Forensic Science International 144 (2004) 269–283

Clinical forensic medicine and its main fields of

activity from the foundation of the German
Society of Legal Medicine until today
S. Pollak*
Institute of Legal Medicine, University of Freiburg, Albertstraße 9, Freiburg D-79104, Germany

Available online 2 July 2004

Abstract

The fields mainly covered by clinical forensic medicine are subject to time-related changes which are described on the basis of
the German literature of the 20th century. Some fields of forensic sexual medicine (diagnosis of virginity, proof of criminal
abortion, potentia coeundi, potentia generandi, potentia concipiendi) have become less important in the daily work of
medicolegal institutes, whereas victims of rape and sexual abuse continue to form a major part of the forensic examination
material in the German-speaking countries. The evaluation of suspected physical child abuse has grown in importance since the
60s, and it is essentially the merit of Elisabeth Trube-Becker that this problem is now dealt with also in scientific medicine. More
recently, medicolegal experts are increasingly confronted with further groups of persons: victims of domestic violence, abused/
neglected seniors, refugees from countries where torture is used. A new special field, which established itself only in the 90s, is
the estimation of age with regard to the criminal responsibility of suspects who have no identity papers or pretend to have none. A
phenomenon frequently observed in the last two decades is the non-accidental self-infliction of injuries. Whereas in the first half
of the 20th century the motive for self-mutilation was typically to evade military service, this category of injury was later mainly
seen in the context of insurance fraud; more recently most forensically relevant self-inflicted injuries refer to simulated offenses
(fictitious sexual offenses and robbery, attacks allegedly having a political background). One of the traditional fields of clinical
forensic medicine continues to be the evaluation of victims and suspects following bodily harm and attempted homicides. In the
field of civil law medicolegal experts are particularly often concerned with controversial consequences of traffic accidents (e.g.
alleged whiplash injuries after rear-end collisions at low velocities).
# 2004 Elsevier Ireland Ltd. All rights reserved.

Keywords: Clinical forensic medicine; Child abuse; Sexual offense; Self-inflicted injury; Bodily harm

1. Introduction
Until the second half of the 19th century, forensic
medicine formed a common subject together with its sister
discipline, public health, at the German-speaking univer-
sities. Eduard v. Hofmann was the first representative of his
subject who, after being appointed holder of the Viennese
chair (1875), devoted himself entirely to forensic medicine
[95]. He defined his subject as ‘‘the discipline dealing with
issues in civil and criminal law which can only be answered
with the help of medical knowledge.’’ The scope and
* of social, civil and traffic law. Issues regarding ability to
Tel.: þ49 761 203 6854; fax: þ49 761 203 6858.
E-mail address: legalmed@sun11.ukl.uni-freiburg.de (S. Pollak).
content of the subject, which must never lose its contact
with the ‘‘roots of medical science’’, are determined by the
problems arising in foro, i.e. the specific forensic purposes
[60].
Forensic medicine has undergone a constant change of its
tasks reflecting the social circumstances of the respective
epoch [130]. This is especially true of clinical forensic
medicine. The significance and thematic orientation of
clinical forensic medicine are decisively influenced by the
general legal and organizational conditions [138]. Beside the
‘‘classical‘‘ tasks performed by most forensic experts, some
concentrate on special areas of evaluation in the field
work, capacity to conduct legal proceedings, occupational

0379-0738/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.forsciint.2004.05.001
270 S. Pollak / Forensic Science International 144 (2004) 269–283
invalidity, fitness to be detained, damages for pain and
suffering and fitness to drive can be mentioned as examples
[34,35,110,159].
2. Forensic sexual medicine and forensic
psychopathology
A look into the old textbooks of the subject shows that
forensic sexual medicine had a very high standing in the
past. Standard reference books such as the one by Hofmann
and Haberda (10th edition, 1919 [61]) devoted more than
20% of their total volume to that complex of issues. The
diagnosis of virginity and criminal abortion was broadly
discussed. Problems of male and female impotentia coeundi,
impotentia generandi and impotentia concipiendi were dealt
with in detail. Other chapters referred to the interpretation of
medical findings after sexual offenses. Another focus of
forensic sexual medicine referred to pregnancy, its duration
and the possible failure to recognize a pregnancy as well as
the diagnosis of spontaneous and criminal abortion.
Forensic psychopathology played a special role already at
the turn from the 19th to the 20th century. In its second
edition (1881) the textbook by Hofmann contained a chapter
on this subject for the first time [60]. It had been included to
make the practicing medicolegal expert familiar with the
fundamentals of forensic psychiatric examinations. Later,
the basis of clinical psychiatry was already assumed as
known, so that the authors mostly confined themselves to
discussing specific forensic aspects [62].
In the second edition of the textbook on Forensic Med-
icine by Kratter (1921) the author emphasized in his intro-
duction to the chapter on ‘‘unclear mental conditions’’ that
the ‘‘science of mental disorders’’ belonged to the field of
psychiatry, but that the application in the juridical field was
a ‘‘domain of forensic psychopathology as a branch of
forensic medicine’’ [84]. This holistic approach, which is
based on a broad competence of forensic medicine, was
largely given up later by the ‘‘somatic school’’, while other
representatives of the discipline, e.g. Müller-Hess - corre-
sponding to their scientific origin and professional training -
continued to regard forensic psychiatry as an integral part of
forensic medicine [95].
