VIII - The Pathologists

From the book: No.46 - Steve Biko by Hilda Bernstein, 1978, South Africa

The cause of death revealed in the medical evidence was not disputed.

Death was brought about by complications following on brain injury. Biko suffered at least three brain lesions occasioned by the application of force to his head; the injury was suffered between the night of 6 September and 7.30 a. m. on the 7 September.

It also established that such brain injury is always followed by a period of unconsciousness of between 10 minutes and one hour.

The evidence that follows concerns the post-mortem and is given by those who participated. Three pathologists testified to the primary injury sustained in Room 619.

The Post Mortem

Witness; Professor Johan Loubser, Chief State Pathologist in Pretoria

He had performed a post mortem examination of Biko's body on 13 September. There had been no sign of dehydration. Leaving aside secondary haemorrhage there were five distinct lesions in Mr. Biko's brain. Two of these lesions might have been noticed macroscopically (with the naked eye).

Kentridge Professor Proctor concluded that the lesions were 'clearly indicative of severe traumatic brain contusions and contusional necros.

Loubser Agreed. The contusions [bruises] came from a 'median origin'.

Kentridge The infliction of these lesions would have required at least in but probably four, blows to the head, usage of the word I meaning the application of force to the head. The first lesion what has been called a contra coup, meaning an injury on side of the brain, caused by a blow on the other side of the head?

Loubser It is my considered opinion that the main lesion was caused blow on the left-hand side of the forehead. I have consider and I am of the opinion that the lesions can be explained single force applied which hit the left frontal region on such broad base that the direction of the impulse fanned out,

Kentridge That would be a very powerful application of force. Could due to a fall?

Loubser Yes.

Kentridge What about a blow from a blunt object such as a rubber trun­cheon?

Loubser I would have difficulty in explaining the size of the wound. The scab that appeared on the surface of Mr. Biko's head was the one aspect of the injury that could be compatible with this. Kentridge Is there a possibility of two or three blows having caused the injury?

Loubser This theory seemed consistent only with the exterior of Mr. Biko's skin.

Kentridge Looking at it externally, a blow might have caused this lesion from a fist?

Loubser I can only agree with such a possibility in the abstract. Kentridge What about the fist of a man wearing a ring?

Loubser That is conceivable.

Kentridge For the injury to have been caused by a fall, it would have had to be a fall that involved the left side of the forehead, including the cheekbone, but not the nose.

Loubser Agreed. It would have to be a fall on the left side of the face with the head turned towards the right.

Kentridge In a normal case of a person falling forward there is an automatic reflex action whereby a person stretches out his hands to save himself. If a fall caused Mr. Biko's injury it would have been a fall allowing his forehead to hit the ground. An epileptic could fall in this way during a fit. Or someone who had been knocked unconscious. What I find difficult to believe was that a conscious man falling to the ground could sustain such an injury.

Loubser This might be difficult.

Kentridge If a man fell on his face or forehead there might be some reason to think that he could not use his hands to save himself?

Loubser Yes.

Kentridge This kind of injury could be caused by a fall, but it could also be caused if somebody's head were taken and banged against the wall or the floor?

Loubser It is conceivable.

Kentridge Referring to your previous evidence that the brain injuries might have been caused by a man bumping his own head against a wall, you are not advancing as a theory that this is what happened, are you?

Loubser I cannot put it forward as a probability, nor aside as a possibility.

Kentridge Would that mean that such a man stood in front of a wall and dashed his head against it?

Loubser Yes, repeatedly.

The Magistrate intervened:

Prins A person in a struggle could bump his head against a wall and this could have been repeated?

Loubser Correct. I have not in my experience found a similar lesion as a self-inflicted injury, but there is always a first time.

Mr. Kentridge showed Professor Loubser two photographs, one of a man lying in the position in which Biko had been chained and another of the man in the position Biko might have been if he had been sitting up.

Kentridge Let us say that Biko had been sitting up with the wall on his right hand side. In order to knock his head against the wall to cause the injury on the left side of his forehead he would have had to contort himself in a rather extraordinary fashion?

Loubser Correct.

Kentridge Taking into account the physical contortions necessary, it would seem very unlikely that a man in that position could have inflicted such a wound on himself?

Loubser If such a person should have lunged forward with his neck turned, it could have been a conceivable way of inflicting such an injury.

Kentridge That is one possibility in a hundred million?

Loubser That is possible.

Kentridge It is a far-fetched possibility?

Loubser I still consider it an alternative””far-fetched as it might be. Kentridge You mean he banged his head repeatedly on the floor?

Loubser No, I mean he fell over on his left.

Kentridge I must submit that is really impossible. Assuming that a man shackled to a grille somehow lost his balance and fell then the necessary acceleration could not have been achieved?

