Download Part Ⅲ Clinical Forensic Medicine

CLINICAL FORENSIC MEDICINE
Chapter 1
History and Development of Forensic
Medicine
SECTION 1
INTRODUCTION
The terms “forensic medicine”, “forensic pathology” and “legal medicine” have been
and continue to be used interchangeably around the world. Forensic medicine is now
commonly used to describe all aspects of forensic work – including both forensic
pathology – that branch of medicine which investigate death, and clinical forensic
medicine (a term that has become widely used in the last two decades) which is used
to refer to that branch of medicine which involves an interaction between the law, the
judiciary and police involving (generally) living persons. In broad terms a forensic
pathology does not deal with living individuals, whereas a forensic physician does not
deal with the deceased. However there are doctors worldwide who are involved in
both clinical and pathological aspects of forensic medicine. There are many areas
where both clinical and pathological aspects of forensic medicine overlap, and this is
reflected in history and development of the specialty as a whole.
Although the term “forensic pathology” is widely accepted and understood, and the
practitioners of clinical forensic medicine have been given many different names over
the years, the term “forensic physician” has become accepted. Other names hat have
been used include, police surgeon, forensic medical officer, forensic medical
examiner – but names such as these refer more to the appointed role, than to the work
done. The extent and range of the role of a clinical forensic medicine practitioner is
variable-many may limit themselves to specific aspects of clinical forensic medicine –
for example sexual assault or child abuse. Box 1 illustrates the range of types of cases
with which a forensic physician may be involved. Some practitioners of clinical
forensic medicine may only perform part these functions, whist others may have a
more extension role which may be dependent on geographical location and local
statute. Part of a forensic pathologist and forensic physician’s remit must be to have a
good knowledge of “medical jurisprudence”- the application of medical science to the
law. On a worldwide basis the function and the role of forensic pathologists and
forensic physicians can differ widely dependent on local judicial systems or statutes.
At present the role and scope of specialty of clinical forensic medicine is ill-defined in
global terms, unlike other medical specialties such as gastroenterology or cardiology.
In many cases those doctors practicing clinical forensic medicine jurisprudence may
only do it as a subspecialty within their own workload.
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Box 1 Typical and additional roles of a forensic physician (expanded and modified from
Howitt & Stark 1996)*
Typical roles

Determine fitness to be detained in a custody

Determine fitness to be released

Determine fitness to be charged: competence to be comprehend charge

Determine fitness to be transfer

Determine fitness to be interviewed by the police or detaining body

Advise that an independent person is required to ensure right for the vulnerable or
mentally disordered

Assess alcohol and drug intoxication and withdrawal

Examine comprehensively a person’s ability to drive a motor vehicle

Undertake intimate body searches for drugs

Make precise documentation and interpretation of injuries

Take forensic samples

Asses and treat personnel injured whilst on duty, including needle stick injuries

Pronounce life extinct at a scene of death and undertake preliminary advisory role

Undertake mental state examinations

Examine adult complainants of serious sexual assault and the alleged perpetrators

Examine alleged child victim of neglect, physical or sexual abuse
Additional roles

Expert opinion in courts and tribunals

Death in custody investigation

Pressure group and independent investigation in ethical and moral issues
-
Victims of torture
-
War crimes
-
Female genital mutilation

Refugee medicine (medical and forensic issues)

