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Skate or die: Unusual circumstances surrounding a natural cause of death
Journal Pre-proof Skate or die: Unusual circumstances surrounding a natural cause of death Frederique Thicot, Tony Fracasso PII:
S1752-928X(20)30012-3
DOI:
https://doi.org/10.1016/j.jflm.2020.101906
Reference:
YJFLM 101906
To appear in:
Journal of Forensic and Legal Medicine
Received Date: 8 October 2019 Revised Date:
4 January 2020
Accepted Date: 6 January 2020
Please cite this article as: Thicot F, Fracasso T, Skate or die: Unusual circumstances surrounding a natural cause of death, Journal of Forensic and Legal Medicine (2020), doi: https://doi.org/10.1016/ j.jflm.2020.101906. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
Skate or die: Unusual circumstances surrounding a natural cause of death
Frederique THICOT*, Tony FRACASSO M.D, Ph.D*, *
University Center of Legal Medicine, Rue Michel-Servet 1, 1205 Geneva, Switzerland.
Corresponding Author: Frederique THICOT E-mail: [email protected] Tel: +33 649 280 735
The total number of words of the manuscript (including text from title page to figure legends): 2133. The number of words of the abstract: 154. The number of figures: 4.
Skate or die Presented at the summer session of the Swiss Society of Legal Medicine (SSML) on the 25th and 26th of May 2018 – Bulle, Switzerland
Ethical approval: This article does not contain any studies with human participants or animals performed by any of the authors.
Informed consent: Formal authorization for anonymous publication was delivered by the local prosecutor.
SKATE OR DIE: UNUSUAL CIRCUMSTANCES SURROUNDING A NATURAL CAUSE OF DEATH
ABSTRACT In a forensic pathologist’s mind, a suspicious death scene involving inflicted injuries and a weapon always raises three possible hypotheses regarding the manner of death—homicide, suicide, or accident; the latter is slightly less common. We present a case of a 43-year-old homeless man with a history of chronic alcohol abuse who was found dead in a skate park in Geneva. He was inflicted with a stab wound to his abdomen, with a knife found in situ. With the suspicion of homicide, a crime scene investigation team, including a forensic pathologist, was summoned to the scene. However, further examination of the body revealed a deep cut with hesitation marks on the left forearm. This discovery raised the hypothesis of a suicide. Here, we have described the investigations made by the police and forensic department, along with the circumstances and autopsy findings that determined the cause of death as an effect of a natural disease.
KEYWORDS forensic pathology; manner of death; suicide; suspected homicide; peritonitis; perforated peptic ulcer.
1
Introduction Determination of the manner of death may be one of the most challenging tasks in forensic investigations. In some cases, the circumstances of a body’s discovery strongly point towards a specific scenario. However, strong views can hinder the neutral approach necessary for any wellconducted investigation, and subsequent conclusions might involuntarily be directed towards validation of initial impressions. Meticulous and rigorous correlation of evidence is essential in order to appropriately certify death in equivocal cases, as the consequences of determining a violent or undetermined manner of death are significant. The following case highlights the misleading findings that may complicate determination of the manner of death in a forensic inquest.
Case report In November 2017, the forensic pathologists on duty were summoned to a death scene in a skate park in Geneva for a suspected homicide (Figure 1). Shortly before, the police had discovered the dead body of a 43-year-old homeless man under a skate ramp with a knife in his abdomen. On arrival on the scene and removal of the ramp, the body of a middle-aged man was found in the supine position over a blanket and surrounded by debris. There was a small amount of blood on the scene and next to the body. However, no blood was evident on the clothes. The preliminary external examination of the body revealed a stab wound to the lower, left quadrant of the abdomen with the knife in situ, passing through the clothes and perforating them (Figure 2). The knife measured 4.3 inches (11 cm) in length and about half an inch (1.2 cm) in width. Following the removal of the knife and mobilization of the body, an abundant yellowish liquid was flowing out from the stab wound. In addition, we discovered a deep cut located at the distal extremity of the left forearm. The cut was associated with hesitation wounds and exposed the underlying tendinous and muscular structures.