3. Child abuse
Without any doubt, the evaluation of proven and ques-
tionable child abuse is one of the core tasks of clinical
forensic medicine today. On perusing the older German
textbooks and manuals it becomes clear that adequate
attention has been given to this topic only in the last few
decades. The growing involvement of forensic medicine in
recognizing and fighting violence against children is essen-
tially due to Elisabeth Trube-Becker who has discussed the
forensic aspects of child abuse in numerous lectures and
publications since the 1960s [192]. Her monograph ‘‘Vio-
lence against the child‘‘ was published in two editions (1982
and 1987) [194]; another publication on abused children
appeared in 1992 [195].
Actually Ernst Ziemke, who was professor of forensic
medicine in Kiel, reported on child abuse and its legal and
social significance already in 1928 at the 17th meeting of the
German Society of Forensic and Social Medicine [212].
After presenting 18 cases of abuse Ziemke summarized: ‘‘If
the fight against child abuse is taken up with energy and
circumspection by all those involved we may hope that
adequate protection can be given to the innocent and defen-
seless child and that such degrading and inhumane cruelty, as
it is described in my study material and that of others, will
gradually become a rarity, although it will not disappear
entirely.’’
As is generally known, patterned hematomas can be an
important clue to clear up injuries as being caused by
physical abuse. A classical example are double-streaked
bruises after blows with a stick. In retrospect it appears
surprising that this distinctive injury pattern was described
only in 1932 by Walcher [206]. In his paper ‘‘On the local
effect of blows with sticks, canes and similar objects with
special emphasis of the presence of double streaks’’ Wal-
cher primarily referred to observations made in abused
children showing contusions from blows with sticks and
canes.
Numerous publications have been devoted to the differ-
entiation of injuries caused by abuse in contrast to accidental
lesions [43,63,146,147,186]. In pertinent articles and in
textbooks a catalogue of criteria was worked out in the last
few decades that can be helpful for differential diagnosis
(type, localization and age of injuries, consistency of alleged
origin and injury pattern, etc. [148]). An important sign
indicating physical child abuse may be the presence of bite
marks [42,193]. Skeletal findings can also make an essential
contribution to diagnosis of maltreatment (subperiostal
hematomas, periosteal calcifications, metaphyseal and epi-
physeal fractures, paravertebral rib fractures, etc. [4,78]).
Only a few years after the first description by Caffey [30],
German forensic pathologists also reported on the ‘‘shaken
baby syndrome’’. This special form of physical abuse and
the resulting combination of injuries (subdural hematoma,
retinal bleeding, contusions from fingertip pressure on arms
or thorax) were studied by several groups of authors
[13,91,100,173,180,191]. Fatal forms of ‘‘shaken baby syn-
drome’’ were repeatedly diagnosed in infants with poor
external symptoms on whom a forensic autopsy was per-
formed for suspected sudden infant death syndrome [156].
Non-accidental burns are another special form of physical
child abuse. The thermal damage is caused either by inten-
tionally bringing the child into contact with a hot object
(cigarette, iron, heater, etc.) or by scalding (pouring a hot
liquid over it or holding parts of the body into a hot liquid).
In the German medicolegal literature several cases of this
kind have been described [48,53,194].
 S. Pollak / Forensic Science International 144 (2004) 269–283
Lately, a form of abuse first presented in 1977 by Roy
Meadow [102] under the name ‘‘Munchausen syndrome by
proxy’’ has been increasingly reported also in the German-
speaking countries. This syndrome is a condition in which a
carer (usually the mother) invents, simulates or provokes
symptoms of an illness in her child, often leading to medical
treatment and hospitalization [85,86]. Apart from simulating
pathological changes on the skin, the furtive administration
of not medically prescribed drugs is common [6].
Besides physical abuse, neglect constitutes a separate
category of damage, which may lead to serious develop-
mental delay and even death [4,93,155,194,207]. Based on
multi-center studies, Vock et al. presented epidemiological
data on fatal neglect of children in the Federal Republic of
Germany and the former GDR [201,202]. Fatal abuse of
children by physical violence has also been the subject of a
large number of medicolegal publications [39,87,174,
203,208]. For differential diagnosis in children presenting
with hematomas one always has to keep in mind that there
may be an underlying hematological disease (e.g. acute
leukosis), as in such cases hemorrhages may occur sponta-
neously or after trivial trauma [116].
Today many authors also subsume sexual abuse under
the broad definition of child abuse. That forensic medicine
plays an important role in the conservation of evidence in
unclear or proven cases of abuse was already pointed out in
detail in the older literature [61,162]. As there are often no
fresh and/or specific morphological findings, it is particu-
larly important to be familiar with the normal anatomical
variations and their differentiation from residues of genital
or anal manipulation. In this context, the cooperation with
pediatricians and gynecologists as well as the appropriate
conservation of biological traces is of paramount impor-
tance [3,197,210].
4. Medicolegal investigations following
sexual offenses
The physical examination to prove that a sexual offense
has taken place has been one of the core tasks in medicolegal
practice since the beginning of clinical forensic medicine.
The diagnostic measures range from the assessment of the
genital findings (e.g. condition of the hymen) via the doc-
umentation of extragenital injuries to the evaluation of trace
evidence.
Contrary to what laymen would expect, only a compara-
tively small percentage of female victims of sexual offenses
shows genital injuries [25,70,74,117,152]. In these cases,
the signs seen most frequently are reddening and excoria-
tions of the vulva, superficial fissures of the introitus
vaginae (less often of the anus) or signs of fresh defloration.