Asylum seeker medicine (medical and forensic issues)
For all these examinations a forensic physician must accurately document findings and when
needed produce these as written reports for appropriate civil, criminal or other agencies and courts.
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The forensic physician must also be able to present the information orally to a court or other
tribunal or forum.
* The information in this Box illustrates the role of police surgeons/ forensic medical examiners in
the UK - roles vary according to geographical location.
New words and expressions:
1. judiciary adj 司法的；法院的 n 司法部；司法官；审判员
2. physician n 医师；内科医师
3. overlap v (与...)交迭
4. statute n 法令；条例
5. jurisprudence n 法学
6. assault n 攻击；袭击 v 袭击
7. abuse n 滥用；虐待 v 滥用；虐待
8. gastroenterology n 肠胃病学
9. cardiology n 心脏病学
10. subspecialty n 附属专业
11. detained v 拘留；留住；阻止
12. custody n
拘留；监禁
13. charged v 起诉
14. vulnerable adj 易受攻击的；易受...的攻击
15. intoxication n 陶醉
16. perpetrators n 犯罪者；作恶者
17. tribunals n 法官席；审判员席；(特等)法庭
18. asylum n 庇护；收容所；救济院；精神病院
19. refugee n 难民；流亡者
20. genital adj 生殖的 n 生殖器(多用于指男性的外生殖器)
21. mutilation n 切断；毁损
SECTION
2
CONTEMPORARY
CLINICAL
FORENSIC
MEDICINE
Despite the vastly larger numbers of living individuals on whom the medicine and law
interact, compared with the deceased, forensic pathology remains at present, the
academic basis for forensic medicine. It is only in the last 2 decades that research and
academic interest in clinical forensic medicine has become an area of much more
focused research. A working definition has been suggested as “… clinical forensic
medicine includes all medical [health care] field which may relate to legal, judicial
and police system” (Payne - James 1994).
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Certainly the recent growth in awareness of human rights abuses and civil liberties
have directed much attention to the conditions of detection of prisoners, and to the
application of justice to both victim and suspect. However it would be naïve and
wrong to believe that such concerns are of only contemporary origin. The differing
roles that a forensic physician may have when attending a prisoner have been
recognized – by identifying three facets of medical care that may conflict
1. The role of the medio-legal expert for a law enforcement agency
2. The role of a treating doctor
3. The examination and treatment of detainees who allege that they have been
mistreated by the police during their arrest, interrogation, or the various stages of
police custody (Editorial 1993)
The latter conflict is well – recognized by forensic physicians. Grant - a police
surgeon appointed to the Metropolitan Police in the east end of London just over a
century ago – records the following incident: “One night I was called to Shadwell
[Police] station to see a man charged with being drunk and disorderly, who had a
number of wounds on the top on his head… [I dressed them] …and when I finished
he whispered “Doctor, you might come with me to the cell door”…I went with him,.
We were just passing the door of an empty cell, when a police constable with a mop
slipped out and struck the man a blow over the head….Boiling over with indignation I
hurried to the Inspector’s Office [and] told him what had occurred”. Dr Grant
recorded that the offender was dealt with immediately (Grant 1920)
Dr Grant was one of the first “police surgeons” (the first superintending surgeons)
having been appointed on 30 April 1830. The Metropolitan Police Surgeons
Association was formed in 1888 with 156 members. In 1949 Dr Ralph Summers and
others reconstituted the Association so that improvements in the education and
training of clinical forensic medicine could be assured. The Association of Police
Surgeons remains the leading professional body of forensic physician worldwide.
How are clinical forensic medical workloads dealt with around the world? Table 1.1 is
a summary of responses to a questionnaire on various aspects of clinical forensic
medicine undertaken in mid – 1997 (Payne – James 1997). It shows with clarity the
range if different standards and procedures in a number of the most important aspects
of clinical forensic medicine. The questionnaire responses were all from individual
familiar with police/forensic medicine and judicial procedures within their own
country. Although this represents a small sample, the answers can be summarized by a
number of key points that illustrate the current state of clinical forensic medicine
around the world as the 21st century begins:
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1. There are no clear repeatable patterns of clinical forensic medicine practice when
viewed on an international basis
2. Several countries have informal/ ad hoc arrangements
3. The emphasis in several countries appears to be on the victim rather than the
suspect
4. The medical care of detainees in police custody is variable
5. There are no international standards of practice or training
6. There are worrying gaps in the investigation of police complains in some countries.
7. There are surprising omissions concerning availability of death in custody statistics
Three key points summarized the aims and requirements of those involved in any
aspect of clinical forensic medicine practice:
1. Forensic physicians should endeavor to ensure that the term “clinical forensic
medicine” is synonymous with knowledge, fairness, independence and
impartiality.
2. That forensic physicians practicing clinical forensic medicine are of an acceptable
and measurable standard
3. (As a result of 1 and 2) To ensure any individual in contact with legal, police or
judicial system will not suffer medically or legally because of lack of availability
of appropriately skilled practitioners.
New words and expressions
1. enforcement n 执行；强制
2. mistreat vt 虐待
3. detainee n 被拘留者；未判决囚犯
4. reconstitute vt 重新组成；重新设立
5. synonymous adj 同义的
6. omission n 懈怠；不履行法律责任
7. questionnaire n 调查表；问卷
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Chapter 2
Assault and injury in the living - PartⅠ
SECTION 1
INTRODUCTION
The incidence of crimes of violence is increasing throughout the world. It is essential
that wounds or injuries are assessed, documented and treated appropriately. This
chapter specifically addressed the issues of physical assault and the assessment and
documentation of wound or injury. Kight (1996) suggested that wounds or injuries
can be defined as “damage to any part of the body due to the application of
mechanical force”. This is a reasonable working definition but excludes certain other
types of deliberate injury (e.g. burns). Perhaps a more appropriate definition in the
forensic medical contest might be “damage to any part of the body due to the
deliberated or accidental application of a mechanical or other traumatic agent”.
The purpose of assessment and documentation is, as far as possible, to assist in
establishing how such a wound or injury was caused, and whether the accounts of
causation are consistent with the injuries documented. The term “wound” has specific
meaning in certain jurisdictions, for example relating to whether the skin or mucosa
has been completely breached. It is more appropriate for those documenting injuries
to ensure that they have documented them in detail and unambiguously so that the
courts can then make the decision as to the most appropriate judicial interpretation of
the injury or injuries described and their relevance to the case.
Demographics and statistics
Crimes of violence occur in many settings. Some of the issues that need to be
addressed in terms of the background to assault and injury will be discussed. There
are no absolute rules for the type or pattern of injury. In very general terms, men are
most commonly the victims of crime, particularly those in younger age groups.
The nature of injuries varies dependent on the setting and patient population studied.
One of the largest studies (Wladis et al 1999) investigated the incidence of injury,
distribution of injuries, age and sex distribution, and geographical differences in all
patients admitted to Swedish Hospitals between 1987 and 1994 for injuries people
were male (n=17453), with a mean age of 30 years, and that craniocerebral injury was
the most common type of injury (72%) followed by injury to extremities (10%),
thorax (5%), and abdomen (3%). The mean hospital stay was 3 days and 0.2% of the
injured persons died of their injuries. A 1989 study of 286 victims from an outpatient
clinic in Chile suggested that many of the injuries present on the victims were caused
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by the police; evidence of blunt injury inflicted by batons was present in 44% of the
patients studied (Aalund et al 1990). Back and colleagues (1996) explored eye injuries
in women subject to domestic violence. Of 79 patients, a blow with a fist was the
most common cause of eye injury, which ranged from bruising to rupture of the globe.
Payne-James& Dean (1994) reviewed the injuries of those seen in police settings,
which included those of both victims and assailants; 86% of those involved were male
with a mean age of 28 years. The victims were predominantly female and weapons
(apart from feet and fists) were used in only 15% of cases. In this study, 49%of the
incidents took place on the road, street or public highway. Of the assailants, 44%
appeared to be under the influence of alcohol or drugs; this figure for the victims was
27%. Of the assault, 35% were said to be unprovoked, 17%were related to domestic
incidents and 8% as a result of driving incidents (so-called “road rage”)…
Examination and documentation of injury
Interpretation of injury is dependent on establishing a good history, undertaking an
appropriate physical examination, and recording the findings clearly and
unambiguously. It must always be borne in mind that each interpretation, set of
medical notes and records may be reviewed by other doctors, legal advisors and the
courts. Consent for the examination and for subsequent production of a medical report
should be sought from the individual being examined unless this has been requested
by the courts. It should also be borne in mind that vexatious or frivolous accusations
of assault can be made, and the examiner should place himself in the best position to
establish the veracity of any accounts, as false allegations and counter-allegations
frequently occur.
A number of factors can be relevant when assessing injury in the living person (see
Box 2.1)
Box 2.1 Factors to determine from history
Time of injury or injuries
Whether the injury has been treated
Pre-existing illnesses (e.g. skin disease)
Regular physical activity (e.g. contact sports)
Regular medication (e.g. anticoagulants, steroids)
Handedness of victim and suspect
Use of drugs and alcohol
Weapon or weapons used (if still available)
Clothing worn
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and should be determined when a history is taken. Not all of these factors will be
relevant for every individual. A general health background is important to establish as
pre-existing illnesses or the use of regular medication (e.g. steroids, anticoagulants)
may affect the appearance of an injury.
Participation in certain sports may result in the appearance of injury unrelated to an
alleged assault. It is important to document the time at which the injury was said to
have occurred. Most injuries heal and thus the appearance of an injury following
assault is time-dependent. In many cases assaults may be reported days or weeks
afterwards. There may be a number of injuries from different incidents and specific
times should be attributed to each. Similarly the type of assault (e.g. with baseball
bats, kicks, fists, knives or scissors) must be documented, and if more than one type
of assault as occurred, clear correlation must be made of which injury was accounted
for by which implement. Document the handedness (Left or right or both) of both
victim and assailant if known, as this may affect the interpretation of injury causation.
It is often the case that widely diverging accounts are given by different witnesses and
it is the forensic physician’s role to assist the court in determining the true account.
These differing accounts may also be influenced by their effect of drugs and /or
alcohol and it is appropriate to assess the influence that these may have in each case.
Knowledge of the type of weapon used can be very important when assessing injury,
particular implements (e.g. batons and serrated-edged knives, giving characteristically
identifiable injuries). The type of clothing worn (e.g. long-sleeved shirts or armless
vests) should be noted It is not unusual for individuals to make claims about how an
injury (e.g. knife wound, bite) occurred despite the presence of clothing which would
have precluded that particular mechanism of injury. When examining an individual
for injury, all these features should at least be considered to see whether they may
have relevance to the case – others may become relevant as the examination
progresses or as other accounts of an assault are given.
Documentation of injuries can be in a variety of formats, including hand-drawn notes,
annotated proforma diagrams, and photographs, the latter for which consent has been
obtained.
Box 2.2 lists the characteristics that may be needed to document each injury
appropriately.
Box 2.2 Characteristic to be assessed for each injury (optional and dependent on history )
Location (anatomical-measure distance from landmarks)
Pain
Tenderness
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Stiffness
Type (e.g. bruise, cut, abrasion)
Size (use metric values)
Shape
Color
Orientation
Age
Causation
Handedness
Time
Transientness (of injury)
Digital images have now become an accepted way of documenting injury, and the
digital image evidence should be supported by contemporaneous written and
hand-drawn notes. If the photographs are being taken by a photographer, ensure that
this person is aware:
(a) of what is to be photographed, and
(b) to include color charts and rules in each photograph.
It is best to form an opinion at the time of examination as to whether injury or injuries
are new or old, and whether they have specific characteristics of particular types of
injury (e.g. self-inflicted or defence-type). Ensure at the time of examination that each
injury is accounted for by the account given. If an injury appears not to be consistent
with the account given, it should be questioned at the time of presentation. In many
cases individuals who have been involved in fights or violent incidents are simply
unaware of the causation of many sites of injury. It is often appropriate (particularly
with blunt injury) to re-examine injuries 24-48h later to see how the injuries evolve
and whether bruises have appeared or other sites of injury noted. Pre- and posttreatment examination and photography may be very useful.
SECTION 2
TYPE OF INJURY
Injuries are classified in many different ways, but with simple underlying themes. It is
important that anyone involved in the assessment of injury understands the range of
terms that can be applied to different types of injury (often dependent on geographical
location or medical specialty). Each examiner should adopt his own system that
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ensures that the mature of each injury is described clearly and reproducibly in note
form.
Deliberated injury may be divided into two main types – blunt impact injury and
sharp implement injury. Blunt impact injury described the cause of injuries not
inflicted with instruments or objects with cutting edges. The injury may be caused by
either traction, torsion, and shear stresses. The body may move towards the blunt
object with a direct application of force (e.g. with a fall or push against a wall) or the
blunt object may move towards the body. Examples of objects that cause blunt impact
injuries include fists, feet, baseball bats, or police batons. A blunt impact blow can
cause a range of symptoms or signs, and the resultant injuries are dependent on a
number of factors including force, location, and impacting surface- which may reveal
no visible evidence of injury, or tenderness or pain at the site of impact, reddening,
swelling, bruising, abrasions, cuts (lacerations) and broken bones.
Each type of injury may be present alone or in combination. Such injuries are seen at
the point or contact of the impacting object on the body. Bruises may migrate away
from the point of contact by gravity after a period of time. Abrasions give a clear
indication of the site of impact. In some cases patterns of injury may indicate whether
a particular impacting object was involved. Blunt impact injuries can be described (in
terms of force applied) as being weak, weak/moderate, moderate, moderate/severe,
severe, the more forceful the impact the more likely that visible marks will be evident.
Sharp injuries are those caused by an implement with cutting edges (e.g. knives,
scissors of glass). The injuries may be classified into either incised – where the
cutting edge runs tangentially to the skin surface, cutting through skin and deeper
anatomical structures – or stabbed – where the sharp edge penetrates the skin into
deeper structures. An incised wound is generally longer than it is deep, whereas a stab
wound is deeper than it is wide. The forces required to cause sharp injuries and the
effect if such injuries are variable as a very sharp pointed object may penetrate vital
structures with minimal force.
New words and expressions
1. assault n 攻击；袭击 v 袭击
2. mucosa n 黏膜
3. interpretation n 解释；阐明
4. allegation n 主张；断言；辩解
5. anticoagulant n 抗凝血剂
6. serrated-edged adj 锯齿状边缘的
7. implement n 工具；器具
8. proforma adj 形式上的；预计的
9. tenderness n 柔和；敏感
10. handedness n 用右手或左手的习惯
11. transientness n 瞬时现象
12. traction n 牵引
13. torsion n 扭转；转矩
14. shear v 剪；剪切
15. baton n 警棍
16. abrasion n 磨损；挫伤
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Chapter 3
Head Injury
Damage
SECTION 1
and
Residual
Brain
HEAD INJURY
Scale of the problem
Every year, approximately one million patients in the United Kingdom will present to
hospitals having sustained a head injury. Half of these will be under age of 16 years.
Sixty – three percent of adults who sustained moderate head injuries and 85% who
sustained sever injuries will remain disable one year after their accident (Teasdale
1995). Patients are often left significant cognitive, behavioral, emotional and physical
problems which have several social as well as economic implications. The cost to
society at large is enormous and considerable burden is placed not only upon the
hospital service but also upon social services. A large proportion of individuals who
sustain a head injury will not rehabilitate into their former occupation and many will
remain either unemployment or unemployable in perpetuity. This not only has
repercussions on individuals but also upon their families and may culminate in the
disintegration of relationship with marital breakdown
Such problems are not only confined to those who sustain moderate or severe head
injuries. Those who have minor head injuries may have not inconsiderable problems:
for instance, only 45% of these patients will have made a good recovery one year after
their head injury. Three months after a minor head injury 79% of patients will
continue to complain of headaches, 59% of memory disturbance and 34% will not
have returned to work. The problems are just as bad or worse in other countries, both
developed and underdeveloped.
Epidemiology
Head injuries can be sustained in a variety of ways but the most common injuries are
falls, which account for 4% of injuries in the United Kingdom; assaults, which
account for 30%; and road traffic accidents, which account for 13%. The remainders
are accounted for by industrial accidents, sporting injuries, and so forth. If all age
groups are taken into consideration the mortality rate for a head injury sustained in
Unite Kingdom is 9 per 100000 per year. This account for 1% of al annual deaths but,
significantly, these figures account for 15 - 20 % of death in the age group 5 - 35
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years (Rimel et al 1981)
A variety of classifications of head injury have been invoked but the Report of the
Working party on the Management of Head injuries produced by the Royal College of
Surgeons of England in 1999 suggests three categories:
1. Minor head injuries. Defined as patients who are admitted to hospital for less than
48 hours.
2. Intermediate head injuries. Defined as those patients who are admitted to hospital
for more than 48 hours but who do not require intensive care and who do not require
surgery.
3. Sever head injury. This group is defined as patients who require intensive care or
neurosurgery.
It should be noted that this classification is clinical and is based on the state of the
patient at presentation; it does not take into account the eventual outcome.
Anatomy
The brain is contained in a rigid, hard box called the cranium. This protects the
underlying brain which is very soft and easily injured. Between the brain and the
cranium are three layers of tissue collectively called the meninges. These add further
protection to the brain, the roughest is the dura mater. Injury to the brain may occur as
a direct consequence of fracture of the skull (when fragments of the skull are pushed
into the brain), as the result of the brain "rattling about" inside the cranium and, finally,
as the result of injury to blood vessels supplying the brain and cranium. Needless to
say, these injuries commonly occur to combination.
New words and expressions
1. cognitive adj 认知的；认识的；有感知的
2. rehabilitate v 使(身体)康复；使复职；使恢复名誉；使复原
3. perpetuity. n 永恒
4. repercussions n 弹回；反响；反射
5. disintegration n 瓦解
6. marital adj 婚姻的
7. epidemiology n 流行病学
8. mortality n 死亡率
9. cranium n 颅
10. meninges n 脑(脊)膜
11. dura n 硬脑(脊)膜
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12. rattling about
迅速移动
SECTION 2
PATHOLOGY OF HEAD INJURY
It is extremely important to have a through knowledge of the mechanisms by which
trauma can affect the brain. Conventionally, brain damage following head injury is
divided into primary damage, which occurs at the moment of impact, and secondary
damage, which results from processes that are initiated at the time of impact (Admas
1990)
Primary damage takes the form of scalp lacerations, skull fractures, contusions and
lacerations of the brain, diffuse axonal injury, and intracranial hemorrhage. Secondary
damage, although initiated at the time of impact, may not be manifest clinically until
much later. Secondary damage takes the form of brain swelling, raised intra-cranial
pressure, hypoxia and ischemia, infection, and epilepsy. It should also be appreciated
at this stage that distinctions must be drawn between closed non-missile head injuries
and penetrating injuries to the head and the different problems that arise from them.
Primary damage
Scalp wound
Scalp wound are important as they indicate the site of injury. They may also overlie a
depressed fracture of the skull, making the injury compound. It is also very important
to appreciate that the scalp is very vascular and such wounds may bleed profusely,
sometimes resulting in massive blood loss.
Skull fracture
Many studies have shown that the more severe the head injury, the more likely it is to
be associated with a fracture. Jennett has shown (Jennett & Teasdale 1981) that skull
fractures are seen in 3% of patients attending in Accident and Emergency Department,
whereas they are present in 65% of patients who are admitted to neurosurgical
departments, and 80% of fatal head injuries have evidence of a skull fracture.
Fractures affecting the skull vault occur in 62% of patients with severe head injuries
and extend into the skull base in 77% of these. Isolated fractures of the skull base
occur in approximately 5% of patients with severe head injury. A depressed fracture
occurs if the fragments of the inner table of the skull are depressed by at least the
thickness of the diploë.
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Depressed fractures are compound if there is an overlying scalp laceration and are
said to be penetrating if there is an accompanying tear in the dura matter. Depressed
fractures are associated with an increased incidence of post-traumatic epilepsy. In
general, a patient who sustains a head injury associated with skull fracture will have
more chance of harboring an intracranial hematoma than one who has not sustained a
skull fracture (Mendelow et al 1983). It should be borne in mind that basal skull
fractures with involvement of the paranasal air spaces or middle ear cleft are
technically compound and may be associated with CSF rhinorrhea and otorrhea. CSF
rhinorrhea can also occur with a middle fossa fracture due to CSF passing into the
nose via the eustachian tube.
A blow sufficiently strong to fracture the skull frequently results in a period of
unconsciousness but this is not invariable. Fractures involving the vault of the skull
tend to require less force than those involving thicker parts of the skull, such as its
base. Fractures involving the skull, although having a horrific portent in the lay mind,
need not be associated with any significant brain damage. They usually require no
special treatment unless one or more fragments have been displaced inwards; in this
instance the depressed fragments have to be elevated, or removed.
Injuries of the meninges, other than these, are of relatively little importance provided
there is no concomitant injury to blood vessels or other structures.
Contusion and lacerations of the brain
A contusion is essentially an area of bruising of the brain and represents an area of
focal brain damage. The lepto-meninges remain intact with the contusion but, if they
are torn, a laceration of the brain is said to have occurred. Contusions occur when the
brain impacts against the bony protuberances that constitute the skull base and to a
lesser extent, areas within the skull vault. Many studies have shown that, no matter
where the point of impact on the skull is, contusions in the frontal and temporal lobes
predominate. Macroscopically, a contusion typically involves the crest of a gyrus,
which will appear hemorrhagic and swollen. The digitate white mater may be
involved if the contusion is extensive but the main significance of contusions lies with
their capacity to excite cerebral edema in the adjacent brain. Old healed contusions
appear as shrunken, yellowish brown areas and are known as plaques jaunes. A
number if attempts have been made to classify contusions such as fracture contusions
that occur at the site of a fracture or herniation contusion that occur along the medial
aspect of the temporal lobes or on the cerebellar tonsils. A coup contusion occurs at
the site of impact, in the absence of a fracture, or as a contrecoup contusion at a point
diametrically opposite the point of impact.
All the contusion described so far occur as a result of forceful contact between the
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brain and bony prominences, but gliding contusions occur as a result of rotational
injury and typically involve the superior surfaces of the cerebral hemisphere. The
distinction between gliding contusions and diffuse axonal injuries can sometimes be
difficult.
An area of confluence contusions, in which the leptomeninges have been torn and
bleeding has occurred into the subdural space, is often referred to as a “burst lobe”. In
view of the predominance of contusions in the frontal and temporal lobes, burst
frontal and temporal lobes tend to predominate.
Diffuse axonal injury
Diffuse axonal injury was first described accurately by Sabina Strich in Oxford in the
1950s (Strich 1965). She correctly attributed this type of primary brain damage to
shearing of nerve fibers that occurred at the time of impact. The term “diffuse axonal
injury” was coined by Hume Adams in Glasgow and is now universally accepted
(Adams et al 1992). Severe diffuse axonal injury is responsible for 75%of all deaths
after head injury and is the most important cause of severe disability and cause for
remaining in a persistent vegetative state. Half of the patients with a severe head
injury who do not have an intracranial mass lesion will have sustained a diffuse
axonal injury. The characteristic features of diffuse axonal injury vary both
macroscopically and microscopically according to the age of the lesion, but typically
occur in the following locations:
1. Within the corpus callosum extending over a variable antero-posterior distance,
typically to one side of the midline. Such lesions may be associated with
intraventricular hemorrhage and damage to the intraventricular septum.
2. Focal lesions of varying size which affect the dorsolateral quadrants of the rostral
brainstem, particularly near the superior cerebellar peduncles.
If the patient lives or only a few days after a head injury the lesions described above
will usually be hemorrhagic in appearance but with the passage of time all that may
be visible macroscopically is a shrunken area of scarring. It is important at this stage
to emphasize that diffuse axonal injury is diffuse. Irrespective of the lesions described
within the corpus callosum and the brainstem, microscopically evidence of
widespread damage to axons will be found. Once again the microscopic appearances
vary according to the length of time the patient survives after staining a diffuse axonal
injury. If the patient survives a few days, the characteristic appearance of retraction
balls will be seen in a silver-stained preparation. These balls represent egress of
axoplasm from torn axons. If the patient survives for 2-4 weeks, microglia will
infiltrate the involved areas, forming microglial stars. Lipid-filled macrophages and
astrocytes wick also be seen amongst these clusters of microglia. If the patient
survives for a prolonged period if time, myelin stains will show demyelination of the
involved tracts. If the brain if a long-term survivor of a diffuse axonal injury is sliced
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in the coronal plane, ventricular dilation is often evident due to loss of adjacent white
matter.
Patients who have sustained diffuse axonal injuries form a distinct
clinico-pathological group who tend to be unconscious ab initio and remain so, and
have a low incidence of skull fracture, lobar contusions and intracerebral hematomas.
In addition, the probability that such a patient will have raised intracranial pressure is
significantly lower than in those who sustain contusional injuries.
Adams et al (1989) have graded diffuse axonal injury as follows:
Grade I: Axonal injury in the white matter of the cerebral hemisphere, corpus
callosum, brainstem and cerebellum.
Grade II: As for Grade I but in addition a focal lesion is present within the corpus
callosum.
Grade III: As for Grade II but in addition a focal lesion is present in the dorsolateral
part of the rostral brainstem.
It should be stressed that such lesions often can only be identified microscopically.
Vascular change
Vascular change are complex when they occur in response to mechanical head injury
and they include changes in the mechanism of cerebral autoregulation.
Ultrastructurally, endothelial changes occur in the pial arterioles, appearing as a
ballon or bleb, which on bursting produces cratering of the endothelium (Go 1991).
The permeability of the vascular wall alters as a result, and escape pf macromolecules
into the perivascular compartment occurs. In addition to such morphologic changes,
alternation in the normal autoregulation of the cerebral vasculature may occur. This
results in a derangement in the dynamics of cerebral blood flow. Experimental modals
have shown that following mild to moderate injury there is an initial hyperemia with
an increase in cerebral blood flow and a decrease in vascular resistance. With more
severe injuries a generalized loss of autoregulation takes place.
Ischemia
Graham& Adams (1971) have shown that focal areas of ischemia may be seen in as
many as 80% of patients who come to autopsy as a result of a head injury. In 45% of
cases ischemic changes are cortical and are particularly noticeable in the watershed
areas between major arterial territories. Overall, 55% of patients will show focal
ischemic areas within the basal ganglia, 45% in the hippocampus, and 30% within the
brainstem. The mechanisms that produce such vascular changes are complex and
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include mass lesions that result in traction on major feeding vessels, traction or
disruption of perforating arteries, vasospasm, raised intracranial pressure, brain
swelling and loss of autoregulation.
Brain edema
Traumatic tends to result in a predominantly vasogenic brain edema.
Secondary damage
Secondary damage can be prevented ir minimized by appropriate timely treatment. It
is convenient to classify the etiology of secondary events into extracranial and
intracranial insults （Marks & Lavy 1992).
Extracranial insults
Hypoxemia This may be attributable to central damage to the brainstem which
results in increased respiratory drive or centrally mediated pulmonary edema. In
addition, pulmonary complications such as pneumothorax, hemopneumothorax,
aspiration pneumonia or rib fracture, particularly when associated with a flail segment
of the thoracic wall, can contribute to hypoxia. The resulting cerebral hypoxia is often
manifest as a decrease in the level of consciousness and such hypoxia itself may
contribute further to brain edema.
Hypotension As head injuries are frequently associated with multiple trauma, the
development of hypotension is a distinct possibility. The combination of hypotension
and hypoxemia is particularly lethal if inadequately treated. Hypotension may lead to
neuronal necrosis or areas of boundary-zone infarction in watershed areas between the
main arterial territories.
Intracranial insults
Injuries to blood vessels
Blood vessels abound within the cranium. They exist:
(a). Between the dura mater and the skull (extradural blood vessels).
(b). Between separated layers of the dura mater (venous sinuses).
(c). Between the dura mater and the brain (sub-dura vessels).
(d). Within the brain substance itself. With injuries of any severity, tearing of one or
more of such groups of blood vessels is inevitable.
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Bleeding may be confined to a particular area or there may be hemorrhages scattered
throughout the brain substance and beneath its coverings. Collections of blood may
accumulate between the cranium and the dura mater (extra-dura hemorrhage),
between the dura mater and the brain (sub-dura hemorrhage), into the cerebrospinal
fluid (sub-arachnoid hemorrhage), or into the brain substance (intra-cerebral
hemorrhage).（Figure 3.1）
Figure 3.1
Extra-dural and sub-dural hemorrhage
When a collection of blood develops either external (Figure 3.2) to or just beneath
(Figure 3.3) the dura mater, cerebral compression follows. The patient gradually
lapses into coma and unless the compressing haematoma is evacuated, death will
ensue. Even where death is prevented by surgical means, there may be severe residual
brain damage, if the period of severe compression was too prolonged.
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Figure 3.2
Figure 3.3
Sub-arachnoid hemorrhage
Bleeding into the sub-arachnoid space is common following head injuries but is of no
special significance as a rule. The blood eventually becomes evenly distributed
throughout the sub-arachnoid fluid space and is gradually absorbed.
Sub-arachnoid hemorrhage may occur spontaneously when aneurysms (thin-walled
dilatations) of cerebral vessels burst. Tearing and disruption of brain may occur, and
late complications include the development of sub-arachnoid adhesions which may
lead to hydrocephalus. Ruptures of aneurysms may be precipitated by heavy lifting of
straining (for example, during coitus).
Intra-cerebral hemorrhage
If vessels lying within brain substance are torn, collections of blood appear (Figure
3.4). If the hemorrhages are very small, symptoms may be minimal. However, even
tiny hemorrhages, if their number is large, may lead to severe brain damage or even
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death. In the case of large collections of blood, portions of the brain are torn apart and
severe disturbance of cerebral function is the rule. On occasion such intra-cerebral
collections are removed surgically.
Figure 3.4
Manifestation of brain injury
As a consequence of an injury to the head, the brain may jump to and fro inside the
cranium, thereby sustaining a number of injuries due to a ricochet effect. Concomitant
injury to blood vessels is, in these circumstances, virtually inevitable but, ignoring
this, tearing of various parts of the brain, particularly its under surface, is frequent and
may be sufficient to cause death.
Diseases or injury to the brain can have an immense number of different effects but
they may be grouped as follows.
(1). Derangement of higher mental function. That is thinking, ability to appreciate
sensations received, memory, etc.
(2). Derangement of motor function. The brain is essential for the initiation control of
all voluntary movements. Loss of function of those parts of the brain responsible for
this control leads to disorders such as paralysis, tremor, lack of co-ordination and
involuntary movement.
(3). Disorders of sensory function. Depending upon the level of injury to the central
nervous system, sensations such as touch , pain, balance, sight, hearing, taste and
smell may become absent, impaired or abnormal.
(4). Disorders of vegetative function. Many of the functions of the body which are not
under conscious direction are nevertheless controlled by the brain, One example is the
regulation of breathing. After severe injury affecting the brain stem, impulses to the
muscles of respiration cease to be delivered by the brain, breathing ceases and death
ensues rapidly.
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New words and expressions
1. Scalp n 头皮
2. Skull n 头骨
3. paranasal adj 鼻旁的；鼻侧的
4. rhinorrhea n 鼻液溢
5. otorrhea n 耳液溢；耳漏
6. Eustachian adj 欧氏的
7. contusion n 擦伤；撞伤；挫伤
8. lacerations n 破口
9. gyrus n 脑回
10. cerebellar adj 小脑的
11. tonsil n 扁桃腺
12. contrecoup n 对侧伤；对侧外伤
13. intraventricular adj 心室内的
14. septum n 隔膜
15. dorsolateral adj 背外侧的
16. peduncle n (肿瘤或息肉的)肉茎
17. rostral adj 喙的；有喙的
18. axoplasm n 轴索浆；轴索原浆
19. astrocytes n (脑和骨髓的)星细胞；星形胶质细胞
20. demyelination n 髓鞘脱夫；脱髓鞘
21. autoregulation n 自动调整
22. cratering n 缩孔(露底)；陷穴(漆病)；磨顶槽
23. pial adj 软膜的
24. vasculature n 脉管系统
25. hypoxemia n 血氧不足
26. hypotension n 血压过低
27. pneumothorax n 气胸
28. hemopneumothorax n 血气胸
