CASE REPORT
Dying Transfixing His Own Heart A Rare Case of Suicide by Stabbing Alessandra Pentone, MD, Liliana Innamorato, MD, and Francesco Introna, MD, PhD
Abstract: A 22-year-old man was found dead in his room, lying on his bed, with a kitchen knife embedded in his thorax. The external examination revealed only 1 deep incised horizontal wound in the third left intercostal space beside the sternum. There were no hesitation marks or defense injuries. On both flexor sides of the wrists, the forearms, and the arms and on the right and the left side of the neck, there were several old transversal cut scars. At the autopsy, once the single-edged knife was removed, and after a median sternotomy, the penetration depth of the stab wound revealed an incision of the left pleura, the pericardium, and the transfixed heart, from the anterior to the posterior side, ending on the seventh thoracic vertebra. Toxicological screening resulted as negative. Death occurred as a result of hemorrhagic shock after deep myocardial injuries. A psychiatric history of paranoid schizophrenia; the old scars, which were marks of previous attempted suicides; and the position of the weapon suggested that it was a suicide caused by a single strong stab wound in the cardiac region. This unusual manner of self-stabbing with a single stab to the heart without hesitation wounds was important to exclude other causes of death. Key Words: self-stabbing, transfixed heart, paranoid schizophrenia, suicide
MATERIALS AND METHODS A 22-year-old man was found dead in his room, sitting and partially lying on his blood-drenched bed (Fig. 1). He was dressed only in black underwear, his slippers being just beside his feet. A kitchen knife was embedded in his thorax, horizontally located in the left anterior chest wall (Fig. 2). The single-edged knife had a 16-cm blade (9 cm inside the chest), a maximum width of 4 cm, and a grip 13-cm long (Fig. 3). The knife laceration splashed an interesting pattern of blood onto the surface of the abdomen and the left lower limb all the way to the floor. A huge blood stain was on the bed sheet near the left part of the corpse. A knife case was near the left thigh, whereas a mobile telephone was hidden under the same limb. The victim’s mother, who lived with him in the same flat, saw her son for the last time the night before, after dinner (approximately 11:30 PM). The next day, she called him for lunch at 3 PM and, not receiving an answer, opened the door of his room and found him lying on the bed. This man had a history of paranoid schizophrenia with previous suicide attempts. He was still under pharmacological treatment.
(Am J Forensic Med Pathol 2013;34: 318Y320)
elf-stabbing is an uncommon method of suicide.1 The left part of the chest (where popular knowledge believes the heart to be) represents 1 of the elected sites of self-inflicted wounds.1,2 Among several cases of a knife penetrating the heart described in the literature,3Y7 not all are fatal.8Y12 In fact, despite the accessibility of the site of the stab to the victim’s hands,13 the force needed to penetrate the chest is the result of many factors such as, for example, the sharpness of the knife, the alignment of cleavage lines of the skin, and the angle of penetration of the weapon.14 The aim of the forensic pathologist was to describe the possible fatality dynamic, without excluding homicidal or accidental causes a priori.15 External examination, autopsy, toxicological screenings, the deceased person’s medical history, findings at the crime scene, and the evaluation of the stabbing implement13 are all important parts of a mosaic ready only after a comprehensive and close examination done by a specialist with a skeptical approach.15,16
S
Manuscript received May 22, 2013; accepted August 25, 2013. From the Interdisciplinary Department of Medicine (DIM), University of Bari, School of Forensic Medicine, Policlinico, Bari, Italy. The authors report no conflicts of interest. Reprints: Alessandra Pentone, MD, Interdisciplinary Department of Medicine (DIM), University of Bari, School of Forensic Medicine, Policlinico, Piazza Giulio Cesare, 11, 70124 Bari, Italy. E-mail: [email protected]. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.amjforensicmedicine.com). Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0195-7910/13/3404Y0318 DOI: 10.1097/PAF.0000000000000056
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RESULTS At the crime scene, rigor mortis was strongly present in the corpse, such as fixed livor mortis in the soles and the posterior parts of the body, compatibly with the corpse position on the bed. The postmortem external examination revealed only 1 horizontal incised wound 4-cm long on the third left intercostal space, just beside the sternum. There were no other lesions, defensive wounds, or hesitation marks. A bruise was found on the right hand’s thenar. On both flexor sides of the wrists, the forearms, and the arms and on the right and the left side of the neck, several old transversal cut scars were found, likely to be the result of previous suicide attempts. At the autopsy, once the weapon was removed and given to the police for fingerprint analysis and after a median sternotomy, a depth penetration of the stab channel (Fig. 4) revealed the cut of the skin and subcutaneous layers and, going through the third left
FIGURE 1. Crime scene. Figure 1 can be viewed online in color at www.amjforensicmedicine.com. Am J Forensic Med Pathol
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Volume 34, Number 4, December 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Am J Forensic Med Pathol
&
Volume 34, Number 4, December 2013
FIGURE 2. The corpse with the embedded knife. Figure 2 can be viewed online in color at www.amjforensicmedicine.com.
