Greivous Hurt: Explained

Even if you have already decided not to bother about the contents of  the Sri Lankan Penal Code (SLPC) as being an irrelevant document for a practising doctor one cannot deny the importance of understanding different types of 'grievous hurt' given in the Section 311, at least  for the doctors who are engaged in medico-legal duties such as MOs-Medico-Legal, MOs-IC of peripheral units and DMOs and, of course the JMOs.

No body would fall in love with the Section 311 at first sight, especially as it is fraught with many confusing terminology. Most of these words are part of the legal jargon but as doctors we find them 'indigestible' so to speak.  

The word privation used in a few places means 'an act, condition, or result of deprivation or loss'.The word 'member' is used in two limbs. It means 'a part or an organ of human or animal body such as an arm or limb or penis (http://www.thefreedictionary.com/member). The rest of the words should not give any problems as far as the meanings are concerned.

Limb (a). Emasculation

Emasculation literally means castration or loss of virility (the ability to engage in sexual intercourse and produce children). This can be achieved either by physical removal of a man's genitals (penis and testicles or either of them) or depriving functionality of his genitals and making him impotent or sterile even if the genitals are physically present e.g. damage to spinal cord or nerves causing impotence, sterility from injury to testicles.

Limb (b).Permanent privation or impairment of the sight of either eye

I hope this is easy to understand. If the vision of an eye is totally lost or impaired permanently it comes under this limb. It is the examiner's responsibility to make sure that the defect is permanent. Eye surgeons opinion has to be sought and the patient should be reviewed until the defect seems to be permanent.

Limb (c). Permanent privation or impairment of the hearing of either ear

This should not cause any problem.

Limb (d). Privation of any member or joint

This deals with physical loss of joints and members such as hands, feet, or a limb. Somebody might argue that this also deals with 'functional' loses as privation may not mean only physical loss. Since functional losses are covered in the next limb it does not matter this limbs deals with it or not.

Limb (e). Destruction or permanent impairment of the powers of any member or joint

This deals with functional losses, both total (destruction) and partial (impairment) of members and joints.

This limb can be subdivided into four parts.

1. Destruction of the powers of any member

2. Destruction of  the powers of any joint

3. Permanent impairment of the powers of any member

4. Permanent impairment of the powers of any joint t

• Total loss of sense of smell due to injury to olfactory nerve following a head injury - Destruction of powers of a member
• Loss of sensation of a hand following neck injury - Permanent impairment of the powers of a member
• Ankylosis of the elbow joint following injury - Destruction of the powers of a joint
• Restriction of the movement of elbow joint following burn contracture - Permanent impairment of powers of a joint

In all these instances the member or joint is physically present but their functionalities are either totally lost or impaired permanently.

Limb (f). Permanent disfiguration of head or face

When an injury causes the skin to be breached (incised and lacerated wounds) it is likely that healing will result in a scar. When this scar disfigures head or face the injury should be categorised as  'grievous'.  Unlike the rest of the limbs this assessment is simply subjective. A disfigurement for one may not be so for another. The doctor does not have a set of objective criteria. He/she might consider many factors such as age, sex, occupation, etc. in deciding whether a scar is disfiguring. For instance, a disfiguring small scar on the nose of a young girl may not be so on the nose of a middle aged man.

Some injuries may be so severe that the doctor may not have to wait till the scar is formed to decide whether it is disfiguring. In not so easy cases the patient should be reviewed until the healing process is complete. The availability of plastic surgery should not be considered. What if the patient had not sought medical assistance when he/she got injured resulting in a severe scar tissue formation? It is my opinion that the doctor should decide whether the scar, as it is now, disfigures and the write in the remarks column that the lack of medical intervention is the likely reason for such a severe scar tissue formation.

Limb (e). Cut or fracture of bone, cartilage or tooth or dislocation or subluxation of bone, joint or tooth

This limb includes

1. Cuts of bones, cartilages and teeth

2. Fractures of bones, cartilages and teeth

3. Dislocations of bones, joints and teeth

and

4. Subluxations of bones, joints and teeth.

Limb (f). Injury endangers life or as a consequence of which an operation involving the opening of thoracic, abdominal or cranial cavities is performed.

This limb has two parts.

1.  Injury endangers life.

2.  Injury, as a consequence of which an operation involving the opening of thoracic, abdominal or cranial cavities is performed.

We have already discussed the first one. The second one needs little bit of explanation I guess. This covers the situations where the 'original' injury is non-grievous but it has become 'grievous' because a body cavity has been opened by the 'surgeon' to exclude internal organ damage or/and haemorrhage. A person was assaulted on the abdomen and admitted to the surgical casualty. The surgeon suspecting an intra-abdominal emergency operated on him only to find nothing. Even if the abdominal wall injury is non-grievous it will become grievous because of the surgical exploration of the abdomen.

Limb ((g). Any injury which causes sufferer to be in severe bodily pain or unable to follow his ordinary pursuit for a period of twenty days either because of the injury or any operation necessitated by the injury.

The two parts of this limb are :-

1. Any injury which causes sufferer to be in severe bodily pain for a period of twenty days either because of the injury or any operation necessitated by the injury.

2. Any injury which causes sufferer to be unable to follow his ordinary pursuit for a period of twenty days either because of the injury or any operation necessitated by the injury.

The doctor's responsibility in terms of this limb is to make sure the patient in fact suffers from 'severe' bodily pain for more than 'twenty' days. Just because the patient is in the ward for twenty days doctor should not make the injury 'greivous'.

With regard to the second part the ordinary pursuit it should be viewed subjectively. One person's ordinary pursuits may be different from another. (Pursuit is defined as an activity engaged in regularly.)