Loubser I don't think he could have fallen. I mean he energetically lunged forward.

Prins Can you explain what you mean by lunging forward?

Loubser A fast, strong movement from the legs. He would have had kick against the wall and with that movement to dive into the floor as a deliberate action. It would have been impossible to knock his head against the wall.

Kentridge If a man wanted to bang his head he could do it on the wall next to him. Only then it would have been on the wrong side.

Mr. van Rooyen (for the police) intervened here by recalling the police account of restraining' Biko.

Van Rooyen Evidence has been given of an incident on the morning of 7 September when Mr. Biko allegedly went berserk, assaulted people and had to be restrained by force. There has been no evidence that anybody thought that he bumped his head against the wall, but the head moved freely on the neck. If there is a reasonable possibility that the head connected with the wall in an acceleration movement, if the left forehead bumped against the wall, there would have been a bruising of the type found?

Loubser Correct.

Van Rooyen There was no evidence that anybody saw Mr. Biko fall with his left side of his forehead against the floor. But if that happened could that have caused the injury?

Loubser I don't want to put it as a probability. It could be a possibility.

Witness: Professor Neville Proctor, Professor of Anatomical Pathology, University of Witwatersrand.

He had been practising as a neuropathologist for 25 years and he must have examined several thousand brains.

Prins Could any one or all of the brain lesions have caused death?

Proctor The combined effect of all five would have done this. Lesion No. 1 was in itself enough to cause death. Treatment might have pre­vented Mr. Biko's possible death from oedema.

Kentridge It is possible to explain all the lesions in terms of a single blow to the left forehead?

Proctor Everyone agreed that the injury to the left forehead region and lesion No. 1 was contracoup. In my opinion all the lesions were not caused by a single blow and I believe there must have been at least three blows.

Witness: Professor lan Simpson, Head of Department of Pathology, University of Pretoria.

He was present at Biko's post mortem at the invitation of Prof. Loubser. Since he had submitted the post mortem report he had modified his opinions slightly on some of the lesions found in Mr. Biko's brain.

Pathological evidence indicated that only one application of force, to Biko's left forehead, caused the five lesions in his brain. He believed the five lesions were of the contracoup type. *

Despite the slight areas of disagreement, all three pathologists were agreed it blows, or a blow, to the head caused Biko's death. The inquiry then moved to consider the immediate consequences of such an attack.

Witness: Prof. Loubser

Kentridge Drawing on the authority of Sir Charles Symons, such a degree of brain injury must have been followed by a period of uncon­sciousness of not less than two minutes, possibly as much as two or three hours. The neurological experts advising us have

expressed the view that Biko's injury must have been followed by a period of unconsciousness of at least 10 minutes, more likely 15 to 20 minutes, and possibly up to one hour. Do you agree?

Loubser I have no reason to disagree.

Prins Can you say if a man with that type of injury would recover immediately or whether he would be unconscious for a long time?

Loubser I would say damage of that region would have led to unconscious­ness. I would have expected the injury to have been associated with unconsciousness but would not have been surprised if unconsciousness had not happened. I would have regarded unconsciousness as more than a 50% possibility.

Van Rooyen You cannot rule out the possibility that he was not unconscious?

Loubser No.

Witness: Prof, Simpson

He believed that after a head injury of the type sustained by Biko there would have been a significant change in the level of consciousness. He would be very surprised if, according to evidence led, the injury to Biko's left forehead occurred with no loss of consciousness. It was impossible to be dogmatic, but he would find it surprising if Biko sustained his brain lesions without loss of consciousness,

Prins At what stage would Biko have passed the point of no return?

Prof. Simpson thought this was very shortly after sustaining his head injury, He believed it was probably within six to eight hours after this had occurred.

Prof. Oliver Was it possible to give an indication of the amount of force (Assessor) necessary to cause the head injury?

Prof. Simpson thought it would have needed a fair amount of localized force.

Witness: Prof. Proctor

There was considerable evidence to indicate that brain injury would result in unconsciousness.

Kentridge On the morning of 7 September Mr. Biko had been difficult to make contact with, did not answer questions, was incoherent, displayed indications of ataxia (staggering gait); the following day he had a weakness of his left side, showed the extensor plantar reflex and the morning after that red cells were found in his cerebral spinal fluid. Given this picture, would the injuries suffered have resulted in immediate unconsciousness?

Proctor From this picture with the nature and extent of Biko's injuries, he must have been unconscious. Biko had suffered moderate'; to severe brain damage. In the case of moderate injury I estimate that 10 to 20 minutes unconsciousness was reasonable.

He had grave doubts, considering the extent of injuries, that Biko been only momentarily unconscious.

