In situations of assault and attack it is a normal reflex to protect oneself. In many instances the reflex involves sustaining injury but reducing the damaging results.
When a knife or a stabbing implement is directed at an individual, blows to the head and face may be defended by raising the hands and arms to cover the head and face. The hand may attempt to grab or deflect a weapon. The arms and hands sustain in juries but the head is protected.
In addition, in incidents involving knives where a knife may be thrust towards an individual the individual may try and defend themselves by grab- bing the knife blade and deflecting it away from, for example, the chest and abdomen. Grabbing of the cutting blade will result (if the knife is sharp enough) in cuts to the part of the hand that grabs the knife (generally the palm or gripping side of the hand and fingers; Figure 8.29). Both assailant and victim can sustain incised wounds if there has been a struggle. In general, the dominant hand may generally automatically be used to defend, but if the dominant hand (most commonly the right) is otherwise engaged, the non-dominant hand may be used. Multiple defence wounds may be sus- tained during an assault, and such wounds to the
(c)
Figure 8.28 Bites.(a) Human bite with tissue loss to right ear.
(b) Bite mark with bruising, skin lifts and teeth marks to chest.
(c) Bite causing tissue loss to chin no clear teeth marks evident.
(b)
(a)
Self-inflicted injur y
hands may be of variable depth, or discontinuous, as the hand is not a flat surface.
Defence-type injury after blunt weapon assault will be seen in the same regions, namely the exten- sor surfaces of arm and upper arm (Figure 8.30) which may be raised to protect against blows, and on the back, or the back of the legs, if an individual is taken to the ground and, for example, kicked. The victim will tend to curl up in a ball with hands and arms over the head and legs tucked up towards the chest.
Defence injuries may be absent following an assault. This may be for a number of reasons includ- ing unconsciousness from assault, or incapacity
through drugs or alcohol or restraint by another person or persons.
■ Survival after injury
The length of survival following infliction of an injury is difficult to determine: every human being is different and this variability in survival and post- injury activity is to be expected. Any expression of either survival time or of the ability to move and react must be given on the basis of the ‘most likely’
scenario, accepting that many different versions are possible. The court should be advised of the difficul- ties of this assessment and should be encouraged also to consider eyewitness accounts.
It must be remembered that survival for a time after injury and long-term survival are not one and the same thing. The initial response of the body to haemorrhage is ‘compensatible shock’, shutting down peripheral circulation; if blood loss continues, the homeostatic mechanisms may be overwhelmed and the individual enters the phase of ‘uncompensated shock’, which leads inexorably to death.
Many examples exist of individuals with appar- ently potentially immediately fatal wounds who have performed purposeful movements/actions for some time after the ‘fatal’ injury. Forensic practi- tioners should always be very wary about allotting fixed times after which somebody could not have survived, only to be confronted with CCTV evidence showing that they clearly did.
■ Self-inflicted injury
All types of injury can be self-inflicted, acciden- tally inflicted or deliberately inflicted by another.
Most deliberate self-inflicted injuries are caused by those with psychiatric or mental health issues, or in association with stressful situations and anx- iety. Patterns of injury are well-documented in such individuals. In the forensic setting there is a small, but significant, group of individuals who self-harm for other motivations, such as staging assault for attention-seeking and similar motives, or to deliber- ately implicate others in criminal acts or for financial gain (e.g. insurance fraud). Such injuries will not fol- low the pattern of ‘typical’ self-arm injury.
Fatal self-inflicted blunt-force injuries may be inflicted following, for example, jumping from a
Figure 8.30 Bruising to extensor aspect of left arm – raised to ward off impact from baseball bat.
Figure 8.29 Defence injuries to right hand caused by knife.
8 Asse ss ment, class ification and do cumentation of injury
height or under a train. There may be no specific features to the injuries that identify them as self- inflicted. Self-inflicted bite marks may occasionally be seen on the arms of an individual who claims to have been assaulted or blunt force injuries to the head or other parts of the body. Abrasions might be created by using objects such as abrasive pads to fabricate injury.
Self-inflicted incised or stabbing injuries, how- ever, frequently show specific patterns that vary depending on the aim of the individual. In sui- cidal individuals, self-inflicted sharp-force inju- ries are most commonly found at specific sites on the body called ‘elective sites’; for incised wounds these are most commonly on the front of the wrists and neck, whereas stabbing injuries are most com- monly found over the precordium and the abdo- men. In individuals who only desire to ‘self-harm’
or mutilate themselves, the site can be anywhere on the body that can be reached by the individual (Figure 8.31). Generally, the eyes, lips, nipples and genitalia tend to be spared.
The other features of self-inflicted injuries lie in the multiple, predominantly parallel, nature of the wounds and, in suicidal acts, the more superficial injuries are referred to as ‘hesitation’ or ‘tentative’
injuries (Figure 8.32).
The forensic practitioner has an important role in the evaluation of the nature and pattern of inju- ries that might be self-inflicted. In the absence of an admission of self-harm from an individual, it may be possible to come to a view as to whether injuries are likely to have been self-inflicted if the characteris- tics listed in Table 8.1 are considered. Some or all of these characteristics - commonly inflicted by some form of implement, such as a knife or a nail, may be present, but it is important to note that only some, and rarely all, may be present in an individual case.
