Self-strangulation: an uncommon but not unprecedented suicide method

The authors report two cases of self-strangulation in which the investigators had initially suspected homicide but eventually deemed the cases to be suicide. Self-strangulation may be mistaken for homicide because it is widely believed to be impossible to carry out this act without assistance. An accurate medicolegal evaluation of the circumstances, a thorough postmortem examination, and methodical inspection of the site are extremely important in such cases. It is equally important to examine the knot or other means used to exert pressure on the neck and to document its position. Finally, to gain a full understanding of these unusual cases, close collaboration between the two different fields, investigative and medicolegal, is essential.     

Homicide‐Suicide in Konya,Turkey Between 2000 and 2007*

Abstract: Homicide followed by the suicide of the murderer is a relatively rare lethal incident in which an individual kills another person and subsequently dies by suicide. Cases involving a homicide and a suicide in which death examinations and autopsies were performed at The Konya Branch of the Forensic Medicine Council between 2000 and 2007 were retrospectively investigated. During the studied time period, there were 10 homicide‐suicide cases identified with 10 perpetrators killing 12 victims. Nine of the perpetrators were men and eight of the victims were women. The precipitating motive was an impending divorce in four of the cases. Two perpetrators were described as severely depressed, one had a diagnosis of antisocial personality disorder, and one was a pedophile who had reactive depression. Firearms were used in eight of the homicide cases and seven of the suicides. Constricting the use of firearms may reduce/prevent future homicide‐suicide cases, as it is the most commonly used method to carry out homicide‐suicides.     

Suicidal ligature strangulation with an elastic band

An unusual case of self-strangulation with an elastic band is described. The victim was a young Hispanic male with a complicated psychiatric history, including suicide attempts. Mechanisms of strangulation and mechanical asphyxial death are discussed briefly.     

How extensive can injury of the larynx in self-choking be?]

Is it possible to distinguish between suicidal and homicidal strangulation by the extent of the injuries of the larynx if the results of the police investigations are uncertain? Therefore evaluation of the German publications (115 reported cases of suicidal strangulation) and our own cases (17 cases). Hereafter more intensive injuries of the neck are extremely rare in cases of self-strangulation. Casuistic: Body of a 40 years old woman with signs of strangulation. The husband declared his wife strangulated herself in the bathtub with the belt of a bathrobe. Autopsy: Typical findings of drowning, intensive injuries of the neck tissues and the larynx. Kind and extent of the findings are speaking well for an assault mainly by manual strangulation. Undepending of the medical findings the police investigations are almost excluding a suicide. Condemnation of the husband.     

Asphyxial suicide by inhalation of helium inside a plastic bag

Asphyxial suicide by placing a plastic bag over the head, especially in combination with inhalation of gases, is a rarely described method of committing suicide. This article reports a case of suicidal asphyxiation by inhaling the inert gas helium inside a plastic bag. A 64-year-old man probably followed the instructions described in an article about committing suicide written by a medical practitioner from Zürich. This form of suicide is recommended by right-to-die groups and in the internet as a certain, fast, and painless suicide method. Additionally, it leaves only seldom externally visible marks or pathomorphological findings on the body. If the plastic bag and other auxiliary means are removed by another person, the forensic death investigation of cause and manner of death may be very difficult. Therefore, the death scene investigation and the inquiry ordered in the environment of the deceased are very important.     

The way assisted suicide is legalised: balancing a medical framework against a demedicalised model

To date, in three European countries and three American states--i.e., The Netherlands, Luxemburg, Switzerland, and the states of Oregon, Washington and Montana--it is permitted by law for one person to assist in the suicide of another person. When comparing the legislations of these countries/states, it becomes apparent that The Netherlands, Luxemburg, Oregon, Washington and Montana have chosen a medical approach (the so-called medical model), whereas the Swiss legal framework for assisted suicide is clearly a non-medical one (the demedicalised model). The differences between these two models mainly concern two aspects: the requirement as to the capacity of the person providing assistance in suicide and the condition regarding the state of health of the person committing suicide. A closer view on the practice of assisted suicide in the depenalising countries shows that the differences are smaller than initially thought. Nevertheless, important distinctions still remain. When analysing which model is most preferable, it is concluded that an involvement of a physician is inevitable and necessary and that the requirement of a certain medical condition is needed to set a clear and objective limit.     

