. Telefono—simultaneous beating of both ears with palms of the hand is done, causing rupture of tympanic membranes.

METHODS OF TORTURE (4)

b. Mutilation—chopping of ears, nose, fingers, etc.

A) Physical torture.

c. Disfiguration—Throwing acids or corrosives over face and other parts of the body, causing severe burns leading to disfiguration.

B) Psychological torture. C) Sexual torture.

B) PSYCHOLOGICAL TORTURE

A ) PHYSICAL TORTURE

1. Deprivation Techniques

Physical methods of torture are those which inflict pain, discomfort, and dysfunction in different parts of body.

The victim is deprived of common and basic necessities, to induce Sensory deprivation—Victim may be blindfolded for a long time.

1. Physical torture that causes extreme and excruciating pain:

a. Perceptual deprivation—making the victim confused and disoriented eg. Frequent transfer of victim from one place to another blindfolded.

1. Severe beating – is a common type of torture by using sticks, cables, whips, iron, rods etc.

b. Social deprivation—Solitary confinement in a dark environment.

2. Falanga torture—Beating on the soles of the feet. It is systematic form of torture used in our country and the person may become disabled for several years.

c. Deprivation of basic needs—Withholding food, water, toilet facilities.

3. Finger torture—Pencils or similar objects are placed in between two fingers and squeezed hard. Sometimes the fingers are twisted to cause severe pain.

2. Coercion Techniques These methods involve a victim to perform certain acts or witness certain traumatic acts which can cause mental anguish. e.g

4. Cold torture—Victim is made to lie on an ice slab without clothing, or on a cold and damp floor. 5. Heat torture—Victim is suspended upside down very near to fire, or cigarette burns are inflicted.

Signing of false statements. Coercion to commit blasphemous acts.

6. Dental torture—Pulling out teeth by clips or forceps. Sometimes the victim is asked to chew hard small stones, metal pieces, etc.

Coercion to witness torture of other victims. Coercion to torture other victims.

2. Physical torture that causes fear of immediate death

3. Communications Techniques.

a. Electrical torture—Electric shock is applied to sensitive parts of body such as nipples, genitals etc. Sometimes the victim is tied to a metallic bed and electricity is

The victim is mentally tortured by exposure to a variety of confusing, contradictory, or false communications, such as 41

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

Misinformation-Giving false information to victim regarding tragedy involving close relatives such as wife and children, which cause mental anguish.

1. Developing a good rapport with the victim. 2. Empathising with the victim and family. 3. Avoiding situations or objects reminding victim of torture event.

C) SEXUAL TORTURE This method of torture inflicts physical and psychological damage on the victim.

4. Punctuality in keeping appointments with the victim. MEDICOLEGAL AND ETHICAL ASPECTS OF TORTURE (8)

Sexual Torture using instruments-infliction of injuries to private parts of both male and female victims, forcible introduction of rods, bottles, or batons in the rectum or vagina, mutilation of breasts or genital organs.

Under the Hippocratic Oath, doctors are prohibited from using their professional knowledge to harm their patients which is again reconfirmed by the World Medical Association.

Sexual torture without the use of instruments-The victims may be forced to undress in front of others, or raped in front of others, or photographed in humiliating positions or situations, or sexually tortured by trained animals.

However, in spite of this, it is sadly true that doctors sometimes involve themselves directly or indirectly in the perpetration of torture, especially military doctors, police and prison doctors and forensic experts.

CONSEQUENCES OF TORTURE (5)

The World Medical assembly (WMA), in Tokyo (1975), adopted a special resolution in this regard. The following are the salient points of the Tokyo declaration.

A) Physical consequences 1. Early consequences

1. A doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures.

Injuries in the form of abrasions, bruises, haematomas, lacerations, incised wounds, penetrating wounds, fractures, dislocations etc.

2. A doctor shall not provide any premises, instruments, substances, or knowledge to facilitate the practice of torture.

2. Late consequences Infections, scars, mal-united bones, disfiguration of the face, impairment of hearing, impairment of vision, vertigo etc.

3. Doctors should not be present during any procedure involving cruel or inhuman activities.

B) PSYCHOLOGICAL CONSEQUENCES

4. A doctor must have complete clinical independence in deciding upon the care of a person for whom he is medically responsible.

Anxiety, depression, sleep disturbances, alcohol/drug abuse, seizures, low self esteem, stress disorders, etc.

5. Doctors shall in all circumstances consider it their bounden duty to alleviate the distress of their fellowmen, and no motive, whether personal, collective or political shall prevail against this higher purpose.

C) SOCIAL CONSEQUENCES Social stigma, employment problems, negativity in social activities, etc.

6. The World Medical Association will support and encourage the international community, the national medical associations and fellow professional colleagues to support a doctor and his family in the face of threats or reprisal resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment.

TREATMENT OFTORTURE VICTIMS (6) Torture has three dimensions that is physical, psychological and social. It is very difficult which is more important and which is less in a particular individual. Treatment may not be effective if it is focused on only one dimension. Doctors, psychologists, social workers, physiotherapist, nurses and legal experts must work together in close collaboration for maximum efficacy.

Victims of torture may either suffer from injuries, or may die because of injuries. Such cases should be examined carefully and thoroughly, and reported to the police or magistrate, and treated appropriately. Systematic and meticulous examination will help in establishing or disproving a charge of torture. Sections 330 and 331 of IPC deal with the issue of voluntary causing hurt and grievous hurt for the purpose of extorting confession or any information.

PRINCIPLES OFTREATMENT (7) Torture victims and their families are a special category of clients, because they have experienced an unusual trauma at the hands of other human beings. The following principles need to be kept in mind. 42

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

The Government of India has enacted the Human Rights Act, 1993, which monitors the violation of any of the rights of the individual of this country.

cases of custodial deaths to it. Upon perusing these messages, the Commission decided to issue notice to the Chief Secretary, Goa, calling for a detailed report on this incident, along with other relevant documents.

ROLE OF DOCTORS

The State Government reported to the Commission in October 1994 stating that Abdul Gafar Khan, who was required in connection with a number of criminal cases, was arrested at 005 hours on 17 May 1994 at Khareband junction, near the railway crossing. It was further stated that he had allegedly resisted arrest, and that he had to be taken to a hospital at about 0200 hours. He was declared dead in the hospital.

Descriptions of where and by whom examinations were conducted and the reporting of information in a format that would ideally include history, physical and psychological findings and diagnosis would greatly improve communication between health professionals as well as facilitate the evaluation of information on this topic. Thus health professionals are in a unique position to foster the prevention of torture. The Istanbul protocol which provides the guidelines or footsteps at each and every level is to be followed by the doctors for proper management and documentation.

A Magisterial enquiry revealed that Abdul Gafar Khan’s death was caused by brutal beating by four police personnel. The post mortem report attributed the death to multiple injuries, which were ante-mortem and which occurred within six hours prior to death. The State Government reported that it had decided the following:

Do’s and Don’ts. Avoid the procedures reminding the victim of torture he or she has been subjected to.

1. The Inspector General (IG) of Police would register a case under section 302 of the Indian Penal Code for murder and take all necessary consequential action against the accused police personnel involved in the incident.

Provide Physical and Psychological treatment simultaneously. Treat the entire family of the torture victim. Document the findings in a prescribed format as per Istanbul protocol guidelines.

2. The IG of Police would start an investigation through the Crime Branch and also move the Government of India for a take over of the case by the Central Bureau of Investigation. (CBI)

And finally rehabilitation should be a part of the treatment.

3. The IG Police would take concrete steps to prevent recurrence of such incidents, which constituted serious violation of human rights in addition to being criminal offences.

CONCLUSIONS After having some back ground knowledge about torture one can strive to get justice to the victims and to the society. The medical professionals armed with the knowledge about torture will be in a better position to probe into this degrading nature with relevant technical skills and they can manage to treat and rehabilitate the torture victims but also document the evidence in a unique way to foster the prevention of torture. Such evidence can attract international attention on human rights abuses even when they are totally denied by various groups and governments that commit them.

Accordingly, four police officials involved in the incident were suspended from service in June 1994 and necessary cases were registered for murder. In September 1994, the CBI took over the case from the local crime branch for further investigation. Upon perusing the report of the State Government, the Commission expressed appreciation of the steps taken. The Commission also decided to ensure expeditious investigation by the CBI and to monitor the progress of the case brought under section 302 IPC.

