SA MEDIESE TYDSKRIF DEEL 65 10 MAART 1984

385

Homicidal penetrating incised wounds

of the thorax
An autopsy study of 52 cases
J. J. MOAR

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.

The infliction of penetrating incised wounds of the thorax by

means of a sharp-edged or pointed instrument dates back to early
recorded history and probably to prehistoric times as well. The
early writings of mankind (from the Ancient Sumerians and
Egyptians to the Ancient Greeks and Romans), contain many
descriptions of penetrating wounds and their treatment by the
physicians ofthe day. The most famous example, Homer's Iliad,
records 147 battlefield injuries, ofwhich 106 were spear wounds
(80% mortality), 17 sword thrusts (100% mortality), 12 arrow
wounds (42% mortality) and the rest sling wounds. Of these
wounds, 67 (46%) were inflicted on the chest.
.
The advent of modem firearms appears to have made little
impact on the use ofthe knife or its analogues as an instrument of
violence - here the ordinary household utensil or workshop tool

Department of Forensic Medicine, University of the Witwatersrand, Johannesburg

J. J. MOAR, M.B. CH.B.
Panly based on a dissertation submitted for the degree of M.Med. (Forensic Pathol.) of the
University of the Witw3tCrsrand.

acquires the medicolegal connotation ofa weapon. Furthermore,

should the victim of an anack by such a weapon die, it falls to the
forensic pathologist to ascertain the nature of the injuries
sustained and their role in the causation of death. In cases in
which the victim reaches a medical facility alive and is operated
upon, initial accurate documentation of the wound and its
relevant external features can be of vital importance not only in
reconstructing the fatal incident but also in correlating the
wound with the causative weapon. That this is not always
possible (for example, a laterally situated chest wound may be
utilized for the insertion of an intercostal drain, thereby
distorting its original dimensions) is regrenable but understandable in view of the circumstances - the patient is in
extremis and all other considerations must be cast aside in the
anempt to save a life.

Subjects and methods

During March-June and August-September 1981,245 medicolegal autopsies were conducted by the author at the Johannesburg
and Diepkloof government mortuaries. In 52 of these (21,2%)
penetrating incised thoracic wounds involving diverse and often
multiple thoracic structures (ventricles, atria, lungs and blood
vessels) were found. Major vessels such as the aorta, pulmonary
arteries, subclavian veins and superior vena cava were involved,
as well as lesser ones such as the internal thoracic artery and
intercostal vessels. In most cases death was ascribed to either
exsanguination and the anendant hypovolaemic shock or, in
those wounds involving the pericardium and myocardium,
cardiac tamponade. In view of the overwhelming number of
subjects who were dead on arrival at a medical facility, the role, if
any, of contributory factors such as cardiac arrhythmias could
not be determined.
All of the subjects were victims of homicidal assaults with
sharp-edged or pointed weapons; there were no cases of
accidental injury or suicide. Age, sex and race were noted in each
case, as well as the time of day and day ofthe week. Whether the
subject reached hospital dead or alive was also noted and, if the
laner, so was the duration of inhospital survival. Except for the 3
subjects who died in hospital, the precise time ofdeath could not
be ascertained; hence neither the postmortem interval (defined
as the period from death until discovery or autopsy) nor the
survival period (the period from time of injury until time of
demise) could be determined. This is in contrast to normal
anatomical pathology autopsies - the patient dies in hospital
and knowledge ofthe exact time ofdeath enables the postmortem
interval to be accurately determined. In assessing the survival
period, use of the electron microscope to detect the presence of
myofibroblasts in the healing edges of wounds l - 6 may help to
surmount this problem in future.
The number of fatal or potentially fatal wounds was noted, as
were the external site/sand size thereof, the direction ofthe track
taken by the offending weapon and the structure in which this
terminated. The anatomical distribution of the injuries was
noted and organ involvement analysed. Associated fmdings were

386

SA MEDICALJOURNAL VOLUME 65 10 MARCH 1984

documented and included only those injuries or lesions directly

related to the major primary wound or wounds; all other injuries
such as abrasions, skull fractures or wounds which were only
superficially penetrating were classified separately. Finally, a
sample of femoral vein blood was withdrawn from each patient
and submitted to the State Chemical Laboratories, Johannesburg, for determination of the alcohol level (in no instance was
blood taken from a pool lying in either the pleural or the
peritoneal cavity).