Suicides in hospitals of Vienna (author's transl)]

An analysis of the autopsies ordered by the Viennese Forensic and Health Authorities between 1967 and 1976 has shown that 2.3% of all suicides were committed in hospitals. Two thirds of the 77 examined cases were carried out by males. Thirty-five patients were in stationary psychiatric treatment; their average age was 50.7 years. In all other kinds of hospitals 42 (mostly male) patients committed suicide at an average age of 65.3 years. Preferred methods of performance were jump and fall from height (44.1%) and hanging (40.3%). Rare methods used were one case of abdominal incisions (harakiri), one self-strangulation, and one case of suffociation in plastic bags. The act was usually accomplished early in the morning or in the late afternoon. Among the suicidal patients who were hospitalized because of organic diseases those with malignant neoplasms [18] and cardiovascular diseases [12] were predominant. Also taking the suicides outside hospitals into consideration the numerical ratio between natural deaths due to cancer and the suicides of cancer patients is about 1:1,000. Amont the suicides in psychiatric institutions schizophrenics [11] and endogenous depressives [7] were the most numerous. In 4 cases the suicide was preceded by acts of injury or homicide.     

Provoked shooting by police as a mechanism for suicide

We report a case which was processed by the Philadelphia Office of the Medical Examiner in which a person with a previous known suicide attempt clearly provoked the Philadelphia police into shooting him. We believe that this is but one of many such incidents in which the victim provokes another into administering fatal injury. This is a mechanism of suicide which, we believe, is exemplified by the case presented.     

Morphologic patterns in suicidal stab injuries of the neck]

Stabs into the neck are seen very seldom in connection with suicide. If there are features typical of suicide, the medico-legal analysis of the pathomorphological findings essentially may contribute to the differentiation from homicidal injuries. On the basis of the observations already published and three own cases an attempt is made to derive criteria of self-infliction for differential diagnosis from the autopsy findings. Concomitant injuries and combination with another method of suicide have turned out to be important indications of self-infliction.     

Current issues in medical liability

Currently, liability discussions are being dominated by AIDS and the legal problems associated with birth and death. The introduction of routine AIDS tests without the knowledge of those concerned is disputed heatedly and, in fact, may well constitute bodily assault and render those responsible liable to prosecution. In AIDS cases, the apparent breach of the Hippocratic oath of secrecy by Physicians can be justified on the grounds of both the extraordinary circumstances prevailing and conflicting duties. The transmission of AIDS could give rise to prosecution for causing bodily injury or manslaughter. The drawing up of a law to protect embryos is designed to establish legal constraints in the fields of reproduction and gene technology. In reframing section 168 StGB, which provides protection to the dead embryo, legislators assume that the head of a medical clinic is the lawful custodian of the corpse of a person who has died in his institution. This should help to resolve many of the problems arising from post-mortem examinations. The questions of euthanasia and medical assistance in cases of suicide were raised at the 1986 Conference of German Lawyers. Whereas medical treatment that could be considered as interference with the natural process of dying may be withdrawn in the case of irreversible terminal suffering, active euthanasia, i.e. the deliberate killing of a terminal patient, was rejected. With regard to noninterference in a suicide attempt by a third party, the free decision of the person wishing to commit suicide should be respected. In general, however, the maxim in dubio pro vita should be respected and where any doubt exists, an attempt should be made to save the person's life.     

Exit association-mediated suicide: toxicologic and forensic aspects

The Swiss German chapter of the Exit Association provides conditional assistance to individuals wishing to end their own lives. The Exit Association advocates death with dignity and fights for the right to freely choose the timing of one's own death. According to the Swiss criminal code (articles 114 and 115), altruistic assistance to suicide is not punishable. Active euthanasia is punished by imprisonment. An individual commits active euthanasia if he or she is driven by honorable motives (e.g., pity) and causes the death of another person wishing to die who seriously and insistently requests such action. Based on our information, the preparation for suicide and its completion relies on a well-defined protocol. First, the candidate's eligibility for Exit Association assistance is verified. The candidate then writes a farewell declaration that explicitly confirms the will to terminate his or her own life. A written report describes the events during the suicide procedure. Depending on the circumstances, the investigative judge requests a forensic autopsy and toxicologic analyses. The results of the forensic investigations conducted in the cases presented here are in agreement with the scenario described in the reports of the Exit Association, namely, suicide by massive ingestion of pentobarbital.     

