J Forensic Sci, January 2015, Vol. 60, No.

S1
doi: 10.1111/1556-4029.12673
Available online at: onlinelibrary.wiley.com

PAPER
PATHOLOGY/BIOLOGY

Fabio De-Giorgio,1 M.D., Ph.D.; Maria Lodise,1 M.D.; Gianluigi Quaranta,2 M.D., Ph.D.;
Antonio G. Spagnolo,3 M.D.; Ernesto dAloja,4 M.D., Ph.D.; Vincenzo L. Pascali,1 M.D., Ph.D.;
and Vincenzo M. Grassi,1 M.D.

Suicidal or Homicidal Sharp Force Injuries?

A Review and Critical Analysis
of the Heterogeneity in the Forensic Literature

ABSTRACT: The differential diagnosis between self-inflicted and nonself-inflicted, suicidal and homicidal, injuries is difficult or impossible

in many cases and, above all, cannot be made on the basis of information obtained solely from the autopsy or the medicolegal clinical examination. The purpose of this study is to analyze the literature on suicidal and homicidal sharp force injuries and identify the relevant parameters
that may help differentiate between suicidal and homicidal deaths. To achieve this goal, a review of 595 potentially relevant articles was performed. After excluding the nonrelevant papers by screening the titles, all abstracts were reviewed, and articles meeting the inclusion criteria
underwent a full-text review. The following parameters were compiled into a table: number of cases, localization of the injuries, and number of
injuries. The data were statistically analyzed and compared with those available in the forensic literature. On the basis of the heterogeneity of
data revealed by the present review, a simple and short checklist of the parameters that should be included when reporting suicides and homicides by sharp force has been proposed.

KEYWORDS: forensic science, suicide, homicide, sharp force injuries, statistical analysis
Sharp force injuries have been and will remain a major cause
of violent death and trauma. Fatalities from sharp force are
mainly homicidal, as suicides by sharp force represent only 1.6
3% of all suicides (15).
Differentiation between homicides and suicides, or between
self-inflicted injuries and nonself-inflicted injuries, is an important issue in common forensic activity. In fact, in many cases,
the forensic pathologist is called by the authorities to establish
the naturesuicidal or homicidal, self-inflicted or notof a
lesion. The distinction requires, in general, an analysis of the
autopsy or forensic findings (e.g., anatomical site, number of
injuries and their characteristics, presence of hesitation or
defense wounds) and a comparison with other results from the
death scene, such as clothing and bloodstain pattern analysis
(6). At the same time, it is critical to integrate these data with
the psychiatric history and information about the personal life
of the victim (history of depression or other psychiatric disorders; previous suicidal attempts; marital, social or financial
problems). However, the differential diagnosis can be difficult
and may even be impossible on rare occasions (7), even with
1
Institute of Public Health, Legal Medicine Section, Medical School, Catholic University, Largo F. Vito 1, 00168 Rome, Italy.
2
Institute of Public Health, Section of Hygiene, Medical School, Catholic
University, Largo F. Vito 1, 00168 Rome, Italy.
3
Institute of Bioethics, Catholic University, Largo F. Vito 1, 00168 Rome,
Italy.
4
Forensic Medicine Section, Department of Public Health, Cagliari University, Km 4.500 SS. 554 Bivio per Sestu, 09042 Monserrato, Italy.
Received 28 Mar. 2013; and in revised form 20 June 2013; accepted 8
Sept. 2013.

2014 American Academy of Forensic Sciences

previous experience with such cases (8). In some cases, many

of the factors reputedly indicative of self-infliction can be
absent, while elements more typical of homicide are present
(912).
To date, there are no studies that have systematically reviewed
the literature in order to identify relevant parameters that may
help differentiate between suicidal and homicidal deaths involving sharp force injuries. The aim of this study is to extract from
the literature critical aspects and relevant parameters that may
help to differentiate between suicidal and homicidal deaths
involving sharp force injuries.
Materials and Methods
A review of the literature on suicidal and homicidal, selfinflicted and nonself-inflicted, sharp force injuries was
conducted.
The research was performed using the Medline electronic
database with the following algorithms:
stab wound* OR stab injur* OR cut wound* OR cut injur*
OR sharp injur* OR sharp wound* AND suicid*;
(stab wound* OR stab injur* OR cut wound* OR cut injur*
OR sharp injur* OR sharp wound* AND murder) OR (stab
wound* OR stab injur* OR cut wound* OR cut injur* OR
sharp injur* OR sharp wound* AND murder*) OR (stab
wound* OR stab injur* OR cut wound* OR cut injur* OR
sharp injur* OR sharp wound* AND homicid*).
Furthermore, scientific articles were found using the Medline
related articles algorithm and reference lists of eligible studies.
The following inclusion and exclusion criteria were used:
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studies published up October 10, 2012 and written in English

were considered;
studies published on suicidal or homicidal sharp force injuries, mortal or not, that report separated data for the two manners of death (e.g., did not mix homicide and suicide
statistics together);
studies containing almost information on the localization and
number of injuries;
abstracts written in English that were related to studies containing information on the localization and number of injuries
that were written in other languages.

