1. health and fitness
2. disease
3. arthritis

Original article
Prevalence and features of triticea cartilage in an autopsy sample
of tertiary care hospital in Sri Lanka
Senanayake S.M.H.M.K.
Teaching hospital Anuradhapura
*Corresponding author: Tel: 0094-71-8195569 E-mail address:[email protected]
MLJSL. Vol 2. No 2. Dec. pp 1-4
Abstract
Introduction
Triticea cartilage is a grain like cartilage situated just above the tips of the superior thyroid horns.
Inexperienced medical officers could mistake this incidental finding for a fracture and thereby an
evidence of pressure on the neck.
Objective
This study was designed to find the prevalence of the Triticea cartilage in an autopsy sample in the
Kurunegala District of Sri Lanka and if present to ascertain its size and shape.
Methodology
All autopsies performed by the author during the last four months of the year 2011 were included in to
this research.
Results
The sample studied included 182 males and 67 females (n=249). In males triticea cartilage was
present in 101 (55.5 %) cases, of which cartilages were present bilaterally in 76
(41.2%).Unilateral cartilage on the left side was found in 12 (6.5%) of the males and on the right
side in13(7.1%) cases. Site was just above the tip of the thyroid cartilage in 94 (93%) cases. Spherical
shape of the cartilage was observed in 80(79.3%) and elongated shape in 21(20.7%) cases. Triticea
cartilage was present in 24(35.8%) of females of which cartilages were present bilaterally in14(20.8%).
Unilateral cartilage on the left side was found in 7(10.5%) of the females and on the right side in3(4.5%).
Commonest site was just above the tip of thyroid cartilage in 23 (95.8%) cases. Spherical shape in
21(87.5%) cases and 3 (12.5%) cases cartilage was elongated.
Conclusion
This study showed that 50.2% (half) of the autopsy population has the triticea cartilage. 36.1% (One
third) of population has it on both sides. More than three quarter (80.8%) of triticea cartilages are
spherical in shape. 92.8% of triticea cartilages were found just above the tip of superior thyroid horn.
Key words: Triticea cartilage, autopsy sample, presence, prevalence, above the tip of thyroid cartilage,
1
Introduction
Triticea cartilage[1](triticea cartilago),tritiate
cartilage[2] or triticious cartilage [3] is a grain
like cartilage situated just above the tips of the
superior horns of thyroid cartilage [1].
“Tritiate” is a Latin word the meaning of which
is grain. Inexperienced medical officers could
mistake this incidental finding for a fracture of
the thyroid cartilage and conclude that there
was evidence of pressure on the neck [4].
Another importance of this cartilage is that
fracture of a thyroid horn could be
misrecognized as a triticea cartilage. One
common postmortem artifact which gained
worldwide attention was laryngeal fracture
occurring due to handling during the autopsy
[5,6]. It is possible that much attention was not
drawn to the triticea cartilage due to its scarcity
in developed countries.
Literature survey showed only a few
publications about this cartilage and a few more
articles just mentioned this name when dealing
with the thyroid cartilage. Even though
anatomy text books devote a few sentences to
this cartilage, many forensic text books [7, 8] do
not even mention it. Anatomically it was
considered unimportant earlier but now it is
accepted as being relevant for strengthening of
the thyrohyoid ligament. In the practice of
radiology it is important to separate calcified
triticea cartilage from a calcified carotid
atheroma and soft tissue calcifications [3]. This
cartilage has been a frequent finding for the
author in the autopsies done in Sri Lanka and
was the reason that prompted this research.
Objective
This study was designed to find the prevalence
of the triticea cartilage in autopsies performed
in the Kurunegala Teaching Hospital and if
present to ascertain its site and shape.
Methodology
during the last four months of the year 2011
were included in to this research. Upper margin
of thyroid cartilage is connected by the
thyrohyoid membrane to the lower border of
the hyoid bone. The thyrohyoid membrane is
limited posteriorly by the thyrohyoid ligament.
When this ligament is palpated, a grain like
nodule is felt somewhere between the tip of
the superior thyroid horn and hyoid bone.
When soft tissues are dissected away, triticea
cartilage is found in the ligament. Rounded and
smooth ends help to separate it from a fracture
of the thyroid horn because fracture surfaces
are flat and irregular [9]. Shape of the cartilage
was studied, length was measured and distance
between the tip of thyroid horn and triticea
cartilage was measured.
Results
Prevalence
Out of the 182 males Triticea cartilage was
present in 101 (55.5 %) cases. (Table no. 01).
Out of these 101 cases, cartilages were present
bilaterally in 76 (41.2%) cases (Table no.02).
Unilateral cartilage on the left side was found in
12(6.5%) cases and on the right side in 13(7.1%)
cases.
In females Triticea cartilage was absent in 43
(64.2%) cases. Cartilages were present
bilaterally in 14(20.8%) cases. Unilateral
cartilage on left side was found in 7 (10.5%)
cases and on the right side in 3(4.5%) cases.
Table no. 01. Prevalence of cartilage
Presence of
the
cartilage
Male
Female
Total
P value
Present
Absent
Total
101
81
182
24
43
67
125
124
249
0.005
All 249 postmortem examinations (182 males
and 67 females) performed by the author
2
Table no. 02.Presence of bilateral and
unilateral cartilages-in males and females
Presence
of Male Female P
bilateral cartilage
value
Bilateral cartilage 76
present
14
Unilateral
cartilage
10
25
0.103
Site
In males, the commonest site was just above
the tip of the superior horn of the thyroid
cartilage(thyroid horn) in 93(92%) cases. In 4
cases it was found 0.25cm above, in 2 cases
0.5cmabove and in 2 cases 1cmabove the tip of
the thyroid horn.
In females, commonest site was just above the
tip of thyroid horn in 23 (95.8%) cases. In the
remaining case cartilage was found 0.5cm
above the tip of thyroid cartilage.
Shape
Spherical shape was seen in 80 (79.3%) males
and elongated in 21 (20.7%)males. Spherical
shape was found in21 (87.5%) females and
elongated in 3 (12.5%) females.
Size
Length of the cartilage was variable and
measured between 0.25 to one centimeter.
Width was equal to the width of its thyroid
horn.
Discussion
This study indicates that 50.2 % of the study
population has the triticea cartilage. 36.1%
(slightly more than one third) of the study
population has it on both sides. Presence of this
cartilage in males is statistically significantly
higher than in females. (P value = 0.005).
Presence of bilateral cartilage is statistically
significantly higher in males than females. (P
value = 0.103).
In more than three quarter of the
subjects(80.8%), the cartilage was spherical in
shape. In 92.8% cases it was found just above
the tip of the thyroid horn. The size was
variable. The length was between 0.25 cm to
one centimeter and the width was equal to the
width of the thyroid horn.
Since half the population possess this cartilage,
careful neck dissection will reveal it. It is
therefore medico legally important to recognize
this cartilage and separate it from a fracture of
thyroid horn. More than 90% of the cases it was
found just above the tip of the thyroid horn and
can be easily mistaken for a fracture of tip of
the thyroid horn. In the remaining cases due to
the larger gap it is unlikely to be mistaken for a
fracture.
One third of the population has it only on one
side. When there is a suspicion about neck
trauma and if fracture of thyroid horn is found
on one side, triticea cartilage on other side may
give the misleading impression of bilateral
thyroid fractures.
A spherically shaped triticea cartilage can give a
false impression of a fracture of the tip of the
thyroid horn. An elongated cartilage can give
the impression of a fracture of the middle of the
thyroid horn. Because of the rounded shape of
its lower end, the cartilage can be easily
distinguished from a fracture. X ray examination
of the larynx will be useful to separate the
cartilage from a thyroid fracture, but practically
it is not required. A study done on laryngeal
cartilages for age changes has not shown any
value of calcification of triticea cartilage [10] for
assessment of age. On calcification, the triticea
cartilage might fuse with the tip of the thyroid
horn and give a false impression of an old
thyroid fracture [11]. This cartilage is known as
a variable cartilage because of embryological
developmental variations [12]. This study
determined the prevalence, sites, size and
3
shape of Triticea cartilage indicating its
importance as one common postmortem
artifact found during neck dissections in Sri
Lanka.
4.
5.
Conclusions
This study showed that 50.2% (half) of the
autopsy population has the triticea cartilage
and in 92.8% the cartilage was found just above
the tip of superior thyroid horn. More than one
third of the population has it on both sides and
more than a three quarter (80.8%) of the
Triticea cartilage were spherical in shape.
Because half of the population possess this
Triticea cartilage just above the tip of superior
thyroid horn, it is a very important, common
artifact of neck dissection in Sri Lanka.
Awareness of the presence of Triticea cartilage
as well as its smooth and rounded upper and
lower ends will prevent medical officers from
misrecognizing it as a fracture of the tip of the
superior horn of the thyroid cartilage.
6.
7.
8.
9.
10.
11.
References
1. Anderson JE. Grant’s Atlas of Anatomy.
Williams & Wilkins 1978; 7th edition.pp-965
2. StandringS.Gray’s
Anatomy.
Elsevier
th
Churchill Livingston; 39 edi.2005 pp-63435
3. Mansur Ahmad et al. Triticeous cartilage:
prevalence on panoramic radiographs and
12.
diagnostic criteria. Oral Surg Oral Med
pathol Oral radiol Endod. 2005;99:225-30.
Vanezis P. Pathology of neck injuries.
Butterworth. First edition. 1989 p-7
Dunsby AM, Davison AM. Causes of
laryngeal cartilage and hyoid bone
fractures at postmortem. Med Sci Law.
2011 Apr;51(2):109-13
Draven KP, Reay DT, Harruff RC. Artifactual
injuries of the larynx produced by
resuscitative intubation. Am J Forensic
Med Pathol. 1999 Mar ;20(1) 31-6
Knight B. Forensic pathology. Edward
Arnold 1991. 1st edition. pp340-345
Mason JK, Purdue BN. The pathology of
trauma. Arnold London.3rd edition.pp241247
Charoonnate N, Narongchai P, Vongvaivet
S. Fractures of hyoid and thyroid cartilages
in suicidal hanging. J Med Assoc Thai. 2010
Oct:93 (10)1211-6
Munir Turk L, Hogg DA. Age changes in
human laryngeal cartilage. Clinical
Anatomy. 1993: 6(3) 154-162
Maxeiner H. Healed fractures of the larynx
and lingual bone in forensic autopsy. Arch
Kriminol. 1999 May-June:203 (5-6): 175-83
Grossman JW. Triticeous cartilage. The
American Journal of Roentgenology &
Radiotheraphy. Vol L111 no 2 Feb1945. pp
166–170
4
Original article
Trends of suicides in Galle-Sri Lanka
Rathnaweera RHAI1
Department of Forensic Medicine, Faculty of Medicine, Karapitiya, Galle, Sri Lanka
*Corresponding author: Tel: 0094-772969060. E-mail address:[email protected]
MLJSL.Vol 2. No 2. Dec. pp 5-10
Abstract
Introduction
Suicide is considered as a complex event that has biological, psychological and social implications. For
many years now Sri Lanka has been among the countries where suicide and attempted suicide have
been frequent.
Objective
To document epidemiological and socio-economic data on suicides reported to the Teaching hospital,
Karapitiya in the year 2011 and to compare with the findings of previous studies done in other parts of
the country.
Materials and Methods
All suicidal deaths reported to Teaching hospital, Karapitiya from 1st of January 2011 to 31st of December
2011 were studied retrospectively.
Results
During the study period, 110 deaths due to suicide were documented and analyzed - 86 males (78%) and
24 females (22%). A significant proportion (22%) was in the 21-30 and (22%) in the 41-50 year age
groups. Sixty males (70%) were alcohol addicts. A suicidal note was found at the scene in 17% of cases.
The majority (85%) of the families had a monthly income of less than $100US. Commonest method used
by males was hanging (60%), and by female was plant poisoning (30%).The commonest reason for
suicide was debt (35%) and dispute with the spouse/marital disharmony (31%). Of the 12 adolescent
deaths 9 had been due to scolding by parents.
