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Medical criminalistics
Forensic Science International 165 (2007) 144–149 www.elsevier.com/locate/forsciint
Medical criminalistics S. Pollak * Institute of Legal Medicine, University of Freiburg, Albertstraße 9, 79104 Freiburg, Germany Received 23 April 2006; accepted 10 May 2006 Available online 5 July 2006 Dedicated to Prof. Dr. h.c. mult. Otto Prokop on the occasion of his 85th birthday
Abstract Medical criminalistics is an essential part of legal/forensic medicine. It includes the clinical examination of surviving victims and suspects, the inspection of the scene in suspicious deaths with subsequent performance of medico-legal autopsies, the assessment of (biological) traces and the reconstruction of criminal events under medical aspects. Just as the circumstances of life and the manifestations of crime are changing with time, there is a permanent alteration regarding the issues of medical criminalistics. Legal/forensic medicine is a university subject in most countries and therefore, research work is one of the main tasks also in medical criminalistics. In contrast to clinical medicine and basic research, some common study designs are not suitable for the special needs of medical criminalistics, whereas other types are more appropriate like epidemiological evaluations, cross-sectional studies and (retrospective) observation studies. Moreover, experimental model tests and case reports also rate high in medical criminalistics. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Medical criminalistics; Legal medicine; Clinical forensic medicine; Medico-legal research
1. Introduction Criminalistics is regarded as a speciality within the field of forensic sciences. According to a definition by the California Association of Criminalists, criminalistics is the profession and scientific discipline directed toward the recognition, identification, individualization and evaluation of physical evidence by application of the natural sciences to law-science matters [13]. Traditionally, legal medicine also covers many fields of activities belonging to forensic sciences. Apart from its academic tasks as a university subject in most countries, legal medicine deals with ‘‘the application of medical knowledge in the administration of justice’’ [24]. Legal medicine and criminalistics are closely related because both are oriented towards forensic needs. Therefore, it is not surprising that the responsibilities of both disciplines differ from country to country. Even in one and the same legal system, the relationship between legal/forensic medicine and criminalistics is subjected
* Tel.: +49 761 203 68 53; fax: +49 761 203 68 58. E-mail address: [email protected]. 0379-0738/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.forsciint.2006.05.014
to time-related changes [33]. In Germany after World War I, Kockel [23] was of the opinion that forensic chemistry and criminalistic technology should be integrated into legal/ forensic medicine. For some time, the university institutes carried the double name ‘‘Forensic Medicine and Criminalistics’’, although objections were raised at that time already – and rightly so – against the ‘‘encyclopaedic’’ claim of a comprehensive competence of the medico-legal expert [41]. As Schwerd [45] and Berg [1] correctly stated, medical criminalistics is a natural part of legal medicine. It includes the examination of victims and suspects and the investigation of traces to reconstruct the course of events and legally relevant facts under medical aspects, especially interpretation of findings in suspicious deaths, inspection of the scene and assessment of biological stains. To make students familiar with criminalistic thinking and working methods is an important objective of academic teaching and post-graduate training of specialists in legal medicine. No matter how the scope of practical medico-legal work is defined, the reconstruction of events has always been a specific feature and domain of legal medicine. Contrary to pathology, which concentrates on the diagnosis of diseases and causes of death, legal medicine uses the diagnosis as a starting point to
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reconstruct what happened. For example, the main purpose of forensic autopsies is not so much to determine the cause of death as such, but to clarify legally relevant circumstances and contexts (determination of the approximate time of death, differentiation between self-inflicted injuries and lesions caused by another person, analysis of wound findings with regard to the object used, recognition and interpretation of trace material, etc.). The evaluation of gunshot wounds as to number and localization of hits, line of fire, firing range, weapon and ammunition used, self-infliction or involvement of another party, effect on the capability to act, etc. is an example how the purpose of an investigation goes beyond purely medical findings to criminalistic and juridic questions of evidence. 2. Study designs and methods As far as medico-legal institutes are affiliated with a university, they belong to the medical faculty in most cases and are often integrated into a university hospital. In that environment, clinical research is the predominant field, which is focussed either on basic research or on the study of diseases and patients, respectively. Most of the methods used for these activities are applicable to legal medicine in general and medical criminalistics, in particular, on a rather limited scale only [27]. Neither the basic research using biological systems and animal models nor the clinical trials prescribed for the registration of new drugs are consistent with the needs of medical criminalistics. Some study designs, which play an important role in medical and therapeutic research (controlled, randomised clinical studies, cohort studies, case–control studies), are not suitable for medical criminalistics because the forensic material is completely different. Other study types are better suited for the specific circumstances in forensic medicine, for example, prospective cross-sectional studies, retrospective observation studies and case reports. For certain subsections of the field (e.g. thanatology, determination of wound age), longitudinal studies are also necessary to describe and quantify time-related changes in the findings [28]. In those areas in which laboratory techniques are to be established for the recording of new parameters or the optimization of existing procedures, validation of the methods is of special significance. For medical criminalistics, which is the main topic of this article, the comparative phenomenology of exactly defined study groups is essential. The evaluation of current case series gives an authentic picture of the criminalistic phenomena in homicides and bodily harm. The development and statistical confirmation of morphological criteria help to characterise typical patterns of findings. Thus, it is possible, for example, to supply evidence-based evaluation tools for differentiation between self-inflicted injuries and injuries caused by another person. The important role played by case reports in the field of medical criminalistics will be described in greater detail below. Nevertheless, forensic research must go beyond the description of unusual individual observations [48]. Many questions cannot