Regarding the weapon, the following exclusion criteria were

used:
cases reporting the use of a pointed weapon (e.g., screwdrivers, skewer, arrows, bodkin, etc.);
cases reporting the use of atypical sharp instruments (e.g.,
glass fragments, etc.);
cases reporting the use of heavy instruments with a cutting
edge (e.g., axes, hatchets, machetes, etc.).
The search strategy yielded 307 potentially relevant articles for
suicidal injuries (Fig. 1). Of the 307 articles found, 102 were not
written in English, 97/102 studies were included via screening of
the titles, abstracts were available in 61/97, and 10/61 were
included based on review of the abstracts. Of the 205 articles written in English, 179 were included via screening of the titles, 156/
179 were selected based on review of the abstracts, and 63/156
met the inclusion/exclusion criteria based on reading the full text;
five more studies were obtained by reviewing references, for a
total of 78 articles (68 full-text articles and 10 abstracts).
For homicidal injuries, the research yielded 288 potentially
relevant articles (Fig. 2). Of the 288 articles found, 90 were not
written in English, 79/90 studies were included from screening
the titles, abstracts were available in 64/79, and 4/64 were
included based on a review of the abstracts. Of the 198 articles
written in English, 158 were included from screening the titles,
139/158 were selected based on reviewing the abstracts, and 48/
139 met the inclusion/exclusion criteria based on reading the full
text, for a total of 52 articles (48 full texts and four abstracts).
Results
The data collected from reviewing the literature concerning
suicidal and homicidal injuries are summarized in Table 1
(18,1180) (6,9,10,18,38,46,48,53,63,66,70,81121).
Suicidal Injuries
The 78 articles contained a total of 672 cases; 503 cases were
male, and 146 cases were female. Abdullah et al. (13) did not
specify the gender of their 23 reports. In 68/78 studies and in
492/672 cases, the age of the victim was included: in 55 papers,
the age was expressed as an exact number, and 13 expressed it
as a mean. The calculated mean age was 46.23 years.
In only 46/78 studies was it possible to identify the exact
localization and number of injuries; thus, only 113 cases were
analyzable. There were a total of 414 injuries, with a mean of
3.7 injuries per case. The distribution pattern of injuries was as
follows: thorax 48.8%, neck 15.7%, upper limbs 15.5%, abdomen 12.3%, head 7.2%, and lower limbs 0.5%. These results
were slightly different when two case reports were excluded
from the total. In fact, Karger et al. (37) reported a case of a 42year-old man who inflicted a total of 92 injuries on himself, and

