[continued from part one]


There are many details the must be examined and this includes a consideration of 'definitions' of various medical terms.

A 'contusion' is defined as 1' an injury usually caused by a blow in which the skin is not broken'.
One then needs to consider the definition of 'injury', which is 'any stress upon an organism that disrupts its structure or function, or both, and results in a pathological process. (2) The resultant hurt, wound, or damage'.
Therefore, if one states that the cause is an 'injury' then it is necessary to provide evidence as to why this is so, and to offer evidence why other explanations are not logical.
This is done, usually, by considering (1) the history provided. (2) the naked eye appearance and (3) the microscope findings (this may need to include electron microscope studies). But the issue does not stop there. For example, blood tests may reveal abnormalities that can spontaneously cause the problem. Genetic tests may reveal further abnormalities. And so can some biochemical tests.
In the case under consideration (Baby Alan) these procedures were not strictly adhered to.
Furthermore, in the autopsy report the term 'blunt force injury' is used by the pathologist. This is misleading for several reasons. First, it conveys to the court a distinct (and only) impression that the cause was a blow. And this is done without a consideration of other causes. (that will be detailed later in this report). Then the word 'force' follows 'blunt'. This also conveys something that means 'abuse'. Then, the word 'injury' immediately follows. Therefore, there is reinforcement of what has now become one, and only one, conclusion - that the cause is 'abuse'. If a proper differential diagnosis had been considered and scientific reasons offered for the exclusion of causes apart from abuse, proper scientific methodology would have been carried out. This was not done.

What was referred to as a 'healing contusion' on the left lateral (outer) side of the chest) is noted. Once again, there is no supporting evidence, and no differential diagnosis for this.

Fractures of left ribs, partially healing5, 6, 7 and 10 posteriorly are noted. There is no mention of the fact that the 10th rib broke while being handled. That this occurred is highly suggestive of excessive brittleness - a matter that is discussed at length later in this report. This detail needs to be considered at length because, if it is a fact, it amounts to define evidence for the existence of pathology in bone structure that not consistent with shaking and certainly consistent with a diagnosis of 'temporary brittle bone disease' which in turn is consistent with problems involving Vitamin C utilization/scurvy and, the association with endotoxin (as discussed later in this report).

The lungs were 'mildly hemorrhagic'. One cannot associate this with shaking. But it can be associated with some forms of pneumonia - in which case there would be microscopic (and bacterial or viral culture) evidence of infection. Or it can be associated with coagulation/bleeding disorders. Often, coagulation/bleeding disorders are associated with infections, and this is detailed later in this report.

During the autopsy it was noted that the kidneys were 'very pale'. This needs to be considered in connection with Dr Shanklin's comments regarding the kidneys and failure to thrive. It introduces pathology that, although not specific, is not consistent with shaking.

There was a thin rim of 'ecchymosis' (defined as (1) extravasation of blood into the subcutaneous tissue discoloring the skin (2) any extravasation of blood into soft tissue) in the right lower eyelid. No differential diagnosis is considered and no detailed examination performed to determine the cause. Therefore, particularly in view of facts supporting the existence of a coagulation/bleeding disorder, one cannot attribute this to trauma alone. Unfortunately, the manner by which it is mentioned in the autopsy, gives a distinct impression that there is one cause, and one cause only, and that is abuse.

The same comments can be made for other so-called 'contusions'.