29. extra-dural hemorrhage 硬膜外出血
30. sub-dural hemorrhage 硬膜下出血
31. sub-arachnoid hemorrhage 蛛网膜下腔出血
32. intra-cerebral hemorrhage 脑内出血
SECTION
3
COMPLICATION
AND
RESIDUAL
SYNDROMES
Brain swelling
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Brain swelling is a well-recognized complication following a head injury and may
contribute to a rise in intracranial pressure. After cranial trauma, three main types of
swelling may occur:
1. Swelling of the white matter adjacent to contusions. This is thought to be due to
leakage of fluid from damaged vessels and loss of arteriolar tone (Go 1991).
2. Diffuse swelling of a hemisphere or the whole brain. Unilateral hemispheric
swelling tends to occur in association with an overlying acute subdural hematoma
and, following its evacuation, the brain can swell, often very rapidly and
dramatically, into the space formerly occupied by the hematoma.
3. Swelling of the entire brain may take place in children and adolescents. The
mechanism of this is not clear, but immaturity of the blood-brain barrier in
younger children may certainly be a contributory factor.
It is important to stress that, whatever the mechanism of brain selling, it can be
exacerbated by extracranial events such as hypoxia and hypotension, and the resulting
vicious circle will tend to increase the amount of brain swelling, contributing further
to a rise in intracranial pressure.
Infection
Meningitis is a well-recognized problem of head injury and may be found with basal
skull fractures associated with a dural tear. It is important to appreciate that this
problem may not develop immediately after head injury and indeed may be seen
several months or even years later. Penetrating injuries associated with compound
depressed fractures may also be associated with meningitis or cerebral abscess (Marks
& Lavy 1992).
Hydrocephalus
Hydrocephalus may be seen after head injury and may be either noncommunicating or
communicating (marks & Lavy 1992).
Noncommunicating hydrocephalus
This may develop acutely secondary to a posterior fossa hematoma which causes
compression and obstruction of the CSF pathways.
Communicating hydrocephalus
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This is a more frequent occurrence after head injury and results from the presence of
blood within the subarachnoid spaces which leads to derangement.of the flow and
absorption of CSF. Typically, this complication may develop between 10 and 14 days
after the injury and will be manifested clinically as a failure to improve after some
initial progress has been seen or by frank deterioration.
Post-traumatic epilepsy
Post-traumatic epilepsy is characteristically divided into early post-traumatic seizures,
which occur within seven days of head injury, and late post-traumatic epilepsy which
occurs at any points thereafter. Some authorities also recognize a third category,
entitled immediate post-traumatic epilepsy, which occurs within one minute to one
hour after cranial trauma (Greenberg 2001)
Early post-traumatic epilepsy
There is a 30% incidence in severe head injury and an approximate incidence of 1%
in mild to moderate injury. In pediatric practice 2.6% of children under the age of 15
years who sustain a head injury which causes brief loss of consciousness or amnesia
will experience an early post-traumatic fit.
Early post-traumatic epilepsy may be associated with the development of adverse
events such as a rise in intracranial pressure, alterations in blood pressure, and the
release of excessive neurotransmitter substances (Greenberg 2001).
Late post-traumatic epilepsy
By definition, late post-traumatic epilepsy occurs more than seven days after cranial
trauma. It has been estimated that the incidence of late post-traumatic epilepsy overall
is somewhere between 10% and 13% within two years of a significant head injury. As
might be expected, the incidence of late post-traumatic epilepsy is higher in severe
head injuries when compare with moderate or mild head injuries. Although the
incidence of early post-traumatic epilepsy is higher in children, the development of
late seizures is less frequently observed in children.
Penetrating cranial trauma is associated with higher incidence of post-traumatic
epilepsy than closed head injuries. The overall incidence is 15% in patients who are
followed up for a period of 15 years. The majority of patients who have not had a
seizure within three years will not go on t develop fits.
Anticonvulsant drugs can be used to prevent early post-traumatic seizures in those
considered to be at high risk. The prophylactic use of anticonvulsant medication does
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not reduce the incidence of late post-traumatic fits (Greenberg 2001).
Outcome and prognosis
Age is a major determinant of the degree of recovery following head injury. In general,
infants recover better than children, and children better than adults (marks & lavy
1992).
A number of factors have been shown to be associated with a poor outcome following
head trauma. These include:
(1) persistent rise in intracranial pressure of more than 20mmHg despite
hyperventilation;
(2) increasing somatic age;
(3) impaired or absent papillary light responses or eye movements;
(4) hypotension;
(5) hypercarbia;
(6) hypoxemia or anemia;
(7) the presence of a mass lesion requiring surgical removal; (8) raised intracranial
pressure during the first 24 hours after injury.
It has also been shown that the presence or absence of the basal cisterns as visualized
on the presenting CT scan is an important prognostic indicator. In general, effacement
of the basal cisterns is associated with a poor outcome (Toutant et al 1984).
Research has also shown that the presence of the genotype apo E4 allele is associated
with a worse prognosis following traumatic brain injury. Interestingly, the presence of
the allele is also a risk factor for the development of chronic traumatic
encephalopathy and Alzheimer’s disease (Friedman et al 1999).
The Glasgow Outcome Scale (GOS) is often used to assess the outcome following a
head injury.
One of the questions that is invariably asked by patients, their realatives, and lawyers
acting in personal injury claims is over what period of time will natural recovery take
place. It is generally accepted that natural recovery following a head injury or other
neurologic event will take place for up to two years and any problems which remain
thereafter can be regarded as being fixed or permanent (mark & lavy 1992).
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It is important to note that the maximum rate of recovery tends to take place within
the first six months; thereafter recovery occurs at a much slower pace. Moreover, if a
patient has scored 4 on the Glasgow Outcome Scale it is most unlikely that he or she
will score 5 by the end of the ensuing 18 months.
Post-concussion syndrome
Post-concussion syndrome consists of a very characteristic and vague stereotyped
concatenation of symptoms that is associated with mild head trauma. Paradoxically,
the milder the head injury, the greater the severity of symptoms described by the
patient. The symptoms that constitute post-concussion syndrome can be divide into
somatic, cognitive and psychosocial problems (Alves % Jane 1990).
A. Somatic: (1) headache; (2) diziness; (3) blurring of vision; (4) disturbances of
smell; (5) tinnitus or alteration of auditory acuity; (6) problems with balance and
equilibrium.
B. Cognitive: (1) poor concentration; (2) impairment of short term memory; (3)
intellectual deterioration.
C. Psychosocial: (1) loss of libido; (2) alteration of the sleep/wake cycle; (3)
personality change; (4) irascibility; (5) intolerance of noise; (6) marital difficulties
and the increased risk of being made redundant.
The treatment of this condition is difficult and a number of studies have shown that a
full explanation of the problems the patient will likely have at the time of discharge
from hospital can go a long way in reducing the duration of such symptoms. It has
been noted that the prognosis is better if symptoms develop earlier than if they
develop some time after discharge from hospital. In patients who have a protracted
course, evaluation in the form of CT or MRI scanning and the performance of an
electroencephalogram may be justified to determine whether correctible pathology is
present. If such studies are negative it is important to inform the patient that no
objective evidence of disease has been found and psychological counseling or
psychiatric referral may then be of benefit.
New words and expressions:
1. swelling n 肿胀
2. infection n 感染
3. hydrocephalus n 脑水肿, 脑积水,患脑积水的
4. posterior fossa n 后颅窝
5. derangement n 紊乱
6. epilepsy n 癫痫症
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7. encephalopathy n 脑病
8. post-concussion syndrome 脑震荡后综合症
SECTION 4
RESIDUAL BRAIN DAMAGE
With increasingly careful statistical research it has been found that the survivors of
severe head injuries are more frequently significantly disabled than was previously
thought. Although it is true that where there has been severe brain damage, death is
more common than severe residual disability, one-sixth of the survivors of major head
injuries find permanent employment at a simpler level than prior to their accident. In
various studies severe head injury is defined in different ways, in some it is defined
according to the length of the period of retrograde amnesia, but probably the best
criterion is the duration of loss of consciousness. Any patient who is unconscious for
more than 24 hours after a head injury will need careful assessment from this point of
view. The following are common residual defects:
Post-traumatic headache
If we exclude those rare cases of post-traumatic imtra-cranial disease which lead to
raised intra-cranial pressure, more authorities agree that post-traumatic headache is
not permanent, and indeed in most cases it disappears during the first year following
head injury. However, a large number of patients who have had a head injury continue
to complain of headaches which persist for many years, or of an increased frequency
in the number of headaches. Unfortunately there is no objective way to determine the
amount of pain experienced, and one is therefore largely dependent on the patient's
statements, tempered by his ability to demonstrate his own veracity in other ways.
Vertigo (dizziness)
Vertigo may be due to injury to the brain stem or to the labyrinth of the inner ear.
Most patients with this disability make a complete recovery within two years.
Paralysis
As the nervous pathways for the brain to the body cross the mid-line, the paralyses
side is opposite (contralateral) to the injured side of the brain. Any degree of paralysis
may occur from trivial weakness to complete inability to move a limb. Where
paralysis has been of long standing, deformities may develop of which the commonest
are flexion of the thigh against the body, and a paralysed arm held in a " praying
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mantis" position.
Muscular rigidity
After severe injury the brain centres concerned with control of muscular tone may be
so disordered that some or all muscles remain in a constant state of contraction. In
extreme cases, all voluntary muscles of the body are held in constant contraction
excepting the muscles of respiration. When this state of generalised rigidity is
associated with a prolonged or permanent state of unconsciousness, it is given the
name "decerebrate rigidity".
Defects of specialised functions
There may be speech defects, defective sense of smell or taste and deafness. These are
by no means rare consequences of head injury.
Epilepsy
Epilepsy may follow head injuries, particularly those where the dura mater has been
penetrated.
Mental disability
With improved resuscitative measures there are more survivors of serious head injury
and many of these are seriously disabled. Thus, in 230 survivors of 433 victims of
severe head injury reported by London, 51 persons were disabled to some extent or
other and of these 13 seriously so , exhibiting "childishness", violent behavior or
psychosis.
Miscellaneous disorders
Weakness, impairment of vision, Horner's syndrome and diabetes insipidus.
New words and expressions
1. retrograde adj 逆行的；退行的
2. amnesia n 遗忘
3. tempter v 搀和；搀杂
4. vertigo n 眩晕
5. labyrinth n 迷宫；迷路
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6. flexion n 屈曲
7. mantis n 螳螂
8. tone n 紧张性；状态
9. contraction n 萎缩；短缩
10. generalised adj 全身性的；扩散的
11. decerebrate rigidity 去脑强直
12. penetrate v 渗透；通过；穿透
13. resuscitative adj 复苏的
14. psychosis n 精神病
15. miscellaneous adj 各种各样的；混杂的
16. diabetes insipidus 尿崩症
SECTION 5
THE ROLE OF A CLINICAL FORENSIC PHYSICIAN IN THE
ASSESSMENT OF NONFATAL HEAD INJURIES
The role of the clinical forensic physician essentially falls into three categories:
1. the acute assessment of the head–injured patient he or she might be called to see
2. the assessment of an accused who may have sustained a head injury and who has
also taken alcohol or illicit drugs
3. the preparation of medical reports as directed by the Court or insurance company,
etc.
In the emergency setting the time-honored principles of maintaining the airway and
ensuring that breathing is occurring and the circulation is maintained are of paramount
importance and cannot be overstressed. Attention should be paid to these factors while
the emergency services are arriving. The details of such resuscitative measures are
well known and are essentially beyond the scope of this chapter, but the reader is
referred to the ATLS manual (1996) for further information.
When called to see an accused in custody who is unconscious or drowsy, the clinical
forensic physician should have a high index of suspicion that the individual may have
sustained a head injury. Assurances from the police that the accused has taken illicit
substances or a large quantity of alcohol should increase the index of suspicion rather
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than decrease it. Many a prisoner has met with an untimely end when persisting
drowsiness or unconsciousness was attributed to the ingestion of alcohol or illicit
drugs, when in fact an extradural or subdural hematoma was present and only
correctly diagnosed at the time of autopsy (Marks & Lavy 1992). If in doubt, assume
that the patient has sustained a head injury and arrange for immediate transfer to
hospital where appropriate assessment by a neurosurgeon can take place.
The clinical forensic practitioner may well be called upon to write medical reports for
the Court on patients he or she has examined. Many books and courses are devoted to
this important area of practice. When reporting on head – injured patients the
following factors should e taken into consideration:
1. date and time of the injury
2. mechanism of the injury
3. whether the injury resulted in loss of consciousness
4. the presence of other injuries
5. neurologic assessment including the presenting Glasgow Coma Scale
6. whether alcohol or illicit drugs were taken
7. whether the patient had had a fit
8. significant past medical history including closed head injury and the presence of
pre - existing epilepsy
9. treatment the patient received including the period of hospitalization
10. estimation of the period of post-traumatic amnesia.
If updated reports are required, the presence of ongoing symptoms that are
attributable to the injury should be chronicled.
It may be difficult to give a definitive prognosis, but the period over which natural
recovery can take place, i.e. two years, should be highlighted. Where specialist
information is required, either from a neurosurgeon, neuropsychologist or other
practitioner, a recommendation that the patient should be seen by such individuals
before a final opinion can be offered is very helpful.
New words and expressions
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1. nonfatal adj 非致命的
2. illicit adj 违法的
3 accused n 被告
4. emergency n 紧急情况；突然事件
5. paramount adj 极为重要的
6. resuscitative adj 使复生的；使复兴的
7. assurances n 确信；断言；保证；担保
8. suspicion n 猜疑；怀疑
9. extradural adj 硬(脑)膜外的
10. subdural adj 硬膜下的
11. hematoma n 血肿
12. epilepsy n 癫痫症
13. amnesia. n 健忘症
14. chronicle v 编入编年史
15. highlighted adj 突出的
16. neuropsychologist n 心理学者
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Chapter 4
The Eyes
SECTION 1
CONCEPTION IN OPHTHALMOLOGY AND DISEASE IN
EYE INJURY
Basic conception in ophthalmology
A statistical verification of the increasing occurrence of complicated eye disorders
associated with facial injuries demands a total eye examination. An ophthalmologic
examination is inadequately performed if only one eye is examined (usually the side
of the facial injury). Comparative studies of each eye in relation to the other eye is
essential in order to ascertain an otherwise undetected eye disorder. A minor
conjunctiva laceration can be associated with a retinal detachment.
The gravity of eye injuries with the possible complication of partial or total vision
loss has culminated in a legal decision in Maryland. The verdict differentiates the
legal obligations of the ophthalmologist, the optometrist, and the optician.
"Ophthalmology is the science which deals with the physiology, anatomy and the
pathology diseases of the eye. It related to the practice of medicine and surgery by an
ophthalmologist who is a duly licensed physician and who specialized in the care of
the eyes. The optometrist examines eyes for refractive error, recognizes (but does not
treat) diseases of the eyes and fills prescriptions for eye glasses. The optician is an
artisan qualified to grind lenses, fill prescriptions and fit frames". In a court of law,
the medico-legal eye expert whose testimony is a acceptable medically is the
ophthalmologist.
Aspects of the cause for eye injuries
Because of the negligence factor in legal actions, two aspects of the cause for eye
injuries require considerable attention. The first is the protective anatomic structures
which, if not injured, prevent or diminish the severity of eye injuries. These are the
strong bony orbits and the resilient fat pad behind the eye globe, that is, a soft
protective cushion. In addition, the facile sensitivity of the cornea, plus the rapidity of
the blinking reflex, are maximum physiologic safeguards in the prevention of eye
injuries. The second concerns the ambiance that exposes the eyes to injuries. For this
reason athletes are trained to use head helmets. Masks are advocated for hockey
players. Mandatory facial protection regulation can reduce ocular injuries in most
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athletes.
Morbid origin with eye disturbance after an accident
On many occasions following an accident a person will present eye complaints to the
examining physician that may arise from diseases in general and constitutional
diseases in particular. A classical example is unfolded in persons with known or
unknown diabetes mellitus. The protean symptoms of this disease may be attributed to
an injury. When in reality the cause for the symptoms is diabetes mellitus. A claimant
can beguile a physician unless the thought is ever present that changes in the retinal
vasculature, alterations in the central nervous system, and nerves are an integral
segment of the diabetic mellitus complex syndrome.
Another eye finding that is erroneously attributed to an injury is a pterygium. This
visible eye disturbance is a triangular fold of membrane occupying the interpalpebral
fissure. Usually it extends from the inner or outer part of the ocular conjunctiva to the
cornea. The blunted apex is united immovably to the cornea with the wider base
merging with the conjunctiva. It occurs mostly in elderly persons as well as in people
who are exposed to wind or dust (farmers, road builders, trick drivers, masons, sailors,
and construction workers). It is less common in blue or white collar workers. It is not
of traumatic origin.
The return if syphilis to the medical scene alerts the examining physician to certain
ocular signs that are not traumatic in origin. Early signs of neurosyphilis are
irregularity and inequality of the pupils. Response of the pupils to accommodation but
not to light is named Argyll Robertson pupil. Paralyses of the extrinsic eye muscles,
especially the levator palpebral superioris, and the external or internal rectus muscles
may be the first manifestation of tabetic neurosyphilis.
SECTION 2
A CASE OF EYE INJURY AND VIEW OF CONTACT
LENSES
A Case report
An insight into an eye injury was exemplified when a 40-year-old psychologist was
injured in a motor vehicle accident. He was examined by his ophthalmologist 4hr after
the accident because he developed blurred vision, as well as double vision,
particularly if looking to the left and downward. When the psychologist moved his
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head from side to side the double vision lessened. The double vision worsened when
the head was tilted to the right. The ophthalmologist's impression was that the patient
had a post-traumatic right trochlear nerve (Figure 4.1, Figure 4.2) palsy with some
refractive difficulty in the left eye that were the causes for the diplopia and other
symptoms. The psychologist was free from symptoms 6 weeks after the accident. The
trochear nerve is the fourth cranial nerve. It supplies the superior oblique muscle of
the eye. The main action of this muscle is depression of the eyeball. The subsidiary
function is abduction with intorsion of the eye.
Figure 4.1
Figure 4.2
Contact lenses
The universal acceptance of contact lenses does not indicate that they are a protection
against eye injuries. Some workers use these lenses in their occupation where fogging
of eyeglasses should be avoided such as working in refrigerators. The majority of
contact lenses are fitted for cosmetic reasons. A frequent use is in athletes. Football,
soccer, basketball, tennis, handball, and racquetball players who wear contact lenses
should use protective eye guards to prevent injuries resulting from being struck in the
eye with the ball. Failure to protect the contact lenses with an injury to the eye via a
contact lens is a basis for mitigation of a negligence claim due to culpable conduct.
New words and expressions
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1. ophthalmologic adj 眼科的
2. conjunctiva n (眼球) 结膜
3. retinal. adj 视网膜的
4. detachment n 分开；分离
5. culminated v 达到顶点；终止
6. Maryland n 马里兰
7. ophthalmologist n 眼科专家；眼科医师
8. optometrist n 验光师；视力测定者
9. optician n 光学仪器商；眼镜商；光学仪器制造者
10. refractive adj 折射的
11. orbit n 眼眶
12. resilient adj 弹回的；有回弹力的
13. fat pad 脂肪垫
14. cornea n 角膜
15. ambiance n 周围环境；气氛
16. morbid adj 病态的
17. constitutional adj 体质的
18. claimant n (根据权利) 提出要求者；原告
19. beguile v 诱谝；诱惑
20. protean adj 反复无常的；变化多端的
21. vasculature n 脉管系统
22. pterygium n 翼状胬肉
23. occupying n 占用；占领
24. interpalpebral adj 睑间的
25. fissure. n 裂缝；裂沟
26. masons n 泥瓦匠
27. syphilis n 梅毒
28. accommodation n (眼镜等的) 适应性调节
29. levator n 提肌
30. palpebral adj 眼睑的
31. rectus n 直肌
32. tabetic adj 脊髓痨的
33. trochlear adj 滑车的
34. palsy n 瘫痪
35. diplopia n 复视
36. abduction n 诱导
37. intorsion n 内扭转；内旋
38. racquetball n 网球等
39. culpable adj 不周到的
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Chapter 5
SECTION 1
The Ears
ANATOMY OF THE EARS
The ear is concerned with two functions, hearing and the sense of balance. The latter
function can, to a very large extent, be replaced by an alternative mechanism, namely,
that which depends upon vision. and on stretch receptors in muscles and tendons, the
impulses from which reach the cerebellum (the portion of the brain at the back of the
cranium). Hence, even if the internal ear on each side is completely destroyed, the
sense of balance is not lost; indeed, the only serious defects suffered by the patients
are (apart from the hearing loss) that he is unable to swim under water, particularly at
night, and has difficult in walking in the dark as there is loss of "gravitational
sense".
During the acute phase of the inflammation of the labyrinth, the patient may be
extremely dizzy and unable to walk at all. However, when the acute phase has settled,
the disabilities due to loss of sense of balance owing to labyrinthine diseases are not
frequently noticed as a serious disability by the patient. Claims for damages owing to
permanent loss of sense of balance following internal ear disease are rare and will
therefore be considered no further.
The function of hearing is subserved by the external ear, the external auditory means,
the tympanic membrane and three ossicles that join the tympanic membrane to the
cochlea. In the cochlea, sounds are "translated" into nerve impulses which are
conducted by the means of the auditory nerve to the brain. Interference with the
function of any part of this chain will lead to loss of hearing of one degree or another.
Auricle
The auricle (or pinna) is one visible part of the ear. In many animals the auricle is
mobile and is used as a cup to concentrate sound waves impinging on it. In man this
function has been lost and the contribution to hearing by the auricle is not great.
The auricle is commonly injured in motor accidents and during fighting. The common
injuries are lacerations, sometimes associated with complete loss of a portion of the
pinna, and crushing injuries, such as commonly occur at wrestling. In the former
instance, if there has been no tissue loss a very satisfactory cosmetic result is
frequently obtained. In crushing injuries, blood vessels are frequently ruptured and
blood may then accumulate between the skin and the auricular cartilage. If such
haematoma is not completely reabsorbed, it is replaced by fibrous tissue and leads to
an ugly lumpiness of the ear commonly referred to as "cauliflower ear".
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In severe burns, the ears are frequently affected, often with considerable destruction
of auricular tissue. Cosmetic deformity may be very serious. Where an ear or a large
portion of an ear has been lost, naturally coloured prostheses may be employed which
closely resemble a normal ear, plastic surgical reconstruction of ears is unsatisfactory,
although small portions of soft tissue may be replaced where losses are not great.
External auditory meatus
The external auditory meatus is the canal leading from the auricle to the middle ear. It
is not commonly severely injured, and as a general rule, even when it is injured,
healing is complete without residual loss of function. Where there has been extensive
loss of tissue, due. for example, to burning, the opening may be narrowed to such a
degree that there is interference with the function of hearing; in addition, debris may
accumulate.
The external auditory meatus is one of the parts of the body where foreign bodies,
including insects and seeds, may easily become lodged. Although an employer may be
liable for treatment of such a condition, residual disability after removal of a foreign
body is rare, and litigation therefore does not commonly arise.
The only other condition of the external auditory meatus which may become the
subject of
litigation is external otitis. This is essentially a dermatological condition affecting the
skin of the auditory canal, and a worker may claim that the condition arose from the
handing of irritating or dirty materials.
Middle ear
The middle ear is that portion of the hearing mechanism which consists of the
tympanic membrane, the three middle ear ossicles, and the cavity in which they lie,
together with accessory structures.
The most common disease affecting this area is infection (otitis), which may be
complicated by infection of the mastoid air cells (mastoiditis). However, both
conditions are rarely the subject of litigation, and will be considered no further.
New words and expressions
1. cerebellum n 小脑
2. gravitational adj 重力的；吸引力的
3. subserve v 对....有益；对....有帮助
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4. meatus n 道
5. tympanic adj 鼓面的；鼓室的
6. cochlea n (耳）蜗；耳迷路
7. auricle or pinna n 耳廓
8. impinging n 撞出；冲击
9. cartilage n 软骨
10. lumpiness n 凸凹不平
11. cauliflower n 花椰菜；菜花
12. prostheses n 修复术
13. reconstruction n 重建；改造
14. debris n 碎片
15. lodge v 容纳；寄存
16. otitis n 耳炎
17. dermatological adj 皮肤科的
18. accessory adj 附属的；辅助的
19. mastoid adj 乳突的
20. mastoiditis n 乳突炎
SECRION 2
AETIOLOGY OF IMPAIRED HEARING
External ear
Loss of hearing due to injury to the external ear and canal arises in significant degree
only when there is narrowing or obstruction of the external auditory meatus.
Medico-legally this is important in cases where wounding or burning of this area has
occurred.
Middle ear
Most conditions affecting the middle ear, which includes the tympanic membrane and
the ossicular chain, are not traumatic in origin and are not commonly directly
involved in litigation. However, they are of great importance in that they may produce
impairment of hearing in their own rights, and where the causation of such middle ear
disease is the result of a "naturally occurring " condition. Such hearing losses as arise
have to be deducted from other causes of hearing loss due to, for example, excessive
noise, where a claim for workers' compensation or damages is involved.
The tympanic membrane may be ruptured by an explosive blast. This may lead to
hearing losses and may also permit the entry of infecting organisms, thereby leading,
in some cases, to otitis media. Similarly, the drum membrane may be ruptured by a
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blow on the ear, but only rarely do foreign bodies produce such defects. On rare
occasions blasts and hard blows on the head will cause dislocations of the ossicular
chain.
Destruction or interference with the function of the tympanic membrane or the middle
ear mechanism produces a very variable amount of hearing loss, ranging from very
little to a maximum (average hearing loss) of 50-55 decibels (equivalent to
approximately 40 percent hearing loss in the affected ear). If the hearing loss is
greater than this, it should be concluded that there is also damage to the cochlea or the
auditory nerve.
Otosclerosis is a disease affecting a large number of people from the third decade of
life onwards. There is progressive impairment of hearing, which is frequently bilateral.
The footplate of the stapes (one of the osscles in the middle ear) becomes attached to
the oval window, and this union becomes ossified. In the fully developed condition
the otosclerotic process may also affect parts of the internal ear and also the canal in
which the auditory nerve runs.
Otosclerosis is not produced by trauma nor is there any evidence that it is an
occupational hazard. It is a common disease, however, and a workman in a noisy
occupation who develops the condition may wrongly attribute it to this work.
Internal ear
Disease of the cochlea and of the auditory nerve leads to what is termed
neuro-sensory hearing loss (also described as nerve deafness and perceptive deafness),
Impairment of hearing arising from this area can be due to a large number of factors
including congenital anomalies. Only those causes which are of medico- legal
importance are considered below.
Injury
A blow to the head, whether it results in skull fracture or not, may produce
neuro-sensory hearing loss. Such losses are most likely to arise when fractures
involve the temporal bone, and particularly if the fracture line passes through the
cochlea. Almost invariably, in injuries of such severity there will have been a periods
of loss of consciousness. Deafness induced by head injuries is usually unilateral, or at
least of unequal severity on the two sides.
Explosive blasts, in addition to producing injury to the middle ear as previously
indicated, may, probably by inducing haemorrhage into the internal ear, produce
neuro-sensory hearing loss. Similarly, pressure changes may produce similar effects
although here again the important injury is usually to the middle ear.
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Following trauma, the neuro-sensory hearing loss produced does not stabilise for at
least six months even though at the end of 14 days the amount of hearing loss which
one may reasonably expect will be fairly clear.
Noise exposure
There is no doubt that exposure to noise impairs hearing. It is common knowledge
that ringing in the ears (tinnitus) can be induced by loud noises. Then again after
exposure to a loud noise, such as, machinery in a factory or a jet aeroplane, a
temporary period of partial hearing loss is almost universally experienced. Exposure
to noise for prolonged periods may induce permanent neuro-sensory hearing loss.
Unfortunately, as all individuals in a civilised society are exposed to noise, it is
impossible to determine precisely what level of noise impairs hearing,, most probably;
all noise is detrimental. As the result of statistical studies, the following statements
can be made:
(1). Hearing loss will occur in many individuals exposed for may years to high noise
levels (explosions produce their effects by a blast wave rather than by a noise wave).
(2). The noise level required to induce hearing loss is widely held to be 85 decibels
per octave band in the audible frequencies. (The 85 decibel level does not refer to the
overall sound level, which in typical industry steady noises may be 20 decibels
higher).
(3). When hearing losses due to noise exposure occur, they are first noticed in the
higher frequencies, that is 3000 to 6000 cycles per second.
In industries with a high noise level, for example, blacksmithing, boilermaking,
grinding work, construction work, mining, aviation and many forms of factory work,
the employer can reasonably be required to pay attention to noise reduction, and
where he fails to do so, he might be deemed negligent. The measures available to
reduce the volume of noise impinging on the ear are:
1). planning the layout of factory.
2). Sound insulation.
3). Design of equipment.
4). Reduction of sound by the use of absorption.
5). The provision of ear muffs or ear plugs for those exposed to noise.
Where the worker is continuously exposed to loud noises, regular checks of hearing
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should he made so that hearing losses can be detected at an early stage, and suitable
arrangements made before serious impairment arises.
Poisons and drugs
A large number of drugs in common use may lead to serious hearing losses. Well
known examples are streptomycin, kanamycin and quinine. Salicylate drugs such as
aspirin may produce some hearing loss, although in these cases it is usually only
temporary. Aminoglycosides, for example, Gentamycin can induce permanent
deafness, accurate doses, controlled by blood level estimations, are required to
diminish the risk.
Hearing loss due to ageing and degeneration
Hearing loss due to this cause is, of course, not induced by trauma or occupations, but
it is of medico-legal importance in that a suitable reduction of detected heating loss
must be made when the patient is over the age of fifty. The usual loss for presbycusis
is 0.5 per cent at the age of 50, and an additional 0.5 per cent for each year thereafter.
New words and expressions
1. aetiology n 原因之说明；原因论；病原
2. explosive blast 爆震冲击
3. equivalent adj 相等的；相当的
4. otosclerosis n 耳硬化症
5. onwards adv 向前地；在先地
6. footplate n 踏板；底板
7. ossified v 使骨化；使硬化
8. perceptive adj 感觉性的
9. unilateral adj 单侧的
10. stabilise v 稳定；安定
11. exposure n 暴露
12. tunnitus n 耳鸣
13. octave n 八个一组的物品；八度音阶
14. band n 带子；波段
15. blacksmithing n 铁匠
16. boilermaking n 锅炉制造
17. grinding n 磨床
18. aviation n 航空
19. layout n 安排；布置
20. ear muffs 耳套
21. plug n 塞子
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22. kanamycin n （药）卡那霉素
23. salicyate n 水杨酸盐（或酯）
24. aminoglycosides n 氨基苷
25. gantamycin n (药）庆大霉素
26. prebycusis n 老年性聋
MEASUREMENT AND TESTS OF HEARING LOSS
Measurement of Hearing Loss
Accurate measurement of hearing has been possible for only 60 years following
developments in the field of electronics. Prior to this, only the severe grades of
impaired hearing could be detected with any accuracy.
The standards of normal hearing have been determined by means of tests conducted
on individuals between the ages of 15 and 35 in whom clinical examination has
shown no aural abnormality. In order to understand the meaning of test results, a
number of terms require definition.
Threshold of hearing
The threshold of hearing is the minimum intensity of sound audible at a particular
frequently. The variation of audibility with different frequencies is very large. Thus, a
normal individual can hear a pure tone of 2000 cycles per second quite easily when
the sound pressure level is only 20 decibels, but at a frequency of 20 cycles per
second (approximately the pitch produced by the lowest not on the piano ), 20
decibels is inaudible. The hearing level for speech is, of course, the most important
one, but unfortunately, owing to the complexities involved in testing reactions to
speech, it cannot be used as a method of accurate measurement; instead a number of
pure tones of different frequencies are employed.
Air conduction
Air conduction refers to the ability of an individual to appreciate sound produced in
the ordinary way and transmitted through air.
Bone conduction
Bone conduction refers to the ability of an individual to appreciate sounds which are
applied directly to a cranial bone
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Conductive hearing loss
If an individual has poor air conduction, but good bone conduction, there is a defect in
the acoustic transmission through the outer ear or the middle ear. Such a condition is
referred to as conductive hearing loss.
Neuro-sensory
hearing
loss
(Nerve
deafness
or
perceptive hearing loss )
This condition is hearing loss due to diseases of the cochlea or of the auditory nerve.
Mixed hearing loss
This exists when both neuro-sensory and conductive hearing losses coexist.
Tests for loss of hearing
Ordinary clinical testing
Is used for the detection of gross auditory impairment. The individual is asked when
he is no longer able to hear a tuning fork or the ticking of a wrist watch.
Rinne test
Normally a vibrating tuning fork will be heard twice as long by air conduction as by
bone conduction. If bone conduction is better, the patient has a degree of air
conduction hearing loss.
Weber test
A vibrating tuning fork is placed in the centre of the patient's forehead. If there is a
conduction type of hearing loss in one ear the note will be heard better in the ear with
impaired function. If there is nerve deafness confined to one ear, the note will be
heard better by the normal ear.
Audiometry
The audiometer is a very sensitive electronic instrument which must be carefully
checked from time to time and correctly calibrated. Tests must be performed in
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non-echo, sound-proofed rooms, so that all external noises are avoided. Finally, the