Dying Transfixing His Own Heart
FIGURE 5. The wound of the pericardium and the heart. Figure 5 can be viewed online in color at www.amjforensicmedicine.com.
ventricle (Fig. 7). The stab channel (12-cm long), going through the myocardium, reached the posterior wall of the heart, where a 0.9-cm lesion in the left ventricle was found and continued with the incision of the posterior wall of the pericardium, ending on the seventh thoracic vertebra. In the left pleural cavity, 300 mL of blood was found, whereas the left lung was deflated. There were no particular toxicological findings. Death occurred not immediately, but after minutes, because of a hemorrhagic shock after deep myocardial injuries. A psychiatric history of paranoid schizophrenia; the old scars; marks of previous attempted suicides, and, in particular, the position, the inclination, and the stab channel of the weapon revealed, beyond doubt, that it was a suicide committed by the right-handed man through a single strong stab. This unusual manner of self-stabbing was of paramount importance to exclude other causes of death. FIGURE 3. The weapon. Figure 3 can be viewed online in color at www.amjforensicmedicine.com.
intercostal space, the infiltration of the pectoral muscles. After the laceration of the left pleura and of the anterior wall of the pericardium was observed, in the pericardial sac, 100 mL of blood was found and collected for analysis, and the 3.7-cmYdeep lesion of the anterior side of the heart became visible (Figs. 5 and 6) This lesion penetrated the left ventricle, the septum, and part of the right
FIGURE 4. The stab channel. Figure 4 can be viewed online in color at www.amjforensicmedicine.com. * 2013 Lippincott Williams & Wilkins
DISCUSSION Suicide is a frequent cause of death all over the world.17 Death by self-stabbing is quite uncommon in Western countries.18 Mostly young men19,20 and persons with a psychiatric history21 choose this manner of suicide.22 In the case described, we have a 22-year-old man with a history of paranoid schizophrenia, but the medical anamnesis could not influence us with a suicide hypothesis, excluding homicide or even accident,
FIGURE 6. The wound of the pericardium and the heart (detail). Figure 6 can be viewed online in color at www.amjforensicmedicine.com. www.amjforensicmedicine.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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3. Shiono H, Takaesu Y . Suicide by self-inflicted stab wound of the chest. Am J Forensic Med Pathol. 1986;7:72Y73. 4. Viel G, Cecchetto G, Montisci M. An unusual case of suicide by sharp force. Forensic Sci Int. 2009;184(1Y3):e12Ye15. 5. Ruder TD, Ketterer T, Preiss U, et al. Suicidal knife wound to the heart: challenges in reconstructing wound channels with post mortem CT and CT-angiography. Leg Med (Tokyo). 2011;13(2):91Y94. 6. Baima Bollone PL. Exceptional case of suicide with a steel kitchen knife, totally embedded, handle included, in the thorax. Minerva Medicoleg. 1967;87(1):28Y30. 7. Laisaar T. Unusual case of self-inflicted thoracic knife wounds with five knives embedded in the left thoracic cavity. Eur J Cardiothorac Surg. 2005;28(4):653Y654. 8. Nakano H, Chikazawa G, Tabuchi T. Penetrating right ventricular trauma by stab injury; report of a case. Kyobu Geka. 2005;58(10):915Y919. 9. Furukawa H, Tsuchiya K, Ogata K, et al. Penetrating knife injury to the heart. Jpn J Thorac Cardiovasc Surg. 2000;48(2):142Y144. 10. Badger JM, Gregg SC, Adams CA Jr. Non-fatal suicide attempt by intentional stab wound: clinical management, psychiatric assessment, and multidisciplinary considerations. J Emerg Trauma Shock. 2012;5(3):228Y232. 11. Leaver DG, Sharma RN, Glennie JS. Self-inflected ventricular septal defect. Br Heart J. 1970;32(4):561Y563.
