All deaths from violent causes and all deaths about which there is any suspicion of violence - including those of infants and children - are reportable by statute in every jurisdiction, whether it be county or state or municipality, in the United States. The reporting of such deaths (and many others) is a requirement in every law governing the operation of the office of coroner and of the medical examiner in those places in which the newer medical examiner's system has been established.
The manner in which infant deaths occur must also be determined, although it is not possible to resolve this problem in every case. But the inability to determine the cause of death should not be an excuse for the physician to fail to report it, or for the coroner or medical examiner to refuse to accept the case. As in the deaths of older persons, violence - evident or merely suspected - is the basis for making a report and conducting an official investigation.
The fact that the evident violence causing an infant's death can be explained in a nonsuspicious way should not be used as an excuse for failing to report the death for investigation. The coroner or medical examiner is responsible for the investigation of the circumstances, and determination of the cause of death, of all persons who die suddenly and unexpectedly when in apparent good health and without medical attention.
This large category of sudden and unexpected deaths includes many that prove to have been from natural causes, including the large perplexing group of tragic sudden natural infant deaths whose cause has not yet been discovered. These are the socalled crib or cot deaths, the sudden infant death syndrome.
But not all crib deaths are of this type, and a careful postmortem study may reveal a previously unsuspected but demonstrable cause. There may have been an unknown infection or congenital malformation. There may have been an undetected traumatic injury that may have been the result of abuse or neglect - an injury that would have escaped discovery had the circumstances of finding the infant dead in the crib led the physician to the conclusion that this was "sudden infant death syndrome" without ordering a complete autopsy. There are no shortcuts to the correct diagnosis of a true crib death.
In view of the fact that the statutes call for the reporting of all violent or suspicious sudden and unexpected deaths, it is surprising that infant deaths are lost track of, and their reporting is sporadic, in so many jurisdictions in which adult deaths are fairly consistently reported for investigation. With the increased interest and concern about child abuse, state legislatures have enacted special laws in recent years specifically requiring the reporting of deaths from child abuse and neglect - but not requiring the reporting of unexpected sudden infant deaths of apparently healthy children. Thus a large category is being skipped over that should be systematically reported and studied, if only for the purpose of actually determining the incidence and causes of the sudden infant death syndrome. Such a systematic effort could identify genuine natural crib deaths and distinguish them from seemingly similar cases in which the actual cause can be demonstrated to be a disease or a traumatic injury.
In the apparent absence of violence or suspicion thereof, the unexpected deaths of infants are considered to be natural in many jurisdictions. Such deaths, without investigation of the circumstances or adequate postmortem studies, have been stylishly designated "crib deaths."
A variety of designations were once used to certify these cases. They were "overlying crib deaths" or crib deaths due to postural asphyxia, bronchopneumonia, aspiration of food, and so on. Postmortem studies were not carried out then, and they are not being carried out today except in a few jurisdictions. Instead of an adequate autopsy, makeshift substitutes are resorted to. Parental objection is usually cited as the reason for not performing an autopsy. This may be the case in some instances, but it is not true most of the time.
In a situation in which postmortem studies are provided on a fee-forservice basis, it is difficult to obtain funds to compensate the pathologist and the laboratory staff for the extensive work that may be needed in connection with such studies. A good medical examiner's system works better. With salaried, qualified forensic pathologists to take charge of the investigation - willing to accept the responsibility of determining the nature of "natural" deaths and able to recognize and understand signs that point to unsuspected violent death from abuse or neglect - such a system provides a better opportunity for the discovery of the cause of all infant deaths, natural or violent. The medical examiner who understands the importance of these distinctions will further the peace of mind of the community and the public health. And he will aid in the administration of justice.
Many violent deaths will continue to escape detection until the public attitude changes. Since they do not reveal their causes automatically, many will remain erroneously reported - mislabeled or unlabeled. This situation will continue until there is enough public pressure to enforce what the statutes now provide: obligatory reporting of all violent or suspicious deaths to the coroner or medical examiner, a mandatory investigation of the circumstances, and an adequate postmortem examination.