technician or physician performing the test must be well versed in its technique.
Before a patient is submitted to audiometry, it must be determined that he was not
subjected to loud noises for at least two days before testing, as temporary deafness
may be induced in this way, thereby, giving a false result. The precise technique used
by different laboratories varies, but as a general rule reading are made at 500, 1000,
2000, 3000 and 4000 cycles per second, but other frequencies may also be chosen.
Similarly, the threshold for hearing is recorded in some laboratories when, after
repeated testing, half the stimuli are heard by the individual tested, whereas in other
laboratories a threshold is determined at that point where two out of every three
stimili are heard. These results are then recorded on a graph and compared with the
normal. An assessment then can be made of the residual disability.
New words and expressions
1. threshold n 阈值；极限
2. frequency n 频率
3. pith n 音调
4. appreciate v 意识到；正确评价
5. tuning fork 音叉
6. calibrate v 标准；标定
7. versed adj 精通的；熟练的
SECTION 4
RESIDUAL DISABILITY DUE TO IMPAIRED HEARING
Before an assessment of residual disability for legal purposes can be made, a number
of factors have to be taken into consideration.
1. Diagnosis or the cause of deafness. Where there is more than one cause, for
example, if a man with a perforated ear drum is also suffering from nerve
deafness due to a noisy occupation, the relative importance of each contributory
cause must be made clear.
2. The age of the patient must be taken into consideration. Presbycusis (loss of
hearing occurring with advancing years), must be taken into consideration. It is
generally accepted that beginning at the age of 50, 0.5 per cent is subtracted from
the percentage hearing loss, and an additional 0.5 per cent is subtracted for each
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year thereafter. Thus at the age of 60, the percentage heating loss would be (even
without any injury) 5.5 per cent.
3. According to the law in different states or countries, an assessment is made either
of monaural or binaural deafness, sometimes both are required.
4. The laws relating to workers compensation and the assessment of hearing loss
vary widely in different parts of the would and sometimes between different
states in the same country, and the scientific bases accepted by different courts of
low also vary. Hence, the figures given here and the particular method of
assessing hearing loss is merely one of many and will not be the one universally
used.
If an assessment is required of the deafness remaining in each ear, the calculation is
simple. Where an assessment of binaural deafness is required, various " loading "
methods are used. They differ widely and no finality has been reached.
Here is one method commonly employed:
The hearing loss present in the better ear is multiplied by four, the reading obtained
from the worse ear is then added, and whose result is divided by five.
To quote a specific example, let us say that the percentage loss, making due allowance
for age and other caused of hearing loss not involved in the litigation, is right ear 20
per cent and left ear 40 percent. The figure of 20 per cent is multiplied by four,
yielding 80 per cent to which is added 40 per cent, making a total of 120 per cent.
When this figure is divided by five the result for binaural loss is 25 per cent.
New words and expressions
1. perforated adj 穿孔的
2. ear drum 鼓膜
3. subtracted v 减去
4. presbycusis n 老年性耳聋
5. monaural adj 单耳的
6. binaural adj 双耳的
7. litigation n 诉讼；起诉
8. finality n 结论；定局
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Chapter 6 Injuries to Nose and Throat
SECTION 1
NOSE
Injuries to Nose
The protuberant nature of the nose makes it vulnerable to injury in addition to
lacerations of the nasal skin, injuries may involve the bony part of the nose, and the
cartilaginous portion of the central septum. The treatment undertaken is to re store the
bone in the best possible position and to subsequently treat any serious disturbances to
the nasal airways that may result. Where bony correction has been obtained, nasal
airway obstruction is much less common.
Residual symptoms following a nasal fracture are as follows:
Cosmetic
Gross cosmetic deformity may occur when the fractures are not completely reduced.
Obstruction of nasal airway
In addition to being a nuisance to the patient, this may also produce disorders of
drainage of the nasal sinuses and predispose the patient to attacks of sinusitis.
Anosmia
As a permanent disability this arises more often from injuries to the front of the base
of the skull rather than injuries confined to the nose.
Allergic rhinitis and sinusitis
Many individuals react excessively to foreign substances in their environment,
particularly those which contain proteins or protein-like. A sensitive individual may
therefore develop allergic rhinitis as an occupational disease if irritating substances
are present in his environment.
SECTION 2
LARYNX
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The larynx has two functions:
(1). Voice production.
(2). As a valvular mechanism to close the windpipe during swallowing.
Injuries
Although in homicidal and suicidal cases injuries to the larynx and trachea are not
uncommon, serious injuries to this area in ordinary civilian medical practice are fairly
rare. Blows to the larynx may lead to a swelling of the vocal cords and serious
interference with breathing, sometimes sufficient to produce death from asphyxia.
Permanent derangements of laryngeal function from such blows are uncommon.
Lacerating injuries to the larynx may produce any one of a number of disorders but
are infrequent and will be considered no further.
Chronic dysphonia
Is common in those whose occupations necessitate lecturing to audiences, for example,
politicians and school teachers. There may be pain in the larynx together with
huskiness and there may be obvious changes in the vocal cords such as oedema or
granulomata; singers 'nodules' are another well-known example. The symptoms arise
more frequently if there is a faulty method of voice production. Although
improvement may be obtained by surgical means, continuation of the occupation is
almost always associated with a recurrence of symptoms.
New words and expressions
1. procuberabt adj 隆凸的；显著的
2. cartilaginous adj 软骨的
3. septum n 隔（膜）；间隔；中隔
4. cosmetic adj 整容的；美容的
5. nuisance n 损害；妨害
6. nasal sinuses 鼻窦
7. predispose v 易感染
8. sinusitis n 窦炎
9. anosmia n 嗅觉丧失
10. rhinitis n 鼻炎
11. larynx n （解）喉
12. valvular n 瓣；瓣膜
13. trachea n 气管
14. vocal cords 声带
15. dysphonia n 发音困难
16. huskiness n 沙哑声
17. granulomata n 肉芽肿
18. nodule n 结节
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Chapter 7
Techniques in Medical Assessment of
Injuries for Legal Purpose
SECTION 1
AUDITORY BRAINSTEM RESPONSE (ABR)
During the last decade, much of the research emphasis in clinical diagnostic
audiology has been focused on unlocking the secrets of the auditory brainstem. This
has been accomplished through the use of behavioral and physiologic measures to
assess the functional integrity of the auditory brainstem pathways. Among the tests
proving useful were auditory brainstem response measures (ABR), binaural masking
level differences (MLD), and transbrainstem acoustic reflex measures (AR)
Since Jewett and Williston (1977) described the ABR in humans, this techniques has
proven a fruitful tool to the investigation of disorders of the central auditory nervous
system. ABR has proven to be useful in the assessment of Ⅷ nerve lesions and
brainstem dysfunction. From many studies, correlative data between lesion location
and ABR abnormalities suggest the following anatomical sites for the origins of
Jewett waveforms Ⅰ-Ⅴ:ⅠⅧth nerve, Ⅱcochlear nucleus (CN) and second firing of
Ⅷth nerve, Ⅲ-superior olivary complex (SOC), Ⅳ-Ⅴlateral lemniscus-inferior
colliculus (LL;IC). This simplified "localizationist" view suggests the discrete lesions
affecting different nuclei of the auditory brainstem will have differential effects on the
resultant ABR.
ABR, as one of objective audiometry, has a great deal to offer in the clinical
assessment of persons with disorders of hearing and / or the central auditory tracts.
Undoubtedly there will be much further development of the techniques themselves.
With increasing knowledge as to the interpretation of the tests and their functional and
topodiagnostic significance. It would help, though, to summarize to present
applications of electric response audiometry, as follows:
Threshold measurement
can be achieved the those who cannot or will
not respond reliably to conventional subjective audiometric tests. The "can not" group
comprises the children, and the "will not " group the cases of non-organic hearing loss
and medico-legal assessments of deafness.
Location of lesion
is also possible since there are eight sites of generation
of evoked potentials, ranging from the cochlea to the cerebral cortex. Not only is this
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of great importance in investigation of adult patients with auditory disorders, but
much further use needs to be made of them in cases of congenital and early acquired
deafness since only by identifying the site and type of disorder is major progress
likely to be made in devising suitable educational techniques for subgroups of such
children.
The nature of dysfunction
can often be indicated by increase of latency,
particularly occurring in demyelinating diseases, and decrease of amplitude in various
of the responses. Changes of waveform are also likely to assume increasing
importance, as will be indicated in the papers by Portmann and Gibson.
Therapeutic testing and monitoring
has been referred to in the
present paper with respect to multiple sclerosis, using the brainstem evoked response.
Alteration in the cochlear microphonic and summating potential as a result of
administration of vasodilator drugs or surgical treatment in patients with Meniete's
disorder will be referred to in the paper by Gibson.
The techniques of electrophysilogical audiometry are now coming widely available,
both geographically and with respect to choice of measuring equipment. At one time,
a particular piece of equipment was often only capable of measuring one type of
response, but this is rarely the case now. Moreover, increasing numbers of otologists,
audiological scientists and specially trained technicians are becoming involve. The
time has come when we must think in terms of an "Electrophysiological Audiometric
Investigation" rather than of conducting this or that particular test procedure or
technique. It must become patient- oriented, that is, the needs of the particular patient,
for information of his threshold or on the site or nature of lesion, etc, should be used
to define the particular evoked responses that should be measured. We need to leave
behind us the days when we had equipment, staff or technique which could dope with
only one type of response and everything depended on what we could obtain from that
one from of measurement (in spite of the fact that some other electrophysiological
measurement would do the job much more effectively).
New words and expressios
1. audiology n 听力学
2. 2.integrity n 全体；整体
3. auditory adj 听力的
4. brainstem n 脑干
5. cochlear n 耳蜗；耳迷路
6. olivary complex 橄榄核
7. lateral lemniscus 外侧丘系
8. inferior colliculus 下丘
9. audiometry, n 听力计
10. topodiagnostic adj 地形诊断
11. demyelinating 脱髓鞘
12. multiple sclerosis 多发性硬化症
13. 13 microphonic n 微音扩大
14. otologist n 耳科医生
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SECTION 2
VISUAL EVOKED POTENTIAL (VEP)
In 1972, Halliday and his colleagues first established that the latency of the pattern
visual evoked potential is affected by demyelination of the optic nerve which
-commonly occurs in multiple sclerosis. Since then, VEP delays have been
demonstrated in several neurological diseases, which may lead to secondary
demyelination. However, VEP delays were also demonstrated in Parkinson's disease,
in which neither demyelination nor involvement of the optic nerve occur. In recent
years, VEP delays have been reported in patients with intrinsic retinal pathology. As
only 5% of the normal population has myelinated fibers in the eye, the demonstration
of delayed VEPs in retinal disease is not consistent with the explanation of VEP
delays due to demyelination alone.
The purpose of this chapter is to summarize evidence and detail critical
methodological aspects of VEP studies which reveal foveal pathway abnormalities in
retinal disease and in Parkinson's disease.
Methodological requirements
The
importance
of
stimulus
selection
checks
vs
gratings-optimal pattern size
It is customary to employ check patterns with individual squares with a size larger
than 50' of arc. It is assumed that the responses to smaller pattern elements and to
sinusoidal grating patterns are either smaller in amplitude, or less 'robust', i.e. show
intersession variability in the normal observer. These assumptions are, however,
incorrect.
Firstly, the optimal check size, yielding the largest amplitude evoked potential, is not
50' of arc; rather it is between 10' and 15' of arc. Human visual sensitivity, consistent
with visual physiology in mammals, 'peaks' to intermediate pattern element sizes.
It is not true that edges are necessary. One obtains robust VEPs with sinusoidal
gratings.
In fact, when one compares pattern Eps to equal contrasts and equal sizes, it turns out
that the amplitude is only a factor of 1/2 larger for the check than for the sinusoidal
grating. The diagonal of one check equals one cycle of a grating. The pattern element
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size of gratings is expressed as spatial frequency, defined as the number of cycles per
subtended angle at the eye. The overall power is greater in the check pattern, and
edges contribute. At the moment we do not yet know why edges are needed for checks
but not for single gratings.
The effect of blur on check patterns and on sinusoidal
gratings
The check pattern will lose its high spatial frequency components as a result of blur,
thereby causing a change in pattern configuration. Sinusoidal gratings lose contrast as
a result of blur, but pattern configuration does not change on the retina. For check
patterns even a slight blur causes considerable VEP delays. When sinusoidal gratings
of low spatial frequencies are used as stimuli, VEP latency is more tolerant of blur
than check VEP latency. Imperfect accommodation and/or refraction has a less
confounding effect on grating VEPs.
The effect of accommodation on retinal patterns
Older people have difficulty with accommodation. Campbell and Green first
determined the detectability of sinusoidal gratings with and without blurring. For
instance, for 1.5 diopter blur their data show a change of less than 10% in the
detectability of low shatial frequency gratings. High spatial frequencies, which create
check edges, are much more affected by accoommodation palsy. Nevertheless, as
we always emphasize, it is important that all patients are refracted, and we believe
that refractive errors larger than 1 diopter do not occur in the patient population we
tested for the purposes of these studies.
The choice of a stimulus pattern for clinical studies
Apart from physiological optics, the selection of what pattern element is to be used
needs to be determined based on the suspected abnormality of the visual system. The
mammalian visual system is composed of a set of stimulus-specific pathways.
Beginning at the retina, different ganglion cells respond to fine, as opposed to coarse,
patterns. As far as foveal vision is concerned, optic nerve fibers which subserve
central vision have receptive field sizes up to a diameter of 14' of arc. Patterned
stimuli with elements which are larger than this diameter most certainly will
preferentially address a gamut of retinal neurons, foremost the peripheral ones. The
interested reader is referred to reviews of parallel pathways by Stone and
Bodis-Wollner. The clinical relevance of selecting proper stimuli can be seen in
studies concerned with glaucoma and in Parkinson's disease.
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Age
VEP latency does depend on the age of the observer. The explanation may be that
neural conduction velocity becomes progressively slower as one ages. However, less
than adequate refraction, loss of accommodation and minor opacities of the media can
cause VEP delays. We compared the effect of age on check and grating patterns over a
range of spatial frequencies. Delay as a function of age is the more pronounced the
higher the spatial frequency of the stimulus. The aging effect is pronounced for
checks, but is minimal for gratings. One may conclude that since check edges are
created by high spatial frequencies, age has a greater relevance when one uses check
stimuli.
The effect of opacities on the VEP
Opacities will degrade the visual response whether or not it is measured with evoked
potentials or subjectively. Cataracts will degrade visual acuity or contrast sensitivity .
High spatial frequency detection is always affected when significant opacities exist.
Therefore, VEP evaluation in the aged is difficult if there is an opacity which is
accompanied by an acuity drop of two lines. We exclude patients whose contrast
sensitivity curve shows a reduced high spatial frequency limit.
VEPs in retinal disease
Originally, we reported VEP abnormalities in only a few patients affected by
maculopathy. Since then, there have been three major studies which provided
evidence for VEP latency changes without significant amplitude attenuation in
patients with both chronic and acute paramacular retinopathy.
Various forms of maculopathies were studied; most commonly, central serous
retinopathy. Typically, CSR is reversible and does not cause a central scotoma. VEP
delays were found in several patients who had well-preserved visual acuity and the
amplitude of the VEP in the affected and unaffected eyes were equal. This provides
evidence that a latency change in retinopathy is not a secondary consequence of
attenuated visual signal aplitude.
One must consider the possibility that VEP latency changes in maculopathy are not
pure 'delays' of intra-or postretinal condustion, but reflect on the existence of
paracentral sootoma. This is unlikely to explain the delays seen in patients with
central serous maculopathy since a rule they do not have paracentral defects. However,
in patients with toxoplasmosis, paracentral defects are com. Blumhardt suggests that
even in MS, VEP delays do not represent conduction defects but are due to visual
field defects. He offers the following explanation.
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In normals, the VEP to a hemifield grating stimulus will be optimally recorded in the
customary NPN configuration over the central and ipsilateral electrode. Similarly to
check EP data, the contralateral electrode will show an inverted polarity response
which may be erroneously labelled as delayed due to the 'later' occurrence of the
major positive wave. Occasionally, even in normals, the central electrode will be
picking up the inverted polarity contralateral response; hence, the recording of the
midline electrode only may mislead one to believe that the response to the hemifield
stimulus is delayed. In a patient with a paracentral scotoma, the full-field stimulus
could cause an erroneously measured 'delayed' VEP at the midline. In our study the
VEP was symmetrical and showed no features of inverted polarity ipsilateral to the
field defect. Our data so far provide no evidence for the explanation of VEP delays
due to erroneous labelling of components.
The mechanisms of VEP delays in retinal disease are unknown, although recent
functional-anatomical studies of the mammalian retina do suggest several possible
mechanisms. Malfunctioning amacrine cells, the kind described by Werblin in the
Necturus, provide a possible mechanism for delays occurring in retinal pathology.
Intraretinal feedback loops may also be candidates. In fact, VEP changes in
Parkinson's disease may be linked to an abnormal dopaminergic retinal circuit.
New words and expressions
1. Intrinsic adj 内在的；固有的
2. foveal adj 视网膜的中心凹
3. sinusoidal adj 正弦曲线的
4. grating n 栅栏；条栅
5. diagonal n 对角线
6. configuration n 外形；结构；构造
7. imperfect accommodation 调节缺陷
8. refraction n 折光；折射
9. confound v 混淆；把....搞混
10. detectability n 可选取性；可测定性
11. glaucoma n 青光眼
12. media n 血管中层(一般指肌肉层)
13. opacity n 混浊；不透明性
14. maculopathy n 黄斑病变
15. paramacular adj 黄斑旁的
16. retinopathy. n 视网膜病
17. reversible adj 可逆的
18. scotoma. n 暗点
19. attenuate v 削弱
20. toxoplasmosis, n 弓形体病；弓浆虫病
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21. ipsilateral adj 同侧的
22. amacrine adj 无长突的（神经细胞）
23. Necturus n 泥螈属
24. feedback loops 反馈环
25. dopaminergic adj 多巴胺能的
__
edited by Chen Xiping
Chapter 8
Adult sexual assault: practical management
Introduction
The recent history of sexual assault care in the US
The medico-legal examination
Sexual assault assessment in England and Wales
The chaperone (Victim Liaison Officer)
The examination suite
Examining doctors
Forensic medical assessment
History of the allegation
Significant medical history
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INTRODUCTION
This chapter describes the recent history of sexual assault, current perspectives, and the
medico-legal examination of victims and suspects as part of the investigation of adult sexual
assault victims. Experienced sexual assault examiners describe the process in the US first,
then the process in England and Wales. An understanding of the differences among these
countries provides insight into differences in local jurisdictions, which may relate to statute,
personnel, and custom and practices.
The examination of adult victims and suspects of sexual assault is difficult, and has to be
conducted carefully and thoroughly. With the exception of homicide, such assaults, both in
females and males, produce the most brutalizing, degrading, and dehumanizing experience.
For a variety of reasons, it has proven difficult for the police and the criminal courts to make a
profound impact in terms of the percentage of convictions that result from prosecutions in
such cases. Many victims, in spite of all the publicity and the changes in practice, still fail to
report such incidents due to self-blame, a lack of energy and confidence to confront the
medico-legal and judicial system, the fear of public stigma in a court room, and a fear of
reprisal. In many countries, there is therefore an attitude and a general belief that sexual
assault is not a common crime, and indeed that it is a rather unusual occurrence. If the victim
does report, the case may not come to court because the law enforcement agencies and the
criminal prosecution services do not feel that the case fulfils the criteria that could result in a
reasonable chance of conviction, e.g. lack of the supporting elements of a crime. The "consent
defense" may in some cases seem to be too difficult to overcome in the estimation of
prosecution, especially if there is little or no physical injury, no witnesses and little other
supporting evidence. In such cases, as the probability of convincing a jury of the guilt of the
suspect is limited, the case does not proceed to trial. As expected in all criminal cases, when a
sexual assault case goes to trial, the jury will have to be convinced "beyond a reasonable
doubt" that the suspect is guilty. Nevertheless, although the incidence of such cases is rising in
Great Britain, United States (US) statistics reveal that rape numbers are dropping (Rennison
2001).
The recent history of sexual assault care in the US
Traditional care
Sexual assault is a broad term, variously defined by each jurisdiction, that includes a number
of offenses such as vaginal penetration, sodomy (anal penetration), penetration by foreign
objects or fingers (digital), and oral copulation. Unwanted sexual penetration is the essential
feature. Victims, (often referred to as "survivors") of this crime, can be female or male,
heterosexual or homosexual or the spouse or parmer of the perpetrator. Victims are referred to
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as "she" because, by far, most victims are female, although incidences of male on male and
female on male continue to rise as awareness of sexual assault increases.
Sexual assault may occur under any of the following circumstances, which by and large are
accepted by most jurisdictions;
according to the California Penal Code, 2001:
●
The victim is incapable of giving legal consent.
●
It is accomplished against a person's will by force or fear of bodily injury.
●
The victim is unconscious.
●
The victim believed that the perpetrator was the victim's spouse.
●
Retaliation is expected.
●
There are threats to use the authority of a public official.
Historically, in the US, the emergency department (ED) of the nearest hospital has cared for
victims of sexual assault. Four problems were related to this process: delay in examining the
victim and collecting forensic evidence; lack of expertise by the medical examiners in
forensic evidence collection; lack of communication and coordination between examiner, law
enforcement agencies, crime laboratory, district attorney and crisis support; and frequently the
male gender of the medical examiner.
DELAY
Because patients who come to the emergency are triaged according to the severity of their
illness or injury, victims of sexual assault typically waited many hours to be examined. Vital
evidence was lost because victims would urinate, defecate, wipe and discard the paper tissues
used for wiping and cleansing, which could contain vital trace evidence. Wipes have been
found to have semen on them when vaginal swabs did not. They would drink and wash away
oral evidence (Thomas & Zachritz 1993). Furthermore, the wait increased the possibility that
the victims would just leave and give up their initial efforts at seeking justice. Many victims
want to avoid another assault to their dignity and privacy that an examination may perhaps
imply to them. In small communities, the possibilities of meeting a friend or neighbor in the
emergency department add to the stress involved and further heap insult on injury.
EXAMINER’ S EXPERTISE
A second problem with any Emergency Department (ED) conducting the medico-legal
examination is that the emergency physician may have little experience in or desire to
examine victims or suspects for the collection of forensic evidence, especially when the
injuries on the victim are modest. Many non-forensic specialists have real concerns about
having to give evidence in court．If the order of collection is not precise，then swabs taken
from one site may have been contaminated by secretions emanating from another area．If all
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the clothing is placed together inside one bag，then secretions from one piece of clothing
might contaminate another piece of clothing and confound the evidence．If clothing is not
closely examined，signs indicating the use of force such as tears，pulled buttons and broken
zippers may be missed．
The inexperienced or untrained examiner may look for internal injury and sperm，not knowing that most
injury is external and sperm is rarely found for a variety of reasons．The presence of trauma correlates with
prosecution(Gray-Eumm et al 2002)：if injury is described，the chances of a conviction increase．Thus，
assess hag and documenting trauma is a critical component ha clarifying the case．The approach in the ED
may be rushed，insensitive，and even judgmental，due to the backlog of other more seriously injured
patients who are awaiting examination．This atmosphere combined with an examiner who may have
conducted few if any forensic examinations contributes to the possibility of overlooking important assault
injury． If the medical examiner is not experienced in photographing injury, then photographs may be
deferred，and the attorneys and jury lose the often quite-illuminating visual perspective to the case．If the
medical photographer is called in，there is yet another violation to the patient's privacy, and there is more
delay in the evidence collection and more resentment on the part of the patient．For some patients，the
gender of the examiner and photographer may compound the assault．Therefore，patients should always be
asked if they have any problems with opposite sex examiners or photo- graphers and their fears or requests
be acknowledged．Colposcopic magnification with photographic capability is rarely available in emergency
departments and the ED physicians typically have little or no recent experience in using it．Furthermore，
when an inexperienced examiner gives evidence，either in reports or in court， the details and interpretation
of forensic evidence collection may be(and indeed should be)challenged．
COMMUNICATION AND COORDINATION
The setting of the ED renders communications between law enforcement agents and the
physician／examiner hurried and lacking in privacy．The law enforcement officer may have
met the particular physician previously and there may be lack of under- standing of the other's
role．There may be in attendance a social worker from the hospital or crisis center, but it is
more frequently the case that yet another crisis care provider carries out the follow up with
further erosion of privacy．
Crime laboratory guidelines for the collection of specimens come to the ED via letters
detailing how the protocol is to change．It then depends on a secretary to change the
documentation and inform the many physicians and assistants about the changes．If the
particular ED rarely conducts a sexual assault examination，the follow through in changing
the protocol and the corresponding documentation may be relegated to a very low priority．
If the district attorney has to talk to the physician to clarify findings，he takes the physician away from his
department with loss of office hours or clinic time；the meeting may be delayed until the physician has
an opportunity to attend and this may result in inaccurate or incomplete data exchange．Knowing that a
subpoena and a day in court is forthcoming may result in additional delays while the physician sets
aside a block of time for preliminary meetings and court time．These ED system characteristics may
result in misinformation，lack of information，outdated protocols， delay, judicial backlog as well as victim
frustration．Any of these features may result in prosecuting these cases．
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GENDER CONFLICT
Commonly the physician in the ED is male，and one study has suggested that this may be
perceived as offensive to over half of the sexual assault victims(Lenehan 1991)．However, if
only male examiners are available，then it is of prime importance that they should always
apply a non-judgmental ， sensitive and skilled approach ， no matter what the time
constrictions are and the number of other patients waiting to be seen．This is of course the
key to the approach for any examiner-male or female．
Sadly, there are some examiners of both sexes who do not fit these criteria．
The Sexual Assault Nurse Examiner (SANE) program
To address the issues of delay, examiner inexperience，communication and coordination
problems，and gender conflict，a Sexual Assault Nurse Examiner(SANE)program was
established．The SANE program began in Memphis，Tennessee，in 1976 and focused on the
victim of sexual assault．Specially trained，experienced nurses conducted the medico-legal
examinations under carefully established protocols ， in a clinical setting outside the
ED．SANEs are directly interested in care for these specific patients，as evidenced by them
paying for their own SANE training．Some settings reimburse a percentage of the tuition after
a period of work as a SANE．In 2002，100 SANE programs were in existence across the
US(Ledray 2001a)．
DELAY
The SANE program was designed to ensure minimal delay in victim examination．Typically,
the SANE arrives within 45 minutes of the call-out，but on many occasions the on-call SANE
is waiting at the clinic for the victim to arrive．The SANE takes the full history, conducts the
forensic examination，photographs injury, provides crisis care，treats for sexually transmitted
diseases， and refers for follow-medical and emotional care．She may have a crisis
care-provider attending to the patient's emotional needs during the examination．
The SANE is on-call with a pager and so does not burden the system with inactive time on the
payroll．Because she is able to do the examination without the co-attendance 0f a biomedical
photographer, or an assistant，the number of man-hours per examination is notably reduced．
SANEs may also be asked to carry out examinations on the instruction of the medical
examiner on deceased victims being dealt with by the coroner's office，and suspect
examinations in the jail，because of their expertise in collecting forensic evidence and
their knowledge of the possible injury inflicted in sexual crimes．
Use of resources is another issue that supports the utilizing of SANEs．Nurses can be taught to
conduct a meticulous medico-legal examination that flees the physician for other
duties．These nurses also provide for emotional care，education，and referral of the sexually
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assaulted patient(Aiken&Speck 1 995)．An over-seeing physician can establish procedures，
write medication protocols，supervise documentation，and attend peer review and continuing
education of the SANEs ． The cost of the system may be reduced yet quality is
maintained．One study of515 patients in a Canadian hospital using SANEs compared to
traditional ED care showed that SANEs conducted a thorough medico--legal examination
witch fewer interruptions and in a shorter amount of time (Stermac&Stirpe 2002)．
EXPERTISE
The traditional SANE training follows the recommendations of
the International
Association of Forensic Nurses．This comprises 40 hours of classroom learning．With the
curriculum comprising such issues as the clinical findings in sexual assault，non-assault
findings，techniques of examination，crisis care，chain of evidence preservation，and the
delivery of expert witness testimony．The next phase of the training includes observing and
conducting pelvic examinations with a gynecologist，midwife similar examiner．SANEs
then observe sexual assault examinations ， and thus gradually acquire the necessary
competence in conducting the examination．They also ride along with law enforcement for
several hours and observe sexual assault testimony in court．The SANE must have yearly
continuing education credits related to sexual assault．Most settings also have monthly peer
review, in which all the SANEs and the physician medical director meet to review
cases．Recommendations are made and recent relevant publications may be discussed．The
SANEs may also be employed as nurses in the ED intensive care，women's health or other
areas，so they bring a more rounded patient perspective to the care of victims．
SETTING FOR THE VICTIM EXAMINATION
The setting is specifically equipped for the care of victims and possibly suspects，if the Sexual
Assault Response Team(see below) chooses to conduct examinations of suspects as well．The
examination room contains equipment specific to the assault examination：
●
An examination table with stirrups
●
A colposcope．Often with integral video capabilities
●
A 35mm camera with a macro lens
●
A light microscope for detecting sperm
●
Vaginal specula and proctoscopes
●
Evidence kits
●
A swab dryer
●
Medications for prevention of sexually transmitted diseases (Workowski & Levine 2002)．
The clinic has hygiene facilities and a private place for any accompanying family members to
wait．
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When forensic care is regionalized，the individual examiner sees a greater number of victims and more
easily maintains expertise (Ledray 2001a)．
COMMUNICATION AND COLLABORATION
When the detective dealing with sex crimes and the SANE conduct many cases together, this
leads to a fuller inter-communication，a better understanding of each other's role，and a mutual
support in achieving the goal of determining all the facts of the case．The detective finds it
easy to call the SANE to ask about a detail．and the SANE may call the detective to inquire
about the legal proceedings．The detective attends the forensic interview, which adds the legal
perspective to the medical interview．The crime laboratory may call or e-mail the SANE
program and inform them verbally about a swab that is being deleted from the evidence kit，
or a casein which the documentation of a tear or stain or timely collection of a tissue wipe was
important to revealing the facts of the case．The crisis care provider stays during the interview
and the examination，and provides information for emotional care and safe housing，if
needed．At the end of the examination，the SANE is free from time pressure，and so can speak
to the victim about the findings，provide risk reduction materials，encourage follow-up
emotional care，and direct the "significant other" in avoiding blaming language(Lynch 1993)．
Using SANEs to conduct the medico-legal examination has provided better collaboration with law
enforcement，better forensic evidentiary collection(Derhammer 2000)，higher reporting rate，shorter
examination time，and more complete documentation(Ledray 2001b)．
The Sexual Assault Response Team
The Sexual Assault Response Team(SART)is a coordinated，multidisciplinary team composed
of a nurse or physician examiner, law enforcement personnel and the rape crisis advocate．It
has evolved from the SANE program with defined members of the team，clear fines of
communication and a network of coordination．Standards of practice，in which the expected
behaviors of each SAINT member are described，have been published，for instance by the
States of New Jersey(Department of Law and Public Safety 1998)and Tennessee(2000)．The
County of San Diego, California has published its standards (San Diego County Health and
Human Services 2001) prior to the State having standards of pray. Second responder members
of the team are involved later. They include the private physician, prosecutor support
personnel in the prosecutor's office, the criminalist, rape crisis counselor and spiritual advisor.
A SART may be affiliated to and supported by a hospital, district attorney's orifice or law
enforcement jurisdiction, or it may be a private enterprise. Additional support comes from
grants and private donations. The crisis care advocate is a volunteer trained in crisis care and
referral, who is on-call for SART. These persons volunteer for the local crisis center, and
respond to rape crisis "hotline" calls and attend to victims of rape. The advocate may be
