Blunt trauma means the impact of the human body against a resistant surface, devoid of sharp edges, regardless whether it is the object, the human body, or both moving. Blunt trauma can be produced by any instrument devoid of sharp edges and endowed by kinetic energy, including “natural” weapons (such as punches, kicks, etc) during fights and the body itself in the violent deceleration in a fall. In blunt trauma, the body absorbs mechanical forces either by the resilience and elasticity of its soft tissues or the rigid strength of the bones; when the intensity of the applied force exceeds the capability of tissues to adapt or resist, an injury occurs.1 The severity of injuries depends on the kinetic energy, which varies directly both with the mass and the square of the velocity of impact. Another relevant factor is the area over which the force acts; the force applied over a small area will deliver a greater impact to any given unit of tissue. The injuries sustained are generally categorized as contusions (or bruises), abrasions, lacerations, and fractures. These are seldom fatal unless the head is involved, or blows to the chest cause rib fractures with lacerations of thoracic structures, or blows to the abdomen rupture internal organs such as the liver or spleen. Mortality from fractures often involves the head, but long bone fractures (for example the femur) may result in delayed death due to fat or to deep venous thrombosis embolism syndrome. In fact, more often than in other traumatic injuries (such as stab or firearm lesions), blunt trauma combines consequences that are both direct (in the site where the force is applied) and systemic, which can directly cause death or contribute to it later. Despite being a classic forensic tool, there is a relative paucity of study regarding homicide by blunt trauma, so we studied this manner of death along a 30-year period.
MATERIALS AND METHODS
Between April 30, 1982 and April 30, 2012, on a total of 11,100 necropsies performed at the University Institute of Forensic Medicine in Brescia (northern Italy), 53 homicides by blunt trauma (0.48% of all necropsies; 16% of all homicides) were identified and reviewed retrospectively. During this time span, the population of the area falling within the purview of the Brescia University Institute of Forensic Medicine amounted to approximately 1.3 million (2.2% of the overall population of the Republic of Italy). The cases in which death was caused by a combination of blunt forces and other methods were excluded. For each case, the following data were registered in a database: sex, age, and nationality (Italian or not) of the victim; anatomical region affected (head, chest, abdomen, limbs); weapon (blunt instrument, human strength, fall to the ground, fall from a height); time elapsed between trauma and death; injuries and preexisting diseases relevant in death determination; direct or indirect causal relationship between trauma and death; victim’s postmortem toxicological test results; and perpetrator’s psychological attitude in the crime.
As previously said, 53 homicides treated by the University Institute of Forensic Medicine in Brescia between 1982 and 2012 were investigated. Figure 1 shows the distribution of the cases according to the period. There is no correlation between the homicide phenomenon and the examined period, considering the absolute temporal heterogeneity of the data.
It prevails, even if only slightly, the male sex (30 cases, 57%) and the Italian nationality (44 cases, 83%). However, the last data can be influenced by the fact that the presence of immigrants in Brescia County became relevant in the last 10 years only.
The age composition for each sex is illustrated in Figure 2. The mean age was 47.9 years; the most frequent victims were males in the age group from 41 to 50 years.
About the instruments involved in blunt trauma, 4 main classes were identified as follows: blunt instrument, human strength, fall to the ground, and fall from a height (Table 1). Blunt instruments (34% of the cases) included different kinds of materials and objects devoid of sharp edges (such as sticks, hammers, iron bars, bats, etc); human strength (39.6% of the cases) included all the body parts generally involved in fighting (kicks, punches, etc). Considering the contact of the victim to the ground consequent to a third party’s action, falls to the ground (18.8% of the cases) and falls from a height (3.8% of the cases) have been differentiated. In 2 cases, there was no substantial information about the weapon; moreover, according to the autopsy reports, both cases had probably been subjected to blows or kicks.
Location of Injuries
For each case, 4 different anatomical regions were considered—head, chest, abdomen, and limbs. Some cases showed a contemporary involvement of different anatomical sites, such as head/chest, chest/abdomen, head/chest/abdomen, and so on (indicated as “multiple”).
Head was the single region more frequently involved (66%), whereas different anatomical regions were contemporary affected in 20.8% of the cases (Table 2).
Correlating the affected anatomical regions to the different instruments, it is evident that head is the most frequently involved (89%) through blunt objects (Table 3).
Time Elapsed Between Trauma and Death
In most cases, death occurred in a very short period from injury production, in 53% less than an hour and in 72% within 1 week (Table 4).
Causal Relationship Between Trauma and Death
A key aspect is undoubtedly the causal relationship between trauma and death; in 75.5% of the cases, the traumatic event was recognized as a direct and exclusive cause of death, whereas in 24.5% of the cases, the causal relationship was established as indirect (Table 5).
In head trauma, a direct and exclusive cause of death was identified in 80% of the cases; when multiple anatomical regions were contemporary involved, a direct causal relationship was identified in 82% of the cases (Table 6). When injuries occurred in the limbs, the ratio reversed, with 67% of the cases with an indirect causal relationship. In these cases, however, the average age was 70 years, and it is likely that the trauma entered on a preexisting pathologic condition resulting in a prevalence of an indirect causal relationship.
The diseases preexisting to the trauma that contributed to the death, allowing the definition of an indirect causal relationship, were considered. The natural pathologic findings most frequently detected were myocardial and coronary artery sclerosis, chronic obstructive pulmonary disease, and cirrhosis (Table 7).