Rautji et al. (60) reported a similar case involving a 50-year-old

man who inflicted a total of 60 injuries on himself. Eliminating
these two case reports, the total count of the lesions was 262 in
111 cases with an average of 2.4 injuries per victim. The new
distribution pattern was as follows: thorax 36.2%, upper limbs
24.4%, abdomen 18.3%, neck 17.2%, head 3.1%, and lower
limbs 0.8% (Fig. 3).
Hesitation marks were present in 322/672 cases (47.9%) and
absent in 194 cases (28.9%), and information was not available
in 156 cases (23.2%). Clothing injuries were visible in 72/672
cases (10.7%) and absent in 235 cases (35%), and information
was not available in 365 cases (54.3%).
Psychiatric history of previous suicidal attempts was positive
in 32/672 cases (4.8%) and negative in 125 cases (18.6%), and
information was not available in 515 cases (76.6%). A clinical
psychiatric diagnosis of the victim was present in 214/672 cases
(31.9%) and absent in 220 cases (32.7%), and information was
not available in 238 (35.4%). The most frequently reported diagnosis was depression, followed by schizophrenia.
Toxicological examination was available in 74 papers corresponding to 462/672 cases. Data were not available in 236 cases
(51.1%), while lab tests were positive in 88 cases (19.0%) and
negative in 132 cases (28.6%) and not performed in six cases
(1.3%).
Homicidal Injuries
The 52 articles contained a total of 2670 cases. The gender of
the victims was not available or not exactly specified in seven
manuscripts containing a total of 1039 cases. The remaining
1631 cited 395 male cases and 1236 female cases. Nevertheless,
excluding the single paper by Mathews et al. (98) with 1045
female homicide victims, there were a total of was 395 male
cases and 191 female cases. Only 30/52 articles included the
ages for the cases, of which 27/30 expressed an exact number.
The calculated mean age was 39.11 years in the 326 homicides.
In only 32/52 studies was it possible to identify the exact
localization and the number of injuries; thus, only 521 homicides
were analyzable. The total injury count was 1977, with a mean
of 3.8 injuries per case. The distribution pattern of injuries was
as follows: thorax 54.1%, limbs 16.1%, abdomen 13.3%, neck
9.3%, head 5.7%, back 1.4%, and pelvis 0.1% (Fig. 3).
Defense wounds were present in 206/2670 cases (7.7%) and
absent in 345 cases (12.9%), and information was not available
in 2119 cases (79.4%). In the paper written by Mathews et al.
(98), the authors collected information from 1045 cases but did
not include information on the presence of defense wounds.
Excluding this article from the analysis, defense wounds were
present in 206/1625 cases (12.7%) and absent in 345 cases
(21.2%), and information was not available in 1074 (66.1%).
Clothing injuries were visible in 143/2670 cases (5.4%) and
absent in 50 cases (1.9%), and information was not available in
2477 cases (92.7). Excluding the article by Mathews et al. (98),
clothing injuries were present in 143/1625 cases (8.8%) and
absent in 50 (3.1%), and information was not available in 1432
(88.1%).
Toxicological examination data could be evaluated in 50
papers, corresponding to 2355/2670 cases. Data were not available in 2120 cases (90.0%), while lab tests were positive in 144
cases (6.1%) and negative in 91 cases (3.9%). Excluding the
article by Mathews et al. (98), toxicology results were not available in 1075 cases (82.1%), positive in 144 cases (11.0%), and
negative in 91 (6.9%).

DE-GIORGIO ET AL.

SUICIDAL AND HOMICIDAL SHARP FORCE INJURIES

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FIG. 1The search strategy yielding 307 potentially relevant articles for suicidal injuries.

Discussion
Sharp force injuries represent the leading cause of homicide in
multiple nations worldwide, including Canada (122), France
(107), Sweden (38,103,123), and the United Kingdom (8,63,93),
and most deaths due to stab wounds are homicides (124,125). Suicidal sharp injuries are relatively uncommon (15,19,27,29,63),
which is why they are more frequently presented as case reports in
the literature (63). Our review of the literature produced 30 and 57
case reports describing homicidal injuries and suicidal injuries,
respectively, which is consistent with this observation.
Classic criteria for the differentiation of self-inflicted injuries
from injuries inflicted by another person are described in both
classic and modern textbooks of forensic pathology (125,126)
and in the literature (812,15,29,35,38,39,63,103,123,127) and
are generally considered to be the following:
anatomical site;
number of injuries and their characteristics;
hesitationdefense wounds;

clothing analysis;
psychiatric history;
scene and autopsy findings.

The first two criteria are strongly correlated. In fact, the presence of an injury in a regionfor example the backthat is not
accessible to the dominant hand of the deceased is commonly
considered a marker of homicide (7,12). Moreover, it is intuitive
that the higher the number of lesions on the victims body the
higher the probability of a homicide (6).
The thorax is identified as the most common site in homicide
(63,93,103,109,128), particularly when the injury is single (101).
Additionally, the thorax is the most targeted region in suicides,
alone (29,63) or together with other anatomical regions (39).
Moreover, there are some landmark regions, such as the flexor
side of the wrist, that are predominantly involved in suicides
(38).
The present review of the literature confirms that thorax is the
most frequent region involved in both manners of death, albeit

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FIG. 2The search strategy yielding 208 potentially relevant articles for homicidal injuries.