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be answered by experience alone, but require experimental research. Experiments performed on appropriate test models to clarify the biomechanical basis of injury formation are such an example. 3. Questions to be answered Medico-legal research draws an essential part of its ideas and questions from practical forensic work. Moreover, the findings and data collected for expert opinions constitute the basis for an empirical approach to research. Without the study material of medico-legal routine work, no new findings could be obtained in many forensically relevant areas. On the other hand, the close relation to university medicine ensures a high scientific standard and independence. Without proper research activities, legal medicine and thus, medical criminalistics would rapidly fall behind the general scientific progress. From the multitude of research subjects, only a few can be dealt with in this context. The collection of epidemiological data, which is possible only on the basis of medico-legal practice, is of importance for the society and legal policy in general. This applies, for instance, to the frequency of certain crimes, such as infanticide [47] or to the number of drug victims depending on different offers of therapy. The results of such investigations also help to elucidate health risks. For example, a medico-legal multicenter study on the HIV prevalence in drug victims demonstrated that the intravenous drug consumption is one of the main causes of HIV infections in Germany. In the course of the observation period (1985–1994), the prevalence level declined from 29% to about 7% [26]. The medico-legal monitoring, thus impressively demonstrates the success of educational campaigns and the importance of prophylactic measures to prevent an infection by sharing unsterile needles. Systematic research of sudden infant death was and still is also essentially conducted by the institutes of legal medicine [12], as in most of these cases both the manner and cause of death are unclear, so that infanticide cannot be ruled out from the very beginning [2,8]. Dettmeyer et al. [7] and other authors have dealt with this topic in greater detail. An important aspect of medico-legal publications is to direct the attention of criminalists to diagnostic problems. Serial killings in hospitals and geriatric care may serve as an example. Knowing the relevant methods, which do not necessarily leave any external injuries on the often multimorbid patients, is an important prerequisite to become suspicious and to induce the performance of an autopsy [30]. The old question, how many homicides are not recognized, was tried to be answered by a joint study of 23 institutes of legal medicine [5]. Among 13,000 autopsies of the study material, 92 ‘‘discoveries by chance’’ were reported where a natural death was given on the death certificate. These cases comprised 49 fatal accidents, 10 homicides and 19 deaths from medical complications. On the basis of this multicenter study, it was estimated that there are at least 1200 homicide cases per year which do not appear in Germany’s official statistics, as they are classified as natural deaths.
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From the large number of criminalistically relevant questions, which can only be clarified by systematic medicolegal investigations, I would like to give a few examples from the field of gunshot injuries. Numerous studies deal with typical and atypical entrance wound localizations in suicides and homicides. The view often taken in older textbooks that suicides almost regularly uncover their chest before firing a shot to the heart, was disproved by Karger et al. [19]. The question of a victim’s ability to act is particularly important for reconstruction purposes. It has been shown that immediate incapacitation is to be expected only if central nervous structures essential to physical activity are affected. Thus, multiple gunshot suicides are possible if the first shot did not injure a target of immediate incapacitation [17,35]. According to investigations and observations of Krauland [25], a weapon found in the hand of the deceased does not necessarily speak against a suicide if there are special circumstances explaining this finding. Another phenomenon of high criminalistic importance is biological ‘‘backspatter’’ and its possible deposition on the perpetrator depending on the shooting distance [20]. Clinical forensic medicine is subject to time-related changes which have to be described and analysed on the basis of the current evaluation material. This is true for sexual offences, forensic psychopathology, child abuse, domestic violence, torture, injuries from traffic accidents, bodily harm, attempted homicide and self-inflicted injuries. In the last-mentioned group the simulation of criminal offences has become a challenging topic with many different categories and manifestations [37]. Among the manifold forms of physical child abuse, the so-called Munchausen syndrome by proxy has been increasingly observed during the last 3 decades [49]. Astonishingly, even in ‘‘standard fields’’ of injury evaluation, such as stab and cut wounds, new questions may be raised concerning the specifity of wound patterns indicating either a knife attack by another person or selfinfliction. Thus, a cut on the palmar side of a hand does not necessarily mean a defence wound, as it can also be selfinflicted unintentionally by the offender when the knife is vigorously thrust and hits a solid resistance so that the hand slides from the hilt onto the blade [43]. In contrast to most autopsy studies, there is no predominance of defence injuries on the left forearm and hand, when looking at surviving victims of sharp force [44]. Other problems, which can only be mentioned briefly in this context, refer to the diagnostic significance of findings associated with survived and fatal strangulation. As is well known, congestive petechial haemorrhages do not constitute a specific sign of asphyxia as they also may occur during physiological processes of pressing [34]. Up to now, there is no generally accepted opinion concerning the minimum time necessary for the manifestation of congestive haemorrhages. Another controversial issue is the practical relevance of possible vagus-mediated consequences (‘‘reflex cardiac arrest’’). It is obvious that apart from the examples given above, a large number of further forensically relevant questions have to be solved on the basis of indisputable evidence.