More serious injuries, such as tears of the vaginal wall, can
be the result of increased vulnerability (e.g. in senile
atrophy) or particularly violent manipulations (e.g. inser-
tion of an object) [152,204].
271
Extragenital injuries may reflect the course of events and
the circumstances of the assault [46]. There are various
combinations of bruises after beatings, scratches due to
undressing the victim by force, injuries of the lips when a
hand was pressed on the mouth, fingertip bruises after
holding a person by the upper arms and wrists, marks from
tying or biting, defense injuries on the hands or ulnar
forearms, hematomas on the inner side of the knees and
thighs (due to forcing the legs apart) or lesions due to a hard
or rough support of the body. Especially sensitive regions
(e.g. the eyes, lips and nipples) are often injured as well. In
cases of manual or ligature strangulation not only local signs
on the neck, but also additional symptoms may be present
such as petechial hemorrhages in the facial skin and con-
junctivae, hoarseness, difficulty in swallowing and urinary/
fecal incontinence [25,70,74,117,118,152]. Of course inju-
ries of rape victims can be minor or absent, if the offense was
committed under threat rather than by applying force
[70,118,152].
5. Self-inflicted injuries
Depending on the underlying motives or personality
disorders, there are generally five main categories of non-
accidental, self-inflicted injuries [140]:
1. Simulated offenses (fictitious sexual offenses, feigned
robbery or alleged assaults with a political or xenopho-
bic background).
2. Self-mutilation for the purpose of insurance fraud.
3. Self-inflicted bodily harm or self-mutilation among
soldiers and prisoners.
4. Dermal artifacts, self-mutilation and other forms of self-
induced bodily harm in psychiatric patients.
5. Suicidal acts.
5.1. Simulation of criminal offenses
Depending on the motive, the group of simulated criminal
offenses comprises several different categories of cases
[133]:
 Simulation of criminal offenses to derive compassion,
affection and attention.
 Self-damage in order to divert attention from previous
misconduct (e.g. burglary, embezzlement) [105].
 False allegation of an assault in order to dissimulate an
attempted, but not completed suicide [137].
 Feigned offense to excuse absence without leave from
school or work, but also as an explanation for coming
home late [46,105,137].
 Fictitious offense with self-inflicted injury to take revenge
on persons or institutions [45,126,140,184].
 Simulation of a (sexual) offense in order to divert
attention from previous autoerotic manipulations [11,
181,198].
272 S. Pollak / Forensic Science International 144 (2004) 269–283
 Self-damage to simulate a situation of defense or to cover
up an offense committed by themselves against another
person [178,211].
 Self-induced injuries to pretend that the informant was the
victim of an offense with a political background
[44,75,154].
In fictitious sexual offenses it is paramount to analyze the
extragenital injuries with regard to their type, localization
and distribution. The wound pattern is often in obvious
contrast to the dramatic story told about the course of events.
Characteristic features are cuts or abrasions of minor inten-
sity, usually with a multitude of individual lesions. Even
curved body surfaces show skin lesions of equally shallow
depth. The typically uniform, grouped and often parallel
arrangement is strangely contradictory to the dynamics of
the alleged fight. Irregularities, as they are expected after a
real assault, are often missing [9,81,82,137,140,183]. Occa-
sionally pattern-like and symbolic pictures are seen [69,81].
The injuries usually heal without complications even when
left untreated.
As instruments pointed or sharp objects (knives, razor
blades, nail scissors, broken glass, etc.) or the person’s own
fingernails are used [47,183]. Easily reachable body regions
(arms, forehead, cheeks, thoracic and abdominal skin, neck
and legs) are preferred; especially sensitive regions like
eyes, lips and nipples as well as the genital regions them-
selves are mostly omitted. Both sides of the body may be
injured almost symmetrically, although sometimes the side
opposite the dominant hand may be more affected [81,137].
On the back, the injured parts are determined by the reach of
the individual’s hands [47,69,183]. In rare cases, injuries
may even be inflicted by a helper [81,105].
Discrepancies between the description of the offense and
the objective findings can support the suspicion of self-
infliction. Special attention should be paid to inconsistencies
between the damage on the clothing and the injuries
[9,81,82,137,183]. Occasionally, the informants inflict
excoriations on themselves by rubbing their skin against
rough surfaces or blunt objects [47]. Self-inflicted hemato-
mas as well as deep stab or cut wounds are also seen in rare
cases [9,47,65,69,81,141].
Most women simulating a sexual assault are young.
Possible motives for reporting a false offense may include
conflicts with the lover, imminent separation from the
partner, problems with the parents, the wish of adolescents
to impress others and the wish to gain attention and care.
Multiple false reports by one and the same person are not
uncommon. In cases of repeated self-infliction of injuries
scars may point to former incidents [46].
Not only sexual offenses, but also attacks and assaults for
other motives can be simulated. Sometimes the informants
inflict cuts and stabs, rarely also injuries by blunt force, on
themselves in order to support their fabricated story of the
event. The phenomenon as such is not new. In 1910, already
Strassmann [187] reported on the ‘‘features of self-inflicted
injuries effected to feign an assault by another party’’. In the
60s, Holzer [65] published a detailed article on the solution
of cases involving fictitious assaults. In the more recent past,
numerous case reports have been written on this subject
[69,82,137,181,200,209].