I hope this will help you in understanding this very important section of the penal code.

Priyanjith Perera

31/12/2012

Few Important Facts about Category of Hurt

I have already taken classes on medico-legal documents and category of hurt for a few clinical groups. During the discussions I found that 'hurt' and its 'categories' had confused most of those young minds. No body should feel disheartened for not being able to understand these concepts as, some would sarcastically say that  they are meant to be confusing. Anyway the truth is that most of the forensic medical experts, including me, still find categorisation of some injuries difficult.

Although it has now been well-established that the doctor should categorise the injury on MLEF (Medico-Legal Examination Form) initially and MLR (Medico-Legal Report) later (and in the high court as well), it is my understanding that the doctor's role really is only to describe the injury and the court should categorise the injury based on the information provided by the doctor.

[I have read in one of the judgement given by a well-known judge (I cannot remember the reference.) where he categorically says that the doctor's role (in expressing opinion not confined to category of hurt) is to describe the scientific criteria he used in his opinion to the court. So that they can form their own opinion using the same criteria used by the doctor. ]

Since the police, prosecutors (Attorney General's Department), defence lawyers and judges expect the doctor to categorise hurt we do not have an alternative but to acquiesce with their 'demand'.

On the other hand giving category of hurt on the MLEF may have a purpose. As you already know that it is a police form and the very brief information the doctor provides on it is used by the police in deciding the kind of action they are supposed to take with regard to the case.

Categorisation of hurt is a sort of a scale used in measuring the 'severity of an injury'. However, it is not the sole criterion used by the courts in sentencing a perpetrator of a crime. For instance, using a firearm to injure a person is considered  to be a serious offence, so much so that even if it has caused a mere abrasion the wrongdoer could be charged for attempted murder.

Although the 'hurt' is defined in the Sri Lankan Penal Code (SLPC) as 'bodily pain, disease of infirmity' (Section 310) all the different types of injuries designated as 'grievous hurt' are physical injuries and their sequelae. ('Hurt' constitutes physical injuries as well as poisoning, mental disorders, infections such as STDs etc. To cause hurt there needn't even be physical contact.)

When you look at MLEF and MLR carefully you would realise that the police and courts wants to know only an injury is 'grievous' or 'non-greivous' (forget about 'endagering life' and 'fatal in the ordinary course of nature' for the moment). They are not concerned with 'hurt' (all the diseases, bodily pains and infirmities of non-physical origin). Therefore the doctor is only required to deal with physical injuries with regard to MLEF and MLR especially in categorising injuries.

The grievous injuries are defined under the Section 311. And they also say that only the kinds of hurt given are grievous (The following kinds of hurt are only designated as grievous.) although there may be infinite number of injuries as it were. The doctor's job is to decide whether a given injury is grievous first. If not it is categorised as non-grievous. In other words, non-grievous injuries are injuries which are not grievous. It is a kind of funny logic isn''t it?

An inquisitive observer might wonder why injury endangering life', though it is one of designated grievous injuries, has been given a separate box in the MLEF. The reason behind this is that the law takes 'injuries endangering life' more seriously, for instance, than a mere fracture of a tooth crown for obvious reasons, though both are 'grievous injuries'. Therefore, depending on circumstances such as intention, motive and many others the prosecutor may decide to charge and a court may decide to sentence a person who is responsible for causing an 'innjury endangering life' for not causing 'grievous hurt' but for attempting to kill (attempted murder and culpable homicide). That is the reason why the police wants to know whether the injury is endangering life when the doctor says it is grievous.  

[What I am going to describe here is beyond your curriculum content. Therefore, these paragraphs (font colour is red) should only be read by those who are interested in seeking knowledge and understanding and not only in passing the exam.  

There is one more 'category of hurt' called 'injury likely to cause death' which does not appear in the MLEF or MLR as it comes under the offences of 'Culpable Homicide' (Section 293) and 'Murder' (Section 294). (A homicide can either be 'culpable homicide not amounting to murder', lesser offence, or 'murder', the ultimate offence, the punishment of which is 'death'.) 

However, there is no consensus among the medical and legal communities about its definition and even whether it is a separate category of hurt.

If a man dies after receiving injury, which is  fatal in the ordinary course of nature, the suspect may be charged for 'murder' (of course the other elements of the offence should be fulfilled such as 'intention' etc.). If he survives the suspect may be charged for 'attempted murder'. That's the reason why 'fatal in the ordinary course of nature is included in the MLEF.

In the same way if a man dies after receiving an' injury likely to cause death' the suspect may be charged for either 'culpable homicide not amounting to murder' or 'murder' depending on many other factors. If the man survives the suspect may be charged for either 'attempted culpable homicide' or 'attempted murder' again depending of many other circumstances.  

This is because 'injury likely to cause death' appears both in the law of culpable homicide (293) and murder (294) whereas injury fatal in the ordinary course of nature to cause death appears only in law of murder.

Therefore, one would wonder why the 'injury likely to cause death' does not appear on the MLEF and MLR when 'injury fatal in the ordinary cause of nature' has places in both of them. The only logical explanation is that the relevant authorities may consider 'injury endangers life' as equal to 'injury likely to cause death' when the victim is dead. ]

Inclusion of 'fatal in the ordinary cause of nature' is for obvious reasons. If a person inflicted an injury with intention on another person and that injury is 'suffiient in the ordinary course of nature to cause death he or she will be charged for 'murder' if the victim is dead or charged for 'attempted murder' if the victim is alive.

