Suicide by Ligature Strangulation Three Case Repor
Suicide by Ligature Strangulation Three Case Repor
Suicide by Ligature Strangulation Three Case Repor
net/publication/38078596
Article in The American journal of forensic medicine and pathology: official publication of the National Association of Medical Examiners · November 2009
DOI: 10.1097/PAF.0b013e318187e06b · Source: PubMed
CITATIONS READS
20 10,933
4 authors, including:
Some of the authors of this publication are also working on these related projects:
All content following this page was uploaded by Kamil Hakan Dogan on 29 January 2018.
Am J Forensic Med Pathol • Volume 30, Number 4, December 2009 www.amjforensicmedicine.com | 369
Demirci et al Am J Forensic Med Pathol • Volume 30, Number 4, December 2009
CASE 3 ”Hypoxic brain syndrome“ was diagnosed. However, she died after
A 30-year-old woman was found unconscious in the room of 1 day of hospitalization.”
her house in the summer of 2006. Her brother immediately took her It was seen on the external examination that rigor mortis was
to the hospital. The physician reported that he removed a scarf from setting in and nonfixed hypostasis was present on the back. Autopsy
around the neck, which included 3 knots at the front of the neck area, showed the common signs of death resulting from asphyxia, includ-
by cutting it. It was learned that the woman had been under ing fluid blood, congestion of the neck vessels, subpleural and
treatment due to schizophrenia for 6 years. subepicardial petechial hemorrhages, and acute pulmonary edema.
A 4 cm-wide, superficial, horizontal ligature mark was ob- Ecchymosis on the left side of the radix of the tongue and a fracture
served around the neck (Fig. 6). Additionally, cutaneous needle with ecchymosis on the left upper horn of the thyroid cartilage were
punctures related to the medical therapy in the hospital were present present (Fig. 7). The toxicological analysis was negative.
over the antecubital veins. In the hospital’s document, it was
specified that “She was taken into the hospital due to a loss of DISCUSSION
conscious. Her general situation was bad. A ligature mark was noted There are many different methods for committing suicide, but
on the patient’s neck. She was connected to a mechanical ventilator. few are likely to be confused with homicide.3 Self-strangulation is one
Gastric lavage was performed due to a question of intoxication. of those methods that, at least at first sight, may easily be mistaken for
FIGURE 5. Ecchymosis at the radix of the tongue (case 2). According to the literature, extensive congestion of the face
and head, insignificant hemorrhaging of the neck structures, or no
hemorrhaging at all, the absence of a clear ligature mark consisting
of mechanical injuries, and the absence of defense injuries, all
characterize a suicidal action.1,10 In our study, there was congestion
of the head and face regions in all 3 cases. The ligature mark was
clear in the first case, in which the tourniquet method was used, as
his corpse was found after a sufficiently long time after death, and
the ligature material was fairly tough. On the other hand, in the other
2 cases, the ligature mark was quite superficial and uncertain, as the
second case’s corpse was found a short time after death, whereas the
third case was found alive. Other causes for the superficial and
uncertain ligature marks in these cases were the softness of the
pantyhose and the scarf as strangulation materials.
Analysis of the literature showed that the localization of the
knot in strangulation suicides is often at the anterior region of the
neck, as was seen in our second and third cases.2,5–7,11 However,
knots localized at the lateral neck region or at the back of the neck
have also been reported as was seen in our first case.1,9 More than
one knot in suicides is not unusual.1,5,9,11 Therefore the presence of
3 knots in the second and third cases was compatible with the cases
reported in these literature. This observation may be important as a
clue in the investigation of the case and may help to determine the
cause. The fundamental question is whether the victim could reach
the knot, and this question must be answered in the death scene
investigation in cases like this. In our 3 cases, the findings of the
death scene investigation and the autopsy showed that the tourniquet
of the first case and the knots of the second and third cases were
FIGURE 6. Ligature mark (case 3). localized over the areas which the victims could easily reach.