with some differences (Fig. 3). In fact, the thorax is targeted in

more than half (54%) of homicidal wounds but only in about a
third (36.6%) of suicidal ones. The second region in the suicidal
group is the upper limbs, which account for almost a quarter of
the cases (24.4%). Regarding the homicidal group, the second
region is the combined percentage of the upper and lower limbs
(16.1%), which was due to the lack of accuracy in the description of the exact position of the lesion in numerous studies (see
the paragraph concerning study limitations). The third most common anatomical site in both the homicidal and suicidal injuries
is the abdomen, with a slightly higher percentage in suicides
(13.3% H vs. 18.3% S). The fourth and the fifth most frequent
regions are the neck and the head, respectively; however, while
the head shows a similar percentage in both (5.7% H vs. 3.1%
S), the percentage for the neck in suicides is almost double that
in homicidal cases (9.3% H vs. 17.2% S).
Some authors have focused their attention on the exact localization of the injury, distinguishing between the left and right
side. This parameter is particularly relevant because forensic
pathologists have to consider the victims handedness and its
correspondence to the observed lesions. Typically, right-handed
people who commit suicide are free of wounds on their right
arm (29). The most common site of a self-inflicted lesion is the
left side of the chest and abdomen (8,29,125). In homicides, the
left chest is the most targeted region because most people are
right handed, and when facing a victim, right-handed people

tend to strike the left side (125). Moreover, the left thorax is
believed to be the most targeted region in both manners of death
because people know it is the anatomical position of the heart
(29,125). Unfortunately, the correspondence between the anatomical site of the lesion and victims/aggressors handedness
has not been considered by most of the authors; thus, it has not
been evaluated in the present review.
The total number of injuries does not represent a significant
predictor for the manner of death (6) and is considered a less
reliable parameter for distinguishing suicide from homicide (29).
In suicides, the injury is usually single with several hesitation
marks near the fatal wound (8). At the same time, unusual cases
are available in the literature, including four suicides in which
number of injuries was between 11 and 15 (5,57,61,73), and five
cases with more than 25 wounds, with a maximum of 92 injuries
(3,35,37,60,75).
In the present review, 2617/2670 homicidal cases (98%) could
be assessed for the number of injuries, and in 1029 cases (39%),
there was a single lesion. However, the localization and the
number of the injuries were exactly identifiable in only 521/
2670 cases (19%), with a total count of 1977 injuries (mean of
3.8 injuries per victim). Among these 521 cases, 265 cases
(51%) presented with a single wound. With respect to the suicidal cases, 632/672 cases (94%) could be assessed for the number of injuries, and in 171 cases (27%), there was a single
lesion. However, the localization and the number of the injuries

DE-GIORGIO ET AL.

SUICIDAL AND HOMICIDAL SHARP FORCE INJURIES

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TABLE 1Synopsis of the homicidal and suicidal case articles.

Homicidal Cases
Ref

No. of Cases

Localization of Injuries

No. of Injuries

[13]
[14]
[15]
[16]
[17]
[6]

23
2
16
54
1
48

Mean 1.5
Multiple
1 in 8 cases; 2 in 4 cases; 3 in 3 cases; >3 in 1 case
1 in 40 cases; multiple in 14 cases (total 62 inj)
1
8.6+/ 18.8

[1]

51

[18]
[19]
[20]
[21]
[22]

2
3
1
1
1

[23]
[24]
[25]

1
1
4

[26]
[7]
[27]
[28]
[2]
[29]
[30]
[31]
[32]
[33]

1
1
1
1
1
65
1
1
1
1

[34]
[35]
[3]
[36]

1
1
1
5

[4]

65

Abdomen
Right upper limb, thorax
Neck and upper limbs most targeted sites
Neck (18); thorax (11); Abdomen (25); Upper limbs (8)
Head
1: head-neck-back-limbs: 2.1%; 2: neck-thorax-abdomen: 56.2%; 3:
upper limbs: 20.8%; 1+2: 4.2%; 2+3: 12.5%; 1+2+3: 4.2%
Upper limbs (M 14F 11); neck (M11F 1); thorax/abdomen (M 5F
1); multiple sites (M5F3)
Thorax, abdomen, left upper limb, right lower limb
Neck, right upper limb and upper limbs
Head
Abdomen (3), neck (2)
Neck (multiple), left upper limb (3), right upper limb (1); right lower
limb (4)
Neck, right upper limb
Neck (1), abdomen (2)
Abdomen (in 3 cases), thorax, abdomen, lower and upper limbs (in 1
case)
Thorax
Neck (3), lower limbs (7)
Abdomen (1), head (1)
Thorax
Neck
Thorax (49%), upper limbs (38%)
Neck
Thorax
Head
Neck (multiple), lower limbs (multiple), upper limbs (multiple), thorax
(13)
Neck (2), right upper limb (2), left upper limb (1), head (2), thorax (1)
Neck, thorax, abdomen, upper limbs, head
19 thorax, 6 abdomen
1st case: thorax; 2nd: right upper limb and neck (2); 3rd: head; 4th:
upper limbs; 5th: upper limbs and back
Neck (39%), upper limbs (47%), thorax (55%)

[37]
[39]

1
89

[38]

105

[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]
[51]
[52]
[11]