Then there is the question of the age of some of the 'contusions'. During the court hearing it was stated that the contusions were fresh (within 24 hours of death). If this was so then they originated, not at home, but in the hospital. This important issue needs to be considered seriously and in detail. Dating bruises and contusions is, if one attempts to be dogmatic, extremely difficult and open to debate. Mason, in Pediatric Forensic Medicine and Pathology, page 275 states:
The aging of bruises is a vital observation in child abuse, as the repetitive nature of the injuries is often the essence of the differentiation from accident. The colour changes of bruising are not a reliable guide as to their absolute age but the well-known sequence is useful in a relative way, bruises of widely differing hues cannot have been caused in the same 'accident' as is often alleged by parents. The rate of colour change depends on the size of bruises, its depth in the tissues and other idiosyncratic factors which differ from child to child. A small fingertip-sized bruise may pass through the spectrum of blue-red-brown-green-yellow to complete fading in 4-5 days, but more extensive collections of blood can last for two to three times that period. Histology may assist, but many of the claims of exact dating by cellular content cannot be substantiated. Bruises which are obviously of very recent origin may not require histological examinations, but older lesions showing colour changes should be sampled; microscopic examination may, at least, show if the cell population is broadly similar or divergent in different bruises if dating becomes a controversial issue. Faint or doubtful bruises seen on the skin should be incised to confirm or exclude bleeding in the subcutaneous tissues
The issue, however, does not end there. Spontaneous bleeding/ bruises can occur when there are disturbances in coagulation/bleeding disorders and/or connective tissue disturbances - as seen in scurvy. If these conditions are not looked for they will not be found. Furthermore, it is likely, if these conditions exist, that bruises/contusions may originate on different parts of the body at different times - thus creating a false diagnosis of multiple acts of abuse.

What does matter, in the case of Baby Alan, is the failure to observe some of the bruises before death. That is, they were observed, first, during the autopsy. Therefore, it cannot be assumed that these bruises were present when Baby Alan was admitted. If that were so the bruises developed after admission. This means that Baby Alan was abused while in hospital or, more likely, the bruises developed after admission. This would be compatible with a coagulation/bleeding disorder. It is not compatible with shaking.

During the autopsy a note was made about lung congestion and the hemorrhagic appearance. Since Baby Alan was on life support it is possible that these findings were related to the conditions requiring that or to life support measures alone. However, it was known that during the few months of life Baby Alan suffered from respiratory problems and there is insufficient information, at this point, to permit an accurate opinion of the cause. The hemorrhagic appearance is, however, compatible with a bleeding/coagulation disorder.

During the autopsy the subdural hemorrhage showed liquid and clotted blood. At this stage there is insufficient information to enable one to clearly state the exact age of the bleeding. However, it was also noted that the clotted blood was slightly adherent to the dura. This could mean that the clot, in places was old and had formed what are known as 'neomembranes' - where a fibrous shell forms around the clot. This takes time to develop - certainly much longer than the period from the final collapse of Baby Alan and death. This issue is of prime importance. If neomembranes were present they demonstrate old hemorrhage - possibly dating from birth. Proper microscopic examination would cast some light on the age. It is known that these membranes may not be visible to the naked eye and may only be found with the aid of a microscope. A reference regarding this is quoted later in this report.

Once again, we are faced with a situation where the possible presence of evidence strongly supporting the defense was not looked for.

Failure to examine how easily the periostium strpped from the surface of long bones.
A serious omission, during the autopsy, involved the failure to examine the manner by which the periostium (what may be regarded as the 'skin' fixed to the surface of the bone) was attached to the bones. Normally this is not easily stripped (there is a variation in infants and adults). In scurvy it strips readily.
The reason for this lies in the fact that, in scurvy, collagen (connective tissue) is defective. So the normal strong bonds, which are a feature of collagen, are easily broken down. This also, of course, contributes to hemorrhages - when the walls of blood vessels readily break down.
Hess, page 95, summarizes the periostium abnormality:
The susbperiosteal hemorrhage has long been recognized as a lesion characteristic of scurvy…It may, however, involve almost any of the bones…It varies greatly in size, being confined to a small area or extending a long distance on the shaft of the bone…The periostium rarely becomes separated at the line of the junction of the epiphysis (growing end of the bone) and diaphysis (shaft of the bone). The underlying blood (that collects under the stripped periostium) coagulate rapidly (provided that a substantial coagulation/bleeding disorder (such as that caused by endotoxin) does not complicate the issue) and the periostium begins to calcify ('ossify or 'converted to bone') within a few weeks, as shown by the X-rays…
There seems to be some misconception as to the pathogenesis (cause) of the subperiosteal hemorrhage in scurvy. In most reports this lesion is described as if it resulted from a hemporrhage burrowing its way beneath the periostium and raising it from the adjacent bone. In point of fact, such an event is impossible, as will be fully realized when one experiences the great difficulty in separating periostium from normal bone. Scurvy involves a periostium which is not normal; it is insecurely attached to the shaft of the bone, so that it is readily stripped off by hemorrhage.
Sometimes, however, the epiphysis (growing end of the bone) is directly involved in scurvy. It can, in a fashion, 'fall, or break apart', or it may swell - as seen in the so-called 'beading' found, often, in the costochondral junctions (where the shafts of the ribs join the cartilages of the breastbone). There can be a substantial amount of hemorrhage involved in this process. If the periostium on the shaft is elevated at the same time, with underlying hemorrhage, the two hemorrhages coalesce, and as ossification proceeds, the entire area becomes involved in new bone formation. This can be easily mistaken as 'traumatically induced' - that is; as evidence of battering.