2
The police also retrieved a video footage that revealed that the deceased bought the knife on the same day, a few hours prior to the discovery of his body. Subsequent external examination of the body enabled a better visualization of the stab wound located in the abdomen. It was observed to be a linear wound with clean and regular margins without any abrasion around its edges. The cut on the left forearm presented irregular margins and shallow hesitation marks along the edges (Figure 3). Other external findings included minor traumatic injuries, such as a blunt injury with healing margins located on the scalp near the vertex, and two ecchymosis on the left shoulder. An abrasion on the left arm along with a few cutaneous hemorrhagic infiltrations on the lower limbs were also observed. Postmortem computed tomography and angiography revealed disruption of normal continuity at the left wrist and the left rectus abdominis muscle, a pneumoperitoneum, and an intra-abdominal trajectory of the stab wound from front to back and from left to right. Liver changes associated with peritoneal collection were detected radiologically, with contrast enhancement and contrast dye leakage at the gastric and duodenal mucosae. The autopsy revealed that the stab wound penetrated the peritoneal cavity. However, the abdominal structures were not injured, as the stab wound’s trajectory ended at the omentum. A brownish liquid with solid components had accumulated within the peritoneal cavity. This liquid was also visible on the surface of the abdominal organs. The peritoneum had become red and was covered with fibrin filaments. Exploration of the abdominal organs revealed the presence of a lesion compatible with a perforated ulcer, located at the junction of the pylorus and duodenum. The aforementioned brownish liquid was being discharged from this lesion. (Figure 4). Other internal findings included hepatic cirrhosis along with mild coronary and generalized atherosclerosis.
3
Dissection of the left forearm revealed a complete section of the radial vein along with the tendinous and muscular structures underlying to the deep cut injury. However, the radial and ulnar arteries were intact.
Histological investigations revealed chronic inflammation at the site of the peptic ulcer and acute peritonitis. Other histological and neuropathological findings included pulmonary edema with siderophages, hepatic steatosis along with cirrhosis, and signs of metabolic encephalopathy. Blood, serum, and urine analyses revealed the presence of alcohol, nicotine, and caffeine in the blood and urine. Presence of elevated levels of the C-reactive protein and procalcitonin suggested inflammation, probably from a bacterial origin.
Discussion This unusual case initially presented as a suspected homicide and was later hypothesized as a possible suicide. However, based on pathological findings consistent with peritonitis, the manner of death was actually natural. A death scene with multiple inflicted injuries produced by sharp forces usually points to a suspected homicide.1–3 According to statistics, homicides involving sharp force trauma are most common in Switzerland. 4 Perforation of clothing that covers the entrance wound has been interpreted to be suggestive of a possible homicide. Although not corroborated by scientific data, it is believed that an individual committing suicide would prefer to expose the skin and push the clothing aside.5 The absence of defense wounds and the presence of a deep cut on the forearm associated with hesitation wounds are suggestive of self-inflicted injuries. Moreover, the accessibility of the site of injury, and the fact that flexor side of the wrist is a frequent localization of cuts while attempting suicide, led us to contemplate suicide as our main hypothesis.6
4