1
1
1
1
1
1
1
1
9
1
1
1
1
8

[53]
[54]
[55]
[56]
[57]
[58]
[59]
[60]

1
1
1
10
1
1
1
1

Head (22); neck (20); thorax (44); thorax-abdomen (6)

Limbs (40); limbs + neck (8); neck (8); neck + abdomen (2); abdomen
or thorax (9); abdomen and/or thorax (9); abdomen + limbs and/or
thorax (9); abdomen + limbs + thorax and/or neck (4)
Head (2%); neck (32%); abdomen (10%); lower limbs (3%); thorax
(18%); upper limbs(72%)
Thorax
Thorax
Thorax
Left upper limb (1), thorax (2)
Neck (2), left upper limb (5), neck (6), thorax (5)
Abdomen
Thorax
Head
Upper limbs (5); neck (2); thorax (2)
Abdomen
Thorax
Thorax
Abdomen
1st case: thorax (1) abdomen (1); 2nd: thorax (1); 3rd: thorax and
abdomen (6+several); 4th: left upper limb (>10); 5th: left upper limb
thorax and abdomen (>10); 6th: left upper limb and neck (multiple);
7th: neck thorax and abdomen (4); 8th: neck (1) thorax (3) abdomen
(1).
Neck
Abdomen
Left upper limb, thorax
Abdomen (9/10); neck (1/10)
Neck (2); upper limbs (8); lower limbs (1)
Thorax
Abdomen
Thorax

1 in 16 cases, 25 in 17 cases, >5 in 18 cases

Multiple
Multiple
1
5
Multiple
2
3
1 in 1 case, 2 in 1, multiple in 2
1
Multiple
2
Multiple
2
1 in 29% of cases, multiple in 71%
3
1
1
Multiple
8
>40
25
Multiple in 4 cases; 2 in 1
1 (37% of cases); 2 (15%); 3 (20%); 49 (14%);
1020 (9%); >20 (5%)
92
89
1 in 20 cases; multiple in 85
Multiple
1
Multiple
3
Multiple
1
1
1
9
Multiple
Multiple
1
2
2 in 1 case, 1 in 1 case, multiple in 6 cases

1
1
Multiple
Multiple
11
1
1
60

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TABLE 1Continued.
Homicidal Cases

Ref

No. of Cases

[61]
[62]
[63]

1
1
8

[64]
[12]
[65]
[66]
[67]
[68]
[69]
[70]

1
1
1
1
1
1
1
17

[71]
[72]
[73]
[8]

1
1
1
28

[74]
[75]
[5]

1
1
1

[76]
[77]

1
3

[78]
[79]
[80]

1
1
1

Localization of Injuries

No. of Injuries

Thorax
Left upper limb
Single wound: thorax (2), abdomen (1); multiple wounds: head and neck,
chest
Thorax
Head (41); right upper limb (3)
Neck
Neck
Thorax and abdomen
Head (15); upper limbs (5); thorax (12); abdomen (35); neck (multiple)
Neck (1), thorax (several)
Most targeted region: upper limbs, followed by neck area, thorax,
abdomen
Thorax (2)
Thorax
Neck (2); thorax (8); left upper limb (2)
Thorax (51%); abdomen (29%); lower limbs (6%); neck (6%); upper
limbs (4%)
Thorax
Neck (3); thorax (9); right upper limb (14); left upper limb (13)
Neck (2); thorax (4); left upper limb (2); right upper limb (5); left lower
limb (1)
Head, right upper limb
1st case: neck; 2nd case: thorax (1), left upper limb (1); 3rd case:
abdomen (2)
Neck; thorax; upper limbs
Thorax
Abdomen

13
Multiple
1 in 3 cases; multiple in 5 (3, 5, 6, 17, 21)
1
Multiple
1
1
Multiple
Multiple
Multiple
2.5  0.48 (min. 1; max. 9)
2
1
12
1 (64% of cases); 25 (21%); 610 (4%);
1119 (4%); >20 (7%)
1
39
15
2
2 in 2 cases; 1 in 1 case
Multiple
1
1

Suicidal Cases
Ref

No. of Cases

[9]
[81]
[6]

1
1
70

[18]
[82]
[83]
[84]
[85]
[86]
[87]
[88]
[89]
[90]
[91]
[10]
[92]
[93]
[94]
[95]
[123]

1
12
1
1
1
9
2
1
315
1
2
2
218
100
35
1
174

[96]
[97]
[46]
[98]
[48]
[99]
[100]
[101]

1
1
1
1045
8
24
52
74

[102]
[53]
[103]
[104]
[105]