The next point to determine was the time and date of the injury.

Witness: Prof. Loubser

Kentridge The visible injury on Mr. Biko's forehead consisted of bruise swelling and scab shown on a photograph before the court.

Professor Loubser said he had conducted an ageing test on this wound and estimated it was between four and eight days old.

Kentridge This wound must then have been suffered before the night of 8 September?

Loubser If my maths serves me well, yes.

Kentridge The date of his death was 12 September, taking five days back would be 7 September and six days back would take us to 6 September?

Loubser Such a period of time lapse would be applicable.

On examining the body, Loubser added, he immediately observed the injury on Biko's forehead. He had no difficulty in seeing the wound. Van Rooyen My advisers say that the age of this injury could make a difference to the visibility?

Loubser This kind of injury takes on a brown colour and becomes visible when it is dried by the atmosphere. My view is that it should have been visible within the first few hours.

Van Rooyen You looked at it post-mortem. It is possible that more visibility developed after death?

Loubser Yes.

Van Rooyen In the photographic process the reflection can also accent the contrast?

Loubser I saw the wound itself, not the photograph, and for me it was an extremely visible lesion. I saw and described the wound before it was photographed.

Van Rooyen My problem is that a large number of people saw Mr. Biko in life but with the exception of one, none of them admitted under oath to having seen the wound. It is possible that in life the wound was not obvious?

Loubser I have found that I, too, in doing post-mortems have missed lesions because of the subjective factor.

Witness: Prof. Proctor

He had estimated contusions in the brain to be at least three to five days old at the date of the post-mortem, 13 September.

12 days was much more likely than 15 as the outside limit of the age of the lesion, but he would agree with Prof. Loubser that a period of five to eight days was the closest one could get to a reasonable analysis of the age of the lesion.

He believed that the lesions were of the same age, but could not say they were inflicted simultaneously.

Van Rooyen Unconsciousness can happen in a wide variety of degrees?

Proctor Yes. Even with severe brain damage, the degree of unconscious­ness could be slight.

Van Rooyen You were in the field of sheer speculation when you mentioned that Biko should have been unconscious for up to 15 minutes?

Proctor I have come to appreciate that unconsciousness is an essential factor in brain damage. Here is a case of brain damage. The patient would have been unconscious in the medical sense.

Kentridge What was the likelihood of unconsciousness in Biko's case? Proctor After considering the number, extent, and nature of the lesions in the brain, and the physical history, I believe Biko was unconscious

The other injuries to Biko's body were also considered, although it was clear that these had not been the cause of death.

Witness: Prof. Loubser

He could not tie the two lip injuries with the other head injuries. It seemed to him the lip injuries were quite separate. He agreed with Mr. Kentridge that the cuts on the lip were more likely to have been caused by two blows than a fall.

Kentridge Turning to the bruising of the rib area. These injuries showed they were probably caused by a jab with a sharp object for exam a finger or a stick?

Loubser Agreed. It wasn't a vicious jab it was just a jab.

Kentridge And the abrasions found on Mr. Biko's wrists and feet?

Loubser believed handcuffs and manacles caused them. He had found a wound on Mr. Biko's left big toe, what appeared to have been a blister' a small hole in it caused by something like a 'pin or needle'.

Kentridge What could have caused it?

Loubser believed it was a mechanical cause ... a bump or pressure at that point.

Besides dealing with the head injury, the pathologists present at the post­mortem were also questioned on other matters. The following evidence is taken from the testimony of the doctor who attended the post-mortem on behalf of the Biko family. The Chief State Pathologist, Professor Loubser, had agreed his presence.

Witness: Dr. Jonathan Gluckman, Pathologist, for the Biko Family.

Although not regarding himself as a specialist neuropathologist, Gluckman had studied the conclusions reached by Prof. Proctor and was completely satisfied with them.

Kentridge Referring to injuries found on Biko's left big toe which had the appearance of a blister which had been pierced; could you throw light on them?

Gluckman None whatsoever. It was a source of considerable speculation. I don't think any of us was able to give a reasonable background to the injuries. It was most peculiar.

When he arrived at the post-mortem, Biko's scalp had been opened up. He observed the bruising within the scalp. It was very striking indeed. Biko's skin colouring was darker than that on the photograph handed in to the Court.

Kentridge Allowing for that, can you explain why in the days before his death it wasn't seen by the doctors and others who saw him?

G luckman It is beyond my comprehension.

On the question of dating the head injuries, Gluckman agreed with Prof. Loubser that it fell between four and eight days before Mr. Biko's death. He believed it was nearer five or six days than four or eight days.

Kentridge Will you, as a pathologist, comment on the report of the lumbar puncture?