(We should not get too involved with 'legal concepts' and 'definitions'. We should understand the law only to the extent that gives us the understanding to execute our duty efficiently. We should always remember to stick to our discipline in terms of expression of opinion. Therefore unnecessary flirting with law should be discouraged.)

Categorisation of injuries to 'endangering life' an 'fatal in the ordinary course of nature'.

Categorisation in to 'non-grievous' and 'grivous' excluding 'endangering life' is relatively easy, I would say. The problems arises only when it comes to 'endangering life' and 'fatal in the ordinary course of nature.

When categorising injuries it should be remembered that we categorise only the 'injuries' and not the 'actions'. In order to understand this one must be aware of the difference between 'action' and its result, which in this case is an 'injury'. For instance, in a case of attempted manual strangulation the victim may present with finger nail abrasions and bruises on the neck. The category of injury is only non-grievous even if the action would have endangered the life of the victim. Only if the victim presents with bilateral florid petechial haemorrhages in the tarsal plates and conjunctivae the category of hurt would be 'endangering life'.

We can say that an injury endangers life when there is an existing possibility (threat to life) of death as opposed to 'potential' and 'imminent' threats. Every injury may have a potential threat to life if a serious complication develops such as tetanus on a nail prick. Injuries which have imminent threat to life are 'injuries fatal in the ordinary course of nature. Injury endanger life lies in between these two extremities so to speak.

If one analyses these two entities more carefully he/she would realises that 'injuries fatal in the ordinary course of nature' would also include the 'injuries endangering life'. In other words when an injury is fatal in the ordinary course of nature it would also endanger the life of the person. Therefore, when defining these categories one should understand that injuries endangering life are the injuries which only 'endangers life'.

 

Every injury to the human body has a 'potential' to cause death as a result of unforeseen or rare complication. For instance a 'nail prick' can be fatal if it is infected with tetanus. But a nail prick is just a non-grievous injury (not even a grievous injury). Whereas in the case of injury endangers life the dangerousness of the injury or possibility of it causing death is felt at the time of the doctor's examination. The doctor knows that the chance of death, however remote, is there, so much so that he/she will not let the patient discharged but keep under observation until the danger passes off even if no active intervention is planned.  For instance, a patient who is unconscious as a result of concussion will be kept under observation in order to prevent him from being asphyxiated or aspirated his own stomach contents even if the doctor would not attempt any active intervention. Would any doctor behave in the same way with a patient who has got a nail prick and come for a toxoid injection to the OPD?

Injuries fatal in the ordinary course of nature have a very high probability of death if not intervened actively ( will be fatal if prompt and proper care is not given.). The doctor will not keep the patient under observation as he would do in the case of the patient with concussion. He will have to do something actively (usually a surgery) to prevent a fatal outcome. For instance a patient with a stab injury to the heart what would the doctor do? Would he/she put him under observation or would he/she take him to the theatre and operate on him?

Injuries endangering life have a low probability of causing death by injury itself or giving rise to complications which might cause death e.g. head injury with concussion has a low probability of causing death by itself. It gives rise to complications such as aspiration or asphyxia very rarely.

Injuries fatal in the ordinary cause of nature have a very high probability of causing death by injury itself or giving rise to complications which might cause death e.g. stab injury to the abdomen causing perforation of the small intestines. Although small intestinal perforation does not cause death by itself it has a very high probability of being complicated by peritonitis and causing death as a result. Therefore, the category of hurt should be fatal in the ordinary course of nature.

If a non-grievous injury develops a complication and it puts the life of the patient in danger as a result it can now be categorised as 'endangering life' provided that the doctor has to specifically mention that the injury itself is 'non-grievos' but because of the complication it has now become 'endangering life' e.g. patient with nail prick who has developed tetanus.

When a doctor examines a patient with injuries and categorise hurt should he/she consider the patient as a whole or only the injury itself? For instance a cut injury which may not be fatal in the ordinary course of nature in a healthy individual will become such in a person with a bleeding disorder. It is my opinion that the doctor should only categorise the injury forgetting about the idiosyncratic factors. If it has become fatal in the ordinary course of nature or endangering life as a result of some other concurrent disease such as a bleeding disorder it should be mentioned in the remarks column. 

A decision as to whether an injury has a potential, existing of imminent threat to life is based on 'proabability'. No scientist would be able to calculate the probability of causing death of each and every type of injury with any mathematical certainty. (One would say this is based on 'inductive reasoning' rather than 'deuductive reasoning'. The best example of 'inductive reasoning' is 'All the swans we have seen are white. Therefore, all swans are white. This was held absolutely true until the European explorers re-discovered 'black' swans from Australia.) Based on past experiences of collective medical mind we calculate the probability of a given injury. Probably this may have given the categorisation of injury a vibrance which would have otherwise been a dull and dry mathematical calculation. This may be true for all branches of medicine. That is why it is regarded as more of an art than a science. 

 

Finally in categorising injuries especially to endangering life and fatal in the ordinary course of nature one should not be too dogmatic. Although medical experts have defined them in order to have a uniformity what matters is how the non-medical people including lawyers and more importantly the general public understand it. We can split hair on theses matters till the sun goes down but at the end of the day what counts is our ability to convince the lay public.

 

Priyanjith Perera

28/12/2012

 

 

Autopsy Techniques

As at least some of you have finished clinical appointment and seen autopsies being carried out I thought of giving you an overview of the different techniques of dissection practised in different centres around the world.

As you may have already seen our standards of autopsy dissection is way below that of the developed world. It is not that we lacked the expertise or time. Just as everything else in our society it is the lack of correct attitude and accountability.