In discussing the responsibility of the coroner and medical examiner, it is necessary to point out that a physician may properly report an infant death, and the case will be erroneously labeled notwithstanding. There are many ways this can happen. The physician is called to the scene of a sudden infant death and then properly notifies the coroner. The coroner - an elected official, a layman more often than not - may or may not summon the pathologist with whom he has an arrangement and ask him to perform an autopsy. The coroner may inform the forensic pathologist of the circumstances, or he may not. So, in many cases in which a wellqualified pathologist with adequate facilities for postmortem examinations is available, he may not even be called, and thus both pathologist and facilities remain unutilized. The coroner may certify the cause of death himself. He may call on the local health officer to do so, or ask a private physician who has treated the infant previously for an unrelated condition.
In any of these eventualities, serious error may occur. The private physician may reluctantly certify the cause of death and, in the circumstances described, may do so erroneously. The pathologist called by the coroner may be unfamiliar with the circumstances; he performs an autopsy without understanding the findings and arrives at a conclusion as to the cause of death that is misleading or even inaccurate - a finding that may lead to a serious miscarriage of justice. A pathologist who is inexperienced in the interpretation of the findings and complications seen in cases of violent death will fail to recognize what he sees.
One of the most serious errors in cases of evident traumatic injury is failure to recognize the pattern and age of the lesions. Not every fatal injury is necessarily a fresh one occurring just before death. The following case is an example of such error.
The death of a two-year-old boy was brought to my attention by the district attorney of a county in a state that will remain unnamed because such incidents are not limited to that locale. The infant was brought in a moribund condition to the emergency room of a busy hospital by the mother and stepfather, and no adequate history of the child's previous illnesses was obtained. There were recent healing injuries of varying age, suggesting localized burns on the genitalia and adjacent areas of the abdomen and extremities - findings not infrequently seen in cases of child abuse (Figure 1, top and center).
Figure 1. The body of the two-year-old boy described in the text, as autopsy begins. Note localized injuries and scars on the penis and on the skin of the abdomen and thighs. They are suggestive of cigarette burns, not infrequently found in cases of child abuse. In top and center photographs the pathologist points with the curved autopsy suturing needle to one of the four postmortem needle puncture marks made by the intern. The bottom two photographs indicate the type of antemortem injuries the intern's needle could not have caused - antemortem vertical laceration of the liver with obvious traumatic infarction and inflammation of the edges visible grossly. (There is a small tear in the left lobe, caused by one of the postmortem exploratory needle punctures.) The lower right photograph reveals antemortem contusion hemorrhage and inflammation of the mesentery, a component of the fatal blunt-force injuries. The postmortem needle punctures could have perforated the tissues inflamed by the antemortem injuries but could have had nothing to do with their origin and progress except to confuse the observer.
Because the child was thought to be near death or dead, the emergency resuscitation team of physicians was called in, and everyone began to work on the infant. Cardiac massage was begun and intravenous injections in the leg were attempted, but without success; after a while, the child was declared dead. In fact, death was pronounced twice - first after vigorous but unsuccessful attempts at resuscitation by a paramedical team and then after the physicians' team had attempted resuscitation. In retrospect, it was apparent that the child had been dead when first seen.
One of the interns on the resuscitation team was curious to know whether there was any blood in the abdomen. Assuming that no autopsy would be ordered, he took it upon himself to do a four-quadrant tap of the abdomen, using a long needle that left distinctly visible puncture marks on the skin (Figure 1). He neglected to record his unauthorized procedure, and there was thus no record on the chart that it had been performed after death had been pronounced twice.
Because of the circumstances, however, the coroner did order an autopsy. The pathologist in the same hospital was called upon to perform it. Autopsy revealed severe vertical laceration of the liver, contusion of the bowel and mesentery, and 500 cc. of blood in the abdomen. There was definite evidence of peritonitis. A localized contusion of the fat of the anterior abdominal wall was visible through the peritoneal lining.
All these injuries - typical of acute, blunt-force injuries to the liver - were definitely antemortem. They had been inflicted recently, yet were of sufficient age to produce a traumatic infarction grossly visible in the margins of the liver laceration, hemorrhage into the mesentery, and acute peritonitis (Figure 1, lower left).
