WEBVTT 00:00:00.000 --> 00:00:01.100 [Music] 00:00:01.100 --> 00:00:06.130 [The U.S. Department of Health, Education, and Welfare, Public Health Service, presents T - 1899, V - 1899, MCMLXIX] 00:00:06.130 --> 00:00:15.620 [A National Medical Audiovisual Center Production] 00:00:15.620 --> 00:00:20.940 [Clinical Pathology Series, A Cooperative Project] 00:00:20.940 --> 00:00:26.280 [Emory University School of Medicine and National Medical Audiovisual Center] 00:00:26.280 --> 00:00:29.840 [Forensic Medicine Outlines, The Battered Child] 00:00:29.840 --> 00:00:33.020 [Part 1] 00:00:33.020 --> 00:00:39.100 [Forensic Medicine Outlines, Milton Helpern, M.D., Chief Medical Examiner, The City of New York] 00:00:39.100 --> 00:00:48.390 [Dr. Helpern:] I'd like to discuss the problem of the battered child or the battered child syndrome, 00:00:48.390 --> 00:00:51.390 as it is sometimes called. 00:00:51.390 --> 00:00:56.950 This subject is extremely important to forensic pathologists 00:00:56.950 --> 00:01:04.900 for the reason that they may be the first in line with the investigation 00:01:04.900 --> 00:01:09.790 to discover this possibility. 00:01:09.790 --> 00:01:14.930 Of course the clinician, the pediatrician, the general practitioner, 00:01:14.930 --> 00:01:17.910 also has a lot of responsibility, 00:01:17.910 --> 00:01:23.840 because in many of these cases the violence has been repetitive, 00:01:23.840 --> 00:01:35.710 and at some time the victim has been taken to the clinic and has been exposed to clinical observation, 00:01:35.710 --> 00:01:41.660 and the doctor does have a chance, if he is on the alert, 00:01:41.660 --> 00:01:48.880 to recognize the possibility that the injuries which a child manifests, 00:01:48.880 --> 00:01:54.400 and the explanation for which is given by a parent or guardian, 00:01:54.400 --> 00:02:01.840 is hardly compatible with the extent of the injury. 00:02:01.840 --> 00:02:10.210 And I thought today we might go into the problem as the pathologist may encounter it. 00:02:10.210 --> 00:02:19.330 It's very important in all forensic work to listen to the history, 00:02:19.330 --> 00:02:23.550 but not necessarily to buy the history that is offered 00:02:23.550 --> 00:02:30.380 by a parent or guardian with regard to how injuries are sustained. 00:02:30.380 --> 00:02:38.410 And to me it's perfectly amazing how in some of the cases of very flagrant violence, 00:02:38.410 --> 00:02:42.390 the explanation of the guardian or the parent of the infant 00:02:42.390 --> 00:02:51.360 that it fell from the sofa onto the floor or that it kept falling down the stairs or this or that, 00:02:51.360 --> 00:02:56.480 is accepted as an explanation and nothing more is done about it. 00:02:56.480 --> 00:02:59.840 Now, this subject is not new. 00:02:59.840 --> 00:03:11.190 We have observed instances of abused and battered children that have died from repetitive violence. 00:03:11.190 --> 00:03:13.240 This is an old subject, 00:03:13.240 --> 00:03:24.420 but recently it has gotten a lot of notice in the public press and in scientific publications. 00:03:24.420 --> 00:03:29.940 But I want to point out and emphasize that we have observed these cases for a long time, 00:03:29.940 --> 00:03:37.490 and it is the responsibility of the physician, and also the pathologist when he encounters a case of this sort, 00:03:37.490 --> 00:03:45.550 to notify the authorities, the Department of Public Welfare, the Police Department, 00:03:45.550 --> 00:03:50.290 so that an adequate investigation can be made. 00:03:50.290 --> 00:03:55.330 Physicians sometimes shy away from this responsibility 00:03:55.330 --> 00:03:59.770 with the excuse that they don't want to get involved, 00:03:59.770 --> 00:04:05.610 that perhaps the families of the infant might bring suit. 00:04:05.610 --> 00:04:18.930 But when a physician calls attention to an injury of a suspicious character or when the pathologist reports the violent character of a death, 00:04:18.930 --> 00:04:24.480 he is not accusing anybody, he is merely exposing a situation. 00:04:24.480 --> 00:04:37.360 The investigation later may point to a suspect and to a perpetrator but the doctor doesn't name perpetrators. He's not concerned with that. 00:04:37.360 --> 00:04:46.090 He's concerned with exposing the situation as he finds it and bringing this to the attention of the authorities. 00:04:46.090 --> 00:04:49.800 I think this is very important to bear in mind. 00:04:49.800 --> 00:04:54.410 There are laws now which require the physician to do this, 00:04:54.410 --> 00:04:59.520 but in the past he always had this responsibility as a physician 00:04:59.520 --> 00:05:04.810 to report any death from suspicious violence or any assault, 00:05:04.810 --> 00:05:09.570 or any case in which there is any suspicion at all 00:05:09.570 --> 00:05:15.490 that the violence might have been inflicted or resulted 00:05:15.490 --> 00:05:21.200 from the assaultive act of another person. 00:05:21.200 --> 00:05:24.360 I think we doctors sometimes tend to rationalize 00:05:24.360 --> 00:05:31.990 in order to not have the job of later on coming forward 00:05:31.990 --> 00:05:38.930 and having to present the findings in a court if this is necessary. 00:05:38.930 --> 00:05:48.090 But the idea that you endanger yourself by exposing these things, this is not so at all. 00:05:48.090 --> 00:05:49.780 You're not accusing anybody. 00:05:49.780 --> 00:05:51.170 You're not naming anybody. 00:05:51.170 --> 00:05:56.540 You're merely calling attention to a situation with regard to an injured infant 00:05:56.540 --> 00:05:59.990 or in the case of a pathologist, to a dead infant. 00:05:59.990 --> 00:06:05.490 Now when these cases are discovered, they have to be reported, 00:06:05.490 --> 00:06:15.160 and a certain amount of activity and awareness has to be, 00:06:15.160 --> 00:06:20.930 the pathologist has to be aware of this responsibility and do something about it at the time, 00:06:20.930 --> 00:06:27.080 and not just simply accumulate these cases in an anatomical diagnosis, 00:06:27.080 --> 00:06:30.060 or just simply place it on a death certificate. 00:06:30.060 --> 00:06:32.680 Death certificates get classified, 00:06:32.680 --> 00:06:38.420 but ordinarily the police department does not comb through the death certificates 00:06:38.420 --> 00:06:41.780 to see whether there are any cases of possible violence. 00:06:41.780 --> 00:06:44.270 That's something that the doctor has to do, 00:06:44.270 --> 00:06:46.050 the pathologist has to do. 00:06:46.050 --> 00:06:52.000 And this is a very important practical point because sometimes these cases, 00:06:52.000 --> 00:06:55.700 which require very careful investigation, 00:06:55.700 --> 00:06:59.140 get lost in the shuffle. 