CUSTODIAL DEATH CASES IN GOAYEAR 1995-96

After investigation, the CBI has decided to prosecute a Police Inspector, a Sub-Inspector, an Assistant SubInspector and a Constable involved in the above mentioned incident. The relevant papers have been sent to the State Government by the CBI for according sanction for prosecution under Section 197 of the Criminal Procedure Code. The Chairperson of the Commission addressed a letter to the Chief Minister, Goa in August 1995, requesting him to expedite sanction, which will enable initiation of prosecution in the appropriate court . The sanction has since been received.

Custodial death of Abdul Gafar Khan in Goa The Commission received messages from the District Magistrate and the Superintendent of Police of South Goa District in regard to the custodial death of Abdul Gafar Khan, who was arrested by the Margao Town Police at 0005 hours on 17 May 1994 and who subsequently died at around 0200 hours on the same day. These messsages were sent in pursuance of the Commission’s direction issued in December 1993 to report 43

Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

CASE 2

mortuary and inquest u/s 176 Cr. Pc. was conducted by SDM, Margao and subjected the body for autopsy by a panel of doctors under videography. The post mortem was conducted by a panel of doctors of GMC and the cause of death was certified as due to acute Myocardial Ischaemia as a result of occlusive coronary artery disease which was a natural cause.

Custodial death of under trial Shri Samuel Darringlu at sub jail Sada, Vasco Da Gama aged 24 years. The SDM, Margao conducted the inquest u/s 176 CrPC on 9/6/2001 and subjected the body for autopsy at Forensic Department Goa Medical College. The facts of the incident were that on 3rd June 2001, between 10 to 10.30 hours the undertrial prisoner at sub jail Sada, Vasco Da Gama suffered scald injuries when he was carrying a hundi of sweet dish which had just been cooked , he slipped and fell and the hot sweet dish fell over him thereby sustaining scalds. He was immediately shifted to Cottage hospital,Chicalim and then was further referred to Goa Medical College Hospital, Bambolim for treatment and expired on 8/6/2001 while undergoing treatment. The post mortem was conducted under videography by a panel of two doctors as per NHRC guidelines. The cause of death was due to septicemia and shock due to infected scalds caused by moist heat which were all amounting to 50%, ante mortem in nature & were sufficient to cause death in ordinary course of nature. After going into the facts of the case, statements of various witnesses including the statement of the deceased while admission in the hospital and the circumstantial evidence all taken together the SDM gave the verdict that it was a clear cut case of accidental death.

REFERENCES 1.

2.

3.

4. 5.

6.

CASE 3 Custodial death of Convict Prisoner Shri Madhukar Parsekar in sub jail Sada, Vasco Da Gama. The said convict was reported sick and taken to Cottage hospital Chicalim where he was declared dead on arrival on 5/1/2002. The dead body was shifted to Goa Medical College hospital

7. 8.

44

Subramanyam BV. Torture and Medicine. Modi‘s Medical Jurisprudence and Toxicology. Buttersworth, India. 22nd Ed: 741-48. Rodley N . The Treatment of Prisoners Under International Law, Oxford University Pr ess,. 2nd Ed 1999 .p.74. Indian Medical Regulations (Professional conduct, Etiquette and Ethics) 2002, 6.6. General Principles, The Physicians Responsibility, MCI, New Delhi. Jacobsen L, Vesti P. Torture Survivors: A New Group of Patients. 2nd ed. 1992. IRCT, Copenhagen, Denmark. Basoglu M. Torture and its Consequences: Current Treatment approaches. 1992. Cambridge University Press, Cambridge. Pagaduan-Lopez JC. Torture Survivors: How can we help them? 1987. Philippine Action. Concerning Torture/ Medical Action Group, Inc., Philippines. Rasmussen OV. Medical aspects of torture. Danish Med Bull 1990. 37:1-88. Peterson HD, Rasmussen OV. Medical appraisal of allegations of torture and the involvement of doctors in torture. Forensic Sci Int 1992. 53: 97-116.

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

ETHICAL AND LEGAL ASPECTS OF END OF LIFE: DILEMMA AND DEBATE Memchoubi1

ABSTRACT The changing scenario of the end of life often presents moral, ethical and legal dilemma to the treating physicians regarding the best course of action considering the futility of care, the right to refuse medical treatment, euthanasia and physician assisted suicide. This paper presents the current world and Indian scenario of these conflicting issues mainly questioning the practicability of euthanasia and the vagaries of the different legal systems. Attention is directed to the ever worsening plight of the patient in the end-of-life care despite the profusion of words and statutes from all directions. Keywords: End-of-life; medical ethics; legal aspects; personal autonomy; sanctity of life; beneficence; nonmalficence; physician assisted suicide; euthanasia.

The modern concept of a good death entails certain goals to be achieved which include control of pain and other physical symptoms; involvement of people important to the patient like family, significant others, friends and caregivers; a degree of acceptance by the patient i.e., to be realistic about the situation; a medical understanding of the patient’s disease by the family and a process of care that guides patient understanding and decision making1. DOCTOR’S DILEMMA

INTRODUCTION

As a medical person a doctor knows the futility of hanging on to uncertain means. At the same time some patients may want to explore all available options. Therefore, a doctor cannot remain detached all the time. He has to get involved at some point or the other.

Changing scenario of the end of life : We live in an amazing world today where values, be it material or precious humanitarian ones, change in the wink of an eye. What was important yesterday may be trivial today. In this rapidly changing world, medical advances and new technologies are taking place by leaps and bounds, even faster than an average man can keep up with. Whether to call it boon or bane depends on personal perspectives. But, the course and management of diseases have been so altered that where in earlier days people had short life expectancy, now, they live longer to die of more intolerable diseases.

ETHICAL ISSUES RELATING TO END OF LIFE Lately, ethical considerations have compelled physicians to shift the focus from aggressive interventions to one of mitigating pain and taking into account the wishes and sensibilities of the patient’s families with regard to continuing with futile care. However, many a time there is unilateral withdrawal of treatment from the family’s side due to the enormous financial and emotional burdens that the family has to endure in the context of critical illness1.

Concept of death: The concept of death itself has also undergone a sea change. Before, nothing could be simpler than the diagnosis of death. Once respiration and circulation stopped, a person was pronounced dead. But now, every now and then, there are reports of people waking up from prolonged coma. A patient in Persistent Vegetative State where the person does not understand anything is being dragged on as being alive. Perhaps, we have come to that stage where we are playing with nature so much that we have even lost sight of something so profound as dying with dignity.

The practice of withholding or withdrawing life support is governed by the ethical principles of autonomy, beneficence, non-malficence and justice2. 1. Autonomy-Patient should be fully informed and enabled to give an informed consent or an informed refusal. 2. Beneficence-Wherever possible, the opinion is in favour of protecting life and doing what is best for the patient.

END OF LIFE ISSUES

3. Non-malficence-It does not permit physicians to intend potentially harmful effects and minimize harm.

The issues involved are the concept of good death, 1

and the goals to be maintained while working towards a decent death for a patient1. The idea of a good death varies from person to person. It is the way a person wants his death to be. Someone may want to say a last precious word to a loved one. Someone else may want to die suddenly without knowing the pain and apprehension, etc.

4. Justice- Doctors should make the best use of available resources2.

Dr. Memchoubi Demonstrator Dept. of Forensic Medicine, Regional Institute of Medical Sciences, Imphal, Manipur 45

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ETHICAL QUESTIONS

life sustaining measures, not resuscitating a terminally ill or defective newborn, not using means to delay death, thereby permitting natural death to occur.

Medical futility and withholding or withdrawing of treatment-It is a universal fact that there is always an inherent risk in any line of medical treatment. But a doctor who knows this cannot make a unilateral appeal from his side alone to withdraw the treatment. A joint decision with the patients or surrogates should be made.

3. Voluntary: Euthanasia is at the will of the person. 4. Involuntary: Here, it is compulsory, even against the will of the person. 5. Non-voluntary: This is done in persons incapable of making their wishes known, like patients in irreversible coma or severely defective infants.

Physician Assisted Suicide (PAS) -The actual killing drug is self-administered with help from a physician. This practice has high chances of being misused putting the terminally ill and the elderly patients at risk.

