Book Review

Physical Signs of Child Abuse: A colour atlas

N Engl J Med 1996; 335:983-984September 26, 1996

Article

Physical Signs of Child Abuse: A colour atlas
By Christopher J. Hobbs and Jane M. Wynne. 245 pp., illustrated. Philadelphia, W.B. Saunders, 1996. $77. ISBN: 0-7020-1778-7

Hobbs and Wynne state that this photographic atlas represents a unique way of recording some of their accumulated experience. Of the 140 pages in the book, 9 contain text and tables. A total of nine references are cited, of which three are the authors' prior publications, two are guidelines from professional associations, two are articles in refereed journals, and two are textbooks.

The book has four main sections, covering techniques of examination and photography, physical abuse, neglect and emotional abuse, and sexual abuse. In the first section the authors summarize what they consider most salient with regard to soft-tissue injuries, fractures, intracranial and abdominal injuries, and sexual abuse. The text on each form of maltreatment is brief (10 sentences or less) and lacks appropriate citations to the literature. The diagnostic findings of sexual abuse are summarized in a three-page table that notes the site of the finding, the lesion, a description, and the cause. The authors' distillation of diagnostic medical findings of inappropriate sexual contact into a table is an apparent effort to simplify the complexities of formulating an objective, forensically defensible diagnosis, and it should be viewed with extreme caution. Terms such as “flattened labia,” “stretched hymenal orifice,” “disorganized fleshy hymen,” “cotton like,” “gaping vagina,” and “funneled,” which appear in both the tables and the text, are not only imprecise and idiosyncratic, but also underscore the authors' avoidance of scientific references and readily available consensus on acceptable terminology (Practice Guidelines: Descriptive Terminology in Child Sexual Abuse Medical Evaluations. Chicago: American Professional Society on the Abuse of Children, 1995).

The remaining sections of the atlas consist of photographs, reflecting the authors' belief that “one photograph can say as much as a thousand words.” The atlas is constructed in this spirit. The photographs and charts accompanying the case studies are technically excellent. Each photograph is accompanied by what the authors describe as a “thumbnail sketch.” Unfortunately, however, these brief descriptions do not help the reader understand how or why the authors interpreted the findings as they did, except in the few cases in which the photographs speak for themselves. The authors must have assumed that users of the atlas would simply accept their experiences and thus their interpretations at face value.

Many diagnostic mistakes have been made when clinicians new to the field of child abuse merely accepted what a more experienced colleague stated as dogma. The field has matured, and critical questions about the interpretation of trauma due to abuse are being answered through rigorous research. Unfortunately, this atlas ignores interpretations based on research and is thus not only limited in its usefulness but also potentially dangerous for the inexperienced examiner. Its most important shortcomings are evident in the section on sexual abuse, where many nonspecific findings, such as erythema, pigmentary changes, venous pooling, labial agglutination, and hymenal bumps, are interpreted as diagnostic of sexual abuse. Many photographs in this section should be interpreted with great caution, and some in a way that differs completely from the interpretation the authors give.

Child abuse can be very difficult to diagnose, and generally the collective wisdom of professionals from a variety of disciplines is required. Except for some of the obvious burn patterns, skin injuries caused by implements, and genital injuries the atlas shows, appearances alone are inadequate for ascertaining whether an injury was accidental or inflicted. It is unusual for the appearance of an injury to say as much as a thousand words. When it does so, in fact, the expertise of a child-abuse clinician is probably unnecessary.

A diagnostic assessment of child abuse requires a careful review of information provided by child-protection workers, law-enforcement officers, and mental health professionals. This supplements the physician's history taking, physical examination, laboratory results, radiographic imaging, and any necessary subspecialty consultation. In cases of physical abuse, investigating a crime scene may be critical in determining the plausibility of the history and deciding whether the injury can be judged to be accidental or inflicted. The authors give no insight into these complexities. None of the photographs of injuries caused by physical abuse show the use of a forensic measuring scale, a technique particularly important in identifying bite marks. When cutaneous injuries caused by implements are shown, a photograph of the implement would have helped explain the pattern of trauma. Many photographs of genital injuries show the examiners' hands ungloved — not the right message to send in a modern textbook.

Have the authors achieved their objective of providing a “detailed account of the common physical signs seen in abused children”? Although much work went into developing this atlas, undoubtedly a reflection of the authors' concern for the abused children they serve, the atlas fails to demonstrate the complex diagnostic issues that clinicians grapple with each day. Simplifying the diagnosis of child abuse to a photograph and thumbnail sketch diminishes the work of those who strive to provide scientific data for use in this field. There can be true advocacy on behalf of abused children only when the professionals working with victims use scientifically derived diagnostic criteria as the basis of their decisions. This atlas does not meet that test.

Martin A. Finkel, D.O.
University of Medicine and Dentistry of New Jersey, Stratford, NJ 08084-1504