4. Appropriate methods Legal/forensic medicine is an applied science in which experience plays a role that is difficult to overestimate. Because of sociocultural, legal and organizational factors, the material examined by the medico-legal experts shows considerable variations, and knowledge will still be incomplete also after many years of vocational training. To correctly interpret morphological findings, it is extremely important to train the ‘‘diagnostic eye’’. Visual memory often sets the course of the analysis of an individual case, even if additional examinations using technical equipment and the application of natural science are necessary later [36]. In spite of the wide variability of phenomena and external circumstances, medical criminalistics is frequently faced with similar, sometimes stereotypic patterns of findings, which derive from archetypal modes of behaviour in the commission of crimes and suicides [38]. For these reasons, it seems not only justified but advisable to publish instructive photographic material of general importance in the form of an atlas, as it has already been done in the late 19th century by von Hofmann [16]. An interesting tool for discrimination between homicides and suicides was presented by Karlsson who used multivariate projective statistical models in sharp force fatalities and in deaths from firearms [21,22]. By analysing a great number of solved forensic cases, he created a model to find out predictive criteria whether a certain fatality shows similarities to homicide or suicide. Afterwards, the statistic model was validated on new sets of authentic cases. This approach has an impressively high sensitivity and specifity regarding its ability to identify homicides. The predicting variables are ranked according to their covariation with homicide or suicide. Other mathematical models can help to simulate the optical properties of human skin to identify the status of haemoglobin and to recognize carbon monoxide poisoning by means of reflection spectrometry [3]. An important tool for the epidemiological evaluation of autopsy data is the introduction of autopsy registers. These should cover all forensically investigated deaths of a country to allow representative statements as to the kinds of unnatural death and the persons involved. Another advantage of such a centralized database is that rare events, such as intoxications with plant or animal toxins are recorded in one and the same place, and thus, become available for scientific collaboration. In Germany, the project of a national forensic autopsy register was initiated in January 2004 and has meanwhile been implemented in almost all parts of the country [4]. Before the project could be realized, conformity with data protection regulations and clear rules, who would be authorized to use the register had to be assured. The scientific activities are coordinated by a committee operating under the roof of the German Society of Legal Medicine. As most of the other sectors of legal medicine, medical criminalistics is also dependent on experimental research. The number of methods used is so large and manifold that only a few can be mentioned here. A special challenge is the systematic analysis of morphological findings for the purpose
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of achieving a better understanding and more reliable interpretation (e.g. with regard to the underlying trauma and the causative mechanisms, the specifity of changes, the probability of incidence, the influence of contributing factors). Some examples from the field of forensic wound ballistics may illustrate this: simulants, such as gelatin and transparent glycerin soaps turned out to be appropriate target media as their behaviour is similar to that of human organs and soft tissue from a physical-ballistic point of view [35]. There is a high level of comparability between damage to the simulants and injuries to the human body. Several working groups have developed composite models in order to carry out replicable firing experiments, but also to reconstruct crime-related injuries [15,31]. Bone tissue has been simulated by coated polyurethane [46]. Composite models of pig skin and gelatin blocks have been used to demonstrate the gunshot-related transfer of skin particles along the bullet path and the transport of microorganisms from the entrance and exit region into the wound channel [14,50]. 5. Case material Case reports are an important type of publication in forensic medicine. Most international journals accept such papers if they contain relevant new information gained by thorough investigation of exceptional cases. In contrast to other medical disciplines, it is not unusual that in forensic medicine new findings are first described within a case report. Until recently, many reputed representatives of medical criminalistics wrote a large part of their scientific work in the form of case reports. The ‘‘Archives of Criminology’’ (in German: Archiv fu¨r Kriminologie), probably the oldest still existing scientific journal of its kind, is a good example for a platform which cultivates the tradition of bringing together specialists of different forensic sciences [40]. Solving complex criminal cases often requires interdisciplinary cooperation. If fatalities are concerned, participation of medical criminalistics is obligatory. So it is not surprising that about four-fifths of the articles published in ‘‘Archives of Criminology’’ are written by authors from institutes of legal/forensic medicine. Approximately, half of these contributions are case reports. Case reports have an important function in forensic literature. By describing individual observations, new injury patterns and causes can be presented. Some forms of physical child abuse, generally known today, such as shaken-baby syndrome, Munchausen-by-proxy and battered-child syndrome, were described in the scientific literature only some decades ago, although they probably existed long before. In self-inflicted injuries to simulate criminal offences a timerelated change in the phenomenology has occurred so that it seems useful and necessary to publish reports on new forms of manifestation. Apart from the usual features of self-infliction, nowadays persons simulating fictitious offences sometimes carve strange motifs, such as swastikas or other symbols into their skin [10]. Case reports on methods of homicide, which are rare or leave few external traces do not only help to make such events