1
1
142
1
2

Localization of Injuries
Neck
Head
1: head-Neck-Back-Limbs (14.3%); 2: neck-thorax-abdomen
(30%); 3: upper Limbs (0%); 1+2 (50%); 2+3 (0%); 1+2+3 (5.7%).
Thorax, abdomen and lower limb
Neck
4 neck, 9 thorax and abdomen, many other superficial on the remaining
Back
17 head and neck, 16 thorax abdomen and back
Neck, thorax, upper limbs
1st case: 15 thorax, 3 abdomen, 5 back. 2nd: neck
Head, neck, back, hands
Thorax, neck, head, abdomen and pelvis, limbs
Thorax, right, upper limb
Abdomen
Neck
Head 76, neck 81, thorax 818, abdomen 232, extremities 314
Thorax the most common site in 39/100 cases
Head, neck, thorax, abdomen, back, upper limbs
Thorax
Head 27%; neck 33%, upper limbs 46%, thorax 79%;
back 34%; abdomen 26%, lower limbs 19%
Thorax
Head and upper limbs
Thorax, back, upper limbs
Head, neck, thorax, abdomen, pelvis, upper limbs, lower limbs
Neck, thorax, abdomen, back
Head
66 thorax, 2 neck, 1 head.
Single wound: 18 thorax, 5 abdomen, 4 neck.
2 head, 2 thorax, 1 abdomen
Neck
Thorax, abdomen
Thorax
Abdomen (daughter) abdomen, back and head (mother)

No. of Injuries
Several but none lethal
1
11.5  14.7 std dev. (165)
41
1-17-4-11-1-1-8-3-25-2-5-5
13 + many other superficial
20
23
Multiple in all cases
24
71
Total of 1613 in 315 cases (mean 5.1)
5
Several; 3
Several; two
1521
1 in 39 cases; multiple in 61
1 in 9 cases; 25 in 12; 69 in 7; >10 in 7
1
1 in 59 cases; 29 in 74; 10 in 41
1
49
14
1 in 60.6% of cases; multiple in 39.4%
Multiple in all cases
1
1 in 37 cases; 2 in 12; 3 in 3.
1 in 27 cases; multiple in 47. Total:
143 in 74 cases (mean 1.93)
5
1
1 in 62 cases; 29 in 57 cases; >10 in 23 cases
1
1 (daughter) NA (mother)

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TABLE 1Continued.
Suicidal Cases
Ref

No. of Cases

Localization of Injuries

No. of Injuries

[106]
[107]
[108]
[109]
[63]

1
1
1
141
148

[110]
[111]
[62]
[68]
[70]
[113]
[114]
[115]
[116]
[117]
[118]
[119]
[120]
[121]

1
1
1
1
53
1
12
1
1
1
1
1
1
1

Thorax, abdomen and neck

Thorax
Thorax
Single wound: 32 thorax, 12 abdomen, 3 neck, 1 head, 1 lower limbs.
Single wound: 12 head + neck, 50 thorax, 5 abdomen,
2 lower limbs; multiple: 4 head + neck; 6 head + neck + other; 26 thorax;
35 thorax + other; 1 abdomen; 3 abdomen + other; 3 lower limbs + other.
Thorax
3 head, 1 thorax
1 back, 1 thorax
4 head, 2 thorax, 1 abdomen
Head, neck, thorax, abdomen, pelvis, back, upper limbs, lower limbs
Thorax
Neck
Thorax
Abdomen and back
Neck
1 neck, 8 thorax, 1 pelvis, 2 lower limbs
Head and neck
Head, neck, thorax, abdomen, pelvis, upper and lower limbs
Back

31
1
1
1 in 50 cases (35%)
1 in 67 cases (45%) multiple in 81 (55%)
1
4
2
7
111.75 std dev. (157)
1
1 in 8, multiple in 4
1
18
13
12
11
49
2

FIG. 3Schematic representation of the body. Percentages for the suicidal and homicidal injuries. The numbers have the same colour as the body areas
affected. The upper and lower limbs in homicidal injuries are counted together (see text for details).

were exactly identifiable in only 113/672 cases (16%), with a

total count of 414 injuries (mean of 3.7 injuries per victim).
Excluding two very unusual cases (37,60), the total number of
lesions was 262 in 111 cases (mean of 2.4 injuries per victim).
Among these 111, there were 66 cases (59%) presenting with a
single injury. These results seem to confirm what is known in
the literature: the total number of injuries cannot be considered

as the sole parameter in distinguishing suicide from homicide;

instead, the total number of injuries must be integrated with the
elements presented in the aforementioned numbered list.
Some of the characteristics of the injuries used to diagnose a
case of suicide rather than homicide are the direction and the
axis of the wound. In suicides, the blows are usually unidirectional (7), also described as parallel or collinear (122), while

