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Planned complex suicide: Self-strangulation and plaster ingestion
Forensic Science International 202 (2010) e35–e37
Contents lists available at ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
Case report
Planned complex suicide: Self-strangulation and plaster ingestion Tanja Germerott a,b,*, Stefanie Jaenisch a, Gary Hatch b, Urs-Vito Albrecht a, Detlef Guenther a a b
Institute of Legal Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany Institute of Legal Medicine, University of Berne, Buehlstrasse 20, 3012 Berne, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 March 2010 Accepted 29 April 2010
The literature contains many case reports of planned and complex suicides, which combine various methods to commit suicide. In this article, we present the anomalous suicide of an adult male by strangulation with a belt and simultaneous ingestion of plaster. The specific circumstances of the case are described and relevant literature is briefly reviewed. This case vignette illustrates one example of the wide ranging methods employed in suicides and may represent the first reported case of a fatal complex suicide involving self-strangulation and plaster ingestion. Knowledge of varied and sometimes unusual suicide methods is important to the forensic investigator to prevent unnecessary criminal investigation and to reliably and confidently establish manner and cause of death. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Planned complex suicide Plaster ingestion Self-strangulation Forensic pathology
1. Introduction Suicides are divided into simple and complex, involving single or multiple methods of suicide, respectively. In complex suicides, planned and unplanned acts are distinguished. In planned suicides, two or more methods are used simultaneously, so that if one method fails then the other will cause death. Conversely, in unplanned suicides, one or more methods are used consecutively after the previous method did not result in death [1–5]. Moreover, the term ‘‘complicated suicide’’ is employed in the literature. In such cases, the actual desired suicide method fails and death occurs by an unforeseen, accidental complication [6]. The use of several, at times extraordinary methods, can raise suspicion of foul play and will often trigger early involvement by forensic investigators. This report details the planned suicide of a man by strangulation with a belt in combination with the ingestion of plaster, taken from the investigation and autopsy conducted by the Institute of Legal Medicine at the Hannover Medical School, in Hannover, Germany. 2. Case report A recently deceased 48-year-old male was found supine, in a wooded area (Fig. 1). There was a belt around his neck; with the hook of the buckle fastened into one of the belt eyelets. Next to the corpse was a torn-open bag with white powder, an empty water
* Corresponding author at: Institute of Legal Medicine, University of Berne, Buehlstrasse 20, 3012 Berne, Switzerland. Tel.: +41 31 631 3049; fax: +41 31 631 3833. E-mail addresses: [email protected] (T. Germerott). 0379-0738/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.forsciint.2010.04.053
bottle, and a sausage jar containing a hardened, white plaster mass. There was also a teaspoon with a whitish plaster deposit on the man’s jacket near the right breast pocket. According to the police investigation, the man had a history of alcohol abuse, a prior suicide attempt, and recently expressed continuing suicidal intent. Exterior examination of the male corpse revealed a 3.5–4-cm wide, circular, pallid area around the throat. The skin of the face was dark red in color. There were individual punctiform hemorrhages on the skin of the upper eyelids. The same type of hemorrhage was also discernible in the heavily congested conjunctiva. Abundant white, crumbly plaster deposits were evident on the area around the mouth and within the oral cavity (Fig. 2). On the flexor surface of the left lower arm, from the elbow to the lower third of the underarm, skin defects that were partially healed and partially scarred over were present. On the flexor surface of the left wrist was a 4.5-cm long, gaping incision wound, that was partially healed, with granulation tissue visible in its depths. In addition, both hands exhibited white plaster deposits. The autopsy of the man displayed hemorrhages due to congestion in the frontal portion of the scalp and punctiform hemorrhages in the epicardium. The palatine tonsils displayed massive blood congestion. After preparation, the neck displayed hemorrhage in a strap muscle to the right of the thyroid cartilage. In addition, the brain was edematous and the spleen was depleted of blood. In the pharynx and the esophagus, a white, partially solidified mass of plaster nearly completely filled the lumen. There was also a white plaster conglomerate in the area of the hypopharynx, almost completely occluding the laryngeal opening. The stomach contained 300 ml of a whitish-gray fluid that was interspersed with streaks of plaster.