requested by law enforcement to be with the victim at the scene of a crime.
More typically, the advocate meets the SANE and the officer or detective at the SART clinic.
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The advocate comforts and pro- vides crisis care to the patient during the course of the
history- taking and examination. Advocates do not translate, nor do they assist with evidence
collection. The advocate attempts to impress the patient with the need for continued emotional
care and later refers the patient to a local crisis center for short-term individual or group
counseling. Following the examination, a counselor trained specifically in sexual assault care
is available to provide companionship for depositions, hearing and court. There is also a
victim/witness-advocate available through the prosecutor's office to provide information, links
to financial social welfare aid, and companionship during some of the proceedings. In some
jurisdictions, an advocate must be provided according to the law, but the victim can refuse to
have the advocate attend to her.
The responding police officer documents the crime, files a report, and transports the victim
for the medico-legal examination if an examination is indicated. The detective specializing in
sex crimes authorizes the examination based on established criteria, attends the interview by
the doctor or nurse, conducts the investigation, arrests the suspect, and testifies in court.
The advantages of the coordinated SART system is that it provides for:
● Specially trained medico-legal staff- the SANE or SAFE
● Representation, communication and coordination among SANE/SAFE, law enforcement
and crisis care.
Because of the coordinated system, there is:
● Streamlined processing through the medical, legal and judicial phases of the prosecution of
the case
● Improved understanding and trust among different disciplines working together
● Reduced frustration in consulting among the SAILT members on cases and in enacting new
standards
● Interdisciplinary education.
Current perspectives
Laws
So-called "rape shield statutes" have been enacted to assist the victims in most States. In trials
for rape, statutes restrict the admissibility of evidence of a victim's past sexual history. Thus,
for example, the sexual activity of a 14-year-old who has been sexually active for two years or
that of a single woman has had two medical terminations of pregnancy by the age of 16 are
not admissible as evidence. These statutes recognize that just because a person has consented
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to sex with someone in the past, does not mean that they consented to the instance of sexual
behavior at issue in the trial. Such statutes have several goals:
●
To increase the reporting of rape
●
To safeguard the victim against the invasion of privacy, potential embarrassment and
sexual stereotyping
●
To encourage victims of sexual misconduct to participate in legal proceedings
●
To reduce acquittals of guilty defendants (The History and Policy of Rape Shield
Statutes 2001).
The need for such a statute arose because, historically, rape prosecution was as much a trial of
the alleged victim as it was of the defendant. Courts typically required a victim to refute a
defense of consent by proof of overwhelming force" against her. The testimony of rape
victims was distrusted due to fear that women would lie to disguise a consensual affair.
Previous sexual history was thought to be relevant in rape trials where consent was the
defense, because courts considered it more likely that a woman who had consented to sex
before could have consented to sex in the instance at issue.
Now, most States no longer require evidence that the victim attempted a minimum degree of
resistance against the attacker. Another outcome of rape shield statutes is the victim cannot be
compelled to participate in the court case and if there is a refusal to testify, she cannot be held
in contempt. In many US states, the law enforcement jurisdiction pays for the medico-legal
examination and permits HIV testing of the alleged or convicted perpetrator without his
consent (Pacquin 1995, FederalViolence Against Women's Act authorizes HIV testing
1998).This does not take place in the United Kingdom, where informed consent for
examination and specimen collection is required.
In cases when either victim or perpetrator is homosexual, the courts have taken a varied
approach in applying rape shield statutes. Some argue that the rape shield laws apply to
homosexuals, so the sexual history as a homosexual cannot be revealed. But, if the alleged
homosexual victim's prior sexual history is not admissible, the jury will assume that the
victim is heterosexual and would therefore never have consented to the act, which may have
been possible. Others argue that information about this victim's sexual history is not only
relevant, but also essential, for an accurate assessment of the situation by the jury.
The Violence Against Women Act (VAWA) of 1998 intends to reduce violence against women.
Primary among its goals is to compel authorities to initiate actions to encourage women to
report, because only 31.6% of rape victims report the crime according to the National Crime
Victimization Survey of 1998.
This Act also intends to:
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●
Improve law enforcement prosecution and victim services
●
Involve advocates in planning government programs for victims of violence
●
Establish grants to determine strategies to prevent coercive sexual intercourse in
minors
●
Train children and child welfare staff
●
Recognize sexual assault and report it
●
Require medical schools to teach the diagnosis and treatment of sexual assault (Shapiro
1998).
Statistics
Sexual assault statistics in the US are derived from two sources. The National Crime
Victimization Survey (NCVS 1998, Bureau 2000), produced by the Bureau of Justice
Statistics, is based on interviews with 159400 people, 12 years of age and older, from 86800
households. The crime rates include reported and un- reported crimes. Crimes are separated
into rape, attempted rape, and sexual assault. The second source, The Federal Bureau of
Investigation's (FBI's) Uniform Crime Reports UCtL; (FBI 2000b), only counts reported
allegations of forced penile-vaginal penetration involving female victims. Assault or attempts
to commit rape by force or threats of force are included. So statutory rape (without force),
male victims, as well as victims of sodomy and forced oral copulation are excluded from the
FBI data.
The difference in the two sources of statistics is notable in the 2000 crime rates. NCVS reported a 33%
reduction in the number of rapes, while the FBI's UCR found that rapes had slightly increased from 1999.
The difference between the two sources suggests that although fewer rapes are occurring, a greater
percentage are being reported. The broader NCVS (Rennison 2001) statistics are described first.
RATES ACCORDING TO SELF-REPORTED SURVEY
(Rennison 2001)
Rapes and attempted rapes decreased in 2000 by 33% and sexual assault dropped by 38%.
Male and female sexual assaults, Caucasian, African-American and Hispanics all decreased
similarly. Rape and sexual assault occurred to females at a rate of 2.1 per 1000 persons, 12
years old and older. Males were sexually assaulted at a rate of 0.1 per 1000 persons.
The age group most victimized by sexual assault is 16-19 years of age, with 4.3 rapes or
sexual assaults per 1000 persons. The 12 to 15-year-old and the 20-24-year-old groups had
rates of 2.1 per 1000 persons. African-Americans and Caucasians were victimized at similar
rates.
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Persons with annual household incomes of less than $7500 experienced an incidence of rape
and sexual assault over twice that of other income brackets. Urban and rural rates were almost
twice as high as suburban rates. In 6% of the rapes or sexual assaults the perpetrator used
firearms or knives.
Of those who have never married, 2.6 out of 1000 were victims of rape and sexual assault.
Those who were divorced and those who were separated, each experienced rape and sexual
assault at a rate of 2.3 per 1000 persons. Those widowed and those married had the lowest
rates. In female assaults, the victim knew the perpetrator in 62% of cases. Intimate persons
constituted 18% of the known perpetrators. In male assaults, in 63% of cases assault was by a
non- stranger and in 37% by a stranger (Lennison 2001).
In Native American Indian country, the rate of violent crime is 2.5 times greater, and that of
rape and sexual assault is 3.5 times greater (Greenfield & Smith 1999) than in non-Indian
populations. One explanation is that they live in an oppressive, dominant society, whose
societal values two decades ago, such as white supremacy, have been internalized. This led to
self-oppression, self-hatred and racism (Greenfield 1997, Greenfield & Smith 1999), and
consequently sexual assault within their own culture.
In a study of 1228 victims of various ethnic groups from 1994 to 1998 in Southern California,
31% reported using alcohol or other drugs at the time of the alleged offense. Alcohol and
voluntary drugs were actually present in 54% of those victims who had forced sexual
encounters with a suspect (Lindsay 1999).
Gang rapes are characterized by increased amounts of alcohol, drugs, fewer weapons, more
night attacks, less victim resistance, and more severe outcomes in the victim. Victims and
offenders in gang rapes were younger, unemployed and not different in marital status or race
than victims and offenders in rapes involving single offenders and single victims (Ullman
1999).
In a classic survey study of 6000 students on college campuses, Koss (1988) reported that one
in eight women were victims of alleged rape. One in 12 men admitted to forcing a woman to
have sexual intercourse by physical or psychological coercion. None of the men identified
themselves as rapists, which implies they believed they did nothing criminal. More recently,
Douglas et al (1997) found that one out of every five young women in two- and four-year
colleges report that they have been forced to have sexual intercourse.
Drug-facilitated sexual assault
Much emphasis has been given in the media in the past year to the issue of drug-facilitated
sexual assault (DFSA), more emotively referred to as "date rape". DFSA is a term used to
define offenses in which victims are subjected to non-consensual sexual acts while they are
incapacitated or unconscious due to the effects of alcohol and/or drugs, and are therefore
prevented from resisting and/or are unable to consent (LeBeau & Moyazani 2001). This
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phenomenon has been reported in both male and female victims.
The ideal substance to facilitate a sexual assault is one that is readily available, easy to
administer, produces loss of consciousness, and causes anterograde amnesia. The drugs that
have been associated with sexual assaults include flunitrazepam, gamma- hydroxybutyrate
(GHB) and ketamine (Stark & Wells 1999, LeBeau & Moyazani 2001). The concern that
drugs are being administered to both females and males in order to facilitate a sexual assault
has led to a number of “prevention" strategies being developed. The prevention strategies
generally relate to ways of avoiding the opportunity of having “date rape" drugs administered
via alcoholic beverages, and include advice such as "do not leave drinks unattended, don't
take beverages, including alcohol from someone you do not know well and trust; at a bar,
accept drink only from the bartender or server, at parties, do not accept open container drinks
from anyone, be alert to the behavior of friends, anyone appearing excessively intoxicated
compared to the amount consumed may be in danger" (Georgia Network to End Sexual
Assault 2002).
Important though these strategies are, few address or emphasize the main fact evident from all
current knowledge - that alcohol itself is the most available and utilized "date-rape" drug.
Hindmarch and colleagues (Hindmarch et al 2001) have shown in an analysis of 3303
analyses of urine samples collected from individuals who claim to have been sexually
assaulted and believed that drugs were involved that of the 2026 (61.3%) samples positive for
drugs, alcohol, either alone (44% of positive samples) or in combination with other drugs,
was the most common substance found. Cannabis was the second most prevalent, being
present in 30.3% of positives. The authors conclude that the results do not support the
contention that any single drug (apart from alcohol), can be particularly identified as a
"date-rape" drug, and that alleged sexual assaults take place against a background of licit or
recreational alcohol or drug use, where alcohol and drugs are taken concurrently. Despite
these findings, media-led coverage and local initiatives still concentrate on the drug aspect of
DFSA while not highlighting the huge significance of excess alcohol (Payne-James & Rogers
2002). Guidelines have been issued in the UK about these risks (Drugs and Therapeutics
Bulletin 2002).
Perpetrators use drugs on their victims because victims are disinhibited, may not sense danger
nor defend themselves, and so, there is no evidence of struggle. Victims report late or fail to
report because of a number of factors including embarrassment and the amnesia. Examiners
find that drugged victims explain that they got much more drunk than the amount of alcohol
consumed would typically cause and they experienced a long gap in their recall. It is critical
that examiners ask what symptoms they have that brought them to report, how long they were
unconscious, and how long was it between ingestion and the urinalysis for drugs, how much
alcohol they consumed, any recreational drug use and when, and what drugs they suspect
might have been used (Fitzgerald & Riley 2000). A large number of potential date-rape drugs
have been identified (Hindmarch et al 2001) but GHB, ketamine and flunitrazepam have
received particular media coverage.
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GHB has anesthetic and amnesic action. It is typically mixed into an opened drink because it
is odorless, colorless and passes undetected in food and drink. It acts within 15 minutes of
oral ingestion. Although banned in the US, it is easily obtained or may be made at home in
clandestine operations (Hodges & Everett 1998). It acts synergistically with alcohol,
benzodiazepines, narcotics and other neuroleptics to produce central nervous system
depression. It remains in the blood for 4 hours and is detectable in the urine as long as 72
hours after ingestion. There is very little difference between the effective and the fatal dose.
Flunitrazepam (Rohypnol) or "roofies" is a sleeping medication prescribed and marketed in
numerous countries outside the UK. When combined with alcohol, marijuana or cocaine, the
drug produces dramatic muscle relaxation, slowing of psychomotor responses, amnesia and
disinhibition. Amnesia or blackout occurs 30 minutes to 2 hours after ingestion. Sedative
effects last typically up to 8 hours. In the US it is abused by three groups: (1) heroin addicts,
who use the drug to boost the high produced by low quality heroin or to self-medicate
withdrawal symptoms from heroin or methadone; (2) teenagers and young adults, who usually
take Rohypnol with beer or marijuana to enhance the high; or (3) cocaine addicts who use
Rohypnol to "parachute down" after a binge of crack cocaine use. Manufactured abroad,
Rohypnol is smuggled into the US from Mexico and Latin America, primarily through the
postal and packaging services (District of Columbia Rape Crisis Center 1998, Kurn 2000).
Ketamine is a veterinary anesthetic with amnesic actions lasting only several hours. It is used
by rapists to incapacitate their victims. The powder is snorted like cocaine or applied to
material that will be smoked or consumed in a drink (Kurn 2000).
It will be noted that the effects of all these mimic, or may be mimicked by alcohol. The
availability of high alcohol containing drinks may account for the prevalence of alcohol
detected in DFSA - where victims have drunk more than they were aware of.
Laboratories must be notified that the urine specimen may be from a drug-facilitated rape
victim, so that they can do a drug screen for these particular drugs. It is recommended that 30
ml of blood in an unclotted tube be collected within 36 hours of ingestion; 100 ml of urine
should be collected up to 4 days after ingestion (LeBeau et al 1999). Appendix 1 is a form for
documenting symptoms seen in drug-facilitated rape. Sensitive assays specifically for the
date-rape drugs should be available in toxicology labs used to evaluate the specimens because
traditional toxicology screening may not automatically screen for these date rape drugs. Some
laboratories may require detection of limits below the typical 10ng/ml level. If the laboratory
is unable to detect the suspected drug, it should report "no detectable level" and specify the
lowest level it is able to detect.
At the Federal level, the Drug-Induced Rape Prevention and Punishment Act of 1996 provides
severe penalties for the use of controlled substances, including alcohol, to commit a crime of
violence, including rape. These enhanced penalties and community education regarding
drug-facilitated rape also operate at the community level (R.ainnews 1999, Kurn 2000).
DNA and sex crimes in the US
Local, state and national databases have DNA codes from criminals convicted of violent and
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felony sex crimes, drug sales, and grand larceny. State and national databases contained about
220000 DNA profiles in 2000.When the perpetrator's DNA is found on the victim, identifying
the donor of that DNA becomes the next step. The DNA is compared to known DNA profiles
in the local, state and national electronic DNA databases. The national database is the FBI's
Combined DNA Index System (CODIS). CODIS is particularly helpful in tracking
perpetrators who may cross state lines to commit their crimes, or have a trail of crimes that
involves many states. In that case, a state may not have the perpetrator's DNA profile in its
database, but it may be in CODIS because a crime was committed in another state. When a
stranger perpetrator's DNA does not match any profile in CODIS, it is run periodically again
as more DNA profiles are added to the databases until there is a "cold hit" (a match) or the
statute of limitations is reached. Such use of DNA will help apprehend rapists sooner, halting
their pattern of repeated assaults and thereby reducing the incidence of sexual assault
(National Institute of Justice 2001). A rapist has an average of seven different victims (in one
study 126 rapists committed 882 rapes and were not yet incarcerated for any of those crimes
(Abel et al 19~5/). t)nce a suspect is identified via the database, a new blood sample is drawn
from the suspect for confirmation of the DNA match.
Recently, laws have helped with solving some of the "suspectless" cases by removing the
typical five-year statute of limitations on suspectless cases where potential DNA evidence has
been collected (Tanner 2000). Other considerations include requiring offenders in all felony
crimes and even some misdemeanours to submit DNA on conviction, and designating funds to
analyze the evidence kits in unsolved rape cases. It is estimated that there are 180 000
evidence kits in the US that have not yet been analyzed (Tanner 2000).
California has a three-year "cold hit" program a 50 million dollar grant funded by the
Governor's Office of Criminal Justice Planning and administered by the Department of Justice,
DNA Laboratory. The goal is to analyze blood and hair from unsolved sexual assault cases
and homicides with a sexual component, then to identify suspects and also to further develop
the statewide DNA database (Berkeley Laboratory 2001). By June of 2001, the California
database consisted of 200000 DNA profiles from convicted sex offenders and from other
violent felons in the state database. The growth of the database from the "cold hit" grant
resulted in 19 "cold hits" in the first year. In one case, a 1983 murder and rape of a young girl
was linked to a convicted rapist who was days away from being released from prison on a
different conviction (Center for Criminal Justice Technology 2001).
Unfounded and false allegations Unfounded rape has many connotations, with false allegation
being only one of them. One US city police department (Archambault 2001) categorizes
sexual assault dispositions that are related to unfounded or false allegations in a way that
clarifies the confusion related to terms:
●
Cancelled:
-
Unfounded due to false allegation
-
Unfounded due to lack of the elements of a crime
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-
Victim declines prosecution with the suspect identified
-
Prosecution rejects the case: poor credibility of the victim and an inconsistent story are
two of the reasons
●
Inactivated:
-
Unsubstantiated, such as recantation
-
Victim declines prosecution without the suspect identified
-
No suspect has been identified.
False allegations of rape occur when an accusation is made, but no offense has occurred.
However, the definition of the term is not standardized across agencies. It is a common
misunderstanding that unfounded and false allegations are lies (Fazlollah 1999). Some official
definitions of false allegation have required a motive of deliberate deception. However,
confusion related to aging or fantasy related to mental illness may also result in a false
allegation. Furthermore, when a victim gives some false information, the entire allegation
need not be considered false. False information may result in a blow to the credibility of the
victim and the prosecutor may reject the case, but it is not necessarily a false allegation.
Other factors improperly used to categorize a case as unfounded or false include: inability to
locate a victim or an uncooperative victim; a victim who is a prostitute, has a criminal record
and/or is a drug addict; a victim who gave a contradictory history of the incident; or a case in
which no suspect can be identified. Cases that fail to meet the criteria of stranger perpetrator,
violence, physical and genital injury, and immediate reporting rape may also result in their
improper classification and closure (Archambault 2001).
Rape allegations may sometimes be encountered in serious mental disorders that are
accompanied by hallucinations and delusions. In many of these cases the current psychiatric
problems demonstrable and the past medical history will clearly reveal the absence of any
foundation for the allegations. Expert emergency psychiatric help should be offered in these
instances.
The percentage of unfounded and specifically false allegations of rape varies widely from one study to the
next. In the past, some law enforcement agencies have reported up to 51% of rapes as unfounded, without
clear evidence being given to support that they are unfounded. In some jurisdictions, officers may declare a
complaint unfounded in the initial report or following a routine, cursory investigation. This implies to some
that these rape allegations are false (Haws 1997). However, the determination made without an
investigation is often based on stereotypes of socalled "real rape" (Archambault 2001). Keeping the rape
arrest rate artificially high and difficult cases out of the crime statistics may motivate some police
departments to classify many rape cases as unfounded, false or informational. When the FBI investigated
the huge percentage of unfounded rapes in one agency, the agency reclassified some of the rape cases in
question as informational, not criminal an effort to continue to hide the numbers (Down with Crime
Online 1999).
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The medicolegal examination
The medicolegal examination should cover fully both medical and forensic purposes. The
medical goal is to assess and treat injury, treat potential sexually transmitted diseases, initiate
crisis intervention refer for continuing care, and teach risk reduction. The forensic goals are to
retrieve findings that would identify the perpetrator and to document injury that confirms the
use of force against the victim. The examiner concludes whether the findings are consistent
with the history and time flame of the reported event. It is not the role of the examiner to
determine if the incident was consensual or not. Consensual intercourse can result in injury
and, vice versa, forced intercourse can result in no injury (Slaughter 1997). Determining
whether the incident was consent seal is reserved solely for the jury after hearing and
considering all the evidence of the individual case.
The medicolegal examination is composed of the history, the physical examination, the post
examination education of the patient and, ideally, a follow up examination two weeks later.
The examination format periodically changes due to updates in crime laboratory activities or
other requirements. For instance, the practice of obtaining a wet mount of the vaginal swab to
deter mine the presence of motile sperm was once defended as being useful for estimating the
time of intercourse; timing is no longer estimated by noting the mobility of sperm. Law
enforcement requested that photographs be taken of the hands and feet of victims and suspects
to further document signs of force. Some jurisdictions are developing standards of practice for
each of the members of the SART team (San Diego County Health and Human Services 2001).
Developing standards of practice challenges a SART to formalize the best practices, revise
outdated practices, and understand the practice of different professionals on the team. This
understanding helps communication and cooperation, which benefits the victim and facilitates
the investigation. Having victims evaluate their care also helps to identify weak nesses and
strengths thereof.
Prior to the patient's arrival, all team members are notified by a central triage center and a
translator is contacted, if needed. The examiner organizes the forms and prepares the
equipment and the examination room for the patient. In California, the law requires that an
"advocate" be available to stay by the patient's side and offer support. The victim may prefer
to have no one present or may request that the support person of her own choice accompanies
her.
The physical examination
The examiner conducts the physical exanimation with only the advocate present, and only if
the victim requests that she stay. The law enforcement officer does not attend and may use the
time to continue making a report or return to other investigations. There is no assistant or
biomedical photographer at this stage. Using a 35 mm camera with a macro lens, photograph
the patient with her clothes on, focusing on signs of a struggle, i.e. rips, stains, broken zippers
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or pulled buttons. Be sure to get close enough that those reviewing the photographs will easily
note the signs of force. Photographs of the hands and feet may reveal defense injuries from a
fight. Use the Wood's lamp (UV light) to scan the clothing and swab any positive findings,
noting the location. The "Wood's lamp is capable of fluorescing semen as well as other
material.
While the patient is standing on top of two long sheets of paper she is asked to remove her
clothing, inspect each piece of clothing for tears, stains and trace evidence. Retrieve foreign
objects or plant matter, and package this separately from the clothing, noting from where that
evidence was collected. Collect each piece of clothing worn during the assault.
If the patient changed clothes and showered prior to the examination, it may still be useful to
collect the underwear. Each article of clothing should be put in a separate paper sack to
prevent evidence transfer from one article of clothing to another. For instance, it would be
important that semen found on the under wear is not accidentally rubbed against the blouse
during the impounding of the clothing. Plastic sacks are avoided because they retain moisture,
and any ensuing mildew on the moist clothing will cause evidence to deteriorate. The top
sheet of paper that the victim was standing on while removing her clothing is also collected.
Fold the top sheet of paper so that trace evidence present on it will not be lost. When the
victim's clothes are inspected and packaged, the patient should be invited to don a gown,
preferably a disposable paper one, with the front opened for the examination.
Take photographs of bruises, cuts and other patterned injuries. Photographs should be taken
successively the whole body part with the injury evident, then a close up with and without a
photo micrographic scale (American Board of Forensic Odontologist 1986), and finally with
colposcopic magnification if it is helpful. A colposcope is an instrument capable of projecting
a light within a shaft or cylindrical area and magnifying an image upon which a powerful light
source is focused. Magnification potential varies among colposcopes. For instance, the
colposcope in still photograph mode magnifies 4x, 10x, 16x and 25x, and has attached 35 mm
and video cameras. The still photographs taken from a video clip may not have the resolution
needed for certain projects involving publication.
Photograph probable bite marks with a 35 mm camera and with colposcopic magnification, it
is critical to capture the full upper and lower arch patterns to assist in identification of
strangers. Position the camera at a 90 degree angle from the surface of the bite and use a two
dimensional linear scale, such as the ABFO No. 2 (Lightning Powder Co., Inc., Salem, OR),
to best capture an undistorted pattern of the teeth (Bowers & Johansen 2002). If the bite has
broken the skin, a casting may be possible. A forensic odontologist may be available through
the police department or crime laboratory, or one of the examiners may- have the special
training to perform the casting of a bite mark.
Record vital signs and draw blood - two unclotted tubes and one clotted tube. Some SARTs
collect buccal swabs for HIV and refer the patient to a confidential or anonymous clinic for
results and instruction. Begin by assessing the head for tenderness and the scalp hair for
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foreign material or patterned hair loss. Obtain about 20 head hairs as determined by the crime
laboratory procedure- snipped or plucked. Assess behind the ears for clapping bruises, seen
with forced fellatio, and the neck for ligature marks or other signs of choking and record. In
the mouth, assess the hard palate, frenula, the palato-pharyngeal and palatoglossal arches, the
gums and the mucosal and vermilion surfaces of the lips.
Photograph each injury with the colposcope. If there was forced fellatio and ejaculation in the
mouth within 12 hours prior to the examination, swab the cheek and gum area proximal to the
molars for evidence of sperm, and prepare a dry mount slide. Identify and label the swab that
was used to prepare the slide. Use dental floss between the molars to retrieve sperm,
especially if the victim has carried out oral care prior to the examination.
Look carefully at the eyes-sclerae, and tarsal and palpebral conjunctivae for petechial
hemorrhages. Similarly, look at the skin around the eye sockets, behind the ear flaps, and on
the mucosal aspects of the lips. Record any blood-tinged fluid emanating from the nose and
any epistaxis, recent or current. Collect fingernail scrapings if the victim scratched the
assailant or there is other history where fingernail scrapings would be helpful, such as when
the dirt under the nails may help to corroborate the scene of a crime.
Assess the chest and abdomen for injuries or pain. There may be saliva on places that have
been licked or kissed. Those sites should be swabbed, with a swab moistened with sterile
water, by rolling the swab over the site. If the victim has showered then swabs of places
kissed or licked are not likely to be useful. Take a second moistened swab and roll it over a
similar body site that was not involved in the kissing. The second swab is a control swab for
comparison. Distilled water is preferred to saline for moistening the swabs, because saline can
crystallize and confound the findings. Assess each leg, moving downward, for grab marks or
sites of tenderness where a bruise may not yet be visible. Photograph findings with the 35 mm
camera and colposcope as appropriate. Look carefully at the back, particularly at sites of
potential counter pressure bruising such as the back of the head, the skin overlying the spines
of the scapulae, the buttocks, the ankles and calves. If tenderness is elicited, record this, and
further confirm the appearance of bruising at this site at a later examination.
Position the patient in supine lithotomy position, using stirrups, maintaining modesty with
warm drapes. Ensure that the examination couch has been swabbed clean and that the sheets,
preferably paper disposable ones, are fresh. Photograph the genital area with a 35 mm camera
before touching the area. Comb pubic hair with a paper placed underneath her buttocks to
retrieve loose hair and foreign material. Fold the paper to contain any material retrieved. Snip
20-30 pubic hairs as close to the skin as possible and from different areas on the genitalia.
Many adolescent and young adult females shave their mons pubis and labia majora. However,
there may be pubic hair around the anus to retrieve. Use a moistened swab around the external
genitalia to retrieve possible semen. Swabs continue to be collected as evidence. Ensure they
are labeled on the swab tray.
Systematically assess and photograph the external genitalia, even if there are no injuries. Use
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a 35 mm camera with a macro lens and a colposcope with adjustable magnification.
Photographs that are ten times magnified are common because the injury is larger, yet
anatomical landmarks can be seen. Proceed from a general perspective of the area to
successively closer images of any injury present. Proceed from lower magnification to higher
magnification, top to bottom and outside to inside. One technique of examining the genitalia
is to start at the mons pubis and examine in concentric circles, proceeding centrally. The
positions on a clock are useful in documenting the site of injury as in "2 o'clock on the
hymen”. When reviewing the roll of photos, a photo index can help identify- the sequence of
images and the injury captured in the photograph as well as the rendition of color. The notable
finding can be marked on the back of the photograph” site of tenderness, no ecchymosis
present at this time"37ictims are told about developing bruises and to inform law enforcement
if the bruise emerges, so that additional photographs can be taken within the next 48 hours
after examination.
Using labial separation, in which the labia majora are moved laterally and inferiorly, the
posterior fourchette, fossa navicularis and other vestibular structures are examined. The
victim can help separate the labia if she is willing. Slaughter (1997) found that the four sites
most commonly injured in forced penile-vaginal penetration were the posterior fourchette, the
labia minora, the hymen and the fossa navicularis. Specific attention needs to be focused on
these sites.
Labial traction helps in straightening the folds of the hymen, especially when the patient is
unable to tolerate a vaginal speculum. The labia majora are grasped close to the posterior
fourchette and pulled gently toward the examiner. This technique may also permit a glance at
the vaginal wall, when the hymen is straightened out. Using a knee-chest position allows the
posterior rim of the hymen to drop down for better assessment of the hymen. This position,
commonly used in child assessments, is also tolerated by adolescents, but less so by adults.
Several techniques are helpful when the hymen is redundant. Most commonly, the examiner
uses a swab to probe the circumference of the hymen, especially noting the continuity from 3
to 9 o'clock. Figure 28.2 shows a colored probe lifting the hymen for assessment of the area
from 7 to 1 o'clock. The color provides a contrast to the tissue color. Using a balloon catheter
is helpful to assess the hymen when it is especially redundant or there are multiple lacerations.
The Foley catheter with the deflated balloon is inserted into the vagina, then fled with 40-50
ml of air and gently pulled toward the examiner.
After the initial examination of the posterior fourchette and fossa navicularis and the
collection of swabs and photographs (Figure 28.6), apply 1% toluidine blue dye to the
posterior fourchette and fossa navicularis from 4 to 8 o'clock. After allowing a minute for the
dye uptake, remove the excess with lubricant or 10% acetic acid. Toluidine blue dye stains
nucleated squalors cells in the deeper layers of the epidermis (Figure 28.7). Dye uptake is
considered positive and affirms injury when there is residual blue coloring of the laceration or
its border after the excess dye has been removed. Abrasions from forced cunnilingus have
resulted in a diffuse pattern of dye uptake. Findings should be noted first without dye, then
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with dye uptake to corroborate the findings.
The internal vaginal examination is completed by inserting the appropriate size of vaginal
speculum (Figure 28.8) using tap water for lubrication. Some lubricants are also acceptable if
they do not destroy sperm. Avoid contaminating the anal area with vaginal secretions or by
using too much lubricant or water. The pediatric speculum may be most suitable for the
sexually inactive adolescent and postmenopausal woman. Speculum examination its not
performed on protuberate adolescents. Evaluate the vaginal wall and cervix for injury, and
photograph with the colposcope at 10X magnification. Note the difference in appearance at
35mm (Figure 28.9) and at 10X colposcopic magnification (Figure 28.10). Be sure to record
the degree of magnification used in a series of photographs when increasing magnification is
used for detail. Then, mark the magnification on the back when reviewing the photographs.
Take vaginal swabs from the posterior vaginal for nix. The crime laboratory will evaluate for
semen markers - prostates acid phosphates, p30 protein or MHS 5 antigen which are
conclusive evidence that ejaculation occurred (Herr, Woodward 1987). If there are cells on the
swabs, the crime laboratory may provide a DNA profile in order to identify or confirm the
