TUTORIAL REPORT

SECOND MODULE
DOMESTIC VIOLENCE
FORENSIC AND MEDICOLEGAL MEDICAL SYSTEMS

Tutor : dr. Irmayanti, Sp. PK

Group : 9
Dzul Rizka Razak 11020160039
Aulia Rizki Rahim 11020160063
Muh. Rachmad Sammulia 11020160070
Fuad Amjad 11020160082
Andi Muh. Riflan Astar 11020160089
Andi Bagaskara Sudirman 11020160098
Rifka Misbah Syarifah 11020160105
Sitti Rahmadani 11020160106
Eka Risdayani 11020160120
Rifka Augina Islami 11020160127
FAKULTAS KEDOKTERAN
UNIVERSITAS MUSLIM INDONESIA
MAKASSAR
2019

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 SCENARIO 2.1
A young adult woman was escorted by the investigator to a forensic
installation for examination. Based on patient information, she was forced to have sex
with her husband about a few hours ago. This incident has occurred several times
during the two years of their marriage age. According to the patient, their marriage
relationship is less harmonious and there is often mouth argument. In addition, the
patient admitted to being often beaten by her husband in a state of anger. The first
patient to report to the police because they can not stand it.

A bruise on the left inner thigh A bruise on the left arm of the outer side

A bruise on front side of upper right arm A blister on the six-hour needle on the vaginal
wall

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DIFFICULT WORD : -
KEY WORD :
• A young adult woman
• She was forced to have sex with her husband about a few hours ago
• This incident has occurred several times
• Their marriage relationship is less harmonious
• The patient admitted to being often beaten by her husband in a state of anger

QUESTION :
1. What are the characteristics of the wound from the scenario?
2. How is the wound / trauma patomechanism from the scenario?
3. What is the cause of possible injury (CODamage) using the proximus
morbus (PMA)?
4. How is the severity / degree of injury in accordance with applicable law?
5. What is possible characteristic of injury by the agent?
6. What is the Islamic Perspective according ti the scenario?

ANSWER :
1. Describes the characteristics of the wound
Number of wounds: 4 pieces of wound
Assessment of wound
1. First wound
a) Assessment localization
Localization: A bruise on the inner side of the left thigh
1. Axis: Can't determined because the center's line of the body can't be seen
2. Ordinate: Can't determined because the center's line of the body can't be
seen
3. Regio: The inner side of the left thigh

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 b) Size of wound: cannot be assessed because there is no description of size or
marker on the photo.
c) Type of wound: closed wound (wound due to blunt trauma)
d) The shape of the wound: oval-shaped
e) Characteristics/nature of the wound :1,2
1. Color: dark blue
2. Wound borderline:
a. Edge of wound: irregular
b. Limits of injury: clear
c. Surface: flat
d. Swelling: none
e. Abnormalities around the wound: none
f. The estimated age of injury: 1-18 hours. 1,2
2. Second Wound
a) Assessment localization
Localization: A bruise on the outer side of the left arm
1. Axis: Can't determined because the center's line of the body can't be seen
2. Ordinate: Can't determined because the center's line of the body can't be
seen
3. Regio: outer side of the left arm

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 c) Size of wound: cannot be assessed because there is no description of size or
marker on the photo.
d) Type of wound: closed wound (wound due to blunt trauma)
e) The shape of the wound: oval-shaped
f) Characteristics/nature of the wound : 1,2,3
1. Color: blue
2. wound borderline :
a. Edge of wound: irregular
b. Limits of injury: clear
c. Surface: flat
d. Swelling: none
e. Abnormalities around the wound: none
f. The estimated age of injury: 1-2 days. 1,2,3
3. Third wound
a) AssessmentLocalization
Localization: A bruise on the front side of the upper right arm
1. Axis: Can't determined because the center's line of the body can't be seen
2. Ordinate: Can't determined because the center's line of the body can't be
seen