REASONS FOR DEMAND BYTHE PATIENT MAY BE5

Quality of care-In cases where medical care would be futile, quality should be maintained even though aggressive intervention is spared.

1. Unrelieved severe pain or symptom 2. Fear of future of intolerable pain

Cost reduction-Critical care is very expensive which compels unilateral withdrawal by the family.

3. Fear of slow deterioration

Principle of double effect-Universal principle/fact that all treatments have an inherent risk. Benefits should be weighed against the undesirable side effects.

5. Adjustment disorder

4. Fear of being kept alive with machines

6. Demoralization

Appropriate treatment-In palliative care the primary aim of treatment is not to prolong life but to make the life that remains as comfortable and meaningful as possible. The points to be considered are-patient’s biological prospects, therapeutic aim/benefit of each treatment and undesirable effects of treatment. There is no need to prescribe a lingering death. Death should be given a chance if it is the preferable option. The guiding principles must be applied with respect for life and acceptance of the ultimate inevitability of death, keeping a balance between the potential benefits against risks and striving to preserve life against providing comfort in dying and individual needs against those of society.

7. Depression 8. Feeling of being unwanted by family 9. Being dependent 10. Feeling of hopelessness, etc. REASONS AGAINST EUTHANASIA 1. Uncertain prognosis: Sometimes patients survive longer than previously anticipated. So, such a final decision like ending one’s life should not be based on uncertain prognosis. 2. Sometimes, patients demand euthanasia during a transient period of despair, which after it passes, the patient may want to live again.

LEGAL ASPECTS The guiding principles are sanctity of life and. personal autonomy which means respectively that wherever possible the aim should be to protect life and that a person has the right to refuse treatment but not the right to die3.

3. Inadequate symptom relief: Patient may demand euthanasia during an unbearable symptom which cannot be controlled adequately. But once the symptom passes patient may not want to die. 4. Uselessness/burden: Patient may feel that he is completely useless and that he is only a burden to the family and may therefore want to die. However, good care restores faith in life once again.

EUTHANASIA Euthanasia literally means mercy killing, by producing painless death in a person who is suffering from an incurable or a painful disease. But, mercy on whom? The patient or some other party with vested interest? The silent question of the duplex human intentions once again!

5. Depression: Sometimes an acute depression may compel the patient to opt for euthanasia. There have been cases where patient wanted to live again when depression was cured.

TYPES OF EUTHANASIA4

6. Budgetary constraints: This is a painful irony. Patient may not want to die but because of the unaffordable cost of end of life care, patient may consider taking the easy way out through euthanasia5.

1. Active/Positive: It is an act of commission, by giving large doses of drugs to hasten death. 2. Passive: These are acts of omission like discontinuing 46

Journal of F orensic Medicine & Toxicology Vol. 25 No. 1, J an-June 2008

DECLARATIONS ON EUTHANASIA6

delirious person, idiot or intoxicated person commits suicide whoever abets the commission of such suicide shall be punished with death or life imprisonment or 10 yrs with fine

1. WMA declaration on Euthanasia: adopted by the 39th World Medical Assembly, Madrid, Spain, Oct 1987.

S.306 IPC: Abetment of suicide-if any person commits suicide whoever abets the commission of such suicide shall be punished with imprisonment of either description with 10 yrs with or without fine.

Euthanasia i.e., the act of deliberately ending the life of a patient even at the patient’s own request or relative’s is unethical. This does not prevent the physician from respecting the desire of the patient to allow the natural process of death to follow its course in the terminal phase of illness.

S.309 IPC: Attempt to commit suicide-whoever attempts to commit suicide and does any act towards the commission of such offence shall be punished with simple imprisonment for 1 yr with or without fine.

2. The WMA statement on Physician Assisted Suicide (PAS): adopted by the 44th World Medical Assembly, Marbella, Spain, Sep, 1992.

CASE STUDIES IN INDIA

PAS, like euthanasia is unethical and must be condemned by the medical profession. Where the intention of the physician is intentionally or deliberately directed at enabling an individual to end his or her own life the physician acts unethically. However, the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient.

P.Rathinam vs Union of India, 1994-a person cannot be forced to enjoy the right to life to his detriment, disadvantage or dislike10. In Gian Kaur vs State of Punjab-the Court stated that the right to live cannot be interpreted to include the right to die an unnatural death curtailing the natural span11. The judge declared that the plea to support the view of permitting termination of life in terminally ill or in persistent vegetative state and to reduce the period of suffering during the process of certain natural death is not available to interpret Art 21.

3. The WMA has noted that the practice of active euthanasia with physician assistance has been adopted into law in some countries but has strictly resolved that euthanasia is in conflict with basic ethical principles of medical practice and has asked physicians to refrain from participating even if national law allows it or decriminalizes it under certain conditions.

Voluntary starvation for religious ending of life (Jainism) is viewed more tolerantly in India12. Attempt to suicide is a lighter offence than abetment to suicide.

LEGAL SANCTIONS ON EUTHANASIA7,8

DRAWBACKS INTHE CURRENT STRATEGIES

1. The first legal sanction of euthanasia was The Northern Territory Rights of the terminally ill Act 1995, Australia which was repealed in 1997.

Personal autonomy dominates over the principle of beneficence in developed countries. This leads to inappropriate treatment. In India there is hardly any exercise of autonomy1. Overall, the vagaries of the legal mechanism complicate every issue, tangible and intangible, involved in the end of life care.

2. The Netherlands never had legal sanctions but because of a “tolerant judiciary” the practice of euthanasia is common among Dutch physicians. 3. In the state of Oregon in the Death with Dignity Act was passed allowing Physician Assisted Suicide (PAS). But the practice is not widespread.

5. The Indian scenario-scarce legal opinion and legislation. Art 21 provides the right to life. However, the concept of autonomy is still weak and even the right to live a dignified life is not adequately explored.

Today’s world is also a world of declining morals and ethics where people are always after the fast buck. So, there is also a very consistent fear that if Physician Assisted Suicide (PAS) is allowed, then the terminally ill and the elderly patients will be at an increased risk from self serving relatives and even family physicians who stand to inherit something. The very thin line of demarcation between PAS and Non-Voluntary Euthanasia will become all the more blurred. This forms the so called ‘legal slippery slope’3.

INDIAN PENAL CODE (IPC)9

CONCLUSION

The following sections of the IPC are relevant with Euthanasia.

One can only conclude this paper with a heavy heart. There is always a dilemma between the legal and ethical duties of a doctor in such issues. The best way would be to consider every case with humanity and compassion. There should be utmost respect about the preferences and feelings

4. Terminal Sedation-sanctioned by the US Supreme Court, but not in India.

S.305 IPC: Abetment of suicide of a child or insane personif any person below 18 yrs or any insane person or any 47

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Clinical Anaesthesiology 1998; 12:121-131. 6. Modi JP . Modi’s Medical Jurisprudence and Toxicology. 23rd Edn.2006. Editors: K. Mathiharan and Amrit K. Patnaik, LexisNexis Butterworths, Section II, p.544-549. 7. Arunabha Sengupta . Stay the hand, yet. Indian Express, 26-11-2001. 8. Sullivan AD, Hedberg K, Fleming DW. Legalised physician- Assisted Suicide in Oregon-the second year. N Engl J Med2000; 342: 598-604. 9. Indian Penal Code, 1860. Modi’s Medical Jurisprudence and Toxicology, 23rd Edn.2006. Editors: K. Mathiharan and Amrit K. Patnaik, LexisNexis Butterworths, Section II, p.756-7. 10. P. Rathinam vs Union of India (1994) 3; Supreme Court cases 394-430. 11. Gian Kaur vs State of Punjab. AIR (1996) Supreme Court; 83:1257-65. 12. Laws of Manu. Transl. Buhler G. In:Muller FM, editor. Sacred Books of the East. 1967 reprint. Vol.25.p.204.

of the patient and paternalism should be completely avoided. For any decision, there should be consensus among the team of treating physicians. Lastly, remaining true to the spirit of a dynamic subject like Medical Science, we should strive further to evolve newer techniques rather than take the easy way out through euthanasia. REFERENCES 1.

2. 3.

4.

5.

