1

Definitions in
Forensics and
Radiology

B. G. BROGDON, M.D.

Forensic is derived from the Latin forens(is): of or belonging to the forum,

public, equiv- alent to for(um) forum + ens — of, belonging to + ic. By extension
it came to also mean disputative, argumentative, rhetorical, belonging to debate or
discussion. From there it is but a small step to the modern definition of forensic as
pertaining to, connected with, or used in courts of judicature or public discussion
and debate. Thus the forensic sciences encompass the application of specialized
scientific and/or technical knowledge to questions of civil and criminal law,
especially in court proceedings.
Forensic Medicine has come to be recognized as a special science or
discipline that deals with relationships and applications of medical facts and
knowledge to legal problems. Some prefer to call it legal medicine or medical
jurisprudence.
Forensic Medicine is often considered to be synonymous with forensic
pathology because full-time involvement of a physician with forensic
activity is almost exclusively the province of that specialty.1 The forensic
pathologist is concerned principally with the post-mortem examination
and, hence, deals mostly with the dead. In acknowledgment of this, Milton
Helpern, M.D., the third Chief Medical Examiner of the City of New York,
caused to be inscribed upon the lobby wall of his new office building in
1961 the Latin admonition, TACEAT COLLOQUIA. EFFUGIAT RISUS. HIC
LOCUS EST UBI MORS
GAUDET SUCCURRERE VITAE, (Let conversation cease. Let laughter flee.
This is the place where death delights to help the living).2 While other
medical specialists may consult with the pathologist in the evaluation of
death, virtually all of their other professional activities may have
medicolegal ramifications and hazards involving both the living and the
dead. These can embrace a large body of legal issues (e.g., age
determination, assault, civil rights violations, inheritance, larceny,
malpractice, parentage, personal injury, product liability, sexual offenses,
smuggling, virginity, and wrongful birth or death).
Thus, in Gradwohl 3 the definition of legal medicine was expanded to
include “the application of medical knowledge to the administration of
law and to the furthering of justice and, in addition, the legal relations of
the medical man.”
Evidence of the origin of legal or forensic medicine can be found in
records of ancient people some thousands of years ago, when
occasionally a law appears to influence medicine or medicine is found to
influence or modify a law.3,4 The Egyptian, Imhotep, may have been the
first to apply both the law and medicine to his surroundings. Hammurabi
codified medical law circa 2200 B.C., and medicolegal issues were covered
in early Jewish law. Later, other civilizations — the Greeks, ancient India,
the Roman Empire — evolved jurispru- dential standards involving
medical fact or opinion.
Early cultures recognized the desirability of controlling the
organization, duties, and liabilities of the medical profession. They also
were acquainted with the importance of the knowledge and opinion of
the medical person in the legal consideration of issues of great
moment such as the use of drugs or poisons, the duration of pregnancy,
virginity, super- fetation, the prognosis of wounds in different body
locations (a physician determined that only one of Caesar’s 23 stab
wounds was fatal), sterility and impotence, sexual deviation, and suspicious
death.
Early in the sixteenth century a separate discipline of forensic medicine
began to emerge. New codes of law required expert medical testimony in
trials of certain types of crime or civil action. The first medicolegal books
appeared in the late sixteenth and early seventeenth centuries and, after
1650, lectures on legal medicine were given in Germany and France. The
first book on medical jurisprudence in the English language appeared in
1788 and 19 years later the first Regius Chair in Forensic Medicine was
recognized by the Crown at the University of Edinburgh. The English
coroner’s system was imported to the Colonies in North America in 1607,
and it was not until 1871 that Massachusetts, later followed by New York
and other jurisdictions, established a medical examiner system. Upon this
base of professionalism in death investigation, supported by the
framework of solid scientific and technical advances during the twentieth
century, was erected the mod- ern structure of forensic medicine which
covers a heterogeneous, sometimes loosely related, family of numerous
disciplines or subspecialties sharing a common interest.
Among those, Forensic Radiology usually comprises the performance,
interpretation,
and reportage of those radiological examinations and procedures that
have to do with the courts and/or the law. Until but a few decades ago,
Radiology could be defined as that special branch of medicine employing
ionizing radiant energy in the diagnosis and treat- ment of disease. Now,
the specialty of Radiology is divided into two quite distinct disci- plines
sharing only a common historical origin and a single certifying body, the
American Board of Radiology. One of those two branches is Radiation
Oncology, which utilizes high- energy ionizing radiant energy wavelengths
and particles in the treatment of (almost exclusively malignant neoplastic)
disease.
It is the other major branch of the specialty, Diagnostic Radiology, with
which this book will be concerned. Diagnostic radiology is devoted
primarily to the study of images of the internal structures of the human
body. Perhaps Harry Z. Mellins, M.D., a superbly talented radiologist and
teacher, best captured the eidolon of the diagnostic radiologist more than
30 years ago when he wrote,5
 The [diagnostic] radiologist perceives a shadow, sees a lesion, and
imagines a man. The bedside physician sees the man, perceives the signs
and images the lesion. They practice from the outside in and we from the
inside out.