The abdominal needle perforations were obviously postmortem. They could not possibly have caused the antemortem injuries and complications in the liver, bowel, mesentery, and other structures that had led to the child's death. But because they had not been charted, were visible, and could be traced into the traumatized area, they confused the pathologist. Disregarding the postmortem character of the punctures and the evidence that the other injuries must have been sustained hours or even days before the child's death, he concluded that the fourquadrant abdominal tap was the cause of death. Thus, in a case without question resulting from child abuse, the pathologist's confusion over the postmortem needle taps caused the investigation to be directed away from the perpetrators and towards the intern. Ironically, the mother who had brought the boy to the hospital dead is now suing the institution and the intern for malpractice!
This simple and not too rare example of error by the pathologist indicates how important it is for the examining physician to recognize and understand the pattern of injuries that occurs in cases of child abuse. The age of the injuries - and of all complications, fatal and nonfatal - is extremely important in determining the direction a subsequent investigation is likely to take.
The discovery of a large quantity of blood in the abdomen at autopsy may lead one to suspect that the injury responsible for death occurred just before the bleeding took place. Such a conclusion is often in error. Hemorrhage from a traumatic injury can be progressive and cumulative, and not entirely immediate. Thus the actual time when injury to a solid or hollow viscus was sustained, leading to intra-abdominal hemorrhage and severe infection, may have been too early for a suspected assailant to have been responsible. Accuracy here can. direct the investigation towards a likely suspect and absolve an innocent person trapped by misleading circumstances. Many miscarriages ol justice, on the other hand, arise when the pathologist issues an arbitrary opinion on the time an injury was received, without comprehending the intermittency of some hemorrhages or understanding the gross or microscopic appearance of traumatized organs and tissues.
The differentiation of antemortem and postmortem traumatic injury is not always easy when the injuries are sustained in the perimortem period - that is, just before or just after death (as judged by ordinary criteria). Hemorrhage is the common criterion for such differentiation, but it has been shown to be in error on many occasions in distinguishing antemortem from postmortem injury. I have seen so many cases of postmortem bleeding, both into the tissues and externally from the body, mechanically produced without requiring any cardiac action, that I do not try to use hemorrhage alone as a basis for differentiating antemortem and postmortem trauma. When I am asked whether an injury of this type occurred before death or after, I answer that I do not know and that I will have to be told by someone who has knowledge of all the circumstances and facts.
This is not academic; the fact that even a trained pathologist is unable to differentiate between antemortem and postmortem hemorrhage by simple observation is extremely important in actual practice. Here is an example.
An infant, several weeks old, was reported by the parents to have been found dead in its crib. The death was reported to the medical examiner. He investigated the scene but did not discover any evidence that would lead him to suspect traumatic injury. The body was ordered to the mortuary for a routine complete autopsy. This revealed unsuspected abundant fresh hemorrhage beneath the scalp, an extensive fracture of the skull, and fresh hemorrhage between the meninges. The immediate impression was that death had been caused by battering.
The father came to the mortuary to identify the body; he was very surprised when told of the injuries and denied any responsibility for them. He then recalled that he had seen the mortuary attendant wrap the body of the infant in a shroud before removing it from the apartment. The attendant had tossed the small package to his assistant on a lower stair landing. The father had left home immediately and gone to the mortuary building, as he had been instructed to do, arriving there before the mortuary vehicle. He was at a window overlooking the mortuary yard when the vehicle drove in. Again he saw the attendant pick up a small package and toss it to another person, who failed to catch it. The bundle dropped to the pavement. The man thought the procedure was somewhat unusual, but since there were other bodies being delivered at the same time, he did not immediately associate the small package with the body of his dead infant.
When the circumstances were checked, the father's story was confirmed. The mortuary attendant had said nothing about the matter, not realizing that a recently dead body could sustain injuries that might confuse the medical examiner. It was only because the father had, by chance, witnessed the incident that the cause of the injuries was learned. The mortuary attendant admitted the facts and was reprimanded and severely disciplined. But it is dismaying to realize how easily such postmortem injuries could be misinterpreted.