00:06:59.140 --> 00:07:02.410 Now I would like in the time that we have 00:07:02.410 --> 00:07:09.110 to point up some of the cases and to indicate how variable they are, 00:07:09.110 --> 00:07:11.360 how some are quite obvious, 00:07:11.360 --> 00:07:16.900 on the other hand some are discovered simply through the routine process 00:07:16.900 --> 00:07:20.570 of performing a postmortem examination, 00:07:20.570 --> 00:07:29.410 including an autopsy in that examination when an infant is found dead or where an infant dies suddenly. 00:07:29.410 --> 00:07:34.270 And I think one of the interesting byproducts of the study on infant death, 00:07:34.270 --> 00:07:38.950 most of which yet have not provided an adequate explanation for the death; 00:07:38.950 --> 00:07:48.880 among these hundreds of cases, we do discover a few cases of violent death 00:07:48.880 --> 00:07:54.020 where this was not suspected during life, 00:07:54.020 --> 00:07:59.210 or actually when the case was brought to the attention of the authorities. 00:07:59.210 --> 00:08:06.640 And this is one important byproduct, one might say, 00:08:06.640 --> 00:08:15.150 of the infant death studies which are being carried out in so many jurisdictions, 00:08:15.150 --> 00:08:19.540 trying to discover the various factors that are responsible 00:08:19.540 --> 00:08:25.140 for the crib deaths and deaths of that type. 00:08:25.140 --> 00:08:29.890 Now I'd like to show a few cases. 00:08:29.890 --> 00:08:36.580 The first case I want to show is that of an infant that was presented 00:08:36.580 --> 00:08:41.980 to our office as an unexpected death of an apparently healthy infant, 00:08:41.980 --> 00:08:46.710 and at first-hand it was believed to be a crib death, 00:08:46.710 --> 00:08:53.160 and the child was found dead in the crib in the usual facedown position. 00:08:53.160 --> 00:08:59.470 And outwardly there were no signs to suggest violence. 00:08:59.470 --> 00:09:02.020 This is a photograph of the face, 00:09:02.020 --> 00:09:09.470 and there are no bruises and ecchymosis that one sometimes encounters in the battered child syndrome. 00:09:09.470 --> 00:09:13.300 There's a little secretion coming from the nostril, 00:09:13.300 --> 00:09:19.610 which might be misleading and lead the unwary pathologist to a conclusion 00:09:19.610 --> 00:09:25.590 that this child had an upper respiratory infection which it might also have in addition. 00:09:25.590 --> 00:09:38.690 And finding an upper respiratory infection does not rule out the possibility of violence in a particular case. 00:09:38.690 --> 00:09:40.140 Now this is a side view. 00:09:40.140 --> 00:09:46.360 There are a few small abrasions on the face but you notice there's no ecchymotic discoloration, 00:09:46.360 --> 00:09:50.270 there are no bruises that one sees on the outside. 00:09:50.270 --> 00:09:54.350 And yet when the scalp was reflected, 00:09:54.350 --> 00:09:59.050 you have this very severe injury 00:09:59.050 --> 00:10:04.490 which actually did produce a boggy swelling of the scalp, 00:10:04.490 --> 00:10:09.070 which was more evident after the scalp was reflected then before, 00:10:09.070 --> 00:10:14.440 but there's terrific hemorrhage here in the galeal portion of the scalp, 00:10:14.440 --> 00:10:17.070 and also in the pericranium. 00:10:17.070 --> 00:10:20.610 And there are also fractures of the skull in this case, 00:10:20.610 --> 00:10:25.270 with intracranial hemorrhage of a traumatic character. 00:10:25.270 --> 00:10:32.360 Now the explanation was offered in this case that the child might have fallen off a couch 00:10:32.360 --> 00:10:36.280 which was about a foot and a half off the floor, 00:10:36.280 --> 00:10:39.390 and this explanation was not adequate, 00:10:39.390 --> 00:10:47.280 and subsequently one of the parents in a situation such as this, 00:10:47.280 --> 00:10:53.400 not infrequently the child is living with its natural parent 00:10:53.400 --> 00:11:03.610 and also with a stepparent or with a person who is consorting with the true parent. 00:11:03.610 --> 00:11:12.090 The children may be by a first marriage and the father or the mother then takes on another mate 00:11:12.090 --> 00:11:17.490 and the children become somewhat of an annoyance because of crying. 00:11:17.490 --> 00:11:22.660 There are many people who are not emotionally able to bring up children 00:11:22.660 --> 00:11:29.400 and haven't got any patience at all to look after a child in the way that it should be, 00:11:29.400 --> 00:11:31.510 when it cries, 00:11:31.510 --> 00:11:38.450 or when it becomes irritating to the parent or to the guardian. 00:11:38.450 --> 00:11:45.920 There's a whole variety of situations that we find in these cases. 00:11:45.920 --> 00:11:54.510 Most commonly you find a person having children sometimes born out of wedlock, 00:11:54.510 --> 00:12:02.950 now exposed to the anger and actions 00:12:02.950 --> 00:12:09.310 of a new companion of the natural parent. 00:12:09.310 --> 00:12:16.980 And you find situations, too, in which the parents, 00:12:16.980 --> 00:12:23.050 or one, the father for example, with a lot of small children, 00:12:23.050 --> 00:12:28.580 marries another woman or takes up with another woman whom he may not marry, 00:12:28.580 --> 00:12:40.730 and these children, most children have a sort of an instinctive ability to get along well with people. 00:12:40.730 --> 00:12:46.380 I mean they behave because they find it very wise, 00:12:46.380 --> 00:12:52.470 I mean in order to avoid injury and corporal punishment they do give in, 00:12:52.470 --> 00:12:59.930 and they do conform to what the new guardian may want them to do. 00:12:59.930 --> 00:13:06.370 But the rebellious child, and it may be rebellious because it just isn't as smart as the other children, 00:13:06.370 --> 00:13:11.730 the rebellious child is always in great peril and may suffer unduly, 00:13:11.730 --> 00:13:20.360 whereas the other children who are docile and who do not offer any problem in discipline 00:13:20.360 --> 00:13:22.720 may be very well taken care of. 00:13:22.720 --> 00:13:32.010 There's some very curious situations that develop during the investigation of these cases. 00:13:32.010 --> 00:13:38.630 Now, the next case that I'd like to show is another example 00:13:38.630 --> 00:13:45.750 of what was thought to have been a crib death, an infant found dead. 00:13:45.750 --> 00:13:53.260 The child had been left in the care of a sitter, 00:13:53.260 --> 00:14:01.370 and the mother of this child had gone off with a new boyfriend, 00:14:01.370 --> 00:14:06.320 and when she came back the child was found dead. 00:14:06.320 --> 00:14:09.990 The sitter indicated that she had fed the child 00:14:09.990 --> 00:14:14.240 and apparently had done all the right things by it. 00:14:14.240 --> 00:14:16.720 There was still another person living in this house. 