It is necessary, at this point, to note that other so-called 'classical' signs of scurvy bone changes need not be present when the pathologies, noted above, are found. That is; their absence does not exclude a diagnosis of scurvy. This great variability in the presentation of scurvy has been documented by Hess. Furthermore, much depends on precipitating factors, the length of time involved, and the possible involvement of endotoxin which was not seriously considered at the time that Hess made his studies.

Therefore, one cannot exclude a diagnosis of scurvy because all of the classical bone changes were not apparent.

Cause of death (according to the pathologist): Subdural hemorrhages due to shaken baby syndrome.

Comment, by Dr Kalokerinos, about this diagnosis of the cause of death
Without excluding causes of spontaneous hemorrhages, such as coagulation/bleeding disorders one is not entitled to arrive at this conclusion - unless there is clear evidence of shaking. That is; the existence of hemorrhages alone is not proof of shaking. It is necessary to demonstrate that a coagulation/bleeding disorder does not exist before a diagnosis of shaking can be established.
Lund et al, Ugeskr Laeger 1998 Nov;160(46):6632-7, states:
Shaken baby…A combination of subdural haematomas and retinal haemorrhages with minimal or no trauma is almost pathognomonic of the syndroma.
Note the word almost' is used - which means that other factors must be also considered.
Furthermore, as discussed later in detail, a normal standard coagulation profile does not totally exclude a coagulation/bleeding disorder. And it is possible for an infant to have a normal coagulation/bleeding profile and spontaneously bleed severely.
Br Med J (Clin Res Ed)1982) July 10;285(6335);133-134, states:
Severe bleeding disorders in children with normal coagulation screening tests.
Note that the word 'screening' is used. This is because only a limited number of tests are performed and those that are selected will detect the majority (and therefore, not all) of the abnormalities. Therefore, serious disorders may not be detected during screening tests.

This is the critical detail that one must understand before considering every other detail in this case. If this is not done it will be impossible to follow the evidence in a manner that will enable one to arrive at a logical verdict.
There will be a lengthy elaboration on this later in this report.

The autopsy report continues with some other findings:
A. Contusions, minor, on both temporal areas of the head.
B. Periorbital ecchymosis, (defined as 'an extravasation of blood into the subcutaneous tissues, discoloring the skin') right lower eyelid.
C. Subdural hemorrhage (defined as 'a collection of blood under the dura which is the outer layer, of three, coverings of the brain), fresh, right and left cerebral hemispheres, predominately right
D. Hemorrhage at the base of the brain
E. Subarachnoid hemorrhage (defined as 'blood under the arachnoid covering of the brain, which is the middle of the three coverings'), thin layer, biparietal (the right and left parts of the skull) areas minimal
F. All cranial bones intact
G. Subdural hemorrhage, lumbar and lumbothoracic region of the spinal cord.
H. Vertebral arteries and dissection of the neck - unremarkable.

Blunt force injury of the chest
The use of the word 'blunt' and the reasons why it is a misleading word have already been discussed.
A. Healing contusion, left lateral chest
B. Fractures of left ribs, partially healing 5,6,7 and 10 posteriorly.