Conclusions
Majority were young married males belonging to lower socio-economic group. A significant number of
teenagers were found to commit suicide following minor disappointments. The method of choice for
suicide was hanging among males and plant poisoning among females. Among males, alcohol addiction
remains a major contributory factor for committing suicide.
Key words: Suicide methods, Hanging, plant poisoning, debt
5
Introduction
Suicide is considered as a complex event that
has biological, psychological and social
implications [1]. Historically, suicide has been
approached as a personal pathology or a sinful
act rather than as a social, structural or
genderized phenomenon [2]. The first
sociologist who systematically studied suicide as
a social occurrence was Durkheim (1951) who
claimed that suicide was a social problem rather
than an individual illness [3]. Durkheim’s
exclusive interest was why men killed
themselves. Ironically, women have the
“highest suicidal behavior” even though more
men die as a result of a suicidal act [4]. Since
Durkheim, although sociological research on
suicide has declined, most research continue to
focus on the behaviour of men.
The World Health organization (WHO)
estimates that every year, nearly one million
people kill themselves [5]. Suicide has become
one of the top 20 causes of death in the world
over for all ages [5]. For many years now Sri
Lanka has been among the countries where
suicide and attempted suicide have been
frequent frequent.
According to Sri Lanka Sumithrayo organization,
an organization set up to help prevent suicide in
Sri Lanka, the rate of suicide has reduced from
47/100,000 of the population in 1995 (highest
suicidal death rate in the world) to 20/100,000
in 2008 [6].
According to the literature, reasons offered to
explain the higher rate of suicide in Sri Lanka
include spouse/marital disharmony, financial
matters,
psychiatric
disorders,
alcohol
dependence, unemployment, broken love
affairs, and problems at work [1,2].
Objective
hospital, Karapitiya in the year 2011 and to
compare with the findings of previous studies
done in other parts of the country.
Materials and Methods
All deaths where a verdict of ‘suicide’ was
issued at the inquest following a post-mortem
examination at the Teaching hospital Karapitiya,
were retrospectively studied during the oneyear period from 1st of January 2011 to 31st of
December 2011. A pre-coded data collection
form was developed and ages, sex, marital and
occupational status, level of education, living
circumstances, and method and reasons for the
suicide were studied.
Results
During the study period, 110 deaths from
suicide were found. They were documented and
analyzed. The study included 86 men (78%) and
24 women (22%).
A significant percentage (22%) of those who
committed suicide were in the age groups of
21-30 and another 22% in the 41-50 year group.
Collectively 59% was in the 21–50 year age
group, indicating that most of the deaths from
suicide occurred among the young and middleaged population (Table 1).
Table 1: Age group of suicide victims
Age group (years)
00 – 10
11 – 20
21 – 30
31 – 40
41 – 50
51 – 60
61 – 70
71 – 80
No
00
12
24
17
24
16
11
06
%
00%
11%
22%
15%
22%
14%
10%
5%
The objective of this retrospective study was to
document epidemiological and socio-economic
data on suicides reported to the Teaching
6
As shown in Table 2, out of the eighty six
males, twenty two (28%) were single, and out of
twenty four females, thirteen (55%) were
single.
Table 2: Marital status of suicide victims
Marital status
Married
Single
Widowed
Living together
Unknown
Separated
Divorced
Total
Males
No.
58
22
00
00
00
00
6
86
%
67
28
00
00
00
00
5
Females
No.
10
13
00
00
00
00
1
24
%
40
55
00
00
00
00
5
Sixty males (70%) were alcohol addicts. A
suicidal note was found at the scene in 17% of
cases.
Occupational status of victims showed that not
a single professional had committed suicide in
this population (Table 3).
Table 3: Occupational status of victims
Occupation
Unemployed
Unskilled
Semiskilled
Skilled
Professional
Clerical and related work
Managerial and administration
No
39
30
20
18
00
03
00
%
35%
27%
18%
16%
00%
02%
00%
Of the study population, approximately 38%
were illiterate or barely literate, without any
formal training. The proportion of those who
had gone beyond high school was less than
20%. (Table 4).
Table 4: Level of education
Level of education
None
Year 01 – 05
Year 06 – 11
Year 12 – 13
Degree or higher
Not known
No.
09
33
22
22
13
11
%
08%
30%
20%
20%
12%
10%
The majority (85%) of the families had a
monthly income of less than $100US
Living circumstances showed that the majority,
(80 subjects - 73%), were living with the family
at the time of committing suicide (Table 5).
Table 5: Living circumstances of the victim
Living circumstances on day of
suicide
With family (including partner)
With others (e.g. friends)
Alone
Not known
Lodging/hostel
Other institution
No.
%
80
09
10
4
4
3
73%
8.5%
9.5%
3.5%
3.5%
2%
Eighty percent committed suicide at their
dwelling place. Sixteen percent of deaths due to
suicide were reported during the month of
April. About42% had been in contact with
medical personnel in the month before their
death.
Analysis of the method of suicide (Table 6)
showed that hanging was the commonest
method (n = 56; 51%).
Agrochemical
substances accounted for 37 (33%) of deaths.
Paraquat was the commonest pesticide used
(11%). Other common causes of death includes
plant poisoning (6%), “Prinso poisoning”( a
detergent
comprising
of
potassium
7
permanganate and oxalic acid) (4%) and
corrosive poisoning (3%).
Commonest method used was hanging in males
(60%), and plant poisoning in females (30%).
Table 6: Method of suicide
Hanging
Agrochemical
Corrosives
Plant poisoning
Prinso
Medicinal drugs
Total
Male
No
51
32
03
00
00
00
86
Female
%
60%
37%
3%
0%
0%
0%
05
05
00
07
05
02
24
21%
21%
0%
30%
21%
7%
According to the evidence given at the inquest,
the commonest reason for suicide was debts
(35%) followed by dispute with the spouse
(31%) (Table 7). Of the 12 adolescent deaths 9
had been due to scolding by parents. Past
history of psychiatric illness was present in 10%
and previous attempts of suicide was reported
in 7%.
Table 7: Reason given at the inquest for
committing suicide
Reason given
Financial matters
Dispute with spouse
Dispute with parents
Disputes in love affairs
Problems at work
Dispute with children
Alcohol dependence
Psychiatric disorders
No
39
33
16
09
4
4
3
2
%
35%
31%
15%
8%
3%
3%
3%
2%
Discussion
Suicidal behavior and, in particular, the
preferred suicide method varies between
countries [7]. Some patterns are well known,
such as the high percentage of firearm suicides
in the United States of America [8]. In addition,
the role of pesticide suicide in Asian countries
became apparent in the 1990s [7].
While numerous factors contribute to the
choice of a suicide method, societal patterns of
suicide can be understood from basic concepts
such as the social acceptability of the method
(i.e. culture and tradition) and its availability
(i.e. opportunity). International or intercultural
comparisons of suicide methods help increase
the understanding of the interplay between
these two factors and provide a basis for
preventive strategies.
In 2008, 3260 men (79%) and 860 women
(21%), (total 4120) committed suicide in Sri
Lanka and in 2009, 1609 men (77%) and 465
women (23%), (total 2074) committed suicide
[6]. The male-to-female ratio was around 5:1. In
the present study the male to female ratio was
around 3.5: 1 (male 78% and female 22%).
In our study the victims of suicide were mostly
young, married men who had interpersonal
problems with their families which they could
not handle. Similar observations were made in
previous studies done within Colombo city
limits in 2006[1] and in the Department of
Forensic Medicine, Galle in 2009[9]. However,
the male-to-female ratio shows that a
significant number of women too had
committed suicide.
A significant number of deaths were reported
(11%) from the age group of 11-20 years.
Similar findings were observed in other studies
as well [1,9]. Measures need to be taken to
address these teenage suicidal trends.
Most of the victims were of a low
socioeconomic status; 35% were unemployed
and 45% had been working as semiskilled or
unskilled workers. Not a single professional
committed suicide in this study. This indicates
8
that the pressures were commoner among the
lower socioeconomic class. Highest number of
suicides was reported during the month of April
(16%). This also could be due to the increased
expenditures during the festival season causing
more stress. Similar findings were observed
during the 2009 study at the Department of
Forensic Medicine, Galle [9].
Of the study population, approximately 38%
were illiterate or barely literate, without any
formal training. Two fifths had completed
primary school (20%) or high school education
(20%). The proportion of those who had studied
beyond high school was less than 20%. Similar
findings were observed during the 2009 study
at the Department of Forensic Medicine, Galle
[9].
In previous studies done at Colombo city limits
in 2006 [1] and in the Department of Forensic
Medicine, Galle in 2009[9], pesticide ingestion
was the commonest method of suicide among
both the males and females (42%). But in this
study, commonest method of suicide used by
males was found to be hanging (60%) and the
commonest method used by females was found
to be plant poisoning (30%).
From the time the first case of pesticide
poisoning was reported in Sri Lanka in 1962,
pesticide
poisoning
reached
epidemic
proportions in the 1990s[1]. Acute pesticide
poisoning is a major health problem and in
several agricultural districts it is the principal
cause of death in hospitals [10]. Reduction in
the number of suicidal deaths due to pesticide
ingestion is a very significant finding in this
study. In all the studies conducted in this regard
in the past in Sri Lanka, the commonest method
of suicide was found to be the pesticide
ingestion. This is the first time; a change has
been reported in this country. The reason for
this change needed to be studied further. The
possible reasons are improved management of
pesticide poisoning patients in the hospitals,
and the measures taken by the authorities to
ban some of the very toxic pesticides in Sri
Lanka.
Not a single case of self immolation had been
reported during this period. Newer methods
like “Prinso” poisoning was found to be popular
(20%) among the female victims.
Debt and marital disharmony was the main
reason for committing suicide (66%). Psychiatric
illnesses were responsible for only 2% of
suicides. Studies done in the past have shown
that only 20% had a psychiatric illness and the
rest were considered to have ‘impulsive
personalities’[11]. The finding in our study also
suggests that the majority of suicide attempts
were due to sudden impulse.
Sixty males (70%) were alcohol consumers and
this remains a major contributory factor for
committing suicide.
Conclusions
Majority were young married males belonging
to lower socio-economic group. A significant
number of teenagers were found to commit
suicide following minor disappointments.
Method of choice was hanging among males
and plant poisoning among females. A
significant reduction in suicides by pesticide
poisoning can be seen. It should be noted that a
new washing powder called ‘Prinso’ is being
used as a method of suicide popularly among
females. It was evident that both social and
personal causes had contributed. Majority had
been first timers. Among males, alcohol
addiction remains a major contributory factor
for committing suicide.
9
References
1.
2.
3.
4.
5.
6.
Fernando R, Hewagama M, Priyangika W,
Range SS, Karunaratne S. Study of suicides
reported to the Coroner in Colombo, Sri
Lanka. Med Sci Law 2010;50(1):25–28.
Isaacs S, Keogh S, Menard C, Hockin J.
Suicide in the Northwest Territories: a
descriptive review. Chronic Dis Can
1998;19(4):152-6.
A. Sev’er & R. Erkan. The dark faces of
poverty, patriarchal oppression, and social
change: Female suicides in Batman,
Turkey. Women
and
International
Development Journal. 2004. 282: 1-24.
Garro LC. Suicides by status Indians in
Manitoba. Arctic Med Res 1988;47 (Suppl
1):590-2.
Lesage AD, Boyer R, Grunberg F, Vanier C,
Morissette R, Ménard-Buteau C, et al.
Suicide and mental disorders: a case–
control study of young men. Am J Psychiatry
1994;151:1063-8.
Sri Lanka Sumithrayo:Statistics and data:
availableat
7.
8.
9.
10.
11.
http://srilankasumithrayo.org/statistics-adata; viewed on 21/01/2012.
Eddleston M, Sheriff MH, Hawton K.
Deliberate self harm in Sri Lanka: an
overlooked tragedy in the developing
world. British Medical Journal 1998; 317:
133-5.
Chan KP, Yip PS, Au J, Lee DT. Charcoalburning suicide in post-transition Hong
Kong. British Journal of Psychiatry 2005;
186: 67-73.