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known, but underline the necessity of careful autopsy taking into consideration all diagnostic alternatives. This applies, for example, to deaths where the body is found suspended: forensic literature is abundant in reports on homicides by hanging and the simulation of suicide by hanging a victim previously killed or made unable to resist [29]. Similar difficulties may be involved in cases of homicide by electricity [32] or killing helpless persons needing care by instilling water into the respiratory tract [30]. Suicides can also be committed in such unusual ways that a publication is justified under criminalistic aspects. 6. Analysis of results The study designs and experimental investigations mentioned under Section 2, require the application of relevant statistical or biometrical methods, which cannot be elaborated here. Especially for prospective cross-sectional and retrospective observation studies, it is essential that the basis of the data and the study material are clearly defined, thus allowing to confirm or qualify the diagnostic significance of certain findings. This was shown by Prokop and Wabnitz [39] in their study on the occurrence and frequency of conjunctival petechial haemorrhages in surviving and dead victims. The authors were able to demonstrate that such congestive bleedings occur not only in deaths from asphyxia, but also in fatalities from electricity (12.5%), carbon monoxide poisoning (2.3%) and in sudden coronary death (4.3%). Even in the ‘‘classical’’ fields of medical criminalistics, many questions have not yet been sufficiently clarified. For example, it was only in 2002 that Karger et al. [18] found out after performing systematic case analyses that some bullet path directions cannot be considered indicative of suicide: downwards and back-to-front in gunshots to the temple, left-to-right in gunshots to the left chest and downwards in mouth shots. Quite recently, Faller-Marquardt et al. [9] demonstrated in a targeted analysis of a large autopsy material that in nearly all contact shots to the cerebral cranium, the periosteum around the bullet entrance hole is detached and reflected with soot on the underside. Another finding largely ignored for a long time is the occurrence of stretchmark-like skin tears away from the entrance wound in gunshots to the head. This phenomenon is caused by the subcutaneous or intraoral expansion of the muzzle gases and/or the radial forces of the bullet resulting in ballooning and overextension of the facial soft tissues [11]. 7. Ethical issues According to the requirements of most biomedical journals, it must be ensured that all human studies were approved by the competent ethics committee and were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki as amended. Reports on animal experiments should state that the ‘‘Principles of laboratory animal care’’ (NIH publication No. 85-23, revised 1985) as well as specific national laws were followed where applicable. Of course, case reports must be anonymised before publication so that the described
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person cannot be identified. Unfortunately, this rule is not always observed in photographs. An important contribution to achieve more transparency is the frank and open discussion of controversial issues. For this purpose, so-called letters to the editor, in which the readers have the opportunity of expressing their comments on new results reported in a scientific journal, is an excellent tool. 8. Quality control If an application for a public grant is made, quality control begins even before the study is started, as the project is usually subjected to critical assessment by relevant experts. A second control takes place when the results of the study are published in a peer-reviewed journal. Even congress contributions are often assessed on the basis of the submitted abstracts before being taken up into the programme. The discussions after oral reports and poster presentations are another corrective tool helping the scientific community to ensure that the rules of honesty and conscientiousness in research are observed. An additional instrument for self-critical analysis of possible errors in scientific work is to make them a topic at conferences and in journals. In forensic routine work, the participation in interlaboratory tests, the official certification of institutes and the implementation of general investigation standards (e.g. harmonization of medico-legal autopsy rules [6,42]) would help to arrive at a higher quality level. 9. Prospects The aim of medical criminalistics is to improve the scientific armamentarium necessary for the elucidation of crime and for related forensic applications at a high level of evidential value. Legal medicine can fulfil its important tasks with the necessary competence only, if the further existence of medico-legal institutes with a clear focus on research is guaranteed. Then it will be possible also in the future to supply the latest medical knowledge to the administration of justice as a strong partner of criminalistics. References [1] S. Berg, Kriminalistik und Rechtsmedizin, in: E. Schlu¨chter (Ed.), Kriminalistik und Strafrecht. Festschrift fu¨r Friedrich Geerds, SchmidtRo¨mhild, Lu¨beck, 1995, pp. 425–439. [2] M. Bohnert, M. Große Perdekamp, S. Pollak, Three subsequent infanticides covered up as SIDS, Int. J. Legal Med. 119 (2005) (Suppl. 2) 31–34. [3] M. Bohnert, R. Walther, T. Roths, J. Honerkamp, A Monte Carlo-based model for steady-state diffuse reflectance spectrometry in human skin: estimation of carbon monoxide concentrations in livor mortis, Int. J. Legal Med. 119 (2005) (Suppl. 2) 355–362. [4] H. Bratzke, M. Parzeller, F. Ko¨ster, Projektstart 2004: Das Deutsche Forensische Sektionsregister, Rechtsmedizin 14 (2004) (Suppl. 2) 371. [5] B. Brinkmann, S. Banaschak, H. Bratzke, U. Cremer, G. Drese, et al., Fehlleistungen bei der Leichenschau in der Bundesrepublik Deutschland, Arch. Kriminol. 199 (1997) (1–12) 65–74. [6] Council of Europe, Recommendation No. R (99) 3 of the Committee of Ministers to Member States on the Harmonisation of Medico-Legal Autopsy Rules, Strasbourg, 1999.
