Overview

Introduction

In the wider sense, clinical forensic medicine means the application of clinical knowledge and skills to living individuals corresponding to the special needs of the respective legal, judicial and police systems. The organization of clinical forensic work differs considerably from place to place, partly depending on the legal situation (e.g. the so-called ‘adversary system’ of criminal procedure in the Anglo-Saxon tradition on the one hand and the ‘inquisitorial system’ in Continental Europe on the other). It is therefore impossible to deal with any regional peculiarities, and this article is necessarily confined to a general view of the main fields of work usually done by forensic medical examiners, sometimes also called ‘forensic physicians’, ‘forensic medical officers’, ‘police surgeons’ or ‘clinical forensic practitioners’. Table 1 shows typical reasons for their attendance although the focal points of demand may vary to a large extent.
From the topics listed in Table 1 it becomes obvious that clinical forensic medicine comprises a large spectrum of duties which are usually handled by doctors of several disciplines involving the medicolegal interface: legal medicine (as a ‘stand-alone’ subject in the undergraduate curriculum at medical schools of Continental Europe), forensic pathology, psychiatry, emergency medicine, pediatrics, gynecology, public health and others.
Some aspects of clinical forensic medicine are dealt with in dedicated articles and will not be discussed here.


Clinical Examination of Living Victims

Victims of an alleged crime or suspected perpetrators often have to be examined with regard to the presence of injuries. The observations and the medical report on the wounds is likely to play an important part in any subsequent legal proceedings. Therefore, the physical examination and the documentation of the relevant results must be performed in an adequate and accurate manner. Descriptions and conclusions should be phrased in terms which are also intelligible to lay persons. If scientific language is inevitable, an explanation must be given.
It is impossible to prescribe a standardized format to suit every case, as the circumstances differ so much. Apart from the actual examination procedures, it has to be decided if samples need to be taken (for instance blood for alcohol or drugs, genital swabs, urine, hair samples and so on). In most cases photography is helpful and desirable, especially in complex and patterned injuries. Sometimes even the absence of visible injuries might be important, e.g. in false allegations. For detailed recording of small marks such as tiny petechiae a magnifying glass or an operation microscope is necessary. Whenever possible, the whole body from head to toe including the genitalia should be minutely inspected in a good light. In order to prevent any reproaches it is recommended that a chaperone should be present whenever a male physician investigates a female patient.

Table 1 Categories of clinical forensic work

1. Examination of living victims:
(a) bodily injury due to criminal assault
(b) rape or other sexual crimes in adults
(c) physical and sexual child abuse
(d) spouse abuse and other kinds of domestic violence
(e) abuse of elderly persons
(f) torture
2. Examination of suspected perpetrators
3. Examination of self-inflicted injuries
4. Medical investigation in traffic accidents:
(a) examination of pedestrians
(b) determination of driver vs. passenger
5. Examination for fitness to drive:
(a) assessment of impairment to drive due to alcohol and/or drugs
(b) specimen taking (blood samples)
6. Assessment of the effect of drink and/or drugs on responsibility
7. Mental health assessment
8. Assessment of fitness to be detained and interrogated
9. Assessment of physical ability required for work
10. Reports, statements, expertise:
(a) written and photographic documentation of medical findings
(b) interpretation of wounds and other medical evidence
• conclusions as to the causation of injuries (e.g. which type of weapon has been used?)
• assessment of the severity of bodily harm and its dangerousness
• identification of offensive and defensive injuries
• medicolegal reconstruction of the circumstances and the course of events
11. Presentation of medical evidence in court:
(a) witness as to fact
(b) professional witness
(c) expert witness
12. Medical care of detainees:
(a) short-term custody (police)
(b) long-term custody (prison)
13. Health care of police officers
14. Determination of age
Each medical report should contain some basic information on the victim, i.e. size, stature, body weight etc. All remarkable findings must be recorded and their location defined in relation to easily identifiable marks or fixed body parts (e.g. the middle line and the distance from the sole in upright position). The size and shape of each wound should be detailed by precise measurement using a ruler or a tape measure. If there is a multitude of wounds, it might be advantageous to group them according to their kind and severity or to their location within anatomical regions. Body diagrams or sketches can be helpful.
The margins of each wound require close inspection and accurate description: whether they are lacerated or incised, whether they are shelved or excoriated, whether there is bridging or embedment of foreign material (e.g. soil, glass, paint). In addition, the examiner has to take note of the wound edges (sharp or blunt ends), of concomitant bruises and all other features which may help to distinguish between lacerations, incised wounds and other kinds of penetrating injuries. The condition of the wounds must also be assessed with regard to surgical treatment, infection and signs of repair.
Similarly, other types of external injuries such as abrasions and bruises have to be reported with reference to their location, size, shape and appearance. Sometimes characteristic details may be imprinted. In fresh abrasions the skin tags sometimes indicate the direction of the blunt force. Bruising mostly concerns the subcutaneous layer, often in combination with intradermal extravasations (Figs 1 and 2); the latter are patterned if the skin has been pressed and squeezed into grooves (for example by the impact of a rubber sole). Parallel ‘tram-line’ bruises derive from the impact of a stick or rod, which is of special importance in suspected physical child abuse. Nevertheless, it should be emphasized that most bruises do not have any characteristic shape. Immediately after contusion, the skin need not show any changes of color; in cases of suspected blunt trauma it is recommended to wait one or two days and to examine the victim a second time when extravasation has extended enough to become visible. It is well known that color changes occur within a few days so that the initially bluish-red bruise becomes greenish-yellow.
Bruises on the left thigh of a young woman from multiple=
Figure 1 Bruises on the left thigh of a young woman from multiple blows with a looped extension cord.
Surviving victim with numerous pellet injuries of the left upper arm and breast from a distant twelve-bore shotgun discharge without penetration of the thoracic wall.
Figure 2 Surviving victim with numerous pellet injuries of the left upper arm and breast from a distant twelve-bore shotgun discharge without penetration of the thoracic wall.
Some major points of external victim examination are specified in Table 2.
Injuries of SurvivingVictims and of Assailants FollowingAttempted Manual or Ligature Strangulation
One of the common tasks of police surgeons and forensic medical experts is to examine persons who are supposed or claim to have been strangled by hand or by ligature: for instance in sex-related offences such as rape, in attempted homicide and due to maltreatment in cases of domestic violence.
In manual strangulation the pressure on the neck is exerted externally by the hand(s) or the forearm resulting in occlusion of the blood vessels and the air passages of the neck. Most victims exhibit typical skin marks from the assailant’s throttling grip: discoid or confluent bruises from finger pads, abrasions from fingernails (crescent-shaped or scratches) and erythematous markings (Fig. 3). Nevertheless there are some victims who do not show any external evidence though there really has been an attempted strangulation: this may be true when the palm or forearm was placed over the neck and when a soft object, such as a garment or a pillow, was interposed during pressure. Prolonged gripping of the neck with concomitant occlusion of the cervical veins leads to congestion and petechial hemorrhages of the conjunc-tivae and on the facial skin, especially the eyelids (Fig. 4). Radiographs of the neck may reveal fractures of the hyoid bone and the thyroid cartilage; the incidence of such fractures is correlated with the extent of ossification mainly depending on the age and sex of the strangled person. Surviving victims mostly complain of pain on swallowing, on speaking and on neck movement. Other possible symptoms following attempted strangulation are unconsciousness and sphincter incontinence.