Nowadays images are acquired by an array of modalities and techniques:

• The x-ray or roentgen ray is an energy form of ionizing radiation from

which may be produced fluorescent or photographic images. The latter
are sometimes also called “x-rays” but are correctly termed
roentgenograms, less accurately radiographs, and vulgarly as films (e.g., “chest
film”) (Figure 1-1).
• The fluorescent image can be electronically enhanced and directly
visualized in real- time motion, cine-photographed, videotaped, or
digitized and stored on magnetic tape or disks for replay (Figure 1-2).
• In the subspecialty of nuclear medicine or nuclear radiology, radioactive
materials or isotopes can be directed to internal target organs or
tissues by injection, inhalation,
Figure 1-1 Chest roentgenogram, radio-
graph, or “ftlm”. This patient has an intracar- diac
tumor but it cannot be distinguished from the
heart muscles or the blood inside the heart since
all have approximately the same ability to
absorb x-rays.

Figure 1-2 A modern fluoroscope with an image intensifter connected to a television camera.
The televised image (arrow) can be seen without darkening the room.

or ingestion; the radiant energy escaping from inside the body can
be collected on sensitive films or phosphors to create images,
scintiscans, of the internal targets (Figure 1-3).
• Sound waves generated outside the body by transponders are reflected
back from internal structural interfaces to be recaptured and converted
into real-time or static images. The modality is called ultrasound or
ultrasonography. The image is a sono- gram (Figure 1-4).
• With special equipment, a roentgenogram of a thin section or slice of
the body or body part can be acquired in the sagittal, coronal, or oblique
plains (Figure 1-5). This technique is known as tomography and the
processed image is a tomogram (now qualified as a conventional tomogram
to distinguish it from a computed tomogram).
Figure 1-3 This is a nuclear scan using a bone-
seeking isotope so the skeleton is imaged. Some of
the isotope is taken up by the kidneys (arrows)
and excreted into the bladder (open arrows)
which should have been emptied before the scan
was done. Unfortunately the full blad- der
obscures a tumor (chordoma) in the sacrum. (See
Figure 1-7B-E, same case.)

Figure 1-4 The ultrasound image of the same heart shown in Figure 1-1 is displayed as a cross-
sectional image of the heart. The tumor is visualized in the interventrical septum (arrows) between
the right ventricles (RV) and left ventricle (LV).

• Conventional roentgenograms result when x-ray photons (or light rays

from inten- sifying screen phosphors excited by x-rays) “expose” a
sensitive silver halide emul- sion which, when processed, leaves a grain
of reduced silver where the light-ray or x-ray photon struck. These
microscopic black “dots” coalesce where the most x–rays were
transmitted to the film and are sparse to absent where the interposed
body absorbed the radiation and are intermediately dispersed in a gray
scale according to the atomic number of the interposed tissue. This
is an analogue image. With proper instrumentation or equipment an
analogue image can be converted into a digital image. Some of the
newer radiographic equipment modalities (i.e., digital fluoroscopy,
digital subtraction angiography, some ultrasonography, computed
tomography, and magnetic resonance imaging) produce a digital
image directly. The advantage of a digital image is that it can be
manipulated by such techniques as contrast shift, density range
adjustment, back/white reversal, and edge enhance- ment (Figure 1-6).
Although the analogue image has better spatial resolution than
Figure 1-5 Example of conventional tomography. A. Chest roentgenogram: close-up of upper lung
showing a large plaque of thickened pleura which obscures the underlying lung. B. Con- ventional
tomogram: slice through the lung shows a nodular lesion that was hidden by the overlying pleural
thickening.

