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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 3  |  Page : 164-167

A case of suicide with multiple stab wounds


Department of Forensic Medicine, Sarawak General Hospital, Kuching, Malaysia

Date of Web Publication18-Sep-2019

Correspondence Address:
Ganesh Raj Selvaraja
Department of Forensic Medicine, Sarawak General Hospital, Kuching
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfsm.jfsm_16_19

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  Abstract 


Multiple stab wounds are very common features of homicidal stabbing. The common findings differentiating homicidal and suicidal stabbing are well described in the medical literature. Among the features mentioned are location, shape, and direction of the wounds. These features are vital in differentiating suicide from homicide. However, this case has an unusual presentation. We discuss the importance of interpretation and differentiation of the stab wounds to determine the manner of death and facilitate the investigation. A 29-year-old male presented with multiple stab wounds. There was no witness at the time of the incident. The body was discovered in his room with pools of blood. A knife was present on his body. No tentative cuts were present on the body. Scene investigation and postmortem examination determined the cause and manner of death.

Keywords: Manner of death, multiple stab wounds, postmortem


How to cite this article:
Selvaraja GR, Jih PK, Subramaniam K, Ibrahim NB. A case of suicide with multiple stab wounds. J Forensic Sci Med 2019;5:164-7

How to cite this URL:
Selvaraja GR, Jih PK, Subramaniam K, Ibrahim NB. A case of suicide with multiple stab wounds. J Forensic Sci Med [serial online] 2019 [cited 2019 Dec 16];5:164-7. Available from: http://www.jfsmonline.com/text.asp?2019/5/3/164/267149




  Introduction Top


Multiple stab wounds are very common features of homicidal stabbing. A stab wound is characterized by an injury that is produced from the penetration of a pointed or sharp object on to the depth of the body where the depth is usually greater than their width.[1] The common findings differentiating homicidal and suicidal stabbing are well described in many medical literature. Among the features mentioned are the location, shape, and direction of the wounds. A homicidal stab wound is more likely to be distorted due to the victim trying to fend off an assailant. The entrance of the wound can be either in a horizontal or vertical axis with the track also either being upward or downward.[2],[3] Whereas, a suicidal stab wound will be more horizontal in plane with a downward track. This is most often due to the position the victim holds the knife, which is most commonly with a straight wrist and a flexed elbow.[2],[3] Suicidal stab wounds are also most commonly seen on the anterior aspect of the left chest, and wounds that lie in positions that are difficult to access by the victim suggest cause other than suicidal stabbing.[2],[3]

In addition, in suicidal stab wounds, typically the injuries at the possible site of self-infliction are not multiple. Tentative wounds are usually present and damage to clothing is usually absent.[4] Tentative marks are believed to be the most useful indication in distinguishing suicide from homicide. Tentative marks are usually seen in close proximity to the fatal injury.[1],[3],[4],[5]

Thus, these features are vital in differentiating suicide from homicide. However, this case has an unusual presentation, and we discuss on the importance of interpretation and differentiation of the stab wounds to determine the manner of death and facilitate the investigation.


  Case Report Top


A 29-year-old male patient was found dead by his mother in his room. He had a history of self-stabbing to his chest 2 months prior to his death but no fatal injuries. He had no medical illness or psychiatric illness. He was last seen alive on December 4, 2017, around 0715H. On December 4, 2017, around 1720 H, the deceased made a phone call to a radio announcer and stated that he was going to hurt himself. The Malaysian Civil Defense Department rushed to the scene and found the room locked; therefore had to force open it to discover the deceased lying supine on pools of blood with a knife on his chest. The mother of the deceased removed the knife from the chest of the deceased.

Postmortem examination

A postmortem examination was performed within 24 h after death. There was a healing wound (number 2) with scab formation consistent with previous stab at the anterior aspect of the left chest [Figure 1]. Three stab wounds were seen at the anterior aspect of the left chest adjacent to the scar and located in between the left nipple and sternum [Figure 1]. The first stab wound (number 1) measured 3 cm × 1 cm, the second stab wound (number 3) measured 2 cm × 1 cm, and the third stab wound (number 4) measured 3 cm × 1.5 cm [Figure 1]. All three stab wounds were directed backward and downward [Figure 2]. The first stab wound cut the left 5th rib. The second stab wound cut the pericardium, anterior left atrium, and posterior wall of the right ventricle [Figure 3] and [Figure 4]. The third stab wound cut the pericardium and lower lobe of the right lung [Figure 5]. The stab wounds resulted in 1700 ml of hemothorax and 100 ml of hemopericardium mixed with blood clots [Figure 6]. The depth of the wounds ranged from 4 to 7 cm. The length of the knife used by the deceased was measured 32 cm. The great vessels were intact. No tentative cuts were seen on the body. There were also no other injuries apart from the one described above.
Figure 1: Multiple stab wounds to the left anterior chest