Table 2 Important external findings in physically injured victims of criminal assaults

Body region Findings Kind of traumatization
Head Excoriation Blunt trauma to the soft tissues (e.g. kicks, blows from fists, flat hands
Bruising or weapons, striking of the head against hard surfaces)
Laceration of the scalp or face
Bleeding from the ear Closed blows to the ear, fracture of the base of the skull
Bleeding from the nose Contusion or fracture of the nose, fracture of the base of the skull,
severe strangulation
Petechiae in the eyelids, conjunctivae Manual strangulation, ligature strangulation, traumatic asphyxia
and facial skin
Bruising or laceration of the lips, loose or Blow to the mouth
damaged teeth
Neck Discoid bruises, fingernail marks, Attempted manual strangulation
scratches
Ligature mark Attempted ligature strangulation
Intradermal bruising from folds of cloth Neck holds or locks
Incised wounds Sharp force (cuts, slashes, stabs)
Trunk Abrasions, contusions Blunt trauma
Tram-line bruising Impact of a rod or similar object
Patterned abrasion or intradermal Impact of an object with a profile surface (e.g. rubber sole)
bruising
Bite marks (two opposing bruises/ Bites (child abuse, sexual assault)
abrasions) from the dental arches
Brush abrasion (‘grazes’) Tangential contact with a rough surface (caused by dragging)
Penetrating wounds:
• Incised wounds Sharp force (stabs)
• Shot wounds Projectile trauma
Limbs Fingertip bruises (especially on the Gripping or prodding
medial aspect of the upper arm)
Stab wounds and cuts (defense injuries) Knife attacks
Bruises and abrasions on the back of the Attack from blunt instruments, fists or feet
hand and on the outer sides of the
forearms (defense injuries)
Circumferential contusions of the wrists Restraining by handcuffs, tying of hands or feet
or ankles

In ligature strangulation, the pressure on the neck is effected by a constricting object (telephone cord, nylons, stockings, belt, towel, scarf) tightened around the neck by a force other than the body weight. The appearance of the skin mark is influenced by the nature of the ligature (width, roughness, surface pattern), the force and duration of the strangulation, and the interaction with a resisting victim (displacement of the noose in attempts to remove it). The ligature mark usually encircles the neck horizontally (Fig. 5); in typical cases the skin reveals a transverse streak-like reddening caused by local erythema often associated with (partial) loss of the epidermis. Congestion and petechial hemorrhages above the ligature are usually more impressive than in victims of manual strangulation. On the other hand, damage to the hyoid or to the laryngeal cartilages is less common.
Suspected assailants may present examination findings indicative of possibly having been the offender in an attempted strangulation. The most frequent injuries seen in throttlers are nail marks inflicted by the opposing victim. Nail marks have been classified morphologically into three types: impression marks, claws and scratches. The majority of the skin lesions are located on the dorsal aspects of the forearms and hands; other classical sites are the face, neck, shoulders and anterior chest wall. Another typical kind of injury, especially seen in rapists, are bite marks on the hands. If a struggle takes place, the assailant may sustain nonspecific blunt trauma from blows or from wrestling with the victim.
Neck of a rape victim with roundish bruises and scabbed abrasions from attempted manual strangulation.
Figure 3 Neck of a rape victim with roundish bruises and scabbed abrasions from attempted manual strangulation.