Vidanapathirana M,Rathnaweera R.H.A.I. A
study on deaths due to suicides, based on
cases reported to Teaching Hospital
Karapitiya from 2007 to 2009. The College
of Forensic pathologists of Sri Lanka –
annual academic sessions 2009.
Hettiarachchi J, Kodituwakku GCS, Chandras
iri N. Suicide in Southern Sri Lanka. Med Sci
Law 1988;28:248–51.
Senanayake N, Peiris H. Mortality due to
poisoning in a developing agricultural
country: trends over 20 years. Hum
ExpToxicol 1995;14:808–11.
10
Original article
Probability of death – a guesstimate or an estimate?
Recommendation for a more accurate prediction
Perera Jean1*, SenanayakeSMHMK2, Appuhamy P1, Hulathduwa S3
1
Department of Forensic Medicine, Faculty of Medicine, Colombo, 2 Institute of Legal
Medicine and Toxicology, Colombo, 3 Department of Forensic Medicine, Faculty of
Medical Sciences, Sri Jayawardenapura.
*Corresponding author: Tel – 0094-77-676-5983, e mail: [email protected]
MLJSL.Vol 2. No 2. Dec. pp 11-14
Abstract
Introduction
The estimation of the probability of death in an injured victim is a crucial duty of the judicial medical
officer in Sri Lanka. Several instruments can be used to approximately predict the probability of death/or
survival. To the authors’ knowledge, so far no instrument has been used or proposed to predict the
probability of death for medico-legal purposes in Sri Lanka. As such there is low inter - rater reliability
with possible confusion in a criminal trial. We propose that it is the need of the hour to use such
instruments in view of the current controversies around the concept “endangering life”. These
instruments can also be used to categorize injuries as “fatal in the ordinary course of nature” , which are
terminology used in criminal trials to categorise the severity of injuries following trauma in Sri Lanka.
Description
The simplest instrument, Abbreviated injury scale (AIS), an anatomical scoring system ranks each injury
individually from 01 to 06. Using the AIS, Injury severity score (ISS)which takes multiple injuries into
consideration is calculated which predicts the probability of death. The Revised trauma scale (RTS)is a
physiologic scoring system which has a high inter - rater reliability and demonstrated accuracy. The
Trauma score – Injury Severity Score (TRISS) determines the probability of survival of a patient with a
formula using both ISS and RTS.
Conclusion and recommendation
Four injury scales/scores would be described with outlines of their usefulness and limitations. The
predictive value of each code can be identified by performing multi centre studies to identify which code
was more accurate in predicting the probability of death for trauma victims. This would ensure uniform
expression of opinions regarding the percentage probability of death; an opinion crucial to express
whether an injury is endangering life or fatal in the ordinary course of nature.
Key words: endangering life, probability of death, injury severity score, estimate
11
Introduction
The estimation of the probability of death in an
injured victim is a crucial duty of the Judicial
Medical Officer (JMO) in Sri Lanka. After
examination of survivors of violence the JMO is
expected to categorise each injury for legal
purposes, depending on their severity and other
factors. The nature of the offence and the
severity of punishment for the accused in cases
of assault may depend on this categorisation. If
there is an existent threat to the life of the
patient, an injury is categorized as “endangering
life”. An injury is designated as “fatal in the
ordinary course of nature”, if it causes death in
the absence of prompt and proper medical
attention. According to section 294 of the Sri
Lanka Penal code “culpable homicide is murder
if it is done with the intention of causing bodily
injury to any person, and the bodily injury
intended to be inflicted is sufficient in the
ordinary course of nature to cause death”.
Thus the JMO has to give an opinion whether an
injury is “fatal in the ordinary course of nature”
or “endangering life” in the columns provided in
the medico – legal examination form.
These two opinions are expressed taking into
consideration the JMO’s knowledge, clinical and
medico – legal experience. It has been noted
that certain injuries categorized as ‘endangering
life’ by one JMO, may not be designated as
endangering life by another. As such there is
low inter - rater reliability with possible
confusion in a criminal trial where two experts
disagree on these technical issues. To the
authors’ knowledge as of now, no validated
instruments are being used nor proposed in Sri
Lanka to cateogorise these injuries, nor
consensus arrived regarding them. At times
these opinions could be a blend of guesswork
and an estimate - a guesstimate.
We propose that it is the need of the hour to
develop an instrument in view of the current
controversies especially around the concept
“endangering life”. These instruments can also
be used to categorise injuries as “fatal in the
ordinary course of nature” , “likely to cause
death”, and “unsurvivable” or “necessarily
fatal” – all legal
expertise. In this
scores that can
instrument will
examples.
concepts needing medical
paper the injury scales and
be used to develop an
be elaborated quoting
Description
In clinical practice the probability of death and
probability of survival are assessed in triage
especially in disaster situations using several
scores and scales. Triage is the process of
classifying patients according to injury severity
and determining the priority for further
treatment [1].These same scores and scales can
be used to quantitatively determine the
probability of death for medico legal purposes.
The purpose of this paper is to create
awareness regarding the scales and scores
available to objectively conclude the probability
of death.
Several instruments can be used to
approximately predict the probability of death
and/or survival. More than 50 experts all over
the world have got together to calculate the
probability of death in a given injury/injuries
and devised these instruments. These are
termed injury scales/scores.
The simplest instrument designed in 1969 by
over 75 experts all over the world and revised
six times after research using trauma victims is
the Abbreviated injury scale (AIS). This is an
anatomical scoring system and ranks each injury
individually from 01 to 06, 01 being minor, 02
moderate, 03 serious, 04 severe, 05 being
critical and 06 unsurvivable (Table 01).
Unsurvivable is a more appropriate medical
term for what is termed as ‘necessarily fatal’ in
legal parlance in Sri Lanka. AIS comprises of a
dictionary with a section for each anatomical
area such as the head. AIS is useful in
predicting the severity of each independent
injury and remains one of the most commonly
used injury coding systems [2].
12
Table 01.
01
02
03
04
05
06
patient and predicts the probability of death, is
calculated using the AIS using 06 main body
regions; head and neck, face, chest, abdomen,
extremities (including pelvis), external. The ISS
is the sum of the squares of the highest AIS
code in each of the three most severely injured
body regions. An example is given below.
Minor
Moderate
Serious
Severe
being critical
Unsurvivable
Abbreviated injury score – AIS
Body region
Abbreviated injury score
Examples of AIS and their corresponding
probability of death is given below.
Head and neck
4
Face
2
Thorax
5
Abdomen
1
Lower
limb(extremities)
Skin(external)
3
AIS(severity
score)
1
2
3
4
5
6
Example
superficial
laceration
fractured
sternum
open
fracture
humerus
perforated
trachea
ruptured liver
with tissue loss
total severance
of aorta
%probability
of death(POD)
0
1-2
8 - 10
1
50
50
100
The disadvantage of AIS when applied to
medico – legal practice is that at a given time
only a single injury is graded. In routine
practice, often injured victims have multiple
injuries and the injuries taken together will
determine whether or not death will supervene.
Therefore, a scale taking multiple injuries in to
consideration should be available. However, in
court trials into homicide and attempted
homicide, sometimes it is crucial to determine
whether a single injury has contributed to
death; especially when there are multiple
assailants and there is the need to determine
the probability of death of a single specific
injury. In such cases the AIS alone would be of
use.
Injury severity score
Injury severity score(ISS) [3] which considers
the overall injury burden sustained by the
The bold numerals represent the three most
severe injuries in a patient. The square of the
AIS of these three injuries are taken to calculate
the ISS. ISS = (5x5)+(4x4)+(3x3) = 50
The ISS range is 0 – 75 where a score of 75 is
unsurvivable. An AIS of 6 = ISS score of 75 or
unsurvivable. An ISS more than 15 has been
designated as a major trauma [4]. An ISS less
than 9 is a minor injury, between9 – 16
moderate, 16 – 25 serious, and over 25 severe.
The Revised trauma score (RTS)is a physiologic
scoring system based on the blood
pressure(BP), Glasgow coma scale(GCS) and the
respiratory rate(RR), and has a high inter - rater
reliability and demonstrated accuracy in
predicting death.
Furthermore current
revisions accommodate correction for low
income countries, thereby it can be applied to
Sri Lanka if studies are conducted to check its
validity to predict death. Although calculating
the score seems complex, simple computer
programs are available to help. The revised
trauma score ranges from 0 (dead) to 7.84
(normal). The formula for RTS = 0.9368 GCS +
13
0.7326 SBP + 0.2908 RR, thus it is heavily
weighted towards the Glasgow Coma Scale to
compensate for major head injury without
multisystem injury or major physiological
changes. The RTS (Table 02)is said to correlate
well with the probability of survival [5]. In fact
it has been suggested as a reliable indicator for
distinguishing life threatening injuries [6].
usage can be recommended through the
college. This will lead to uniformity in the
expression of opinions regarding the
percentage probability of death; an opinion
crucial to express whether an injury is
endangering life or fatal in the ordinary course
of nature.
References
1. ACS-COT: Resources for optimal care of the
injured patient: Chicago: American College
of Surgeons; 2006.available at
www.ncbi.nlm.nih.gov/pubmed/22237112
(Table 02)
The TRISS Calculator - Trauma - Injury Severity
Score
The Trauma score – Injury Severity Score (TRISS)
determines the probability of survival of a
patient with a formula using ISS and RTS and
patient's age [7].
Conclusion and recommendation
Four injury scales/scores which can be used in
order to ascertain the probability of death or
survival have been defined with outlines of their
usefulness and limitations.
The authors
recommend a multi centre research through
the College of Forensic Pathologists of Sri Lanka
to ascertain the most appropriate score or scale
for Sri Lanka. If the available scores are not valid
for the above purpose then an instrument could
be developed based on the above scores and a
consensus should be reached. Thereafter its
2. William C Wilson, Christophe M Grandy,
David B Hoyt,Trauma and critical care, First
edition 2007 Informa Healthcare USA p.
432.
3. Baker SP et al, The Injury Severity Score: a
method for describing patients with
multiple injuries and evaluating emergency
care, J Trauma, Vol.14,1974:187-196.
4. Lossius HM, Rehn M, Tjosevik KE, Eken T,
Calculating trauma triage precision: effects
of different definitions of major trauma.
Journal of Trauma Management &
Outcomes, 6:9
5. WWW.TRAUMA.ORG//archive/scores/rts.ht
ml
6. Boyd CR, Tolson MA, Copes WS, Evaluating
Trauma Care: The TRISS Method. J Trauma
Vol. 27, 1987:370-378.
7. Bilgin N.G., Mert E., ÇamdevirenH., The
usefulness of trauma scores in determining
the life threatening condition of trauma
victims for writing medical-legal reports,
Emerg Med J 2005; Vol.22 issue 11:783-787.
Contribution of authors
Design to the study – JP
Analysis of the data– JP, KS
Interpretation of the results- JP, KS
Writing the manuscript –JP, KS
Revising the manuscript- JP, KS, PA, SH
14
Original article
Sudden unexpected deaths of young adults in a tertiary care
hospital for a period of four years
Kitulwatte IDG*, Edirisinghe PAS,
1
Department of Forensic Medicine, Faculty of Medicine, Ragama,
*Corresponding author: Tel: 0094-71-961237. E-mail address: [email protected]
MLJSL. Vol 2. No 2. Dec. pp 15-21
Abstract
Introduction
Sudden unexpected natural death of a young adult is rare, but has a disproportionate impact on the
community. This always requires a systematic forensic autopsy. At the completion of the autopsy it is
expected to have the answers for all unanswered questions. However it is a challenge to the forensic
pathologist since there are many sudden deaths without significant morphological anomalies.
Objective:
The aim of the study was to identify the causes and characteristics of sudden death among the young
adults (less than 40 years of age)
Study Design:
Retrospective descriptive study was done based on the reports of post mortems performed on young
adults who had died suddenly and unexpectedly due to natural reasons during past 4 years. The
information was gathered on a pro-forma to fulfill the objectives. The data was analyzed using SPSS
statistical package version 18.