It is the standard of practise all over the civilised world that the skin incision and dissection of the organs should be done by a suitably qualified doctor. Where there are trained 'autopsy technicians' they can eviscerate the organs after the body cavities are opened by the doctor. Even if the 'de facto' situation may differ from place to place I cannot imagine a mortuary in the developed world where the 'specialist', or any other doctor for that matter, comes to the mortuary after the untrained 'labourer' has made the skin incision, eviscerated and dissected the organs just to see the cut section wearing a 'offce attire' with the tie tucked into the pocket and to peep through the body cavities to see whether any thing is wrong.

At least some of you would be posted as DMOs and MOs-Medico-Legal in the near future. Whatever we would teach you during this brief period of you lives, I am sure that it will not retain in your brains, at least in a great majority. You would also follow this age-old path well trodden by your colleagues of bygone era as it is the norm, easy, less messy, quick etc and moreover, there is no body to oversee your work. It is also called lack of accountability both to your immediate supervisors and to the society at large. Anyway, I accept that blame cannot be entirely doctors' as the authorities who is responsible for providing facilities should also be held responsible for the 'status-quo' as doctors need decent place to enjoy their work.

Without wasting your valuable time  I would like to introduce to different techniques of autopsy dissection. Although history of autopsy techniques is interesting I am not going to dwell in there as most of you may not be concerned with such information.

There are basically four autopsy dissection techniques and many modified versions. 

Roakitansky's

Karl Rokitansky developed this technique in early nineteenth century. The basic idea is not to disturb the connection between the organs as much as possible. Each organ is dissected in situ. If abnormal anatomic relation is found the regions should be removed intact. It is, in other words, a combination of  'in situ' dissection with 'en bloc' removal (which will be discussed later). It can be performed by a single examiner. Disadvantage is that the prosector needs certain degree of pathological knowledge to identify the abnormal relationship.

 

Virchow's

 

It was developed by Rudolph Virchow (a German doctor considered to be the father of modern pathology. Remember Virchow's Triad?) The basic principle is to examine all organs systematically and to arrive at diagnosis as quickly as possible.

 

First the cranial cavity is opened and brain is dissected in the fresh state. The spinal cord is removed from the back. Abdominal cavity is opened and then the thorax. The organs are removed one by one. First from thorax. Then neck followed by abdomen.

 

They are dissected outside. This approach is good in demonstrating pathological changes in individual organs.  Advantages are its systematic stepwise approach and its simplicity. Disadvantage is the destruction of anatomic relationship of various organs making it hard to interpret findings

 

En Bloc (Ghon's)

 

In this method all the connection between physiologically connected organs are retained. The organs of the neck and thorax were removed in one block before the peritoneal cavity is opened. The gastro-intestinal tract with mesentry attached is removed. This technique is attributed to either Zenker or Ghon.

Advantages are the preservation of the important anatomic relationship and easy to handle organ blocs.  Disadvantages include the requirement of skill to remove the blocs and possibility of some diseases having multiple system involvement making the separation of blocs not conducive to proper evaluation. 

 

En Masse (LeTulle's)

 

In this technique the cervical, thoracic, abdominal and pelvic organs are removed as a single organ mass. Then they are dissected into organ blocks. Advantages are complete preservation of relationships between organs and vasculature. The speed with which it can be learned and performed is another advantage. The body can be handed over to the undertaker with no time. The negative point is the large organ mass which is difficult to be handled. This technique is attributed to Heller and LeTulle.

 

The Rokitansky technique has gone out of favour but skill in this technique may be advantage in certain autopsies as the permission to do the dissection is restricted e.g. high risk autopsy. Modern autopsy techniques include modifications of Virhow, En Bolc (Ghon's) and En Masse (LeTulle's) techniques.

 

Whatever the autopsy technique is adopted by the pathologist he/she should be prepared to modify it for the best demonstration of the pathological process which has caused the death.

 

In Sri Lanka a great majority of the forensic pathologists, who perform the dissection by themselves, like the 'En Masse' or 'LeTulle's technique as it is quick though the organ mass is pretty cumbersome to handle.

 

I personally like Gohn's 'En Boc' method as it gives you organs masses, which are easier to handle. Since the oesophagus and aorta are separated from the stomach and the abdominal aorta respectively this method has to be modified in cases of suspected oesophageal varices and abdominal aortic aneurysms.

 

This is the way I would do my dissection.

 

a. Mastoid to mastoid cut on the scalp. Separate and the anterior half and posterior half of scalp from the skull separating through the loos areolar tissue beneath the galea aponeurotica.

b. Make a horizontal cut across the temporalis musles. I do not recommend their removal as they can be sutured together when the skull is reconstructed to give it an added strength.

c. Using the bone saw (preferably the electric saw) a horizontal cut is made on skull, which runs through the frontal eminences in the front 1-2 cm above the superior margin of the orbits, through the squamous temporal bones along the cuts made on the temporalis muscles in the sides 2-3 cm above the ears and through the occipital bone 2 -3 below the lambda on the back of the skull.

d. Dissect the dura and remove the brain. (if a special neck dissection is not required the removal of the brain can be done later. Although I dissect all my cases myself the removal of skull is usually done by the 'autopsy assistant'.)

e. Make a 'U' shape skin dissection on the sides of the neck from mastoids over the clavicles (approximately over the junction between the medial and lateral halves) to a point slightly below the sternal notch over the sternal angle.

f. From that point a vertical incision is made to the pubic symphysis.

g. Abdomen and chest cavities are opened cutting across the sternum just below the first rib keeping the attachments of the clavicles and first ribs to the remaining part of the sternum intact. This may help the undertakers to reconstruct the body more easily. 

h. Then all the neck organs together with chest organs are removed in a single block after tying and cutting across the oesophagus and thoracic aorta.

i. Bowels from the duodeno-jejunal junction to recto-sigmoid junction is removed with or without mesentry (if the mesentric arteries need to be dissected the bowels are removed without it.) after tying both ends.

j. Then the rest of the abdominal organs are removed as a single block or

k. The liver is separated first.

l.  Then the duodenum, stomach, pancreas and spleen as a single bloc

m. Rest of the retro peritoneal structures aorta, IVC, kidneys, ureters, bladder, uterus, a part of the vagina and the rectum are removed as a single block after cutting through the all the structures at the floor of the pelvis.