identity of a suspect. Prepare a wet mount of the vaginal swabs, then inspect it immediately
under the light-staining microscope for the presence of sperm (O'Brien /998). An
endocervical swab and wet mount may also be obtained to examine for spermatozoa, if the
assault occurred more than 24 hours before the examination and no possibility exists of an
intervening coitus. Be sure to indicate which swab was used to prepare the wet mount.
FINDINGS OF INJURY IN SEXUALLY ASSAULTED VICTIMS
At the end of a medico legal examination, it is common to hear "Was it consensual? “The jury
answers this question, following a full investigation by law enforcement and argument by
counselors. The medico legal examination is critical in identifying injury and concluding
whether it is consistent with the history (Figure 28.15) but does not conclude whether
intercourse was consensual. Injury may occur in some instances of consensual intercourse as
well as in forced intercourse, and absence of injury occurs in consensual as well as forced
intercourse (Slaughter 1997).Thus, determination of whether a particular case was
forced or consensual is beyond the examiner's conclusions. Nevertheless, when injury is
present, prosecution for sexual assault is more probable (Gray-Eurom et al 2002).
Using a trained examiner, colostomy and 1% toluidine blue dye aqueous solution, when
victims were seen within 72 hours of the assault, Slaughter (1997; n=213) reported that 68%
bad genital trauma, and 76% of those had a mean number of 3.1 sites of injury. By
comparison, 11% of the women examined within hours after consensual intercourse bad just
single site trauma. The consensual group was composed of volunteers and those who were
seen as victims but later recanted their rape accusation. Lindsay (1999) had findings similar to
those of Slaughter (1997). In 642 victims of rape, 73% had ano-genital injury at one or more
sites; conversely, 27% had no injury.
The results of Adams et al's (2000) study of sites of genital injury in assaulted adolescents
were similar to those of Slaughter (1997), who studied adults. The four most common sites of
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injury in adolescents are the posterior fourchette (lacerations), fossa navicularis
(lacerations), labia minora (erythema and edema) and hymen (erythema and edema). In 31
self-reported virgins, hymenal lacerations were found in 6. Lacerations were found in 3 of the
92 girls who were not virgins, a significant difference between non-virgins and virgins. There
were no lacerations, abrasions or ecchymosis of the labia, posterior fourchette, fossa
navicularis, hymen, anus, or rectum in 36% of the 214 subjects, seen within 72 hours of the
assault. Of those who did suffer injury 25% had injury at one site, 21% had injury at two sites
and 16% had injury at three or more sites.
Erythema, ecchymosis and hypervascularity of the mucosal and vermilion surfaces of the lips
or soft and hard palates, arches or uvula characterize oral injury from forced fellatio.
Perianal injury from forced anal penetration may result in perianal tears, erythema and
swelling. Internally, there may be injury to the sphincter muscle, mucosal tears, abrasions or
erythema. Extensive tears are less likely with penile penetration, but may occur with inserting
a fist into the anus -"fisting".
General injuries like ecchymosis occur with grabbing and abduction of the legs. Suction
ecchymosis (love bites; hickeys) occurs commonly on the neck and breasts. Bites produced by
teeth occur anywhere, but are more common on the breasts. Other patterned injuries from
ligatures occur around the wrists and more rarely around the neck. Belt marks or handprints
occur from grabbing, spanking or beating the victim into submission. Collect any vegetation
found on the surface of the body and any soil or other extraneous material still adherent to the skin, scalp
and pubic hair.
Aftercare
When the examination is complete, offer a shower. Women's community groups may provide
hygienic supplies and clothing. After showering, the patient returns to the interview room for
"closure". Findings from the examination are explained if the patient desires. She is told the
results of her pregnancy test and other findings such as genital warts that may require follow
up. The patient receives a written discharge plan which includes recommendations for
comfort and hygiene, medications received, referral to her private physician or clinic to
monitor for sexually transmitted diseases, human immunodeficiency virus (HIV), and to
receive the hepatitis B vaccine series. The patient is strongly encouraged to seek free
emotional counseling through a local rape crisis center or private provider. One estimate is
that less than 10% of the patients seek out this free emotional care. This is tragic since there
are significant longterm emotional and physical consequences of failing to care for one's
emotional health.
Potential sexually transmitted diseases are treated according to the Centers for Disease
Control (2002) recommendations for sexually transmitted diseases in sexual assault. Many
experts recommend routine preventive therapy after a sexual assault, because the follow-up of
these patients can be-difficult. If penile penetration of the vagina occurred midway in the
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menstrual cycle and there is a possibility of pregnancy, an anti- conception agent ("morning
after" pill) is offered. The patient's history and blood pressure are checked for possible
contraindications to its use. The side-effects and the success rate of the medication is
discussed. If the pregnancy test-urinary chronic gonadotrophins (hCG) - is positive, this is
contraindicated.
Occasionally the patient will ask about risk reduction. She is offered techniques and given a
booklet. The booklet details community resources that can help with safety, making healthy
choices and even self defense. The victim is asked whether she feels safe going home. If not,
she is encouraged to go to a relative or friend's house. Women's shelters may be available if
personal safety is at risk. A friend or law enforcement officer returns the victim to safe
housing. Law enforcement will contact her the next day to continue the investigation. The
evidence is locked in a temperature-controlled refrigerator. The SANE does not leave the
evidence unattended until it is locked up. A chain-of-custody record is kept identifying
everyone who had possession of the evidence. The next day the evidence, record and the
photographs are taken by law enforcement.
Ensure that all exhibits are labeled appropriately and correctly.
Scene attendance
The police, together with trained scenes of crime officers or scientists, will examine carefully
and collect trace evidence from the scene where the incident is said to have taken place. A
used condom, for example, will contain penile material and semen internally, and vaginal
cells from the victim externally. Sometimes it may also be useful for the medical examiner to
look over the scene to attempt to interpret the injuries seen. Any weapons used against the
victim that are retrieved should also be shown to the clinical personnel for matching against
the injuries observed on examination.
The SART follow-up examination, two weeks following the original examination, is intended
to compare findings on the acute examination with healed tissue and to evaluate physical and
emotional healing. The examiner reviews the photographs of the acute findings before the
patient arrives. Then the examiner takes repeat photographs of the healed injury with the same
patient position, separation or traction, and magnification. The comparison photographs
clearly show resolution of injury. If there is a question whether a laceration is really a normal
skin crease or if erythema and swelling is over-interpreted, it will be clarified by comparing
the injury photographs to the follow-up photographs. It is easier to get patients to return for
the follow-up visit, if the appointment is arranged during the acute examination. Alternative
telephone numbers should be taken in case the patient stays with a friend or moves. A
reminder call prior to the follow- up is important to ensure that the patient will come.
At two weeks, the patient should have a strong support network and plans for her immediate
future. Normalize her feelings of denial and anger, but encourage her self-care and help her
identify healthy patterns of response. If she has not contacted the crisis center and begun
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emotional care by an experienced rape counselor, the follow-up examination is a time to
encourage her to make that commitment to her emotional care. A member of the crisis center
will accompany her to hearings and the trial if she desires. Ensure that she is in contact with
law enforcement and has the contact numbers to maintain that connection.
Once the prosecuting attorney has taken up the case, then that office activates victim-witness
advocates. These advocates help to ensure that the victim is informed about the processing of
the case, has an advocate attending them at hearings and the trial if desired, and will help with
applying for financial support as a crime victim. Documentation - narrative and photographic
Accurate, detailed narrative and photographic documentation is critical in processing the case.
Evidence of physical injury is probably the best proof of force, and it follows that when more
extensive injury is present and documented, the laying of charges is more likely (McGregor et
al 1999). However, assault can occur with no injury, and injury can occur in consensual
intercourse. The California Office of Criminal Justice Planning form OCJP 923
Adult/Adolescent (Appendix 2) is a detailed written checklist for documentation of the history
and the physical examination. General, oral, genital and anal injury are described and
diagrammatically recorded for both females and males on this form.
The suspect
The medico-legal examination of the suspect in the US
The goal of the examination of the suspect is to identify any offensive or defensive injury
from the victim that will help clarify the facts of the case and to take appropriate samples that
may assist in proving or disproving the allegations. If the perpetrator is arrested, the consent
to proceed with the examination is given by law enforcement. The examiner explains the
process to the suspect and law enforcement provides the brief history of the offense. The
perpetrator usually remains speechless during the suspect's medico-legal examination. The
examination of the alleged suspect should be impartial and non-judgmental as in the case of
the alleged victim.
The examination may be abbreviated compared to the victim examination, because there may
be no injuries. An accused perpetrator may agree to an examination prior to his arrest, in
defense of his innocence.
Vital signs and general demeanor are recorded. Blood is taken for toxicology including
alcohol levels and DNA profiling. All clothing is inspected and collected with special
attention to underwear.Foreign objects are collected and packaged, noting the site from which
they were retrieved. The clothing and entire body are scanned with a Wood’s lamp. Swabs
moistened with sterile distilled water are used to retrieve residue from fluorescing areas or
from stains. Dry swabs are used to retrieve wet secretions. 35mm photographs are taken of
tattoos, scars, body piercing, chronic skin lesions and other distinguishing features that may
be of help to identify the perpetrator for the victim. Photographs are taken with and without a
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scale. Head and body hair samples are snipped or plucked according to the local policy. Hair
comparison is better made when the entire length of it is obtained. If hair is snipped, it should
be snipped as close to the skin as possible.
The head, neck and mouth are examined for injury and foreign material. Moistened swabs are
used to retrieve secretions, foreign objects, and perhaps lipstick smudges.
The genital area is examined for injury, foreign material and other findings such as penis
piercing. All findings should be described and photographed with 35 mm and colposcopic
magnification. Pubic hair is combed downward, onto a paper that has been placed beneath the
buttocks. In addition, 20-30 pubic hairs are plucked or cut as reference samples. They are
used to compare with foreign pubic hairs that might be found on the victim or at the crime
scene. Two penile swabs are obtained by holding two moistened swabs and rolling them over
the glans penis, shaft and base of the penis. Scrotal swabs are taken by holding two moistened
swabs together and rolling them away from the base of the penis.
All evidence must be dried, packaged and labeled with the contents, the collector's name and the date and
time of collection. Evidence is locked in a refrigerator and the chain-of-custody record is signed. Narrative
documentation is completed on the standard form, such as the California Office of Criminal Justice
Planning OCJP 950 (Appendix 3) and photographs are sent for development. The examiner reviews the
photographs the next day to ensure that the photographs are properly labeled with the suspect identification
and notable findings are indicated on the photograph backs. Law enforcement returns for the
documentation when the photographs are developed (within 12-48 hours).
Legal disposal of cases
The US legal system operates on the principle that the accused is innocent until proven guilty.
Most defendants can therefore be released from jail on bail on the promise to return for court
and to avoid contact with the victim. The procedure for the arrest and charging of perpetrators
varies according to the age of the perpetrator and the nature of the offense. If he is under 19
years of age and was under 18 at the time of the offense, he is tried as a juvenile. A juvenile is
issued a juvenile petition.
If a juvenile is convicted of sexual assault, the juvenile probation officer will explore
alternative non-custodial dispositions. A psychological examination may be ordered. The
court holds a dispositional hearing and will rule on the least restrictive alternative that is in the
best interest of the juvenile and society. The range is from dismissal to incarceration, plus one
of the following: a fine of up to $100; repayment of the victim for damages; public service;
postponement or suspension of driving privileges. Even if the juvenile is transferred to adult
status, the court may make his disposition as if he were a juvenile. The perpetrator may appeal
any disposition and that appeal may delay punishment (Prosecution of a Sexual Offense
2000).
If the suspect is an adult and he can be located, he may be arrested. Law enforcement may
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delay arrest for various reasons. At the preliminary hearing, it is determined whether there is
enough evidence for a judge to decide if a crime probably was committed. If not, the accused
is released. If there is probable cause, he is jailed or released on bail. Then the Grand Jury, a
group of 16 people, meets to hear the evidence and decide if there is enough evidence to make
formal charges. If there is enough evidence, an indictment will be issued and the case
proceeds to arraignment. At the arraignment, the accused is informed again of the formal
charges and can enter a plea, admitting or denying the allegations. If he pleads guilty, a
sentencing date is set. If he pleads not guilty, a trial date is set. Before the trial date, the
attorneys may try to negotiate a settlement. This plea-bargaining occurs when the defendant
admits to committing the offense and accepts an agreed-on punishment. If the case goes to
trial it is up to the prosecution to prove beyond a reasonable doubt that the accused is guilty of
this crime. Prosecution and defense present the evidence and argue the case for the jury. At
the end of the evidence, the jury is dismissed to make the decision on guilt. A "hung jury" is
when the members of the jury cannot agree on innocence or guilt. If the jury finds the
defendant innocent, then it means there was not enough evidence for the jury to believe,
beyond a reasonable doubt, that the defendant was guilty. The defendant is then released. If he
is guilty, the judge will set a date for sentencing and the defendant has the option to appeal the
case. If the defendant is acquitted of criminal charges, the victim can bring civil charges
(Prosecution of a Sexual Offense 2000).
ADULT
SERIOUS
SEXUAL ASSAULT ASSESSMENT
IN
ENGLAND AND WALES
The approach to complaints of serious sexual assault is handled in a different manner in the
United Kingdom (UK) compared with the US. Usually the police handle the initial complaint
at their expense and organize a medico-legal examination of the alleged victim on
police-owned or leased premises. They provide a specially trained police officer to act as a
chaperone, and arrange for a forensically trained and experienced physician, rather than a
nurse, to conduct the examination. This part of the chapter will describe the practice in
England and Wales, which is a separate jurisdiction from Scotland and Northern Ireland.
The Koyal College of Nursing of the United Kingdom consider that there is scope for
developing a forensic nursing service in clinical forensic medicine (Home Office Working
Group of Police Surgeons 1996). This has progressed more in the direction of custodial
nursing rather than as specific sexual assault teams.
From this author's (JH) experience, nurses are also employed else- where, for example in the
State of Victoria, Australia, in the custodial care of detainees, but are not involved with
complaints of sexual assault. In adult serious sexual assault allegations, the Victoria Police
transport the complainant to an examination suite and collect and transport the forensic
samples, but are not present during the examination. Rape examination suites are organized
within the Accident and Emergency Department of a hospital, Centers Against Sexual Assault
(CASA), by a politically strong feminist group. This group insists that a protocol be followed
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by the police, the examining doctor and by their own appointed "counselor advocates". These
counselors interview the complainant first, and may be present during the examination and are
also involved with the arrangement of follow-up medical or counseling procedures (Howitt
1995).
Outside agencies, such as counselors, are not involved at the time of the physical examination
in the UK, with the exception of the Social Services, who may be involved when the alleged
victim is a child- below the age of 18 years.
The police in England and Wales are obliged to investigate thoroughly all complaints of
serious sexual assault. A senior investigator unconnected with the case, providing an element
of independent review, monitors all such cases. The Metropolitan Police Service will now
only permit officers to record an allegation of serious assault as "no crime" if there are
substantial indications that the allegation is actually false. This must follow a full enquiry
and be based on evidence, not speculation (WiUiamson 1995):
The law
Under the law of England and Wales: "A man commits rape if he has sexual intercourse with
another person (whether vaginal or anal) who at any time of intercourse does not consent to it
and at the time he knows that the person does not consent to the intercourse or is reckless as
to whether that person consents or not" Sexual Offences A~ 1957, as amended by the
Criminal Justice and Public Order Act 1994. Proof of penetration only is required and there is
no requirement to prove "emission of seed". Case law has determined that if a penis
penetrates within the labia, no matter how little, that is sufficient to constitute penetration
(Lines 1884 1.C and K.393). In Scotland, rape is the carnal knowledge (vaginal sexual
intercourse) of a female by a male against her will and is a crime under common law.
The chaperone (Victim Liaison Officer)
In England and Wales, following a complaint of serious sexual assault, the Criminal
Investigation Division (CID) of the police is informed.
A Sexual Offence Examination Trained (SOIT) officer, ideally of the same sex as the
complainant, is allocated to the case. The designation Victim Liaison Officer is also used in
this context. These police officers are normally engaged in uniformed patrol duties and not
employed full-time in victim care. The training of this chaperone explores in depth the
psychological as well as the practical aspects of managing victims. The officer acts as a link
between the investigator and the victim, freeing the detective or investigating officer to
concentrate on gathering evidence (Williamson 1995). It is the role of the chaperone to take
an initial report, which is a brief statement. The chaperone befriends and transports the
alleged victim to an examination suite, arranges a change of clothing, takes some forensic
samples of mouth swabs and urine before the doctor arrives, and makes the complainant more
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comfortable. This officer will usually attend the medical examination to give the examining
doctor a summary of the complaint and to assist while the forensic samples are taken and
exhibited. They also take significant clothing as their own exhibits. About 12 hours following
the examination, the chaperone takes a full statement and acts as the liaison between the
police and the victim during the investigation and trial. She or he will transport all the
forensic exhibits and also arrange follow-up services such as with the Victim Support Agency
(counseling) and genito-urinary medicine (GUM) clinic.
The examination suite
In England and Wales, when there are considered to be serious medical problems or injuries,
the complainant will be taken to the nearest hospital Accident and Emergency Department (A
& E) for assessment and emergency treatment. When the hospital doctor is satisfied that the
patient is well enough, the forensic physician accompanied by the chaperone undertakes the
medico-legal examination at the hospital.
In most cases, the alleged victim is transported to a police Victim Examination Suite and
arrangements made for a forensic physician to attend. These suites are ideally situated in quiet
areas away from police stations and hospitals, yet where the patient can feel secure. The suite
consists of a sitting room, a kitchen for providing hot drinks, a medical examination room and
a bathroom. The police are responsible for fitting and maintaining the suites with essential
facilities for the medical examination and for the patient's comfort. In some areas, the
National Health Service, the police and forensic physicians have collaborated to create
specialist units, which optimize examination and investigation.
Examining doctors
The examining doctors are usually forensic physicians, known variously as Police Surgeons,
Forensic Medical Examiners (FME) and Forensic Medical Officers (FMO). These are
independent doctors providing clinical forensic medical services to the police. and unbiased
evidence to the Criminal Justice System. Their role generally includes the medical and
forensic examinations of detainees in police custody, victims of assault, and injured police
officers. They also attend sudden death scenes at the request of the police (Association of
Police Surgeons 1999). They undergo initial training in forensic medicine and attend specific
training for the examination of adults and children in allegations of serious sexual assault.
Then they receive in-house practical experience from a proficient colleague. There are
specialist training courses such as study groups for the postgraduate Diploma in Medical
Jurisprudence and for the Diploma in Forensic Medicine. There are also academic forums,
such as the Association of Police Surgeons, the Royal Society of Medicine (Section of
Clinical Forensic and Legal Medicine), the British Academy of Forensic Sciences and the
Medico-Legal Society.
It is essential that doctors undertaking sexual assault examination have a good knowledge of
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injuries and of genital-anal anatomy. Some doctors, who are specifically trained in sexual
offence examinations, do not undertake the general forensic work.
The examination doctor needs to be professional, confident, but non-judgmental and not aloof,
regardless of any personal opinions about the allegation. It is important to establish a rapport
with and show empathy toward the patient throughout the examination. Detailed notes have to
be made, and must be as contemporary as possible, because they may be scrutinized at a later
date in court.
Forensic medical assessment
After introductions have been made, the doctor will aim to put the patient at ease, reassure her
and explain what the medical examination entails. Consent, which should be written and
signed, is obtained for the examination, sample collection, reports and statements to the police
and courts. The process of and the reasons for the examination must be carefully explained
with the importance of confidentiality. Patients are told that despite giving consent, they may
withdraw their consent at any time and stop the procedure.
History of the allegation
Privately, the chaperone briefs the doctor with an account of the complaint so far obtained.
This should include significant points such as where the incident took place, how many
assailants, what sort of sexual intercourse (oral, vaginal or anal), how many times intercourse
occurred, whether a condom was used and if any injuries occurred. The chaperone assists the
doctor by preparing for the appropriate forensic samples specific to the allegation. In some
constabularies, a Scenes of Crime Officer (SOCO) assists with the forensic samples. A special
Sexual Offences Examination Kit is avail- able from the Forensic Scene Service. It contains
the appropriate containers and swabs likely to be needed for an examination. The patient is
invited to choose who is present during their examination, such as her mother, a friend, or an
interpreter. Further specific details of the incident may be obtained, such as any injuries
received, drugs or alcohol used, ejaculation, and sites of kissing or licking. What has occurred
since the incident can also be determined, such as has the victim washed, changed clothing or
had sexual intercourse. It is considered better practice to help relieve distress to avoid asking
the patient to repeat the allegation in too much detail.
Significant medical history
The complainant is asked to give information about her medical history. This should include
any systemic diseases, psychiatric problems and any medical problems related to the site of
forced intercourse (mouth, vagina, and anus). A full menstrual and obstetric history, including
details and the date of last intercourse, is necessary when forced vaginal intercourse is
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reported.
General assessment and relevant forensic sample taking
Following the medical history, the doctor will then undertake the examination, taking forensic
samples. Throughout the examination, the modesty of the patient should be respected. It
should never be necessary for her to be naked. The doctor Hill make detailed records of the
demeanor and mental state of the patient, noting any signs of inebriation by drugs and/or by
alcohol. This should be assessed throughout the period of the examination. An apparently
calm, collected patient may experience breakdown of control at times. The state of clothing,
such as soling, tearing or turning inside out is noted. Jewelry worn during the incident is also
documented. The height and weight should be measured and the dominant hand identified and
recorded.
The complainant may not know nor be able to report where her injuries are. So, as areas of the
body are exposed, the doctor Hill carefully inspect all body surfaces and orifices for injury.
The finger- nails are examined, and negative as well as positive findings are noted. Any
injuries must be described very precisely. Each site of injury should be drawn and
documented on a full body or a specific body part diagram. Measure the site of injury and the
distance to the nearest bony point or crease, type of injury, covering surface, color, shape,
degree of swelling, degree of blanching, dimensions, and degree of healing. Areas where the
patient complains of tenderness or discomfort are also recorded on the body chart or diagram
together with any negative or positive findings.
Each piece of clothing worn at the time of the incident is separately bagged and exhibited by
the chaperone or Scenes of Crime Officer (SOCO) and an examination gown is provided for
the victim. In some areas, the patient is asked to stand on a sheet of paper while undressing.
This technique helps to collect any falling debris. The paper is also exhibited by the
chaperone.
Forensic samples routinely taken include:
 A blood sample for drugs and alcohol analysis, collected in a universal bottle containing
sodium fluoride and potassium oxalate
 Two buccal swabs for DNA
 Urine for drugs and alcohol, collected in a jar with sodium fluoride
 Saliva collected in a sterile container when there has been alleged oral penetration or a
bite mark is seen
 Specific swabs of sites that have been kissed, bitten, licked, sucked on, penetrated by a
penis or ejaculated upon.
When the victim has no knowledge of the details of the incident, due for instance to drugs or
alcohol use, swabs should be taken from all body orifices, and from the breast. Any debris or
foreign matter is removed. Fingernails can be cut or scraped and are particularly significant
when the patient reports that she scratched her assailant - use of swabs moistened in distilled
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water may produce an increased yield of evidential material. Pubic and head hair samples are
taken for identification purposes and when there is foreign matter in the hair.
When bite marks are suspected or reported, the area should be detailed on a body chart or
diagram and specific photographs should be taken as soon as possible. A saliva sample should
be taken, together with the swabs from the bite mark and from an area of skin adjacent to it.
The services of a forensic odontologist should be sought when depending on bites for the
identification of the assailant.
It is unwise to take samples that are not indicated, even if the samples have been requested by the
investigating officer. The examining doctor may have to give justification in court for those samples being
taken.
Genito-anal assessment and relevant forensic sample taking
The genital examination is undertaken with the patient supine on the examination couch. It is
considered inappropriate to use lithotomy stirrups. Sometimes the knee-chest position is used
to verify findings noted in the supine position. The patient is placed in the left lateral position
for the anal examination. The position used should be recorded. All trace evidence is retrieved
before the examination begins. Collecting trace evidence first avoids destruction or
contamination of that evidence. Next there is inspection of the inner thighs and buttocks. All
abnormalities, injuries, blood or other stains are recorded on a body chart or diagram. The
sites are referred to by the positions on an imaginary clock face placed over the anogenital
area. 12 o'clock points toward the pubis and 6 o'clock toward the coccyx. Negative as well as
positive findings should be recorded. The degree of sexual maturity is recorded using the
Tanner stages (Table 28.2;Tanner 1962).
Any areas showing secretions or stains should be noted, swabbed or cut if on pubic hair, and
exhibited specifically. In females, the external genitalia is swabbed over the labia and
vestibules and exhibited as a vulval swab. The low vagina is swabbed by passing the swab
into the vagina under direct vision and avoiding contact with the external genitalia. This is
exhibited as a low vaginal swab. Any foreign bodies such as tampons are removed and
exhibited. After careful insertion of a disposable speculum of the appropriate size, using only
warmed water as a lubricant, two high vaginal swabs are taken above the speculum from the
fornices. Care should be taken to avoid contaminating the swab on the sides of the instrument.
A disposable speculum is used because autoclaved specula can be contaminated if not
properly cleaned. If more than 48 hours have elapsed since the time of the alleged incident,
one or two endocervical swabs are also taken, as spermatozoa remain longer in this area. High
vaginal swabs are also taken when the allegation is only of anal penetration - particular care
should be exercised in taking these swabs to ensure that they are not contaminated with
material from the lower vagina.
With the speculum still in place, the vaginal vault and cervix are inspected and evidence of
injury, blood or discharge is noted. Following removal of the speculum, the’ external genitalia
is then inspected for any signs of injuries, blood or discharge.The type of hymen (annular,
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crescentic, septate or remains only) should be recorded and the free edge inspected carefully
for any defects. A bi-manual examination may be indicated to localize pelvic tenderness or
prior to prescribing post-coital emergency hormonal contraception.
In male patients, when appropriate, the shaft of the penis is swabbed (penile swab), and the
foreskin retracted and a swab rubbed around the glans and coronal sulcus (coronal sulcus
swab). Any injuries or abnormalities of the foreskin, penile shaft, scrotal sacs and testes are
noted together with any evidence of vasectomy or circumcision.
When anal penetration is alleged, the perianal area is swabbed (external anal swab) by
rubbing a swab over the anal margin and adjacent skin. A disposable proctoscope is carefully
inserted one to two centimeters into the anal canal and the distance is noted. The obturator is
removed and an anal swab is taken (internal anal swab) above the proctoscope. Avoid
contaminating the swab from the sides of the instrument. With the proctoscope still in place,
the anal canal and rectum are then inspected for injuries, blood or discharge.
Subsequent to the medical assessment
After the medical examination is completed, the complainant is invited to have a bath or
shower, wash the hair, clean teeth and offered a hot drink. During this time the doctor finishes
the examination notes and completes a form with brief significant information for the forensic
laboratory. The chaperone assists to bag, label, sign and seal the forensic samples. Each
sample is separately timed and exhibited with the doctor giving each a personal exhibit
number, usually his or her own initials followed by sequential numbers. The exhibits are then
handed to the chaperone or Scene of Crime Officer who then signs each receipt and transports
them to the forensic laboratory. If there will be an unavoidable delay in the samples reaching
the laboratory, provision should be made for placing them in refrigerated cabinets. The
findings are discussed with the chaperone or the investigating officer. Then appointments are
made to screen for sexually transmitted diseases at the genito-urinary medicine clinic in 7-14
days.
Counseling services, Victim Support, Survivors and Social Services are contacted, usually by
letter, and appointments are made by the chaperone. The patient's family doctor - with the
consent of the examinee - should also be contacted and information given on "a need-to-know
basis" of the findings, any treatment given and the referrals made.
Where appropriate, advice should be given about possible pregnancy and emergency
postcoital hormonal contraception. If postcoital contraception is indicated, written instructions
about administration should be given. Referral for emergency intrauterine device (IUD)
insertion may be appropriate if more than 72 hours has elapsed since unprotected vaginal
intercourse or if estrogens are contraindicated. It is not routine for antibiotic prophylaxis to be
given for STDs at the time of the examination. However, urgent referrals for relevant
prophylaxis should be made if hepatitis or human immunodeficiency virus (HIV) risks are
apparent. The patient or suspect can be asked to provide a blood specimen for HIV testing
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only after receiving counseling discussions and the giving of informed consent. Ideally, the
patient should be re-examined a few days later to reassess the findings, but this is not usual practice in
England and Wales, unless new and obvious injuries such as bruises become evident.
Photography, colposcopes, Wood's light and toluidine blue
Where significant injuries have been found, the doctor can recommend photography. Such
evidential photographs are taken by qualified photographers who are sometimes serving
police officers. It is not generally recommended that the doctor takes photographs unless he or
she has received specific training as the photographic images can be questioned in court.
Photography is arranged by the police, after the examination is complete. The doctor ~ be
present to direct the photographer to the areas that should be photographed or the injuries can
be shown to the photographer on a body chart or diagram.
Colposcopes with attached still cameras or video recorders are in use in some areas of England and Wales,
mostly for child victims of sexual assault. Wider use of these at present is restricted because of financial
constraints. Low output ultraviolet light, Wood's light, is sometimes used to locate areas of semen or saliva,
but there can be many negative and false positive results. Toluidine blue is not routinely used in England
and Wales. Injuries not apparent to the naked eye, but which might be seen with the colposcope or with
toluidine blue, are so minor that it is difficult to know their significance.
The interpretation of findings
The examining doctor is frequently asked by the police to provide a statement of the
examination. Initially this should be a resume of the findings but later a detailed account
should be given with headings in a dear, unambiguous manner, avoiding medical jargon.
Interpretation of the findings is expected and alternative explanations, such as consensual
sexual intercourse, defense injuries or the possibility that injuries may have been self-inflicted
should be explored. Features associated with self-inflicted injuries include (Rogers 1995):