Results:
Out of 54 autopsies analyzed, 78 % were males. 39% of the victims were of the age group of 36 to 40
years. 33% of the victims were brought to hospital before death. In 76% of the cases, a cause of death
could be identified after macroscopic autopsy examination and the percentage increased to 89% after
microscopy. Microscopy revealed or confirmed the cause of death in 52% of the cases. 44% were
victims of sudden cardiac death. Cause of death was unascertained at the end of all the investigations in
11% of the cases.
Conclusion:
Cause of death has a cardiac origin in majority of sudden unexpected deaths in young adults in the
sample examined. Macroscopic autopsy examination could identify a cause of death in majority while
abnormalities identified at microscopic examination accounted for death in nearly half of the sudden
unnatural deaths in young adults.
Key words: sudden natural death, young, autopsy, microscopy, cardiac, unascertained
15
Introduction
From a forensic point of view, a sudden death is
defined as a rapid, natural and unexpected
death [1]. Sudden unexpected natural death of
a young is rare, but has a disproportionate
impact on the community. The incidence of
sudden natural deaths among the 1-40 year age
group, is reported as 1.3 to 8.5 per 100 000
person years [2,3] while the incidence of
sudden death in the general population is
reported as 1 in 1000 individuals[4]. Sudden
death of a young adult is a tragedy to the family
and always requires systematic forensic autopsy
performed by a pathologist. It is expected to
have the answers for all unanswered questions
at the completion of the autopsy. Historical
evidence obtained from the witnesses and the
family members of the deceased is crucial for
this investigation. Recent symptoms prior to
death and past medical history and the family
history must be probed. Notes of resuscitation
and the hospital records are also useful.
Recent autopsy studies have revealed coronary
artery disease as the major cause of death in
people aged more than 35 years while
cardiomyopathies are commonly seen in
younger age groups (less than 35 years of age).
Arrhythmogenic
right
ventricular
cardiomyopathy is an increasingly recognized
type of cardiomyopathy causing sudden deaths
in young adults [5]. Diagnosis of these
cardiomyopathies at the autopsy plays an
important role to counsel and screen the first
degree relatives.
However, since all sudden deaths are not
thoroughly autopsied, extracardiac causes are
not well estimated [5].There are many cases of
sudden
deaths
without
significant
morphological anomalies. Thus, a significant
number of sudden deaths remain as autopsy
negative sudden unexplained deaths even after
a through autopsy. Presently due to the
advancement of molecular biology, many such
autopsy negative sudden unexplained deaths
have ended up with a pathogenic basis
worldwide [6]. An accurate diagnosis through a
molecular autopsy, directs initiation of
preventive strategies among the relatives.
However, the molecular studies are still new
and not available to the forensic community of
Sri Lanka due to its high cost.
Objective:
The aim of the study was to identify the
presentation, causes, and characteristics of
sudden death among the young (less than 40
years of age) with a view to have an insight into
the causation in our community and to make
suggestions to improve the standards in our
investigation process.
Method:
Retrospective descriptive study was performed
based on the recorded historical evidence and
the reports of the post mortems done on young
adults who had died suddenly and unexpectedly
due to natural reasons during past 4 years. The
information was gathered on a pro-forma to
fulfill the objectives. The data was analyzed
using SPSS statistical package.
Results:
Out of the 54 autopsy cases studied, 42 (78%)
were males and 12 (22%) were females. 21
(39%) were of the age group of 36 to 40 while
there were 11 (20%) each for the age groups of
21-25 and 31-35. (Table:1)
Table 1: Age distribution of the group
Age group
Frequency
<20 yrs
20-25 yrs
26-30 yrs
31-35 yrs
36-40 yrs
Total
5
11
6
11
21
54
Percentage
(%)
9
20
11
20
39
100%
Most deaths (43%; n=9 out of 21) in the age
group of 36 to 40 were due to ischaemic heart
disease and majority of deaths (50%; 9 out of
18) due to ischaemic heart disease are also
16
coming under this age group.18 (33%) of the
group were hard working manual labourers
while there were 12 (22%) office workers.
(Table: 2)
to death. 14 (26%) had a witnessed collapse
while 12 (22%) died at sleep.(Table: 4)
Table 2: Occupation of the victims
Death occurred
Died at sleep
Witnessed collapse
Brought to hospital
Died on the way to
hospital
Died at work
Other
Total
Occupation
Manual labourer
Office worker
Student
Other
Total
Frequency
18
12
5
19
54
Percent (%)
34
22
9.
35
100
29(54%) were smokers. Ethanol abuse was
observed among 29 (54%).
40 (74%) had some form of ill health prior to
death. Out of these 40, 15 (28%) were suffering
from some illness for less than 1 day. 13 (24%)
had some form of ill health for 2 days to 1
week. There were 14 (26%) with no complaints
of any ill health. However 13 (24%) out of them
had a diagnosed chronic condition for
years.(Table: 3)
Table 3: Duration of ill health
Duration of ill
health
<1day
1day
2days-1wk
1 wk-2wk
>2wk
Diagnosed for years
but no recent ill
health
None
Total
Frequency
Percent (%)
15
2
13
5
5
13
28
4
24
9
9
24
1
54
2
100
Chest pain was observed by the next of kin in 8
(15%) of the victims while14 (26%) had
shortness of breath.
Symptoms were
nonspecific in 15 (28%).
24 (44%) had consulted a doctor for the ill
health.18 (33%) were brought to hospital prior
Table 4: Presentation
Frequency
12
14
18
2
Percent
22
26
33
4
1
7
54
2
13
100.0
At the end of the gross examination a cause of
death was found in 41 (76%) of the cases while
at completion of the microscopic examination
the cause of death could be identified in 48
(89%).
Macroscopic or gross autopsy
examination revealed cardiac findings in 27
(50%) while 9 (17%) had nonspecific findings
and 8 (15%) had none. (Table: 5)
Table 5: Autopsy findings –macroscopy
Macroscopic findings at
autopsy
Cardiac
Other
Nonspecific
None
Frequency
27
10
9
8
Percent
(%)
50
18
17
15
Microscopy had been done in 34 (63%) of the
cases and 6 (11%) had no significant
microscopic findings. The cause of death was
revealed or confirmed by microscopy in 28
(52%) cases. Microscopic examination revealed
3 cases of myocarditis and 4 cases of recent
myocardial infarction where gross examination
revealed nonspecific or negative findings. Thus,
following microscopy, positive cardiac findings
further increased and a total of 34 (63%) were
observed to have cardiac findings at the end.
Cardiac
findings
observed
either
macroscopically and microscopically were
coronary artery disease in 17(31%) cases with
associated thrombosis in 6 of them. A recent
17
myocardial infarction was observed in 5 cases
(9%).
Myocardial fibrosis with no recent
infarction was noted in 6(11%) cases and 3(6%)
had isolated myocardial hypertrophy while
there were 8 others with myocardial
hypertrophy associated with other cardiac
findings.
Cardiac causes accounted for deaths in 22 (41%)
cases while 6(11%) had negative autopsy after
toxicological and microscopic studies.(Table:6)
Table 6: Cause of death
Cause of death
Frequency
Sudden cardiac death
Non cardiac
Unascertained
Total
22
26
6
54
Percent
(%)
41
48
11
100
Discussion:
The etiologies of sudden death of young vary
among studies [7-10]. Unexplained case of
sudden natural death of a young individual has
a great impact on the living relatives. With the
advancement of science, new methods to
screen for risk factors of sudden adult deaths
are available [11]. However, without a proper
understanding into the etiologies in our own
community, population screening methods
cannot be planned. Inadequate or inconsistent
investigation of young sudden deaths, results in
failure to identify potentially fatal, yet treatable
familial disease. A detailed investigation of
sudden death in the young can reveal
hereditary cardiac disease in more than 40% of
the cases [12, 13]. Systematic forensic autopsy
and autopsy based studies are extremely
important for this purpose.
Study revealed that 78% of the victims of
sudden natural death are males. The mortality
rate for sudden cardiac death per 100,000
person-years was observed as 6.7 for males and
1.4 for females in an autopsy-based series of a
population undergoing active surveillance
[14].Most of the sudden deaths due to
ischaemic heart disease belonged to the age
group of 36 to 40.
A similar picture was
observed in a study done in India where
majority were towards the upper limit of the
age group [15]. Majority of deaths due to
ischaemic heart disease are coming under this
age group. Puranik R. et al found in their study,
more than two thirds of deaths caused by acute
myocardial infarction occurred in the age group
from 30-35 years [16]. 33% of the group were
hard working manual labourers. Exertion acts
as
a
trigger
for
lethal
ventricular
tachyarrhythmias, especially when there is
underlying cardiac disease [17-19]. Literature
reveals that the reported cases of sudden
deaths among the young athletes are on the
rise [20]. More than half of the victims were
reported smokers and also there were more
than half with a history of ethanol abuse.
Cigarette smoking is a known risk factor for
sudden cardiac death. Similarly, heavy alcohol
consumption is associated with an increased
risk of sudden cardiac death [21, 22].
74% of the group reported to have some form
of ill health prior to death. Mostly the
symptoms were nonspecific and of a short
duration. However in a study on prodromal
symptoms only 18% had symptoms prior to
death [23]. The recorded prodromal symptoms
in this group are based on statements made by
the relatives who at this desperate moment, try
to relate their loved one’s death to some form
of illness. However chest pain and shortness of
breath were observed in 41%. Further, 44% had
consulted a physician for their ill health prior to
death which has to be considered important.
33% was brought to hospital prior to death
while 26% had a witnessed collapse.22% of the
deaths had occurred while at sleep. DeVreede
Swagemakers JJM had reported that 40% of
sudden deaths can be un-witnessed[24].
Macroscopic examination revealed positive
findings in 85% with 50% cardiac findings.
Positive cardiac findings further increased up to
63%at the end of the microscopic examination,
where 3 cases of myocarditis and 4 cases of
recent myocardial infarctions were added to the
group. Furthermore, microscopy revealed or
confirmed the cause of death in 52% of the
18
cases. The cause of death was revealed only
after microscopy in 13%. At the end of the
external and internal examination a cause of
death was found in 76% while it increased to
89% at the end of the microscopy. Coronary
artery disease was observed in 31% cases and a
recent myocardial infarction was observed in
9%. Myocardial fibrosis with no recent
infarction was noted in 11%. Myocarditis was
diagnosed 6%. Atherosclerotic coronary artery
disease accounts for the large majority of cases
of sudden natural deaths in older people (over
40 years of age)[1]. The most frequent
structural cardiac diseases in the young
population reported are premature coronary
artery disease, myocarditis, left ventricular
hypertrophy and hypertrophic cardiomyopathy
respectively[25,26].
Although, there were 63% cardiac findings there
were only 41% cases of sudden cardiac death
while there were 48% deaths due to non
cardiac causes. This is due to presence of other
morphological abnormality accounting for
death in a person with a cardiac pathology.
However, the main cause responsible for the
sudden natural deaths was cardiac pathology.
This highlights the importance of methodical
autopsy with microscopy in all sudden natural
deaths of young. However, this study revealed
that microscopy had been done only in 63% of
the cases in this group which needs further
attention. This can prevent detection of cardiac
causes of death which is extremely important in
planning the screening process of the family
members.
11% had no morphological cause of death.
Autopsy of sudden unexpected death is
sometimes inconclusive even after microscopy
and molecular biology may have played a
crucial role in coming to a conclusion [27].
Thus, it is high time for us to pay attention to
molecular autopsy. This will reduce the number
of cases ending up as “cause of death
unascertained”.
Conclusions:
Predominantly male victims of 36-40 years are
the risk group for sudden natural deaths.
Cardiac causes account for majority of sudden
natural deaths of young adults with coronary
artery disease placed first. Systematic forensic
autopsy with proper ancillary testing is essential
in sudden natural deaths of young. There is a
significant proportion of cases with an
unascertained cause of death highlighting the
importance of further studies.