Mani RK. Limitation of support in the ICU: Ethical issues relating to end of life care. Indian Journal of Critical Care Medicine 2003; 7(2): 112-117. Gillon R. Medical Ethics: four principles plus attention to scope. British Medical Journal 1994; 309:184-188. Walker RM. Ethical Issues in End-of-Life Care. Cancer Control: Journal of the Moffit Cancer Center 1999; 6(2): 162-167. Reddy KSN. Medical law and Ethics. The Essentials of Forensic Medicine and Toxicology. 28th Edn. 2008. Om Sai Graphics, Hyderabad, p.42. Zylicz Z and Janssens . Options in Palliative Care: Dealing with those who want to die. Bailliere’s

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CHOKING ACCIDENTS: AN AUTOPSY REVIEW O.P. Murty1, Ravi Rautji 2, Adlisan Bin Hj Deraman1, Lau Hung Chiun1, Normaskinah Bt Yahaya1 Siti Sarah Binti Zainal Abidin1

ABSTRACT

INTRODUCTION

Aspiration of a foreign body is common in children and also in adult which can cause upper airway obstruction, leading to significant morbidity or mortality. Choking on food and non-food objects has been one of the leading cause of accidental death among children. Candy, gum and coins ar e the objects responsible in two thirds of the non-fatal cases. The retrospective study was conducted in the dept of Forensic, Medicine University of Malaya. A total of 47 deaths caused by choking on foreign bodies had been subjected to autopsy at Department of Forensic, UMMC over a period of ten years (1 st January 1996 to 31 st December 2005). The detailed analysis of these cases was based on the medical records and the evaluation of autopsy reports. The majority of the victims were male (n=37, 78.7%) as compared to female (n=10, 21.3%). Chinese showed the highest percentage (n= 17, 36.2%), followed by Malay (n= 12, 25.5%), and Indian (n= 9, 19.1%). Other races such as, Indonesian, and orang asli accounted for 9 cases (19.1%). Commonest age group involved was 0-5 years (n=18, 38.3%), followed by 21-30 year (n=10, 21.3%), 31-40 year (n= 7 cases 14.9%), 4150 year (n= 5, 10.6%), 51- 60 year (n=4 8.5%), and 1620 year (n= 2, 4.3%). There were many causes for choking. Obstruction of the airways with food bolus was the most common cause (n=15, 31.9%), followed by aspiration of blood (n= 12, 25.4%), others (choking on sand and neurological disorder) (n= 11, 23.4%) and aspiration of gastric content (n= 9, 19.1%). This study demonstrates that food is the most common cause of choking especially in 0-5 years old group children. Chinese (36.2%) was the highest ethnic group, followed by Malay (25.5%), Indian (19.1%) and other races (Indonesian and orang asli) (n= 9, 19.1%). The common sites for obstruction was trachea, right bronchus and bronchioles.

Choking occurs when someone cannot breathe adequately because a foreign object such as food material, toy or any other object is blocking the airway (throat or windpipe). A choking person’s airway may be completely or partially blocked. Complete blockage is an urgent medical emergency. A partial obstruction can quickly become life threatening if the person loses the ability to breathe in and out sufficiently. Without oxygen, permanent brain damage can occur in as little as 4-5 minutes. Immediate first aid is essential for saving the life of the individual.(1)

Keyword: Choking; food; Aspiration; Gastric contents; Bronchus; Foreign body. 1

2

Forensic Pathology Unit , University of Malaysia Kuala Lumpur Department of Forensic Medicine and Toxicology Armed Forces of Medical Sciences, Pune, India Correspondence Author: Dr. O.P.Murty, Additional Professor Forensic Medicine and Toxicology All India Institute of Medical Sciences New Delhi, 110029 , India Email – [email protected]

Choking is a major cause of respiratory emergencies and cardiac arrest in infants and children. In many cases of choking, particularly in adults, the individual actively coughs and is able to expel the foreign object with no assistance or medical attention. However, children and infants are at increased risk of choking and airway obstruction due to their immature airway and peculiar dental anatomy, distraction, playing while eating, and a natural tendency to put objects into their mouths. (2, 3, 4, 5) Food-related choking usually occurs because infants and young children do not chew their food well, and larger pieces can stuck in their throat. The following foods have been identified by the American Academy of Pediatrics as choking hazards such as hot dogs, chewing gum, nuts and seeds, chunks of meat or cheese, whole grapes, popcorn, chunks of peanut butter, raw vegetables, and raisins. Some other common things that can cause choking are coins, buttons, marbles, deflated balloons, watch batteries, jewelry, small toys and toys with small detachable parts.(6) ‘Café coronary’ was the term coined by Haugen in 1963 for sudden and unexpected death occurring during a meal due to accidental occlusion of the airway by food. (7) The typical victim of a café coronary was initially thought to be a previously healthy middle-aged male with predisposing factors including a large food bolus, poor condition or absence of the teeth, and alcohol intoxication.(7) Further studies, however, showed that the range of victims was broader than this and included individuals with neurological conditions such as atherosclerotic cerebrovascular disease, dementia and Parkinson’s disease, and those on sedative or antipsychotic medication. It may also occur in young children. (8,9,10) METHODOLOGY Present study is a retrospective study that requires analysis of data. Data was collected from the autopsy log

49

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book of Department of Forensic Pathology, Faculty of Medicine, University of Malaya. All cases where death is caused by choking on food and aspiration were studied in details. 84 such cases were found in 10 years (1st January 1996 to 31st December 2005). Then the autopsy reports of all victims were traced and the relevant information was extracted and finally only 47 cases were confirmed as choking cases. Data were entered into SPSS version 11.0 a computer database and were analyzed epidemiologically based on their gender, age, ethnicity, level of choking and etiology of choking. All the data for each category were then transformed into chart forms.

Fig 3: Race of the deceased

RESULTS

The most common cause of choking was food items, (31.9%), blood aspiration (25.5%). and aspiration of gastric contents (19.1%). Others contributed 23.4% of the total.(Figure 4). Majority of male died due to blood aspiration (29.7%) (Figure 6) whereas food items were the principal cause of choking in female (60%) (Figure 5). Among the food items, milk and food bolus were the most common agents (33.33% each), followed by peanut (13.33%), candy, jelly and orange ( 6.67% each) (Table 2).

The total number of deaths due to choking in ten years (1996-2005) in UMMC was 47, which was 0.84% of total autopsies carried out during the same period. The majority of victims were males (78.7%) (Figure1). Most of them were adults (55.3%), compared to children (44.7%) (Figure 2).

Fig 1: Sex of the deceased

Fig 4: Material of choking

Fig 2: Age of the deceased Chinese have the much higher proportion as choking victims (36.2%), followed by Malay, (25.5%), Indian (19.1%) and others (19.1%) (Figure 3).

Fig 5: Material of choking (female) 50

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Table 3: Material of choking (Adults)

Table 4: Material of choking (Children)

Fig 6: Material of choking (male) Table 1: Age group of the deceased

Majority of choking deaths are due to choking at both the levels of trachea and bronchus, (59.6%) followed by at the level of upper vocal cord (14.9%), bronchus (14.9%) and trachea (10.6%).(Table 5) Most of the choking deaths occurred on the spot (46.8%) (Table 6). Table 5: Level of choking

Table 2: Type of food that caused choking

Table 6: Time of death

As far as pathological findings in lungs, majority were voluminous. On left side 57.7% lungs were voluminous, 23.1% were shrunken and 19.2% were normal. While on right side figures were 53.8%, 19.2% and 26.9% respectively. (Table 7)

There is no specific pattern of choking based on BMI group of adults (Figure 7). Majority of the victims of choking had normal BMI (50.0%), followed by those who were underweight, (26.9%), overweight, (19.2%) and obese (3.8%)

Table 7: Weight of both lungs (Adult)

Among 26 adults, the maximum weight of left lung was 1025 gms whereas right lung was 1100gms. Mean weight of left lung was 494.04gms while right lung was 550.42gms. On dissection, majority of the lungs showed congestion and edema, (68.1%) (Figure 8). Rests of the findings were inflammation (12.8%), and hemorrhage (10.6%). 6.4% of the lungs were normal on dissection. 2.1% of the lungs showed

Fig 7: BMI of the deceased 51

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followed by peanut (13.33%), and candy, jelly and orange (6.67%). Choking with milk usually occurred in children and infant while choking on food bolus usually causes death in adults. Risk factors in children include the availability of riskful foods/objects, natural diseases with difficulty feeding, poor eating habits, and uneducated or ignorant parents/others at the scene. 13

all three abnormalities, i.e. congestion, edema, inflammation and hemorrhage.