Located on the body surfaces accessible to the dominant hand

Sparing of sensitive body areas, e.g. nipples, eyelids

Multiple incised wounds, usually parallel

State of healing consistent with the proposed etiology.
A final opinion of the most likely cause of the findings should be stated. However, it should
never be said that the findings are consistent with rape as this is a crime for the courts to
establish. Where there are no significant physical findings, it should be stressed that this does
not confirm, nor does it exclude serious sexual assault. There are many reasons why a
complainant is un- injured. Reasons for absence of general injuries in alleged victims of
serious sexual assault include (McLay 1996):
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●
Submission of the victim may be achieved by emotional manipulation, fear of violence
or death or by verbal threats.
●
The force used, or the resistance offered, is insufficient to produce an injury.
●
Bruises may not become apparent for 48 hours following assault.
●
A delay in reporting the incident will allow minor injuries to fade or heal.
Reasons for the absence of ano-genital injuries in alleged victims of serious sexual assault
include (McLay 1996):
●
Less than half of all complainants of sexual assault have injuries to the genital and anal
areas.
●
The alleged sexual act (such as rubbing, touching) was unlikely to result in injuries.
●
The victim is sexually experienced.
●
The natural elasticity of the post pubertal female genitalia, including the hymen.
●
The natural elasticity of the anus.
● The use of lubricants.
Suspect assessment
Examinations of suspects are not undertaken by the same doctor who examined the victim
(unless he had showered and changed clothes in the interim) but by another forensic physician
to avoid contamination of the trace evidence.
These assessments are carried out in the medical examination facility within the custody suite
of the police station in which the suspect is detained. The examination needs to be carried out
with the same respect and sensitivity as that of the victim and with a similar top-to-toe
assessment. Details of the allegation and results of the victim examination, especially any
injuries inflicted, can be helpful to the examining doctor and will ensure that particular areas
are scrutinized. One example is the examination of the suspect's knuckles where a punch from
a fist was alleged.
Informed consent must be obtained from the suspect and, in addition, in England under the Police and
Criminal Evidence Act 1984 (PACE), written approval from a police officer above the rank of
superintendent is required. The samples taken are relevant to the allegation and they are handled in the
same careful manner as those of the victim. Each sample is given a unique exhibit number, bagged, labeled,
signed, sealed and, together with a completed laboratory form, handed to the police officer or Scene of
Crime Officer for signature and transportation to the forensic laboratory. The investigating officer should be
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informed of any injuries or other findings, and the patient given advice to attend a sexually transmitted
disease clinic if appropriate.
Court
Complainants have few rights in courts in the UK. They do not have specific legal
representation and have no say in what happens to the suspect if found guilty. In comparison
to the US, their needs are not adequately provided for.
The forensic physician is inevitably required to give evidence in contested cases and is called
by the prosecution team; often a medical expert has also been instructed and is called by the
defense lawyers as an integral part of the adversarial system. This can be intimidating, but
presents a good learning encounter, especially for the less experienced doctor. The
inquisitorial court system in England and Wales is similar throughout most of the
English-speaking nations.
REFERENCES
1.Abel G, Becher J, Mittleman M, Cunningham J, Roulean J, Murphy W 1987 Self reported sex crime of
non-incarcerated paraphiliacs. J Inter personal Violence 2(1):3-25
2.Adams J, Girardin B, Fangno D 2000 Signs of genital trauma in adolescent rape victims examined
acutely.J Pediatt Adolesc Gynecol 13(2): 88
3.Adams J, Girardin B, Fangno D 2001 Adolescent sexual assault: documentation of acute injuries using
photo-colposcopy. J Pediatr Adolesc Gynecol 14:175-180
4.Aiken MM, Speck PM 1995 Sexual assault and multiple trauma: A SANE challenge’s Emerge Nursing
21(5): 466-468
5.American Board of Forensic Odontologists 1986 Guidelines for bite mark analysis. JAm Dent Assoc
122:383
6.Archambault J 2001 Unfounded and false allegations. Paper presented in San Diego, California June
2000. Meeting of International Association of Forensic Nurses, Local Chapter. See website:
www.mysati.com
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Chapter 9 Assault and injury in the living
Type of injury
No visible injury
Wheals and erythema
Bruises
Abrasions and scratches
Cuts
Deliberate self-harm
Defence injuries
Handcuffs and arrest injuries
Other injuries
Summary
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TYPE OF INJURY
Injuries are classified in many different ways, but with simple underlying themes. It is
important that anyone involved in the assessment of injury understands the range of terms that
can be applied to different types of injury (often dependent on geo- graphical location or
medical specialty). Each examiner should adopt their own system that ensures that the nature
of each injury is described clearly and reproducibly in note form. Deliberate injury may be
divided into two main types - blunt impact injury and sharp implement injury. Blunt impact
injury describes the cause of injuries not inflicted with instruments or objects with cutting
edges. The injury may be caused by either traction, torsion, and shear stresses. The body may
move towards the blunt object with a direct application of force (e.g. with a fall or push
against a wall) or the blunt object may move towards the body. Examples of objects that cause
blunt impact injuries include fists, feet, baseball bats, or police batons. A blunt impact blow
can cause a range of symptoms or signs, and the resultant injuries are dependent on a number
of factors including force, location, and impacting surface - which may reveal no visible
evidence of injury, or tenderness or pain at the site of impact, reddening, swelling, bruising,
abrasions, cuts (lacerations) and broken bones.
Each type of injury may be present alone or in combination. Such injuries are seen at the point
of contact of the impacting object on the body. Bruises may migrate away from the point of
contact by gravity after a period of time. Abrasions give a clear indication of the site of impact.
In some cases patterns of injury may indicate whether a particular impacting object was
involved. Blunt impact injuries can be described as being weak, weak/moderate, moderate,
moderate/severe, severe. The more force full the impact the more likely that visible marks
will be evident. Sharp injuries are those caused by an implement with cutting edges (e.g.
knives, scissors or glass). The injuries may be classified into either incised - where the cutting
edge runs tangentially to the skin surface, cutting through skin and deeper anatomical
structures - or stabbed - where the sharp edge penetrates the skin into deeper structures. An
incised wound is generally longer than it is deep, whereas a stab wound is deeper than it is
wide. The forces required to cause sharp injuries and the effect of such injuries are variable as
a very sharp pointed object may penetrate vital structures with minimal force.
No visible injury
It is extremely important to be aware that many types of impact may cause initial pain and
discomfort - which may resolve within a few minutes, and tenderness - which may still be
elicited hours or days later, with no visible sign of injury. The lay person must be aware that
the absence of visible injury does not imply that no assault or injury has taken place.
Wheals and erythema
Wheals and erythema are also non-permanent evidence of trauma caused by initial
vasodilatation and local release of vasoactive peptides following an injury such as a slap,
scratch or punch which will leave little or no mark after a few hours. The classic features of
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the triple reaction are present but no specific damage is done to any tissues. Thus an initial
reddening associated with pain and possible subsequent development of local swelling may be
present initially but after a few hours has completely resolved, unlike bruising, which will still
be present after 24 hours or longer.
Bruises
The terms "contusion" and "ecchymosis" have been and are used to differentiate between
different types of injury which can more simplistically be called bruising. The different terms
have been used variously to describe different sizes of injury but do not enhance
understanding of either causation or mechanism of injury and should no longer be used.
Bruising is caused when an impact damages blood vessels such that blood leaks into the per
vascular tissues and is evident on the skin surface as discoloration. Such discoloration
changes in color, shape and location as the blood pigment is broken down and resorted. In
some cases although blood vessels may be damaged, there may be no visible evidence on the
skin. In certain cases it may take hours or days for a bruise to become apparent (as the blood
diffuses through damaged tissue). The color of bruises and rate of intrinsic color change are
widely considered to be an important indicator of the timing of injury. However, ageing of
bruises is a notoriously inexact process and the most authoritative work published is based on
a study of bruises of a known age in 369 subjects (Langlois & Gresham 1991).The study
concluded that it was only possible to state that a bruise with a yellow color was more than 18
h old and that the colors red, blue and purple/black could occur anytime within 1 h of bruising
to resolution (up to 21 d in the study).Thus coloration of bruises and the progress and change
of color patterns cannot (with the exception of a yellow bruise, which may be considered to
be more than 18 h old) be used to time the injury. It should be emphasized that estimation of
bruise age from color photographs is also imprecise and should not be relied upon, as the
color values are not accurate (Stephenson & Bialas 1996).This has recently been confirmed in
another study (Munang et al 2002), which identified great inter-observer variability in color
matching both in vivo and in photographic reproductions. Other information (e.g. a witnessed
blow) is the only way of reliably timing a bruise. The color of a bruise is further confused by
the fact that many bruises exhibit multiple colors at the same site despite being caused at the
same time. Figure 36.6 shows a bruise caused following an i.v. injection range of color
changes may be seen yet the initial trauma was all at the same point in time. This photograph
was taken 24 h after injection.
The site of the bruise does not necessarily indicate the site of impact as gravity, and other
factors such as the presence or absence of tissue planes will allow blood to track to sites
remote from the initial impact.The amount of bruising is dependent on a number of factors
including site and force of impact. The soft parts of the body, e.g. the abdomen, rarely have
visible bruising. Those areas with under- lying bone are more likely to bruise easily (e.g. the
limbs, scalp). Other factors which may increase the tendency to bruise include conditions
which might affect the fragility of blood vessels or conditions which slow or prevent blood
clotting. Such factors include not only underlying disorders, e.g. hemophilia, but also the
administration of certain drugs such as anticoagulants, aspirin and steroids. Other factors,
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such as advanced age, may predispose to an increased tendency to bruise, as will a relatively
young age and alcoholism, or hepatobiliary dysfunction. If necessary, clotting studies or liver
function tests should be undertaken.
Abrasions and scratches
Abrasions (of which a scratch is a linear version) often known as grazes - are superficial
injuries involving (generally) only the outer layers of skin and not penetrating the full
thickness of the epidermis. Occasionally the full thickness of the skin can be abraded.
Abrasions are mostly caused by the shearing movement of the skin across a rough surface (or
vice versa). Close examination of abrasions can give an indication of the direction of
movement 0f the skin surface in relation to the traumatizing surface. They are always
indicative of the position of impact. Figure 36.16 shows a large oblique abrasion of variable
depth along the extensor surface of a forearm. The part near the otecranon is deeply abraded.
Discoloration may be apparent and pigmentation may develop dependent on the surface.
Some abrasions are very superficial - merely removing the upper few layers of skin without
causing serous ooze or bleeding. These may be termed "scuff" or "brush" abrasions and are
often very good indicators of the direction of movement. Figure 36.18 shows an injury which
represented a bite through clothes. Visual inspection confirmed bruising, swelling and scuff
abrasions. Many such injuries benefit from review with magnification - on screen either at the
time of examination or subsequently - particularly if photographs have been taken digitally.
Figure 36.19 shows a close up of this bite mark and the direction of 'skin lift' can be seen to be
from opposite directions where the maxillary and mandibular teeth have opposed each other,
confirming this was caused by a bite.
Fingernail scratches are frequently seen. Linear regular scratches of similar depth in a
converging pattern are typical of such injuries. They may be up to the width of a nail across.
Some just cause wheals, others draw blood. Figures 36.20 and 36.21 illustrate typical
examples. In cases of assault it is essential to examine the nails of victim and assailant, as
both may attempt to scratch the other and significant evidential material may be retained
under the nails. The presence of false nails, broken nails, or nails bitten to the quick all may
assist in determining the true course of events. Fingernail scratches may be isolated and/or
multiple, and need to be distinguished from other types of injury. Figure 36.22 shows
fingernail scratches to the right neck following a domestic argument, which the male "victim"
then tried to reproduce to imply a worse attack on his right cheek - these however are
abrasions of a different type - "point" abrasions and were not caused by fingernails but were
self- inflicted with a metal nail.Point ('gouge') abrasions or scratches are those caused by
objects not sharp enough to incise or cut, but pointed enough to gouge or scratch i.e. remove a
portion of the skin's surface.
Some point abrasions are not caused by weapons. The two point abrasions seen on the
forehead of the man in were caused by the nose supports of a pair of glasses being pushed up
the head following a punch.
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Cuts
Cuts (excluding point abrasions described earlier) may be divided into those caused by blunt
impact injury - lacerations (or tears) - and those caused by sharp implements or edges incisions (or incised type). Sharp force trauma is dealt with in detail in Chapter 22. The
distinction between incised wounds and lacerations is of the greatest importance
medico-legally as causation (blunt impact or sharp implement) is often the key to the outcome
of a case. A lack of understanding of the difference and significance of the difference between
lacerations and incised-type wounds is probably the most common mistake made by
non-forensic doctors at all levels, when providing a statement or reports for courts.
Lacerations are caused by blunt force impact compressing and splitting the skin, or
occasionally by shearing force. Lacerations most commonly occur where underlying bone is
prominent - classically at the orbital margin. After treatment, i.e. by suturing or gluing, it is
often impossible to distinguish between a laceration and an incised wound - which is why
adequate documentation before treatment is essential. The most significant difference that can
distinguish between lacerations and incised wounds is that incised wounds have clean, distinct
edges. Lacerations may have macroscopically clean, distinct edges, but under magnification,
do not. Generally lacerations have irregular or macerated edges, residual skin bridging
(particularly at the ends), and may have other features of blunt impact injury associated, e.g.
swelling, reddening, and bruising. Figure 36.25 shows a small laceration with associated
swelling and irregularity of the wound edge after a punch to the face.
Incised-type wounds may be caused by anything with a sharp edge, including knives and
broken glass. If glass breaks at the time of impact, multiple cuts from sharp glass shards may
be seen. Figure 36.26 shows the fingers of a male arrested for breaking into a house, having
broken a window with his hand. The illustration shows multiple small incised wounds.
Incised wounds crossing irregular surfaces may be irregular in depth, but their linearity will
assist in confirming causation. Figure 36.27 shows the dorsum of a hand across which a knife
had been drawn.
Assaults with broken glass or bottles are increasing in frequency. The characteristics of such
injury are of multiple irregular incised- type wounds of variable depth and severity. Figure
36.28 shows a male who had a broken bottle thrust in his face. The wound edges are all clean
with no skin bridging, confirming that sharp edges caused these injuries.
Sharp blades may have features which give rise to a patterned appearance. Figure 36.30
illustrates the sutured incised wound of a male who alleged that he had been assaulted with a
serrated bread knife. This was confirmed by review of the injury, where a repeated regular
pattern can be observed along the length of the scar, which matched exactly with the serration
pattern on the bread knife that was used in the attack.
Stab wounds are generally deeper than wide because of the mode of injury - a thrusting rather
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than a drawing or slicing movement across the skin. Some injuries are a mixture of both - for
example glassing injuries where irregular edges of cutting glass may create both superficial
and deep injuries. Meticulous documentation and assessment is essential as this may assist
determination of causation (Karlsson 1998). Heavy weapons with sharp blades (e.g. meat
cleavers, machetes, swords) are capable of causing very major injuries with damage to soft
tissues and bone (Missliwetz & Denk 1994, Ong 1999). A mixture of blunt and sharp injuries
may be present and lacerations and incised wounds may be evident. Slash wounds ("slicing"
or "striping") may be caused by the earlier mentioned implements used with the intention of
killing or simply disfiguring .The face is surgically but leave clean scars. Figure 36.31 shows
a scar that has been surgically repaired, which was made with a sharp blade. Figure 36.32A
and B shows scarring following a serious assault with a machete about 2 years previously.
The victim did not attend hospital and simply dressed the wounds until they healed.
Death and loss of body parts may also be sequelae following cuts. Compound fractures have
been described - the term "bony lacer- ation" has been used - although "bony incision" may be
a better term (Rymaszewksi & Caullay 1984). Ong (1999) reported that slash/chop injuries
tend to be directed towards the head and neck region. Clearly some injuries do not fit directly
into categories. Levin &Joseph (1996) have described a penetrating trauma with a meat
thermometer, which had initially been thrust into the female victim's left medial orbit,
removed and then thrust into her neck. The author emphasizes the need to be aware of the
anatomical structures that may be damaged and have a low index of suspicion ensuring that
appropriate investigations are instigated. A similar case of a male struck by an arrow which
passed through the right orbit has been described (Ricci /999).
DELIBERATE SELF-HARM
Individuals injure themselves for a number of reasons including psychiatric illness, and other
reasons such as attempting to imply that events took place that did not, or for motives of gain.
Self inflicted injuries have a number of characteristics, which are not diagnostic, but which
together may give an indication of self` infliction. The following features may assist in the
recognition or suspicion that cuts or other injuries such as scratches are self" inflicted (all or
some may be present and their absence does not preclude self infliction nor does their
presence necessarily imply self infliction):
 Injuries must be on an area of body accessible to the dominant hand of person to injure
themselves
 Injuries are superficial or minor
 Injuries are regular with an equal depth at the beginning and end (for cuts)
 Injuries are regular and similar in style or shape (for scratches, burns, etc.)
 Injuries are multiple
 Injuries are parallel or grouped together
 In right-handed persons injuries are predominantly on the left side (but not inclusively)
 There may be lesser injuries where initial attempts at self "harm are made ("tentative"
scars)
 Injuries are on selected sites; forearms, wrists, abdomen, upper thighs the face is usually
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avoided
 There may be old scars from previous attempts at self harm. There may be a psychiatric
history or a personality problem.
Figure 36.33 illustrates five linear parallel fresh injuries with older pale scars caused by the
self application of a knife heated over a gas stove. This 24-year-old Asian male had been self
harming in this manner since the age of 15.
DEFENCE INJURIES
Certain types of injuries may be described as "defence" injuries. These are injuries that are
typically seen when an individual has tried to defend themselves against an attack, and these
are the results of instinctive reactions to assault. When attacked with blunt objects most
individuals will attempt to protect their eyes, head and neck by raising arms, flexing elbows
and covering head and neck. As a result the exposed surfaces of the arms become the impact
point for blows. Thus the extensor surface of the forearms (the ulnar side) may receive blows,
the lateral/posterior aspects of the upper arm, and the dorsum of the hands. Similarly the outer
and posterior aspects of lower limbs and back may be injured as an individual curls into a ball,
with flexion of spine, knees and hips to protect the anterior part of the body.
In sharp blade attacks, the natural reaction is to try and disarm the attacker, often by grabbing
the knife blade. This results in cuts to the palm and ulnar aspect of the hand. On some
occasions the hands or arms may be raised to protect the body against the stab bing motion,
resulting in stab wounds to the defence areas, which in some cases may be through and
through because of the sharp- ness of blade. Figure 36.37 shows the palmar and dorsal surface
of a hand and the sutured through and-through cut where the victim had put the palmar
surface of his hand out to ward off a knife attack. Note that the alignment is the same,
confirming that this was from a single stab.
HANDCUFFS AND ARREST INJURIES
Handcuff injuries are important injuries, and often poorly documented. Handcuff neuropathy
was the most common neurological problem acquired by US prisoners of war during
Operation Desert Storm (Cook 1993) and all were sensory in nature generally, exhibiting
diminished sensitivity to pin-prick and light touch on the dorsolateral surfaces of the affected
hand. Atrophy was absent and all examinations showed normal deep tendon reflexes, muscle
tone and an absence of Tinel’s sign. Stone and Laureno (1991) identified a superficial radial
nerve deficit and to a lesser extent a median nerve deficit in five prisoners as a result of
compressive neuropathy due to tight application of handcuffs. Some of these deficits lasted
for up to 3 years. The authors advise the use of nerve conduction studies in the presence of
prolonged symptoms in order to rule out fraudulent claims. In each case handcuffs were
applied for no longer than an hour or so. Levin and Felsenthal (1984) additionally identified
ulnar nerve lesions.
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OTHER INJURIES
It is essential that an open mind is kept when assessing any injury. Injuries may not appear to
be what they seem and Prahlow & McClain (1997, 2001) described a number of apparent
injuries due to gunshot wounds which were not - examples included iatrogenic injuries from
resuscitation, such as insertion of drainage tubes.
Certain burn injuries not necessitating hospital admission can cause diagnostic puzzles if the
individual does not supply a complete or true story. Figure 36.43 shows a partial-thickness
burn caused by hot coffee being poured onto a %shirt (by the 'victim'). The "victim" alleged
that he had been dragged along a road and this was a graze. The scratches were also self
inflicted.
SUMMARY
Assessment of assault and injury in the living requires meticulous attention to detail. A good
history, from the patient and others, is essential and unambiguous, accurate documentation of
all injuries in a way that win ensure that the records can be reviewed easily by peers and
courts at a later date. In the medico legal setting it is important to ask specific questions about
causation, and if patterns of injuries and witness accounts do not match up, be prepared to ask
further. Also be prepared to revise opinions further or when different evidence becomes
available.
REFERENCES
1.Aalund O, Danielsen L, Sanhueza RO 1990 injuries die to deliberate violence in Chile.
Forensic Sci Int 46:189
2.A1-Quarainy A, Stassen LE Dutton GN, Moos KF, El-Attar A 1991 The characteristics of
midfacial fractures and the association with ocular injury: a prospective study. BrJ Oral
Maxillofac Surg 29:291-301
3.Beck SR, Freitag SK, Singer N 1996 Ocular injuries in battered women. Ophthalmology
103:14-151
4.Berlet AC,Talenti DP Carroll SF 1992 The baseball bat: a popular mechanism ofurban
injury.JTrauma 33:167 170
5.Birnie RH 1987 Significance of assault injury of the hand. S Afr Med J 74:183
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Chapter 10
The physical and emotional abuse of children
Definition
Setting and incidence
Patterns of accidental bruising
Patterns of injury that might arouse suspicion of abuse
Factors in the presentation of physical abuse
Physical injuries seen in abused children
Head injuries
Bites
Mouth injuries
Eye injuries
Thermal injury
Conclusion and summary
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PHYSICAL ABUSE
Definition
The physical and emotional abuse is a worldwide phenomena. This chapter addresses the
issues and describes the investigations and management within the UK as an example
although principles apply worldwide. In the UK, child abuse was formally defined in the 1999
Department of Health guidelines and redefined in 2000 (Department of Health
2000) Physical abuse involves hitting, shaking, throwing, poisoning, burning or scalding,
drowning, suffocating or otherwise causing physical harm to the child which is actual or likely.
Fictitious (or factitious) illness by proxy is also included under physical abuse. From a
clinical perspective, the severity of the injury, the number of injuries, the age of the child and
any previous injuries and other abuses (neglect, child sexual abuse, emotional
abuse) are all part of the jigsaw which leads to a diagnosis of physical abuse.
Setting and incidence
Much physical abuse is considered by the carer to be "reasonable chastisement", and over
90% of 4-year-old children in the UK are hit (Leach 1999). However, an increasing body of
adults perceive physical punishment to be physical assault and, as such, not an acceptable part
of child rearing (Newell 1989). At the time of writing, in England the use of physical
punishment in the form of reasonable chastisement (which in practice has become "bruising
means the hit was too hard") is allowable by the child's parents and, with their consent, their
child minder. Physical punishment is not permitted in nurseries, schools, foster and children's
homes, but hitting does occur, and levels may be higher in foster and children's homes (Hobbs
et al 1999a).
The belief is that the career inflicts pain on the child so he learns. Smith et al (1995) also
noted that a majority of children are hit (over 90% of those aged 4 to 7 years). Considerable
pain may be inflicted: 14% of the punishment was assessed as severe by the researchers.
Cawson et al (2001), in a helpful paper in a field which is lacking a firm evidence base
(Department of Health 1995), asked young adults about their own, recent experience of
physical punishment:
● 26% had witnessed domestic violence
● 20% had been physically assaulted
● 7% had been severely assaulted
● 6% had been hit with an implement
● 4% had been choked
● 1% had been burned or scalded.
Domestic violence is common in the UK (Jewkes 2002): it occurs in a third of households,
where children watch, listen to, or are part of the violence. Most of these children suffer
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emotional abuse; physical abuse is estimated to occur in haiti child sexual abuse (CSA) is
estimated to occur in as many as a third of the children in these violent households. Domestic
violence is related to certain occupations: soldiers, prison officers, police and, a worldwide
problem, boy soldiers. Over 90% of abuse takes place at home, with mothers hitting more
than fathers, but men causing more damage. Teenage babysitters pose a risk to small babies.
All ethnic groups in the UK appear to hit their children.
Mothers who are physically abused are more likely to hit their children, and their parenting
may be impaired as they are 15 times more likely to abuse alcohol, 9 times more likely to
abuse drugs, 3 times more likely to be depressed and 5 times more likely to attempt suicide
than non-abused mothers (Stark & Flitcraft 1996). Domestic violence may begin or escalate
during pregnancy (Morgan 1998): prevalence rates of fetal abuse, 0.9-20% are given. The
injuries to mother and fetus may be serious (see Box 30.1) and lead to placental separation,
ruptured uterus, preterm onset of labor and fetal fractures. (See Chapter 16).
A study of women in a refuge (Casey 1989) found that 60% of women spoke of violence
during pregnancy, 13% miscarried, and 22% threatened miscarriage or went into premature
labor. Further indication of the importance of drugs and alcohol in child abuse is found in the
25% of child protection conferences that record them as a significant factor (Leeds ACPC,
KWatson 1998). There are many complex issues concerning maternal drug use and abuse, for
example sodium valproate for maternal epilepsy is teratogenic, as well as non-prescribed
drugs such as alcohol and opiates. Poor diet, cigarette smoking, and mental health problems in
the mother are damaging to the fetus.
It is recognized that women are more physically violent than was formerly acknowledged. A
trend for girls to be part of violent gangs follows a pattern seen in the US.
A further complication for careers who hit arises in adolescence, when the teenager hits back
and is likely to use offensive language. In households where conflict is resolved by violence,
the boy (and, increasingly, gift) is at risk of developing generally aggressive behaviors and
being suspended from school. Later, he or she may play truant or run away, with all the
associated dangers of living on the streets.
Bullying affects the majority of schoolchildren at some time and, for some, becomes
intolerable leading to suicide. Programs for management and prevention are available (Elliott
1991, Dawkins & Hill 1995).
It has been estimated that there are between 200 and 300 nonaccidental child deaths each year,
and this figure has varied little. There are persisting recording differences and accurate
statistics are not available in many areas (Creighton & Noyes 1989, McDonald 1995). It has
been estimated by the National Society for the Prevention of Cruelty to Children (NSPCC)
that there are between 200-300 non-accidental child deaths each year in the UK. This is
thought to be an underestimate. The Home Office figures of 29 child murders each year have
changed little over 30 years (Ending child abuse deaths, 2002). In this series nearly half the
children were aged 0-4 years, 25% 5-9 years, and 25% 10-14 years; 12% of the sample were
aged less than 12 months. Seventy per cent of serious head injuries occur in children under 12
months, and deaths due to head injury occur mainly in this abused group. The severity of
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injuries was summarized as: moderate injury 90%, severe injury 9%, and fatal abuse
0.6%.The ratio by gender is 55% boys to 45% girls.
Much abuse is associated with emotional damage to the child but the association of physical
abuse and CSA of 1 in 6 (Hobbs & Wynne 1990) and the recognition of neglect with all types
of abuse is more recent.
Children at particular risk of abuse are disabled children, whether in their own homes, foster
homes, children's homes or boarding school.
Patterns of accidental bruising
Children bruise themselves in the course of their ordinary play. The numbers of bruises seen
depends on age, the type of play (such as with a new skateboard or bike), and the nature of the
child. Careers may claim "he always bruises easily".
Very few bruises should be seen in infants aged 0-6 months. Bruises over bony prominences
occur in 30-40% of 9-12-monthold infants. Up to 12 bruises are seen in normal active
children; the bruises are mainly distal and few are seen on the chest or abdomen. Shin bruises
should not be ignored adults kick too and were assumed to be always accidental (Robertson et
al 1982, Leventhal et al 1993).
Patterns of injury that might arouse suspicion of abuse
Bruises are rarely seen on the ear due to the protective triangle of the side of the skull and
shoulder tip. A bruise on the pinnais likely to be a pinch (Figures 30.3 and 30.4), and linear
marks with stippled bruising or petechiae extending from the cheek above, below and behind
the ear are typical of a blow from an outstretched hand.
A penetrating blow to the upper face orbit is needed to cause a black eye (Figure 30.5).
Bilateral black eyes are worrying and suggest intracranial damage but may follow a blow to
the forehead. Petechiae over the face and neck should be investigated: they may be part of a
viral illness but might also indicate strangulation or neck compression, which always has to
be excluded. Bleeding from the mouth and other dental injuries may warrant referral to a
forensic odontologist. Bony injury is uncommon under 12 months and should be investigated.
Fractures of the clavicle and parietal bone may be seen in infancy from, for example, falling
out of the highchair, or rolling off the settee.
Ambulant children may fall, and fractures are usually distal, e.g. radius and ulna e.g. of the
limb.
Toddler fracture is an undisplaced spiral fracture of the lower tibia seen in toddlers who
having just begun walking and try to run fall, twist the leg, and cause the fracture.
Note: fractures are painful and there is disuse. There may be swelling, but not always
bruising.
Factors in the presentation of physical abuse
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Some presentations strongly suggest abuse, e.g. a badly bruised face in an infant (Figure 30.2)
or a fractured tibia in a non-ambulant child. There may also be, for example, bruises that do
not match
the given history, being too many, too severe, in the wrong distribution (Figure 30.6) or of the
wrong duration.
Multiple injuries following a moderate fall necessitate careful assessment, as do all head
injuries in infants and young children"
(Figure 30.7). Subdural hematoma, usually associated with retinal hemorrhages, must always
be investigated (see later), as must burns and scalds.
In physical abuse there may be a delay in seeking medical help and non-compliance with
advised treatment.
The injury may be discovered incidentally at nursery or school, and the parents behave
unexpectedly, for example aggressively, toward staff, refusing treatment or admission to
hospital. The child may be seen repeatedly with minor injuries at the general practitioner's
(GP) or family physician's surgery and also the hospital; it is therefore important to check
records.
Further indicators include:
 Discrepancies in the history.
 The history may change with repeated telling or according to teller.
 The telling varies according to whom it is told.
 The history may be vague and lack detail.
 There may have been delay in seeking help.
 There may be denial of pain or minimization of symptoms.
Trigger factors, such as feeding or sleeping difficulties, prolonged crying, wetting, soiling,
stealing, or lying may precipitate aggression toward the child. The adult may be physically or
mentally ill, drugged or drunk; overlying of young children only occurs if the adult is
"unnaturally sedated". There may be social factors such as abuse in childhood, poverty, loss of
job, or partnership break-up (see Box 30.2).
Conclusion and summary