Lungs - mildly hemorrhagic. Air passages clear.
Kidneys - very pale.
No hemorrhages at the thoracic, lumbar or sacral spine
Buttocks - no superficial or deeper contusions

Description of injuries (external)
Right, lower eyelid - a thin rim of ecchymosis. Pinkish in color and measures 1x0.2 cms.
On the left temporal area, slightly above and in front of the tragus of the left ear, there is a very pale area of contusion measuring 12x16mm. Its edges are irregular and appear diffuse. There is no change in coloration from pink to green to yellow, etc. The color in general appears a very pale, pink.
On the right temporal area there is a very pale contusion, of similar appearance, measuring 10x9 mm. The auricle of the right ear shows similar pale appearance, which is diffuse, and measures 15x4 mm. Its distribution is more towards the posterior surface of the middle portion of the right auricle. On the parieto-occipital regions (the parts of the head on the back of the sides) of the head bilaterally, the scalp shows a slightly pinkish discoloration of the skin. On the right side there appears to be a small impression mark from some medical monitoring device.

On the left lateral surface of the chest there is a very pale, slightly pinkish, ovoid, healing type contusion measuring 10x8 mm. It is located in the region of rib 7. Palpation of the chest does not reveal any evidence of subcutaneous emphysema.
Internal examination
On the left side of the chest, the following ribs showed irregular swelling, probably resulting from healed fractures: left rib 5, 6, 7 and 10. The fractures are located on the posterior and posterolateral surfaces of these ribs. X-rays are taken and confirm the presence and positions of these healing fractures. Multiple sections are taken for histopathological study.

Note that no report could be found in the notes provided to me about what was seen under the microscope when these ribs were examined. Nor was any attempt made to discover if the periostium (fibrous tissue 'skin over the bone surface) stripped easily - as it may do when scurvy is present.

Both lungs appear congested and show irregular areas of hemorrhagic appearance.

Systemic examination of the body.
Subdural hemorrhage, prominently seen on the right cerebral hemisphere, is noted. This hemorrhage is in liquid as well as clotted form, total weight is about 10 grams. There is subdural hemorrhage on the left cerebral hemisphere posteriorly. This hemorrhage is relatively less prominent as compared to the right. The dura mater of the cortex of the cerebral hemispheres shows thickened and slightly clotted blood adherent to the dura mater. At places the thickness of this clotted material is between 2-4 mm. The entire surface of the dura mater appears wet, and as mentioned previously there is liquid and clotted blood.
The brain is edematous, shiny and symmetrical. There are minor areas of subarachnoid hemorrhage seen in the cerebral hemispheres. One area of hemorrhage is located on the medial aspect of the parietal lobe measuring 3x2 cm. A similar small area of subarachnoid hemorrhage is also seen on the right cerebral hemisphere on the posterior parietal lobe.

Brain examination with Dr Pearl.
The brain appears very edematous, shiny and fluffy. There are areas of subdural hemorrhage which appear relatively fresh. There are minor areas of subarachnoid hemorrhage on the left parietal lobe. Serial cut sections of the brain do not show any internal hemorrhage in the brain parenchyma grossly. Cerebral edema is confirmed. Differentiation of the cortex and medulla appears poor. The ventricles are slightly reduced in size and the cerebrospinal fluid appears clear. The eyeballs are examined and these are also sectioned for confirming the presence of retinal hemorrhages.
It is noted that there is a small quantity of hemorrhage in the subdural space of the spinal cord representing the areas of thee lower thoracic, lumbar and sacral regions. At the base of the brain on the right side middle cranial fossa and the major part of the posterior cranial fossa on the right side contain a small quantity of blood. On the left side a very small portion of the left middle cranial fossa and the posterior cranial fossa show presence of blood.
Organs of the thoracic cavity.
Both lungs are congested. Externally, the lobes of the lungs show evidence of hemorrhages. On serial cut section both lungs show irregular areas of hemorrhages.

Comments (by Dr Kalokerinos)
The cause and nature of the lung hemorrhages need to be considered. One would expect, if the cause was trauma (fractured ribs) that there would be some damage to the pleura (covering of the lungs. And one would expect that the hemorrhages would be related to the ribs fractures. No evidence for this has been presented. Even if one assumes that a relationship with the rib fractures is 'apparent' then one must still exclude coagulation/bleeding disorders - particularly since it is known that spontaneous bone fractures, and elevations of the periostium with blood clots beneath the periostium, that became organized, then changed to bone, and resemble, in X-rays and scans trauma initiated fractures, are a feature of scurvy. Furthermore, the disturbances leading to scurvy (Vitamin C utilization and endotoxin) also may lead to coagulation/bleeding disorders. Therefore, the pathology under consideration need not be caused by shaking.