T. Germerott et al. / Forensic Science International 202 (2010) e35–e37
e36
Fig. 1. Death scene: The deceased in supine position with whitish material in the region of the mouth. Note the fastened belt around the neck as well as the torn-open bag filled with plaster and the empty water bottle on the right side of the corpse. On the left side of the deceased a sausage jar with white plaster mass is visible.
According to the autopsy, cause of death was compression resulting from a force against the throat by a belt fastened around the throat with additional obstruction of the laryngeal opening due to a large mass of plaster.
3. Discussion The planned suicide by self-strangulation and ingestion of plaster presented here is unusual in its combination of these two methods. Our literature review revealed no prior description of such a combination. Plaster is a white to gray powder consisting of 98–100% calcium sulphate hemihydrate (CaSO41/2H2O), frequently used in building construction. In combination with water, a paste forms that hardens to a solid. Plaster is ranked as non-toxic; no lethal dose for humans is known. For rats, the LD is 50–5000 mg/kg [7]. Acute exposure to plaster can cause irritation of the eyes, skin and respiratory tract. Chronic exposure may result in silicosis or lung cancer. Oral ingestion can cause gastrointestinal tract obstruction, most commonly in the pyloric region, causing abdominal pain, nausea, and vomiting [7]. Several case reports are present in the literature, consisting primarily of reports from Iran, describing the oral ingestion of
plaster with suicidal intent, none of which were fatal [8–10]. A single review article, also from Iran, describes 40 such cases of suicide attempts by orally ingested plaster [11]. Only one patient in this review died, due to simultaneous ingestion of an organophosphate. The states of the other patients were ranked as non-life threatening. Treatment in the non-fatal cases consisted of stomach irrigation to dissolve the accumulated plaster and/or surgical intervention. In the case presented here, the primary cause of death was determined to be strangulation by the belt. It can be assumed that the man mixed the plaster, placed the belt around his neck and then ingested the plaster. Compression of the throat caused both a hindrance to the act of swallowing and loss of consciousness after a very short time, explaining why the autopsy found only small amounts of streaks of plaster in the stomach. In agreement with Turk et al., in a planned suicide death will have already occurred due to one method of suicide, so that no combined lethality in the classical sense takes place [12]. Complex suicides are described in 1.5–5% of all suicides [2,5,13–16]. A distinction is made between planned and unplanned suicides, with the former characterized by simultaneous use of two or more methods with the goal of preventing self-rescuing attempts, of accelerating death, of increasing the effect, or as a replacement if one of the methods failed. The combination of one suicide method with ingestion of hypnotic or sedative substances may also occur, with the intent of preventing pain or conscious experience of the onset of death. In unplanned suicides, the lethality of the first attempted method is low in most cases. Due to pain and frustration over the failure of the first attempt, additional and possibly more destructive methods are employed [17]. In many cases, non-lethal cuts are made first, especially to the upper extremities [2,13,16]. Preexisting psychiatric illnesses such as personality disorders, depression, and schizophrenia frequently exist in cases of complex suicide [3,18–21]. The same methods used in simple suicides are primarily used in planned and unplanned suicides [2,14,15]. Typical combinations in planned suicides are intoxication and hanging or drowning, or shooting injuries and hanging, drowning or falling from a high place [2]. It is assumed that these methods were used, especially in the combinations listed above, because to a medical layman they appear as reliable and fast causes of death. Less frequently, cases are reported where self-immolation occurs in the context of a planned suicide [3,4,12,16,19]. Further, the literature contains individual reports describing a planned suicide through the simultaneous use of two firearms or in vehicular traffic [16]. Self-strangulation in the context of a planned suicide is rare [2,13,15,16,22]. Primarily, self-strangulation in the context of autoerotic activity is reported as an accidental event. We believe our case is the first reported instance of planned complex suicide involving self-strangulation and plaster ingestion. This case is illustrative of the wide range of methods employed by those who commit or attempt to commit suicide. Given that suicide, particularly when combined and/or unusual methods are employed, will commonly trigger a complete forensic evaluation, it is important for the investigating physician to keep the range of documented methods in mind. This knowledge may assist the investigating Forensic Pathologist by preventing unnecessary criminal investigation and buttressing the final determination of manner and cause of death. Conflict of interest statement
Fig. 2. White plaster material in the oral cavity and on the left cheek.
The authors declare that they have no conflict of interest.