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 3. Regio: front side of the upper right arm

c) Size of wound: cannot be assessed because there is no description of size or

marker on the photo.
d) Type of wound: closed wound (wound due to blunt trauma)
e) The shape of wound: a doughnut-like shaped
f) Characteristics/nature of the wound :
1. Color: greenish-yellow
2. Wound borderline:
a. Edge of wound: irregular
b. Limits of injury: clear
c. Surface: flat
d. Swelling: none
e. Abnormalities around the wound: none
f. The estimated age of injury: green 4-5 days, & yellow 7-10 days. 1,2,3
4. Fourth wound
a) Assessment Localization
Localization: There are 6-hour blisters on the vaginal wall

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 b) Size of wound: cannot be measured based on the picture from the scenario
c) The types of injuries: closed wound (injury due to blunt trauma)
d) The form of the wound: oval-shaped
e) Characteristics/nature of injuries : 1,2,3
1. Color: red
2. the boundary line cuts:
a. Edge of wound: irregular
b. Limits of injury: clear
c. Abnormalities around the wound: none. 1,2,3
Conclusion :
a. A bruise on the left inner thigh: there is a closed wound on the upper right arm,
with irregular clear border, the size of wound can't be measured, a dark blue of
color, flat surface, no swelling, no abnormalities in the area around the wound
b. A bruise on the left arm of the outer side: there is a closed wound on the upper
right arm, with irregular clear border, the size of wound can't be measured, a blue
of color, flat surface, no swelling, no abnormalities in the area around the wound
c. A bruise on the upper right arm of the front side: there is a closed wound on the
upper right arm, with irregular clear border, the size of wound can't be measured, a

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 greenish-yellow of color, flat surface, no swelling, no abnormalities in the area
around the wound
d. The 6-hour blisters on the vaginal wall: there is a 6-hour closed wound on the
vaginal wall, clear border, redness, no abnormalities in the area around the wound,
the sized can't be measured. 1,2,3
2. How is the wound / trauma patomechanism from the scenario?
Trauma is the leading cause of morbidity and mortality in patients under 35-
years of age and the sixth leading cause of death worldwide. The majority of serious
traumatic injuries are due to blunt trauma from motor vehicle crashes and pedestrian
injuries. Falls are also an important cause, particularly in the elderly. Direct blows,
assaults, and sporting injuries are also common. Non-accidental trauma is an
important cause and should be suspected with certain presentations and injury
patterns. Blunt impact to the body may result in a variety of injuries. Severity is
related to both the mechanism of injury as well as the underlying comorbidities of the
patient. Blunt impact injuries generally can be classified into four categories:
contusion, abrasion, laceration, and fracture. Blunt impact injuries are commonly
seen in forensic autopsy practice, and appropriate interpretation of wounds is
essential for accurate medicolegal testimony. 4

Blunt impact injuries result from direct contact of a blunt object with a body.
A contusion results from the blunt impact of significant force to rupture capillaries
underneath the skin surface while leaving the skin surface intact, while an abrasion
results from scraping off of the superficial epidermis. Contusions and abrasions may
show distinct patterns which can be used to match a specific wound to a potential
weapon or implement; for example, a contusion over the forehead with multiple
parallel, zig-zag lines may be matched to the sole of a shoe collected at the crime
scene. A laceration results from the blunt impact of significant force to tear the skin,
leaving strands of subcutaneous tissues bridging the wound. Contusions and

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lacerations may also be present on internal organs. Blunt impact of significant force
to a bone results in a fracture. 5

Blunt impact injuries are commonly seen in living and deceased patients. The
appearance of wounds depends on multiple factors, including the force, speed, length
of time of impact, surface area of contact, and elasticity of tissues impacted. A large,
crushing force applied to a sizable area over several minutes will result in vast tissue
damage; for example, failure of the integrity of a retaining wall at a construction site
will likely cause significant blunt impact injury if the wall collapses on and traps the
legs of an individual. Alternatively, a smaller force applied to a smaller area will
result in less tissue damage; for example, the impact of a thrown baseball to the
shoulder of an individual will likely cause minor blunt trauma. 4,5