 

This  could be called a modified En Block or Ghon's technique.

 

Priyanjith Perera

25/12/2012

Commonly used post-mortem instruments

 

Bone Saw - to open the skull

Rib Shears - to cut the ribs

 

Bowel Scissors - to open the bowel

Osteotome - similar to chisel - to cut the bones

 

Surgical Scissors

 

Chisel and Mallet - to open the skull

 

PM 40 Scalpel - larger than the usual scalpel

 

Metal Probe

Bone Cutter - to cut bones

Bone Cutter

Brain Knife - to dissect the brain

 Cartilage Knife - to cut cartilages

Double Blades Spine Saw - to open the vertebral colum to access the spinal code

 

Toothed Foreceps

 

A Scalpel

 

Using Brain Knife

 

Electric Saw - to open the skull

 

Many Instruments in One Picture

 

Variety of Scissors

Skull Breaker

 

 

Priyanjith Perera

24/12/2012

SEXUAL OFFENCES - INJURIES

Injuries of sexual offences can be classified in to General and Sexual. Some experts would like to have another category of injuries called ‘para-sexual injuries’, which means ‘besides’ or ‘near’ sexual injuries. Injuries on the breasts, buttocks and inner thighs belong to this category.  

General Injuries

It may not be easy to classify general injuries of sexual offences as many combinations of different types of injury may occur. Nevertheless, some types and distributions are commoner than others.

Contrary to the expectation of many, most of the alleged victims sexual abuse do not sustain general injuries. It is good to remember that the absence of injuries does not indicate that the allegation of sexual assault is false. There are many reasons why a person is uninjured during a sexual assault.

a.       The victim was sexually assaulted after been subjugated by fear of violence or death or threats or simple emotional manipulation.

b.      The perpetrator has used force but it was not enough to cause injuries or the resistance offered by the victim is not enough to cause injuries.

c.       The injuries were healed by the time it is reported.

As mentioned earlier every single centimetre and recess of the body has to be examined. The most insignificant injury may have a very significant forensic value.

Exact dating of injuries may be impossible but it can be used to see whether there is discrepancy between the history and physical findings.

Attending to the immediate medical needs of the examinees should always take the priority over examination for injuries and collection of forensic samples.

Some of the General Injuries of importance

Bite Marks

They are usually found on the neck, shoulders, and so-called para-sexual areas such as breasts and buttocks. They are important in identification of the assailant by comparison of the bite mark and the dentition of the suspect using techniques of forensic dentistry and by extracting DNA from saliva for ‘DNA Identification’.

Suction bites (sometimes called ‘love-bites’ when sustained during consensual sexual activity) are a variety of bites and occur as a result of suction of the skin with mouth causing multiple petechial haemorrhages as a result of the ‘vacuum’ effect caused by ‘sucking’. They may also present over the upper neck, behind the ear, shoulders and around the nipple.

The lips may get bruised and lacerated from forceful kissing by pressing against the teeth and gums.

Finger Nail Abrasions and Finger Tip Bruises

Finger tip bruises are of round or discoid shape measuring 1 – 2 mm in diameter caused by the pressure generated by finger tips when used to squeeze or manipulate an area of the body.

In sexual abuse they may occur on the buttocks when they are squeezed or manipulated, on the inner aspect of the things when they are forcefully separated to gain access to the genitalia, on the buttocks when they are forcefully separated to gain access to the anus or genitalia during the posterior entry of the vagina.

They may also be present around mouth in cases where the mouth was forcefully closed to prevent screaming, on the neck in attempted manual strangulation or around the upper arms, wrists and ankles when the victim is restrained to prevent struggling. 

Finger nail abrasions are linear abrasions of scratch marks caused by finger nails and usually present on the areas where the ‘finger tip bruises’ are commonly seen.

The assailant may also sustain finger nail abrasions on the face, neck and the trunk.

The long and manicured finger nails of the victims may be broken during the assault and the fractured ends might contain the fibres and hairs of the assailant, which could be used to identify the assailant.

General Bruising and Abrasions

The bruises and abrasions may occur on the back of the victim depending on the type of surface on which the assault took place. If the assault took place on grass or in a jungle the victim may have vegetable matter adhered to her wounds.

Sharp Force Trauma

 They may occur if the assailant has used sharp cutting instruments to threaten the victim. They may be present on the face or neck. In rape-murder cases they may be used to inflict the fatal wound or in some bizarre cases of ‘sadistic rape-murder’ they may have been used to mutilate the victim.

Head injuries

Head injuries are not commonly seen in the clinical cases but they may be present in the rape-murder cases.