According to the autopsy reports preserved in Forensic department of UMMC, the normal weight of lungs in adult were 350-550g for right lung and 325-450g for the left lung. In the present study, 19.2% of left lung were normal, 23.1% were shrunken, and majority of them (57.7%) were voluminous. While 26.9% of right lungs were normal, 19.2% were shrunken and 53.8% were voluminous. Among 26 adults, the maximum weight of left lung was 1025gms whereas it was 1100gms for right lung. Mean weight of left lung and right lung was 494.04gms and 550.42gms respectively.

Fig 8: Histopathology of lungs DISCUSSION

For the body mass index (BMI), there was no specific pattern. Majority of the choking victims had normal BMI, (50.0%) while 26.9% were underweight and 19.2% were overweight.

In our study the majority of the victims were male (n=37, 78.7%) as compared to female (n=10, 21.3%.) This may be due to personal and behavioral characteristics of male, and greater male exposure. This is similar to a study conducted by Bonte W and Jacob B11

On dissection and histo-pathological examination, majority of the lungs showed congestion and edema (68.1%). The rest of the findings were inflammation (12.8%) and hemorrhage (10.6%). 6.4% of the lungs were normal on investigation. 2.1% of the lungs showed all three abnormalities i.e. congestion, edema, inflammation as well as hemorrhage .

From our study which involves all age groups, higher incident of choking occurred in adult (55.3%) as compared to the children (44.7%). Maximum incidence of choking was seen in 0-5 year’s age (38.3%), followed by 21-30 year (21.3%) and 31-40 age group (14.9%) Food asphyxiation in infants/children follows a different pattern from the adult. In the absence of ethanol intoxication, infants/children are prone to mishandling nonfriable, firm, slippery foods/ objects with a rounded contour.

The airways are divided into four levels, which are upper vocal cord, trachea, bronchus and bronchioles. Foreign bodies tend to arrest at any of these levels. In our study, the level that have highest tendencies to be obstructed with foreign bodies were both trachea and bronchus (n= 28, 59.6%), followed by upper vocal cord (n=7, 14.9%), bronchus (n=7, 14.9 and trachea (n=5, 10.6%). Usually large foreign bodies tend to arrest at the level of upper vocal cord while substances like milk, and gastric content tend to arrest at the level of bronchus. The right bronchus tends to get easily obstructed by foreign bodies because it is more vertical as compared the left bronchus.

Malaysia is a multiracial country which has Malay, Indian, and Chinese as the main races. Chinese contributes the highest rate of death (36.2%) followed by Malay (25.5%) and Indian (19.1%). Food items were the major choking agents (n=15, 31.9%). Round or cylindrical food items, hard candy, chewing gum, and balloons may increase choking hazards. In infants, choking usually results either from inhalation or ingestion of small objects of small objects (coins, small toys, deflated balloons, and buttons) they place in their mouths out of curiosity while playing. Similar observations were seen in a study by Rimell FL et.al.12. Aspiration of blood into the respiratory tract was second highest with 12 cases (25.5%), which are commonly seen in severe traumatic injuries. It is followed by aspiration of gastric contents into the respiratory tract (n=9, 19.1%).Some people choked with gastric contents while vomiting. Individual suffering from certain neurological disorder like dementia, and Parkinson’s syndrome are also prone to choking (11, 23.4%).

Most deaths occurred on the spot (n=22, 46.8%) while 18 cases (38.3%) died at the time of and 7 cases died after being hospitalized. Most of the deceased who died on the spot were involved in traumatic accidents with severe injuries to face and neck. Suggested tips for caregivers feeding children include keeping an eye on them while they eat, and cutting food articles into small bite-sized pieces. Various risk factors responsible for choking incidence are old age, poor dentition, neurological disorders, certain types of foods, and the intake of sedatives.

Most common types of dietary agents that cause choking death were milk and food bolus, (33.33% each), 52

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MedlinePlus. Foreign Object Aspiration or Ingestion. 2000 (cited 2001 December 11). Available from: URL: http://www.nlm.nih.gov/medlineplus/ency/article Centers for Disease Control and Prevention. “Nonfatal Choking-Related Episodes among Children—United States, 2001.” Journal of the American Medical Association 2002; 288 (Nov 20) : 2400-02 “Choking Episodes among Children.” National Center for Injury Prevention and Control. Available online at (accessed December 8, 2004). “Heimlich Maneuver.” American Heart Association, 2004. Available online at (accessed December 8, 2004). “Infant First Aid for Choking and CPR: An Illustrated Guide.” BabyCenter, 2004. Available online at (accessed December 8, 2004). h t t p : / / w w w. r e d c r o s s . o rg / s e r v i c e s / h s s / t i p s / choking.html Science direct- Journal of Clinical Forensic Medicine Café Coronary Syndrome ‘fatal choking on food an

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autopsy approach.mht Mittleman RE, Wetli CV. The fatal cafe coronary. Foreign-body airway obstruction, JAMA 1982; 247; 1285-1258. Ruschena D, Mullen PE, Palmer S, Burgess P , Cordner SM Drummer OH. et al. Choking deaths: the role of antipsychotic medication. Br J Psychiat 2000; 183: 446-430. Byard RW, Unexpected death due to acute airway obstruction in daycare centers, Pediatrics 1994; 94: 113-114. Bonte W, Jacob B. Death by bolus impaction of the larynx. Acta Med Leg Soc(Liege) 1990;40:139-51. Rimell FL, Thome A Jr, Stool S, Reilly JS, RiderG, Stool D, Wilson CL. Characteristics of objects that cause choking in children. JAMA 1995 Dec 13;274(22):1763-6. Mittleman RE. Fatal choking in infants and children.Am J Forensic Med Pathol 1984 Sep;5(3):20110.

Kumar A, Tyagi A, Aggarwal NK. Sex Determination By Morphology Of Talus Bone. Journal of Forensic Medicine & Toxicology. 2008 Jan-Jun;25(1):54-7. Journal of Forensic Medicine & Toxicology Vol. 25 No . 1, J an-June 2008

SEX DETERMINATION BY MORPHOLOGY OF TALUS BONE Ajay Kumar1, A. Tyagi2, N.K. Aggarwal3

ABSTRACT Discriminant function analysis method was used to find out the bisexual and bilateral variations in the talus bone. Talus bone of 50 males and 50 females wer e studied, five discriminant functions were generated of which Body Height gave the highest accuracy followed by Maximum Length, Maximum Width, Maximum width of the trochlea, Maximum length of the trochlea. Significant male preponderance of all the measurements in talus of either side was found. Bilateral variations in both the sexes were present but were statistically insignificant. Keywords: Talus; S teletal r emains; Identification; Morphology etc. INTRODUCTION

conditions and are less likely to be fragmented further. Therefore possibility of finding this bones intact, in fragmented skeletal remains, is much higher as compared to other bones. Visual methods of sex determination have long been predominant in the area of human skeletal identification 2,3,4. Various scientists have studied the sex differences in Talus 5-9. In India very few authors have explored these bones, as regarding the problem of determination of sex and very scanty data is available for Indian population. The method employed by Singh & Singh 6 in 1975 was based on bone weights alone. It is therefore this study was undertaken to study the sex differences in adult Talus in Indian population using Discriminant Function Analysis and thus to be made available and used in future for determination of sex. MATERIALS AND METHODS

Sex determination is one of the major challenges for the forensic anthropologist within a medico-legal context; it is considered an early step in personal identification from skeletal remains and it is indispensible for applying procedures to define race and age at the time of death 1. The task of identification of human skeleton requires thorough knowledge, especially in the field of comparative osteology, craniometry and racial morphology. Not only this, a vast experience and acquaintance with the latest available statistical data is of utmost importance. The gravity of the problem of identification is further enhanced and tax the resources of most experienced forensic experts when the bodies are recovered in skeletonised form ( when death has occurred long ago) or in mutilated state. The mutilation of the dead body is done by criminals to destroy all traces of identity or to facilitate the disposal of the body. The various methods of attempted disposal of the body are: mutilation (slashing, gouging, pounding or other attempts at regional disfigurement or obliteration), dismemberment (so that only widely scattered parts are found), use of corrosives for specific or general destruction and by the action of fire. In country like India, the dead body can be mutilated by animals and vultures when disposed in isolated lonely places. Mass disasters like earthquakes, bomb explosions, air-crash, railway accidents, etc. are other common sites where bodies can be found in mutilated state. Talus is a small, stout bone, and by virtue of its anatomical position resist putrifaction better than other bones, can remain preserved for longer times under natural climatic