Hanging: suicide or homicide?

Death by Hanging: Suicide or Homicide. Six cases of homicidal hanging and murder presented as suicidal hanging are recorded. Suspension followed strangulation by ligature or throttling and head injuries in 4 cases. Distinction between homicide and suicide was easy in 5 cases: two of the perpetrators gave themselves up to the police, one committed suicide immediately after he had hanged his 15 year old daughter; in two cases tracks of blood, heavy injuries of the victims, and traces of robbery were obvious. Unless the victim is an infant or an adult person incapacitated by drink, disease, or drugs, or unless there are several assailants murder is difficult to accomplish. Distinction between murder and suicide may be impossible by an examination of the body alone. Detailed investigation of the scene, reconstruction of the position of the suspended body, examination of the rope, the knots, the direction of the fibres on the rope may serve to discover homicidal hanging. - Compared to suicidal hanging homicide has a frequency of about 1% in our autopsy material. However, we cannot estimate the number of obscure cases.     

Suicide with associated acts of arson: two cases from Colorado

We report on two cases of suicide in which the victims started fires before their deaths. In one case the victim died of a single self-inflicted gunshot wound to the head after setting several fires in his residence. In the second case the victim hung himself after setting several fires in his residence and an adjoining building. In both cases, the victim's position was not near the origin of the fires suggesting that the arson was not a failsafe device to the primary mechanism of suicide. Neither victim showed a significant percentage of carboxyhemoglobin, or thermal damage from the fires. Both cases are remarkable in that, had the fire caused more damage to the remains and dwellings, a finding of suicide may not have been reached. We discuss similar aspects between the two reported cases and discuss differences observed with similar events such as complex suicide, suicide by self-immolation, and concealed homicide by burning. Similar cases should be reported to broaden our understanding of these complex events.     

Survived stab to the heart in a schizophrenic man

Schizophrenia is associated with a significant risk of suicide. According to recent research, 10-15 % of all schizophrenic patients die by suicide. It is not uncommon that the victims show sharp force injuries, so that the forensic pathologist first has to differentiate between self-infliction and involvement of another person. The authors' case report presents a 68-year-old schizophrenic patient who committed suicide by jumping out of a window of his apartment located on the second floor after inflicting multiple stab wounds to his thoracic region. At autopsy, an older stab wound to the apex of the heart was detected. In the criminal investigation, a suicide attempt made 13 days before could be ascertained. As the patient did not want to be taken to a hospital at that time, the injury had never been examined or documented. Since there was no evidence suggesting homicide, the older stab to the heart was interpreted as a tentative injury.     

自杀的认定及其相关行为的刑法评价

刑法中认定自杀有主客观两方面要求。在主观方面,被害人不仅应当认识到并且意欲死亡结果发生,而且必须自愿地、也即自主决定地选择了死亡。对于自愿性的判断应当以有效承诺的主观要件为标准。重大的动机错误同样导致不能成立自杀。此外,被害人还必须客观上事实性地支配着直接导致死亡的行为,在将不可逆转地造成死亡结果的最后关键时刻自己控制着事态的发展。自杀本身并非刑事不法行为,教唆或帮助自杀、对自杀者不予救助或者过失导致他人自杀等自杀相关行为也不应受到刑事处罚。     

Complex suicide by two gunshots to the chest and consecutive hanging: circumstances and aspects of reconstruction

In cases of suicidal gunshots, the capacity to act may be preserved for a certain period of time, so that the suicide may be completed with another method. In the presented case a 74-year-old man was found hanged on the first floor of his house with two gunshot wounds in the chest. Both on the ground and the upper floor traces of suicidal acts were detected. As shots to the precordial region suggest rapid incapacitation, a suicide extending over two floors seemed almost impossible without knowledge of the cause of death and evaluation of the ability to act. The autopsy findings confirmed vital signs of hanging. Moreover, a through-and-through gunshot wound of the chest and abdomen affecting the spleen and a shot lodged in the body without injuring the lung were found. The injury findings thus sufficiently explained the preserved ability to act. The presented case shows characteristics of a complex suicide not yet described so far, but could be clearly classified as suicide in congruity with the pertinent literature.     