Genital and anal findings

It is claimed that less than half of the alleged victims of sexual assault have injuries to the genitalia and anal region. The reasons for absence of injuries to these areas may be

a.       The sexual act is such that it would not leave any injuries e.g. touching, kissing etc.

b.      The alleged victim is sexually experienced

c.       The female genitals especially after puberty has natural elasticity

d.      Even the anus has some degree of natural elasticity

e.      The assailant may have used lubricants

Some of the genital injuries and their significance   

Genital erythema/redness/inflammation of external and internal genitalia

Reddening of the vulva, penis or anal margin is considered as non-specific finding. It can be a result of wide variety of causes including consensual sexual intercourse. Especially in children they may be due to acute trauma, infection, dermatological conditions, allergies, reaction to chemicals or poor hygiene.

When an alleged victim, especially a child is present with them, all the possible causes should be considered in differential diagnosis. Examination should be repeated if the doctor is doubtful about the diagnosis.

Oedema

It is usually sign of inflammation, infection or trauma. When a victim is presented with genital oedema, especially a child all the possible causes should be considered in differential diagnosis. Examination should be repeated if the doctor is doubtful about the diagnosis.

Genital Bruising

Most of the time bruises are caused by trauma. But bruises can also be caused spontaneously due to haematological conditions, especially in children, who have not been previously diagnosed. Some of the dermatological conditions such as lichen sclerosis, localised erythema, haemangioma and pigmented lesions may be confused with bruises.

When a victim is presented with genital bruising all the possible causes of bruising and other lesions, which may mimic bruising, should be considered in differential diagnosis. Examination should be repeated if the doctor is doubtful about the diagnosis. When bruising is found in genitalia sexual abuse is always considered, especially in children.

Genital Abrasion

Possible causes of genital abrasions, especially in children include excoriation of itchy skin and trauma.

When a victim presented with genital bruising, especially a child, all the possible causes should be considered in differential diagnosis. Examination should be repeated if the doctor is doubtful about diagnosis. When abrasions are found in genitalia, especially in children, sexual abuse should always be considered.

Genital lacerations and tears

Small lacerations or tears (a few millimetres in length) of the vulva, foreskin, frenulum and anal margin are likely to be due to stretching of the skin. They may also be due to some local skin condition or local irritation. They are more commonly seen in the fossa navicularis and posterior fourchette than in the hymen in sexual abuse, especially in child victims. When lacerations found on the genitalia sexual abuse should be strongly suspected in the absence of a convincing history of penetrating accidental injury especially in children. 

 Hymenal Tears

Hymen may be lacerated when stretched. Theses lacerations can be ‘complete’ or ‘incomplete’ depending on the size of the object and the elasticity of the tissues. Fresh lacerations bleed but heal rapidly with or without leaving a scar. The healing may complete within weeks.

They may also heal leaving a ‘v’ shape gap, which is called a transaction if it extends up to the vaginal wall. If it terminates before reaching the vaginal wall it is called a ‘notch’ which can be superficial or deep. (Superficial notches only extend less than the 50% of the hymenal width and the deep notches extends more than 50%).

When describing hymenal disruption, a uniform and precise terminology should be used. The recommended terms are as follows. Acute injuries are termed lacerations. They can be partial or complete (to base of hymen). Non-acute injuries when partial are termed ‘notches’ and when complete are ‘transections’.( Hymenal transection is a discontinuity of the hymenal tissue which extended to the base. The term should be limited to healed appearance. )Notches may be ‘deep’ or ‘superficial’. (>50% of the hymenal width is deep. <50% of hymenal width is superficial.)

The following appearances on the hymen are important in ‘child sexual abuse’ as children are generally presented for medical examination much later than the adult victims of sexual abuse and therefore, the cases have to be decided on the sequelae of child sexual abuse and not on acute changes. It is important to appreciate the significance of these changes or appearances to use them in the diagnosis of child sexual abuse.

Clefts/notches

They are indentations on the hymenal membrane. Their shape, depth, location, proximity to hymenal projection, hymenal configuration and examination position should be considered. They may be a part of the normal hymenal morphology.

Hymenal transactions/tears can heal to leave notching/narrowing on the hymen.

 The term cleft or notch should be limited to describe a defect of hymen that does not extend to the base. In fimbriated hymen technique to separate the hymenal folds will facilitate the visualisation of cleft/notches. Where deep posterior clefts /notches can be clearly visualised penetrative injury should be considered.

Hymenal Bumps/mound

A bump or mound is a solid localised rounded thickened area of tissue on the edge of the hymen. They are commonly found in the annular or crescentic hymen. The appearance may depend on the position of examination. Bumps and mounds do not indicate sexual abuse. The child should be examined in different positions.

Size of the hymenal orifice

The association between the size of the hymenal orifice and penetrative sex has been debated for many years. It was the common knowledge that larger hymenal opening indicated penetrative sex. Now it has been agreed that it is nearly impossible to obtain accurate measurements of the hymenal orifice size due to the elasticity of the tissue. The position of examination and even gentle pressure may change the size of the orifice. Therefore the measurement of hymenal orifice is not recommended.

Hymenal Width

It is the widely held belief that trauma can ‘attenuate’ the hymenal tissue making it narrow. This is usually seen at the posterior hymen. The term now preferred is ‘narrow’ and not ‘attenuation’ and described according to the ‘usual’ clock face.

However, measurement of width of the hymen is not recommended. Absent or narrow posterior hymen should be confirmed in the knee chest position. In a prepubertal girl penetrative abuse must be considered where there is complete or almost complete absence of posterior hymenal tissue. There is insufficient evidence to assess whether a ‘narrow’ posterior hymen indicates sexual abuse in pubertal girls.

Some injuries and changes in anal examination and their significance

Anal / perianal erythema

Erythema is redness of the skin and mucous membrane. In addition to injury, possible causes in children are infection, scratching associated with thread worm, poor hygiene including faecal soiling, lactose intolerance, dermatological conditions and inflammatory bowl diseases.