The study was conducted in the Department of Forensic Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi. The material was collected from the dead bodies coming for medico-legal autopsies in the mortuary of Guru Teg Bahadur Hospital during year 2002 to 2004.The informed consent, was taken from the relatives before taking out the bones from the dead bodies. The Talus of 100 persons (50 males and 50 females), all adults, were taken out of the dead bodies. Deceased having any deformity or pathology of bone were not included in the study. Immediately after removal, permanent and indestructible tags, were put on the bones. The bones were first cleaned by blunt dissection taking utmost care, so that no injury is caused to the bone. The bones were then buried under the soil for 6-8 weeks to separate the remaining soft tissues attached to the bone, in natural climatic conditions in which bones are usually found. After 6-8 weeks the bones were removed from the soil, washed with tap water and then air- dried. All measurements of talus bone were taken by standardized anthropometric caliper graduated to 0.1mm on anthropometric board. FIVE MEASUREMENTS OF TALUS WERE TAKEN 7 1. Maximum length (Max. L) : The fixed arm of the sliding caliper was applied to the most posterior point of the groove for the tendon of flexor hallicus longus. The movable arm was brought into contact with the most anterior point of its articular surface for the navicular. The caliper was rotated from side to side to achieve the maximum length.

1

. Senior Resident ( Corresponding Author) . Professor 3 . Professor & H.O.D Dept. of Forensic Medicine Univercity college of Medical Science, New Delhi-110095 2

2. Width of the talus (Max. W) : The fixed arm of the sliding caliper was applied to the most lateral point of talus on 54

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to right side having a range of 41.80 mm to 49.00 mm with a mean of 45.06 mm. The measurement is significantly more on either side, in males as compared to females.

its articular facet for the lateral malleolus. The movable arm was brought into contact with the medial surface of the talus. The caliper was rotated from side to side until the maximum width perpendicular to the sagittal plane was obtained. Steele 7 described this measurement as usually bisecting the trochlear articular surface, slightly anterior to the midpoint of the surface.

Univariate Discriminant function equation derived for Maximum Length is For right side Y = (Maximum Length)(0.422) +(-20.610) For left side Y = (Maximum Length)(0.427) +(-20.834)

3. Body height (BH) : The talus was placed on a flat surface and the fixed arm of the sliding calliper as applied to the most superior point on its trochlear articular surface. The movable arm was rought into contact with the inferior surface of the talus. The caliper was rotated from side to side to achieve the maximum body height. Steele 7 commented that the superior point used in this measurement is usually located on the medial rim of the trochlear articular surface.

Table 2: Showing Range, Mean, S.D. of Maximum width of talus bone

Sex could be ascertained with 94% accuracy each from the right side and left side.

4. Maximum length of the trochlea (MLT) : The fixed arm of the sliding caliper was applied to the most posterior point of the trochlear articular surface. The movable arm was brought into contact with the most anterior point of the same surface.The caliper was rotated from side to side to achieve the maximum length of the trochlea in the sagittal plane.

A slight left side dominance was observed in value of mean (40.75) for males as compared to right side mean (40.44). The range was 37.00 mm to 50.00mm on the left side and 36.00 mm to 49.00 mm on the right side. Similar was the case of females with a mean of 34.65 mm and a range of 31.00 mm to 37.60 mm on the right side and a mean of 36.60 mm , range varied from 31.40 mm to 38.30 mm. The measurement is significantly more on either side, in males as compared to females.

5. Maximum width of the trochlea (MWT) : The fixed arm of the sliding caliper was applied to the most lateral point of the trochlear articular surface.The movable arm was brought into contact with the most medial point of the same surface.The caliper was rotated from side to side to achieve the maximum width perpendicular to the previous measurement.

Univariate Discriminant function equation derived for Maximum Width is For right side Y = (Maximum Width)(0.455) +(-17.085) Table 3: Showing range, mean and S.D. of body height of talus bone

In the present study Univarient Discriminant function analysis (DFA) was used where the individual measurement taken is used as one function. The DFA equation Y =mx +c, where Y is the Discriminant function score, m is the coefficient, x is the magnitude of the variable in millimeters, and c is the constant. The sectioning point in each equation is taken as ‘0’ (zero). The positive values of ‘Y’ indicate bone to be male and negative values of ‘Y’ indicates a female bone.

For left side Y = (Maximum Width)(0.404) +(-15.220) Sex could be ascertained with 93% accuracy from the right side and with 91% accuracy from the left side respectively.

Table 1: Showing range, mean and S.D. of maximum length of talus bonc

A. slight predominance was observed in value of mean (36.20) for males as compared to right side mean (35.92). The range was 33.00 mm to 41.00mm on the left side and 32.30 mm to 39.00 mm on the right side. Similar was the case of females with a mean of 31.17 mm and a range of 29.00 mm to 33.60 mm on the left side and a mean of 30.95 mm , range varied from 28.00 mm to 33.00 mm. The measurement is significantly more on either side, in males as compared to females.

OBSERVATIONS ANDDISCUSSION It is observed that Maximum length is more on right side in males, ranging from 47.10 mm to 58.80 mm with a mean of 52.54 mm, as compared to left side having a range of 47.00 mm to58.70 mm with a mean of 52.44 mm. The same was found to be more on left side in females with range of 41.00 mm to 49.00 mm with a mean of 45.05 mm as compared

b. Univariate Discriminant function equation derived for body height is for right side Y = (Body Height)(0.701) +(-23.445) for left side Y = (Body Height)(0.659) +(22.195). 55

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Table 6 : Showing equation of univarient discriminant function analysis

Sex could be ascertained with 96% accuracy from the right side and with 97% accuracy from the left side Table 4: Showing range, mean and S.D. of maximum length of trochlea

It was observed that maximum length of trochlea is marginally more on right side in males, ranging from 33.30 mm to 44.80 mm with a mean of 37.98 mm, as compared to left side having a range of 31.00 mm to43.90 mm with a mean of 37.50 mm In case of females the range was 28.80 mm to 38.60 mm with a mean of 32.34 mm for the right side whereas for the left side it was 29.10 mm to 43.90 mm with a mean of 32.09 mm. The measurement is significantly more on either side, in males as compared to females.

function out of the five parameters measured on the talus bone the Body height was the variable with the highest percentage accuracy of sex determination. The accuracy was 97% for the left side and 96% for the right side Talus bone. Maximum length of the trochlea was the parameter with the lowest accuracy of 92% and 90% for the right and left side respectively. The accuracy of the other three variables lied in between 92% and 96% for the right side and 92% and 97% for the left side respectively.

Table 5: Showing range, mean and S.D. of maximum width of trochlea

Table 7: Comparision of bilateral variation of all parameters of right and left talus of males Univariate Discriminant function equation derived for Maximum Length of Trochlea is For right sideY = (Maximum Length of Trochlea )(0.446) +(-15.696) For left sideY = (Maximum Length of Trochlea) (0.439) +(-15.261) Sex could be ascertained with 92% accuracy from the right side and with 90% accuracy from the left side It was found that measurements of Maximum width of trochlea is marginally more on right side as compared to left side in males. The range was 27.10 mm to 34.00 mm with a mean of 30.37 mm on the right side, as compared to left side having a range of 26.00 mm to 33.60 mm with a mean of 30.27 mm. Contrary to males the measurements of the left side of females was marginally more with a mean of 26.35 mm as compared to mean of 26.27 mm of right side. The range was 24.30 mm to 28.30 mm on the left side, and 24.00 mm to 30.00 mm on the right side.