00:14:16.720 --> 00:14:24.580 This was a small apartment occupied by a whole group of people, 00:14:24.580 --> 00:14:29.450 and all that the sitter could recall was that the child had been crying, 00:14:29.450 --> 00:14:36.240 and when she went into the kitchen to warm up the bottle, she put a big pacifier in the child's mouth 00:14:36.240 --> 00:14:40.160 and when she came back the pacifier was missing. 00:14:40.160 --> 00:14:46.510 And so was the particular person who had been seemingly playing with the child while she was, 00:14:46.510 --> 00:14:50.180 while the sitter was in the kitchen. 00:14:50.180 --> 00:14:58.980 This was a very strange situation too because there was quite a background of narcotic addiction. 00:14:58.980 --> 00:15:04.320 The mother had taken up with a person in the narcotics business, 00:15:04.320 --> 00:15:07.990 a pusher who apparently had been very successful 00:15:07.990 --> 00:15:11.830 so that the mother was extremely well-dressed. 00:15:11.830 --> 00:15:16.170 The babysitter was paid off with shots of heroin. 00:15:16.170 --> 00:15:27.250 In other words, her employment was paid for by providing heroin shots so a very sordid situation. 00:15:27.250 --> 00:15:29.120 Now when the autopsy was started, 00:15:29.120 --> 00:15:31.610 there was nothing externally to see, 00:15:31.610 --> 00:15:37.770 but when the pathologist got into the region of the neck after removing the throat, 00:15:37.770 --> 00:15:42.130 here this is all the front portion, the skin is lifted up, 00:15:42.130 --> 00:15:48.100 you can see coming down through the throat a large nipple. 00:15:48.100 --> 00:15:51.980 This is the pacifier pushed down into the throat. 00:15:51.980 --> 00:15:54.380 Now the child couldn't possibly have swallowed this. 00:15:54.380 --> 00:16:01.320 There was a big flange on the nipple and this was evidently pushed down, 00:16:01.320 --> 00:16:07.880 and it was a very difficult type of case to investigate. 00:16:07.880 --> 00:16:15.200 Now if you simply do an autopsy on the body and take out the heart and the lungs and all that and just go through the routine, 00:16:15.200 --> 00:16:18.590 this would very easily be overlooked. 00:16:18.590 --> 00:16:22.290 To find things like this you really have to get into the throat 00:16:22.290 --> 00:16:27.840 and have an ample exposure, and then things begin to appear. 00:16:27.840 --> 00:16:34.820 So this was a case of homicide in which the nipple of the pacifier 00:16:34.820 --> 00:16:43.450 was forced down into the baby's throat for reasons which are very, 00:16:43.450 --> 00:16:52.570 I mean what prompted the perpetrator to do this is one of those very difficult things to answer. 00:16:52.570 --> 00:16:58.670 Here's another type of case that is very suggestive to start with. 00:16:58.670 --> 00:17:09.080 This is a child that is found dead by the parents and when one gets a history, 00:17:09.080 --> 00:17:12.950 that is when the medical investigator goes to the home 00:17:12.950 --> 00:17:17.980 he gets a history that this child was a feeding problem, 00:17:17.980 --> 00:17:22.940 cried a great deal, had had the sniffles and this, that, and the other thing. 00:17:22.940 --> 00:17:27.440 And if you're gullible you can sort of write a case like this off 00:17:27.440 --> 00:17:32.390 as a case of acute gastrointestinal auto-intoxication, 00:17:32.390 --> 00:17:39.890 or whatever other funny things appear on death certificates in various parts of the country. 00:17:39.890 --> 00:17:45.390 This type of case is not routinely investigated, unfortunately. 00:17:45.390 --> 00:17:51.180 But these cases should all be subjected to a very searching type of autopsy, 00:17:51.180 --> 00:17:57.640 because frequently the initial story, if one isn't too critical and one is gullible, 00:17:57.640 --> 00:18:03.530 may lead to a certification of an inadequate sort, 00:18:03.530 --> 00:18:08.150 sometimes done over the telephone by instructions from the coroner 00:18:08.150 --> 00:18:15.220 to the local doctor in the community who might be called upon to issue the certificate. 00:18:15.220 --> 00:18:20.560 And some physicians will issue a certificate when they're requested to do so by someone in authority. 00:18:20.560 --> 00:18:27.060 Other physicians are more independent and feel that they don't have the right to do that, 00:18:27.060 --> 00:18:29.830 and that the circumstances and their findings or their impressions 00:18:29.830 --> 00:18:34.120 do not entitle them to write this case off as a natural death 00:18:34.120 --> 00:18:43.980 simply because they're instructed to do so by the coroner in the local area. 00:18:43.980 --> 00:18:51.990 Now you notice this child is rather poorly nourished and the child, 00:18:51.990 --> 00:18:55.420 when one turns it over, one sees some very interesting findings, 00:18:55.420 --> 00:19:02.490 and not so much on the front of the body but on the back there are these welts, of varying age. 00:19:02.490 --> 00:19:05.570 This child apparently had been beaten. 00:19:05.570 --> 00:19:10.060 One not infrequently finds welts like this over the region of the genitalia. 00:19:10.060 --> 00:19:20.360 The child that urinates in bed and is considered one that needs disciplinary action 00:19:20.360 --> 00:19:25.510 and sometimes the beating is inflicted over the genitalia, 00:19:25.510 --> 00:19:33.230 with the idea that you might do with a puppy, to sort of housebreak the infant. 00:19:33.230 --> 00:19:38.420 And I want to show you some more of these things. 00:19:38.420 --> 00:19:44.260 Now there was a small bruise around the temple of this child, which wasn't too evident in that photograph, 00:19:44.260 --> 00:19:52.470 but again when the scalp was reflected there was very extensive injury here and this is all rather fresh, 00:19:52.470 --> 00:19:56.260 the blood here is quite fresh-looking and not hemolyzed, 00:19:56.260 --> 00:20:01.130 and there's also a fracture of the skull in this case, 00:20:01.130 --> 00:20:02.830 with an intracranial injury. 00:20:02.830 --> 00:20:11.390 And here's the skull fracture that you can see very well on the inner surface of the calvarium. 00:20:11.390 --> 00:20:14.810 And as many of these fractures tend to be, 00:20:14.810 --> 00:20:19.880 they radiate down from the parietal boss, 00:20:19.880 --> 00:20:24.910 and there's quite a lot of hemorrhage in the surrounding tissue in the bone. 00:20:24.910 --> 00:20:30.780 Now there are indications here that this was not all one injury, 00:20:30.780 --> 00:20:34.150 but this was a series of repetitive injuries. 