Blunt trauma may result in internal or external hemorrhage depending on

location and mechanism. Recent contusions are typically red/purple and go through a
series of color changes as they heal. In general, a red/purple contusion will be more
recent than a yellow/green contusion on the same patient. Similarly, recent abrasions
and lacerations are typically red/purple and heal through the process of scab
formation which imparts a tan/brown, crusted appearance to the wound. Postmortem
abrasions will demonstrate a more tan/yellow, parchment-paper-like appearance
indicating the absence of blood flow at the time the injury occurred. Fractures heal
through the process of callus formation and bony remodeling, features which can be
examined microscopically to estimate the approximate age of the fracture and time
since the injury. 4,5

A bruise (echymosis) is a collection of blood beneath the skin, resulting from

extravasations of blood from surrounding vessels, without breaking the epidermis
layer of skin. Physical injury to a blood vessel normally triggers a vigorous
physiologic response. Damage to endothelial tissue causes activation and adhesion of
circulating platelets. This in turn results in the rapid formation of platelet plug at the

1
site of injury, causing mark on the skin below. It takes two weeks till months for a
bruise to fade. Start off as a redish color, and then turn bluish-purple and greenish-
yellow before returning to normal. 4,5

Gambar 1Pathogenesis of bruise

Gambar 2Colour changes of bruise

In scenario that occur in the victim is a bruise on the limbs and also abrasions
in the victim's vagina. Bruises on the victim's body caused by the presence of blunt
object with the patient's body causing the rupture of blood vessels without damaging
the skin layer. Due to the rupture of the blood vessels cause a color on the skin that
can be seen by the eye and will change color as time passes. In the first and second
images of the bruise color is purplish red and blue which means age bruises are under

10
the age of 4 days. While in the third picture of yellow bruises that indicate the age of
bruising 7-10 days. 4,5

While the blisters that occur in the vagina of the patient is caused by sexual
intercourse by the husband. When a person is forced to have sexual intercourse then
the victim does not experience a phase of stimulation so that the bartholini gland will
not release mucus that serves as a vaginal lubrication. This means that when the
victim associated with the husband, the victim's vagina in a state of dryness that
causes blisters that damage the vaginal lining. The damaged vaginal lining reaches
lamina propia which can be seen from the blood dries up in the victim's vagina. 4,5

3. Determine the cause of possible injury (CODamage) using the proximus

morbus (PMA)

Three bruises on the left side of the

Current finding thigh, arm outside the left side and the
front upper right arm.

Extravasation of blood into the

A-1 interstitial tissue

A-2 Ruptured blood vessels

A-3 Blunt force trauma

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 A blister on the six-hour o’clock on
Current finding
the vaginal wall

Extravasation of blood into the

A-1 interstitial tissue

A-2 Ruptured blood vessels

4. Explain the severity / degree of injury in accordance with applicable law

The protection of Domestic Violence Victims in the Indonesian Criminal
Law. The existence of the Law No. 23 Year 2004 on the Elimination of
Domestic Violence are expected to provide legal protection for victims of
domestic violence (KDRT) significantly. 6,7
Pasal 44
1. Anyone committing physical violence within the home the ladder as
referred to in Article 5 letter a shall be criminalized with a maximum
imprisonment of 5 (five) years or a maximum fine of Rp 15.000.000,00
2. In the case of the acts referred to in paragraph (1) result the victim gets
sick or severely injured, is punished by imprisonment a maximum of 10
(ten) years or a fine of not more than Rp 30.000.000,00
3. In the case of an act as referred to in paragraph (2) resulted the death of
the victim, shall be sentenced to a maximum imprisonment of 15 (fifteen)
years or a maximum fine of Rp 45,000,000.00
4. In the case of the acts referred to in paragraph (1) shall be done by
husband against wife or otherwise that does not cause illness or obstacles
to performing employment or livelihood work or daily activities, shall be

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 punished with imprisonment for a maximum of 4 (four) month or a fine of
not more than Rp 5.000.000,00. 6,7

