Multiple gunshot suicides: potential for physical activity and medico-legal aspects.

Out of 138 clearly defined gunshot suicides which were autopsied, 11 persons (8%) fired two or more gunshots to the body. From these 11, 5 cases involved 2 gunshots to the head where the bullets fired first had missed the brain. The trajectories were restricted to the chest in three cases and a combination of gunshots to the head and chest including two perforating heart wounds without immediate incapacitation occurred in three more cases. Reliable incapacitation is based on physiological effects (tissue disruption) and can only be achieved by decreasing the functioning capability of the CNS. This can be accomplished by direct disruption of brain tissue or indirectly by cerebral hypoxemia from massive bleeding. Targets of immediate incapacitation are restricted to certain CNS areas and targets of rapid incapacitation include the heart, the (thoracic) aorta and the pulmonary artery. Other major blood vessels and major organs (lungs, kidneys, liver, spleen) constitute targets of delayed incapacitation. This general classification can be derived from the literature and is illustrated by the cases presented. A thorough post mortem can exclude or quantify the potential for physical activity. Typical features of single gunshot suicides such as contact shots, classical entrance wound sites and soot/backspatter on a hand also occur in multiple gunshot suicides.