00:20:34.150 --> 00:20:36.660 And the remarkable thing is how these infants 00:20:36.660 --> 00:20:42.910 and how these young children can withstand the amount of trauma that they receive. 00:20:42.910 --> 00:20:48.820 So that when they die you sometimes can't pinpoint the particular injury 00:20:48.820 --> 00:20:53.630 which was responsible entirely for the cause of death. 00:20:53.630 --> 00:20:57.650 Death is due to the effects of the combination of the injuries. 00:20:57.650 --> 00:21:01.570 The cause of death in cases like this is complex, 00:21:01.570 --> 00:21:06.620 and you can't say that this injury did it or that injury did it. 00:21:06.620 --> 00:21:09.680 Not infrequently when one is examined, cross-examined, 00:21:09.680 --> 00:21:13.850 in court and testifying in a case like this, 00:21:13.850 --> 00:21:18.800 the lawyer representing the defendant will say, now which injury killed the child? 00:21:18.800 --> 00:21:20.920 Well, it isn't one injury that killed the child. 00:21:20.920 --> 00:21:23.160 It's the combination of all the injuries. 00:21:23.160 --> 00:21:28.900 And you cannot pinpoint and you should not pinpoint a particular injury 00:21:28.900 --> 00:21:39.250 just to provide an answer which is unanswerable in a particular case. 00:21:39.250 --> 00:21:45.590 Now this is the picture of the inside of the skull. 00:21:45.590 --> 00:21:50.730 There's a fracture right here, you can see it right now very well. 00:21:50.730 --> 00:21:54.950 And this is the posterior fossa and the foramen magnum is around here. 00:21:54.950 --> 00:22:02.640 Again you'll notice this tremendous amount of surrounding hemorrhage. 00:22:02.640 --> 00:22:08.750 And here is a picture of the brain showing very severe contusion and hemorrhage 00:22:08.750 --> 00:22:12.070 on the surface and in the substance. 00:22:12.070 --> 00:22:15.180 And to get this effect in an infant brain, 00:22:15.180 --> 00:22:21.570 does require a great deal of trauma so that one can say in this case that the brain injury, 00:22:21.570 --> 00:22:26.400 the intracranial injury, was the cause of death 00:22:26.400 --> 00:22:29.770 and didn't require all the other injuries. 00:22:29.770 --> 00:22:33.230 This is rather an unusual type of finding, 00:22:33.230 --> 00:22:41.780 because when infants have fractured skulls one doesn't see, as a rule, the extensive brain contusion 00:22:41.780 --> 00:22:49.350 that one would see, for example, in an adult brain with a corresponding type of injury. 00:22:49.350 --> 00:22:54.510 And one of the other findings in this case 00:22:54.510 --> 00:23:01.880 is indicative of prior trauma that this infant received, 00:23:01.880 --> 00:23:08.140 You can see in the ribs, these are the costachondral junctions, 00:23:08.140 --> 00:23:13.880 but in the bony portion of the rib you can see these calluses, 00:23:13.880 --> 00:23:21.950 these cartilaginous calluses representing healing of old rib fractures, 00:23:21.950 --> 00:23:24.780 and this is a very common type of finding. 00:23:24.780 --> 00:23:32.700 One does see in the skeletal system evidence of old healing injuries. 00:23:32.700 --> 00:23:37.240 Now sometimes these are observed by the clinician, 00:23:37.240 --> 00:23:41.480 by the physician in the clinic or in private practice, 00:23:41.480 --> 00:23:46.630 and x-rays may be taken, and this material has to be examined, 00:23:46.630 --> 00:23:54.790 interpreted very carefully and the pattern of the findings is suggestive of prior trauma, 00:23:54.790 --> 00:23:57.750 and should immediately bring up the possibility 00:23:57.750 --> 00:24:02.310 that this is a child that is being abused. 00:24:02.310 --> 00:24:06.590 Again, too often an explanation which the parents 00:24:06.590 --> 00:24:09.160 or the guardians offer about the child 00:24:09.160 --> 00:24:15.830 having been falling or running around and being overactive 00:24:15.830 --> 00:24:20.450 is a rather unsatisfactory one for the extent of the injury. 00:24:20.450 --> 00:24:28.360 Children fall a great deal and they don't injure themselves very often in falling, 00:24:28.360 --> 00:24:33.400 but they are very easily injured when they are battered 00:24:33.400 --> 00:24:39.730 by someone else who is inflicting the trauma. 00:24:39.730 --> 00:24:47.240 Now this is another case but it shows a very, 00:24:47.240 --> 00:24:54.220 it's a good example of the type of bone injury that you see in the battered child. 00:24:54.220 --> 00:24:57.690 This is an infant that died of multiple injuries, 00:24:57.690 --> 00:25:00.860 including injuries to the long bones which were not evident 00:25:00.860 --> 00:25:03.310 from the external appearance of the limb, 00:25:03.310 --> 00:25:07.280 but we had x-rayed this child and found evidence of this, 00:25:07.280 --> 00:25:10.410 and then removed the humerus. 00:25:10.410 --> 00:25:13.640 You can see the ossification centered in the head there, 00:25:13.640 --> 00:25:21.300 and here's the shaft and here is a fracture, recent, undergoing some degree of repair 00:25:21.300 --> 00:25:25.400 with subperiosteal hemorrhage undergoing organization. 00:25:25.400 --> 00:25:28.860 It's rather important to recognize this as a fracture, 00:25:28.860 --> 00:25:38.790 and not as some dyscrasia or some variation of scurvy. 00:25:38.790 --> 00:25:49.130 I've had bones like this described as scurvy on the basis of subperiosteal hemorrhage, 00:25:49.130 --> 00:25:53.360 which obviously is in relation to the fracture of the cortex 00:25:53.360 --> 00:25:57.830 and the shaft of this long bone. 00:25:57.830 --> 00:26:05.250 These heal rather rapidly and the callus which is initially laid down 00:26:05.250 --> 00:26:08.270 is not ossified but after a period of time, 00:26:08.270 --> 00:26:15.870 the lime-salts are deposited and one recognizes this for what it is. 00:26:15.870 --> 00:26:22.610 But I thought you'd like to see an example of a long bone in a battered child. 00:26:22.610 --> 00:26:26.700 I might say that if you're doing an autopsy like this, 00:26:26.700 --> 00:26:30.710 you can remove a bone and examine it, 00:26:30.710 --> 00:26:38.040 and this is one time when you can go beyond the conventional incisions. 00:26:38.040 --> 00:26:42.540 And I think we'll continue this discussion in the next presentation. 