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JOURNAL OF FORENSIC SCIENCES

homicidal wounds are multidirectional (7) or chaotically

arranged (3). Concerning the axis, injuries have been defined as
vertical when their major axis is parallel to the bodys longitudinal axis and horizontal when their major axis is parallel the
bodys transversal axis (38). The horizontal orientation is
assumed to be more common in suicides than in homicides
because of the manner of holding the knife, which results in the
victims self-inflicted injuries being more often horizontal
(4,6,35,38). As explained for the leftright localization of the
injury and its relation to the victims handedness, the axis and
the direction of the injuries have not been studied in depth by
most of the authors; thus, it has not been evaluated in this
review.
Hesitation or tentative injuries are those superficial stab or cut
wounds, usually perforating only the skin, which are oriented
parallel to each other and grouped in clusters. The tentative injuries are often seen in close proximity to the fatal wound and are
believed to be the most useful parameter, especially in the
absence of defense wounds (1), for discriminating between suicide and homicide because they are typical of self-infliction
(9,10,29,127). They are present in more than 50% of cases
(1,8,11,29,63,77) and, in some studies, in more than 75% of suicides (4,15,123). A very small number of cases have been
reported in which tentative injuries were observed in a homicidal
case and they have been explained by victims inability to
defend himself, bluntness of the blade, and inebriation of the
assaulter (9) or are considered part of an extended suicide(10).
In the present review, hesitation injuries were present in 322
cases (48%) and absent in 194 cases (29%), while the data were
not available in 156 cases (23%). Excluding these 156 cases,
hesitation injuries were present in 62% of the cases, agreeing
with the percentage already reported in the literature.
Defense wounds are sharp injuries of the extremities, typically
the hands and forearms, which are consistent with the victim
placing his or her extremities between the attacking weapon and
his own body (also called passive injuries) or with his attempts
to push away or grab the weapon (also called active injuries)
(9,93,122). These types of injuries may be absent, particularly
when the deadly wound is single and unexpected by the victim;
thus, their absence does not rule out homicide (93,129). Defense
wounds are localized either on the extensor sides of the forearms
and hands ormore oftenon the palms, the flexor sides of the
fingers, and the interdigital spaces, particularly in the region of
the thumb, the index finger, and pertinent metacarpal regions I
and II, and especially the first intermetacarpal space (129).
Defense wounds are present in more than 40% of cases
(63,93,94), and some studies have reported that they are present
in more than 75% of homicides (48,94).
In the present review, 2670 homicidal cases were evaluated
for the presence of defense wounds, and these wounds were
present in 206 cases (7.7%) and absent in 345 cases (12.9%),
while the data were not available in the remaining 2119
(79.4%). Excluding these 2119 cases, defense wounds were present in 37% of cases, a percentage slightly lower than that in the
literature.
The well-known importance of a thorough examination of victims clothing is highlighted in the literature, especially for
homicides (108), because the analysis of clothing damage can be
useful for confirming or refuting hypotheses concerning the type
of death (115,116). Generally, self-inflicted injuries are on
uncovered sites or regions that are uncovered after clothing has
been pulled up (7,29). Although classically considered to be an
indication of homicide (39), the presence of clothing damage

