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385
Summary
During March-June and August-September 1981, 245
medicolegal autopsies were conducted by the author
at the Johannesburg and Diepkloof government mortuaries. In 52 cases (21,2%) penetrating incised
wounds of the thorax were found to be the cause of
death. These involved diverse and often multiple
thoracic structures - ventricles, atria, interventricular
septum, lungs, and, in particular, blood vessels. In
most of these cases death was ascribed to either
exsanguination and the attendant hypovolaemic shock
or, in those wounds involving the pericardium and
myocardium, cardiac tamponade.
Several findings emerged from this study. (I) an
. abysmally low number of the victims (5,8%) reached a
medical facility alive; (ii) no females were seen, and the
21 - 3O-year age group predominated (46,2%); (iit)
80,8% had arrived at the casualty department during a
weekend; (iv) 71,2% had received a single fatal penetrating incised wound; (v) nearly two-thirds of the
wounds seen were inflicted over the precordial area;
(vI) almost 80% of the victims had a positive blood
al~hollevel,-thisranging from 10 mg/dl to 340 mg/dl;
(vii) there was a paucity of blunt force injuries in
addition to the primary penetrating incised wound/s;
and (viii) there was a low percentage of 'defence'
wounds among these victims of homicidal assaults.
S AIr lied J 1984; 65: 385-389.
386
Results
All victims studied were Black males ranging in age from 16 to 54
years. An interesting age distribution soon became apparent.
Twenty-four subjects i.e. (46,2%) fell into the 21 - 30-year age
group; 17 (32,7%) were in the 10 - 20-year age group, 6 (11,5%) in
the 31 - 40-year age group, and 3 (5,8%) in the 41 - 50-year age
group, while 1 (1,9%) was over the age of 50 years. In 1 case the
age was unknown. There were no subjects over the age of 55
years.
Forty-two victims (80,8%) arrived at the casualty department
during the weekend, 32 ofwhom (76,2%) arrived between 18hOO
and 07hoo of the same 'night'. If the early hours of Monday
morning (between 01 hoo and 07hoo) are included as an extension
of the weekend, the percentage increases to 90,4%. Only 5
victims (9,6%) arrived on a weekday night (either Tuesday or
Wednesday; none presented on a Monday or Thursday night)
(Table I). This is similar to the distribution encountered in other
studies, 7 which have showed that weekend evenings take the
heaviest toll.
cases
Monday*
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
5
3
2
4
26
12
Structure
wounds
L. ventricle
R. ventricle
L. atrium
R. atrium
Interventricular septum
L. lung
R.lung
L. hemidiaphragm and stomach
R. hemidiaphragm
Tail of pancreas and spleen
7
7
2
1
1
15
14
1
1
2
Vessels
Aorta
L. pulmonary artery
R. pulmonary artery
Internal thoracic artery
L. common carotid artery
Superior vena cava
L. internal jugular vein
Subclavian vein
Intercostal vessels
12
2
1
12
1
1
1
2
19
387
been associated with this finding even when the mucosa of the
stomach exhibits little evidence of irritation, 13 and may thus act
as a clue to previously unsuspected ingestion or administration of
this poison.
Other injuries included superficial penetrating incised
wounds, incised defence wounds (both discussed earlier), facial
abrasions, skull fractures and blunt force injuries ofnon-thoracic
organs, the distribution being as follows: facial abrasions - 6
cases (11,5%), skull fractures - 4 cases (7,7%), and blunt force
injury - 1 case. Finally, a positive blood alcohol level was
present in 41 subjects (78,8%), this ranging from 10 mg/d! to 340
mg/d!.
Discussion
The finding of a preponderance of victims in the 2nd and 3rd
decades of life appears to reflect the greater tendency for young
adult and adolescent males to be involved in violent situations.
Interestingly, a striking comparison with another study7 as
regarded ages at opposite ends ofthe spectrum was seen: KnonCraig et al. 'S7 youngest victim was 17 years old (compared to 16
years old in this study) and the oldest 41 years old. While the 2
oldest subjects in this series were aged 54 and 49 years - the next
oldest .were both 41 years old. This probably reflects no more
than a chance finding. However, as in the other study/ the
absence of Black females, Whites, or children (except for
Coloureds) was notable.
388
0- 40
50- 90
100-140
150-290
300-390
400+
No. of
subjects
1
2
6
30
.2
consideration tissue tolerance. Blood alcohol tests cannot, therefore, provide a precise guide to the degree of intoxication which
was present, and any opinion given in coun should be guarded.
This point has been well stressed by Cooper et al. 20
A number ofquestions are sometimes raised in court regarding
postmortem blood alcohol levels. The first involves the actual
method of collection and is usually the initial line of attack
adopted by a cross-exarnining anomey. It cannot be stressed
enough that all postmortem samples for chemical analyses
should be collected, stored and transported in appropriate
containers, which means that all glassware, syringes, and needles
used in collecting specimens must be chemically clean and
should not have come into contact with volatile organic fluids.
The simple precaution of leaving as little space as possible
between the 'sample and the top of the container should also be
followed to prevent any alcohol evaporation. Regarding the
collection site, although there is no significant difference in the
alcohol levels of blood samples from the intact heart chambers
and the femoral vessels,21-2 autopsy samples from pooled blood
in the peritoneal or pleural cavities are unsatisfactory. Blood
which has pooled in body cavities during anatomic dissection is
liable to become contaminated, either by diffusion of alcohol
from the stomach after death or directly by gastric contents
which have leaked into these sites from perforations or ruptures.
Blood should therefore be taken from the femoral or subclavian
veins.
Other questions are whether ethanol and other alcohols can be
produced in the body after death or in vitro as a result of
improper storage of blood obtained at autopsy, and whether a
normal endogenous blood alcohol level exists during life.
Although the answer to the laner is still controversial,24 blood
alcohol levels are generally believed to be negligible in the
absence of ingested alcohol. So-called endogenous alcohol in
human blood exists at a concentration ofless than 0,15 mg!dl but
putrefactive changes before autopsy or during blood storage may
result in alcohol production by fermentation of proteins and
carbohydrates by enzymes, bacteria or fungi. 21-24 The problem is
compounded by the fact that refrigeration of a cadaver will not
prevent bacterial production of ethanol. 25,26 Cases have been
described where bodies have been refrigerated after motor
vehicle accidents, no obvious putrefaction being present and
blood being placed in test tubes containing fluoride. 27 Nevertheless, the blood samples contained enteric Gram-negative rods
such as Enterobacter agglomerans, Citrobacter freundii and Klebsiella oxytoca, and both the Klebsiella and the Citrobaeter proved
capable of fermenting glucose to ethanol in refrigerated human
plasma at 4C. Therefore, when blood alcohol concentration is
likely to play a part in legal proceedings, the sample should be
taken as soon as possible after death. If this is not possible,
vitreous humour, which is not readily contaminated with
bacteria and fungi/HO should also be taken at autopsy.
Within certain limitations, postmortem alcohol specimens can
be used to estimate blood alcohol levels at various times before
death, basing such calculations on the assumption that the blood
alcohollevel decreases from its peak at a fairly constant rate of 15
mg/dl (0,015%) during each hour until death. 3l However, it
should be borne in mind that certain conditions lower tolerance
to alcohol, contributing to death at levels which are not usually
fatal. Such conditions include chronic obstructive airways
disease, arteriosclerotic cardiovascular disease, drugs such as
389
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