It is interesting to note that in all cases younger than the age of 40 years, a direct causal relationship was observed, whereas in 57% of subjects older than 60 years (8 of the 14 cases), an indirect causal relationship was found (Fig. 3). This is easily explained considering that diseases are more frequent in elderly people.
Toxicological analysis on victims were performed when requested by the judicial authorities; ethyl alcohol was tested in 6 cases (positive results in 2 cases), illicit drugs in 5 cases (positive results in 2 cases), and psychotropic drugs in 3 cases (all negative results).
Psychological Attitude in the Crime
According to the World Health Organization, homicide is defined as any death resulting from injury purposely inflicted by another person (International Statistical Classification of Diseases, Ninth Revision codes E960 to E978; International Statistical Classification of Diseases, 10th Revision codes X85 to Y09).
According to the Italian law, there are different kinds of homicide, among which we have to cite “voluntary homicide” (victim’s death was wanted by the perpetrator); “homicide further the intention” (the perpetrator is moved by the desire to harm but not to kill the victim); and “death as a consequence of another crime” (death occurred as an “accident” during the commission of another crime). Passing from the voluntary homicide to the death as a consequence of another crime, the law forecasts a punishment gradually lower.
In our study, according to the anamnestic data available, 25 cases were classified as voluntary homicide, 24 cases as homicide further the intention, and 4 cases as death as a consequence of another crime, all 4 referring to falls during bag snatching (Table 8).
In most cases of voluntary homicide (76%), the victim’s head was the anatomical region affected (Table 9).
Another aspect that may be considered epiphenomenon of the homicidal will is the survival time because it is directly related to the violence of the action (Table 10). Eighty percent of voluntary homicide deaths occurred almost instantaneously, rising to 84% considering deaths occurring within 1 day, whereas in homicide further the intention, this value decreases to 37%.
It is interesting to note the relation between the kind of homicide and the causal relationship. In all voluntary homicides, a direct causal relationship was found, whereas in homicide further the intention, a direct causal relationship was demonstrated in 58% of the cases only (Table 11).
In voluntary homicide, the trauma was due to blunt objects in 72% of the cases, whereas in none of the homicide further the intention, in which human strength was involved in 67% of the cases and fall in 29% (Table 12). As previously said, all the 4 cases of death as a consequence of another crime were due to falls.
Homicide by blunt trauma in Brescia County represents 16% of all homicides in the period from 1982 to 2012.
Similar values are reported in Copenhagen, Denmark (16%); Oslo, Norway (21.2%)2; in Ireland (18.4%)3; in the western suburbs of Paris, France (19.5%)4; and in Stockholm, Sweden (19.8%).5 However, higher values were reported from Tours, France6; Turku, Finland7; India8–10; and Australia,11,12 where more than 25% of homicides are caused by blunt forces (Table 13).
As reported in most studies,2,6,7,13 the weapon most frequently involved is human strength (kicks, punches, etc) (39.6% of the cases), followed by blunt instruments (sticks, hammers, bats, etc) (34% of the cases) (Table 13).
The data collected in our study outline a particular “type of victim”—male, Italian, and aged between 20 and 60 years. In other studies, male predominance is seen, with a peak age of incidence at the third,9,14,15 fourth,16–18 or fifth decade.6
In the group with individuals aged 0 to 10 years, we found only 3 deaths (5.7%), more than that reported from India (1%),9 Turku (2%),7 and Oslo and Copenhagen (3.9%),19 but much less than that reported from Tours (21.7%, 5 cases of 23 homicides by blunt trauma).6
The head was the victim’s anatomical region most frequently involved, especially from blunt instruments, as recorded in other studies regarding different countries.7,9,13,20,21
There was a direct causal relationship between trauma and death in 75.5% of the cases, mostly involving the head district; an indirect causal relationship was sustained when the victim was affected by serious preexisting diseases (myocardial sclerosis, cirrhosis, etc) contributing to death.
In cases of voluntary homicide (47.2% of the cases) in which death is wanted by the perpetrator, the head was hit in most cases (76%); furthermore, the low survival time observed in these cases (84% of the cases survived less than 24 hours) underlines a very great violence. In all of these cases, preexisting diseases did not influence the causal relationship between trauma and death, which was direct and exclusive in all. The instruments most frequently involved in this kind of homicide were blunt objects (72% of the cases). These findings are consistent with the logic that underlies the traumatic event, which is made with the preview and the aim of the victim’s death. Similar results are reported in a Scandinavian study.19
In cases of homicide further the intention (45.3% of the cases), the will to harm but not to cause the death is testified by the more frequent involvement of natural means (67% of the cases), generally occurring during fights. Often, in these cases, there was the presence of an underlying disease contributing to death (42% of the cases).
In cases of death as a consequence of another crime (7.5% of the cases) in which there is not the will of killing or injuring (all the 4 cases were secondary to falls during bag snatching), the traumatic event was generally less serious, and preexisting diseases played a role in death in 75% of the cases.
In conclusion, homicides due to blunt trauma are still a relevant challenge for the forensic pathologist, who must obtain a complete and accurate history of the crime (including details regarding the crime scene), interpret patterns of injury and other findings at autopsy, and correlate all of the findings to make an accurate ruling of the cause and manner of death.
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