00:26:42.540 --> 00:26:44.130 [Music] 00:26:44.130 --> 00:26:47.200 [Forensic Medicine Outlines, Milton Helpern, M.D., Chief Medical Examiner, The City of New York] 00:26:47.200 --> 00:26:49.690 [Forensic Medicine Outlines, The Battered Child] 00:26:49.690 --> 00:26:52.340 [Clinical Pathology Series, A Cooperative Project] 00:26:52.340 --> 00:27:00.000 [The End, T - 1899, V - 1899, MCMLXIX] 00:27:00.000 --> 00:27:04.950 [Clinical Pathology Series, A Cooperative Project] 00:27:04.950 --> 00:27:10.110 [Emory University School of Medicine and National Medical Audiovisual Center] 00:27:10.110 --> 00:27:13.000 [Forensic Medicine Outlines, The Battered Child] 00:27:13.000 --> 00:27:16.210 [Part 2] 00:27:16.210 --> 00:27:22.590 [Forensic Medicine Outlines, Milton Helpern, M.D., Chief Medical Examiner, The City of New York] 00:27:22.590 --> 00:27:29.930 I should like to continue the discussion of the battered child syndrome 00:27:29.930 --> 00:27:35.670 with a few more illustrated cases. 00:27:35.670 --> 00:27:40.880 There's a great variety of findings in some of these. 00:27:40.880 --> 00:27:49.950 Most of them are evident, as I indicated from circumstances and external findings, 00:27:49.950 --> 00:27:56.120 but as I also pointed out, some of them show no external signs of traumatic injury 00:27:56.120 --> 00:28:03.700 and the initial story can be very misleading and very similar to the story one gets 00:28:03.700 --> 00:28:13.250 in the crib death where the parent or guardian simply find the infant dead in the morning 00:28:13.250 --> 00:28:18.380 and rush the body to the hospital. 00:28:18.380 --> 00:28:23.110 And the doctor and the clinic may or may not suspect something, 00:28:23.110 --> 00:28:28.300 but in DOA cases generally the admitting doctor feels 00:28:28.300 --> 00:28:31.640 he doesn't have that responsibility, which he doesn't, 00:28:31.640 --> 00:28:34.930 and he reports the death to the medical examiner's office 00:28:34.930 --> 00:28:38.900 as a so-called DOA and this can be anything 00:28:38.900 --> 00:28:41.740 once the body has been taken from the scene. 00:28:41.740 --> 00:28:48.620 Many parents in finding a child dead, not wanting to recognize that it is dead, 00:28:48.620 --> 00:28:52.340 will pick the body up and rush with it to the clinic. 00:28:52.340 --> 00:28:56.060 Sometimes it may even arrive after rigor mortis has set in 00:28:56.060 --> 00:29:02.090 and obvious death is noticed. 00:29:02.090 --> 00:29:05.000 Sometimes the admitting physician will record this 00:29:05.000 --> 00:29:11.960 and sometimes he doesn't do this in the pressure of other work 00:29:11.960 --> 00:29:13.980 that he has to do. 00:29:13.980 --> 00:29:19.540 Now this next example that I want to show you is an infant 00:29:19.540 --> 00:29:23.580 that was brought in from one of the outlying boroughs. 00:29:23.580 --> 00:29:25.780 It was found dead. 00:29:25.780 --> 00:29:29.740 There was a history, which our medical investigator obtained, 00:29:29.740 --> 00:29:36.020 that this child had fallen a short distance, 00:29:36.020 --> 00:29:39.930 and he wasn't satisfied with the history that the family gave him 00:29:39.930 --> 00:29:46.770 and ordered the body removed to the mortuary for a routine autopsy. 00:29:46.770 --> 00:29:53.140 And one notices, for example, a small abrasion, this is fairly fresh, 00:29:53.140 --> 00:29:58.520 on the forehead and the child is malnourished. 00:29:58.520 --> 00:30:00.730 It's eight months of age. 00:30:00.730 --> 00:30:11.480 And then you see some areas of depigmentation on the left knee and this was explained away by the family 00:30:11.480 --> 00:30:18.630 as a slight scald that the child had received and you wonder how that happened. 00:30:18.630 --> 00:30:26.920 And then if you look at the back of the child you notice that there's very extensive scalding 00:30:26.920 --> 00:30:32.650 which would indicate that the child had been dipped into very hot water. 00:30:32.650 --> 00:30:34.030 And this is an old lesion, 00:30:34.030 --> 00:30:41.100 you see it's completely epithelialized with non-pigmented skin. 00:30:41.100 --> 00:30:50.550 At the time this was not considered suspicious when this child was treated in the hospital and it should have been but it wasn't 00:30:50.550 --> 00:30:55.810 and the police were not notified of this particular incident. 00:30:55.810 --> 00:30:57.450 There's some bruising of the buttocks, 00:30:57.450 --> 00:31:01.980 and a very easy way to demonstrate injuries in the buttock fat 00:31:01.980 --> 00:31:06.420 is to incise through the subcutaneous fat. 00:31:06.420 --> 00:31:09.710 And one not infrequently finds bruises 00:31:09.710 --> 00:31:17.910 indicative of whipping that the child might have received. 00:31:17.910 --> 00:31:25.190 Now, a very characteristic injury that one sees in the battered child, 00:31:25.190 --> 00:31:34.450 which is not evident from the outside, and this often results from blows to the abdomen, 00:31:34.450 --> 00:31:42.090 sometimes the child may be punched and sometimes the child may be thrown. 00:31:42.090 --> 00:31:50.160 All sorts of violence are exerted on these infants. 00:31:50.160 --> 00:32:00.880 This is a case in which the liver shows a fairly characteristic type of injury, 00:32:00.880 --> 00:32:11.980 a longitudinal laceration between the lobes with considerable bruising of this lower margin here 00:32:11.980 --> 00:32:15.900 and the liver is almost cracked in two, 00:32:15.900 --> 00:32:19.420 and there is blood in between the edges. 00:32:19.420 --> 00:32:23.490 Now this is an injury that occurred not at the time of death 00:32:23.490 --> 00:32:29.990 but sometime before because it shows some evidence of repair. 00:32:29.990 --> 00:32:35.510 The next slide shows the lungs of this infant, 00:32:35.510 --> 00:32:39.580 which also show very extensive contusion, 00:32:39.580 --> 00:32:44.540 suggesting that it had been thrown about and sometimes these infants are picked up 00:32:44.540 --> 00:32:50.980 and physically thrown against hard projecting objects, 00:32:50.980 --> 00:33:01.080 and this type of contusion of the lung with a large subpleural [?] filled with blood 00:33:01.080 --> 00:33:05.630 is not an uncommon type of injury 00:33:05.630 --> 00:33:13.940 and very evident when the organs are examined. 00:33:13.940 --> 00:33:18.880 And with regard to the liver injury, if one takes it in the hand 00:33:18.880 --> 00:33:22.560 and gently separates the edges after taking some of the tissue 00:33:22.560 --> 00:33:24.840 from microscopic examination, 00:33:24.840 --> 00:33:29.490 you can see that this laceration which extends deeply into the parynchema 00:33:29.490 --> 00:33:32.340 of the liver from the anterior surface 00:33:32.340 --> 00:33:34.710 in the region of the interlobar fissure, 00:33:34.710 --> 00:33:38.770 has already produced a reparative reaction. 