Paper Hearts

A roughout history most societies have exhibited ambivalent and often inconsistent behaviours toward children: on the one hand, espousing the value and sanctity of the child and, on the other, condoning if not codifying various modes of maltreatment. In some countries such as Sweden, rigorous and sweeping laws protect all aspects of the child’s life, whereas in others, maltreatment, slavery, sexual exploitation, infanticide, and mutilation are tolerated. In most advanced societies a well-defined system of law exists for children to grant to them the same degree of protection under the law afforded to adults, but even in ancient times laws existed that proscribed the killing of babies and children, and various punishments were stipulated for individuals found guilty of this activity.  However, it was well recognized that it was often not possible to determine if the death of a child was due to natural causes or the actions of another. Autopsies, after a fashion, even in medieval times, were often sought to resolve this issue, and the legal quandaries posed by difficulties in obtaining reliable medical information were well known that the lungs of infants who had breathed floated in water whereas those of stillborns did not constituted a valuable advance in pathological knowledge that went a long way toward proving infanticide at the time. Further reports corroborated this early observation, but like many historic observations and the conclusions that arose from them, experience and research have developed exceptions. It is now recognized that lungs of stillborn infants can sometimes float, for which there may be several reasons. Among them are bacterial contamination with gas formation, manipulation after stillbirth, attempted resuscitation, possibly elastic expansion of the thorax in precipitous deliveries of the stillborn infant, and probably others. Very early on there were observations regarding fatal head trauma in infants and children, which led many writers of the late seventeenth and eighteenth centuries to advise against striking the heads of infants or children for fear of producing bleeding inside the skull or “water on the brain.” Furthermore, a review of papers on subdural hematomas in infancy that date from the late 1800s into the early 1900s clearly implies in some case reports the strong likelihood of abusive injury as a basis for the injuries. It is interesting to note that in some of these case reports, fundoscopic examinations revealed retinal hemorrhages, a finding that, again, was rediscovered many years later and about which there is considerable interpretive controversy. Tere have been a number of reports on the magnitude of fatal child abuse in given populations, but out of necessity for the methods employed and many basic uncertainties that underlie the cases, these figures are estimates only. Anyone who reports suspected or observed child abuse is protected by the law and is never asked to confront an accused person. All reports are investigated by presumably competent professional personnel of the department before any action is taken relative to the alleged abuser or the child. In some communities, computer data banks exist that allow hospital emergency rooms to coordinate information on possible previous emergency room visits to other hospitals by an injured child in order to develop an awareness of repeated injury and take corrective action.

A problem of child abuse, over the past 40 years, has led to a number of phenomena within the medical community. Many pediatrics residency programs and teaching hospitals have now established child abuse response teams, interdisciplinary child abuse teams, child abuse training programs, and fellowships in child abuse. Many of these organizations have become politically and legally active largely within the context of providing counsel, primarily to police authorities and prosecutors, and in some cases to assume a nearly prosecutorial or adjudicative position. As a consequence of increasing vigor in seeking prosecutions of possible abusers, a body of law has developed that has elevated child abuse to special status, often demanding very harsh penalties not only for the death of a child but also for child endangerment or condoning abuse. An involvement of the general pathologist, forensic pathologist, or neuropathologist in the phenomenon of child abuse is multifaceted. On the one hand, as concerned citizens, there is an important role that such health care professionals can play in raising public and professional awareness to the problem, but there is also an important professional and statutory responsibility to report suspected cases and to assist in legal processes that come into play when a child dies out of neglect or overt action on the part of another. It is role often very difficult because there is frequently conflicting information regarding a fatal event, a child cannot speak for himself or herself, and in the case of nonfatal abuse, if the child is old enough to communicate, he or she may not be believed. Furthermore, there is often a high degree of concern and anxiety on the part of physicians that if an accusation is made, it will or cannot be proved, and libel or damage actions may follow.  A further complication in the analysis of fatalities in children is the fact that they may not be due to willful abuse; some children are purposefully killed under circumstances that do not constitute child abuse in the usual sense. An analysis of potential or alleged child abuse fatalities by the forensic pathologist poses one of the most difficult challenges possible. Child abuse fatalities rarely involve identification problems of the body, DNA trace evidence is rarely involved, witnesses who can or will provide information are only rarely encountered, confessions are often suspect, trace evidence is rarely germane, and the case almost always hinges on circumstantial evidence and medical opinion that may be ill-informed, prejudiced, or based on dogma. Almost every alleged child abuse case, especially involving young infants, includes the possibility of some pre-existing brain injury or other condition, possibly emanating from birth, or the possibility of inherited or acquired disorders of bleeding/coagulation or some other process that can mimic traumatic lesions. At least some service should be paid by the pathologist to the long list of differential and confounding conditions that may be present before reaching a decision concerning both the cause and manner of death. Evidence may surface that the child had been seen repeatedly in emergency rooms for similar injuries over a period of time, often at different institutions. Not infrequently the child may appear normal and well fed with no obvious outward signs of injury. One must be ever mindful that circumstances under which admissions or confessions are obtained may be coercive or otherwise suspect, and information thus obtained may be tainted.  Autopsies on possible victims of child abuse may well be the most complex and challenging of any forensic case, even though perhaps at the outset a given case may appear simple. An interaction of inherited disorders, accident scenarios, medical treatment effects, and inflicted injuries demands careful attention to detail and an appreciation for possibilities that include many rare conditions of which the average forensic pathologist may be unaware, but ignorance of such conditions cannot be an excuse for an erroneous conclusion that may have serious consequences for persons who may be accused of injuring the child victim. Although it is unsatisfying professionally, there is often plenty of justification for the forensic pathologist to use the “undetermined” manner of death in many cases. Upon beginning an analysis of a possible abuse fatality, information that should be available to the forensic pathologist charged with determination of cause and manner of death prior to an examination of the body of a suspected victim of child abuse is vital in the interpretation and correlation of subsequent anatomic findings of the body surface, in the viscera, or in the central nervous system.  It is also important, at some point prior to sign-out, to have a report available, including photographs of the scene (or to have made a personal visit), which include the state of repair and cleanliness of the surroundings and proximity of beds to windows, radiators, and other objects. A composition of the floor and its covering is also important to later interpretation of head injuries and possible pattern injuries that might be observed on the skin. If falls from cribs or other furniture or surfaces are alleged to have occurred, measurements and photographs of these surfaces should be taken with scales in the photographs. Any stains should be sampled and appropriately collected for analysis, a presence of pets, other children, and adults and their relationship to the child may also be important. Attention should be paid to the state of repair and cleanliness of the clothing the victim is wearing or was wearing at the time of death or injury. If there are soiled towels or papers on the scene, they should be preserved for later analysis. Further considerations on proper scene analysis are beyond the scope of this discussion and are within the ken of the burgeoning field of scene forensics and trace evidence analysis. Examination of the body orifices may reveal signs of injury, but care should be exercised in premature interpretation of any dermal or mucosal injury because there may be many causes, including medical treatment or examinations, that may give an ominous impression of inflicted injury, including sexual abuse. Smears of the orifices may also be useful in determining the presence of semen and establishing valuable DNA evidence, patterns of external injuries seen in child abuse cases have been described in detail in many texts and monographs cited above. It is common to discover tears or other injuries to the interior of the mouth and frenulum that may attributed to forceful feeding or some other abusive action, but intubation and resuscitation may also cause such lesions. Bruises of the pinnae of the ears, often viewed with extreme suspicion, may also be iatrogenic, caused by straps from a respirator mask or adhesive tape. Likewise, injuries to the penis, vulva, and anus may not be due to abuse but, rather, insertion of catheters, thermometers, or other instruments. Nevertheless, these lesions, when found, should be photographed. A careful examination of the viscera may reveal old and recent traumatic lesions that may include lacerations of viscera, tears in the mesentery, and puncture or other injuries of the viscera. If intravascular catheters were employed, they should be left in situ so that if there is possible puncture of a viscus from a misplaced catheter, its relationship to the hemorrhage or injury can be ascertained. It is vital that histological sampling of visceral hemorrhages or other lesions be made in order to provide aging/dating information on the injuries, which may permit correlation with historical events or facts in evidence. Newer methods than can probe for induction of the apoptosis pathway and collagen synthesis in response to injury show duration-dependent alterations, but precision is problematic, as is the availability of what are essentially research techniques to the forensic pathologist in most circumstances.