According to Marcinkowski’s classification of suicides in 1974, we could argue that this case displayed features suggestive of an unplanned complex suicide. 7–10 For unplanned complex suicides, cut wounds are a common first method of choice. However, it is debatable whether switching from cut to stab wounds falls into that category. Some authors seem more prone to interpret it as a manifestation of hesitation marks.8 In this case, there was an undeniably clear intent to commit suicide. However, none of the selfinflicted injuries presented by the victim were severe enough to ensure death. However, peritonitis is a serious complication of a perforated peptic ulcer (PPU) that rapidly progresses to sepsis and may have a fatal outcome, especially in the absence of medical care. PPU occurs in 2% to 10% of patients with peptic ulcer disease and is associated with short-term mortality of up to 30%. This mortality rate is higher if this condition is associated with other comorbidities and poor living conditions, as depicted in this case.11 Individuals with PPU often present a typical history of a sudden onset of acute, sharp abdominal pain, frequently located in the epigastric region.11,12 Given the presence of a medical condition that is potentially fatal on its own, it was a challenge to associate this death to the non-fatal injuries. Therefore, we concluded that the cause of death, in this case, was an advanced peritonitis, in spite of the self-inflicted lesions. The aforementioned injuries caused a modest bleed, and may have had a minor contribution to the death by precipitating the fatal outcome. On a different level, this case caused us to wonder about the circumstances of the victim’s death. We wonder whether the symptoms, especially pain, influenced his decision to commit suicide. Moreover, this case may raise questions regarding the persistence of deaths from preventable diseases among the least fortunate classes of our society. We reviewed the forensic literature for similar case reports featuring unusual injuries and context association. To our knowledge, only one case, reported by A. di Luca et al. exhibited similar findings, with an initial homicide hypothesis ending with a natural cause of death. 13
5
Both these cases displayed peculiar circumstances discovered at the death scene, and suggested foreign intervention. However, the hypothesis of suicide was not considered in the case reported by A. di Luca et al. Moreover, one could argue that cardiac infarction, reported as the cause of death in their case, may potentially be observed in numerous violent scenarios. As debated by many authors regarding the “homicide by heart attack” model, acute cardiac events are more likely to occur in a stressful and/or violent situation if the victim had an underlying cardiovascular pathology.14 In contrast, although peritonitis could not have occurred as a result of the self-inflicted injuries or the circumstantial evidence presented in our case, it may very well have influenced this man’s tragic attempt to take his own life. To summarize, our case illustrates the complexity behind some cases deemed “obvious” at first glance. However, these cases may raise more questions than anticipated. We believe this case report could contribute to the widening of the knowledge base, and stimulate forensic minds.
Conclusion Given the paucity of borderline case scenarios in the forensic literature, this case report may demonstrate the interconnectedness of possible causes and manners of death. It also emphasizes the need to be careful when correlating such atypical findings with the evidence.
Declaration of competing interest The authors declare that they have no conflict of interest.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
6
References 1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12.
13.
14.
Hunt AC, Cowling RJ. Murder by stabbing. Forensic Science International. 1991;52(1):107-112. doi:10.1016/0379-0738(91)90102-O Mazzolo GM, Desinan L. Sharp force fatalities: suicide, homicide or accident? A series of 21 cases. Forensic Science International. 2005;147:S33-S35. doi:10.1016/j.forsciint.2004.09.097 Voss HL, Hepburn JR. Patterns in Criminal Homicide in Chicago. The Journal of Criminal Law, Criminology, and Police Science. 1968;59(4):499. doi:10.2307/1141830 Scheidegger F, Darbellay S. Criminalité et Droit Pénal Homicides Enregistrés Par La Police.; 2018. www.statistique.ch. Strassmann F, Strassmann G. Lehrbuch Der Gerichtlichen Medizin.; 1931. Karger B, Niemeyer J, Brinkmann B. Suicides by sharp force: typical and atypical features. International Journal of Legal Medicine. 2000;113(5):259-262. doi:10.1007/s004149900093 Marcinkowski T, Pukacka-Sokolowska L, Wojciechowski T. Planned complex suicide. Forensic Science. 1974;3:95-100. doi:10.1016/0300-9432(74)90013-2 Racette S, Sauvageau A. Planned and Unplanned Complex Suicides: A 5-year Retrospective Study. Journal of Forensic Sciences. 