T. Germerott et al. / Forensic Science International 202 (2010) e35–e37
References [1] T. Marcinkowski, L. Pukacka-Sokolowska, T. Wojciechowski, Planned complex suicide, J. Forensic Sci. 3 (1974) 95–100. [2] S. Pollak, Statistik und Pha¨nomenologie kombinierter Selbstto¨tungen und anderer suizidaler Mehrfachscha¨digungen im urbanen Bereich, Arch. Kriminol. 161 (1978), 20–30, 68–81. [3] M. Cingolani, D. Tsakri, Planned complex suicide: report of three cases, Am. J. Forensic Med. Pathol. 21 (2000) 255–260. [4] M. Bohnert, M.A. Rothschild, Complex suicides by self-incineration, Forensic Sci. Int. 131 (2003) 197–201. [5] S. Racette, B.S. Sauvageau, A. Sauvageau, Planned and unplanned complex suicide: a 5-year retrospective study, J. Forensic Sci. 52 (2007) 449–452. [6] K. To¨ro˝ , S. Pollak, Complex suicide versus complicated suicide, Forensic Sci. Int. 184 (2008) 6–9. [7] United States gypsum company, White Moulding Plaster, Material Safety Data Sheet Version 4, 2003. [8] R.A. Yegane, M. Bashshati, R. Bashtar, M. Ahmadi, Gastrointestinal obstruction due to plaster ingestion: a case report, BMC Surg. 6 (2006) 4. [9] A.R. Sorush, M. Nasr-Esfahani, M.R. Hakimian, A. Gholamrezanezhad, S. Madhkhan, Unusual attempted suicide by plaster ingestion, J. Chin. Clin. Med. 2 (2007) 42–46. [10] M.S. Taheri, S.M. Kharrazi, H.R. Haghighatkhah, Y. Moharamzad, Unusual acute formed gastric bezoars due to plaster ingestion successfully treated by gastric irritation: report of two cases, Emerg. Radiol. 15 (2008) 357– 359.
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[11] R. Yeganeh, N. Rafie, A. Kazemi, F. Dortaj, M. Ahmadi, Ingestion of plaster: a new strange method of committing suicide in Lorestan Province, J. Chin. Clin. Med. 2 (2003) 42–46. [12] E.E. Tu¨rk, S. Anders, M.M. Tsokos, Planned complex suicide. Report of two autopsy cases of suicidal shot injury and subsequent self-immolation, Forensic Sci. Int. 139 (2004) 35–38. ¨ ber kombinierte und protrahierte Suizide, Kriminal. [13] V. Hofmann, F. Herber, U Forens. Wiss. 53–54 (1984) 83–88. [14] A. Fieguth, U. Grimm, W.J. Kleemann, H.D. Tro¨ger, Suizidmethoden im Sektionsgut des Instituts fu¨r Rechtsmedizin der Medizinischen Hochschule Hannover, Arch. Kriminol. 199 (1997) 13–20. [15] G. Lasczkowski, J. Ro¨hrich, H. Bratzke, Suizidexzeß-Darstellung eines ungewo¨hnlichen Falles, Arch. Kriminol. 202 (1998) 100–108. [16] M. Bohnert, S. Pollak, Kombinierte Suizide-eine Literaturu¨bersicht, Arch. Kriminol. 213 (2004) 138–153. [17] M.L. Taff, L.R. Boglioli, B.L. Danto, Planned complex suicide, Am. J. Forensic Med. Pathol. 19 (1998) 194. [18] G. Altun, Planned complex suicide: report of three cases, Forensic Sci. Int. 157 (2005) 83–86. [19] E. Lignitz, H. Strauch, Kombinierter Suizid durch Verbrennen und Sturz aus der Ho¨he, Arch. Kriminol. 178 (1986) 51–53. [20] C. Markwalder, F. Ba¨nziger, Der protrahierte Suizid als kriminalistisches Problem, Arch. Kriminol. 180 (1987) 79–87. [21] H. Nadjem, W. Weimann, S. Pollak, Ingestion of pointed objects in complex suicide, Forensic Sci. Int. 171 (2007) e11–e14. [22] C. Palmiere, E. Risso, O. van Hecke, R. La Harpe, Unplanned complex suicide by self-strangulation associated with multiple sharp force injuries: a case report, Med. Sci. Law 47 (2007) 269–273.