Table 8 : Comparision of bilateral variations of parameters of right and left talus of females

The measurement is significantly more on either side, in males as compared to females. Univariate Discriminant function equation derived for Maximum Width of Trochlea is For right sideY = (Maximum Width of Trochlea )(0.707) +(-20.016)

In the talus three variables 1)Maximum length 2)Maximum length of trochlea 3) Maximum width of the trochlea were slightly greater on the right side, rest were more on left side in males. In the case of females again three variables 1) Maximum length 2) Body Height 3) Maximum width of the trochlea were slightly greater on the left side, rest were more on right side.

For left sideY = (Maximum Width of Trochlea )(0.719) +(-20.191) Sex could be ascertained with 93% accuracy from the right side and the left side In the present study using Univariate Discriminant 56

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CONCLUSION

country for sex determination from the Talus bone and will be of immense forensic value in the field of crime detection.

Sex could be ascertained with 96% accuracy for the right side and with 97% accuracy for the left side from the

On comparing the measurements of theTalus bone of Rt. and Lt. side in either sex it was found that in males the parameter Max. L, MLT,MWT were bigger on the Rt. Side while in females the parameters Max. W, MLT were marginally more on the Rt. Side. The difference was marginal and statistically insignificant.

Table 9: Comparisionof percentage accuracy of talus bone of various authors8,10

REFERENCES Introna Jr F, Di Vella G, Campobasso CP, Dragone M. Sex determination by discriminant analysis of calcanei measurements. J Forensic Sci 1997;42(4): 725-8. 2. Srewart TD. Medico-legal aspects of the skeleton, Age, Sex, race and stature. Am J Physical Anthropol 1948; 6: 315-21. 3. Krogman WM. The human skeleton in legal medicine: medical aspects. In levinson SA ed. Symposium on medico-legal problems, Series 2. Philadelphia: JB Lippincot Co; 1949. 4. Hrdlicka A. Practical Anthropology, 3 rd Fdn, Philadelphia: Wistar Institute, 1947. 5. Olivier G. Practical Anthropology. Springfield, Thomas 1969. 6. Singh and Singh SP. Identification of sex from the tarsal bones. Acta Anat 1975;93:568-73. 7. Steele DG. The estimation of sex on the basis of talus and calcaneus Am J Physcial Anthropol 1976;45:58188. 8. Murphy A M C. The Talus : sex assessment of prehistoric New Zealand Polynesian skeletal remains. Forensic Sci Int 2002; 128:155-8. 9. Murphy A M C. The calcaneus: sex assessment of prehistoric New Zealand Polynesian skeletal remains. Forensic Sci Int 2002;129:205-8. 10. Bidmos MA, Dayal MR.Sex determination from the talus of South African whiles by discriminant function analysis. Am J Forensic Med Pathol 2003 ; 24(4): 322-8. 1.

parameter Body Height of Talus. Sex could be ascertained with 94% accuracy for both the sides from the parameter Maximum Length of Talus. Sex could be ascertained with 93% accuracy for the right side and with 91% accuracy for the left side respectively by the parameter Maximum width of Talus. Sex could be ascertained with 92% accuracy for the right side and with 90% accuracy for the left side from the parameter Maximum length of Trochlea. Sex could be ascertained with 93% accuracy each from the right side and left side from the parameter Maximum width of Trochlea. Significant male preponderance of all the measurements in Talus bone of either sides was found. The results are in contravention to the common belief that bigger parameters form better Discriminant functions with the body for the purpose of identification. Body height of the talus and Maximum length of Trochlea being comparatively smaller parameters achieved higher accuracy percentage as compared to other parameters. The present study was conducted on a cosmopolitan population , and the Discriminant function equation thus derived in this study, can be routinely used all over the

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MYOCARDIAL INFARCTION WITH NORMAL CORONARY ARTERY (MINCA): A SUDDEN DEA TH CASE REPOR T IN FORENSIC PRACTICE Shahrom AW1, Khairul A Z1, Zarida H1, Swarhib M S2

ABSTRACT Death attributed to myocardial infarction associated with normal coronary artery is uncommon. It is even rare when the death occurs during an uneventful pr egnancy. We report a 29 year-old lady in her first pregnancy at 32 weeks gestation, suddenly collapsed at home and died at the hospital. She was neither known to have significant medical illness nor eventful antenatal records prior to her death. No family history of cardiac rhythm disturbances was noted. The main coronaries were patent but there were foci of fibrosis within the left ventricular wall of the heart. Histopathological examination of the heart showed multiple infarcts of varying ages as well as mature fibrotic scars. No inflammatory signs were detected at autopsy. This case illustrates an extr emely rare cause of sudden and unexpected death during pregnancy attributed to myocardial infarction with normal coronary arteries (MINCA). It emphasizes the need for a full autopsy examination in such cases. It also highlights that certain pregnant mothers may show minimal or no symptoms of illness despite the presence of a life-threatening disease. Keywords: Sudden unexpected death; Pregnancy; Myocardial infarction; Coronary angiogram; MINCA. INTRODUCTION Coronary atherosclerosis remains the most frequent cause of death around the world. In general, these deaths arise as a consequence of ongoing coronary stenosis or due to its long term effects like plaque rupture and coronary thrombosis. Myocardial infarction, being one of the outcome of coronary atherosclerosis, is invariably presented as a sudden and unexpected death. Autopsy examination most often reveals two facts; a significant narrowing of coronary lumen by the usual atheromatous lesion or its complications and the site of a new or ongoing infarct.

due to myocardial infarction associated with normal coronary artery. The full autopsy examination involved is properly outlined and the predisposing aetiological risk factors of developing the disease are discussed. CASE REPORT A 29 year-old Chinese lady, in her first pregnancy at 32 weeks gestation, suddenly collapsed one morning at her house. She was rushed to the nearby hospital by the ambulance. She was actively resuscitated. However, despite the efforts, she succumbed to her illness and so did the fetus which was certified dead in-utero. In the weeks prior to her death, she did not show any symptoms of systemic illness. There was no family history of significant illnesses or cardiac rhythm disturbances. Her state of health before pregnancy was excellent. The antenatal record reviewed with her obstetrician was uneventful. However, no coronary angiography was done as it was not indicated as claimed by the obstetrician. Forensic autopsy examination was performed as requested by the coroner . Since this death falls into maternal death category, hence the need for the case to be investigated under the “Maternal Death Inquiry”, the autopsy approach was clinically inclined. Apart from the police officer-in charge of the case, also present during the autopsy was an obstetric & gynaecology consultant of the hospital. At autopsy, signs of pregnancy were confirmed by presence of breast changes and fundal height measurement at 32 cm. Therapeutic marks of resuscitative efforts were evident by multiple injections signs and defibrillator pad marks over the chest. There were facial and conjunctival congestion as well as cyanosed fingernails (Fig. 1). There were otherwise no obvious marks of suspicious trauma.

Nevertheless, there are instances when the infarct is somehow clearly defined but with the absence of diseased coronaries. These deaths tend to occur in younger age group people whom careful history taking fails to disclose significant medical history. We present a case of sudden and unexplained death during pregnancy in a young lady 1

2

Forensic Unit, Department of Pathology, Medical Faculty, Universiti Kebangsaan Malaysia. Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia.

Fig 1: Cyanosed fingernails 58

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Internally, the larynx was generally congested while the trachea contained moderate amount of froth. The lungs were heavy and oedematous. The heart looked generally pale. The myocardium showed whitish fibrous tissue of old infarcts over the left ventricle (Fig.3) The left ventricular wall was slightly thickened. The main coronary arteries were patent (Fig.2) and of normal caliber. The heart valves were healthy and all major chambers were not dilated.

was intact with absence of amniotic fluid constituents. Sections from the rest of the organs were unremarkable.

Fig 4: Section from the heart showing islands of myocytes degeneration with surrounding tissue fibrosis (H&E X100)

Fig 2: Section from the heart showing patent coronary artery

Fig 5: Infarct areas showing fibrous tissue of both young and mature collagen (MassonTrichrome x100) Toxicolgical analysis of the blood showed no detectable level of alcohol or other common drugs of abuse. Laboratory investigation revealed elevated Troponin-T and CKMB mass level. RapidToponin-I test also showed positive result. Haemoglobin level was of low normal (10.9 g/dL) while the D-dimer was positive. Both prothrombin and activated partial thrombin time were normal.