All the possible differential diagnosis should be considered. Examination should be repeated if the doctor is doubtful about the diagnosis.

Perianal venous congestion

This refers to collection of venous blood in the perianal venous plexus especially in children. In any child prolonged traction might lead to appearance of engorged venous plexus. Even if it appears in a relaxed child who is examined for 30 s it should not be considered as indicating sexual abuse. It is reported to have been present both in non-abused and abused children.

Anal/perianal bruising

Apart from trauma spontaneous bruising due to haematological condition or drugs should also be considered, especially in children.

If present the child should be re-examined. All the possible differential diagnosis should be considered. When bruising is found in the perianal/anal area sexual abuse should always be considered.

Anal fissures, lacerations, scars and tags

Anal fissure is a break in the perianal skin, which radiates out from the anal orifice. They are confined to anal margin and may be superficial or deep.

Chronic fissures are usually deep and transverse fibres of internal sphincters may be visible.

Perianal lacerations are acute tears and tissue immediately surrounding anus. They extend beyond anal margin and are usually longer than 1cm.

Healing of fissures and lacerations can result in the formation of scars in the anal margin.

Anal tags most often result from fissures.

In children, presence of anal fissure with a history of alleged anal abuse may provide some corroboration if the appearance is consistent with the timing of abuse. However, passing of hard stool or consistent constipation should always be considered.

In children presenting with anal laceration the possibility of sexual abuse should always be considered.

In children presenting with anal scars or tags (outside midline) sexual abuse should be considered.  At the same time other possible caused should also be considered.

Reflex anal dilatation (RAD) in children

Reflex anal dilatation refers to dynamic action of the opening of the anus due to relaxation of the external and internal sphincter muscle with minimum buttock retraction (the anus is usually closed initially, then opens, then closes again over a period of several seconds)

RAD has been described more in children who allege anal abuse than those allege sexual abuse. There is insufficient evidence to determine the significance of laxity or reduced tone relation to sexual abuse.

If RAD is seen sexual abuse should always be considered in the context of history, medical assessment and other anogenital signs.

Precise measurements of diameter of dilated anal sphincter are not possible.

However doctor should record details of RAD including approximation of the maximum transverse diameter with relation to the examination finger, whether the rectum is seen and presence or absence of stools.

After the examination

The doctor has to fill the MLEF and apprise the police of the findings relevant to them.

Emergency contraception

If the doctor feels that the alleged victim has been exposed to pregnancy due to unprotected sexual intercourse emergency contraception has to be discussed with her. Even if the perpetrator had not ejaculated in her vagina or ejaculated on the external genitalia they should be considered as unprotected sex.

Sexually transmitted diseases

Sometimes alleged victims are much worried about contracting STDs especially HIV if they are knowledgeable enough to appreciate the danger of unprotected sex.  They should be reassured and refer to the STD clinic for further management.

Psychiatric Referrals

The acute response to sexual assault differs from patient to patient. While some would demonstrate stereotype of behaviour of a victim of ‘rape’, a distraught and frightened individual, others may be calm and controlled. Those who have previous history of mental health problems may show acute exacerbation of symptoms.  Some victims of sexual abuse may end up with ‘post-traumatic stress syndrome’.  Some would show combination of behavioural, somatic and psychological reaction called ‘the rape trauma syndrome’.

 (The lecture notes were prepared from two books

1.       The physical signs of child sexual abuse, an evidence-based review and guidance for best practise, March 2008, Royal College of Paediatrics and Child Health.

2.       Clinical Forensic Medicine, 3^rd Edition, Ed. W.D.S. McLay, 2009, Cambridge.)

Priyanjith Perera

24/12/12

 

 

 

 

 

 

 

 

Assassination of President John F Kennedy and Shored Exit Wound

John F. Kennedy, 35th president of the United States of America was assassinated on 22 November 1963 at 12.30 p.m. while travelling in a presidential motorcade with his wife Jacqueline, John Connally (Texas Governor) and his wife Nellie in Dealey Plaza, Dallas, Texas.

 

^{https://www.youtube.com/watch?v=1q91RZko5Gw (The was taken by Mr. Abraham Zapruder using a home movie camera)}

 

Gun Used by Oswald to Kill the President

 

A commission appointed by the government (Warren Commission) concluded after ten months of inquiry that Lee Harvey Oswald assassinated President Kennedy acting alone using a bolt action rifle with six round magazine (6.5 mm Carcano Model 91/38).

 

(A bolt action rifle has a manually operated firing mechanism. The bolt or the rear of the rifle is opened manually with a handle. Then the spent cartridge is withdrawn and ejected. New round is placed in the firing chamber and firing pin is cocked. All this happen with the movement of the handle.)

 

The bullet used was round-nosed fully copper-jacketed bullet [ Diameter is 6.5 mm (.264 in) 160 gr (10 g)]

A Cartridge Similar to this was  Used to Kill the President

 

The commission report was accepted by the majority of the American people when it was  released. But the polls conducted between 1966 and 2003 found that as many as 80 percent of Americans have suspected that there was a plot or cover-up.

There are number of 'conspiracy' theories put forward by various people to explain their version of events which lead to the killing of the president. The agents or agencies which were believed to have been involved include the CIA, the KGB, the American Mafia, the Israeli government and Mossad, FBI director J. Edgar Hoover, sitting Vice President Lyndon B. Johnson, Cuban President Fidel Castro, anti-Castro Cuban exile groups, the Federal Reserve, or some combination of those entities.

 

According to the official version three bullets were fired at Kennedy: one of the three bullets missed the vehicle entirely, one hit Kennedy, passed through him and struck Governor John Connally, and the third bullet was the fatal head shot to the President.