Organs of the abdominal cavity.
The kidneys show fetal lobulations and on serial cut section appear very pale.

Musculoskeletal system.
A few very pale contusions are noted on the bitemporal regions of the head. A very faint contusion is also noted on the left lateral side of the chest. The left 5th, 6th, 7th and 10th ribs show old healing or partially healed fracture sites. These fracture sites appear as globular masses of cartilaginous tissue. Cut sections of these healing fractures show normal appearance of the cartilage.

Comments (by Dr Kalokerinos)
Scurvy bone lesions heal in the same way that fractures heal. Furthermore, the note by the pathologist ('old and partially healed fracture sites) suggests to those who are not aware of other causes, very strongly, that this pathology represents multiple acts of abuse. To arrive at this conclusion one must exclude scurvy. The pathologist did not do that and, therefore, cannot justify his conclusion.

The pathologist detailed retinal hemorrhages. There is considerable confusion about these. Dr Gold stated (court records page 204), 'The right eye had diffuse scattered interretinal hemorrhages and preretinal hemorrhages meaning blood in the back of the eye. The left eye appeared to be normal.'
Dr Pearl stated (pag315), 'There was only one minute hemorrhage to the right eye only'.
Dr Gore stated (pages 271-272), 'There were minute hemorrhages in the retina…It was on the right eye.'.
Dr Shanklin noted one small retinal hemorrhage. More important was his observation of chronic inflammatory white cells - long standing in nature. He dates these changes to 'weeks, perhaps months'.
There is, therefore, room for controversy surrounding the nature of the retinal hemorrhages. This simply adds to the degree of difficulty when attempts are made to analyze the evidence.

Comments (by Dr Kalokerinos). These 'old' inflammatory changes are not characteristic of recent shaking. There are compatible with long standing inflammatory responses associated with infections (and almost certainly, endotoxin). It is also compatible with the diagnosis of infections, endotoxin, coagulation/bleeding disorders and scurvy.

Microscopic examination.
Lungs: The alveolar spaces are uniformly inflated with evidence of a few red blood cells and clumps of inflammatory cells. The inflammatory cell infiltrates are scattered throughout one section. There is no evidence of bronchopneumonia or lobar pneumonia. This picture appears somewhat similar to interstitial pneumonitis.

Comments(by Dr Kalokerinos). Interstitial pneumonitis is a complex condition. It is a diffuse (spread out) disease of the lungs and is a reaction to diverse 'irritations' that can be inflammatory in nature (for example, infections), but the cause is often obscure. The important issue is that the pathology is intraalvoar - that is there is infiltration (fluid or cells, for example) into the air sacs (alveolar spaces).
Causes are numerous. Included are infections, excessive fluid in the lungs, and hemosiderosis ( an iron containing substance, from broken down red blood cells), what is known as 'hypersensitive pneumonia' (allergic response). Whatever the cause, in Baby Alan, this represents an allergic/inflammatory response. It is not consistent with shaking.

Kidneys: The tubules show minimal vacuolation of the cells, consistent with an early degenerative change but no acute tubular necrosis is noted.

Brain: There is no evidence of inflammatory cellular infiltration. The two sections which are stained with H and E show presence of very minute parenchymal hemorrhages
One section of the cerebellum shows evidence of shearing type injury with multiple foci of minute hemorrhages.

Comment (by Dr Kalokerinos)
There is no detailed description of what is meant by 'evidence of shearing type injury'. The term, in itself, when used in this fashion can be misleading.
First; it assumes (and thus sows in the minds of those who are considering the evidence) a concept that dogmatically implies 'injury'. This is a serious error for several reasons:

1. The cause is not always an injury, (defining, 'injury', considered in this context, as 'something inflicted by a person').
2. Anoxia (lack of oxygen) can cause the condition
3. There is no detailed description of what was actually seen - just a 'diagnosis'.
4. The slides were not made available for examination in court.