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[42] P. Saukko, S. Pollak, Postmortem examination. Procedures and standards, in: J.A. Siegel, P.J. Saukko, G.C. Knupfer (Eds.), Encyclopedia of Forensic Sciences, vol. 3, Academic Press, London, San Diego, 2000 , pp. 1272–1275. [43] U. Schmidt, M. Faller-Marquardt, T. Tatschner, K. Walter, S. Pollak, Cuts to the offender’s own hand – unintentional self-infliction in the course of knife attacks, Int. J. Legal Med. 118 (2004) (Suppl. 2) 348–354. [44] U. Schmidt, S. Pollak, Sharp force injuries in clinical forensic medicine— findings in victims and perpetrators, Forensic Sci. Int. 159 (2006) (Suppl. 2) 113–118. [45] W. Schwerd, Gerichtliche Medizin und Kriminalistik, Z. Rechtsmed. 102 (1989) (Suppl. 2) 421–428. [46] M.J. Thali, B.P. Kneubuehl, U. Zollinger, R. Dirnhofer, The ‘‘skin–skull– brain model’’: a new instrument for the study of gunshot effects, Forensic Sci. Int. 125 (2002) (Suppl. 2) 178–189. [47] H. Thomsen, M. Bauermeister, R. Wille, Zur Kindsto¨tung unter der Geburt. Eine Verbundstudie u¨ber die Jahre 1980–1989, Rechtsmedizin 2 (1992) (Suppl. 2) 135–142. [48] E. Ungar, Introductory lecture, in: Proceedings 4th Congress of the German Society of Forensic Medicine, Cologne, 21–29 September 1908, Vierteljahresschr. Gerichtl. Med. 37 (1909) 1–6. [49] B. Vennemann, T. Bajanowski, B. Karger, H. Pfeiffer, H. Ko¨hler, B. Brinkmann, Suffocation and poisoning – the hard-hitting side of Munchausen syndrome by proxy, Int. J. Legal Med. 119 (2005) (Suppl. 2) 98– 102. [50] B. Vennemann, M. Große Perdekamp, B.P. Kneubuehl, A. Serr, S. Pollak, Gunshot-related displacement of skin particles and bacteria from the exit region back into the bullet path, Int. J. Legal Med., in press.
Medical criminalistics S. Pollak * Institute of Legal Medicine, University of Freiburg, Albertstraße 9, 79104 Freiburg, Germany Received 23 April 2006; accepted 10 May 2006 Available online 5 July 2006 Dedicated to Prof. Dr. h.c. mult. Otto Prokop on the occasion of his 85th birthday
Abstract Medical criminalistics is an essential part of legal/forensic medicine. It includes the clinical examination of surviving victims and suspects, the inspection of the scene in suspicious deaths with subsequent performance of medico-legal autopsies, the assessment of (biological) traces and the reconstruction of criminal events under medical aspects. Just as the circumstances of life and the manifestations of crime are changing with time, there is a permanent alteration regarding the issues of medical criminalistics. Legal/forensic medicine is a university subject in most countries and therefore, research work is one of the main tasks also in medical criminalistics. In contrast to clinical medicine and basic research, some common study designs are not suitable for the special needs of medical criminalistics, whereas other types are more appropriate like epidemiological evaluations, cross-sectional studies and (retrospective) observation studies. Moreover, experimental model tests and case reports also rate high in medical criminalistics. # 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Medical criminalistics; Legal medicine; Clinical forensic medicine; Medico-legal research
1. Introduction Criminalistics is regarded as a speciality within the field of forensic sciences. According to a definition by the California Association of Criminalists, criminalistics is the profession and scientific discipline directed toward the recognition, identification, individualization and evaluation of physical evidence by application of the natural sciences to law-science matters [13]. Traditionally, legal medicine also covers many fields of activities belonging to forensic sciences. Apart from its academic tasks as a university subject in most countries, legal medicine deals with ‘‘the application of medical knowledge in the administration of justice’’ [24]. Legal medicine and criminalistics are closely related because both are oriented towards forensic needs. Therefore, it is not surprising that the responsibilities of both disciplines differ from country to country. Even in one and the same legal system, the relationship between legal/forensic medicine and criminalistics is subjected
* Tel.: +49 761 203 68 53; fax: +49 761 203 68 58. E-mail address: [email protected]. 0379-0738/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.forsciint.2006.05.014
to time-related changes [33]. In Germany after World War I, Kockel [23] was of the opinion that forensic chemistry and criminalistic technology should be integrated into legal/ forensic medicine. For some time, the university institutes carried the double name ‘‘Forensic Medicine and Criminalistics’’, although objections were raised at that time already – and rightly so – against the ‘‘encyclopaedic’’ claim of a comprehensive competence of the medico-legal expert [41]. As Schwerd [45] and Berg [1] correctly stated, medical criminalistics is a natural part of legal medicine. It includes the examination of victims and suspects and the investigation of traces to reconstruct the course of events and legally relevant facts under medical aspects, especially interpretation of findings in suspicious deaths, inspection of the scene and assessment of biological stains. To make students familiar with criminalistic thinking and working methods is an important objective of academic teaching and post-graduate training of specialists in legal medicine. No matter how the scope of practical medico-legal work is defined, the reconstruction of events has always been a specific feature and domain of legal medicine. Contrary to pathology, which concentrates on the diagnosis of diseases and causes of death, legal medicine uses the diagnosis as a starting point to
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reconstruct what happened. For example, the main purpose of forensic autopsies is not so much to determine the cause of death as such, but to clarify legally relevant circumstances and contexts (determination of the approximate time of death, differentiation between self-inflicted injuries and lesions caused by another person, analysis of wound findings with regard to the object used, recognition and interpretation of trace material, etc.). The evaluation of gunshot wounds as to number and localization of hits, line of fire, firing range, weapon and ammunition used, self-infliction or involvement of another party, effect on the capability to act, etc. is an example how the purpose of an investigation goes beyond purely medical findings to criminalistic and juridic questions of evidence. 