2007;52(2):449-452. doi:10.1111/j.1556-4029.2007.00387.x Vidhate SG, Pathak H, Parchake M, Sukhadeve R, Meshram V. A planned complex suicide: Cut injury to the wrist with corrosive acid poisoning. Egyptian Journal of Forensic Sciences. 2016;6(4):478-480. doi:10.1016/j.ejfs.2015.11.002 Zribi M, Dhoueb R, Benamar W, Jammeli K. Complex Suicide: Unusual Combination. Journal of Forensic Medicine. 2016;1(2). doi:10.4172/2472-1026.1000111 Bertleff MJOE, Lange JF. Perforated Peptic Ulcer Disease: A Review of History and Treatment. Digestive Surgery. 2010;27(3):161-169. doi:10.1159/000264653 Murty OP, Fan LY, Siang TL, Hasbullah NE, Mohd Ismail NA. Fatal Gastrointestinal Perforations in sudden death cases in Last 10 years at UMMC- Malaysia. Internet Journal of Medical Update EJOURNAL. 2007;2(1). doi:10.4314/ijmu.v2i1.39845 di Luca A, de Matteis V, Marcelli A, Polacco M, Pascali VL, Oliva A. The Differential Diagnosis Between Natural Death and Homicide, an Everlasting Challenge for the Forensic Pathologist. The American Journal of Forensic Medicine and Pathology. 2016;38(1):14-17. doi:10.1097/PAF.0000000000000282 de Giorgio F, Arena V, Arena E, et al. Homicide by heart attack? Legal Medicine. 2009;11:S531-S532. doi:10.1016/j.legalmed.2009.02.060
Figure Legends Figure 1 – Skate ramp covering the body Figure 2 – Knife in situ Figure 3 – Cutting injury on the left forearm Figure 4 – Perforated peptic ulcer
7
Acknowledgments The authors wish to thank the entire University Center of Legal Medicine in Geneva and Lausanne for their support in the preparation of this manuscript.
HIGHLIGHTS • • •
Post mortem examination excluded the lethality of the stab and cut injuries The Autopsy and histopathology confirmed the presence of an acute peritonitis due to a perforated peptic ulcer Careful correlation of each post mortem finding is an essential aspect of the forensic pathologist’s practice
CONFLICTS OF INTEREST STATEMENT
The authors of this original manuscript certify that they have no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.
S1752-928X(20)30012-3
DOI:
https://doi.org/10.1016/j.jflm.2020.101906
Reference:
YJFLM 101906
To appear in:
Journal of Forensic and Legal Medicine
Received Date: 8 October 2019 Revised Date:
4 January 2020
Accepted Date: 6 January 2020
Please cite this article as: Thicot F, Fracasso T, Skate or die: Unusual circumstances surrounding a natural cause of death, Journal of Forensic and Legal Medicine (2020), doi: https://doi.org/10.1016/ j.jflm.2020.101906. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Ltd.
Skate or die: Unusual circumstances surrounding a natural cause of death
Frederique THICOT*, Tony FRACASSO M.D, Ph.D*, *
University Center of Legal Medicine, Rue Michel-Servet 1, 1205 Geneva, Switzerland.
Corresponding Author: Frederique THICOT E-mail: [email protected] Tel: +33 649 280 735
The total number of words of the manuscript (including text from title page to figure legends): 2133. The number of words of the abstract: 154. The number of figures: 4.
Skate or die Presented at the summer session of the Swiss Society of Legal Medicine (SSML) on the 25th and 26th of May 2018 – Bulle, Switzerland
Ethical approval: This article does not contain any studies with human participants or animals performed by any of the authors.
Informed consent: Formal authorization for anonymous publication was delivered by the local prosecutor.
SKATE OR DIE: UNUSUAL CIRCUMSTANCES SURROUNDING A NATURAL CAUSE OF DEATH
ABSTRACT In a forensic pathologist’s mind, a suspicious death scene involving inflicted injuries and a weapon always raises three possible hypotheses regarding the manner of death—homicide, suicide, or accident; the latter is slightly less common. We present a case of a 43-year-old homeless man with a history of chronic alcohol abuse who was found dead in a skate park in Geneva. He was inflicted with a stab wound to his abdomen, with a knife found in situ. With the suspicion of homicide, a crime scene investigation team, including a forensic pathologist, was summoned to the scene. However, further examination of the body revealed a deep cut with hesitation marks on the left forearm. This discovery raised the hypothesis of a suicide. Here, we have described the investigations made by the police and forensic department, along with the circumstances and autopsy findings that determined the cause of death as an effect of a natural disease.