Contents lists available at ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
Case report
Planned complex suicide: Self-strangulation and plaster ingestion Tanja Germerott a,b,*, Stefanie Jaenisch a, Gary Hatch b, Urs-Vito Albrecht a, Detlef Guenther a a b
Institute of Legal Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany Institute of Legal Medicine, University of Berne, Buehlstrasse 20, 3012 Berne, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 March 2010 Accepted 29 April 2010
The literature contains many case reports of planned and complex suicides, which combine various methods to commit suicide. In this article, we present the anomalous suicide of an adult male by strangulation with a belt and simultaneous ingestion of plaster. The specific circumstances of the case are described and relevant literature is briefly reviewed. This case vignette illustrates one example of the wide ranging methods employed in suicides and may represent the first reported case of a fatal complex suicide involving self-strangulation and plaster ingestion. Knowledge of varied and sometimes unusual suicide methods is important to the forensic investigator to prevent unnecessary criminal investigation and to reliably and confidently establish manner and cause of death. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Planned complex suicide Plaster ingestion Self-strangulation Forensic pathology
1. Introduction Suicides are divided into simple and complex, involving single or multiple methods of suicide, respectively. In complex suicides, planned and unplanned acts are distinguished. In planned suicides, two or more methods are used simultaneously, so that if one method fails then the other will cause death. Conversely, in unplanned suicides, one or more methods are used consecutively after the previous method did not result in death [1–5]. Moreover, the term ‘‘complicated suicide’’ is employed in the literature. In such cases, the actual desired suicide method fails and death occurs by an unforeseen, accidental complication [6]. The use of several, at times extraordinary methods, can raise suspicion of foul play and will often trigger early involvement by forensic investigators. This report details the planned suicide of a man by strangulation with a belt in combination with the ingestion of plaster, taken from the investigation and autopsy conducted by the Institute of Legal Medicine at the Hannover Medical School, in Hannover, Germany. 2. Case report A recently deceased 48-year-old male was found supine, in a wooded area (Fig. 1). There was a belt around his neck; with the hook of the buckle fastened into one of the belt eyelets. Next to the corpse was a torn-open bag with white powder, an empty water
* Corresponding author at: Institute of Legal Medicine, University of Berne, Buehlstrasse 20, 3012 Berne, Switzerland. Tel.: +41 31 631 3049; fax: +41 31 631 3833. E-mail addresses: [email protected] (T. Germerott). 0379-0738/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.forsciint.2010.04.053
bottle, and a sausage jar containing a hardened, white plaster mass. There was also a teaspoon with a whitish plaster deposit on the man’s jacket near the right breast pocket. According to the police investigation, the man had a history of alcohol abuse, a prior suicide attempt, and recently expressed continuing suicidal intent. Exterior examination of the male corpse revealed a 3.5–4-cm wide, circular, pallid area around the throat. The skin of the face was dark red in color. There were individual punctiform hemorrhages on the skin of the upper eyelids. The same type of hemorrhage was also discernible in the heavily congested conjunctiva. Abundant white, crumbly plaster deposits were evident on the area around the mouth and within the oral cavity (Fig. 2). On the flexor surface of the left lower arm, from the elbow to the lower third of the underarm, skin defects that were partially healed and partially scarred over were present. On the flexor surface of the left wrist was a 4.5-cm long, gaping incision wound, that was partially healed, with granulation tissue visible in its depths. In addition, both hands exhibited white plaster deposits. The autopsy of the man displayed hemorrhages due to congestion in the frontal portion of the scalp and punctiform hemorrhages in the epicardium. The palatine tonsils displayed massive blood congestion. After preparation, the neck displayed hemorrhage in a strap muscle to the right of the thyroid cartilage. In addition, the brain was edematous and the spleen was depleted of blood. In the pharynx and the esophagus, a white, partially solidified mass of plaster nearly completely filled the lumen. There was also a white plaster conglomerate in the area of the hypopharynx, almost completely occluding the laryngeal opening. The stomach contained 300 ml of a whitish-gray fluid that was interspersed with streaks of plaster.