2. Study designs and methods As far as medico-legal institutes are affiliated with a university, they belong to the medical faculty in most cases and are often integrated into a university hospital. In that environment, clinical research is the predominant field, which is focussed either on basic research or on the study of diseases and patients, respectively. Most of the methods used for these activities are applicable to legal medicine in general and medical criminalistics, in particular, on a rather limited scale only [27]. Neither the basic research using biological systems and animal models nor the clinical trials prescribed for the registration of new drugs are consistent with the needs of medical criminalistics. Some study designs, which play an important role in medical and therapeutic research (controlled, randomised clinical studies, cohort studies, case–control studies), are not suitable for medical criminalistics because the forensic material is completely different. Other study types are better suited for the specific circumstances in forensic medicine, for example, prospective cross-sectional studies, retrospective observation studies and case reports. For certain subsections of the field (e.g. thanatology, determination of wound age), longitudinal studies are also necessary to describe and quantify time-related changes in the findings [28]. In those areas in which laboratory techniques are to be established for the recording of new parameters or the optimization of existing procedures, validation of the methods is of special significance. For medical criminalistics, which is the main topic of this article, the comparative phenomenology of exactly defined study groups is essential. The evaluation of current case series gives an authentic picture of the criminalistic phenomena in homicides and bodily harm. The development and statistical confirmation of morphological criteria help to characterise typical patterns of findings. Thus, it is possible, for example, to supply evidence-based evaluation tools for differentiation between self-inflicted injuries and injuries caused by another person. The important role played by case reports in the field of medical criminalistics will be described in greater detail below. Nevertheless, forensic research must go beyond the description of unusual individual observations [48]. Many questions cannot
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be answered by experience alone, but require experimental research. Experiments performed on appropriate test models to clarify the biomechanical basis of injury formation are such an example. 3. Questions to be answered Medico-legal research draws an essential part of its ideas and questions from practical forensic work. Moreover, the findings and data collected for expert opinions constitute the basis for an empirical approach to research. Without the study material of medico-legal routine work, no new findings could be obtained in many forensically relevant areas. On the other hand, the close relation to university medicine ensures a high scientific standard and independence. Without proper research activities, legal medicine and thus, medical criminalistics would rapidly fall behind the general scientific progress. From the multitude of research subjects, only a few can be dealt with in this context. The collection of epidemiological data, which is possible only on the basis of medico-legal practice, is of importance for the society and legal policy in general. This applies, for instance, to the frequency of certain crimes, such as infanticide [47] or to the number of drug victims depending on different offers of therapy. The results of such investigations also help to elucidate health risks. For example, a medico-legal multicenter study on the HIV prevalence in drug victims demonstrated that the intravenous drug consumption is one of the main causes of HIV infections in Germany. In the course of the observation period (1985–1994), the prevalence level declined from 29% to about 7% [26]. The medico-legal monitoring, thus impressively demonstrates the success of educational campaigns and the importance of prophylactic measures to prevent an infection by sharing unsterile needles. Systematic research of sudden infant death was and still is also essentially conducted by the institutes of legal medicine [12], as in most of these cases both the manner and cause of death are unclear, so that infanticide cannot be ruled out from the very beginning [2,8]. Dettmeyer et al. [7] and other authors have dealt with this topic in greater detail. An important aspect of medico-legal publications is to direct the attention of criminalists to diagnostic problems. Serial killings in hospitals and geriatric care may serve as an example. Knowing the relevant methods, which do not necessarily leave any external injuries on the often multimorbid patients, is an important prerequisite to become suspicious and to induce the performance of an autopsy [30]. The old question, how many homicides are not recognized, was tried to be answered by a joint study of 23 institutes of legal medicine [5]. Among 13,000 autopsies of the study material, 92 ‘‘discoveries by chance’’ were reported where a natural death was given on the death certificate. These cases comprised 49 fatal accidents, 10 homicides and 19 deaths from medical complications. On the basis of this multicenter study, it was estimated that there are at least 1200 homicide cases per year which do not appear in Germany’s official statistics, as they are classified as natural deaths.
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From the large number of criminalistically relevant questions, which can only be clarified by systematic medicolegal investigations, I would like to give a few examples from the field of gunshot injuries. Numerous studies deal with typical and atypical entrance wound localizations in suicides and homicides. The view often taken in older textbooks that suicides almost regularly uncover their chest before firing a shot to the heart, was disproved by Karger et al. [19]. The question of a victim’s ability to act is particularly important for reconstruction purposes. It has been shown that immediate incapacitation is to be expected only if central nervous structures essential to physical activity are affected. Thus, multiple gunshot suicides are possible if the first shot did not injure a target of immediate incapacitation [17,35]. According to investigations and observations of Krauland [25], a weapon found in the hand of the deceased does not necessarily speak against a suicide if there are special circumstances explaining this finding. Another phenomenon of high criminalistic importance is biological ‘‘backspatter’’ and its possible deposition on the perpetrator depending on the shooting distance [20]. Clinical forensic medicine is subject to time-related changes which have to be described and analysed on the basis of the current evaluation material. This is true for sexual offences, forensic psychopathology, child abuse, domestic violence, torture, injuries from traffic accidents, bodily harm, attempted homicide and self-inflicted injuries. In the last-mentioned group the simulation of criminal offences has become a challenging topic with many different categories and manifestations [37]. Among the manifold forms of physical child abuse, the so-called Munchausen syndrome by proxy has been increasingly observed during the last 3 decades [49]. Astonishingly, even in ‘‘standard fields’’ of injury evaluation, such as stab and cut wounds, new questions may be raised concerning the specifity of wound patterns indicating either a knife attack by another person or selfinfliction. Thus, a cut on the palmar side of a hand does not necessarily mean a defence wound, as it can also be selfinflicted unintentionally by the offender when the knife is vigorously thrust and hits a solid resistance so that the hand slides from the hilt onto the blade [43]. In contrast to most autopsy studies, there is no predominance of defence injuries on the left forearm and hand, when looking at surviving victims of sharp force [44]. Other problems, which can only be mentioned briefly in this context, refer to the diagnostic significance of findings associated with survived and fatal strangulation. As is well known, congestive petechial haemorrhages do not constitute a specific sign of asphyxia as they also may occur during physiological processes of pressing [34]. Up to now, there is no generally accepted opinion concerning the minimum time necessary for the manifestation of congestive haemorrhages. Another controversial issue is the practical relevance of possible vagus-mediated consequences (‘‘reflex cardiac arrest’’). It is obvious that apart from the examples given above, a large number of further forensically relevant questions have to be solved on the basis of indisputable evidence.