FIGURE 7. The transfixed heart (anterior side). Figure 7 can be viewed online in color at www.amjforensicmedicine.com.
before all the forensic examinations are completed.15,16 The presence of fatal sharp injuries necessarily entails a discrimination between homicide and suicide.1 The presence of several selfinflicted stabs and hesitation marks and the absence of clothing are the classic criteria required for a self-inflicted suicide.1 In our case, we have 1 single incision, no hesitation marks, and the exposition of the stabbing site. The old cut scars on the wrists, the forearms, the arms, and the neck are likely to be signs of previous attempted suicides. According to the position, the number, the shape, the size, and the major axis of the wounds,1,23 it is possible to get more information to understand the causes of death. First of all, the accessibility of the left part of the chest to the victim’s hand and the corresponding thenar’s right hand bruising. The horizontal axis of the single incision wound could, moreover, explain the way the weapon was held. The knife was in the palm of the right hand with the elbow bent at 90 degrees to the body, in agreement with the angle of penetration of the blade14 producing a self-inflicted stab. The absence of foreign biological trails particularly on the corpse and the lack of defense or scuffle injuries support the suicide hypothesis. Toxicological screening resulted as negative, not adding any element to our investigation. In light of all this, we can confirm the unusual case of a single selfstabbing suicide of a man penetrating his own heart. REFERENCES 1. Oshima T, Kondo T. Eight cases of suicide by self-cutting or -stabbing: consideration from medico-legal viewpoints of differentiation between suicide and homicide. J Clin Forensic Med. 1997;4:127Y132. 2. Edirisinghe PA, Busuttil A. Medical suicideVgroin stabbing. J Clin Forensic Med. 2006;13:92Y95.
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www.amjforensicmedicine.com
12. Hibino N, Tsuchiya K, Sasaki H, et al. Delayed presentation of injury to the sinus of valsalva with aortic regurgitation resulting from penetrating cardiac wounds. J Card Surg. 2003;18(3):236Y239. 13. Yasuhiro U, Migiwa A, Hideyuki N, et al. An unusual case of suicide by stabbing with a falling weighted dagger. Forensic Sci Int. 1999;101:229Y236. 14. Hainsworth SV, Delaney RJ, Rutty GN. How sharp is sharp? Towards quantification of the sharpness and penetration ability of kitchen knives used in stabbing. Int J Legal Med. 2008;122:281Y291. 15. Solarino B, Buschmann CT, Tsokos M. Suicidal cut-throat and stab fatalities: three case reports. Rom J Leg Med. 2011;19:161Y166. 16. Ventura F, Bonsignore A, Gallo M, et al. A fatal case of suicidal stabbing and cutting. J Forensic Leg Med. 2010;17:120Y122. 17. Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern Med. 2002;136:302Y311. 18. Fekete JF, Fox AD. Successful suicide by self-inflicted multiple stab wounds of the skull, abdomen, and chest. J Forensic Sci. 1980; 25:634Y637. 19. Mo¨ller-Leimku¨hler AM. The gender gap in suicide and premature death or: why are men so vulnerable? Eur Arch Psychiatry Clin Neurosci. 2003;253(1):1Y8. 20. Kuroda N, Saito K, Takada A, et al. Suicide by self-stabbing in the city of Tokyo: a review of accumulated data from 1976 to 1995. Nihon Hoigaku Zasshi. 1997;51(4):301Y306. 21. Appleby L, Cooper J, Amos T, et al. Psychological autopsy study of suicides by people aged under 35. Br J Psychiatry. 1999;175:168Y174. 22. Karger B, Niemeyer J, Brinkmann B. Suicides by sharp force: typical and atypical features. Int J Legal Med. 2000;113(5):259Y262. 23. Karlsson T. Homicidal and suicidal sharp force fatalities in Stockholm, Sweden. Orientation of entrance wounds in stabs gives information in the classification. Forensic Sci Int. 1998;93(1):21Y32.