T. Germerott et al. / Forensic Science International 202 (2010) e35–e37
e36
Fig. 1. Death scene: The deceased in supine position with whitish material in the region of the mouth. Note the fastened belt around the neck as well as the torn-open bag filled with plaster and the empty water bottle on the right side of the corpse. On the left side of the deceased a sausage jar with white plaster mass is visible.
According to the autopsy, cause of death was compression resulting from a force against the throat by a belt fastened around the throat with additional obstruction of the laryngeal opening due to a large mass of plaster.
3. Discussion The planned suicide by self-strangulation and ingestion of plaster presented here is unusual in its combination of these two methods. Our literature review revealed no prior description of such a combination. Plaster is a white to gray powder consisting of 98–100% calcium sulphate hemihydrate (CaSO41/2H2O), frequently used in building construction. In combination with water, a paste forms that hardens to a solid. Plaster is ranked as non-toxic; no lethal dose for humans is known. For rats, the LD is 50–5000 mg/kg [7]. Acute exposure to plaster can cause irritation of the eyes, skin and respiratory tract. Chronic exposure may result in silicosis or lung cancer. Oral ingestion can cause gastrointestinal tract obstruction, most commonly in the pyloric region, causing abdominal pain, nausea, and vomiting [7]. Several case reports are present in the literature, consisting primarily of reports from Iran, describing the oral ingestion of
plaster with suicidal intent, none of which were fatal [8–10]. A single review article, also from Iran, describes 40 such cases of suicide attempts by orally ingested plaster [11]. Only one patient in this review died, due to simultaneous ingestion of an organophosphate. The states of the other patients were ranked as non-life threatening. Treatment in the non-fatal cases consisted of stomach irrigation to dissolve the accumulated plaster and/or surgical intervention. In the case presented here, the primary cause of death was determined to be strangulation by the belt. It can be assumed that the man mixed the plaster, placed the belt around his neck and then ingested the plaster. Compression of the throat caused both a hindrance to the act of swallowing and loss of consciousness after a very short time, explaining why the autopsy found only small amounts of streaks of plaster in the stomach. In agreement with Turk et al., in a planned suicide death will have already occurred due to one method of suicide, so that no combined lethality in the classical sense takes place [12]. Complex suicides are described in 1.5–5% of all suicides [2,5,13–16]. A distinction is made between planned and unplanned suicides, with the former characterized by simultaneous use of two or more methods with the goal of preventing self-rescuing attempts, of accelerating death, of increasing the effect, or as a replacement if one of the methods failed. The combination of one suicide method with ingestion of hypnotic or sedative substances may also occur, with the intent of preventing pain or conscious experience of the onset of death. In unplanned suicides, the lethality of the first attempted method is low in most cases. Due to pain and frustration over the failure of the first attempt, additional and possibly more destructive methods are employed [17]. In many cases, non-lethal cuts are made first, especially to the upper extremities [2,13,16]. Preexisting psychiatric illnesses such as personality disorders, depression, and schizophrenia frequently exist in cases of complex suicide [3,18–21]. The same methods used in simple suicides are primarily used in planned and unplanned suicides [2,14,15]. Typical combinations in planned suicides are intoxication and hanging or drowning, or shooting injuries and hanging, drowning or falling from a high place [2]. It is assumed that these methods were used, especially in the combinations listed above, because to a medical layman they appear as reliable and fast causes of death. Less frequently, cases are reported where self-immolation occurs in the context of a planned suicide [3,4,12,16,19]. Further, the literature contains individual reports describing a planned suicide through the simultaneous use of two firearms or in vehicular traffic [16]. Self-strangulation in the context of a planned suicide is rare [2,13,15,16,22]. Primarily, self-strangulation in the context of autoerotic activity is reported as an accidental event. We believe our case is the first reported instance of planned complex suicide involving self-strangulation and plaster ingestion. This case is illustrative of the wide range of methods employed by those who commit or attempt to commit suicide. Given that suicide, particularly when combined and/or unusual methods are employed, will commonly trigger a complete forensic evaluation, it is important for the investigating physician to keep the range of documented methods in mind. This knowledge may assist the investigating Forensic Pathologist by preventing unnecessary criminal investigation and buttressing the final determination of manner and cause of death. Conflict of interest statement
Fig. 2. White plaster material in the oral cavity and on the left cheek.
The authors declare that they have no conflict of interest.