00:33:38.770 --> 00:33:41.780 There's a little bit of traumatic infarction in the margin 00:33:41.780 --> 00:33:46.640 and there's organization of this blood clot indicative of a process 00:33:46.640 --> 00:33:49.510 that has been there for some time. 00:33:49.510 --> 00:33:53.420 And then there are also some intraparynchemal tears 00:33:53.420 --> 00:34:02.000 due to the very severe distortion which the liver has undergone. 00:34:02.000 --> 00:34:12.800 And another injury that one sees as the result of a blunt force impact over the right upper quadrant, 00:34:12.800 --> 00:34:15.780 the liver is pressed against the right adrenal. 00:34:15.780 --> 00:34:18.790 The right adrenal is very vulnerable to contusion. 00:34:18.790 --> 00:34:21.480 And here you have a contused adrenal 00:34:21.480 --> 00:34:27.260 with a very thick hemorrhage in the medullary portion. 00:34:27.260 --> 00:34:31.290 Outwardly this adrenal merely showed swelling 00:34:31.290 --> 00:34:36.780 and when it was incised this very severe hemorrhage was found, 00:34:36.780 --> 00:34:47.180 all adding to the shock of the injuries and to be included in the cause of death. 00:34:47.180 --> 00:34:56.320 Now, in connection with the liver injuries, blunt force applied to the abdomen after death 00:34:56.320 --> 00:35:00.590 can also produce injury 00:35:00.590 --> 00:35:03.850 and sometimes an infant is brought in 00:35:03.850 --> 00:35:08.480 and the true nature of the case is not recognized in the hospital 00:35:08.480 --> 00:35:14.670 and very violent attempts at resuscitation are made. 00:35:14.670 --> 00:35:23.140 And as sometimes happens in adults too, these attempts at resuscitation can produce postmortem injuries 00:35:23.140 --> 00:35:27.170 which in their pattern are very much like the antemortem injuries 00:35:27.170 --> 00:35:30.180 and sometimes they are difficult to tell apart, 00:35:30.180 --> 00:35:32.720 except that in the postmortem cases, 00:35:32.720 --> 00:35:36.820 one does find a lack of reaction in the margins. 00:35:36.820 --> 00:35:41.160 And this is a case in which a child, a young child, 00:35:41.160 --> 00:35:45.520 was brought into the hospital without any external sign of injury. 00:35:45.520 --> 00:35:54.410 It was thought that it had passed out, and in the attempts to resuscitate this child, 00:35:54.410 --> 00:35:59.810 artificial respiration and resuscitative measures were taken 00:35:59.810 --> 00:36:04.740 by a number of persons, 00:36:04.740 --> 00:36:10.530 and with considerable violence applied to the region of the heart. 00:36:10.530 --> 00:36:15.130 This was sort of a closed-cardiac massage with a little bit of extension 00:36:15.130 --> 00:36:18.110 into the epigastrium. 00:36:18.110 --> 00:36:21.110 And while the heart didn't show any contusion, 00:36:21.110 --> 00:36:27.180 there was this extensive laceration, this, liver in this case, 00:36:27.180 --> 00:36:33.320 very much like the actual laceration I showed you in the other case, 00:36:33.320 --> 00:36:35.030 but without any reaction at all, 00:36:35.030 --> 00:36:38.060 and this was borne out by the microscopic studies. 00:36:38.060 --> 00:36:43.220 But if one isn't careful, one can confuse this with a true injury. 00:36:43.220 --> 00:36:46.730 Now there's also some passive outpouring of blood 00:36:46.730 --> 00:36:54.220 from the large vessels which are torn in a case of this sort. 00:36:54.220 --> 00:36:56.010 And on the posterior surface, 00:36:56.010 --> 00:37:00.870 again you can see the rather bloodless appearance of these tears 00:37:00.870 --> 00:37:08.440 and the lack of reaction of this type of postmortem injury. 00:37:08.440 --> 00:37:18.400 So that these attempts at resuscitation of a dead child may confuse the issue, 00:37:18.400 --> 00:37:26.240 especially when these are made in cases of a true and actually battered child. 00:37:26.240 --> 00:37:33.650 I recall one case I was asked to review that happened in another state. 00:37:33.650 --> 00:37:38.720 It was one in which a child was brought into the hospital in shock, 00:37:38.720 --> 00:37:40.960 in a moribund condition. 00:37:40.960 --> 00:37:48.700 And where the resident who was on duty administered artificial respiration 00:37:48.700 --> 00:37:51.380 and closed cardiac massage. 00:37:51.380 --> 00:37:56.830 When the autopsy was done, it was found that there was a hemopericardium, 00:37:56.830 --> 00:38:02.480 a contusion of the auricular appendage and a rupture, 00:38:02.480 --> 00:38:05.880 delayed rupture of this contusion. 00:38:05.880 --> 00:38:10.620 But what made it complicated was the fact that the manipulation had occurred after death, 00:38:10.620 --> 00:38:13.010 and whether the amount of blood in the pericardium 00:38:13.010 --> 00:38:16.940 was increased by this procedure or not was not determined. 00:38:16.940 --> 00:38:22.540 Microscopically one could actually see that the rupture was antemortem. 00:38:22.540 --> 00:38:24.950 There was a reactive lesion around the contusion. 00:38:24.950 --> 00:38:31.490 This child had been picked up and thrown against a hard, pointed object 00:38:31.490 --> 00:38:38.860 and had fractured ribs and a contused heart with a delayed rupture. 00:38:38.860 --> 00:38:47.020 And in that case the parents, the mother and the stepfather, 00:38:47.020 --> 00:38:54.960 were brought to the district attorney's office for questioning. 00:38:54.960 --> 00:38:59.250 They admitted disciplining the child. 00:38:59.250 --> 00:39:03.900 They believed in the old adage of spare the rod and spoil the child 00:39:03.900 --> 00:39:08.030 but they didn't quite know how to handle the situation 00:39:08.030 --> 00:39:12.730 when the rod was overused. 00:39:12.730 --> 00:39:20.290 They used a paddle on this particular child and the infant showed evidence of having been paddled 00:39:20.290 --> 00:39:25.200 and the stepfather said well, that's the way he was brought up. 00:39:25.200 --> 00:39:28.000 There was reason to believe that the violence had been inflicted 00:39:28.000 --> 00:39:32.330 by the mother rather than by the stepfather. 00:39:32.330 --> 00:39:41.810 The first husband of the mother, the father of the child, stated that he got himself divorced from this woman 00:39:41.810 --> 00:39:46.130 because she was very vigorous and he was getting tired 00:39:46.130 --> 00:39:49.180 of all the corporal punishment that he was receiving. 00:39:49.180 --> 00:39:52.680 So they had reason to believe that in that case, 00:39:52.680 --> 00:39:57.100 the injuries might have been inflicted by the true parent 00:39:57.100 --> 00:40:00.040 rather than by the stepfather. 00:40:00.040 --> 00:40:07.190 But these are difficult cases sometimes to handle because you don't know what the intent is 00:40:07.190 --> 00:40:14.040 and just to define how much corporal punishment a parent can administer, 00:40:14.040 --> 00:40:19.940 and the question of the threshold of patience in handling children. 