The motives for such false reports range from covering up
a person’s own misconduct [65] to the dissimulation of
suicide attempts or autoerotic manipulations [11,181,198].
Similar to the fictitious sexual offenses, the wish to derive
sympathy and attention is often the primary motive for the
self-infliction of injuries.
A significant sign of self-infliction is the lack of consist-
ency between the damage on the clothing and the injury
pattern on the one hand and the story told about the incident
on the other [90,137]. The pattern of findings often resem-
bles that seen in fictitious sexual offenses, although
untypical manifestations are not uncommon. Sometimes
persons claiming to have been assaulted are found to be
completely unharmed, even though they pretend to have
been severely traumatized and to have been unconscious for
a prolonged period of time [105]. In members of medical
professions the application of medical knowledge and spe-
cial skills must be kept in mind [44,163]. In the group of
feigned assaults (without sexual motivation) males are also
frequently represented as alleged victims [69,137,181].
Self-inflicted injuries may serve to simulate criminal
offenses with a political or xenophobic background. Persons
pretending that their self-inflicted injury was caused by an
assault or attack often accuse members of social fringe
groups as perpetrators. For some years the problem of
right-wing radicalism has been discussed throughout
Europe. It is therefore not surprising that fictitious offenses
are increasingly attributed to right-wing offenders [44,75,
81,153,154,188]. In this context the informants accuse the
attackers - who do not exist in reality - of acting out of
xenophobic motives. From the large number of relevant
cases one has achieved worldwide publicity: A 17-year-
old female wheelchair user was allegedly assaulted by three
skinheads, who insulted and threatened her and finally cut a
swastika into her left cheek. Medicolegal assessment
revealed that the injury showed all the morphological criteria
of being self-inflicted [75,153].
Apart from the usual features of self-infliction (see
above), geometrical pictures, symbols, letters and words
carved into the skin are not uncommon in fictitious assaults
[81,153]; especially swastikas are a frequent motif
[133,147,188]. Broad coverage of such incidents in the
media may trigger an endemic avalanche of self-inflicted
injuries [209].
5.2. Self-mutilation for the purpose of insurance fraud
The medicolegal differentiation between injuries due to
accidents and intentionally self-inflicted harm was of major
importance already at the beginning of the 20th century.
Under the social conditions of that time soldiers accounted
 S. Pollak / Forensic Science International 144 (2004) 269–283
for a high percentage of the persons to be evaluated. Fritz
Reuter was one of the first, who in 1911 already concerned
himself thoroughly and comprehensively with the problem
of self-mutilation; by analyzing the wound findings he was
able to demonstrate their non-accidental origin [161].
At the 8th Meeting of the German Society of Forensic
Medicine in Münster (1912), Theodor Lochte, professor of
forensic medicine in Göttingen, gave a lecture on self-
inflicted injuries in which he also discussed the issue of
fraudulent claims against public and private insurance com-
panies [90]. Referring to Taylor [190], he already defined
criteria suggesting intentional self-infliction:
 Superficial character and harmlessness of the wounds as
well as localization on body sites where the effect can be
safely predicted.
 Localization of the injuries on the side opposite the
dominant hand.
 Presence of a multitude of individual lesions.
During war the number of self-inflicted injuries with
firearms was naturally disproportionately high [103], but
amputation by cutting off fingers was also seen in soldiers. In
some of these cases, several parallel strokes had to be
performed before the finger was severed. In 1938, Martin
Nippe stressed that finger bones can be completely severed
only if the finger is lying on a solid base [119]. Gottfried
Raestrup underlined the necessity to check the alleged origin
of the injury in comparison with the objective wound find-
ings [157].
In the 70s and 80s of the 20th century it was especially
Günther Dotzauer and Wolfgang Bonte who worked on the
proof of self-mutilations in connection with private accident
insurances. The common feature of these cases is that an
accident is simulated in order to fraudulently obtain insur-
ance benefits. Mostly the self-damage consists of mutilating
a peripheral part of the body (finger or hand). This is usually
done by using sharp instruments such as axes, choppers,
cutters or motor saws. In rare cases objects causing blunt
traumatization, e.g. presses, hammers and V-belts, are also
used [19,36,50,113].
Intentionally inflicted injuries from axe blows are often
proximal amputations of a single finger being severed at a
right angle to its longitudinal axis. In contrast to this, most
real accidents involve concomitant injuries of the adjoining
fingers as well. An oblique and distal course with incomplete
severance is more indicative of an accident [19,21]. Prox-
imal, complete severance of the index finger without
involvement of the neighboring fingers is highly suspect
of self-mutilation; as Bonte [18] and Püschel et al. [150,151]
appropriately stated, this type of severance is possible only
when the finger is placed in a so-called ‘‘execution posi-
tion’’. In the last few years a considerable number of
physicians have been convicted of defrauding insurance
companies by self-mutilation; most of them severed the
index finger of their left hand, sometimes after local or
nerve block anesthesia [113].
273
When investigating a questionable accident suspected of
attempted insurance fraud all available sources should be
used (photographs, X-rays, operation report, physical exam-
ination, biological traces). Moreover, the local circum-
stances at the scene, the properties of the instrument used
for inflicting the injury, the distribution of the blood traces
and the whereabouts of the amputate should be taken into
account [20,22,37,49,50].
