A fatal wrist incised wound: A case of homicide mimicking suicide

Umanah I. N,[1] Akhiwu W, [2]Ochang A, [3]Tanimowo M. [1]Department of Pathology, University of Uyo Teaching Hospital (UUTH), Uyo

[1]Police medicals, Force Headquarters, Abuja  and [2]Department of Medical Microbiology & Parasitology, UUTH, Uyo, NIGERIA[3]

Abstract

Crime scene staging is uncommon in Africa. A 26 year old male was found dead on the outskirts of a market with cuts on both hands. There were no other sharp force injuries or features of blunt trauma. The autopsy revealed acute tubular necrosis of the kidneys indicative of ante mortem hemorrhage and prolonged survival of the victim. We report a case of homicide by wrist incision simulating suicide.
Distinction between murder and suicide may be impossible by an examination of the body alone. The purpose of this paper is to emphasize that in every case with fatal sharp weapon injuries, differentiation between suicide and homicide is always required.

Keywords: fatal injury, wrist incision, suicide, homicide

Introduction
Death by wrist cutting is usually suicidal[1,2]. Homicidal cutting of the wrist with the intent of simulating suicide is rare and can present diagnostic difficulties. This was a novel case of wrist cutting by a suspected mob, in which the autopsy findings and forensic evidence were crucial in differentiating between suicide and homicide. To the best of our knowledge, there are no other reported cases of homicide  by isolated incised wrist wound in literature.

Case report
A 26 yr old young man was found dead on the outskirts of a town market at 22.10 hours. There was a deep cut on the left wrist, and superficial lacerations on the right palm, otherwise there were no other external injuries on other parts of the body. The body was deposited in the mortuary and a formal report made to the police who immediately requested an autopsy. The time of death was estimated to be between 15.00h and 21.00h the same day based on the specific death signs and the body temperature.
The ensuing autopsy showed a clean, deep incised wound measuring 60mm across the left wrist and completely severing the ulnar artery (Fig. 1, Fig.2a)  In addition, several smaller, superficial incised wounds (simulating hesitation or tentative marks) that ran parallel to the incised wound on the left wrist were seen. The right palm had a superficial incised wound measuring 30mm as well (Fig. 2b). There were no other external or internal features of trauma. At this point, it looked like suicide.
Investigation of the scene of crime had yielded no cutting implements. The deceased was a right handed university undergraduate who also engaged himself in the daily collection of illegal “toll” fees, a token amount imposed by influential local authorities, from market women.  Earlier the same day, he was seen pursued by a crowd of commercial motor cyclists popularly known as 'Alalok.
Eye witness accounts state that he was chased by some people during which he had to scale a wall. Although the sound of a gunshot was heard during this period, nobody could ascertain where it came from, even though policemen had been invited to forestall breakdown of  law and order.
Autopsy histologic examination findings showed acute tubular necrosis of the kidney and microvesicular steatosis of the liver. Toxicology could not be done due to the lack of available facilities in our environment. We concluded that the cause of death was exsanguination and that there was prolonged survival after the injury.

Discussion
Distinction between homicide and suicide is a major issue in forensic pathology.  In their paper on suicide, Oshima and Kondo stated that “in every case with fatal sharp wound injuries differentiation between homicide and suicide is always required”.[1] In this case, the pattern of injuries we found at autopsy, especially the deep cut on his left wrist initially suggested suicide. For a victim who was allegedly under mob aggression and was possibly lynched, it was intriguing that there were no other sharp force injuries or features of blunt trauma. Deaths from isolated incised wounds of the arm and/or hand are uncommon and usually suicidal.[1,2] In cases of homicides, such hand lesions  are often defense wounds which commonly involve both sides and are more widely distributed.[1-4] Homicidal death from isolated wrist incision is extremely rare and this appears to be the first reported case in literature. We noted the location of the injury on the left hand and the deceased's right handedness since the relationship between the injury localization and the victims' handedness is important. Fatal incision wounds on the arm and/or hand of most suicide victims are most commonly found on the left, when the victim is right handed.[1] Other clues such as the superficial, parallel cuts near the fatal incised wound simulating hesitation or tentative marks, and the absence of blunt trauma indicative of beating, were initially indicative of suicide in this case. Hesitation marks are often found in most cases (>70 %) of suicides from sharp weapon injury[1,5]

Although the victim's external injuries appeared to be self-inflicted, circumstantial evidence indicated homicide.
Crime scene investigation is crucial in distinction between homicides and suicides and in this case there were several eye witness accounts of mob aggression directed at the deceased in the same market his body was later found. The absence of any cutting implement or weapon at the scene suggests a criminal act.[2] Another major factor in favor of a homicide in this case was the absence of a prior psychiatric history in this victim. Specific enquiries from family did not yield any information suggestive of a prior intent to commit suicide.

On further consideration, the pattern of the victim's incised wound to the right palm was inconsistent with suicide. It is generally considered that a wound is unlikely to be present on the right hand/arm of the victim if he is right handed although an unusual case was reported by Fukomoto in Japan[6]. Although the victim had smaller, contiguous cuts resembling hesitation marks near the victim's fatal wound, hesitation or tentative marks have been reported in cases of homicides, sometimes inflicted during attempts made by the victim to pull away[3,7]. On the upper limbs, hesitations marks were more often observed on the anterior aspect of the limb, while defense wounds were equally distributed on the anterior and posterior aspect in a recent study.[4]

In critical cardiovascular trauma, collapse and death are fairly rapid, usually within minutes.[8]   In this report, the deceased's left ulnar artery was completely severed. Although this portends rapid collapse and death, the autopsy findings of acute tubular necrosis in the kidneys indicate prolonged survival of the deceased after the cut.
His activities in the period before death, like the murder weapon, remain a mystery also indicative of crime. Karger et al reported the unusual case of a 48 year old woman who survived for six hours after fatal right ulnar trauma and in the intervening period, dressed her wound and walked.[9]
The sophistication exhibited in the planning and execution of this homicide is unprecedented in a Nigerian setting such as ours. However the likely involvement of the deceased with questionable groups in the course of his 'toll' collecting activities in the market may be attributed to this manner of death. These groups, known to operate in a typical gang-like fashion, use force or threat of violence to ensure clients' compliance.[10,11]

Conclusion
Circumstantial evidence, crime scene investigation, statements by relatives and neighbors, the absence of blunt trauma injuries and autopsy findings of prolonged survival, indicated that the deceased had been a victim of homicide rather than suicide. In every case with fatal sharp weapon injuries, differentiation between suicide and homicide is always required.

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