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Journal 2012;125(20):3619-3623
de VreedeSwagemakers JJM, Gorgels APM,
Dubois-Arbouw WI, van Ree JW, Daemen
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MJAP, Houben LGE, Wellens HJJ. Out-ofhospital cardiac arrest in the 1990’s: a
population-based study in the Maastricht
area on incidence, characteristics and
survival. J Am CollCardiol. 1997; 30:1500 –
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25. Wren C, O’Sullivan JJ, Wright C. Sudden
death in children and adolescents. Heart.
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26. Morris VB, Keelan T, Leen E, Keating J,
Magee H, O’Neill JO, Galvin J. Sudden
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doi:
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Contribution of authors
Design to the study - IDGK, PASE,
Analysis of the data- IDGK
Interpretation of the results- IDGK
Writing the manuscript -IDGK
Revising the manuscript-IDGK, PASE
21
Original article
Practices and attitudes of specialists in Forensic Medicine in the
management of general health care needs of victims of sexual
violence
Perera J1*, Arambepola C2, Wijeratne P1
1
Department of Forensic Medicine and Toxicology, 2Department of Community Medicine,
Faculty of Medicine, University of Colombo, Sri Lanka
*Corresponding author: Tel – 0094-77-676-5983, e mail: [email protected]
MLJSL.Vol 2. No 2. Dec. pp 22-29
Abstract
Introduction
The emphasis of sexual assault forensic management (SAFM) in Sri Lanka has been mainly pertaining to
collection of forensic evidence and as a referral point to other specialist services.
Objectives
To describe the practice and attitudes of Specialists in Forensic Medicine (SpFM) regarding the
management of general health care needs in victims of sexual violence as part of sexual assault forensic
management (SAFM) with a view to providing a victim friendly management.
Methods
A cross-sectional study was conducted to include all practicing (SpFM) in Sri Lanka. Victim centred
practices as well as attitudes underlying their practice were assessed using a self-administered
questionnaire.
Results
The response rate was 52.08% (n=25). 92% of the SpFM were males and had a mean age of 45.48years
(SD=5.561). Many (48%) felt that only those who appeared to be psychologically disturbed need to be
referred to a counselor. The majority (72%) never provided and 32% never prescribed emergency
contraceptive pills (ECP) to victims. Most of them strongly disagreed that giving emergency
contraception or reviewing the victim introduced victim bias.
Conclusions
Despite positive attitudes towards victim-friendly management, health care needs like pregnancy
prevention and relieving psychological distress were not addressed adequately. Fear of being accused of
victim bias was not a significant factor for not taking adequate steps. It could be due to inadequate
awareness regarding new developments in victim friendly management and hesitancy to change existing
practice during SAFM.
Key words: Sexual assault forensic examination, victim-friendly management, emergency contraception,
attitudes, victim bias, health care needs
22
Introduction
Sexual assault is an aggressive act motivated by
power and control [1]. It has both long term and
short term physical and psychological effects on
the health and wellbeing of a victim. Thus,
during sexual assault medical forensic
management (SAFM), the health and welfare of
patients become the foremost priority [1] that
goes well beyond proving the case in a court of
law [2]. As such, in addition to providing
evidence for legal proceedings, forensic medical
practitioners have a crucial responsibility to
ensure that the health care needs of victims of
sexual violence are addressed adequately in
their clinical practice.
The “victim-friendly approach or management”
advocated in many SAFM protocols recognizes
that “every sexually assaulted victim deserves
timely,
compassionate,
respectful
and
appropriate care”[3]. In many centres in the
developed countries appropriate care in SAFM
includes the treatment of injuries, prevention of
unwanted pregnancies, prevention and
treatment of sexually transmitted infections
(STI), and the provision of psycho-social support
and adequate rehabilitation programs [3,4] in
addition to the collection of forensic evidence.
In these countries, victims are often referred to
emergency medical units where all these
services are available under one roof. However
at times, lapses on addressing health care needs
of these victims are reported from these
countries as well. A survey done on emergency
departments in Pennsylvania, USA revealed that
16% of the hospitals do not offer any
emergency contraception nor counseling [5]
while in USA on the whole, 42% of non-Catholic
and 55% Catholic hospitals neither dispense ECP
nor provide a valid referral for ECP [6], thus
causing lost therapeutic opportunities.
In Sri Lanka, the legal procedure when a victim
lodges a police complaint regarding sexual
violence is to subject her to medico–legal
examination. Quite commonly, the first contact
health care personnel for such examinations
would be the Specialist in Forensic Medicine
(SpFM).
In the absence of guidelines on providing
victim-friendly SAFM, the SpFM are in the
practice of engaging exclusively in the medicolegal aspect of care and referring the victims to
relevant specialists for management of their
general health care needs. However, there is no
systematic approach to verify whether in fact all
referred victims would access these clinical
services.
Clinical guidelines ensure the provision of
minimum care with acceptable standards and
are proven to be effective universally [1,3,7,8].
However, when developing guidelines for
providing victim-friendly SAFM, they should be
pragmatic, based on the challenges faced by
SpFM in addressing the general healthcare
needs of victims as well as their own attitudes
that may influence their practice. Authors
particularly intended to find out whether fear of
being accused of victim bias had affected the
decision to look after the general health care
needs. Therefore, in the absence of such
evidence in Sri Lanka, we conducted a study
that aimed at describing the practices and
attitudes of SpFM in the management of
general health care needs of victims of sexual
violence.
Methodology
A descriptive cross-sectional study was
conducted among all clinicians who were Board
certified by the Postgraduate Institute of
Medicine (PGIM) as Specialists in Forensic
23
Medicine in Sri Lanka. Those who did not have
more than six months experience as specialists
and those who were not in active practice were
excluded from the sample. Data on the
attitudes and practices of SpFM with regards to
psychological counseling, pregnancy and STI
prevention, and review of victims was collected
using a self-administered questionnaire
prepared in English language. Guidelines for
medico – legal care of victims of sexual violence
by the World Health Organisation (WHO)1 were
perused for developing the questionnaire.
A five-point Likert scale (‘strongly agree’,
‘agree’, ‘neutral’, ‘agree’, ‘strongly disagree’)
was used as responses to the questions on
attitudes.
They were requested to return the
questionnaire within six weeks. Those who did
not return the questionnaire at the end of six
weeks were taken as not consenting to the
study and thus taken as non-respondents.
Ethics clearance for the study was obtained
from the Ethics review committee of the Faculty
of Medicine, University of Colombo. SPSS
statistical software was used for data analysis.
Categorical data were described in proportions
and quantitative data in mean and standard
deviation (SD).
Results
Out of 48 SpFM Board certified by the PGIM,
University of Colombo as at September 2012,
25 returned the completed questionnaires
(response rate =52.08%).92% of the participants
were males and of the average age
of45.48years (SD=5.561). All except one (96%)
had examined more than 80 victims of sexual
assault during their entire practice while the
majority (57%) had performed the last SAFM
within the last week.
The level of victim friendly management during
communication with the victim was assessed.
The key phrases used were “speaking to victims
in a nonjudgmental manner” , “encouraging the
victim during history taking by appropriate body
language”, and using appropriate words like”
hmm”, “go on” with a scale ranging from
‘always to never done’.
The questionnaire with an enclosed selfaddressed envelope and an information sheet
about the objectives of this study were posted
to all SpFM in the specialist register maintained
at the PGIM.
Most of the SpFM practiced speaking to a victim
in a non-judgmental manner always or most of
the
time
(84%).
(See
Table
1.)
Table 1: Results concerning, following the formal routine in Communicating with victims (n = 25)
(%- Number of respondents as a percentage)
Form of routine
Speaking to a victim in a nonjudgmental manner
Using appropriate gestures or non
verbal communication skills
Using appropriate words
Number of respondents
Always
Most of the
Time
figure %
Figure
%
Sometimes
Never
figure
%
figure
%
13
52%
08
32%
01
4%
01
4%
10
40%
07
28%
03
12%
05
20%
10
40%
08
32%
02
8%
05
20%
24
Only 10 (40%) always used appropriate
gestures. Two (8%) used appropriate words only
sometimes and 20% never did so. Out of the
five who never used appropriate gestures or
words reasons were given by three. One
comment was “not aware of the importance of
it’, another, “gestures are not always reliable”
and the other one “it is an inappropriate
practice in medico-legal setting”.
A statement was included in the questionnaire
“Giving emergency contraception denotes
partiality towards victims”. Most of the
participants (80%) strongly disagreed with this
statement. Furthermore, taking action to
prevent pregnancy was considered as being
‘extremely important’ by 96% of responders.
During SAFM, 80% explained the risk of getting
pregnant to victims ‘always’ or ‘most of the
time’.
However, a significant number (72%) never
provided emergency contraception to the
victims and 32% never prescribed emergency
contraceptive pills (ECP)(Table 02) One reason
for not prescribing ECP was due to the referral
made to a Gynecologist ‘sometimes’ (60%) or
‘most of the time’ (20%).
Reviewing the victim for late psychological
complications was not a regular event, with
32% never reviewing and 16% rarely doing so
(Table 02). Likewise, review for assessment of
healing was not common, with 16(64%)
reviewing rarely or never. 72% considered that
‘review of the victim was not extremely
important. However, 68% ‘disagreed’ or
‘strongly disagreed’ that reviewing the victim
indicates victim bias.
Table 2: Prevention of pregnancy, referral for counseling and Post-examination reviews (n = 25)
(%- Number of respondents as a percentage)
Number of respondents
Always
Figure
%
Most of the
Time
figure %
09
(36%)
06
(24%)
04
(16%)
01
(4%)
05
20%
02
(08%)
04
(16%)
09
(36%)
02
(8%)
08
32%
01
4%
04
16%
08
32%
04
16%
08
32%
01
04%
03
12%
05
20%
07
28%
09
36%
Form of routine
Referral
psychological
counseling
Prescribing ECP
Review
for
psychological
complications
Review
assessment
healing
Sometimes
Rarely
Never
figure
%
figure
%
figure
%
for
late
for
of
25
Only 60% referred the victim ‘most of the time’
or ‘always’ to a counselor. 48% either agreed or
strongly agreed with the statement “only those
who appear to have psychological disturbances
should be counseled” (Chart 01).
Information regarding risk of getting STI was
given always or most of the time by 76% of
respondents. STI prophylaxis (Table 03) was
never prescribed by 23(92%); lack of knowledge
regarding STI prophylaxis being the reason
given by 01 SpFM for not prescribing. Others
gave the reason as referral to STI clinic. STI
prophylaxis was provided sometimes by 01(4%),
most of the time by 01(4%) and never provided
by the remaining 23(92%).
stronly
disagreed
disagreed
6, 24%
7, 28%
agreed
5, 20%
Unavailability of drugs for STI prophylaxis was
given as the reason for not prescribing by 04
(16%). Obtaining necessary samples for STI
testing was never done by 21(84%), sometimes
by 02(08%) and most of the time by 02(08%).
However, all 25(100%) referred them to the STI
clinic always or most of the time. 20(80%)
strongly agreed that it is their duty to prevent
STI in sexual assault victims while 03(12%)
agreed with the view, but 02(8%) strongly
disagreed.
neutral
5, 20%
stronly agreed
2, 8%
Chart 01.Response to the statement
“Only those who appear to have
psychological disturbances should be
counseled”
Table 03: Action taken to prevent STI (n = 25)(%- Number of respondents as a percentage)
Number of respondents
Form of routine
Giving Information
regarding risk of
getting STI
Prescribing
STI
prophylaxis
Referral to STI clinic
Always
Figure
%
Most of the Time
figure
%
Sometimes
figure
%
Rarely
figure
08
(32%)
11
(44%)
01
(04%)
-
-
01
04%
01
13
52%
12
48%
-
Discussion
The SpFM is in many instances the first contact
health care professional for the sexual violence
victim in Sri Lanka. Therefore, it is in the
interest of the victim if SpFM addresses the
%
Never
figure
%
04
(16%)
01
04%
04%
-
-
23
92%
-
-
-
-
-
general health care needs of the victim
whenever possible or devise a mechanism to
ensure they are addressed.