The use of more than 1 ligature has been reported in suicides,
as well as up to 20 turns.1,9 A single ligature and a single turn were
homicide because many investigators and forensic pathologists believe found in all of our cases.
that it is impossible to carry out self-strangulation as a means of Fractures of the hyoid bone or the laryngeal cartilages are
suicide.2,4 –7 This is due to the misconception that strong pressure is rarely found in suicide cases and are restricted to only 1 broken
needed on the neck to occlude the airways and the arterial vessels of the upper thyroid horn in most instances. Rothschild and Maxeiner12
neck. Polson8 has brilliantly demonstrated that a force of only 3.2 kg is reviewed 116 suicide ligature strangulation cases in which sufficient
necessary to occlude the airways, whereas a force of 2 kg is enough to details were available. They found that the number of laryngohyoid
occlude the venous system. Moreover, to stimulate the vagal reflex, fractures generally was low and the involvement of the hyoid bone,
even minimal pressure may suffice.9 In the current report, death in all as well as major injuries (eg, a fracture of the cricoid cartilage), was
3 cases was due to pressure of both the airway and venous system. extremely uncommon. Maxeiner and Bockholdt1 analyzed 47 homi-
cide and 19 suicide death cases by ligature strangulation. They facilitate and expedite the correct interpretation of the cause of death
reported that there was bleeding on the tongue in 25 homicide and 19 in cases like those presented herein.
suicide cases, whereas injury in the laryngohyoid complex existed in 21
homicide and 2 suicide cases. In our study, there was a fracture on the REFERENCES
left upper horn of thyroid cartilage in the third case only. 1. Maxeiner H, Bockholdt B. Homicidal and suicidal ligature strangulation-a
The term “garroting” or “tourniquet method” is the tightening comparison of the post-mortem findings. Forensic Sci Int. 2003;137:60 – 66.
of a noose around the neck by twisting a rod within the ligature.9 2. Di Nunno N, Costantinides F, Conticchio G, et al. Self-strangulation: an
The tourniquet method was used in our first case. We could not find uncommon but not unprecedented suicide method. Am J Forensic Med
Pathol. 2002;23:260 –263.
in any similar cases in which the tourniquet method had been used
3. Siciliano C, Costantinides F, Bernasconi P, et al. On a case of suicide using
in the literature during the last 50 years. It is our opinion that this a hand grenade. J Forensic Sci. 2000;45:208 –210.
method is important as a finding of suicide in strangulation cases. 4. Frazer M, Rosenberg S. A case of suicidal ligature strangulation. Am J Med
There were not any findings which were suggestive of homi- Pathol. 1983;4:351–354.
cide in the death scene investigation in any of our 3 cases. There 5. Claydon SM. Suicidal strangulation by ligature: three case reports. Med Sci
were no defensive wounds on any of our corpses. A suicide note was Law. 1990;30:221–224.
found in the first case. The actions in all of our cases were carried 6. Zecevic D. Suicidal strangulation with a double-knotted noose. J Forensic
out with common, personal goods (ie, a belt, pantyhose, and a scarf). Sci. 1982;27:963–967.
It was concluded, based on all of the above stated findings, that the 7. Gaur JR, Verma RK, Thakur GC. Suicidal strangulation. Med Sci Law.
1992;32:55–56.
cause of death in each of the 3 presented cases was suicide.
The third case had a chronic psychiatric disorder (schizophre- 8. Polson CJ. Hanging. In: Polson CJ, Gee DJ, Knight B, eds. The Essentials of
Forensic Medicine. New York, NY: Pergamon; 1985:357–388.
nia), whereas the first and second cases had depression, similar to
9. Knight B. Fatal pressure on the neck. In: Knight B, ed. Forensic Pathology.
reports in the literature.2,6,13 London: Arnold; 1996:361–385.
As in all cases of ligature-related asphyxiation, the type of 10. Ruszkiewicz AR, Lee KAP, Landgen AJ. Homicidal strangulation by vic-
knot is important. Therefore, the ligature should be removed with tim’s own hair presenting as natural death. Am J Forensic Med Pathol.
care, leaving the knot intact. In the investigation of the death scene 1994;15:340 –343.
in the first case, the tourniquet and the ligature on the victim’s neck 11. Kogan Y, Bloom T. Suicidal ligature strangulation with an elastic band.
were examined by a forensic pathologist. In the second case, the Am J Med Pathol. 1990;11:329 –330.
ligature was removed by the victim’s son, who untied the knots. In 12. Rothschild M, Maxeiner H. Wie umfangreich kann die Verletzung des
Kehlkopfes beim Selbsterdrosseln sein? (How extensive can laryngohyoid
the third case, the ligature was removed by the physician in the injuries be in suicidal ligature strangulation? ) 关in German兴. Arch Kriminol.
hospital who cut the binding and protected the knot. 1992;189:129 –139.
It should be emphasized that collaboration and transfer of 13. Kennedy NMJ, Whittington RM, White AC. Suicide by self-strangulation
information among investigators and the forensic pathologist will whilst under observation. Med Sci Law. 1995;35:174 –177.