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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. 52 CLINICAL FORENSIC MEDICINE 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. 53 CLINICAL FORENSIC MEDICINE 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). 54 CLINICAL FORENSIC MEDICINE 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: 55 CLINICAL FORENSIC MEDICINE 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 56 CLINICAL FORENSIC MEDICINE 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 57 CLINICAL FORENSIC MEDICINE 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 58 CLINICAL FORENSIC MEDICINE 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 59 CLINICAL FORENSIC MEDICINE 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 60 CLINICAL FORENSIC MEDICINE 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 61 CLINICAL FORENSIC MEDICINE 62 CLINICAL FORENSIC MEDICINE 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 63 CLINICAL FORENSIC MEDICINE 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 64 CLINICAL FORENSIC MEDICINE 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. 65 CLINICAL FORENSIC MEDICINE 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 66 CLINICAL FORENSIC MEDICINE 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 67 CLINICAL FORENSIC MEDICINE 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 68 CLINICAL FORENSIC MEDICINE 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. 69 CLINICAL FORENSIC MEDICINE 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. 70 CLINICAL FORENSIC MEDICINE 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 71 CLINICAL FORENSIC MEDICINE 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. 72 CLINICAL FORENSIC MEDICINE 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 73 CLINICAL FORENSIC MEDICINE 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 74 CLINICAL FORENSIC MEDICINE 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 75 CLINICAL FORENSIC MEDICINE 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). 76 CLINICAL FORENSIC MEDICINE 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 77 CLINICAL FORENSIC MEDICINE 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 78 CLINICAL FORENSIC MEDICINE 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 79 CLINICAL FORENSIC MEDICINE 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 80 CLINICAL FORENSIC MEDICINE 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 81 CLINICAL FORENSIC MEDICINE 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 82 CLINICAL FORENSIC MEDICINE 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 83 CLINICAL FORENSIC MEDICINE 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 84 CLINICAL FORENSIC MEDICINE 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 85 CLINICAL FORENSIC MEDICINE 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 86 CLINICAL FORENSIC MEDICINE 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". 87 CLINICAL FORENSIC MEDICINE 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 88 CLINICAL FORENSIC MEDICINE 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 89 CLINICAL FORENSIC MEDICINE 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. 90 CLINICAL FORENSIC MEDICINE 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 91 CLINICAL FORENSIC MEDICINE 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 92 CLINICAL FORENSIC MEDICINE 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 93 CLINICAL FORENSIC MEDICINE 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 94 CLINICAL FORENSIC MEDICINE 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 95 CLINICAL FORENSIC MEDICINE 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 96 CLINICAL FORENSIC MEDICINE 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 97 CLINICAL FORENSIC MEDICINE 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 98 CLINICAL FORENSIC MEDICINE 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 99 CLINICAL FORENSIC MEDICINE 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 100 CLINICAL FORENSIC MEDICINE 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 101 CLINICAL FORENSIC MEDICINE 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. 102 CLINICAL FORENSIC MEDICINE 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. 103 CLINICAL FORENSIC MEDICINE 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 104 CLINICAL FORENSIC MEDICINE 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 105 CLINICAL FORENSIC MEDICINE 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 106 CLINICAL FORENSIC MEDICINE 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 107 CLINICAL FORENSIC MEDICINE 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. 108 CLINICAL FORENSIC MEDICINE 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 109 CLINICAL FORENSIC MEDICINE 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. 110 CLINICAL FORENSIC MEDICINE 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. 111 CLINICAL FORENSIC MEDICINE 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 112 CLINICAL FORENSIC MEDICINE 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: 113 CLINICAL FORENSIC MEDICINE ● 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. 114 CLINICAL FORENSIC MEDICINE 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 115 CLINICAL FORENSIC MEDICINE 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. 116 CLINICAL FORENSIC MEDICINE 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 117 CLINICAL FORENSIC MEDICINE 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 118 CLINICAL FORENSIC MEDICINE - 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). 119 CLINICAL FORENSIC MEDICINE 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 120 CLINICAL FORENSIC MEDICINE 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 121 CLINICAL FORENSIC MEDICINE 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 122 CLINICAL FORENSIC MEDICINE 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 123 CLINICAL FORENSIC MEDICINE 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 124 CLINICAL FORENSIC MEDICINE 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 125 CLINICAL FORENSIC MEDICINE 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 126 CLINICAL FORENSIC MEDICINE 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 127 CLINICAL FORENSIC MEDICINE 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 128 CLINICAL FORENSIC MEDICINE 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 129 CLINICAL FORENSIC MEDICINE 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 130 CLINICAL FORENSIC MEDICINE 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 131 CLINICAL FORENSIC MEDICINE 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 132 CLINICAL FORENSIC MEDICINE 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 133 CLINICAL FORENSIC MEDICINE 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, 134 CLINICAL FORENSIC MEDICINE 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 135 CLINICAL FORENSIC MEDICINE 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): 136 CLINICAL FORENSIC MEDICINE ● 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 137 CLINICAL FORENSIC MEDICINE 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 138 CLINICAL FORENSIC MEDICINE 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 139 CLINICAL FORENSIC MEDICINE 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 140 CLINICAL FORENSIC MEDICINE 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, 141 CLINICAL FORENSIC MEDICINE 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. 142 CLINICAL FORENSIC MEDICINE 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 143 CLINICAL FORENSIC MEDICINE 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 144 CLINICAL FORENSIC MEDICINE 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. 145 CLINICAL FORENSIC MEDICINE 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 74:183 146 CLINICAL FORENSIC MEDICINE 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 147 CLINICAL FORENSIC MEDICINE 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 148 CLINICAL FORENSIC MEDICINE 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 149 CLINICAL FORENSIC MEDICINE 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 150 CLINICAL FORENSIC MEDICINE 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 151 CLINICAL FORENSIC MEDICINE 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 152 CLINICAL FORENSIC MEDICINE 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. 153 CLINICAL FORENSIC MEDICINE 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 1 CLINICAL FORENSIC MEDICINE 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 2 CLINICAL FORENSIC MEDICINE 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 3 CLINICAL FORENSIC MEDICINE 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 4 CLINICAL FORENSIC MEDICINE 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. REFERENCES 1.Agran PF, Dunlde DE, Winn DG, Kent D 1987 Med 16:1355-1358 Fetal death in motor vehicle accidents. Ann Emerg 2.Aitokallio-Tallberg A, Halmesmaki E 1997 Motor vehicle accident during the second or third trimester of pregnancy. Acta Obstet Gynecol Scand 76:313-317 3.Booze CF 1989 Sudden in flight incapacitation in general aviation. Aviat Space Environ Med 60:332-335 4.Bourbeau R, Desjardins D, Maag U, Laberge-Nadeau C 1993 Neck injuries among belted and unbelted occupants of the front seat of cars. J Trauma 35: 794-799 5.Bureau of Transportation statistic. National Transportation Statistics 2000 Online: http://www.bts.gov/btspmd/nts/ 6.Buttner A, Heimpel M, EisenmengerW 1999 Sudden natural death "at the wheel":a retrospective study over a 15-year time period (1982-1996). Forensic Sci Int 103:101-112 5 CLINICAL FORENSIC MEDICINE Figure 1.4 7.Campbell GH, Lutsep HL 2001 Driving and neurological disease, eMedicine Journal 12: 1-27. Online: http://www.eMedicine.com — Edited by- Zhang zhixiang 6