4. Appropriate methods Legal/forensic medicine is an applied science in which experience plays a role that is difficult to overestimate. Because of sociocultural, legal and organizational factors, the material examined by the medico-legal experts shows considerable variations, and knowledge will still be incomplete also after many years of vocational training. To correctly interpret morphological findings, it is extremely important to train the ‘‘diagnostic eye’’. Visual memory often sets the course of the analysis of an individual case, even if additional examinations using technical equipment and the application of natural science are necessary later [36]. In spite of the wide variability of phenomena and external circumstances, medical criminalistics is frequently faced with similar, sometimes stereotypic patterns of findings, which derive from archetypal modes of behaviour in the commission of crimes and suicides [38]. For these reasons, it seems not only justified but advisable to publish instructive photographic material of general importance in the form of an atlas, as it has already been done in the late 19th century by von Hofmann [16]. An interesting tool for discrimination between homicides and suicides was presented by Karlsson who used multivariate projective statistical models in sharp force fatalities and in deaths from firearms [21,22]. By analysing a great number of solved forensic cases, he created a model to find out predictive criteria whether a certain fatality shows similarities to homicide or suicide. Afterwards, the statistic model was validated on new sets of authentic cases. This approach has an impressively high sensitivity and specifity regarding its ability to identify homicides. The predicting variables are ranked according to their covariation with homicide or suicide. Other mathematical models can help to simulate the optical properties of human skin to identify the status of haemoglobin and to recognize carbon monoxide poisoning by means of reflection spectrometry [3]. An important tool for the epidemiological evaluation of autopsy data is the introduction of autopsy registers. These should cover all forensically investigated deaths of a country to allow representative statements as to the kinds of unnatural death and the persons involved. Another advantage of such a centralized database is that rare events, such as intoxications with plant or animal toxins are recorded in one and the same place, and thus, become available for scientific collaboration. In Germany, the project of a national forensic autopsy register was initiated in January 2004 and has meanwhile been implemented in almost all parts of the country [4]. Before the project could be realized, conformity with data protection regulations and clear rules, who would be authorized to use the register had to be assured. The scientific activities are coordinated by a committee operating under the roof of the German Society of Legal Medicine. As most of the other sectors of legal medicine, medical criminalistics is also dependent on experimental research. The number of methods used is so large and manifold that only a few can be mentioned here. A special challenge is the systematic analysis of morphological findings for the purpose
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of achieving a better understanding and more reliable interpretation (e.g. with regard to the underlying trauma and the causative mechanisms, the specifity of changes, the probability of incidence, the influence of contributing factors). Some examples from the field of forensic wound ballistics may illustrate this: simulants, such as gelatin and transparent glycerin soaps turned out to be appropriate target media as their behaviour is similar to that of human organs and soft tissue from a physical-ballistic point of view [35]. There is a high level of comparability between damage to the simulants and injuries to the human body. Several working groups have developed composite models in order to carry out replicable firing experiments, but also to reconstruct crime-related injuries [15,31]. Bone tissue has been simulated by coated polyurethane [46]. Composite models of pig skin and gelatin blocks have been used to demonstrate the gunshot-related transfer of skin particles along the bullet path and the transport of microorganisms from the entrance and exit region into the wound channel [14,50]. 5. Case material Case reports are an important type of publication in forensic medicine. Most international journals accept such papers if they contain relevant new information gained by thorough investigation of exceptional cases. In contrast to other medical disciplines, it is not unusual that in forensic medicine new findings are first described within a case report. Until recently, many reputed representatives of medical criminalistics wrote a large part of their scientific work in the form of case reports. The ‘‘Archives of Criminology’’ (in German: Archiv fu¨r Kriminologie), probably the oldest still existing scientific journal of its kind, is a good example for a platform which cultivates the tradition of bringing together specialists of different forensic sciences [40]. Solving complex criminal cases often requires interdisciplinary cooperation. If fatalities are concerned, participation of medical criminalistics is obligatory. So it is not surprising that about four-fifths of the articles published in ‘‘Archives of Criminology’’ are written by authors from institutes of legal/forensic medicine. Approximately, half of these contributions are case reports. Case reports have an important function in forensic literature. By describing individual observations, new injury patterns and causes can be presented. Some forms of physical child abuse, generally known today, such as shaken-baby syndrome, Munchausen-by-proxy and battered-child syndrome, were described in the scientific literature only some decades ago, although they probably existed long before. In self-inflicted injuries to simulate criminal offences a timerelated change in the phenomenology has occurred so that it seems useful and necessary to publish reports on new forms of manifestation. Apart from the usual features of self-infliction, nowadays persons simulating fictitious offences sometimes carve strange motifs, such as swastikas or other symbols into their skin [10]. Case reports on methods of homicide, which are rare or leave few external traces do not only help to make such events