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.

TABLE I. DISTRIBUTION OF CASES ACCORDING TO

DAY OF THE WEEK
No. of

cases
Monday*
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

5
3
2
4
26
12

*AII cases which presented on a Monday did so between 01hOO and

07hOO.

Of the 52 victims, only 3 (5,8%) reached hospital alive. The

longest period of survival after admission was 4% hours in spite
of strenuous attempts at resuscitation. The extremely high
percentage of subjects arriving at hospital dead appears to reflect
not only the type of injuries sustained and anatomical structures
involved (i.e. major arterial trunks, myocardium and lungs) but
also the circumstances in which the injuries occurred, immediate
therapeutic intervention 8- 1O being absent (in contrast to the
situation with similar (i.e. bayonet) wounds sustained on the
battlefield, where a medical team is often in close proximity).
At postmortem examination 37 victims (71,2%) were found to
have received a single fatal penetrating incised wound. In 12
(23,1%) 2 wounds were present, and in only 3 were there 3
wounds. Superficially penetrating wounds terminating in the
subcutaneous tissues or external musculature and not involving
any vital structures were classified separately as 'additional
injuries'. These were present in 14 (26,9%) ofthe subjects, and all
involved the same areas - chest, back, shoulders and upper
arms. Defence wounds, i.e. incised wounds on the palmar or
dorsal aspects of the fmgers, hands, or forearms resulting either

from an attempt to grasp the assailant's weapon or to ward off a

thrust, were classified for convenience as 'additional injuries',
although they really deserve to be placed in a separate category
because of their great forensic significance. Intriguingly, they
were present in only 3 subjects (all occurred on the palm of the
right hand), which could mean either that the attacks occurred so
quickly that the victims had no time to react or that they were
incapable of doing so because of alcohol intoxication. .
Altogether 70 wounds were present, of which 42 (60%) were
situated directly over the precordium or slightly higher beneath
the medial third of the left clavicle. The next most frequent site
was the right side of the chest (anteriorly or laterally) with 18
wounds (25,7%). Four wounds (5,7%) were situated over the
back close to the left scapula, suggesting that the victim had bent
forward during the assault in an attempt to avoid the thrust, as
indicated by a reversal of the normal pattern with the lower end
of the wound being blunt and the upper end terminating in a tail
of abrasion; 2 were situated immediately above or below the left
costal margin, 1 was situated at the base of the skull (in a victim
who also sustained 2 thoracic wounds), while 2 victims who also
sustained thoracic injuries each had a wound in the side of the
neck. The size of 49 of the wounds was 3 x 2 cm or less, this
conforming to that of an average-sized knife blade. In only 8 of
the wounds was the longitudinal axis greater than 5 cm,
suggesting the use ofa larger weapon such as a panga. In 1 ofthe
victims 2 rounded puncture wounds were present,.. these indicaring the use of an instrument such as a bicycle spoke or
screwdriver.
The directions taken by the wound tracks as seen at autopsy
were interesting in that 65 of the 70 wounds (92,9%) took' an
inferomedial direction. Only 2 followed a superomedial course,
and 3 were horizontal. The preponderance of wounds taking an
inferomedial direction is in keeping with the natural tendency to
strike a blow with a knife from above downwards, the hand
fulfilling its normal prehensile function with the rest of the limb
being an adjustable support for the hand. The line of force would
then travel transversely across the palm ofthe hand and along the
knife blade.
Of the 70 wounds, 18. (25,7%) involved the myocardium
(Table 11), with the right and left ventricles sharing an equal
distribution (7 wounds each); 2 wounds involved the left atrium,
1 the right atrium, and 1 the interventricular septum. However,
the heart was only the third most frequently involved organ.
Second were parenchymal pulmonary injuries, with 15 involving
the left lung and 14 the right lung, but by far the most frequently
involved structures were bloodvessels, 51 injuries being sustained
- 28 arterial, 4 venous and 19 combined arterial and venous.
(The reason for the sum tot~l of injuries being greater than 70 is
that in many cases more than one structure was pierced.)
Although a total of 51 vascular 'injuries were sustained, the
number ofthose to major vessels was equal to that ofthose to the
heart, i.e. 18. These vessels were the aorta, pulmonary arteries,
superior vena cava, left internal jugular vein and left common
carotid artery. These last two structures were both involved in a
single penetrating incised wound to the neck in 1ofthe 3 subjects
who sustained 3 penetrating incised wounds each.
Internal thoracic artery transection was present in 12 cases and
was a constant feature of those wounds involving the upper 5 rib
cartilages - not surprisingly in view of the course taken by this
vessel as it descends behind the upper 6 costal cartilages, 1,25
cm 11 from the lateral border of the sternum to the level ofthe 6th
intercostal space. (No wounds involved the 6th costal cartilage so
no arterial transection occurred at this level.) Similarly, intercostal vessel transection was a constant and expected finding in
all cases involving the upper 9 ribs and was present in 19 ofthe 70
woupds.
'
Associated fmdings were haemothorax, haemopneumothorax,
haemopericardium, pulmonary collapse and subendocardial
haemorrhages of the left ventricle. Haemothorax was a constant