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Dying Transfixing His Own Heart A Rare Case of Suicide by Stabbing Alessandra Pentone, MD, Liliana Innamorato, MD, and Francesco Introna, MD, PhD
Abstract: A 22-year-old man was found dead in his room, lying on his bed, with a kitchen knife embedded in his thorax. The external examination revealed only 1 deep incised horizontal wound in the third left intercostal space beside the sternum. There were no hesitation marks or defense injuries. On both flexor sides of the wrists, the forearms, and the arms and on the right and the left side of the neck, there were several old transversal cut scars. At the autopsy, once the single-edged knife was removed, and after a median sternotomy, the penetration depth of the stab wound revealed an incision of the left pleura, the pericardium, and the transfixed heart, from the anterior to the posterior side, ending on the seventh thoracic vertebra. Toxicological screening resulted as negative. Death occurred as a result of hemorrhagic shock after deep myocardial injuries. A psychiatric history of paranoid schizophrenia; the old scars, which were marks of previous attempted suicides; and the position of the weapon suggested that it was a suicide caused by a single strong stab wound in the cardiac region. This unusual manner of self-stabbing with a single stab to the heart without hesitation wounds was important to exclude other causes of death. Key Words: self-stabbing, transfixed heart, paranoid schizophrenia, suicide
MATERIALS AND METHODS A 22-year-old man was found dead in his room, sitting and partially lying on his blood-drenched bed (Fig. 1). He was dressed only in black underwear, his slippers being just beside his feet. A kitchen knife was embedded in his thorax, horizontally located in the left anterior chest wall (Fig. 2). The single-edged knife had a 16-cm blade (9 cm inside the chest), a maximum width of 4 cm, and a grip 13-cm long (Fig. 3). The knife laceration splashed an interesting pattern of blood onto the surface of the abdomen and the left lower limb all the way to the floor. A huge blood stain was on the bed sheet near the left part of the corpse. A knife case was near the left thigh, whereas a mobile telephone was hidden under the same limb. The victim’s mother, who lived with him in the same flat, saw her son for the last time the night before, after dinner (approximately 11:30 PM). The next day, she called him for lunch at 3 PM and, not receiving an answer, opened the door of his room and found him lying on the bed. This man had a history of paranoid schizophrenia with previous suicide attempts. He was still under pharmacological treatment.
(Am J Forensic Med Pathol 2013;34: 318Y320)
elf-stabbing is an uncommon method of suicide.1 The left part of the chest (where popular knowledge believes the heart to be) represents 1 of the elected sites of self-inflicted wounds.1,2 Among several cases of a knife penetrating the heart described in the literature,3Y7 not all are fatal.8Y12 In fact, despite the accessibility of the site of the stab to the victim’s hands,13 the force needed to penetrate the chest is the result of many factors such as, for example, the sharpness of the knife, the alignment of cleavage lines of the skin, and the angle of penetration of the weapon.14 The aim of the forensic pathologist was to describe the possible fatality dynamic, without excluding homicidal or accidental causes a priori.15 External examination, autopsy, toxicological screenings, the deceased person’s medical history, findings at the crime scene, and the evaluation of the stabbing implement13 are all important parts of a mosaic ready only after a comprehensive and close examination done by a specialist with a skeptical approach.15,16
S
Manuscript received May 22, 2013; accepted August 25, 2013. From the Interdisciplinary Department of Medicine (DIM), University of Bari, School of Forensic Medicine, Policlinico, Bari, Italy. The authors report no conflicts of interest. Reprints: Alessandra Pentone, MD, Interdisciplinary Department of Medicine (DIM), University of Bari, School of Forensic Medicine, Policlinico, Piazza Giulio Cesare, 11, 70124 Bari, Italy. E-mail: [email protected]. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.amjforensicmedicine.com). Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0195-7910/13/3404Y0318 DOI: 10.1097/PAF.0000000000000056
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RESULTS At the crime scene, rigor mortis was strongly present in the corpse, such as fixed livor mortis in the soles and the posterior parts of the body, compatibly with the corpse position on the bed. The postmortem external examination revealed only 1 horizontal incised wound 4-cm long on the third left intercostal space, just beside the sternum. There were no other lesions, defensive wounds, or hesitation marks. A bruise was found on the right hand’s thenar. On both flexor sides of the wrists, the forearms, and the arms and on the right and the left side of the neck, several old transversal cut scars were found, likely to be the result of previous suicide attempts. At the autopsy, once the weapon was removed and given to the police for fingerprint analysis and after a median sternotomy, a depth penetration of the stab channel (Fig. 4) revealed the cut of the skin and subcutaneous layers and, going through the third left
FIGURE 1. Crime scene. Figure 1 can be viewed online in color at www.amjforensicmedicine.com. Am J Forensic Med Pathol
&
Volume 34, Number 4, December 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Am J Forensic Med Pathol
&
Volume 34, Number 4, December 2013
FIGURE 2. The corpse with the embedded knife. Figure 2 can be viewed online in color at www.amjforensicmedicine.com.