Medical Hazards in Police Custody

Even in countries with a high standard of health care of detainees, some deaths do occur in police cells and in prisons. A large number of custodial deaths are due to natural causes, mainly from cardiovascular diseases, which account for the great majority of sudden and unexpected deaths. Another category of fatalities concerns suicides, mostly committed by hanging. In prisoners with suicidal tendencies it is therefore recommended to remove any objects that could be used for attempted strangulation like belts, ties, stockings and bootlaces. In spite of all precautions of the custodians, some detainees manage to find devices suitable for strangulation such as strips of bedding material or clothing.
Wrist cutting is another self-injurious behavior frequently seen in police custody, either as (attempted) suicide or as self-harm without intention to die. Incised wounds may be inflicted with any sharp-edged instrument such as a piece of glass or sheet metal from a tin. Risk factors associated with self-injurious behavior include the custodial setting itself (especially in isolation cells), being under the influence of alcohol and drugs at the time of incarceration, the availability of means for self-destructive behavior and many others.
A detainee who is suspected of being drunk and/or drugged at the time of committal needs particularly close observation. If the prisoner has consumed a large quantity of ethanol or (illegal) drugs just before arrest, he or she may be conscious and responsive at first, but he may become comatose later and die from acute alcohol or drug poisoning while he erroneously is thought to be sleeping off his drunkenness. This is not only true for ethanol ingestion but also for narcotic drugs (mostly heroin, methadone and codeine). The victims do not necessarily die from the depressive effects upon the brain (especially the respiratory center); in a high percentage, a secondary aspiration of vomit is found as the immediate cause of death.
Petechial hemorrhages on the skin of the eyelids and subconjunctival (scleral) hemorrhage in the medial angle of the left eye (one day after having been throttled).
Figure 4 Petechial hemorrhages on the skin of the eyelids and subconjunctival (scleral) hemorrhage in the medial angle of the left eye (one day after having been throttled).
Sharply defined ligature mark encircling the neck in a horizontal plane; the victim had been strangled with a shoe-lace three days before examination.
Figure 5 Sharply defined ligature mark encircling the neck in a horizontal plane; the victim had been strangled with a shoe-lace three days before examination.
Alcohol is an important causal factor in aggression and violent resistance frequently leading to the arrest of the suspect. Physical overpowering of an offender involves the risk of inflicting injuries. In other cases the person concerned may have sustained injuries due to falls or assaults before the police officers could intervene. It has to be stressed that even a fatal blunt trauma is not always associated with externally visible signs such as bruises, abrasions or lacerations. The authors had to give opinions on several custody deaths due to blunt head injuries without any wound or palpable swelling; the (deep) bruise on the site of impact became visible only when the inner aspect of the scalp was inspected during autopsy.
Severe and ultimately fatal head injuries need not be associated with unconsciousness in the early post-traumatic period. In persons developing an epidural or subdural hematoma, the symptoms due to the elevated intracranial pressure may set in only after a ‘lucid interval’ of several hours so that they are falsely thought to be uninjured. From this it follows that cases of suspected cranial trauma require close observation and the possibility of rapid transfer to a hospital.

Torture

According to the 1975 Tokyo Declaration of the World Medical Association, torture is defined as the deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.
Torture has to be criticized as a particularly reprehensible offense against human rights, nevertheless it does exist in numerous countries throughout the world. Within the scope of this article, only a few medicolegal remarks on the physical manifestations of torture can be made. Unfortunately, often there is a long delay before medical examination so that conclusions as to the causation may be difficult because of the unspecificity of most scars.
Beating is probably the most common form of torture. Apart from kicks and blows from fists and flat hands, a great variety of weapons and instruments are used to inflict pain (for instance rifle butts, clubs and whips). When the body is struck by a rod or a similar object, each impact causes a double line of parallel bruises. Patterned abrasion or intradermal bruising may reflect characteristic details of the weapon’s surface. Series of skin marks arranged in approximately the same orientation point to an unchanged position of the attacker in relation to the helpless (held or tied) victim. Heavy blows to the face are typically followed by peri-orbital hematomas (‘black eyes’), extensive bruises and excoriations of the other facial regions, laceration of the lips and displacement of incisors, fractures of superficial bones (nasal bone, zygomatic bone, jaws). The other main targets of beating and whipping are the back, the buttocks, the legs and the soles of the feet, the abdomen, the breasts and the genitals which are also pinched and squeezed. Physical abuse other than blunt traumatization can only be mentioned briefly: cutting, piercing and stabbing, hair pulling, burning with cigarettes, repeated dipping of the victim’s head under water, applying electric current, suspension and sexual abuse.

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