5.3. Self-inflicted injuries and self-damage in prison
Autoaggressive behavior is a common problem with
detainees in police custody, in pre-trial detention and in
prison [211]. Particularly frequent is the self-infliction of
cuts (especially on the forearms) by using sharp-edged
objects such as knives, razor blades, pieces of metal or
broken glass. Another method of self-damage consists of
swallowing foreign (metal) bodies, which are sometimes not
excreted naturally because of their size and shape and have
to be removed by surgery [24]. In a broader sense simulation,
aggravation and prolongation of illnesses are also forms of
self-harm [41].
5.4. Artifacts in patients with psychopathological
disorders and mental diseases
In this group it is rarely necessary to differentiate self-
inflicted injuries from accidental or criminal injuries. Con-
sequently, the majority of the relevant publications was
written by psychiatric or dermatological authors. Emotion-
ally unstable patients with a personality disorder of the
borderline type tend to inflict injuries on themselves (e.g.
cuts and scratches) to achieve temporary relief in situations
of emotional tension [56,71,72]. A detailed description of
the mental diseases sometimes associated with autoaggres-
sive behavior was recently published by Möllhoff and
Schmidt [112,113].
Apart from mechanical injuries, self-induced ulcers and
burns caused by heat or chemicals may also occur. Patients
with severe mental handicaps associated with hyperactivity
sometimes tend to self-injurious behavior patterns (e.g.
‘‘head banging’’: constantly hitting the head against an
obstacle). Psychotic diseases can occasionally be associated
with bizarre autoaggressions, which may even include
mutilation with self-amputation of parts of the limbs or
genitals [111,127]. Occasionally cases of ‘‘Munchausen
syndrome’’ have to be evaluated under medicolegal aspects.
Within the scope of this chronic neurotic disorder physical
illnesses are simulated and/or injuries are inflicted on
oneself in order to be admitted to hospital and to undergo
surgery [140].
5.5. Suicidal acts
Apart from subsequent dissimulation attempts [137], the
self-inflicted injuries summarized in this chapter usually
274 S. Pollak / Forensic Science International 144 (2004) 269–283
present no differential diagnostic or criminalistic problems.
In suicidal gestures and attempted suicides sharp instru-
ments are used particularly often. Preferred localizations for
inflicting suicidal cuts are the flexor side of the forearms near
the wrists, the anterior and lateral parts of the neck and the
cubital fossa. The classical picture is characterized by a
number of grouped, mainly superficial and parallel individ-
ual lesions mostly running transversely to the longitudinal
axis of the arm. Under special conditions findings mimicking
tentative cuts may also be seen in homicides [14,58,59].
Suicide attempts with stab injuries are very much rarer; the
preferred localization for stabs is the precordial region.
Sometimes the injury pattern in these cases may suggest
an assault [131]. In this context perforation of the clothing is
not a reliable sign of infliction by another person [16,68,94].
6. Domestic violence
The term ‘‘domestic violence‘‘ describes traumatizations
in the immediate social environment of a person, normally
between adults who have or had a close partner relationship
with each other. Domestic violence is considered particu-
larly traumatizing, as it typically hits the victims in their own
house and is caused by individuals with whom they wanted
to live together in a relation of personal trust. The violence is
predominantly directed against women, but occasionally
also against the male partner. The site of domestic violence
is usually the apartment. The victims are generally reluctant
to report the perpetrator to the police. Often he is not
reported because the victim is ashamed or afraid of reprisals.
As a consequence there is probably a large number of
undetected offences. In those cases in which the victims
consult a doctor or a hospital for treatment of their injuries,
they often conceal the real cause and claim that they are due
to an accident.
More recently German forensic medicine has taken an
active role in detecting and fighting domestic violence.
The goal of the initiatives is to offer the possibility to the
victims to accept help and support and to realize the basic
right to a life without violence. In December 2003, the 4th
Forensic Workshop Kiel-Lübeck was devoted to the subject
‘‘Violence against women and children: facts – diagnosis –
prevention’’.
7. Forensic gerontology
Beside women and children, there is a growing tendency
that elderly persons become victims of ‘‘daily violence’’.
Especially old people living in cramped social conditions are
subject to physical and emotional abuse. Aside from phys-
ical violence, neglect in the care of the aged is a real problem
[124]. Because of the dramatic change in the age pyramid of
the German population more and more aged people require
outpatient or inpatient care.
A research report published by the Hamburg Institute of
Legal Medicine in 1999 on the epidemiology of decubitus in
the agonal phase - based on 10,000 cremation postmortems -
created a great stir [149]. The prevalence of decubitus ulcers
in this study was 11.2% with varying percentages in the
different institutions involved in nursing care. Another
problem in the care of geriatric patients is the permanent
administration of psychotropic drugs, which is justified only
for specific indications. In this respect, too, forensic med-
icine and the new field of forensic gerontology must play the
role of an ‘‘early warning system’’ [205].
8. Torture
That human rights are inviolable is one of the funda-
mental principles of all democracies. Although the
Declaration of Human Rights was adopted by the General
Assembly of the United Nations more than 50 years ago,
these provisions are still violated in many countries. The
proof of physical maltreatment and torture makes high
demands on the forensic expert, as months or even years
may have passed between the offense and the physical
examination, so that scarred residues can be expected at
best. Moreover, some methods of torture leave few traces
anyway, so that pathognomonic sequels are missing. In
connection with asylum proceedings, forensic medicine in
the German-speaking countries is also increasingly con-
cerned with the evaluation of questionable traces of torture.