SA MEDIESE TYDSKRIF DEEL 65 10 MAART 1984

TABLE 11. ANATOMICAL DISTRIBUTION OF STRUCTURES

INVOLVED
No. of

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

finding in penetrating pulmonary injuries, occurring in all 29

cases and being associated with collapse ofeither the injured lobe
or of the entire lung. However, it was also present in subjects
with aortic injuries (l of the arch and 3 of the root), in 4 subjects
with ventricular wounds (22,2% of the victims with cardiac
injuries), and in 1 subject with a wound involving the superior
vena cava. In the subject with a wound involving the right
pulmonary artery haemomediastinum was present. There was no
blood in the pleural cavity of the subject with a wound involving
the right lower lobe, but in this case the wound track had
penetrated through the right hemidiaphragm and entered the
peritoneal cavity where 1 200 ml of blood was found. In another
subject with a pulmonary injury and a transection of the left
subclavian vein (and in whom no haemothorax was found at
autopsy), an intercostal drain had been inserted in the casualty
department, the victim surviving for 2 hours. In all cases of
pulmonary injury blood was confined to the homolateral pleural
cavity, except when an additional structure such as the diaphragm had been pierced, allowing blood to track down. This is
hardly surprising in view of the fact that the right and left pleural
cavities are distinct from each other and only come into contact
for a short distance behind the upper half of the body of the
sternum. In the subjects with aortic and cardiac injuries giving
rise to a haemothorax the track of the wound had in each case
traversed the pleural cavity; in some it also transected ribs and
their corresponding intercostal vessels.
In all myocardial injuries haemoperic~dium was a constant
finding, the volume ranging from 50 ml to 250 m!. It was also
present in 8 of the 10 subjects with wounds involving the
ascending aorta within the fibrous pericardium. Haemopericardium is a well-recognized complication of myocardial trauma,
and as little as 250 ml may cause tamponade if the fluid
accumulates rapidly; removal of even 20 mil 2 may make a
remarkable difference as regards the patient's vital signs.
Delayed deaths from haemopericardium can be recognized by
the organization of the intracavitary blood clot.
Subendocardial haemorrhage of the left ventricle was found in
25 victims (48,1 %), and is a nonspecific finding occurring in such
diverse conditions as acute haemorrhage, heat stroke, head
injury and heavy metal poisoning. Acute arsenic poisoning has

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.