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Figure 2: Stab wound directed backward and downward

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Figure 3: Stab wound cutting the pericardium, anterior left atrium, and right ventricle

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Figure 4: Thin arrow shows entrance wound cutting the Anterior Left Atrium; Thick arrow shows exit wound at Right Ventricle

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Figure 5: The third stab wound cut the pericardium and lower lobe of the right lung

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Figure 6: Arrow shows 1700 ml of haemothorax

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  Discussion Top


The stab wound to the chest is associated with a high mortality rate due to the fatal complications of the trauma such as hemothorax, pneumothorax, and cardiac tamponade. They can be homicidal, suicidal, or accidental. The medical literature differentiates stab wounds according to the anatomical region on the chest, axis of the wound which can be horizontal or vertical, type of the sharp object, number of stab wounds sustained, and also the organs that are injured.[1],[2],[3],[4],[5],[6]

Suicidal sharp force injuries are not uncommon in Malaysia. According to the latest Annual Report of the National Suicide Registry Malaysia 2009, the most common method of committing suicide is by hanging, strangulation, and suffocation which was 53.66%, whereas sharp force injuries such as knife or sharp objects were only 3.05%.[7]

In this case, the location of incident favors suicide. The deceased was found in his room which is the most common place of death where suicides took place.[2] The room also was locked from inside, and there were no signs of struggle in the room. The stressor is this case was the relationship problems with his fiancée.

Postmortem examination showed a healing nonfatal suicidal stabbing over the left anterior aspect of his chest. The examination of the stab wounds showed that the wounds were accessible by the deceased and was directed backward and downward. This is consistent with the deceased being right hand dominant and the blood stain noted on his palms, corroborated with the history from the mother.

The number of stab wounds and position of the wounds are unusual for suicide. The finding of multiple stab wounds on the deceased usually favors homicide.[2]

It is possible for the deceased to have stabbed himself three times. There are reports that a stab wound to the heart does not cause instantaneous death. Knight et al. reported a case of stab wound to the heart which was successfully surgically repaired. The position of all three wounds sustained by the deceased was almost vertical. In suicidal stabbing, the common position is horizontal, whereas in homicidal stabbing, it can either be in a horizontal or vertical axis.[2],[4] Other parameters such as victims' clothes were not consistently available and were not included in our case report. Toxicological analyses for the deceased were negative.

Although multiple stab wounds and position of the stab wounds favors homicide, the full autopsy examination corroborated the scene investigation indicating suicide. It was concluded that the cause of death was chest injury due to stab wounds, and the manner of death was suicide.

In conclusion, a forensic autopsy can help the investigation with important details to determine the manner of death in relation to the multiple stab wounds. The difference between homicidal, suicidal, and accidental stabbing requires the findings of an autopsy investigation; careful comparison with other details from the crime scene and information from the witnesses.

Consent

The author of the manuscript has obtained verbal consent for publication from the parents of the deceased and registered the manuscript with the National Medical Research Register Malaysia (Research ID 47932).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Acknowledgments

The author would like to thank Ministry of Health Malaysia for providing governance for this case study and Head of Forensic Medicine Department, Sarawak General Hospital, Malaysia, Dr. Norliza Binti Ibrahim for all the advice and guidance given for the completion of this case report successfully. We would like to thank the Director General of Health Malaysia for his permission to publish this article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma M, Khajja BS, Jha S, Mathur GK, Mathur VN. Forensic interpretation of injuries/wounds found on the human body. J Punjab Acad Forensic Med Toxicol 2011;11(2).  Back to cited text no. 1
    
2.
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;93:21-32.  Back to cited text no. 2
    
3.
Brunel C, Fermanian C, Durigon M, de la Grandmaison GL. Homicidal and suicidal sharp force fatalities: Autopsy parameters in relation to the manner of death. Forensic Sci Int 2010;198:150-4.  Back to cited text no. 3
    
4.
Fukube S, Hayashi T, Ishida Y, Kamon H, Kawaguchi M, Kimura A, et al. Retrospective study on suicidal cases by sharp force injuries. J Forensic Leg Med 2008;15:163-7.  Back to cited text no. 4
    
5.
Start RD, Milroy CM, Green MA. Suicide by self-stabbing. Forensic Sci Int 1992;56:89-94.  Back to cited text no. 5
    
6.
Rouse DA. Patterns of stab wounds: A six year study. Med Sci Law 1994;34:67-71.  Back to cited text no. 6
    
7.
National Suicide Registry Malaysia. National Suicide Registry Malaysia Annual Report for 2009. Kuala Lumpur: Clinical Research Centre; 2009.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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