Gluckman This report has contradictions. The analysis reports show the spinal fluid to be colourless, and at the same time containing 1655 red cells. Spinal fluid containing this count could not possibly have been clear. Anything from 200 to 300 red cells is slightly turbid, and this increases as the number of red cells increases. It is not possible to have fluid containing over 1600 red cells, and for that fluid to be clear. One or other is incorrect.

Gluckman added that the tests for xanthrochromia, which would indicate brain damage, had proved negative.

Gluckman As I reject absolutely the statement that the fluid was clear, so must I reject that there was no xanthochromia. Clearly the obser­vation was faulty.

Kentridge Who signed the report?

Gluckman The signature was illegible, but a rubber stamp bore the name 'Nelis'.

Kentridge What should be the reaction of a physician receiving such a report?

Gluckman I wouldn't accept it. Alternatively, the lumbar puncture should be repeated because of the paradoxical result.

Kentridge A false name, Stephen Njelo, appeared on Mr. Biko's lumbar puncture analysis form. According to accepted medical practice, where does the responsibility lie for putting the name of the patient on the sample that is sent?

Gluckman There can be no equivocation. It lies solely in the hands of the doctor in charge of the case. It cannot be delegated.

Kentridge Dr. Tucker told the court that the Hippocratic Oath had a bearing on his ethical conduct, but that his conduct was actually governed by the rules of the SA Medical and Dental Council.

Gluckman I was somewhat surprised at this. There is nothing in the Hippo­cratic Oath that conflicts with the rules of the Medical and Dental Council. The ethical component of the rule is a legal codification of the principles fundamental to Hippocratic Oath. In terms of accepted medical ethics, the interest of the patient””and nothing else””is paramount to the doctor.

Mr. Van Rooyen then questioned Dr. Gluckman about the lumbar puncture performed on Biko before his death.

Van Rooyen Dr. Colin Hersch, a Port Elizabeth specialist, has told the court that macroscopically (to the naked eye) the fluid had appeared clear.

Gluckman It could not have been so. The reports were patently contradic­tory.

Van Rooyen You don't know which of the two reports, that the fluid was clear or that it had a count of 1655 red blood cells, was correct?

Gluckman Agreed.

Prof. Gordon The point is that the fluid went to the institute under the name of Njelo. I don't even know if the fluid was the correct fluid. For me that wipes out the whole thing.

Gluckman As far as I'm concerned the report from the institute is only for the wastepaper basket. It contradicts itself. If it is not faulty in one respect it is faulty in another respect. We pathologists are critical of laboratory tests because such a lot depends on observa­tion. At a glance I would say the report is nonsense.

Van Rooyen Let us put ourselves in the Port Elizabeth context. The doctor who made the lumbar puncture said the fluid was clear and the report stated that the fluid was clear. Would that doctor not be entitled to accept the report?

Gluckman It cannot be clear if there are 1655 red blood cells in it.

Questioned by Mr. Pickard (for the doctors). Dr. Gluckman said that if the report had stated that the fluid was turbid he would have accepted it.

Pickard You have told the Court that you were concerned about the fact that a pathologist had not signed the report from the medical institute?

Gluckman I am concerned.

Dr. Gluckman said that a technologist had probably done the test but that a pathologist in clinical laboratories, showing that a pathologist had scrutinised the report, always signed such a test.

Pickard Do you suggest that Dr. Hersch should have known that the report was not signed by a pathologist?

Gluckman I presume it is normal procedure in Port Elizabeth for a pathologist not to sign the report. Otherwise Dr. Hersch would have questioned it.

Prins I can see your point that the report should be signed by a qualified practitioner. But can you say that any general practitioner would check the signature?

Gluckman That is a very difficult question but a general practitioner must be in a position to phone the pathologists to discuss the tests. Even an indecipherable squiggle is often recognizable.

Pickard We are now trying to determine if anybody was responsible for the death of Steve Biko. I assume that you came to court with the object of assisting it in that respect. Was the suggestion about the signature raised merely to build a case against Dr. Hersch?

Gluckman I must protest in the strongest terms. I cannot blame Dr. Hersch for not being hypercritical of reports issued by the medical institute. I merely say that I am very critical.

Pickard Are you criticising the South African Institute for Medical Research?

Gluckman The high-sounding name means nothing. A report is only as good as the man who signs it.

Pickard Surely it is as good as the technician who did it?

Gluckman The pathologist has to supervise his staff closely. I would not be prepared to have my head opened on a technologist's report in the absence of a pathologist's confirmation.

Pickard What is your opinion of the South African Institute for Medical Research?

Gluckman I am of the opinion that the Institute employs some very competent individuals, some of medium competence and some who are not so competent.