Pasal 46
Anyone who commits a sexual assault act referred to in Article 8 letter a
shall be liable to a maximum imprisonment of 12 (twelve) years or a fine of not
more than Rp 36,000,000.00. 6,7
A degree of wound severity was arranged on KUHP.
a. Mild injury is the formulation of the law on minor maltreatment provided
for in article 352 (1) of the Criminal Code states that "non-infectious
persecution or barriers to perform work or search, are threatened, as light
maltreatment". So if the wound on a victim will be perfect and not cause
disease or complication, then it will be included in that category.
Article 352 can be seen in below :
(1) Except as mentioned in the articles 353 and 356, Persecution/maltreatment
that does not cause illness or obstacles to run a job or job search, shall be
threatened, as minor maltreatment, with a maximum imprisonment of three
months or a fine of four thousand five hundred rupiah . Criminal can be
added one-third for the person who committed the crime against the person
who works for him, or become his subordinate.
(2) Trials to commit this crime shall not be criminalized.
b. Moderate injury: Furthermore the legal formulation of the persecution
(medium) in Article 351 (1) of the Criminal Code does not reveal anything
about the disease. If you check a victim and do a "disease" of violence,
then the victim will fall into that category. 6,7

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 Article 351 and 353 can be seen below : 6,7
o Article 351 KUHP
(1) Persecution/maltreatmet shall be subject to imprisonment of a maximum
of two years and eight months or a fine of four thousand five hundred
rupiah,
(2) If the act resulted in serious injury, the guilty party shall be punished
with a maximum imprisonment of five years.
(3) If resulted in death, threatened with imprisonment maximum of seven
years.
(4) With mistreatment deliberately deliberate damaging health.
(5) Trials to commit this crime shall not be criminalized.
o Article 353
(1) Persecution with prior plan, threatened with imprisonment maximum of
four years.
(2) If the act resulted in severe injuries, the guilty person is imposed a
maximum imprisonment of seven years.
(3) If the act involves a guilty death sentenced to a criminal prison
maximum of nine years.
c. Severe injury, in article 90 KUHP, severe injury means: to fall ill or to
have a wound that gives no hope of healing at all, or that creates a danger
of death; incapable of continuing to perform job duties or job searches; lose
one of the senses; got severely deformed; suffered from paralysis;
disruption of power over four weeks; death or death of a woman's contents.
the legal formulation of seriously injured lawsuits in article 351 (2) of the
Criminal Code which states that if it deals with serious injuries, the guilty
party shall be threatened with a maximum of five years ".
Based on the scenario the wound is cathegorized into mild injury because
of wounds not cause illness or obstacles to run a job or job search. So the

14
 prepetrator shall be threatened with a maximum imprisonment of three months
or a fine of four thousand five hundred rupiah. 6,7
5. What is possible characteristic of injury by the agent?
a. Contusion
Contusion is usually due to an injury produced by a blunt object like
bamboo stick, iron rod, stone, or a blow by fist or boot or by a fall or by
compression of crushing etc, besides being due to some disease.8
Causitive Object
 The shape of the bruise is most likely to reflect the shape of the
causative object when the object is small and hard and death occurs
soon after injury,
 A doughnut bruise is produced by an object with a rounded contour (e.g.
baseball). Two parallel linear bruises result from a blow with a rod or
stick,
 Bruises can follow rounded contours if they are caused by a flexible
object like a lash.8
Determining the degree of force in bruise pattern
The condition and type of tissue injured
1. A bruise will be extensive and will occur easily at the place where skin
is loose i.e. round the eyes, scrotum and vulva.
2. It is less in areas which are tough and less supplied with blood i.e. scalp,
palm of hand and sole of feet.
3. It may not appear in the abdomen even though the death may occur due
to the passage of cart wheel and consequent rupture of internal organs.8,9
Age of the subject
Children and old people tend to bruise more easily because the skin of
the child is loose and delicate, the skin of the old is devoid of flesh and
there is some pathological change in the circulatory system of the body. 8,9