00:40:19.940 --> 00:40:23.440 It's not all mother love or parental affection. 00:40:23.440 --> 00:40:26.810 One thing one learns in a medical examiner's office, 00:40:26.810 --> 00:40:31.770 that it's always a case of mother love and father love. 00:40:31.770 --> 00:40:34.420 Looking after all these infants, the remarkable thing is 00:40:34.420 --> 00:40:38.390 how some of these infants and children actually survive the perils 00:40:38.390 --> 00:40:45.870 and hazards of growing up within their own household. 00:40:45.870 --> 00:40:48.940 Now this is a rather interesting case. 00:40:48.940 --> 00:40:57.510 It's an infant of eight months that was found unconscious 00:40:57.510 --> 00:41:01.870 and taken to the hospital where it died shortly thereafter. 00:41:01.870 --> 00:41:10.750 And if one examines the face you can see bite marks on the nose, blunt force injuries on the head. 00:41:10.750 --> 00:41:16.100 This infant was assaulted by a two year old sibling 00:41:16.100 --> 00:41:19.180 who attacked it with a heavy toy 00:41:19.180 --> 00:41:25.170 and also bit it, evidently resenting its arrival and presence in the family. 00:41:25.170 --> 00:41:31.270 This is a problem, I think, that families do have to consider, 00:41:31.270 --> 00:41:37.330 the attitude of an older child toward the new arrival. 00:41:37.330 --> 00:41:43.910 And we had a very interesting case not too long ago of a three months old infant, 00:41:43.910 --> 00:41:46.760 or two and a half months old infant, 00:41:46.760 --> 00:41:51.980 whose head was battered very much like the one you just saw. 00:41:51.980 --> 00:41:56.100 The mother was questioned and she said she allowed the infant 00:41:56.100 --> 00:42:01.010 to remain in the room with two older children. 00:42:01.010 --> 00:42:09.540 The oldest one was four years and the one in between was a one year old. 00:42:09.540 --> 00:42:12.490 One thought that the one year old couldn't have done this, 00:42:12.490 --> 00:42:14.520 and that it was probably the four year old. 00:42:14.520 --> 00:42:19.690 The mother brought the four year old and the one year old down to the office. 00:42:19.690 --> 00:42:22.670 The four year old was a perfectly placid child, 00:42:22.670 --> 00:42:27.300 just sat where you placed it, wasn't interested in what was going on. 00:42:27.300 --> 00:42:33.030 But the one year old was an overactive infant, rather child, 00:42:33.030 --> 00:42:38.710 and very vigorous, very active, and obviously was the one 00:42:38.710 --> 00:42:42.860 that was responsible because it was brought into my office 00:42:42.860 --> 00:42:46.260 by our receptionist and I was told, 00:42:46.260 --> 00:42:52.970 "Dr. Helpern, I want you to meet the youngest perpetrator of a homicide we've had in our experience." 00:42:52.970 --> 00:42:56.740 And she brought in this one year old child, walked him into the office 00:42:56.740 --> 00:43:00.300 and he became very active and climbed over everything 00:43:00.300 --> 00:43:05.470 and you could see how he could very easily batter his baby sibling 00:43:05.470 --> 00:43:14.840 with a toy that was the nature that one hit the pegs with a hammer, you see. 00:43:14.840 --> 00:43:19.150 So the child had the hammer and the pegs and all he had to do was let go 00:43:19.150 --> 00:43:24.010 and probably considered the new infant somewhat like a doll 00:43:24.010 --> 00:43:29.460 and exercised this destructive action on it. 00:43:29.460 --> 00:43:34.830 One does see very bizarre cases and they're not the ones we're worried about. 00:43:34.830 --> 00:43:36.830 I mean we try to prevent that sort of thing. 00:43:36.830 --> 00:43:38.700 But at least they're understood 00:43:38.700 --> 00:43:42.800 and they're subject to handling by the authorities. 00:43:42.800 --> 00:43:49.520 But the cases in which the violence is inflicted by older people, 00:43:49.520 --> 00:43:54.360 these are the ones that really have to be looked into 00:43:54.360 --> 00:44:03.240 and these infants protected from those who are supposed to be guardians. 00:44:03.240 --> 00:44:08.880 Now of course to leave a child exposed to the action of an older child 00:44:08.880 --> 00:44:12.280 is also a sign of irresponsibility, 00:44:12.280 --> 00:44:16.440 but in crowded families one can see how this can happen. 00:44:16.440 --> 00:44:21.620 The mother goes out on an errand and leaves the children at home 00:44:21.620 --> 00:44:28.560 and this type of assault sometimes takes place. 00:44:28.560 --> 00:44:35.400 Now this is the, this last case in which the child was battered by the two year old sibling, 00:44:35.400 --> 00:44:40.330 this is the extensive skull fracture that was produced with the blunt object, 00:44:40.330 --> 00:44:45.900 with the object that was used to strike the baby's head. 00:44:45.900 --> 00:44:49.880 You see this fracture of the parietal bone 00:44:49.880 --> 00:44:53.150 with some depression of the fragments 00:44:53.150 --> 00:44:56.890 and a lot of hemorrhage into the tissues. 00:44:56.890 --> 00:45:04.430 The child died from these injuries and the shock of the injuries. 00:45:04.430 --> 00:45:13.000 Now this is a case which I photographed to show welts on the body 00:45:13.000 --> 00:45:17.870 and these should be evident to any physician who examines the case. 00:45:17.870 --> 00:45:20.240 They very often go across the buttock. 00:45:20.240 --> 00:45:26.080 and the buttock has a sort of dusty color which is somewhat difficult 00:45:26.080 --> 00:45:33.160 to see through the pigmented skin, but incision into the buttock tissues 00:45:33.160 --> 00:45:40.170 will readily determine or confirm the presence of severe bruises. 00:45:40.170 --> 00:45:44.990 Many of these cases are brought into the admitting rooms of the hospitals 00:45:44.990 --> 00:45:55.270 and the resident physicians on duty should certainly consider the possibility of a battered child 00:45:55.270 --> 00:46:00.590 when an infant is in shock, and not accept the explanations 00:46:00.590 --> 00:46:06.880 which are offered by the parents or the guardians. 00:46:06.880 --> 00:46:10.550 They should alert the Department of Public Welfare 00:46:10.550 --> 00:46:12.770 and they should alert the police department, 00:46:12.770 --> 00:46:16.840 not that they are accusing anybody, as I said before, 00:46:16.840 --> 00:46:26.540 but to bring the situation to light so that it can be promptly investigated. 00:46:26.540 --> 00:46:35.790 And here you see these stripe-like welts from beating on the extremities 00:46:35.790 --> 00:46:50.370 which represents the effects of corporal punishment that many people inflict on children. 