Figura 2. A: Antemortem liver laceration in a child who died from battering. Front view, with liver elevated to show the vertical laceration between the lobes, with reaction in the margins. Note the massive contusion or hemorrhage in the right adrenal, a not uncommon associated injury. B: Postmortem liver laceration caused by overly vigorous attempts to resuscitate a child already dead from natural causes. The reactionless, through-and-through vertical laceration of the liver simulates findings in the battered child syndrome, and requires careful pathologic study and investigation of the circumstances.
I have seen other incidences of postmortem injuries to the soft tissues. In one instance, a contusion and bleeding laceration of the upper eyelid occurred more than 12 hours after the natural death of a middleaged person from congestive heart failure. The injuries, which occurred while the body was being transferred from the hospital bed to the hospital mortuary, were due to clumsy handling and the dropping of the carrying bag containing the body. It was impossible to determine from appearances whether the injuries were antemortem or postmortem. Only the history, and the information that the wound had not been present when the patient was admitted dead on arrival to the hospital, provided the basis for concluding that they were postmortem.
When an infant has died from natural causes, vigorous attempts to resuscitate the body may cause vertical liver laceration with some bleeding into the abdomen. Such injuries are, of course, postmortem; microscopic examination of the margins of the injured organ will not reveal any evidence of a reparative reaction. The difference, admittedly hard to detect, can be seen in Figures 2a and 2b. The injuries shown in Figure 2a are antemortem; those in Figure 2b are postmortem, caused by vigorous cardiopulmonary resuscitative procedures conducted after death had occurred. The pattern is somewhat the same in each, but the reparative vital reaction can be detected in the photograph on the top and not in the other. So it is important to document resuscitative efforts, in order to prevent misinterpretation of the gross findings (which should always be checked microscopically).
The medical examiner, by definition, is a forensic pathologist with the responsibility of investigating the circumstances at the scene of death and examining the body. But in many child-abuse cases the physician has no opportunity to view the scene of death. Child abuse may not even be suspected, and the infant may be removed from the scene and brought to the hospital before any suspicion is aroused. In such circumstances the examination of the scene of death is usually conducted by the police, and it is not until the results of the postmortem examination are known that anyone suspects child abuse as a cause of the fatality. In all cases the medical examiner should perform a complete autopsy as promptly as possible and include microscopic and other indicated examinations.
In contrast to the pathologist who is called upon by a coroner to perform an autopsy in such a case, the medical examiner is responsible for initiating the examination, carrying it out, performing the autopsy, determining and certifying the cause of death, and notifying the law enforcement authorities of his conclusions. He closely directs their investigations as well.
His work starts before the autopsy and is not completed with it. He works independently of the prosecutor but has the responsibility of obtaining and transmitting information to him. He is also responsible for informing the police and the appropriate social-service agencies of every case in which there is an indication or suspicion that physical abuse or neglect contributed to the death.
Evidence of child neglect leading to emaciation and fatal complications must be carefully documented. Postmortem descriptions must be recorded in language that is meaningful and accurate. Terminology should be precise and unequivocal. The medical examiner's inquiry into the circumstances of a death must be complete and carefully recorded. If the autopsy findings confirm the suspicion of neglect and physical injury, the description of those findings should not deteriorate into the monotonous patter indulged in by too many report writers.
Not infrequently, what was clearcut, incriminating evidence at autopsy has been lost in the casual preparation of the report; the phrases used are equivocal and do not convey the real sense of the autopsy findings. Thus, misinterpretations follow in the judicial proceedings. When the language of a poorly written report becomes binding in a legal action, it can provide the basis for a defendant to modify his story, or it may provide a medical expert with an opportunity to interpret the findings differently. Histologic examination of tissues should be carried out. If the gross and microscopic findings do not confirm the report or the suspicion that the death was the result of traumatic injury and its complications or of neglect, the inability of the pathologist to find such evidence should be made known to the district attorney and the other agencies concerned. So should evidence indicating that the age and complications of the injuries are such as to exonerate a suspect.
It should be evident that the investigations and postmortem examinations by the medical examiner or coroner are not automatically selfrevealing. Each death from suspected child abuse or neglect is an individual problem in which these officials carry a tremendous responsibility if the community and justice are to be served.