1
 Texture and the colour of the skin
In fair coloured persons, a bruise appears more easily than in the dark
coloured persons. 8,9
Colour changes in a bruise
The blood collected under the skin due to the tearing of the blood
vessels is gradually absorbed. During this process of absorption, some
colour change are seen. The blood consists of red blood cells (R.B.Cs)
which have the matter Haemoglobin' (Oxygen carrying red pigment of the
red blood cells). Due to the injury, these red blood cells disintegrate
and the haemoglobin is acted upon by enzyme (An organic compound
capable of producing a specific action). This produces the colour changes
in the bruise and this gives an indication of the age of the bruise. The
colour changes begin first at the periphery and later extend to the
centre.9,10
Age of a bruise
a) To begin with, a bruise is red in colour.
b) Within next 3 days, it appears blue or bluish black or brown or livid
red.
c) By the 5th or 6th day, it becomes greenish.
d) Between 7th and 12th day, it becomes yellow. This yellow colour
fades away gradually by the 14th or 15th day when the skin regains
its normal colour. 8,9,10
b. Abrasion
An abrasion is denuded skin caused by frictional force. A wound may
be either deep or superficial depending on the force and the coarseness of
the surface which caused the abrasion. Abrasion over arms, forearms,
breast, inner aspect of thigh, external genitalia of female suggest rape or
attempted rape. Abrasion of prepuce or glans penis indicates forceful sex
act or attempted penetration through narrow passage (vagina or anus). 8,9

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  Side impact produces a moving abrasion: indicates direction and trace
material (e.g. grit).
 Direction impact produces an imprint abrasion: Pattern of causative
object. 8,9,10

6. What is the Islamic Perspective according to the scenario?

QS AN NISA AYAT 19

“Those who believe, it is not lawful for you to destroy women by force and do not
trouble them because they want to take back some of what you have given him,
except when they do a real abominable work. And associate with them properly. Then
if you don't like them, (then be patient) because maybe you don't like something, even
though Allah makes him a lot of goodness”. (QS An Nisa 4:19).

Mean :

God highly respects women and takes good care of their rights. One proof is
that Allah abolished the tradition of jahiliyyah which was carried out by Arabs. The
tradition is to make women like things that can be inherited when her husband dies.
So Allah revealed this verse to erase the tradition. Islam comes to bring justice to

1
humans. Women are also human like men. It is inappropriate for men to be arbitrary
towards women. Besides that, in this verse Allah wants to remind with His command
to men so that they get along with their partners well. Not arbitrary. Any hatred must
remain good to them. Because it could be that a man hates his wife even though there
is a lot of goodness in the wife.

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 DAFTAR PUSTAKA

1. Kristanto, E., Enma PS, Z. & Siwu, JF, 2018. Patterns of Injuries to victims Dieddue to
Gathering Violence that was adopted at RSUP Prof. Dr. RD Kandou Manado Period
January-December 2014. E-Clinic Journal (ECL), 6 (1), p. 56.
2. Aflanie, I., Nirmalasari, N. & Arizal, MH, 2017. Forensic MedicineMedical Sciences &.
1 penyunt. Jakarta: PT Raja Grafindo Persada
3. Hasanuddin, FKU, 2018. Forensic Documentation. pp. 6-11.
4. Leslie V.Simon,Kevin C.King. Blunt Force Trauma. StatPearls Publishing
llc.NCBI.2019
5. Aflanie et al. 2017. Ilmu Kedokteran Forensik & medicolegal. Jakarta:PT
RajaGrafindo Persada.
6. Undang-Undang Republik Indonesia Nomor 23 Tahun 2004 Tentang
Penghapusan Kekerasan Dalam Rumah Tangga
7. LA Janna, 2014. Perlindungan dalam Korban Kekerasan pada KDRT Vol 2.
No.2. Jakarta
8. Nelwan, Berti. Bahan Kuliah Blunt Force Trauma. 2018. Fakultas Kedokteran
UMI.
9. Rabindra Nath Karmakar. Forensic Medicine and Toxicology: Theory, Oral &
Practical. 2015. Kolkata(india): Academic Publishers. Pg.30. Accesed by google
books.
10. Prof. J.P. Saxena (Medicolegal expert cum Toxicologist and Advocate).
Medicolegal significance of Bruise. Online version
http://www.legalserviceindia.com/medicolegal/bruise.htm access on July, 9th
2018 at 19.30 WITA