Geddes et al, Neuro Pathol Appl, Neurobiol 2000, April 26 (2):105-16 states:
They have revealed a whole new field of previously unrecognized white matter (brain tissue) pathology, in which axons are diffusely damaged by processes other than head injury: this in turn led to some terminological confusion in the literature. This matter is detailed, further, later in this report.

Eyeball sections: The right shows definite evidence of minute retinal hemorrhage.
Spinal cord: Minute epidural hemorrhages are seen on the cord at C5 and C6 corresponding areas.

A serious omission
In the case notes provided to me I could find no reference to microscope reports on the rib fractures. A careful examination of the fractures may reveal evidence of scurvy-like changes. Many sections should be examined because the changes may be difficult to recognize. Related to this is the failure to examine the periostium of the ribs to see if it stripped easily, as it may do when scurvy is present. This has already been discussed.

CONCLUSION: (by the pathologist): This 2 month old black (should be 'white) male infant died as a result of Shaken Baby Syndrome. There are old healing fractures of the left ribs. Subdural hemorrhage is recent.

Comments (by Dr Kalokerinos).
The contusions - Discrepancies between what was documented before death and what was documented after death.
Therefore, there is no evidence that they existed before death, and it follows that the nature of the lesions and their ages must be carefully considered.
By definition, a contusion is an injury where the skin is not broken. A bruise is defined as an injury producing hemorrhage beneath unbroken skin.
These definitions are not absolutely specific because the word injury suggests just that - an injury. Hemorrhage beneath unbroken skin can be caused by a great variety of conditions apart from injuries - such as coagulation/bleeding disturbances. And bruises and contusions can overlap in nature.
Unfortunately, when these words are used in reports it is natural, for many non-medically trained, and some medically trained individuals, to immediately and totally imagine that the cause of the pathology is an injury.
So there are two things to consider -
1. The ages of the lesions and
2. Is there any evidence that suggests the presence of a coagulation/bleeding disorder and/or an inflammatory process?

Mason'stext book Paediatric Forensic Medicine and Pathology ISBN 0 412 29160 6, page 275, states:
"The age of bruises is a vital observation in child abuse, as the repetitive nature of the injuries is often the essence of the differentiation from accident. The colour changes of bruising are not a reliable guide as to their absolute age but the well-known sequence is useful in a relative way; bruises of widely differing hues cannot have been caused by the same 'accident' - as is often alleged by parents. The rate of colour change depends upon the size of bruise, its depth in the tissues and other idiosyncratic factors which differ from child to child. A small fingertip-sized bruise may pass through the spectrum of blue-red-brown-green-yellow to complete fading in 4-5 days, but more extensive collections of blood can last for two or three times that period. Histology may assist, but many of the claims of exact dating by cellular content cannot be substantiated. Bruises which are obviously of very recent origin may not require histological examination, but older lesions showing colour changes should be sampled: microscopic examination may, at least, show if the cell population is broadly similar or divergent in different bruises if dating becomes a controversial issue."

Faint or doubtful bruises seen on the skin should be incised to confirm or exclude bleeding in the subcutaneous tissues. In the case of Alan Yurko none of this was done. The evidence, though not totally conclusive, may have been significant.
Furthermore, because most of the lesions were not observed when Baby Alan was admitted, and during the period he was alive in hospital, one cannot exclude the possibility that the lesions developed after admission.
Since, from soon after admission, a diagnosis of 'abuse' (shaken baby) was made one would expect that a careful note would have been made of signs, such as bruising on parts of the body, that would (in theory) support the diagnosis. In other words, the fact that most of the bruises/contusions noted during the autopsy were not noted on admission is very significant.
There are other issues involved in this. A careful, microscopic examination (and, even better, an electron microscope study) may have revealed evidence of scurvy - such as changes in the blood vessel walls and connective tissue.
One detail is certain. That is; the possibility that the lesions were scorbutic in nature. If one does not look, then one will not find this. In view of other evidence that strongly suggests that scurvy was a factor the failure to look becomes an important issue.

[Part 8 missing and being requested--ed]

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