Forensic significance of wound size,

site and distribution
The forensic significance of wound size, site, configuration
and distribution is that clues as to the type of weapon used, the
nature of the anack, the duration of survival and, most importantly, whether the victim would have been capable offurther
movement after injury, may be gained. However, even so simple
a feature as wound size must be interpreted with caution since
'rocking' or moving a knife in a wound will enlarge it beyond the
dimensions of the blade. Similarly, the natural elasticity of the
tissues tends to appose wound edges, reducing the size of the
defect (except in muscle, where wounds may gape). In addition,
a person may be stabbed twice through the same wound, this
altering its original dimensions. Hence, there is rarely an exact
correlation between the external size and shape of a wound and
the inflicting weapon, and this correlation is even less precise
when axe-like weapons, such as the panga, which produce large
gaping defects are used.
.
Aortic injuries were of particular interest in that only 2 of the
12 injuries seen involved the arch; all of the others involved the
ascending aorta within the fibrous pericardium. This is understandable since in all but 3 cases the external wound sites lay
below the origin and course of the arch, i.e. in the 2nd or 3rd
intercostal spaces, whereas the arch begins behind the manubrium sterni at the level of the upper border of the 2nd right
sternocostal articulation, runs upwards, backwards, and to the
left, and terminates at the sternal extremity of the 2nd left costal
cartilage. 14 However, an intriguing feature emerged - 1 of the
wounds overlaid the course of the arch but did not involve it,
whereas another wound commenced below the origin of the arch
but nonetheless did involve it. The former is easily explained on
the basis of the inferomedial direction taken by the knife track,
and the laner on the basis of a point to which insufficient
anention has perhaps been drawn in pathology texts. Where the
emphasis is on the postmortem findings when the elastic lungs
have collapsed, the thorax is in the extreme phase of'expiration
and the diaphragm, being relaxed, is forced upwards and

388

SA MEDICAL JOURNAL VOLUME 65 10 MARCH 1984

backwards by the abdominal organs. In contrast, in the living,

erect subject the organs are under the influence of gravity,
resulting in their downward displacement and hence accounting
for the seeming discrepancy between the external site ofa wound
and the visceral involvement thereof.
The involvement ofthe precordium in nearly two-thirds ofthe
injuries seen is due to the fact that this area is a site of
prediliction, a 'target' site, in any homicidal assault, and a
number of surveyslS have tended to bear this out. There is a
natural tendency to strike at the heart as the target organ of
choice. Confirming that the left thoracic area was a site of
prediliction was the finding that the external sites of the 4
abdomin~ penetrating incised wounds (3 involving the tail ofthe
pancreas and 1 the left hemidiaphragm and stomach) all overlay
the left costal margin..
Regarding the question of survival after injury, as a general
rule arterial injuries are more rapidly fatal than venous ones of
equal calibre, and large-vessel injuries are more rapidly fatal than
ones to smaller vessels ofthe same type. An occasional exception
is when the injured structure is a transected elastic artery retraction of the severed ends of the vessels may create some
degree of haemostasis delaying fatal outcome.
In considering myocardial' injuries, remarkable cases are on
record 16 of patients surviving several weeks after sustaining
penetrating myocardial wounds, the extent of injury only being
discovered at autopsy. In these instances survival is directly
related to the size of the defect and, in particular, that of the
pericardial defect. A large traumatic laceration of the pericardium will usually result in severe haemorrhage either into the
mediastinum or the pleural cavity or externally through the
wound. Should a small penetrating injury such as that produced
by a bicycle spoke be sustained, normal haemostasis can occur,
sealing off the pericardial defect by means of clot formation.
Blood can then accumulate in the pericardial cavity and the
ultimate outcome will then depend on the rapidity of its
accumulation. It has been suggested that clot formation within
the myocardial wound is directly proportional to the thickness of
cardiac wall penetrated, 17 but it should be borne in mind that the
unique anatomy of the heart with its intricate interlacing of
muscle fibres also plays a role since myocardial contraction tends
to appose these fibres, limiting blood flow and initiating
coagulation in the damaged area through release of tissue
thromboplastins. Both of these factors are possibly responsible
for the fact that ventricular wounds are less rapidly fatal than
atrial ones.
The medicolegal significance of the above concerns the
question of movement, or rather the possibility of movement,
after injury; this is sometimes raised by defence counsels to infer
that the accused could not have been aware of the severity of his
assault - a wound which is not rapidly exsanguinating and
which may allow continued consciousness and movement on the
victim's part allows the suggestion that the intention was merely
to deter by wounding rather than to kill. However, this is a legal
matter with which the pathologist should not unduly concern
himself. He should direct his attention to those situations in
which the question of movement after injury has a more direct
medicolegal bearing, such as when a blood-stained knife is found
some distance from a body and the question then arises whether
one is dealing with homicide or suicide. In other words, could the
deceased have stabbed himself, dropped the weapon and then
staggered some distance to die in another spot? Or was he
stabbed to death by an assailant who dropped the weapon some
distance from the body in his haste to get away? These are
questions which are sometimes exceedingly difficult to answer
- corroborative evidence, such as fmgerprints on a weapon's
handle, does not always offer elucidation. One fmal point to be
made is that the possibility of movement after injury should not
result in the erroneous conclusion that death was accidental or
suicidal (a body with penetrating incised wounds found buried