In December 1997, the 8th Lübeck Meeting of German
Medicolegal Experts was devoted to the complex of
‘‘Abuse and Torture‘‘. The results of this interdisciplinary
meeting were published in volume 19 of ‘‘Research in
Legal Medicine‘‘ [120].
9. Surviving victims of traffic accidents
In many institutes of forensic medicine the evaluation of
persons involved in traffic accidents is part of the daily
routine with the issues to be solved being determined by the
legal regulations of the individual country. In Austria, for
example, a large part of medicolegal expert opinions deals
with the question, whether a bodily injury caused by negli-
gence was associated with a damage to the victim’s health of
more than three days and whether under medical aspects the
sustained injury is to be qualified as severe [8,108].
In traffic accidents the actual facts of the case – e.g. the
kind of involvement – often have to be clarified first.
Apart from the medical assessment of findings and their
documentation the expert opinion will focus on recon-
structive aspects (e.g. where did the passengers sit in the
car [104,128,168], in which direction was the injured
pedestrian walking, etc.). In civil cases the questions to
be answered are the intensity and duration of the post-
traumatic impairment and whether the reported complaints
 S. Pollak / Forensic Science International 144 (2004) 269–283
are really due to the accident. Lately, the assessment of
indirect lesions of the cervical spine (‘‘whiplash trauma’’)
has become very important in the forensic evaluation
practice [171,172]. Classification may be difficult espe-
cially in those cases, in which injuries of the cervical spine
are claimed after rear-end collisions with minor changes in
velocity [38,101,109,182].
Fortunately, the number of fatal traffic accident victims
has strongly declined in Germany. On the other hand, the
number of injured persons still amounts to almost 500,000
per year and thus remained almost constant in the last three
decades [99]. Consequently, reconstructive analysis of injury
patterns in surviving accident victims continues to be very
important. In the past, the principles of evaluation were
demonstrated primarily by means of the autopsy findings
[7,40,92,97,104,144].
The construction improvements in motor vehicles have
made an essential contribution to passive safety. This has not
only resulted in a reduction of the severity of injuries, but
also in a change of the traumatic findings (belt marks,
injuries typical of airbags!).
10. General aspects of injury evaluation
10.1. Blunt force
A large part of the physical examinations is performed on
adult victims of aggression [107]. In most cases, the offense
is committed by using physical strength directly (blows with
the fist or open hand, punches, kicks, etc.). From the
victimological point of view it can be stated that a high
percentage of the persons concerned is under the influence of
alcohol at the time of the offense; for the victims of injuries
caused by kicks this relation was demonstrated in several
studies [15,52,57,158].
In view of the fact that most injuries localized on the body
surface are uncharacteristic in appearance, the recognition
and correct interpretation of any pattern injuries that may be
present is of particular importance. In abrasions in which the
offending object hits the body approximately at a right angle,
it may stamp a mirror image of its contours/surface structure
on the skin (e.g. imprint marks of the hitting object or of the
tooth edges in bite marks [79,131,135,170]). For several
years defined skin injuries have been evaluated also by
photogrammetry [27]. With this method a three-dimensional
data model of the injury findings can be produced and
compared as to corresponding features with a suspected
weapon.
Under favorable conditions intra- and subcutaneous
hematomas may also reflect characteristic features of
the offending object. Supplementary to the conventional
investigation methods, diaphanoscopy is used to detect
and demarcate subcutaneous hemorrhages [66]. By
vertically transilluminating the skin with a halogen lamp
a zone of lucency forms around it with an asymmetrically
275
narrowed diameter above the optically denser subcutaneous
hematoma.
Intracutaneous hematomas can show a detailed negative
imprint, if the skin is pressed into narrow hollows by the
effect of local pressure. Pattern injuries of this type may be
caused by the shoe soles in injuries due to kicking
[15,52,57,158], but also by the weave of textiles worn
directly on the skin traumatized by blunt force [167].
Reactive skin reddening caused by local mechanical irrita-
tion is quite often associated with petechial intracutaneous
hemorrhages [12,80].
Subcutaneous hematomas may also show characteristic
shapes, as emphasized above already in the example of
bruises consisting of two parallel lines after blows from a
cane. The roundish subcutaneous hematomas resulting from
the local pressure of fingertips must also be regarded as
special forms; they are seen particularly often on the medial
aspect of the upper arms and suggest that the victim was
grabbed or held vigorously [131,141]. Primarily uncharac-
teristic hematomas may become subsequently structured, if
they are compressed by corresponding objects for a pro-
longed period of time; under these circumstances pale areas
or zones of different intensity develop within the contusions
[142].
The dating or aging of hematomas in surviving victims is
one of the most difficult tasks in clinical forensic medicine.
Already Berg [10] stated that the sharp or vague demarcation
of the hematoma discoloration against the surrounding skin
is no reliable criterion. At the beginning subcutaneous
hematomas often show vaguely from the depth, especially
as they are often associated with tissue edema in the first few
days. Hematomas may therefore appear to have clearer
contours and more intense color after a few days than in
the initial phase. Then, as the hematoma gradually resolves
and fades, the margins become vague again.
In view of the numerous, partly differing statements in
the literature regarding the age-related color changes of
subcutaneous hematomas great caution seems justified.