KEYWORDS forensic pathology; manner of death; suicide; suspected homicide; peritonitis; perforated peptic ulcer.
1
Introduction Determination of the manner of death may be one of the most challenging tasks in forensic investigations. In some cases, the circumstances of a body’s discovery strongly point towards a specific scenario. However, strong views can hinder the neutral approach necessary for any wellconducted investigation, and subsequent conclusions might involuntarily be directed towards validation of initial impressions. Meticulous and rigorous correlation of evidence is essential in order to appropriately certify death in equivocal cases, as the consequences of determining a violent or undetermined manner of death are significant. The following case highlights the misleading findings that may complicate determination of the manner of death in a forensic inquest.
Case report In November 2017, the forensic pathologists on duty were summoned to a death scene in a skate park in Geneva for a suspected homicide (Figure 1). Shortly before, the police had discovered the dead body of a 43-year-old homeless man under a skate ramp with a knife in his abdomen. On arrival on the scene and removal of the ramp, the body of a middle-aged man was found in the supine position over a blanket and surrounded by debris. There was a small amount of blood on the scene and next to the body. However, no blood was evident on the clothes. The preliminary external examination of the body revealed a stab wound to the lower, left quadrant of the abdomen with the knife in situ, passing through the clothes and perforating them (Figure 2). The knife measured 4.3 inches (11 cm) in length and about half an inch (1.2 cm) in width. Following the removal of the knife and mobilization of the body, an abundant yellowish liquid was flowing out from the stab wound. In addition, we discovered a deep cut located at the distal extremity of the left forearm. The cut was associated with hesitation wounds and exposed the underlying tendinous and muscular structures.
2
The police also retrieved a video footage that revealed that the deceased bought the knife on the same day, a few hours prior to the discovery of his body. Subsequent external examination of the body enabled a better visualization of the stab wound located in the abdomen. It was observed to be a linear wound with clean and regular margins without any abrasion around its edges. The cut on the left forearm presented irregular margins and shallow hesitation marks along the edges (Figure 3). Other external findings included minor traumatic injuries, such as a blunt injury with healing margins located on the scalp near the vertex, and two ecchymosis on the left shoulder. An abrasion on the left arm along with a few cutaneous hemorrhagic infiltrations on the lower limbs were also observed. Postmortem computed tomography and angiography revealed disruption of normal continuity at the left wrist and the left rectus abdominis muscle, a pneumoperitoneum, and an intra-abdominal trajectory of the stab wound from front to back and from left to right. Liver changes associated with peritoneal collection were detected radiologically, with contrast enhancement and contrast dye leakage at the gastric and duodenal mucosae. The autopsy revealed that the stab wound penetrated the peritoneal cavity. However, the abdominal structures were not injured, as the stab wound’s trajectory ended at the omentum. A brownish liquid with solid components had accumulated within the peritoneal cavity. This liquid was also visible on the surface of the abdominal organs. The peritoneum had become red and was covered with fibrin filaments. Exploration of the abdominal organs revealed the presence of a lesion compatible with a perforated ulcer, located at the junction of the pylorus and duodenum. The aforementioned brownish liquid was being discharged from this lesion. (Figure 4). Other internal findings included hepatic cirrhosis along with mild coronary and generalized atherosclerosis.
3
Dissection of the left forearm revealed a complete section of the radial vein along with the tendinous and muscular structures underlying to the deep cut injury. However, the radial and ulnar arteries were intact.