According to our study, SpFM seemed to have
positive attitudes regarding prevention of
26
pregnancy (96%), with only one participant (4%)
dissenting, which indicates that they are much
concerned about the welfare of the victim.
Despite these positive attitudes, they preferred
to entrust this responsibility to a Gynaecologist
routinely even though there was no way of
verifying whether they in fact obtained
emergency contraception when indicated. Such
dependence on the gynaecologist to prescribe
or administer ECP can lead to secondary
victimization due to long waits; consequent
failure to comply can cause an unwanted
pregnancy. This practice is unlikely to be due to
the attitude that providing ECP indicates victim
bias or partiality as 80% strongly disagreed with
that view.
The role of therapy or psychological counseling
for recovery from sexual violence is well
established [1,7,8]. However, only 60% referred
victims to a mental health professional or
counselor most of the time or always. This may
be in connection with the decision of 48% of the
participants to refer only those victims who
appear to be psychologically disturbed for
counseling. This attitude appears risky as
psychological effects of trauma may be more
difficult to recognize [7] than physical effects
especially to the doctor who has only a basic
knowledge in psychiatry. When severely
traumatized, victims can appear to be calm,
indifferent, submissive, jocular, etc. [3], thus
masking the real emotional disturbance.
Furthermore, the late occurrence of mental
health effects of sexual violence are well
documented [7].
Reviewing the victim regularly is recommended
in the WHO guidelines [1] and in many other
protocols [7,8]. This is necessary for follow-up
action for pregnancy and STI, to ascertain
evidence of healing of injuries that could have
medico–legal significance, to assess the
emotional or mental status [1] and also for
further relevant referral. However, according to
our study, 32% never reviewed the victim for
psychological complications and 36% never
reviewed for evidence of healing (Table 02).
This practice reflects the attitude of the
majority (72%) that review is not extremely
important. However, it can be concluded from
this study that reluctance to review the victim
was not directly connected with their fear of
being accused of victimbiasas68% of SpFM
either disagreed or strongly disagreed with that
view. It could probably be due to lack of
awareness regarding the benefits and the global
stand regarding review. However, 20% have
deviated from the traditional practice and have
been conducting a review for psychological
effects most of the time or always.
The role of a SpFM is to conduct the SAFM in a
manner that initiates fast healing of the victim
physically as well as mentally9. The fact that
84% treated the victims in a nonjudgmental
manner, with 68 % routinely using appropriate
gestures - nonverbal communication and a
significant percentage(72%) often using
appropriate words indicate that SpFM have
endeavoured to create a victim friendly
environment in SAFM. Using words like “please
go on” and appropriate gestures such as
nodding the head make victims comfortable
and encourage them to reveal the complete
story. However, 32% of the SpFM stated that
they did not routinely use such gestures and
05(20%) stated that they never used them.
Judging from the comments, one reason for not
using effective communication skills could be
the traditional stand that medico-legal
professionals have to appear impassive and
without expression in order to appear impartial.
On the contrary, an ideal SpFM should be
27
sensitive to the victim’s physical and
psychological
trauma
while
avoiding
partisanship [4] and being impartial [1].
Another reason is the inadequate training in
nonverbal communication skills as commented
by one or even lack of awareness for its
necessity in SAFM [9].
Conforming with standard traditional practice
for SpFM in Sri Lanka 92% never prescribed or
provided STI prophylaxis but all took necessary
action by referring them to the STI clinic either
always or most of the time which is satisfactory.
But it is interesting to note that 02 have broken
away from the traditional practice and have
been either prescribing or providing STI
prophylaxis as advocated in many protocols.
Limitations of the study
The response rate was only 52.08%, which was
relatively satisfactory for a postal questionnaire.
Conclusions
In keeping with the current global thinking, the
majority of SpFM possessed the attitude that
attending to general health care needs such as
prevention of pregnancy and STI, provision of
counseling and victim friendly communication
was important. However, many did not take
adequate steps to apply it to practice except in
the case of victim friendly communication. Fear
of being accused of victim bias was not a
significant factor for not taking adequate steps.
One possibility is inadequate awareness of new
global developments in SAFM. Another
possibility is their attitude of not taking a
different view from traditional practices,
thereby being hesitant to change while
confining themselves exclusively to taking care
of only forensic management during SAFM.
Recommendations
Specialization courses in Forensic Medicine
should include a mental health module and
input in effective communication skills.
Attitudes of SpFM described above should be
taken into consideration when developing
guidelines for the management of general
health care needs of victims. Awareness
programmes should be conducted for SpFM on
the global changes regarding SAFM. Such
programmes could contribute towards an
attitudinal change towards victim-friendly
SAFM.
References:
1. Guidelines for medico – legal care of victims
of sexual violence. Geneva, World Health
Organization, 2003.
2. Nadesan K (2001)Rape: An Asian
perspective. Journal of clinical forensic
medicine, 8: 93 – 98.
3. U. S. Department of Justice. A national
protocol for sexual assault medical forensic
examinations (adults/adolescents), U.S.
Department of Justice, Office of Violence
Against Women; 2004.
4. Cunningham N (2012) Sexual assault
consultations: From high risk to high
reliability. Journal of Forensic and Legal
Medicine.19:pg 53 – 59
5. Harrison T. (2005) Availability of emergency
contraception: a survey of hospital
emergency department staff. Annals of
Emergency Medicine, 46(2):105-110
6. Patel A, Simons R, Piotrowski ZH, Shulman L,
Petraitis C. (2004)Under-use of emergency
contraception for victims of sexual assault.
International Journal of Fertility and Women's
Medicine, 49(6):269-273.
7. Harris L, Freccero J, Sexual violence: medical
and psychosocial support, Sexual violence
and accountability project, Human Rights
centre University of California, May 2011.
28
8. Clinical management of rape survivors:
Developing protocols for use with refugees
and internally displaced persons, InterAgency Lessons Learned Conference:
Prevention and Response to Sexual and
Gender-Based
Violence
in
Refugee
Situations,
2001,
World
Health
Organisation, Geneva, Switzerland pg 25 28.
9. Perera JM, De Zoysa P. The need for
effective communication skills in the
medico-legal management of child sexual
assault victims: observations from the Sri
Lankan context. Sri Lanka Journal of forensic
medicine science and law 2012;3(1) 16 – 19.
Acknowledgements
All specialists in Forensic Medicine who
participated in the study, Dr. Subhani
Poornima for assisting in data analysis,
and formatting the paper.
CONTRIBUTION OF AUTHORS
Design and Supervision of the study - JP, CA
Data collection – JP, PW
Analysis of data – CA, JP, PW
Interpretation of results – JP, CA
Writing the manuscript – JP, CA, PW
Revising the manuscript –CA, JP
29
Case report
An unusual case of mediastinal malignant melanoma with a cardiac
metastasis
Lakmali MGN, Mudduwa L, Fernando LBM, Mahinda HA
Institute of Legal Medicine and Toxicology, Colombo
*Corresponding author: Tel: 0094-718208938. E-mail address: [email protected]
MLJSL. Vol2. No2. Dec. pp30- 34
Abstract:
Introduction
Mediastinal tumours are often seen in patients aged 30–50 years. Most of them are neurogenic tumours
and thymomas. Others include lymphomas, phaeochromocytomas, melanomas, germ cell tumours and
thyroid and parathyroid lesions. Although primary cardiac tumours are rare, metastasis in the heart is
commoner than primary cardiac tumours.
Case report
A 41 year old woman was admitted to the Teaching Hospital, Karapitiya with a recent onset progressive
dyspnoea. She was found to have a rapidly filling pericardial effusion. She died on the third day of
admission. A whitish mass infiltrating the full thickness of the right atrial myocardium was found at the
autopsy. A similar tumour was present in the anterior mediastinum measuring 7x3cm. There was no
direct connection between the two tumours. H&E stained sections revealed a similar microscopic
appearance in both mediastinal and cardiac masses. The differential diagnosis included lymphoma,
melanoma, carcinoma and germ cell tumors. Immunohistochemical staining for LCA, pan cytokeratin,
S100 and PLAP were done and only S100 was positive.
Conclusion
Negative staining for LCA, pan cytokeratin and PLAP excluded the possibility of lymphoma, carcinoma
and germ cell tumours. Positive staining for S100 confirmed the diagnosis of melanoma. This was
diagnosed as a rare case of primary mediastinal malignant melanoma with a right atrial metastasis
causing pericardial effusion.
Key words: mediastinal tumours, melanoma, metastasis, heart
30
Introduction:
Malignancies are found rarely in the
mediastinum. Only 3% of mediastinal
tumours are primary tumours [1]. Out of
them 25-49% are malignant. Primary
mediastinal malignancies comprise 55%
lymphomas, 16% germ cell tumours, 14%
thymomas, 5% sarcomas, 3% neurogenic
tumours and 7% other rare tumours [2].
Malignant melanoma belongs to this rare
category. Patients with mediastinal tumours
often present with cough, dyspnoea, chest
pain and fever. Investigations helpful in
diagnosis are chest X-ray, computed
tomography, MRI chest and mediastinoscopy
with biopsy. Treatment for these tumours
include radiation, chemotherapy and surgical
excision [1]. The prognosis of primary
mediastinal malignant melanoma has not
being described probably due to the rare
occurrence of the disease [3]. The five year
survival of malignant melanoma of the skin is
extremely poor; one will therefore not expect
that of the mediastinum to be any better [4].
At autopsy the pericardium contained 100cc
of straw coloured fluid. Heart was enlarged
and measured 370g. There was a mass
involving the full thickness of the anterior
wall of the right atrium and measured
7×7×1.5cm in size (Figure 01). The cut surface
appeared whitish with necrotic areas.
Bleeding into the myocardium was found.
Coronary arteries and the large blood vessels
appeared normal.
Figure 01: Cardiac tumour
Case report:
A 41 years old mother of 3 children presented
to a medical ward complaining of loss of
appetite for 2 months, dyspnoea on mild
exertion and chest pain for 2 weeks and on
and off fever for 1 week. She was found to be
having anaemia and features of pericardial
and bilateral pleural effusions. Urgent
echocardiogram revealed an early cardiac
tamponade. Straw coloured pericardial fluid
measuring 850ml was aspirated. It was
rapidly filling and 500cc of fluid was removed
during a second pericardiocentesis done on
the next day. Microscopic examination of the
pericardial fluid was negative for acid fast
bacilli but contained malignant cells.
Ultrasound scan of the abdomen revealed
mild hepatomegaly with a small amount of
free fluid in the peritoneum. The patient
expired away on the third day of admission
while waiting for further investigations.
Another whitish mass measuring 7×3×2cm in
size was found in the middle mediastinum.
The tumour was lying anterior to the trachea,
above the bifurcation and it encircled the left
carotid vessels (Figure 02). The cut surface
had a similar appearance with the cardiac
tumour. Mediastinal lymph nodes were not
enlarged. Mild pulmonary oedema was
present. Peritoneum contained 300cc of
ascetic fluid. Liver was congested with no
macroscopic metastatic deposits.
Other organs were normal except for the
kidneys which showed surface scarring.
Sections were obtained from both tumours
and each organ for histological examination.
Haematoxylin and Eosin stained sections
were evaluated (Figure 03).
31
Figure 2: Mediastinal tumour
The
differential
diagnosis
included
lymphoma, melanoma, epithelial cell tumours
and germ cell tumours. Immunohistochemical
staining for LCA, pancytokeratin, S100 and
PLAP were done and only S100 was positive
which was confirmatory of melanoma.
Figure 3: Tumour cells
myocardium (H&E x10)
infiltrating
I.
II.
III.
IV.
the
Discussion:
Skin is the most common site for primary
malignant melanoma; the most fatal
cutaneous
neoplasm
[5].
Malignant
melanomas are developed by neoplastic
transformation of melanocytes in the
epidermis invading the dermis secondarily.
Patients with cutaneous melanomas often
develop metastasis at other sites of the skin,
lymph nodes and lungs. More than 90% of
malignant melanomas are cutaneous in origin
[5]. In addition, melanoma can arise from
mucous membranes of nasal cavity, sinuses,
lips, buccal mucosa, palate, base of the
tongue and tonsils [4]. They can arise in the
oesophagus,
larynx,
gallbladder
and
leptomeninges rarely. Primary malignant
melanoma in the mediastinum is extremely
rare, with only a few cases reported to date
[6].