Dying Transfixing His Own Heart
FIGURE 5. The wound of the pericardium and the heart. Figure 5 can be viewed online in color at www.amjforensicmedicine.com.
ventricle (Fig. 7). The stab channel (12-cm long), going through the myocardium, reached the posterior wall of the heart, where a 0.9-cm lesion in the left ventricle was found and continued with the incision of the posterior wall of the pericardium, ending on the seventh thoracic vertebra. In the left pleural cavity, 300 mL of blood was found, whereas the left lung was deflated. There were no particular toxicological findings. Death occurred not immediately, but after minutes, because of a hemorrhagic shock after deep myocardial injuries. A psychiatric history of paranoid schizophrenia; the old scars; marks of previous attempted suicides, and, in particular, the position, the inclination, and the stab channel of the weapon revealed, beyond doubt, that it was a suicide committed by the right-handed man through a single strong stab. This unusual manner of self-stabbing was of paramount importance to exclude other causes of death. FIGURE 3. The weapon. Figure 3 can be viewed online in color at www.amjforensicmedicine.com.
intercostal space, the infiltration of the pectoral muscles. After the laceration of the left pleura and of the anterior wall of the pericardium was observed, in the pericardial sac, 100 mL of blood was found and collected for analysis, and the 3.7-cmYdeep lesion of the anterior side of the heart became visible (Figs. 5 and 6) This lesion penetrated the left ventricle, the septum, and part of the right
FIGURE 4. The stab channel. Figure 4 can be viewed online in color at www.amjforensicmedicine.com. * 2013 Lippincott Williams & Wilkins
DISCUSSION Suicide is a frequent cause of death all over the world.17 Death by self-stabbing is quite uncommon in Western countries.18 Mostly young men19,20 and persons with a psychiatric history21 choose this manner of suicide.22 In the case described, we have a 22-year-old man with a history of paranoid schizophrenia, but the medical anamnesis could not influence us with a suicide hypothesis, excluding homicide or even accident,
FIGURE 6. The wound of the pericardium and the heart (detail). Figure 6 can be viewed online in color at www.amjforensicmedicine.com. www.amjforensicmedicine.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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3. Shiono H, Takaesu Y . Suicide by self-inflicted stab wound of the chest. Am J Forensic Med Pathol. 1986;7:72Y73. 4. Viel G, Cecchetto G, Montisci M. An unusual case of suicide by sharp force. Forensic Sci Int. 2009;184(1Y3):e12Ye15. 5. Ruder TD, Ketterer T, Preiss U, et al. Suicidal knife wound to the heart: challenges in reconstructing wound channels with post mortem CT and CT-angiography. Leg Med (Tokyo). 2011;13(2):91Y94. 6. Baima Bollone PL. Exceptional case of suicide with a steel kitchen knife, totally embedded, handle included, in the thorax. Minerva Medicoleg. 1967;87(1):28Y30. 7. Laisaar T. Unusual case of self-inflicted thoracic knife wounds with five knives embedded in the left thoracic cavity. Eur J Cardiothorac Surg. 2005;28(4):653Y654. 8. Nakano H, Chikazawa G, Tabuchi T. Penetrating right ventricular trauma by stab injury; report of a case. Kyobu Geka. 2005;58(10):915Y919. 9. Furukawa H, Tsuchiya K, Ogata K, et al. Penetrating knife injury to the heart. Jpn J Thorac Cardiovasc Surg. 2000;48(2):142Y144. 10. Badger JM, Gregg SC, Adams CA Jr. Non-fatal suicide attempt by intentional stab wound: clinical management, psychiatric assessment, and multidisciplinary considerations. J Emerg Trauma Shock. 2012;5(3):228Y232. 11. Leaver DG, Sharma RN, Glennie JS. Self-inflected ventricular septal defect. Br Heart J. 1970;32(4):561Y563.