or locked in a cupboard is hardly likely to have arrived there of its

own accord!).

Forensic significance of defence wounds

These are incised wounds on the palmar or dorsal aspects of
the fmgers, hands or forearms resulting either from an attempt to
grasp the assailant's weapon or to ward off a thrust, and were
present in 3 of the victims. Is the fmding of defence wounds a
valid medicolegal observation, and do they indicate that the
mode of death was homicidal rather than suicidal? This point
was raised as far back as 1894 in the British court ~se of R. v.
Deakin. 18 In this case the deceased was found with a ~ut throat.
However, other incised wounds were present on the palmar
aspect ofthe left thumb, in the interdigital space betw~en the left
thumb and index finger, and over the dorsal aspects of both
hands. Defence counsel put forward the suggestion that death
was suicidal and the judge, after questioning the medical wimess,
stated that it passed his comprehension how wounds on the
hands could have any bearing on a wound of the throat. The
doctor quite rightly replied that a single cut could not be judged
in isolation.

Forensic significance of other injurie~

These comprised either superficial penetrating incised wounds
or various blunt force injuries. Superficial penetrating incised
wounds were seen in only slightly more than one-quarter ofthe
victims, two-thirds of the victims having received a single fatal
wound. This would appear to indicate a singular degree ofintent,
with the assailant bent on inflicting a single fatal thrust rather
than a number of tentative, non-life-threatening wounds.
Blunt force injuries to abdominal viscera were present in only
1 subject, involving haemorrhage into the body of the pancreas
and root ofthe mesentery beneath the 4th part ofthe duodenum.
This would seem to indicate that in those instances where the
assailant chooses to use a knife as his weapon little attention is
directed to inflicting blunt force injuries as well. The paucity of
facial abrasions (11,5%) and skull fractures (7,7%) is also in
keeping with this.

Forensic significance ofa positive blood alcohol

level 19
A positive blood alcohol level was present in 41 subjects
(78,8%), ranging from 10 mg/dl to 340 mg/dl. Table III shows
that fully 30 (57,7%) ofthe victims had blood alcohol levels in the
150 - 290 mg/dl range, indicative of a marked degree of intoxication; 6 (11,5%) had a lesser degree of intoxication, 2 were
only mildly intoxicated, and 2 would have been on the verge of
coma. In 1 victim the alcohol level was barely detectable at 10
mg/dl. However, it should be borne in mind that blood alcohol
tests only measure the amount of alcohol being delivered by the
blood to the central nervous system and do not take into

TABLE Ill. BLOOD ETHANOL CONCENTRATIONS

Blood ethanol level
(mg/dl)

0- 40
50- 90
100-140
150-290
300-390
400+

No. of

subjects
1
2
6
30
.2

SA MEDIESE TYDSKRIF DEEL 65 10 MAART 1984

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

barbiturates,32 narcotics and antihistamines, and poisoning with

carbon tetracWoride or carbon monoxide.
Sincere thanks are due to Professor N. J. Schepers for the many
valuable suggestions and criticisms he made during the course of
preparation of the manuscript.

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