Tutsch-Bauer et al. [196] found yellow-colored portions
in the marginal areas of artificially generated hematomas in
three of 30 subjects already on day 1; on day 7 yellow was
present in 93% of the subjects. Around day 4 many of the
subjects showed the colors blue, green, brown and yellow
side by side. On day 4 the hematomas also reached their
maximum size. Already in 1970, Lins and Hamper [89]
recorded reflectance curves of artificially generated hema-
tomas and evaluated the color changes with time. The
authors showed that reflectance values in the orange-yellow
and blue–green range of hematomas slowly declined within
4–6 days. With an ophthalmospectrometer Klein et al.
[76,77] performed reflectance measurements in the spectral
range of 430–700 nm on hematomas artificially generated
under standard conditions and on periorbital hematomas.
At the wavelength 580 nm (yellow) periorbital hematomas
with an age difference of more than 2 days could be
distinguished.
276 S. Pollak / Forensic Science International 144 (2004) 269–283
Beside excoriations and hematomas, lacerations are
among the most important sequels after blunt traumatization
of the body surface. Only in rare cases does the severance of
the skin as such allow conclusions as to the shape of the
causative object. Occasionally, however, the wound edges
may reflect a characteristic contour of the striking object
[64]. Experimental studies have demonstrated that the linear
parts of the skin severance correlate well with the length of
the edge of the wounding object [67].
10.2. Sharp force
The information contained in stab and cut wounds is
seldom sufficient to describe the properties of the inflicting
tool precisely enough to allow definite attribution. Repeat-
edly parallel, linear excoriations were observed when a
serrated blade was drawn across the skin transversely to its
longitudinal axis, leaving tangential abrasions [199]. The
serrated back of a ‘‘survival knife‘‘ can also produce
analogous excoriation lines with its saw teeth [129]. Sharp
blows with a so-called fine-tooth saw leave wound edges
with regular indentations corresponding to the serrations
of the saw blade [23]. Cut wounds caused by glass can
show morphological features that may facilitate differen-
tiation from wounds due to other types of sharp instru-
ments [1].
In stab wounds the presence of a blunted end sometimes
points to the use of a knife with a single cutting edge. With a
serrated back of the blade, the pertinent wound end shows
concomitant abrasions that may occasionally resemble a
fish’s tail [96,129]. In rare cases a blade without a serrated
back can also cause a slightly abraded wound end [98]. If a
stab wound is inflicted by massively thrusting the blade into
the body up to the hilt, the bladeguard may produce a
characteristically shaped imprint [11,134,160,179].
Screwdrivers produce special wound shapes. Tools with a
wedge-like blade end create slit-like skin wounds often
associated with squared or torn ends [26] and abraded
margins. So-called Philipps screwdrivers show cross-shaped
or roundish wounds with four radial cuts arranged in pairs
opposite each other [115].
10.3. Burns and electrotraumas
As mentioned above, contact burns and scalds play an
important role in child abuse. Burns by glowing cigarettes
are seen in abused children, but also in torture victims, in
self-inflicted injuries and accidentally in intoxicated drug
consumers [54,131,140]. The examination of arsonists often
shows thermal lesions, especially if a liquid fire accelerant,
e.g. gasoline, was used. By evaporation an explosive gas–air
mixture forms whose ignition leads to a ‘‘flashover’’ with
potential burns of exposed body parts (face, hands and other
unclothed body regions facing the explosion). Singeing of
eyebrows and eyelashes as well as beard, head and body hair
is also common [17].
For several years so-called electroshocking devices have
been in use for self-defense or for abuse by intimidation and
torture. The purpose of these devices is to put assailants out
of action by electrical impulses without causing long-term
damage to them [5,32,169]. At the sites where the electrodes
approached or touched the body red spots about 5 mm in
diameter and minor swelling of the tissue may occur. These
local erythemas are transient and fade within a few hours.
The paired arrangement of the small red spots with the same
distance as the electrodes can be an important clue that the
lesion was caused by an electroshocking device [131].
Contrary to conventional electroshocking devices, so-called
‘‘Tasers’’ fire arrow-like electrodes connected to about 5 m
long wires, whose pin-like probes adhere to the clothing or
the skin [29].
In survived electrotraumas one often finds fluid-filled skin
blisters instead of normal electric marks [125,136]. If cir-
culation continues even for a short time, fluid-filled vesicular
detachment of the epidermis (‘‘electrical burn blister’’)
occurs. Electrical burns often reflect morphological details
of the contacted surface. After healing with scar formation,
an interrupted pattern of the dermal ridges will remain on the
friction skin [136].
Two of three individuals struck by lightning survive. In
most of these cases the victims are unconscious initially.
Moreover, there are often neurological symptoms, e.g. light-
ning paralysis, sensory disturbances and paresthesias. The
electrothermal changes on the body surface of surviving
victims struck by lightning are similar to those of fatal
accidents [83].
10.4. Strangulation
Survived strangulations are often the subject of medico-
legal evaluation. Attacks against the neck occur very often in
the course of sexual offenses, fights or robberies with the
number of manual strangulations being higher than that of
ligature strangulations. Naeve and Lohmann [118] found
that 30% of the victims were under the influence of alcohol.
Often both the perpetrator and the victim are intoxicated.
The strangulation findings may range from discrete red-
dening of the skin via various forms of excoriations to intra-
and subcutaneous hematomas [131,141]. The reddening of
the skin, which is mostly patch- or streak-like in shape, is
often associated with superficial defects of the epidermis
and/or intracutaneous petechial hemorrhages [12]. The num-
bers as to the incidence of externally visible injury on the
neck vary. In the material studied by Strauch et al. [189] all
81 victims showed discernible strangulation or throttling
marks on the skin of the neck. Mere reddening of the skin can
be demonstrated up to 2 days at the most [12,55,80].