Accidental injury is common in childhood.
Certain patterns of injury should cause the possibility of abuse to be considered.
Mothers and fathers are the main abusers.
Any bruising in infancy should be investigated.
Fractures under 12 months or in non-ambulant children require investigation.
Severe head injury following minor falls in infancy usually results from abuse.
Physical abuse is associated with neglect, CSA and domestic violence.
FICTITIOUS
ILLNESS
IN
CHILDHOOD
Fictitious illness (also termed "fabricated", "falsified" or "factitious illness") was initially known as
Munchausen Syndrome by Proxy (Meadow 1977). Much debate continues as to the most descriptive title
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for this form of abuse, in which the career presents a false picture of illness to the physician. The "illness"
from which the child is suffering has been fabricated by the career. The syndrome has as its prerequisites
the career, usually the mother, who describes the "illness", and the child who is cast in the "ill" role. The
career may cause the symptoms directly, as in suffocation (or apneic attacks), exaggerate an existing
disorder such as convulsions, leading to more investigations and drug therapy, or present the child with a
history of an imaginary disorder such as asthma for which the child has no objective signs.
The symptoms most commonly seen include:
~ Vomiting
~ Diarrhea
~ Bleeding
~ Fever
~ Convulsions
~ Rashes
~ Failure to thrive
~ Drowsiness/coma.
Consequences of the behavior include:
~ Attention for the mother, "such a wonderful career", on the hospital ward.
~ Status for the mother amongst friends and family.
~ Financial gain through disability allowance.
~ Relationships with medical staff (to the extent of going on "ward outings").
~ The career may become the local authority on the "disorder" and run the parents' support group.
~ The child who is forced into the role of illness is made part of the fabrication and deception, and is
betrayed by his careers.
~ The abuse is emotional, may be physical, and above all denies the child a childhood with ordinary peer
relationships through being "ill" and needing invasive and painful investigations and drug therapy (with the
associated side-effects).
Induced apnea and drug overdose might be more appropriately labeled "suffocation" and "poisoning".
EMOTIONAL ABUSE
The definition of emotional abuse (Department of Health 1989) is the actual or likely severe adverse effect
on the emotional and behavioral development of a child caused by persistent or severe emotional
in-treatment or rejection. All abuse involves emotional ill-treatment to a greater or lesser degree. A wider
definition includes: "acts of omission or commission by a parent or guardian that are judged by a mixture of
community values and professional expertise to be inappropriate or damaging" (Gabarino & Gilliam 1980).
The Children Act (England and Wales, 1989) uses the term "harm" to describe the effects of ill-treatment
and poor care leading to injury, impairment of the health or development of a child. "Significant harm" is a
measure of the severity of ill-treatment, i.e. that it is noteworthy.
The incidence of abuse (number of new cases occurring during a given time period) and prevalence of
abuse (the proportion of adults abused during childhood) is not known. The latest UK data for prevalence
of emotional abuse (Cawson et al 2000), based on interviews, record that 30% of the adult population
recalled this form of abuse. The National Commission of Enquiry into the Prevention of Child Abuse
(Childhood Matters 1996) estimated the incidence of abuse to UK children as:
 350 000-400 000 cases of emotional abuse
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 450 000 cases of children being "bullied at least once a week".
The Commission used a wider definition: "child abuse consists of anything which individuals, institutions,
processes do, or fail to do, which direcdy, or indirecdy, harms children or damages their prospects of safe
and healthy development into adulthood".
This definition includes physical and developmental growth as well as educational, medical and social
neglect. Failure to thrive (nonorganic) is the failure to grow and gain weight despite the absence of physical
illness. To grow and develop optimally, the child should be well fed and loved. Emotional abuse is part of
all the other abuses but also occurs without them. Thus, a child witnessing family violence may be
physically well cared for but emotionally distraught.
Emotional abuse includes discouragement, ridicule, unfairness, hostility, threats and bullying, "You are bad,
stupid, useless and I don't love you". Children at risk of emotional abuse include those who are:
 Unwanted
 Of the "wrong sex"
 Disabled
 Ill
 Difficult (e.g. to feed)
 In a family where parents have a difficult relationship, have themselves been abused in childhood,
abuse substances or alcohol, or there is domestic violence.
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Chapter 11
Transportation medicine
Introduction
Road traffic accidents
Driver license and medical requisites
Epidemiologic aspects
Alcohol, drugs, and driving
Accident investigations: Mechanism and pattern of injury
Particular concerns
Boating traffic accidents
Railway traffic accidents
Air traffic accidents
Deaths in traffic other than accidents
Natural death
Suicide
Homicide
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INTRODUCTION
Every day around the world, almost 16000 people die from injuries, of which more than
20% are related to transport (World Health Organization 1999). Transportation injuries and
self-inflicted injuries are the leading causes of injury-related deaths worldwide. The Global
Burden of Disease study undertaken by the WHO showed that in 1990, traffic accidents
were the world's ninth most important health problem and forecast that by 2020 they would
move up to third place among leading causes of death and disability (Murray & Lopez
1996).
Transportation safety is, therefore, a major social and public health concern in both industrialized and
developing countries. Preventive measures range from design of infrastructures and construction of
vehicles to the health status and behavior of vehicle operators. Investigation of transport accidents and
traffic related deaths and injuries may call upon the entire spectrum of forensic sciences and
medico-legal expertise.
ROAD TRAFFIC ACCIDENTS
In most industrialized countries the primary mode of transportation is the motor vehicle.
More than 600 million motorized vehicles are registered worldwide: of these, one-third are
in the United States (US) and another third in the European Union (EU) (Bureau of
Transportation Statistic 2000, European Commission 2001). Deaths in motor traffic
account for more than 90% of all transportation-related fatalities. In 1998, road traffic
accidents claimed 850 000 male and 320 000 female victims, the respective figures for the
injured being 28.4 and 10.4 million (World Health Organization 1999). Of motor
traffic-related deaths, about 85% occur in developing countries (Nantulya & Reich 2002).
In these countries, the majority of those injured and killed are no motorized occupants and
pedestrians, in addition to motorcyclists and bicyclists. Conversely, in industrialized
countries, vehicle occupants account for the majority of traffic fatalities, followed by
pedestrians, especially the elderly, and bicycle riders. Despite the general downward trend
observed in North America and Europe during the last decade, road traffic incidents are
still the leading cause of death in many countries among 5 to 44-yearolds (World Health
Organization 1999).
Epidemiologic aspects
National agencies and international organizations provide data on road traffic accidents and
related casualties. For instance, in the US, the National Highways Traffic Safety
Administration (NHTSA) of the Department of Transportation provides detailed statistics
on road traffic accidents based on data collected through the Fatality Analysis Reporting
System (FARS). The International Road Federation (IRF) publishes annually the World
Road Statistics with data on traffic accidents for more than 120 countries. The
Organization for Economic Cooperation and Development (OECD), working closely with
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the European Conference of Ministers of Transport (ECMT), has developed the
International Road Traffic and Accident Database (IRTAD) that gathers detailed data on
road accidents for most of the member countries. Euro stat provides general data on
transport and safety concerns for EU member states and every year publishes part of these
in the booklet Panorama of Transport.
During 1998 there were in the US (270 million inhabitants, 215 million motorized vehicles)
more than 6 million traffic crashes, in which 41 501 people were killed and 3 192000
injured (US Department of Transportation 2001a). In the EU (374 million inhabitants, 183
million motorized vehicles), the total number of road accident victims was 42 608 in 1998
(European Commission 2001).Tables 35.1 and 35.2 show the rates of killed and injured in
road traffic accidents, and the percentage breakdown of casualties by road-user category in
the EU countries and in the US in 1998.
The enforcement of preventive countermeasures at different levels varying from
improvement in road infrastructure and car safety, to stricter legislation on drink driving,
use of safety belts and air bags for car passengers and helmets for motorcyclists has
resulted, in most industrialized countries, in a general downward trend in casualties since
the 1970s. In the EU, the total number of road accident victims has decreased by nearly
25% in less than a decade, from 56 414 in 1990 to 42 608 in 1998 (European Commission
2001). Greece is the only EU country where the number of road fatalities has not shown a
downward trend during the last decade. In the US, the fatality rate per 100 million vehicle
miles fell from 2.1 in 1990 to 1.5 in 2000 (US Department of Transportation 200 la).
Accident investigations: Mechanism and pattern of injury
Investigation of transport accidents aims to establish the sequence of events leading to a
crash and requires a multidisciplinary approach to evaluate the role of the vehicle and
infrastructural, environmental, and human factors. The collection of organic and inorganic
traces from victim and suspect vehicle(s) is an essential part of the investigation of specific
cases such as "hit-and-run" accidents.
Accurate determination of the causes and effects of vehicular accidents is necessary for
forensic purposes but can also contribute significantly to improving road traffic safety. In
Finland, beside routine police and medico-legal activities, 23 teams of the Traffic Safety
Committee of Insurance Companies have investigated almost all road traffic accidents
occurring in the country since the 1970s where driver and/or passenger of car has been
killed. These teams include traffic police officers, vehicle and road engineers, and
physicians (often a forensic pathologist), supplemented on occasion by psychologists or
other experts on specific issues (Hantula 1987).
The identification, documentation, and interpretation of each traffic accident victim's injuries are a
central task of the forensic pathologist at the accident scene and during the autopsy, and require a basic
knowledge of their mechanisms of infliction. Pedestrian versus motor vehicle accidents In a collision
between an upright adult pedestrian and a car, different impact phases occur and produce specific
injuries (Table 35.6; Figures 35.5 and 35.6). The primary site of impact is between the vehicle bumper
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and the lower extremities, mostly on their posterior aspect. Primary impact injuries include abrasions
and contusions-at times patternedon legs, thighs, or buttocks, together with fractures of the tibia and
fibula, and, more rarely, of the femur and pelvis. The site of these impact injuries depends on the type of
car, possible lowering of the car's front end (from braking), and pedestrian height. If the victim is
walking at the time of impact, the bumper injury will be higher on the weight-bearing leg. The fracture
of tibia and femur may present a wedge shaped fragment, the base which indicates the direction of
impact and the front of the wedge the direction in which the vehicle was traveling. In small adults or
children, the site of primary impact may be the pelvis or other regions above the center of gravity, when
up to the head. In these cases, the victim is more likely to be run over, especially by a reversing vehicle.
FRONT-CRASH CAR ACCIDENTS
Frontal car crashes are the most common type of motor vehicle accident. Vehicle accident
simulation with the use of dummies has made it possible to evaluate in detail the sequence
of events during a car front crash. In the unrestrained driver and front seat passenger the
deceleration force causes first an extension at the lumbar spine and a slide forwards with
knee impact against the Fascia, then a move upwards and forwards of the body with impact
of the crown against the roof frame and of the chest against the steering wheel (driver) or
dashboard (front seat passenger). This is followed by a forward flexion of the cervical or
thoracic spine, and a final strike of the head against the windshield or the pillars.
Other types of car crash accidents
Rear-impact crashes account for many civil suits for the whiplash syndrome caused by
violent acceleration-deceleration of the cervical spine, which can sometimes be fatal if
neck hyperflexion causes cervical spine fracture. In side-impact crashes, occupants are
exposed to severe injuries of virtually any region of the body because restraint devices
offer little or no protection and the thin lateral structures provide scant resistance to the
impact crash. Roll- over crashes are often fatal when occupants do not wear a seat belt
since the head and upper trunk can protrude outside the car with severe regional injury.
Occupants can be also completely ejected from the car, violently impact against the road
surface, and eventually be crushed and struck by the vehicle they were in or other
vehicle(s), resulting in severe head, chest, and abdominal injuries.
DRIVER STATUS
The identity of the driver at the moment of a vehicular accident is an issue that can be
disputed, for instance when occupants are ejected from or relocated within the car or when
their position is not documented at the time of removal from the car. In addition to vehicle
dynamics, occupant kinetic evaluation and the study of patterned injuries and of trace
evidence (pedal imprint, fibers, hair, blood and tissue from passengers) with their
distribution in the vehicle may assist in clarifying this issue. The direction of the seat-belt
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contusion or the steering wheel contusion on the thoracic region are among the most
common and useful patterns of injury, together with air-bag injuries and recovery of their
chemical components from the victim's body. The pattern of skin lesions caused by
automobile glass can be useful, because tempered lateral and rear glass causes dicing
lacerations, whereas laminated front glass determines deeper lacerations.
Other motor vehicle traffic accidents
Motorcycle and pedal cyclist accidents can consist of single accidents, collision with
other vehicles, or striking a pedestrian. The most common scenario for a motorcycle
accident is sudden deceleration and collision, with the driver thrown forward and upward
into a vehicle or a stationary object, whereas collision with a motor vehicle is the more
frequent bicycle accident. Common injuries in motor bikers are head injuries (skull
fractures including ring fractures and hinge fractures, brain contusion, and laceration),
cervical spine fractures and atlanto-occipital dislocations, and leg injuries by primary
impact or trapping in the motorcycle frame. In contrast, injuries to thorax and abdomen are
rare. Several studies have demonstrated the decrease in motorbike fatalities after the
introduction of helmet laws; in a high-speed crash, however, blunt or penetrating injuries to
the head or other body regions can be fatal. In a cold climate, such as that of Finland,
snowmobile accidents (often caused by the effects of alcohol) on the sea and lake ice
account for a relatively high number of traffic accidents involving middle-aged males, with
drowning and hypothermia being the cause of death in more than half of the fatal cases.
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3.Booze CF 1989 Sudden in flight incapacitation in general aviation. Aviat Space Environ Med
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Figure 1.4
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— Edited by- Zhang zhixiang
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