Simultaneous Homicide–Suicide: A Case Report of Double Drowning

Homicide–suicide is a tragic phenomenon which typically does not result in a criminal charge or trial. However, correct diagnosis and classification of homicide–suicide cases are important to determine the perpetrators and dynamics of each category properly. The deaths in the homicide–suicide acts can be divided into two categories with respect to the number of involved individuals: dyadic deaths and triple or multiple deaths. These two categories can also be divided into two subgroups according to the chronology of the incidents: simultaneous deaths and consecutive deaths. Herein, a simultaneous homicide–suicide case of a father and daughter where both deaths occurred through drowning which was not found in the selected literature review and where the victim was a child is presented. The article aims to clarify the term discrepancies about multiple death cases in the literature and to discuss the pathological and psychosocial characteristics of the simultaneous dyadic death cases.     

Misidentification of self and the Riel Phenomenon.

Misidentification syndromes or phenomena are found in a number of psychiatric situations that may become the subject of forensic science review. One of the most curious is misidentification of self in which the individual perceives himself or herself as another being while able to explain the loss of the original identity. Recognizing these phenomena may be helpful in accurate diagnosis, in considering such conditions as psychosis of whatever type, multiple personality disorder, and other amnesia and fugue states, and in understanding the person's psychopathology. Two cases are presented to illustrate a process that the authors have named the Riel Phenomenon, after the person who was a party to what is often recognized as the most famous case in Canadian history.     

Criteria for homicide and suicide on victims of extended suicide due to sharp force injury

This report is about the findings in association with the extended suicides of nine victims killed by sharp force. All victims were killed by sharp force. The perpetrators were predominantly the parents, the victims their children. Regarding the criteria for differentiating self-inflicted injuries from injuries inflicted by another person, the victims' injuries presented patterns usually found solely in suicides. Thus eight of nine cases presented tentative and hesitation injuries, in three of five cases areas of injury covered by clothing had been exposed beforehand. Despite extremely narrow intercostal spaces in children, injuries to the bones in thoracic stabbing were avoided more often than not (four of seven cases). Only the criterion "defence injury" occurred nearly as often as in homicide victims (three of nine cases). The psychopathology of extended suicide can explain this pattern. The perpetrator's motive is characterised by his pseudoaltruistic belief to save the loved ones from a world that is in his opinion unacceptable. A fusion or integration of the victim into the perpetrator's own self is based on an identity problem. Physical interrelation of forces between perpetrator and victim restricts the victim in his defence and presents an important prerequisite for acquiring the patterns of described injuries.     

Pathologic features of suicidal complete decapitations

Despite high suicide rates all over the world, complete decapitation as a consequence of violent suicide methods is exceptionally rare and there is always a potential for confusion with homicide as well as with body dismemberment or mutilation. We analyzed the phenomenology and morphology of 10 cases (six male, four female; individual age 18-60 years) of suicidal complete decapitation that were subjected to medico-legal autopsies at the Institute of Legal Medicine, University of Hamburg, Germany, between 1995 and 2002. All decapitations occurred while the person was alive as proven by signs of vitality. Blood alcohol levels were positive in five cases and ranged between 28 and 202 mg/dl. The applied methods of suicide were running over by a train in eight cases and hanging in two cases. In suicidal hanging resulting in complete decapitation the wound margins were clear-cut with an adjacent sharply demarcated circumferential band-like abrasion zone showing a homogenous width, the latter determined by the thickness of the rope. In decapitations due to railway interference a broad spectrum of pathologic alterations such as the co-existence of irregular, ragged and sharp-edged wound margins, vascular and nervous pathways forming bridges in the depth of the wound and bruising could be observed. In such cases skin abrasion zones were generally not circumferential and showed a heterogenous width. Concerning hanging-related complete decapitations, our findings are well in line with those of other authors, namely that heavy body weight of the suicidal, fall from a great height and in some cases inelastic and/or thin rope material used for the noose are the determining factors decisive for complete decapitation.