A high percentage of the strangulation victims does
not only show local findings on the neck, but also concurrent
injuries on the remaining parts of the body [55,88,118].
Often injuries can also be found on the assailant’s body
as a consequence of the victim’s defense. For example
 S. Pollak / Forensic Science International 144 (2004) 269–283
scratch-like excoriations may be inflicted by the use of the
fingernails on the neck, the shoulders and the chest
[55,74,118,141]; bite marks and contusions are also lesions
often occurring due to the victim’s defense [117]. Surviving
victims typically complain about dysphagia, dysphonia,
spontaneous pain and tenderness to pressure in the laryngeal
region as well as pain on moving the neck. The percentage of
those becoming unconscious during an attack to the neck
varies greatly depending on the composition of the study
material. This applies also to sphincter incontinence.
Congestive petechial hemorrhages after survived attacks
to the neck are of great diagnostic significance, although
they do not constitute a specific sign of asphyxia. As is well
known, similar extravasations of blood may occur also after
physiological processes of pressing [51,145]. In surviving
strangulation victims the incidence of petechial congestive
hemorrhages depends, inter alia, on the duration and inten-
sity of the manual or ligature strangulation, the physical
strength of the persons involved and the kind of cervical
compression. The minimum time necessary for the mani-
festation of congestive hemorrhages is difficult to define.
Bschor [28] assumed that after totally interrupting the
venous flow it takes at least 10–20 s before the venous
vessels in the region of the head and neck are completely
filled with blood.
Often the forensic expert has to comment on how dan-
gerous a compression of the neck was. The most contro-
versial issue in this context is the practical relevance of the
vagus-mediated consequences (‘‘reflex cardiac arrest’’)
[185]. On the basis of a survey of the literature, Kleemann
et al. [73] arrived at the conclusion that sudden death due to a
short grip to the neck is imaginable only if there is an
individual predisposition of the victim, but seems to be
‘‘practically impossible’’ under normal conditions. In stran-
gulation by the forearm obstruction of the arterial blood flow
to the brain is the essential pathophysiological mechanism
[33]. With this grip subjects became regularly unable to act
within less than 15 s [31].
10.5. Defense injuries
Defense injuries are of special forensic significance, as
they are indicative of an assault [132,139]. Moreover, they
justify the assumption that the attacked individual was - at
least initially - conscious and able to use his limbs. In
addition, the victim must have anticipated the assault and
been able to protect himself.
In knife attacks, traditionally a distinction is made
between ‘‘active’’ and ‘‘passive’’ defense injuries [114,
143]. Accordingly, the active type of injury occurs when
the victim tries to grasp the knife with his or her hand; in
these cases the wounds are typically localized on the palmar
side of the hand. The passive wound type is sustained when
the victim raises their hands/arms for protection; conse-
quently these wounds will primarily be localized on the
extensor sides of the forearms and the back of the hands. It
277
seems justified to express doubts as to the stereotyped
distinction between ‘‘active’’ and ‘‘passive’’ defense injuries
[2,106]. In victims capable of acting their incidence
increases with the number of stabs. More than 2/3 of all
defense wounds are found on the left arm or left hand. Cuts
on the palmar side of the hands cannot only occur when the
victim tries to ward off a knife attack, but also when the
perpetrator’s hand slips from the grip of the knife and slides
along the blade on performing the stab.
Defense injuries due to blunt force are to be expected
when the victim attempts to ward off blows or kicks with his
hands or arms. The preferred localizations resemble those of
knife attacks. If the skin of the affected region is over a bony
support, lacerations may occur in addition to abrasions and
hematomas [135,170].
In a wider sense defense injuries can be due also to
bullets. Persons threatened with a firearm often ‘‘instinc-
tively’’ keep their hands in front of their head or chest, so that
the hand or forearm is hit first by the shot [139].
11. Forensic age estimation
Since the early 90s, institutes of forensic medicine have
been performing estimations of the age of living individuals
in an increasing number of cases [164,165,176,177]. These
refer mostly to foreigners without valid identity papers, who
do not know their age or presumably make a false statement
and whose chronological age is legally relevant for criminal
or civil proceedings. On 10 March 2000, the study group on
Forensic Age Estimation of the German Society of Legal
Medicine was founded in Berlin under the chairmanship of
Gunther Geserick. Before a nation-wide analysis had been
made on the current status of forensic age estimation in
living individuals within the scope of the 10th Lübeck
Meeting of German Medicolegal Experts (3–4 December
1999) [121]. The study group worked out recommendations
for the estimation of the age in criminal proceedings which
were adopted on 15 September 2000 [175]. According to
them the following investigation methods should be used:
physical examination recording anthropometric parameters,
signs of sexual maturity and any developmental disturbances
in relation to age, X-ray examination of the left hand, dental
status including X-ray of the teeth. Another recommendation
[166] refers to the estimation of the age of living individuals
in pension proceedings.
In view of the different origin of the subjects coming to
Germany in the course of global migration movements the
question arises, whether ethnicity has an influence on
the chronology of third molar mineralization – which is
a main criterion of the dental estimation of age [122].
Comparative studies of German, Japanese and South Afri-
can populations [123] showed that population-specific
standards should be used for the assessment of the miner-
alization stage of the third molars to improve the indicative
value.
278 S. Pollak / Forensic Science International 144 (2004) 269–283
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