T. Germerott et al. / Forensic Science International 202 (2010) e35–e37
References [1] T. Marcinkowski, L. Pukacka-Sokolowska, T. Wojciechowski, Planned complex suicide, J. Forensic Sci. 3 (1974) 95–100. [2] S. Pollak, Statistik und Pha¨nomenologie kombinierter Selbstto¨tungen und anderer suizidaler Mehrfachscha¨digungen im urbanen Bereich, Arch. Kriminol. 161 (1978), 20–30, 68–81. [3] M. Cingolani, D. Tsakri, Planned complex suicide: report of three cases, Am. J. Forensic Med. Pathol. 21 (2000) 255–260. [4] M. Bohnert, M.A. Rothschild, Complex suicides by self-incineration, Forensic Sci. Int. 131 (2003) 197–201. [5] S. Racette, B.S. Sauvageau, A. Sauvageau, Planned and unplanned complex suicide: a 5-year retrospective study, J. Forensic Sci. 52 (2007) 449–452. [6] K. To¨ro˝ , S. Pollak, Complex suicide versus complicated suicide, Forensic Sci. Int. 184 (2008) 6–9. [7] United States gypsum company, White Moulding Plaster, Material Safety Data Sheet Version 4, 2003. [8] R.A. Yegane, M. Bashshati, R. Bashtar, M. Ahmadi, Gastrointestinal obstruction due to plaster ingestion: a case report, BMC Surg. 6 (2006) 4. [9] A.R. Sorush, M. Nasr-Esfahani, M.R. Hakimian, A. Gholamrezanezhad, S. Madhkhan, Unusual attempted suicide by plaster ingestion, J. Chin. Clin. Med. 2 (2007) 42–46. [10] M.S. Taheri, S.M. Kharrazi, H.R. Haghighatkhah, Y. Moharamzad, Unusual acute formed gastric bezoars due to plaster ingestion successfully treated by gastric irritation: report of two cases, Emerg. Radiol. 15 (2008) 357– 359.
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[11] R. Yeganeh, N. Rafie, A. Kazemi, F. Dortaj, M. Ahmadi, Ingestion of plaster: a new strange method of committing suicide in Lorestan Province, J. Chin. Clin. Med. 2 (2003) 42–46. [12] E.E. Tu¨rk, S. Anders, M.M. Tsokos, Planned complex suicide. Report of two autopsy cases of suicidal shot injury and subsequent self-immolation, Forensic Sci. Int. 139 (2004) 35–38. ¨ ber kombinierte und protrahierte Suizide, Kriminal. [13] V. Hofmann, F. Herber, U Forens. Wiss. 53–54 (1984) 83–88. [14] A. Fieguth, U. Grimm, W.J. Kleemann, H.D. Tro¨ger, Suizidmethoden im Sektionsgut des Instituts fu¨r Rechtsmedizin der Medizinischen Hochschule Hannover, Arch. Kriminol. 199 (1997) 13–20. [15] G. Lasczkowski, J. Ro¨hrich, H. Bratzke, Suizidexzeß-Darstellung eines ungewo¨hnlichen Falles, Arch. Kriminol. 202 (1998) 100–108. [16] M. Bohnert, S. Pollak, Kombinierte Suizide-eine Literaturu¨bersicht, Arch. Kriminol. 213 (2004) 138–153. [17] M.L. Taff, L.R. Boglioli, B.L. Danto, Planned complex suicide, Am. J. Forensic Med. Pathol. 19 (1998) 194. [18] G. Altun, Planned complex suicide: report of three cases, Forensic Sci. Int. 157 (2005) 83–86. [19] E. Lignitz, H. Strauch, Kombinierter Suizid durch Verbrennen und Sturz aus der Ho¨he, Arch. Kriminol. 178 (1986) 51–53. [20] C. Markwalder, F. Ba¨nziger, Der protrahierte Suizid als kriminalistisches Problem, Arch. Kriminol. 180 (1987) 79–87. [21] H. Nadjem, W. Weimann, S. Pollak, Ingestion of pointed objects in complex suicide, Forensic Sci. Int. 171 (2007) e11–e14. [22] C. Palmiere, E. Risso, O. van Hecke, R. La Harpe, Unplanned complex suicide by self-strangulation associated with multiple sharp force injuries: a case report, Med. Sci. Law 47 (2007) 269–273.