00:46:50.370 --> 00:46:56.640 Now this is a very severe case that goes back many years ago. 00:46:56.640 --> 00:47:07.510 This is a four year old child, one of five children, living with a stepmother. 00:47:07.510 --> 00:47:18.170 And actually the person, this woman was not married to the father whose first wife had died, 00:47:18.170 --> 00:47:20.640 the mother of the children had died. 00:47:20.640 --> 00:47:25.530 Four of the children were exceedingly well-taken care of. 00:47:25.530 --> 00:47:28.150 They were well-dressed and well... 00:47:28.150 --> 00:47:37.050 But they were docile and they apparently were smart enough to keep away from the temper of the mother, 00:47:37.050 --> 00:47:41.240 the stepmother or the step-guardian 00:47:41.240 --> 00:47:45.590 or whatever you want to call her, legally. 00:47:45.590 --> 00:47:51.670 This little boy was somewhat defiant 00:47:51.670 --> 00:47:58.520 and in order to be punished, apparently he received the punishment for all the children. 00:47:58.520 --> 00:48:01.810 I mean he was really the whipping boy in this case. 00:48:01.810 --> 00:48:05.550 And he shows very severe injuries. 00:48:05.550 --> 00:48:09.870 What this woman used to do to him, he was in the habit of touching things 00:48:09.870 --> 00:48:11.930 that she didn't want him to touch 00:48:11.930 --> 00:48:16.550 and she would take his hands and put them over the flame of a gas stove. 00:48:16.550 --> 00:48:22.030 And he has these very severe burns you see which are all festered and infected. 00:48:22.030 --> 00:48:26.050 And then he has very extensive evidence of whipping, 00:48:26.050 --> 00:48:27.880 I mean the external appearance. 00:48:27.880 --> 00:48:36.760 How this could go on so long, this child had been seen from time to time by, 00:48:36.760 --> 00:48:38.310 taken to clinics and so on, 00:48:38.310 --> 00:48:41.870 but the simple explanation, well, the child burned itself. 00:48:41.870 --> 00:48:47.380 Well how could a child burn itself by its own actions? 00:48:47.380 --> 00:48:56.910 And I think that we doctors tend to be a little too gullible and to accept explanations which sound plausible at the time 00:48:56.910 --> 00:49:05.660 but what we are really doing is rationalizing a situation so that we don't do all the things that we're supposed to do 00:49:05.660 --> 00:49:09.040 based on our findings rather than on the story. 00:49:09.040 --> 00:49:15.230 And most of these stories that we get are very unsatisfactory 00:49:15.230 --> 00:49:20.950 and provide an inadequate explanation of what has really happened. 00:49:20.950 --> 00:49:24.450 And it's up to the doctors to really stimulate a little activity 00:49:24.450 --> 00:49:28.250 on the part of the investigating agencies, and they want to do this, 00:49:28.250 --> 00:49:32.350 but they can't do it unless they're alerted to these situations. 00:49:32.350 --> 00:49:37.560 And too often there's a lot of passivity on the part of the persons 00:49:37.560 --> 00:49:39.450 who have an opportunity of doing this 00:49:39.450 --> 00:49:42.120 and this is one of the responsibilities 00:49:42.120 --> 00:49:48.680 of the forensic pathologist in completing his work. 00:49:48.680 --> 00:49:54.910 It's all right to determine the cause of death and photograph and catalogue these findings but one has to do something about it, 00:49:54.910 --> 00:49:57.310 just like one has to do something about it 00:49:57.310 --> 00:50:02.430 when we discover a case of carbon monoxide poisoning. 00:50:02.430 --> 00:50:07.580 And here's the other hand, these granulating wounds, terrific amount of injury 00:50:07.580 --> 00:50:17.340 and how the child survived as long as he did is really beyond belief. 00:50:17.340 --> 00:50:20.630 Those are the cases I wanted to show. 00:50:20.630 --> 00:50:27.390 There are many other points that one can make. 00:50:27.390 --> 00:50:32.180 Not infrequently the roentgenologist is the first one 00:50:32.180 --> 00:50:39.830 to pick up the multiple fractures in a healing state. 00:50:39.830 --> 00:50:46.070 Sometimes the fracture, in some of these children the arms are pulled 00:50:46.070 --> 00:50:48.910 and the child is swung by the arm 00:50:48.910 --> 00:50:53.630 and there may be a separation of the epenthesis from the [?] of the bone. 00:50:53.630 --> 00:51:01.670 Initially, since the cartilage doesn't show up in the x-ray, no real finding is noted in the x-ray, 00:51:01.670 --> 00:51:10.070 but after a relatively short period of time the reparative process sets in 00:51:10.070 --> 00:51:17.530 and the hemorrhage begins to undergo ossification, new bone is laid down. 00:51:17.530 --> 00:51:22.200 There have been instances, you know, where this process 00:51:22.200 --> 00:51:26.380 was mistaken for a bone tumor. 00:51:26.380 --> 00:51:33.040 But I think most roentgenologists now and most clinicians, pediatricians and pathologists, 00:51:33.040 --> 00:51:37.050 are aware of this finding. 00:51:37.050 --> 00:51:42.260 And if you're in doubt and you have an x-ray available in the autopsy room, 00:51:42.260 --> 00:51:46.960 then I think it's justifiable to make an incision over the bone 00:51:46.960 --> 00:51:54.590 and to examine that bone in situ and to remove whatever portions are necessary. 00:51:54.590 --> 00:51:57.700 The skeletal manifestations are extremely interesting, 00:51:57.700 --> 00:52:02.540 the multiple rib fractures that are sometimes sustained 00:52:02.540 --> 00:52:08.280 when the infant is thrown against the corner of a hard object like a chest, 00:52:08.280 --> 00:52:13.830 and the impact against the chest will crack the ribs in a line. 00:52:13.830 --> 00:52:16.410 And then the reparative process will set in. 00:52:16.410 --> 00:52:20.600 If you see these children immediately after the injury is inflicted, 00:52:20.600 --> 00:52:27.600 then the fractures are not so evident as they are when the callus formation develops. 00:52:27.600 --> 00:52:33.180 But certainly an autopsy of the ribs and the skeletal system, the whole skeletal system, 00:52:33.180 --> 00:52:40.110 should be very carefully explored and sections taken for, 00:52:40.110 --> 00:52:44.010 microscopic sections taken for collaboration. 00:52:44.010 --> 00:52:47.550 I think this will complete our discussion today. 00:52:47.550 --> 00:52:48.050 [Music] 00:52:48.050 --> 00:52:51.250 [Forensic Medicine Outlines, Milton Helpern, M.D., Chief Medical Examiner, The City of New York] 00:52:51.250 --> 00:52:53.770 [Forensic Medicine Outlines, The Battered Child] 00:52:53.770 --> 00:52:56.350 [Clinical Pathology Series, A Cooperative Project] 00:52:56.350 --> 00:53:23.200 [The End, T - 1899, V - 1899, MCMLXIX]