neither implies nor excludes homicide or suicide (3). In fact,

according to the literature, such findings are not unique and can
be found in up to 25% (4), 28% (8), or even 39% (29) of
suicides.
In the present paper, the analysis of the suicidal group showed
the presence of clothing injuries in 72/672 cases (11%) and their
absence in 235 cases (35%), while the data were not available in
365 (54%). Excluding these 365 cases, clothing was damaged in
23% of cases and not damaged in 77% of cases. Of 2670 homicidal cases, clothing injuries were visible in 143 cases (5.4%)
and absent in 50 cases (1.9%), and information was not available
in 2477 (92.8%). The proportions of cases presenting with clothing damages versus the cases that did not mention clothing damage were 74% and 26%, respectively.
To determine the manner of the death, additional background
information can be extracted by reviewing the victims psychiatric history, which could provide data such as a history of depression or other psychiatric pathologies, previous ideation of some
sort of suicide (orally or otherwise), and previous suicidal
attempts (7,8,35). In fact, psychiatric disorders were often found
in victims who committed suicide using sharp force (29).
Previous suicidal attempts were detectable in 32/672 cases
(4.8%) and not identifiable in 125 cases (18.6%), while this
information was not available in 515 (76.6%). A clinical psychiatric diagnosis of the victim was positive in 214/672 cases
(31.8%) and negative in 220 cases (32.7%), and this information
was not available in 238 cases (35.4%). The most frequently
reported diagnosis was depression, followed by schizophrenia.
The last point of the numbered list concerns the analysis of
the crime scene and the results of the autopsy. It is well known
that the pathologist has to carefully note the position of the
body, the position of stains, the conditions of the surroundings,
the presence or absence of a farewell letter, and evidence of a
struggle. Finding of a weapon beside the body is not necessarily
indicative of suicide (7), because a murderer may leave a
weapon at the scene of the crime to simulate suicide (14). The
most common location was the victims home both in suicides
and in homicides (15,38,48). However, some differences have
been identified; for example, suicides may prefer a staged or
selected scene, involving the use of mirrors (7). Autopsy results
are important not only for the aforementioned evaluation of the
localization, number, and characteristics of the injuries but also
for collecting specimens for toxicological analyses. Victims of
homicide may be drugged or inebriated and unable to react (9)
while suicides may have failed in poisoning themselves (15) or
may have planned to use multiple methods for self-destruction to
ensure a successful suicide (14).
Reviewing these papers, it was not always possible to interpret
or quantify toxicological data because the summarized information lacked detail. In 462 analyzed suicides, data were not
available in 236 cases (51.1%), while lab tests were positive in
88 cases (19.0%), negative in 132 cases (28.6%), and not performed in six cases (1.3%). Of the 1310 homicides, toxicology
results were not available in 1075 cases (82.1%) and were positive in 144 cases (11.0%), negative in 91 cases (6.9%), and not
performed in 0 cases.
The limitation of the present review is strongly correlated
with the lack of data in some of the articles found using the
aforementioned search strategy. To compile the tables and analyze some results, it was important to exclude some incomplete
articles even if they were overall rich with information. As a
consequence, a discrete number of data have not been included
in the present review because they were contained in studies

DE-GIORGIO ET AL.

with imprecise descriptions. In fact, as already noted in the literature (129), the localization of the lesion is often described
only in general terms, such as the extremities and trunk. Additionally, forensically relevant aspects are not specifically
mentioned in most cases, for example, the presence of defense
injuries, hesitation marks, previous suicidal attempts, and
psychiatric history.
The aim of the present review was to identify the relevant
parameters that may help to differentiate between suicidal and
homicidal deaths involving sharp force injuries. Nevertheless,
the data available in the literature are often not detailed, clear, or
homogenous enough to perform a meaningful comparison
between different studies. Thus, it was not possible to identify
one or more parameters that are sufficient for making an absolute differential diagnosis between suicide and homicide.
To improve reporting in studies of homicides and suicides by
sharp force injuries and to ensure clear presentation of what was
observed, it would be helpful to use a simple and short checklist
of the key parameters that should be addressed.
The articles should satisfy at least the following points:
identification of the anatomical site of the injury with its
exact position on the body, including the left or right side;
description of the total number of injuries (exact number
rather than mean number);
the direction/axis and the depth of the injuries;
an explicit assertion of the presence or absence of:

a)
b)
c)
d)

hesitation/defense injuries,
clothing injuries,
positive psychiatric history,
lab tests and their results.

Incorporating the answers to this checklist in future studies

could be useful for a uniform presentation of the data and could
represent a starting point for a more detailed statistical evaluation
of the literature.
Conclusions
When encountering a victim of a sharp force injury, forensic
pathologists should consider all the diagnostic parameters
described, which are considered essential in the differential diagnosis between homicide and suicide. Nonetheless, these parameters must be considered to be merely indicative and not absolute
because they must be integrated according to the individual case.
In fact, many studies have reported suicides with unusual findings, such as multiple self-inflicted injuries, clothing injuries,
and the absence of a relationship between handedness and lesion
localization (11,12); in addition, homicidal cases often present
with unusual features, most commonly the presence of hesitation
marks (9,10).
Both case reports and case series should accurately illustrate
the aforementioned points (in more than general terms) to produce more homogenous scientific data that can be used for a
meaningful comparison between medicolegal studies and the
studies performed by clinicians.
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Additional information and reprint requests:
Fabio De-Giorgio, M.D., Ph.D.
Institute of Legal Medicine
School of Medicine, Catholic University of the Sacred Heart
Largo Francesco Vito 1
00168 Rome
Italy
E-mail: fabio.degiorgio@rm.unicatt.it

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