 

In the car President Kennedy and his wife were sitting behind the Governor Connally and his wife.

 

 

 

Lee Harvey Oswald shot the president from behind from the 6th floor of Texas School Book Depository.

 

 

Texas School Book Depository with 'A' indicating the place a man with a rifle was seen 

 

 

The white arrow indicates where the president was hit on the head and the background building is the Texas School Book Depository (2008) 

 

The postmortem report described an entry and exit on the back of the chest and front of the neck.

Wound on the Back

 

Wound on the Front of the Neck

 

 

Situated on the upper right posterior thorax just above the upper
border of the scapula there is a 7 x 4 millimeter oval wound. This
wound is measured to be 14 cm. from the tip of the right acromion
process and 14 cm. below the tip of the right mastoid process.

 

Situated in the low anterior neck at approximately the level of the
third and fourth tracheal rings is a 6.5 cm. long transverse wound
with widely gaping irregular edges. (The depth and character of these
wounds will be further described below.)

 

(According to the doctors who had attended the President immediately after he was shot, the wound on the anterior neck was altered during the 'treacheostomy. That was why it was large. The original size of this wound had given rise to much controversy. Since it was thought be a few millimetres in diameter (4-5 mm) (The diameter of the bullet was 6.5 mm) and smaller than the 'entry' on the back of the chest some people did not believe that this was an exit. They claimed that this was another entry wound and hence there should have been another gunman who shot the President from the front as well. )

 

This is the description of the tract.

 

The second wound presumably of entry is that described above in
the upper right posterior thorax. Beneath the skin there is ecchymosis
of subcutaneous tissue and musculature. The missile path through
the fascia and musculature cannot be easily proved. The wound
presumably of exit was that described by Dr. Malcolm Perry of
Dallas in the low anterior cervical region. When observed by Dr.
Perry the wound measured "a few millimeters in diameter", however
it was extended as a tracheostomy incision and thus its character is
distorted at the time of autopsy. However there is considerable
eccymosis of the strap muscles of the right side of the neck and of
the fascia about the trachea adjacent to the line of the tracheostomy
wound. The third point of reference in connecting these two wounds
is in the apex (supra-clavicular portion) of the right pleural cavity. In
this region there is contusion of the parietal pleura and of the extreme
apical portion of the right upper lobe of the lung. In both instances
the diameter of contusion and ecchymosis at the point of maximal
involvement measures 5 cm. Both the visceral and parietal pleura are
intact overlying these areas of trauma.

 

The second wound was described in the postmortem report as follows.

 

Entry Wound at the Back of the Head

 

Exit Wound at the Right Side of the Head

 

Diagrammatic Representation of the Mechanism of the  Skull Wound

 

 

There is a large irregular defect of the scalp and skull on the right
involving chiefly the parietal bone but extending somewhat into the
temporal and occipital regions. In this region there is an actual
absence of scalp and bone producing a defect which measures
approximately 13 cm. in greatest diameter.

 



Situated in the posterior scalp approximately 2.5 cm. laterally to the
right and slightly above the external occipital protuberance is a
lacerated wound measuring 15 x 6 mm. In the underlying bone is a
corresponding wound through the skull which exhibits beveling of
the margins of the bone when viewed from the inner aspect of the
skull.

 

Upon reflecting the scalp multiple complete fracture lines are seen to
radiate from both the large defect at the vertex and the smaller wound
at the occiput. These vary greatly in length and direction, the longest
measuring approximately 19 cm. These result in the production of
numerous fragments which vary in size from a few millimeters to 10
cm. in greatest diameter.

 

The entry wound with  inner bevelling on the occiput confirmed that the President was shot from behind and the large bone and scalp deficiency on the right side of the skull was the exit. When you look at the Zapruder film you would appreciate the unbelievable destructive power of a high velocity rifled bullet

 

Since the controversy regarding the wounds suffered by the President is centred around the wound on the front of the neck I would like to deal with it in more detail. The conspiracy theorists argue that it could not have been the exit as it is smaller than than the entry wound on the back of the chest.

 

As a general rule the former is true. All the text books say that the exit wounds of rifled firearm injuries are generally larger than than the entry wounds. The reason for this is that the bullet acquires certain movements (yawing and tumbling) as soon as it enters the body due to the contact with tissues, whether soft or hard and sometimes it gets deformed after contact with hard tissue. As a result instead of the nose, the bullet may present the side or rear end at the point of exit. Since the surface area of the side and the rear end is more than that of the nose the exit wound can be larger and more irregular  than those of the entry wound. A deformed bullet also present a larger surface area than the nose at the exit point. 

 

Then what caused the exit wound on the President's neck to be smaller than the entry? 

 

The presence of objects pressing against the skin in the area of exit of the bullet may affect the size and the appearance of the exit wound. Due to the pressure of such objects the external stretching of the margins is limited producing a wound with minimal tearing at the margin. The exit wound may be round and also have an 'abrasion collar'. Exit wounds of this nature may be seen when the victim is lying on the ground or standing against a wall when shot and the exited bullet is stopped by the ground or the wall. They may also be caused when the exited bullet hits a belt, buckle, tough clothing or a similar object in tight contact with the skin.

 

The wound tract of the President's neck wound had gone through his shirt and tie. Since the neck tissues were 'shored' and 'buttressed' by clothing the exit would appeared smaller than the exit and regular.

 

Therefore, the claim that there was a second gunman who shot at the President from front can be based on the appearance of the the wound on the front of the neck. 

 

Priyanjith Perera

19/12/2012