The absence of a particular feature listed does not preclude self-infliction; neither does its presence necessarily imply self-infliction.
In some difficult cases, it may not be possible to exclude assault, and evidence of self-harm, rather than assault, must come from alternative sources, such as other witnesses.
The staging of assault or injury may also involve other individuals complicit in the proc- ess. In such a setting, injuries that are unusual as
‘self-harm’ injuries (e.g. black eyes or deep abra- sions) may have been inflicted by an accomplice.
In such cases the detail of the accounts given (or
(a)
(b)
Figure 8.31 (a) Multiple linear burn marks (caused by heated knife blade applied to the skin) – note healed lesions between acute lesions. (b) Multiple incised wounds to forearm – note different ages of scars.
Figure 8.32 Multiple new incised wounds with smaller and more superfi cial tentative injuries (arrowed).
T orture
not given) can be crucial in determining the actual course of events.
■ Torture
Article 3 of the European Convention on Human Rights states that no-one shall be subjected to torture or to inhuman or degrading treatment or punishment. Unfortunately, such treatment and punishment is still widely found throughout the world. Forensic physicians and pathologists may be asked to assess individuals claiming torture or human rights abuse. Such assessments can be com- plex and it may be necessary to assess and interpret physical findings for which there may be a number of explanations. The doctor’s role is to assess these finding impartially. In order to make an assessment for physical evidence of torture a structured examina- tion must take place, which involves the history, the medical history and then the physical examination.
The physical examination must involve systematic
examination of the skin, face, chest and abdo- men, musculoskeletal system, genitourinary system and the central and peripheral nervous systems.
Specific examination and evaluation is required following specific forms of torture which include:
beatings and other blunt trauma; beatings of the feet; suspension; other positional torture; electric shock torture; dental torture; asphyxiation; and sexual torture, including rape. Specialized diag- nostic tests may be required to assess damage (e.g.
nerve conduction studies).
The history taking should include direct quotes from the victim, establishment of a chronology, where possible backing it up, for example with old medical records and photos. A summary of deten- tion settings, and abuses, must be obtained with details of the conditions within those settings and methods of torture and ill-treatment. Atten- tion must also be paid to, and may require spe- cialist assessment of, the psychological status of the victim. Specific torture techniques that may be described include:
Table 8.1 Some characteristics that may be associated with self-infl icted injury
Characteristic Additional Comments
1. On an area of the body that the individual can access themselves Injuries in sites less accessible (e.g. the middle of the back) are less likely to have been self-infl icted
2. Superfi cial or minor injury Severe self-infl icted injuries may also be caused, particularly in those with psychiatric disorder
3. If there is more than one incised wound, they are of similar appearance, style and orientation to one another (e.g. parallel with each other)
Typically, self-infl icted sharp force injuries are more superfi cial, numerous and similar to each other than those sustained in an assault, where the natural reaction of the injured person is to avoid repeated injury
4. If there are other types of injury (e.g. scratches, cigarette burns) these are also of similar appearance, style and orientation to each other
As above – multiple superfi cial, and relatively trivial injuries that are similar in nature and extent to each other should raise the possibility of self-infl iction
5. Injuries grouped in a single anatomical region As above 6. Injuries are grouped on the contralateral side to the patient’s
handedness
A right-handed person will tend to harm themselves on the left side of the body
7. Tentative injuries Smaller or lesser injuries grouped with the main injuries are termed
‘tentative’ or ‘hesitation’ marks, where initial attempts at injury have been made
8. Old healed scars in similar sites May indicate previous attempts at self-harm 9. Scars of different ages in similar sites May indicate repeated previous attempts at self-harm
10. Slow-healing injuries Persistence of wounds that would otherwise have been expected to
heal, in the absence of any other factors 11. Psychiatric and related issues (such as eating disorders, drug
and alcohol misuse)
There may be an increased incidence of self-infl iction with such conditions
12. Possibility of self-infl icted injuries created to stage a crime These may lack many of the features referred to above.
8 Asse ss ment, class ification and do cumentation of injury
■ beating of the soles of the feet (falanga, falaka or bastinado; Figure 8.33)
■ amputation (Figure 8.34)
■ positional torture – e.g. cheera (legs stretched apart) or Parrot’s Perch (wrists tied over knees – a pole placed under the knees)
■ suspension – e.g. Palestinian hanging (arms and wrists tied and elevated behind the back;
figure 8.35), which can result in disruption of shoulder joint complexes and subsequent deformity.
■ electrical burns (Figure 8.36)
■ wet submarine – immersing the victim’s head in a container full of water until the person almost drowns
■ dry submarino – placing the victim’s head inside a plastic bag until nearly suffocated.
Each of these may have short and long-term sequelae.
It is important to recognize that there may be no physical evidence of torture. Where scars or marks are present it is important, for the credibility of the examination to distinguish between alleged tor- ture scars and injuries and non-torture scars and injuries.