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known, but underline the necessity of careful autopsy taking into consideration all diagnostic alternatives. This applies, for example, to deaths where the body is found suspended: forensic literature is abundant in reports on homicides by hanging and the simulation of suicide by hanging a victim previously killed or made unable to resist [29]. Similar difficulties may be involved in cases of homicide by electricity [32] or killing helpless persons needing care by instilling water into the respiratory tract [30]. Suicides can also be committed in such unusual ways that a publication is justified under criminalistic aspects. 6. Analysis of results The study designs and experimental investigations mentioned under Section 2, require the application of relevant statistical or biometrical methods, which cannot be elaborated here. Especially for prospective cross-sectional and retrospective observation studies, it is essential that the basis of the data and the study material are clearly defined, thus allowing to confirm or qualify the diagnostic significance of certain findings. This was shown by Prokop and Wabnitz [39] in their study on the occurrence and frequency of conjunctival petechial haemorrhages in surviving and dead victims. The authors were able to demonstrate that such congestive bleedings occur not only in deaths from asphyxia, but also in fatalities from electricity (12.5%), carbon monoxide poisoning (2.3%) and in sudden coronary death (4.3%). Even in the ‘‘classical’’ fields of medical criminalistics, many questions have not yet been sufficiently clarified. For example, it was only in 2002 that Karger et al. [18] found out after performing systematic case analyses that some bullet path directions cannot be considered indicative of suicide: downwards and back-to-front in gunshots to the temple, left-to-right in gunshots to the left chest and downwards in mouth shots. Quite recently, Faller-Marquardt et al. [9] demonstrated in a targeted analysis of a large autopsy material that in nearly all contact shots to the cerebral cranium, the periosteum around the bullet entrance hole is detached and reflected with soot on the underside. Another finding largely ignored for a long time is the occurrence of stretchmark-like skin tears away from the entrance wound in gunshots to the head. This phenomenon is caused by the subcutaneous or intraoral expansion of the muzzle gases and/or the radial forces of the bullet resulting in ballooning and overextension of the facial soft tissues [11]. 7. Ethical issues According to the requirements of most biomedical journals, it must be ensured that all human studies were approved by the competent ethics committee and were performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki as amended. Reports on animal experiments should state that the ‘‘Principles of laboratory animal care’’ (NIH publication No. 85-23, revised 1985) as well as specific national laws were followed where applicable. Of course, case reports must be anonymised before publication so that the described
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person cannot be identified. Unfortunately, this rule is not always observed in photographs. An important contribution to achieve more transparency is the frank and open discussion of controversial issues. For this purpose, so-called letters to the editor, in which the readers have the opportunity of expressing their comments on new results reported in a scientific journal, is an excellent tool. 8. Quality control If an application for a public grant is made, quality control begins even before the study is started, as the project is usually subjected to critical assessment by relevant experts. A second control takes place when the results of the study are published in a peer-reviewed journal. Even congress contributions are often assessed on the basis of the submitted abstracts before being taken up into the programme. The discussions after oral reports and poster presentations are another corrective tool helping the scientific community to ensure that the rules of honesty and conscientiousness in research are observed. An additional instrument for self-critical analysis of possible errors in scientific work is to make them a topic at conferences and in journals. In forensic routine work, the participation in interlaboratory tests, the official certification of institutes and the implementation of general investigation standards (e.g. harmonization of medico-legal autopsy rules [6,42]) would help to arrive at a higher quality level. 9. Prospects The aim of medical criminalistics is to improve the scientific armamentarium necessary for the elucidation of crime and for related forensic applications at a high level of evidential value. Legal medicine can fulfil its important tasks with the necessary competence only, if the further existence of medico-legal institutes with a clear focus on research is guaranteed. Then it will be possible also in the future to supply the latest medical knowledge to the administration of justice as a strong partner of criminalistics. References [1] S. Berg, Kriminalistik und Rechtsmedizin, in: E. Schlu¨chter (Ed.), Kriminalistik und Strafrecht. Festschrift fu¨r Friedrich Geerds, SchmidtRo¨mhild, Lu¨beck, 1995, pp. 425–439. [2] M. Bohnert, M. Große Perdekamp, S. Pollak, Three subsequent infanticides covered up as SIDS, Int. J. Legal Med. 119 (2005) (Suppl. 2) 31–34. [3] M. Bohnert, R. Walther, T. Roths, J. Honerkamp, A Monte Carlo-based model for steady-state diffuse reflectance spectrometry in human skin: estimation of carbon monoxide concentrations in livor mortis, Int. J. Legal Med. 119 (2005) (Suppl. 2) 355–362. [4] H. Bratzke, M. Parzeller, F. Ko¨ster, Projektstart 2004: Das Deutsche Forensische Sektionsregister, Rechtsmedizin 14 (2004) (Suppl. 2) 371. [5] B. Brinkmann, S. Banaschak, H. Bratzke, U. Cremer, G. Drese, et al., Fehlleistungen bei der Leichenschau in der Bundesrepublik Deutschland, Arch. Kriminol. 199 (1997) (1–12) 65–74. [6] Council of Europe, Recommendation No. R (99) 3 of the Committee of Ministers to Member States on the Harmonisation of Medico-Legal Autopsy Rules, Strasbourg, 1999.
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