Themes of a forensic´s every day work

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This page is supposed to inform you in a loose succession about themes of a forensic´s every day work:

IContent:

Auto-aggression

Although auto-aggression has always been relevant to physicians faked or provoked illnesses and injuries have become more and more important in the last years. The forensic investigator is confronted with this phenomenon in the form of insurance fraud and the simulation of child abuse, rape, mugging and accidents. There are various types of auto aggression:

1. Open auto-aggression:

Unhidden self-aggression in schizophrenics, depressives, persons with borderline personalities and other psychiatric disorders.

2. Hidden auto-aggression:

a) Simulation of illnesses and diseases deceiving other persons about the
true reason of the injury
b) Insurance fraud, for example by injuring a body member after insuring it
highly

3. Münchhausen´s syndrome: Simulation of physical or psychical symptoms

4. MSBP = Münchhausen´s syndrome by proxy: Simulation of physical or psychical symptoms in children

Literature:

Behrmann K, Wienberg H, Püschel K (1990) Zur Vortäuschung von Sexualdelikten. Kriminalistik 4: 207-210
Bonte W, Rüdell E (1978) Fehlschlag oder gezielte Selbstverstümmelung? Die Wahrscheinlichkeit akzidentieller Verletzungen beim Beilhieb. Arch Krim 161: 143-152
Eckhardt A (1996) Artifizielle Störungen. Dt Ärztebl 93: B1266-1270
Karger B, DuChesne A, Ortmann C, Brinkmann B (1997) Unusual self-inflicted injuries simulating a criminal offence. Int J Legal Med 110: 267-272
Kernbach-Wighon G, Thomas RS, Saternus KS Forensic Sci Intern 89: 203-209
König HG, Freislederer A, Baedeker C, Pedal I (1987) Arch Krim 180: 13-27
Lochte (1913) Vjschr Gerichtl Med 45 (Suppl): 261-268
Maxeiner H, Klug E (1997) Lethal suicidal intoxication with propafenone, after a history of self-inflicted injuries. Forensic Sci Intern 89: 27-32
Peschel O, Betz P, Eisenmenger W (1997) Self-mutilation with needles. Med Sci Law 37: 175-178
Pollak S, Reiter C, Stellwag-Carion C (1987) Vortäuschung von Überfällen durch eigenhändig zugefügte Schnitt- und Stichwunden. Arch Krim 179: 81-93
Püschel K, Hildebrand E, Hitzer K, Harms D (1998) Zur Beurteilung verstümmelnder Hand- und Fingerverletzungen bei Ärzten im Zusammenhang mit privaten Unfallversicherungen. Versicherungsmedizin 50: 232-240
Püschel K, Kleiber M, Erfurt C (1994) Morphologie und Rekonstruktion des Traumas durch Vortäuschung einer Straftat durch selbstbeigebrachte Verletzungen. Hautnah päd 6: 170-177
Püschel K, Kernbach G, Brinkmann B (1988) Notzuchtsdelikte. Tägl Prax 29: 257-269
Risse M, Weiler G, Jedamzik J (1992) Kasuistischer Beitrag zur krankhaften und kriminellen Selbstbeschädigung. Arch Krim 189: 77-83
Vendura K, Strauch H (1997) Selbstbeschädigung mit einer Schreckschusspistole. Arch Krim 200: 37-44

Münchhausen Syndrome by Proxy

In 1977 Meadow established the term "Münchhausen´s syndrome by proxy"* to give a name to a bizarre kind of child maltreatment. A parent or another person who looks after the child provokes symptoms in the child and usually takes him or her to a doctor. Often the children have to bear painful diagnostic and therapies or even die because of their severe injuries or diseases.
In the last years the MSBP has become better known to German physicians. Until today various case reports have been published, but it is not yet possible to make substantiated statements about the epidemiology of the syndrome. For further information we have to conclude from data of other countries like the USA and Great Britain. All we can say is that boys and girls are similarly often affected, and that the culprits usually are the children's mothers.

In the literature about MSBP various symptoms have been described as appearing in little patients maltreated by their parents:
- consciousness disorders: breathing arrest, epileptic fits, unconsciousness, attacks of cyanosis, lethargy
- haemorrhages: gastrointestinal bleedings, haemoptysis, haematocryal, auricular bleedings
- infections: fever of unknown origin, abscesses, osteomyelitis, dermatitis, recurrent infections of the urinary tract
- others: vomit, diarrhea, allergies. diabetes mellitus, skin diseases, hypernatriemia

* The name of this phenomenon derives from the "Münchhausen´s syndrome" which was first described by Asher in 1951.

Considering that these symptoms are very frequently seen in consulting hours it is important to keep the MSBP in mind when examining children. Every physician should become suspicious when he or she notices one of the following things:

1. Persistent or recurrent symptoms without a clear organic substrate
2. Appearance of the symptoms only in the presence of a certain person
3. The parent does not leave the child alone, is in very good contact to the medical staff, is solicitous, concerned and cooperative.
4. Frequent stays in hospitals with recovery in absence of the parent
5. Unusual course of the assumed disease and unusual symptoms
6. Therapies that usually are promising do not help.
7. Brothers or sisters with similar symptoms, sudden or mysterious deaths of brothers or sisters

Many culprits, at a percentage of 90% mothers, do have certain medical knowledge. They hardly leave their kids alone, very often accompany them to consulting hours and are present during their children's stays in the hospital. Others get to know them as friendly, affectionate and caring mothers. Until now a clear explanation for the mothers´ behaviour pattern does not exist. Meadow supposed the mothers to be motivated by the attention of relatives and friends as well the medical staff. In the mothers´ anamnesis self-aggression is frequent. Mistreating the child they use him or her as a substitute for themselves.
The forensic investigator is confronted with the MSBP when examining living persons or realizing autopsies. The mortality of the children is supposed to be between 5 and 33%. The repeat risk of the maltreatment is about 25%, even higher if the mother used medicaments or toxic substances (up to 40%) or provoked apnoea periods (up to 50%). Because of that it is very important to scrutinize if the children can stay at their parents´ house or if they would develop better separated from their family.

Literature:

Artingstall K (1999) Munchausen by Proxy and Munchausen Syndrome Investigation. CRC Press Boca Raton Boston London New York Washington
Asher R (1951) Munchhausen´s syndrome. Lancet I: 339-341
Krupinski M, Tutsch-Bauer E, Frank R, Brodherr-Heberlein S, Soyka M (1995) Münchhausen-by-proxy-Syndrom. Nervenarzt 66: 36-40
McClure RJ, Davis PM, Meadow SR, Sibert JR (1996) Epidemiology of Munchhausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. Arch Dis Child 75: 57-61
Marcus A, Ammermann C, Klein M, Schmidt MH (1995) Munchhausen syndrome by proxy and factitious illness: Symptomatology, parent-child interaction, and psychopathology of the parents. Eur Child Adosl Psychiatry 4: 229-236
Meadow R (1977) Munchhausen syndrome by proxy: the hinterland of child abuse. Lancet II: 343-345
Poets CF (1995) Das Münchhausen-Syndrom. Kriminalistik 8-9: 543-546
Southall DP, Plunkett CB, Banks MW, Falkov AF, Samuels MP (1997) Covert video recordings of life-threatening child abuse: Lessons for child protection. Pediatrics 100: 735-760