A primary malignant melanoma of the
mediastinum could be confirmed on the
following grounds [4, 5, 7].
No history suggestive of previous melanoma
on skin.
No demonstrable melanoma was found in the
skin or other organs during the autopsy.
Tumour morphology compatible with that of
a melanoma.
Confirmation
by
immunohistochemical
staining for S100.
There are several explanations as to
how these primary melanomas developed in
the mediastinum. The most likely explanation
is that these tumours arise from melanocytes
which have migrated along with the down
growth of the primordial respiratory tract
during the intrauterine life from the primitive
foregut [7]. Ectopic naevus cells in the
mediastinal lymph nodes or thymus may
undergo malignant change and produce
primary melanoma of the anterior
mediastinum [7]. Alternatively tumours may
arise from areas of squamous metaplasia in
which some of the epithelial cells have
undergone differentiation into melanocytes
[7].
Almost half of mediastinal tumours
cause no symptoms and are found on a chest
x-ray done for some other reason. Symptoms
that do occur are due to compression of local
structures and may include: chest pain, chills,
cough, haemoptysis, fever, hoarseness, night
sweats and shortness of breath
In this case tumour metastasis was
found in the heart. Although primary cardiac
32
tumours are rare, metastasis in the heart is
common. Due to its resemblance of the
morphology and histology to the mediastinal
tumour and the absence of possible
explanation for a primary malignant
melanoma of the heart, we suggest that the
cardiac tumour is a secondary from a primary
mediastinal tumour. Myocardial involvement
by neoplasm arising elsewhere in the body is
no longer considered rare [8]. Secondary or
metastatic
heart
tumours
occur
comparatively more frequently, with at least
a 100 times higher incidence than primary
tumours [9].
Effects of metastases to the heart
include a rapid increase in heart size by
pericardial effusion, new signs of heart failure
or valve disease, conduction defects, and
atrial
or
ventricular
heart
rhythm
disturbances [9]. Pericardial involvement of
tumour cells causes pericarditis and
serosanguinous or haemorrhagic pericardial
effusion. Rapid filling of pericardial fluid leads
to cardiac tamponade due to the low
compliance
of
the
pericardium
to
accommodate such an acute increase of
pericardial fluid [9]. It causes severe
haemodynamic compromise and death. It is
treated with expansion of intravascular
volume (small amounts of crystalloids or
colloids may lead to improvement, especially
in hypovolaemic patients) and urgent
pericardial drainage [10].
Replacement of the myocardium by
tumour cells and obliteration of the heart
chambers by intra cavitatory growth of the
tumour end up in cardiac failure. Invasion of
the conducting tissues of the heart leads to
atrial and ventricular rhythm abnormalities.
Complete AV block causes syncope and
sudden death. Tumour embolism to a
coronary artery and invasion or compression
of coronaries by tumour result in myocardial
infarctions [9].
In this case the pericardial fluid at the
time of death was 100cc and as little as 100ml
of pericardial fluid can be fatal depending on
the rapidity of its accumulation although 400-
500ml of fluid is thought to be sufficient to
cause fatal cardiac tamponade [11]. So the
mechanism of death can be cardiac
tamponade, arrhythmia, heart failure,
myocardial infarction or sudden cardiac
death.
Conclusion
We report this case as a primary malignant
melanoma of the mediastinum with a right
atrial metastasis causing pericardial effusion,
as there was no evidence of a primary
pigmented lesion on the skin or at any other
site in spite of thorough pathological
evaluation.
1.
References
1. Strollo DC, Christenson RD, Jett JR. Primary
mediastinal tumours. Part 1. Tumours of the
anterior mediastinum. Chest 1997 Aug;
112(2): 511-522
2. Temes R, Chavez T, Mapel D, Ketal L, Crowell
R, Key C, Follis F, Pett S, Warnly J. Primary
mediastinal malignancies; Findings in 219
patients. West J med 1999 march; 170(3):
161-166
3. Kalra A, Kalra A, Palaniswami C, Gajendra E,
Rajput V. Primary malignant melanoma
presenting as superior mediastinal mass. Int
J Surg Case Rep 2011; 2(8): 239-240
4. Adebonojo SA, Grillo IA, Durodola JI. Primary
malignant melanoma of the bronchus.
Journal of the national medical association
1979; 71(6): 579-581
5. Neri S, Komatsu T, Kitamura J, Otsuka K,
Katakami N, Tkahashi Y. Malignant
melanoma of the lung. Report of two cases.
Ann Thoracic Cardiovascsurg 2011; 17(2):
170-171
6. Park SY, Kim MY, Chae EJ. Primary malignant
melanoma of the mediastinum. KJR 2012;
13(6) : 823-826.
7. Farrel DJ, Kashyap AP, Ashcroft T, Morrit GN.
Primary malignant melanoma of the
bronchus. Thorax 1996; 51: 223-224
33
8. Young JM, Goldman JR. Tumour metastasis
to heart. J of the American heart Association
1954; 9: 220-227.
9. Reynen K, Kockeritz U, Strasser RH.
Metastasis to the heart. Annals of Oncology
2004; 15: 375-381.
10. Hoit BD. Pericardial disease and pericardial
tamponade. Crit Care Med. Aug 2007;35(8
Suppl):S355-64
11. Ebert LC, Ampanozi G, Ruder TD, Hatch G,
Thali MJ, Germerott T. CT based volume
measurement and estimation in case of
pericardial effusion. J of forensic and Legal
Medicine 2012; 19: 126-131.
Contribution of authors
Performing the autopsy-LMGN, MHM
Opinion- LMGN, ML
Writing the manuscript –LMGN
Revising the manuscript- FLBM, ML
34
Stories given by children, when to take it with a pinch of salt?
Case report
Warushahennadi J1. Hewage Chandanie G.2
1. Department of Forensic Medicine, Faculty of Medicine, University of Ruhuna, Galle.
2. Department of Psychiatry, Faculty of Medicine, University of Ruhuna, Galle.
*Corresponding author: Tel: 0094-773909525. E-mail address: [email protected]
MLJSL. Vol 2. No 2. Dec. pp 35 –38
Abstract
The history given by a child is very important in child abuse investigations. This is especially relevant in
cases of child sexual abuse as in some forms of sexual abuse injuries may be absent. The only evidence
to prove the case sometimes is the evidence given by the child. The law presumes that the statements
given by the child are true. To what extent can a doctor believe a child’s history?
This case report describes a situation where a child gave a history of being kidnapped and in the child’s
own words, “cared for” twice, by an unknown person. There was a suspicion that the child may have
been sexually abused. The child gave a similar detailed history to the Judicial medical officer (JMO),
police, and the psychiatrist. Based on the information received from the child, various investigatory
procedures were initiated by the police.
But the detailed examination of this “victim” by the child psychiatrist revealed that the child was having
a significant and very prominent fantasy life of a romantic/sexual nature. It was also detected that the
child was not very bright intellectually. It appeared that a big proportion of the story given by the child
was coloured by her experiences and fantasies.
This case reveals the importance of suspecting the possibility of fantasy, when an unusual story without
supporting evidence is given by a child.
Key words: child abuse, fantasy, admissibility, evidence
Introduction
The investigation of a case of child abuse is
initiated with the history obtained from the
child in many instances. The history given by the
child is taken as a guide for medico legal
investigation by the doctor and for criminal
investigation by the police and it helps the
clinician to judge whether the child’s history fits
the given situation [1].The child’s history plays a
very important role especially in cases where
there is no medical evidence or laboratory
evidence to support sexual abuse.
35
This is a case where a child gave a story of being
taken away by an unknown male which aroused
the suspicion of possible abuse, and was later
found to be a fantasy.
the girl. The examination of genitalia revealed
no evidence of penetration. She was referred
to the child psychiatrist as part of the routine
assessment.
Case report
The police had started investigations in to the
case and done a scene visit of the house where
she lived. The house was a partially broken mud
hut which was an illegal construction. Police
had taken the child along several roads to see if
she could identify the house she was taken to.
An 11 year old girl disclosed to her mother that
a teacher of her school promised to give her a
new house to live in and took her to visit this
new house during school time. She claimed that
she was shown a beautiful house and there she
was given food and drinks. Her illiterate mother
who is not legally married and has no income or
a proper place to live, believed this story
because school teachers have been helping
them throughout in various ways. But her
partner did not believe this story and insisted
that the mother go and meet the teacher. The
mother went to see the teacher to thank her for
trying to help them. The teacher was surprised
to hear the story and started to probe in to it.
Then the girl revealed that on the way to school
she met a man and a woman in a van, who
promised to gift her a house to live, and had
taken her by van to a house where there were
several naked foreign women. She claimed that
she was given a meal of fried rice and a drink of
lemon juice after which she felt sleepy and they
helped her by giving a comfortable bed to sleep.
When she woke up she was brought back and
dropped near the school by the time the school
was over. She claimed that the man and
woman asked her to tell the mother that it was
a teacher who took her to show the house.
According to her the incident happened twice.
She gave a detailed description of the house,
people who were there and the meals she was
given. Then the school authorities contacted
the police due to a suspicion of child abuse.
Similar detailed description of the incident was
given to the JMO and the police repeatedly by
The girl attended psychiatric assessment with
her mother. Mother agreed that they were
desperately looking for a better place to live.
She also revealed that the food and drink the
child claimed to have been served by those who
took her away were her favorites. The school
attendance was checked and she was found to
have 100% attendance during that particular
school term. At the end of the assessment, the
mother produced an exercise book with the
child’s handwriting. As there were “hearts”
drawn everywhere in the book, the mother
thought it was not a school book. The
psychiatrist found seven romantic letters which
were addressed to the girl, and sent by seven
different males judging from the names of the
sender. All were of the girl’s handwriting and
on confrontation she agreed that she wrote
them as if boys were writing to her. There were
drawings of a sexual nature in some of her
school books as well. At the end of the
psychiatric assessment it was concluded that
the child’s story was a fantasy.
Discussion
The law presumes that a history given by a child
is true. Therefore it is important to evaluate the
credibility of the history given by a child. A false
history given by a child may lead to unnecessary
investigations by the doctors, police and law
36
enforcement personnel and may lead to the
conviction of an innocent person and also
destroy the family especially when the accused
is a parent [6].
Children usually have fantasies; preschoolers
have more fantasies [2]. With age their fantasy
may reduce, but school going children also have
a rich fantasy life. During early adolescence
fantasies of romantic and erotic nature appear.
Frequency of the occurrence is not clearly
known. Most children’s fantasies are selflimited. Few reveal them in various ways. Some
children colour their stories with their fantasies
and experiences. Those who are craving for love
and attention are more likely to tell stories
coloured by fantasies [3].
Fantasy prone personality (FPP) is a disposition
or personality trait in which a person
experiences a lifelong extensive and deep
involvement in fantasy [3]. An individual with
this trait (termed a fantasizer) may have
difficulty differentiating between fantasy and
reality. A fantasy prone person is reported to
spend a large portion of his or her time
fantasizing, have vividly intense fantasies, have
paranormal experiences, and have intense
religious experiences [4]. The fantasies may
include dissociation and sexual fantasies.
Fantasizers have had a large exposure to
fantasy during early childhood [3,5]. This overexposure to childhood fantasy has at least three
important causes: Parents or caregivers who
provided a very structured and imaginative
mental and/or play environment, exposure to
physical and/or sexual abuse, such that
fantasizing provides a coping or escape
mechanism from the abuse and exposure to
severe loneliness and isolation, such that
fantasizing provides a coping or escape
mechanism from the boredom.
Regarding
psychoanalytic
interpretations,
Sigmund Freud has stated that "unsatisfied
wishes are the driving power behind fantasies,
every separate fantasy contains the fulfillment
of a wish, and unproves an unsatisfactory
reality."