Histological investigations revealed chronic inflammation at the site of the peptic ulcer and acute peritonitis. Other histological and neuropathological findings included pulmonary edema with siderophages, hepatic steatosis along with cirrhosis, and signs of metabolic encephalopathy. Blood, serum, and urine analyses revealed the presence of alcohol, nicotine, and caffeine in the blood and urine. Presence of elevated levels of the C-reactive protein and procalcitonin suggested inflammation, probably from a bacterial origin.
Discussion This unusual case initially presented as a suspected homicide and was later hypothesized as a possible suicide. However, based on pathological findings consistent with peritonitis, the manner of death was actually natural. A death scene with multiple inflicted injuries produced by sharp forces usually points to a suspected homicide.1–3 According to statistics, homicides involving sharp force trauma are most common in Switzerland. 4 Perforation of clothing that covers the entrance wound has been interpreted to be suggestive of a possible homicide. Although not corroborated by scientific data, it is believed that an individual committing suicide would prefer to expose the skin and push the clothing aside.5 The absence of defense wounds and the presence of a deep cut on the forearm associated with hesitation wounds are suggestive of self-inflicted injuries. Moreover, the accessibility of the site of injury, and the fact that flexor side of the wrist is a frequent localization of cuts while attempting suicide, led us to contemplate suicide as our main hypothesis.6
4
According to Marcinkowski’s classification of suicides in 1974, we could argue that this case displayed features suggestive of an unplanned complex suicide. 7–10 For unplanned complex suicides, cut wounds are a common first method of choice. However, it is debatable whether switching from cut to stab wounds falls into that category. Some authors seem more prone to interpret it as a manifestation of hesitation marks.8 In this case, there was an undeniably clear intent to commit suicide. However, none of the selfinflicted injuries presented by the victim were severe enough to ensure death. However, peritonitis is a serious complication of a perforated peptic ulcer (PPU) that rapidly progresses to sepsis and may have a fatal outcome, especially in the absence of medical care. PPU occurs in 2% to 10% of patients with peptic ulcer disease and is associated with short-term mortality of up to 30%. This mortality rate is higher if this condition is associated with other comorbidities and poor living conditions, as depicted in this case.11 Individuals with PPU often present a typical history of a sudden onset of acute, sharp abdominal pain, frequently located in the epigastric region.11,12 Given the presence of a medical condition that is potentially fatal on its own, it was a challenge to associate this death to the non-fatal injuries. Therefore, we concluded that the cause of death, in this case, was an advanced peritonitis, in spite of the self-inflicted lesions. The aforementioned injuries caused a modest bleed, and may have had a minor contribution to the death by precipitating the fatal outcome. On a different level, this case caused us to wonder about the circumstances of the victim’s death. We wonder whether the symptoms, especially pain, influenced his decision to commit suicide. Moreover, this case may raise questions regarding the persistence of deaths from preventable diseases among the least fortunate classes of our society. We reviewed the forensic literature for similar case reports featuring unusual injuries and context association. To our knowledge, only one case, reported by A. di Luca et al. exhibited similar findings, with an initial homicide hypothesis ending with a natural cause of death. 13
5
Both these cases displayed peculiar circumstances discovered at the death scene, and suggested foreign intervention. However, the hypothesis of suicide was not considered in the case reported by A. di Luca et al. Moreover, one could argue that cardiac infarction, reported as the cause of death in their case, may potentially be observed in numerous violent scenarios. As debated by many authors regarding the “homicide by heart attack” model, acute cardiac events are more likely to occur in a stressful and/or violent situation if the victim had an underlying cardiovascular pathology.14 In contrast, although peritonitis could not have occurred as a result of the self-inflicted injuries or the circumstantial evidence presented in our case, it may very well have influenced this man’s tragic attempt to take his own life. To summarize, our case illustrates the complexity behind some cases deemed “obvious” at first glance. However, these cases may raise more questions than anticipated. We believe this case report could contribute to the widening of the knowledge base, and stimulate forensic minds.
