Dark Side: Release

 

Injuries that are deliberately self-inflicted are common and their examination is a frequent task for both pathologists and clinical forensic practitioners. These events consist of suicide, attempted suicide and suicidal gestures, the latter lacking the intention to kill though death may inadvertently ensue. In addition, there is non-suicidal self-inflicted trauma, as described below. One of the most difficult decisions that can face pathologists ,medical examiners and legal authorities, such as coroners, is the differentiation between homicide, suicide, accident and other self-inflicted injury. Though it is not the legal function of a pathologist to attribute motive, his  experience and training are often the factors that lead the official authority to make a decision as to the classification of the manner of death or injury.

 

In addition, when a pathologist is assisting the police in the early stages of a death investigation, his opinion and decision about the manner of the death may be crucial in initiating or aborting a homicide investigation - an onerous decision which may have serious and expensive consequences if wrong. It is therefore a most important function of the forensic pathologist to decide on the evidence of a death scene and subsequent autopsy whether murder, suicide or accident is the most likely explanation. Self-inflicted injury, when not suicidal, is often not fatal and the pathologist is usually not consulted unless he also includes clinical forensic medicine in his work. The pathologist may, however, be asked for his opinion, as he is a specialist in trauma and may be able to provide the most useful opinion available. In other cases, self-inflicted injury, which the victim did not intend to be fatal, may end in death from a variety of causes and thus the pathologist will be directly involved.

 

This discussion is confined to physical trauma, self-poisoning being considered later in the book. Suicides may injure themselves in many different ways, some bizarre in the extreme. The must always be alert to the possibility that such injuries are not true suicides, but some manifestation of peculiar practices that have taken a course unintended by the victim. A prime example is masochistic asphyxia, which is still sometimes mistaken for suicide.

 

Many incised and stab wounds are self-inflicted, either from motives of self-destruction, from mental aberrations or deliberately for some form of gain. These must be differentiated from each other, and from accidental and homicidal wounding.

 

Sometimes the distinction may be difficult and even impossible, but the experience of the forensic pathologist is paramount in assisting investigative agencies to come to the correct conclusion. Suicide, attempted suicide and suicidal gestures commonly employ cutting weapons as the means of injury. There are certain features that are quite reliable pointers to these motives, though they are by no means infallible:

 

Suicidal wounds are typically multiple, often being characterized by a number of preliminary trial cuts, called 'tentative incisions'. These are most often seen on the throat and wrists, where the person often makes a series of shallow incisions, presumably hesitating while gaining courage to make a final decisive cut. In many suicidal attempts the subject abandons this method after a few trial incisions and uses some other method of self-destruction. Although the presence of tentative incisions is strong presumptive evidence of suicide, exceptions do occur, and the pathologist must take all other aspects of the scene into account before giving an opinion to the investigators. In fact, the almost absolute statements of some older textbook that tentative incisions must indicate suicide, is to be disregarded.

 

A suicidal cut throat usually has these trial incisions; there may be only one or two, or there may be scores of trial cuts. If successful, there will be one or more deep incisions superimposed, which may destroy some of the previous shallow cuts. The classical description of the cut throat is of incisions starting high on the left side of the neck below the angle of the jaw, which pass obliquely across the front of the neck to end at a lower level on the right. This assumes that the victim is righthanded, the obliquity being reversed in a left-handed person. The cuts are said to be deeper at their origin, becoming shallower as they cross the throat, tailing off into surface cuts at the extremity. This description, though hallowed by repetition in many textbooks, is often incorrect and many cut throats have horizontal cuts that show no variation in depth at either end. Most suicides appear to raise the chin to provide better access to the throat, so that the skin is stretched when cut. This tends to cause straight-edged incisions, rather than the jagged cut (the so-called 'dentele' toothed incision) seen when a knife is drawn over loose skin. Throwing back the head moves the carotid bundle under the protection of the sternomastoid muscles and, if the cuts are confined to the centre of the front of the neck, only the larynx or trachea may be damaged, rather than large blood vessels. Death from a cut throat depends on the nature and extent of local damage to the neck. A rare cause of death is air embolism, caused by aspiration into cut jugular veins while standing or sitting with the neck at a higher level than the thorax. The possibility that the victim of a cut throat may have died from some unrelated cause must always be borne in mind.

 

Deliberate cutting of the wrists is rarely effective as the sole method of suicide, but it is a common injury. Many suicides from other causes are seen at autopsy to have scars on the wrists from previous unsuccessful attempts or gestures. The usual site is on the flexor surface at the level of the skin flexion creases. As with the neck, there may be a number of shallow tentative incisions, but commonly several deep gashes are made without trial cum. The left wrist is the more common target, because of right-handed dominance As with the neck, there is a tendency for the victim to hyperextend the wrist before making the cut, which causes the radial artery to slip into the shelter of the lower end of the radius. The knife cuts may then miss major blood vessels and merely divide flexor tendons, though many cuts are too shallow to cause anything but superficial damage.

Suicidal injuries of the chest are almost always stab wounds. Sometimes linear incised cuts are made over the precordium or more widely over the front of the chest; these may be multiple, parallel and sometimes criss-cross, but rarely do any serious damage. Though naturally a series of severe wounds always raises the presumption of homicide, many undoubted suicides can inflict a number of injuries upon themselves, each potentially fatal.

 

The position of the clothing in suicidal knife wounds is equivocal. It is more common for the self-stabber to lift the garments to expose the area of chest or abdominal skin to be attacked, but exceptions are common and the point has little diagnostic significance. Women rarely shoot themselves, a shot woman is a murdered woman until proved otherwise, though - as always - exceptions do occur, especially in communities where firearms are commonplace, such as farming or hunting areas.

 

The pathologist may be asked if a dead person could have reached the trigger of a rifle or long shotgun, which may have been placed against the neck, head or chest. Having first established that the entry wound was close contact, the length of the gun from muzzle to trigger can be measured and compared with the distance from wound to tip of finger. It must be remembered, however, that the length of the limb after death, especially if rigor is present, is not necessarily the same as in Life when mobile joints and muscles may have allowed a slightly longer reach than that measured after death. Allowance must also be made for lateral or other flexion of the trunk, and mobility of the shoulder girdle before declaring dogmatically that the victim could not have fired the gun and therefore did not shoot himself.

 

All suicidal attempts are acts of desperation, problems caused by pandemic, lack of job, or work from home causes numerous psychological inhibitors. Family problems, family break-up – constant misunderstandings. It does not come unnoticed, how could it. Most destructive is loneliness – it crushes one’s mind – being alone among one’s family is the worst one can experience, and a mean of escapism, release from that tribulation is suicide. In the end of the day, above all that happened to us bad or good – let’s remember one thing – people are the most important. There is nothing more important then people.

Acknowledgements:

www.politie.nl  Politiekorpschef  @Janny Knol©

www.aived.nl    AIVD – @Erik Akerboom ©

www.politie.nl WEB Politie - @Henk van Essen©

https://www.police-nationale.interieur.gouv.fr/ @ Stephane Folcher ©

 

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