oliver@unc.UUCP (Bill Oliver) (12/13/85)
Answer:
External examination at autopsy revealed a thin, well developed, well
nourished black male wearing blue jeans, shoes, socks, undershorts, and
a dark blue T-shirt with the logo "ZZ Top". Examination of the pocket
contents revealed a wallet with identifying papers, including a photo
ID driver's licence. In addition, a small plastic bag containing white
crystalline powder is present. No defects suggestive of gunshot or
stab wound are
present in the clothing. The clothing is removed and retained for disposition
to the appropriate law enforcement agencies. Fingerprints, hand wipings,
fingernail clippings, and trace evidence are obtained and retained.
After removal of the clothing, external examination of the body reveals
numerous well healed scars, including a 3/4" linear scar over the right
upper chest, a 3/4" linear scar over the lower left chest, and a 6" linear
scar over the left arm. There is marked scarring over the antecubital
fossae on both arms ("needle tracks").
The thorax and abdomen are opened by utilization of the the usual Y-shaped
incision. Upon opening the left thoracic cavity, copious, bloody, foul
smelling fluid is present. The left lung is collapsed. A dilated, fluid and
air filled loop of bowel is present in the lower left thorax. The wall
of the bowel is bluish-red, foul smelling, and friable (i.e. dead). The
posterior aspect of the necrotic bowel displays a 0.3 cm circular defect, and
the lumen of the bowel is in communication with the chest cavity.
Examination of the bowel reveals the necrotic loop to in fact be the
fundus of the stomach, which had traversed a 0.5 cm defect in the anterior
aspect of the diaphragm.
Examination of the remainder of the organs of the body reveals only an
early pneumonia in the collapsed lung, and the sequelae of chronic alcohol
abuse (alcoholic liver disease), tobacco abuse (early centrilobular
emphysema, squamous metaplasia and dysplasia of of bronchial mucosa on
microscopic exam, coronary artery disease), and intravenous drug abuse
(foreign body granulomata in the skin, lungs, spleen).
Re-evaluation of the decedent's police record reveals that he had been
arrested 20 years previously for being involved in a knife fight, for
which he had been hopitalized.
Diagnosis:
Immediate cause of death : shock
due to, or as a consequence of: strangulation/perforation of bowel
due to, or as a consequence of: diaphragmatic hernia
due to, or as a consequence of: status post stab wound, 20 years ago
Manner of death: Homicide.
Further investigation revealed the perpetrator to have died three years
ago of cocaine poisoning.
Comments: Strangulation of the bowel occurs when a portion of the bowel
traverses a defect (hernia) or is otherwise twisted or caught (as by, for
instance adhesions within the abdomen). If, for some reason, the bowel
becomes irritated and swells, or enough bowel escapes to cause compression,
or the bowel becomes twisted, the blood supply to that part of the bowel
is cut off, and it dies. Strangulation of the bowel in and of itself can
lead to shock and death, or may do so indirectly due to perforation and
infection or bleeding.
The reason that no blood was returned on ng tube placement was probably
due to swelling of the bowel with occlusion of the contact between the
strangulated and non-strangulated parts. The connection can
intermittently open and close with the dynamics of the disease.
Any death resulting from an assault, such as a knife fight, is a homicide,
even if the death is delayed. Since the stab wound, which had perforated
the diaphagm, was the proximal cause of death, the knife wielder is
culpable even 20 years later.
Since death does not occur until the bowel becomes strangulated, as long
as the bowel can move in and out of the defect, and as long as it never
becomes swollen or irritated, the diaphragmatic hernia may not present
with serious symptoms for years. A developmental defect, called a
Bochdalek hernia (named after Vincent Bochdalek, 1801-1883, Prague
anatomist), is a diaphragmatic hernia - usually on the left and
posterior. If it is large, the infant may display trouble breathing
early on in life. If it is small, it may never be diagnosed.
The packet contained a mixture of heroin and cocaine.
Bill Oliver oliver@unc.UUCP (Bill Oliver) (12/13/85)
I forgot to add this to the case study: The case is a synthesis from previous cases of the Office of the Chief Medical Examiner, and does not reflect any individual previous or ongoing investigation by the Office. Furthermore, the comments are mine and should not be taken to represent those of any other official, nor any Office, or Agency of the State of North Carolina. May God bless you all this Christmas, Bill Oliver