This
shows
loneliness
and
dissatisfaction in life and can result in people
creating a fantasy world of happiness in order
to fill the void. Young children who once were
treated for abuse and had a parent leave
created a world of fantasies to escape from
reality [1]. It is not a psychiatric illness and
there is no treatment or therapy required.
This case report reveals the importance of
suspecting the possibility of fantasy when an
unusual story without supporting evidence is
given by a child. The introduction of psychiatric
testimony intended to impeach the child`s
credibility will be helpful in this type of case
where substantial corroboration supporting the
charge is lacking. In order to justify the
admissibility of mental health evidence, courts
should identify specific and legitimate relevance
to the complainant`s credibility [6]. This should
be balanced against the potentially misleading
and confusing effect that the information will
have on the fact finding procedure. In some
states of America a psychiatric evidence of
credibility of sexual assault complainants are
adopted but no state has adopted a coherent
approach that considers mental health as a
category [6].
References
1. Roy Meadow, Jacqualine Mak, Donna
Rosenberg, ABC of child’s protection. 4th
Edition Blackwell publishing 2007 P - 6.
2. Taylor M, Carlson SM, Maring BL, Gerow L,
Charley CM. Department of Psychology,
University of Oregon, Eugene, OR, USA.
[email protected]. Pub Med – indexed
for Medicine.
37
3. Lynn, Steven J., and Judith W. Rhue (1988).
Fantasy Proneness: Hypnosis,
developmental antecedents, and
psychopathology. American Psychologist,
vol. 43, pages 35 - 44.
4. Merckelbach, H. et al. (2001). The Creative
Experiences Questionnaire (CEQ): a brief
self-report measure of fantasy proneness.
Personality and Individual Differences, vol.
31, 987-995.
5. Rhue, Judith W., and Steven Jay Lynn
(1987). "Fantasy Proneness: Developmental
Antecedents." Journal of Personality, vol.
55, 121 – 137.
6. Cossins, A. (1999) 'Recovered Memories of
Child Sexual Abuse: The Science and the
Ideology' in J. Breckenridge and L. Laing
(eds) in Australian Perspectives on Violence
against Women, Allen & Unwin: Sydney.
Contribution of authors
Examination of the patient-JW
Opinion- JW,CH
Writing the manuscript –JW, CH
Revising the manuscript- CH
38
Ravindra Fernando
Department of Forensic Medicine and Toxicology, Faculty of Medicine, Colombo
Appreciation
m
Professor H. V. J. Fernando – A tribute
MLJSL. Vol 2. No 2. Dec. pp 39 – 42
Dr. Fernando could not enter the MD
programme in the UK without a primary British
medical degree. Therefore, to obtain MBBS of
the University of London, he was attached for
two years to the School of Medicine, University
of Leeds, as an External Student. During this
period he also worked part time with Professor
Matthew Stewart, Professor of Pathology of the
University.
On 1st April 1919 a child was born to wealthy
parents, Henry Domingo Fernando and Vivienne
Muriel Fernando (nee de Mel), who was
destined to become an intelligent doctor, a
great academic, a teacher par excellence, a true
friend, a faithful colleague and a great
humanist. He was named Hubert Vernon
Jerrold.
He was a brilliant student at Royal College,
Colombo and entered the University College,
Colombo, in 1937 and the Medical College of
the University of Ceylon in 1938. In 1943, he
passed MBBS (Ceylon) with Second Class
Honours. From 1943 to 1947 he worked as a
medical officer in the Department of Health
Services serving as a House Officer to the
Professor of Medicine and in the Department of
Pathology. He then worked at the Medical
Research Institute, Colombo and as a
pathologist in the Civil Hospital, Kandy. He
resigned from this post in July 1947 to proceed
to the United Kingdom to pursue higher studies.
He passed M.B.B.S. (London) with ease in 1949
and was appointed as Demonstrator in the
Department of Pathology of the King’s College
Hospital Medical School, London. He took part
in the routine work of the Department and the
teaching. In June 1952, he obtained MD
(London) in Pathology with Morbid Anatomy as
his special subject.
After his MD, he worked with Dr. Keith
Simpson, then a Home Office Pathologist and a
Reader in Forensic Medicine, at Guy’s Hospital
Medical School, University of London. He also
spent some time in the Biological Laboratories
of Scotland Yard learning their crime
investigating techniques.
After returning to Ceylon in October 1952, he
joined as a Pathologist of the Colombo Group of
Hospitals.
On 13th February 1953 after Dr. Fernando’s
selection to the University of Colombo,
Professor G.S.W. de Saram, the first Professor
of Forensic Medicine, wrote to the University
39
stating that “Dr. Fernando be appointed on the
maximum salary of a Grade 2 Lecturer and be
stepped up to Grade 1 a year later, because he
has obtained the highest degree in his specialty
and has also acquired practical knowledge of
medico-legal work under Dr. Keith Simpson who
is one of the leading consultants to Scotland
Yard. Dr. Simpson’s high opinion of Dr.
Fernando has already been submitted to the
Selection Committee”. On 4th March 1953 Sir
Ivor Jennings, the Vice- Chancellor appointed
him to the lecturer post in the Department.
After the retirement of Professor de Saram in
May 1958, he had been the acting Head of the
Department of Forensic Medicine, and he was
responsible for the administrative work of the
Department.
Dr. H. V. J. Fernando was appointed the second
Professor of Forensic Medicine on 10th July
1959.
In 1961, Professor Fernando took one year
sabbatical leave and proceeded to London and
was successful in the Barrister’s examination of
the Lincoln’s Inn of the Inns Court, London.
However, he was not called to the bar due to
inability to “keep dining terms” – a traditional
requirement before a student is called to the
bar at the Inns of Court.
During his sabbatical leave, he visited medicolegal institutions at London, Sheffield, Leeds,
Edinburgh, Glasgow, Cambridge, Cardiff, and
Copenhagen.
In January 1962, the Asia Foundation awarded a
grant to Professor H. V. J. Fernando to visit the
medico-legal institutions at New York,
Connecticut, Washington, Chicago, Los Angeles
and San Francisco in the USA.
Later he visited the All India Institute of Medical
Sciences to attend a WHO conference on
“Evaluation Methods in Medical Teaching”. He
has also visited Turkey and the Federal Republic
of Germany to attend conferences. Participating
in professional activities with dedication,
Professor Fernando served as the President of
the Medico-Legal Society of Sri Lanka in late
seventies. He was the President of the Sri Lanka
Cancer Society and served the Society with
dedication.
His professional colleagues included Drs. W.D.L.
Fernando, Chandra Amarasekera, Dr. Haris
Ranasinghe, Dr. C. H. S. Jayawardene, Dr. N.
Saravanapavananthan
and
Dr.
S.
Sivaloganathan. Professor Fernando always
wrote very favourable reference letters to his
juniors and also kept in touch with them when
they went on study leave.
He had many friends in the international
forensic scene. Some of them were Professor
Donald Teare, Professor of Forensic Medicine at
St. George’s Hospital, London, Dr. H. P. Terfloth,
Institute of Forensic Medicine, University of
Munchen, West Germany, Dr. J. M. Cameron,
the Professor of Forensic Medicine at the
London
Hospital,
Dr.
Tom
Noguchi,
Chief Medical Examiner and Coroner for
the County of Los Angeles, who was known as
the "coroner to the stars", as he determined the
causes of death in many high profile cases such
as Marilyn Monroe, Robert F. Kennedy, Sharon
Tate and Natalie Wood, Dr. W. G. Eckert and Dr
Milton Helpern of the USA.
A keen and dedicated teacher in the Faculty of
Medicine, Colombo, he held the post of
Chairman of the Centenary Celebration
Association of the Faculty in 1970. He was the
Founder Chairman of the Statistical Unit of the
University of Ceylon.
In 1982, he became the Registrar of the Ceylon
Medical Council when Professor Milroy Paul
retired, and served in this position till 1994.
During this period he compiled “An Index of
Important Decisions of the Medical Council
from 1948 to March 1996”, and “Legislation
relating to the Sri Lanka Medical Council
formerly Ceylon Medical Council”, which
40
included a “Summary of Legislative Enactments
from 1905”.
He was the first Chairman of the Board of Study
in Forensic Medicine in the Post Graduate
Institute of Medicine, which commenced the
postgraduate training in Forensic Medicine in
Sri Lanka. He was responsible for the initial
spade work of the Board to prepare the training
programme and conducting the first couple of
post graduate examinations.
Professor Fernando was consulted by the
Attorney General’s Department and the private
bar for expert opinion in difficult cases and
many eminent legal professionals visited him at
his residence for expert opinion.
He performed the post mortem examinations of
Mrs. Padmini Kularatna of Galle, who died of
arsenic poisoning. In the well known
Getangama murder case in Ratnapura, where a
man murdered and hanged his wife with the
help of his mistresses, Professor Fernando was
requested
by
the
Attorney-General’s
Department to advice on the post mortem
findings of Dr. D.J. Bandara and Dr.
Saravanapavananthan, who did the first and the
second postmortems respectively.
In 1960s excavations at the site of Dakkina
Thupa, Anuradhapura, were recommenced by
Professor Senarath Paranavithana and when
the ashes were recovered from the basement of
Dakkina Thupa, which was believed to be of
king Dutugemunu, they were sent to Professors
H V J Fernando for expert opinion by the
archaeologists.
When he was in King’s College he contributed
an article on “Pulmonary Aspergillosis Following
Post-influenzal Bronchopneumonia Treated
with Antibiotics” with J. D. Abbott, K. Gurling,
and B. W. Meade to the prestigious British
Medical Journal in 1952. Only very few Sri
Lankans are fortunate enough to get an article
published in the prestigious British Medical
Journal.
Professor Fernando’s other publications include
“Forensic aspects of post-maturity” in the
Ceylon Medical Journal in 1957, “Distribution of
A-B-O and M-N blood groups among the
Ceylonese, their Significance in Forensic Work”
in the Ceylon Journal of Medical Sciences in
1958, and “Survival after penetrating injury of
the heart” with Dr. C. Mylvaganam, in the
Journal of Forensic Medicine in 1959.
He presented several scientific papers with
other colleagues. For example with Chandra
Amarasekera,
N. Saravanapavananthan and
others he read papers on “Socio-medical
aspects of road traffic accidents in Colombo”
and “An epidemiological study of intentional
violence in Colombo” at the Annual Scientific
Sessions of the Sri Lanka Medical Association in
1979.
A very useful publication of Professor Fernando
was “Injuries and their legal definition” with
Consultant Surgeon Dr. A. Thavendran, Chief
Justice H.N.G. Fernando, and eminent lawyer
Eardley Perera in the Journal of the Colombo
General Hospital in 1973.
Another joint publication with Chief Justice
H.N.G. Fernando, Dr. Chandra Amarasekera and
Dr. N. Saravanapavananthan and others was on
“Hurt in relation to the Ceylon Penal Code” in
the Sri Lanka Police Journal in 1974.
In 1984 Professor Fernando and I submitted a
paper on "Examination and reporting of victims
of assault to Police and Courts in Sri Lanka” for
the Tenth Meeting of the International
Association of Forensic Sciences, held in Oxford,
England. The abstract of this article was published
in the Journal of Forensic Science Society.
In September 1984, Professor Stanley
Wijesundera, the then Vice Chancellor of the
University wrote to Professor Fernando about
his impending retirement stating that he would
like to make special mention of the invaluable
counsel and support given to him during his
tenure of office as Vice Chancellor.
41
I wish to quote a sentence from Professor
Fernando’s reply. “I have always felt that loyalty
is an important part of any service and I have
tried to live up to it”. A profound statement to
be made note of! In 1944 young Dr. Fernando
married Marie Constance Gwendoline Philip, a
daughter of Dr. B.D.H. Philip from Kaluthara.
Their son Nirmal and daughter Marina became
accountants but one of his grand daughters,
Sahani, is now a Consultant Anaesthetist in the
USA. He retired on 31st December 1984 and the
Senate of the University elected him Emeritus
Professor on 12th September 1985. After a
fruitful academic and social life Professor
Fernando passed away peacefully on 2nd May
1998.
42