Generally, the higher the fall height, the more serious the injuries that can occur, which is logical because the energetics of falls are largely determined by the terminal velocity the body reaches at time of impact on a firm surface by Newtonian physics, a terminal velocity of a free fall for any object is V = 2GS.  where V is the velocity in feet/second at the impact with the floor or ground surface, S is the distance in feet of the fall, and G is 32.2 feet/second/second—the force of gravity. Once contact of the head with the impact surface occurs, a series of events occurs that determines the amount of acceleration (or deceleration) that will occur to the mass of the head. These events are not totally predictable, though their effect on acceleration can be estimated. If the characteristic of the impact surface, scalp (thickness, stiffness, etc.), and skull (stiffness and other properties) are known or can be estimated, estimates may be made for the so-called stopping distance (the distance that it takes for the head to decelerate from the terminal velocity to a resting state). From a practical point of view, the notion that infants cannot suffer serious injuries from short falls is illogical. If one were to imagine a baby being propelled into a wall at 5–10 miles per hour (equivalent of a 1- to 3-foot fall), as if being thrown forward into a wall, would one seriously maintain that they would not be injured? The nature and extent of injuries would, of course, be determined by what body part struck the wall first and what clothing or protective devices might dampen the forces of the impact, but the facts remain, sustained by our own everyday experiences, that no one in his or her right mind would, assume that walking into a wall at several miles per hour or more would not be injurious to an adult, much less to an infant. An almost-infinite variety of supracondylar, condylar, and distal epiphyseal fractures can occur, but with the exception of distal epiphyseal fractures, they usually affect adults because most of these fractures appear to occur with rotational forces on the extremity when it is loaded, which would not be the case with infants. Certain high-energy scenarios can also affect children. Other types of fractures of long bones may be described as transverse (a straight lateral break), oblique, spiral, comminuted (multiple fragments that may penetrate the skin), or segmental, in which a section of the long bone is separated from the proximal and distal diaphysis. When obvious abuse is absent, probably very few of these cases are labeled homicide for lack of evidence deemed sufficient to merit prosecution. Even when there is evidence of physical abuse, but there is no obvious anatomic cause of death, many of these cases are never correctly labelled as homicides (death at the hands of another). In the latter case, it is quite understandable that forensic pathologists would be hard-pressed to communicate the cause of death to a state’s attorney, judge, or jury; nevertheless, there are circumstances in which surprisingly strong testimony from a pathologist can be presented in such difficult cases.

The problem of analysis of potential or suspected child abuse fatalities, especially in younger children, is a very difficult task, having to deal with a commonly embedded mindset that holds that certain findings rarely or never occur outside the environment of abuse and have considerable discriminatory potential to rule out accidental injuries, medical conditions, or combinations in favor of abuse.

Acknowledgements:

The Police Department; 

www.politie.nl and a Chief Inspector – Mr. Erik Akerboom     ©

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