Conclusion Given the paucity of borderline case scenarios in the forensic literature, this case report may demonstrate the interconnectedness of possible causes and manners of death. It also emphasizes the need to be careful when correlating such atypical findings with the evidence.
Declaration of competing interest The authors declare that they have no conflict of interest.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
6
References 1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12.
13.
14.
Hunt AC, Cowling RJ. Murder by stabbing. Forensic Science International. 1991;52(1):107-112. doi:10.1016/0379-0738(91)90102-O Mazzolo GM, Desinan L. Sharp force fatalities: suicide, homicide or accident? A series of 21 cases. Forensic Science International. 2005;147:S33-S35. doi:10.1016/j.forsciint.2004.09.097 Voss HL, Hepburn JR. Patterns in Criminal Homicide in Chicago. The Journal of Criminal Law, Criminology, and Police Science. 1968;59(4):499. doi:10.2307/1141830 Scheidegger F, Darbellay S. Criminalité et Droit Pénal Homicides Enregistrés Par La Police.; 2018. www.statistique.ch. Strassmann F, Strassmann G. Lehrbuch Der Gerichtlichen Medizin.; 1931. Karger B, Niemeyer J, Brinkmann B. Suicides by sharp force: typical and atypical features. International Journal of Legal Medicine. 2000;113(5):259-262. doi:10.1007/s004149900093 Marcinkowski T, Pukacka-Sokolowska L, Wojciechowski T. Planned complex suicide. Forensic Science. 1974;3:95-100. doi:10.1016/0300-9432(74)90013-2 Racette S, Sauvageau A. Planned and Unplanned Complex Suicides: A 5-year Retrospective Study. Journal of Forensic Sciences. 2007;52(2):449-452. doi:10.1111/j.1556-4029.2007.00387.x Vidhate SG, Pathak H, Parchake M, Sukhadeve R, Meshram V. A planned complex suicide: Cut injury to the wrist with corrosive acid poisoning. Egyptian Journal of Forensic Sciences. 2016;6(4):478-480. doi:10.1016/j.ejfs.2015.11.002 Zribi M, Dhoueb R, Benamar W, Jammeli K. Complex Suicide: Unusual Combination. Journal of Forensic Medicine. 2016;1(2). doi:10.4172/2472-1026.1000111 Bertleff MJOE, Lange JF. Perforated Peptic Ulcer Disease: A Review of History and Treatment. Digestive Surgery. 2010;27(3):161-169. doi:10.1159/000264653 Murty OP, Fan LY, Siang TL, Hasbullah NE, Mohd Ismail NA. Fatal Gastrointestinal Perforations in sudden death cases in Last 10 years at UMMC- Malaysia. Internet Journal of Medical Update EJOURNAL. 2007;2(1). doi:10.4314/ijmu.v2i1.39845 di Luca A, de Matteis V, Marcelli A, Polacco M, Pascali VL, Oliva A. The Differential Diagnosis Between Natural Death and Homicide, an Everlasting Challenge for the Forensic Pathologist. The American Journal of Forensic Medicine and Pathology. 2016;38(1):14-17. doi:10.1097/PAF.0000000000000282 de Giorgio F, Arena V, Arena E, et al. Homicide by heart attack? Legal Medicine. 2009;11:S531-S532. doi:10.1016/j.legalmed.2009.02.060
Figure Legends Figure 1 – Skate ramp covering the body Figure 2 – Knife in situ Figure 3 – Cutting injury on the left forearm Figure 4 – Perforated peptic ulcer
7
Acknowledgments The authors wish to thank the entire University Center of Legal Medicine in Geneva and Lausanne for their support in the preparation of this manuscript.
HIGHLIGHTS • • •
Post mortem examination excluded the lethality of the stab and cut injuries The Autopsy and histopathology confirmed the presence of an acute peritonitis due to a perforated peptic ulcer Careful correlation of each post mortem finding is an essential aspect of the forensic pathologist’s practice
CONFLICTS OF INTEREST STATEMENT
The authors of this original manuscript certify that they have no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.