FIGURE 7. The transfixed heart (anterior side). Figure 7 can be viewed online in color at www.amjforensicmedicine.com.
before all the forensic examinations are completed.15,16 The presence of fatal sharp injuries necessarily entails a discrimination between homicide and suicide.1 The presence of several selfinflicted stabs and hesitation marks and the absence of clothing are the classic criteria required for a self-inflicted suicide.1 In our case, we have 1 single incision, no hesitation marks, and the exposition of the stabbing site. The old cut scars on the wrists, the forearms, the arms, and the neck are likely to be signs of previous attempted suicides. According to the position, the number, the shape, the size, and the major axis of the wounds,1,23 it is possible to get more information to understand the causes of death. First of all, the accessibility of the left part of the chest to the victim’s hand and the corresponding thenar’s right hand bruising. The horizontal axis of the single incision wound could, moreover, explain the way the weapon was held. The knife was in the palm of the right hand with the elbow bent at 90 degrees to the body, in agreement with the angle of penetration of the blade14 producing a self-inflicted stab. The absence of foreign biological trails particularly on the corpse and the lack of defense or scuffle injuries support the suicide hypothesis. Toxicological screening resulted as negative, not adding any element to our investigation. In light of all this, we can confirm the unusual case of a single selfstabbing suicide of a man penetrating his own heart. REFERENCES 1. Oshima T, Kondo T. Eight cases of suicide by self-cutting or -stabbing: consideration from medico-legal viewpoints of differentiation between suicide and homicide. J Clin Forensic Med. 1997;4:127Y132. 2. Edirisinghe PA, Busuttil A. Medical suicideVgroin stabbing. J Clin Forensic Med. 2006;13:92Y95.
320
www.amjforensicmedicine.com
12. Hibino N, Tsuchiya K, Sasaki H, et al. Delayed presentation of injury to the sinus of valsalva with aortic regurgitation resulting from penetrating cardiac wounds. J Card Surg. 2003;18(3):236Y239. 13. Yasuhiro U, Migiwa A, Hideyuki N, et al. An unusual case of suicide by stabbing with a falling weighted dagger. Forensic Sci Int. 1999;101:229Y236. 14. Hainsworth SV, Delaney RJ, Rutty GN. How sharp is sharp? Towards quantification of the sharpness and penetration ability of kitchen knives used in stabbing. Int J Legal Med. 2008;122:281Y291. 15. Solarino B, Buschmann CT, Tsokos M. Suicidal cut-throat and stab fatalities: three case reports. Rom J Leg Med. 2011;19:161Y166. 16. Ventura F, Bonsignore A, Gallo M, et al. A fatal case of suicidal stabbing and cutting. J Forensic Leg Med. 2010;17:120Y122. 17. Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern Med. 2002;136:302Y311. 18. Fekete JF, Fox AD. Successful suicide by self-inflicted multiple stab wounds of the skull, abdomen, and chest. J Forensic Sci. 1980; 25:634Y637. 19. Mo¨ller-Leimku¨hler AM. The gender gap in suicide and premature death or: why are men so vulnerable? Eur Arch Psychiatry Clin Neurosci. 2003;253(1):1Y8. 20. Kuroda N, Saito K, Takada A, et al. Suicide by self-stabbing in the city of Tokyo: a review of accumulated data from 1976 to 1995. Nihon Hoigaku Zasshi. 1997;51(4):301Y306. 21. Appleby L, Cooper J, Amos T, et al. Psychological autopsy study of suicides by people aged under 35. Br J Psychiatry. 1999;175:168Y174. 22. Karger B, Niemeyer J, Brinkmann B. Suicides by sharp force: typical and atypical features. Int J Legal Med. 2000;113(5):259Y262. 23. Karlsson T. Homicidal and suicidal sharp force fatalities in Stockholm, Sweden. Orientation of entrance wounds in stabs gives information in the classification. Forensic Sci Int. 1998;93(1):21Y32.
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
