victim's home, with the bathroom and bedroom being the most common rooms (2,6,8,13,18,26). Other locales have included hospitals, hotel rooms, detention facilities, and the workplace. Victims found in bathtubs may have believed that warm water dilates blood vessels and prevents coagulation (see Chapter 5, Subheading 13.2. and ref. 8). In jail, suicide victims are typically first-time offenders arrested on minor charges, intoxicated, strip-searched, and isolated (26). A history of prior suicide attempts is rare, and the self-infliction occurs within 24 h of incarceration. Improvised weapons (e.g., a broken piece of glass) are used.

In a Swedish study, more than 50% of homicidal sharp-force fatalities took place in either the victim's or the assailant's home (4). Another Scandinavian study revealed that

78% of women were killed in their own home, compared with 49% of males (1). Twenty-one percent of males were killed outdoors, as opposed to only 6% of the females (1). The high frequency of familiar locales in homicide may reflect the fact that about 80% of victims and assailants were acquainted with each other (4). Another review showed that the victim and assailant knew each other in 86% of cases (1). Single wounds were often a result of a quarrel or fight between drinking companions, but in cases of multiple wounds, an emotional relationship existed between the victim and perpetrator in 60% of cases (4). Kitchen knives and razor blades are common in suicides (2,6,9,13,18,27). In a Japanese series of 923 cases of suicidal self-stabbing, 57.2% used knives and 17.7% razors (18). Scissors and swords are uncommonly used (13,18). Rarely used items, such as broken glass, suggest a hasty decision to commit suicide (13,18). There is a case report of a physician who made a long incision, under local anesthesia, exposing his femoral artery (13).

A history of psychiatric illness, alcohol and drug abuse, and previous suicide attempts may be elicited (6,22). Studies have shown that almost half of sharp-force suicide victims had a history of alcoholism and/or mental illness (9,13). Suicide notes are found in a minority of cases (6). The Stockholm study showed that 19% of men and 31% of women (28% overall) left a suicide note (13). In contrast, a New York study revealed that about half of victims left a note (8). Verbalization of intent is more common (6). Voiced suicidal intention was expressed in 53%, and past attempts were known in 27% of the 105 sharp-force suicides studied in Stockholm (6).

Suicide by sharp-force in the presence of another person is rare and indicates either a psychiatric disorder or a spur-of-the-moment decision during a highly emotional situation (28). In an English study of 28 self-stabbings, a close relative or friend was present nearby in half of the cases, but the stabbings were actually witnessed in only two incidents (2).

2.2. Accidents

Sharp-force injuries arising from accidents are relatively uncommon and comprise a spectrum of incised, stab, and chop wounds (7). Accidental stab and incised wounds tend to be single (Fig. 2; ref. 7). Incised wounds typically involve major arteries or veins in the extremities and neck, but puncture wounds and multiple cutaneous injuries also lead to fatal exsanguination (11,29,30). Alcohol is a factor in adult accidents (11,29).

Injuries from broken glass are usually accidental (Fig. 2; refs. 7, 29, and 31). Suicides and homicides by this means are rare (32). Various types of glass are described: annealed (plate) glass, which shatters into slim sharp fragments capable of penetration; tempered glass, which typically breaks into irregular rectangular fragments; laminated glass, which has a sheet of plastic interposed between glass layers and cracks but remains intact; and wired glass, which is held together by wire mesh (30). Serious injuries are caused by glass doors and windows (33). They usually occur in children and young individuals (7,30). A prospective study of 1086 consecutive injuries due to glass showed that the age range was 5 to 31 yr (peak at 15 yr of age), and about two-thirds of cases involved males (33). The most frequent locations were the home (39%), public places (31.3%), and the workplace (21.1%). Examples of household accidents include falling against or walking through a door panel or window, upsetting glass furniture, and breaking a window to gain entry into the house (Fig. 2; refs. 8, 11, 31, 34, and 35).

Wounds are either clean-edged or irregular and abraded, depending on the nature of the broken glass and the movements of the victim (11,31,35). Multiple superficial

Fig. 2. Accidental sharp force injury. Ethanol intoxication. (A) Large incised wound of leg. Inset: shard of glass from broken table. (B) Exploration of wound track. Probe in transected vein. (C) Adjacent transected peroneal artery (lifted by probe).

abrasions and cuts are seen when the victim falls (11). A tip of broken glass deep in the wound can arrest hemorrhage (31). Accidental stabbing by a knife has been described (11,36). Other sharp objects (e.g., sewing needle) can accidentally penetrate the torso (35,37,38). Individuals can be killed by flying sharp objects (39).

2.3. Impalement

All manners of death are associated with impalement, although homicide is rare (40,41). Falls cause impalement in adults and children (42-45). In children, impalement can occur during play. Falls in adults can be precipitated by alcohol and medication (46). Underlying disease (e.g., epilepsy) can be a factor (46). Falls occur in the workplace (e.g., fall onto a steel bar). Motor vehicle occupants have been impaled by fixed, rigid structures (e.g., fence, post, tree branch) following collisions (Fig. 3; refs. 47-51). Self-inflicted impalement happens in psychiatric patients, demented individuals, and the mentally challenged (see Subheading 6.2. and refs. 52-56).

2.4. Anorectal Injuries

Penetrating anorectal injuries occur under various circumstances. Clinical recognition may be delayed because of the trauma is not obvious, and symptoms evolve slowly (34,41,42). Autoerotic activities may involve insertion of foreign objects into the vagina and rectum (see Chapter 3, Subheading 2.7. and ref. 50). Children can sustain "straddle-type" injuries (42,57,58). The entry site can be vaginal, perineal, or transanal (42,57). Clothing does not prevent impalement (42). This injury arouses suspicion of molestation (42,57,58). Intraperitoneal extension can injure the urinary bladder, bowel,

Fig. 3. Motor vehicle collision. (A) Impalement by car mirror. (B) Radiograph of skull. (C) Penetration of calvarium.

abdominal solid organs, and major vessels (41,42,57,58). Extension to the thorax is possible (42). Iatrogenic injuries (e.g., insertion of thermometer) have been described, particularly in children (Fig. 4; ref. 42).

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