the digital image, maximal contrast resolution is required to exploit

the spatial resolution, and shades of gray are not easily separated.
Thus the analogue roent- genogram may display muscle, water,
blood, or brain in a gray scale in which they are indistinguishable one
from another (Figure 1-7). The digital image can be computer
processed or manipulated to separate shades of gray, thus
permitting, for instance, visual separation of the brain substance
from its interventricular fluid or the gallbladder wall from the bile it
contains.
• Computed axial tomography caught the public fancy as the “CAT Scan” but
is now more commonly and properly referred to as computed
tomography or simply CT and the product also called a CT or, preferably,
a CT scan. This device uses an array of photoreceptors to detect slight
differences in attenuation of roentgen rays emitted by a rotating x-ray
tube as they passed through the body or body part over multiple
diametric pathways in the axial or cross-sectional plane. The computer-
processed result is a series of images of cross-axial sectional slices of
the body or part, allowing
Figure 1-6 A and B are digital images of a chest containing multiple pulmonary nodules
(arrows). The visual effect of black/white reversal image manipulation is demonstrated.

a much higher differentiation between body tissues than can be

achieved from a conventional x-ray machine (Figure 1-8). The
electronically acquired and computer- processed image can be
manipulated in a variety of ways; for instance, to reconstruct images
in coronal or sagittal planes or even two-dimensional displays of
three- dimensional (3-D) reconstructions.
• Magnetic resonance imaging (MRI) utilizes strong magnetic fields to
generate elec- tromagnetic signals from elements and compounds
found in body fluids and tissues (Figure 1-9). With computer
manipulation one can obtain multiplanar, multidirec- tional,
sectional images or slices (MR scans). The signal strengths for
individual tissues can be identified or manipulated by varying
computer protocols.
• The subspecialty of interventional radiology is almost a separate
discipline. A com- plex armamentarium of tools, devices, and
instruments (e.g., catheters, balloons, lasers, needles, drains, stints,
“wooly worms”, macrospheres, enzymes, etc.) are used to invade the
body — not only to create images and enhance diagnoses, but also to
intervene therapeutically in disease processes or anatomic
abnormalities.
Figure 1-7 Schematic drawing showing differ-
ential absorption of x–rays by the tissues of the
body in conventional radiography. From most to
least radiodense these are (1) bone or calcium; (2)
all soft tissues and liquids (muscle, blood, brain,
heart, liver, urine, etc.) except (3) fat; (4) air or
other gases. [

Forensic radiology so far has depended almost exclusively on the x-

ray and the static image captured on the roentgenogram. Newer
imaging methods have revolutionized the field of diagnostic radiology
in a time span so short that it falls within the career experience of
radiologists still engaged in active practice. Already, some of these
advances are being incorporated into forensic studies. If problems of
accessibility and cost can be resolved, other of the newer radiologic
techniques and modalities may be appropriated by the forensic
sciences.
After all, it took six or seven thousand years of growth and
development for forensic medicine to reach its present level of fruition.
The flowering of forensic radiology had to wait on Professor Röntgen.
Figure 1-8 Examples of computed tomography. A. CT slice of heart showing tumor (arrows) in
interventricular septum (same case as in Figures 1-1 and 1-4). B and C: frontal and lateral
roentgenograms of a sacrum being partially destroyed by a tumor (arrows). D: CT slice through
same sacrum showing bone area of destruction (arrows). E: CT reconstruction of sagittal (lateral)
view from cross-sectional image. Note similarity to lateral view in C.
Figure 1-8 (continued)

Figure 1-9 Magnetic resonance image (MRI) of cardiac tumor

(arrows) shown in Figures 1-1, 1-4, and 1-8A.

References
1. Knight, B., How radiography aids forensic medicine, Radiography, 50, 5, 1984.
2. Helpern, M. and Knight, B., Autopsy, New American Library, New York, 1979, 184.
3. Camps, F. E., Ed., Gradwohl’s Legal Medicine, 3rd ed., Yearbook, Chicago, 1976, chap. 1.
4. Wecht, C. H., Forensic use of medical information, in Legal Medicine: Legal Dynamics of
Medical Encounter, 2nd ed., Am. Coll. Legal Med., Mosby-Yearbook, St. Louis, 1991, chap. 47.
5. Mellins, H. Z., Personal communication, 1963.