Fig 3: Cross section of the heart showing whitish fibrous tissue of old infarcts The uterus was intact. It contained a non-viable male fetus with clear liquor. Both umbilical cord and placenta were healthy . Neither signs of conceal or reveal haemorhages were evident. The rest of the organs of the body were grossly unremarkable.

The death was attributed to acute heart failure due to extensive myocardial infarction with normal coronary artery. DISCUSSION

Histopathological examination with both standard H&E stain demonstrated scattered foci of myocardial degeneration and karryolysis of myocytes nuclear content (Fig. 4). Some of these areas were replaced by immature collagen while other areas composed entirely by mature fibrous tissues. Special stains with Mason trichrome and Van Giesson clearly outlined these changes (Figure 5). No marker of inflammation was present. The coronary arteries showed normal wall layers devoid of atheromatous changes. Sections from the lung tissue showed pulmonary oedema with sporadic alveolar haemorhages. The lungs’ vasculature 59

The major category of unexpected and sudden death around the world remains due to coronary atherosclerosis and its possible long term consequences (Robbins et al. 2003). Myocardial infarction is definitely one of its recognized outcomes. Clinicians arguably tend to consider this disease entity purely as a syndrome which can be diagnosed entirely based on clinical symptom of chest pain, cardiogenic shock and later hospitalization. However, it is a common fact that a significant portion of people does end up on the mortuary table requiring an autopsy by the pathologist in order to establish the diagnosis (Knight B,

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Saukko P.) Death due to myocardial infarction, presented as a sudden and unexpected death, is diagnosed after a proper history taking, autopsy examination and later completed by a laboratory analysis as well as histopathological examination. Shahrom et al (2007) had shown the usefulness of rapid Troponin-I test to diagnose acute myocardial infarction in suspected sudden cardiac deaths. Though the unexpectedness of the death may occasionally pose significant challenge to the pathologist, the availability of information suggesting death attributed to cardiac cause in origin, will invariably give him some idea of the best autopsy approach to employ. Demonstration of a significant coronary narrowing and presence of patterned haemorhages within myocardium are certainly a minimum prerequisite whereas laboratory confirmation of myocardial necrosis and histopathological evidence of tissue infarct will certainly complete the autopsy diagnosis. This case demonstrates an uncommon cause of death manifested by myocardial infarction in association with normal coronary artery. This disease is by now a recognized clinical entity. Its occurrence is not common in the living, let alone its detection at autopsy following a sudden and unexpected death. In survivors of non-fatal myocardial infarction, MINCA is diagnosed following lack of detectable obstructive coronary artery disease by coronary angiography (Betriu et al). Skeppholm et al desribed “myocardial infarction with normal coronary arteries in women as a specific type ofmyocardial infarction known as MINCA. OP Murty et al (2007) reviewed ten year cases of “female deaths due to cardiac causes in Malaysia” and in the series there was no incidence of MINCA. This might be due to the rarity of this entity. Despite its occurence and clinical recognition, the aetiology of MINCA remains partially obscured. Early report suggests coronary angiogram misinterpretation, coronary embolization and cocaine abuse as the possible aetiology. Pinney S.P. and Rabbani L.E. (2001) implicate the role of coronary thrombosis with or without antecedent spasm as the likely reason for the occurrence. They reasoned this conclusion based on combination of several factors which include the role of coronary wall dynamic with its dormant atherosclerotic plaque, hypercoagulable state of the blood and of certain exogenous agents that may trigger spasm within these normal coronaries. Kardasz and De Caterina (2007) believe that MINCA is a conundrum with multiple aetiologies and variable prognosis. Kakkar et al (2006) and Chutkow et al (2002) hypothesize that “episodic coronary artery vasospasm and hypertension develop in the absence of Sur2 K(A TP) channels” from their experiments in mice. Whether this is the underlying pathology of MINCA is yet to be probed further. 60

There are however, some predisposing risks that are commonly associated with MINCA. Age is the most commonly studied risk factor in MINCA. Patients who suffer from MINCA tend to be younger with fewer risk factors of developing coronary atherosclerosis albeit cigarette smoking was found to be a common habit (Legrand et al 1982, McKenna et al 1980). Gender is a non-relevant risk so does the affected site of infarct. Ichiba et al (2005) described a case of acute myocardial infarction due to coronary artery spasm after caesarean section. In their case the woman was successfully resuscitated with emergency percutaneous transluminal coronary angioplasty. We believe in their case, MINCA can be excluded due to the suscessful treatment with percutaneous transluminal coronary angioplasty. Because of the rare occurrence of MINCAin pregnancy, its predisposing role as a risk factor is hardly evaluated. We speculate that in our case the pregnancy had physiologically induced the state of blood hypercoagulability. At the same time, she might also have been taking some exogenous coronary spasm-prone substances during this pregnancy. Given the nature of the infarcts (old and new), this could happen within a period of few days to months prior to her death. While antemortem symptoms and signs may be present in people who died of myocardial infarction, these may be quite subtle. In retrospect, these symptoms might be overlooked by the deceased as being part and parcel of pregnancy. REFERENCES 1.

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Anthony PP, Macsween R . Recent Advances in Histopathology. 1994. Churchill Livingstone. Pathology of death in pregnancy. P 189. Betriu A, Pare JC, Sanz GA, Casals F, Magriña J, Castañer A, Navarro-Lopez F. Myocardial infarction with normal coronary arteries: a prospective clinicalangiographic study. AmJ Cardiol 1981; 48: 28-32. Chutkow WA, Pu J, Wheeler MT, Wada T, Makielski JC, Burant CF, McNally EM. Episodic coronary artery vasospasm and hypertension develop in the absence of Sur2 K(A TP) channels. Journal of Clinical Investigation 2002; 110(2): 203-8. Ichiba T, Nishie H, Fujinaka W, Tada K . Acute myocardial infarction due to coronary artery spasm after caesarean section. Jap J of Anes 2005; 54(1): 546. Kakkar R, Ye B, Stoller DA, Smelley M, Shi NQ, Galles K, Hadhazy M, Makielski J C, McNally EM. Spontaneous coronary vasospasm in KA TP mutant mice arises from a smooth muscle-extrinsic process. Circulation Research 2006; 98(5): 682-9. Kardasz I, De Caterina R. J Intern Med.Myocardial infarction with normal coronary arteries: a conundrum

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with multiple aetiologies and variable prognosis: an update 2007; 261(4): 330-48. 7. Knight B, Saukko P . Forensic Pathology 3 rd Ed. London. Edward Arnolds. 2004. Pathology of Sudden Death. 8. Legrand V, Deliege M, et al. Patients with myocardial infarction and normal coronary arteriogram.Chest 1982; 82: 678-695. 9. Manzar KJ, Padder FA, Conrad AR, et al. Acute myocardial infarction with normal coronary artery: a case report and review of literature. Am J Med Sci 1997; 314: 342-345. 10. McKenna WJ, Chew CY, Oakley CM. Myocardial infarction with normal coronary angiogram. Possible mechanism of smoking risk in coronary artery disease. Br Heart J 1980; 43: 493-498. 11. Meadow WR. Idiopathic myocardial failure in the last trimester of pregnancy and the puerperium. Circulation 1957; 15: 903-914. 12. Murty OP, Seng LK, Nuraeiniza I, CheeAS, Syahir BM. Female deaths due to cardiac causes in Malaysia:

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10 years autopsy review. Mal J For Path Sci 2007; 2 (1): 9-19. Pinney SP, Rabbani LE . Myocardial infarction in patients with normal coronary arteries: Proposed pathogenesis and predisposisng risk factors. Jour of Thrombosis and Thrombolysis. 2001; 11: 11-17. Robbins, Cotran and Kumar. Basic Pathology. 7th Ed. 2003. WB Saunders Company . Ischaemic hear t disease. p 363. Skeppholm M, Agewall S, Ljungman P, Daniel M, Eriksson M, Hofman-Bang C, Malmqvist K, Reistam U, Svane B, Tornvall P. Myocardial infarction with normal coronary arteries in women. MINCA - a specific type of myocardial infarction. Lakartidningen 2007; 104(37): 2586-8. Shahrom AW, Swarhib MS, AzuriahAA, Zarida H, Aznool HA. Cardiac Troponin I in suspected sudden cardiac deaths at Forensic Unit, UKM Hospital: A preliminary observation. Mal J For Path Sci 2007; 2(1): 84-90.