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Suicidal Ligature Strangulation without a Knot -A Case Report

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Keywords: a B S t r a c t Strangulation is a form of death due to asphyxia. Suicide by ligature strangulation is rare & very unique. In suicidal strangulation, the signs of venous congestion are very well developed above the ligature mark. The above said feature is seen where the ligature is twisted several times round the neck, which is followed by a knot. In suicidal strangulation the marks of violence, struggle on other parts of the body are rare and as a rule absent. The following is an unusual case of suicidal strangulation where the victim maintained pressure over neck by pulling the ligature with his left hand. Scene of a crime, relative position of body, absence of violent marks/struggle marks, entangled thread within the grasp of the deceased's hand, past history of suicidal attempt and mental condition of the deceased assisted in arriving at the manner of death. World Health Organization mortality data found that hanging was the most common method used for committing suicide in most of the countries [1]. Literature search suggests that the suicidal hanging is the most common method used in India. Self-strangulation by ligature is uncommon [2]. Strangulation is a type of mechanical asphyxia produced by constriction of the neck by ligature material, without suspending the body [3]. Most of the strangulation deaths are homicidal in nature. Accidental and self-strangulation death are very rare to meet in practice. In the case of suicidal strangulation, there will be no signs of struggle & resistance, the neck including the laryngeal cartilages will not show injury and thus can be differentiated with homicidal strangulation where injuries to the neck musculature are more [2]. Attending the scene of crime, examination of the neck with respect to the pattern, course, position and the method as to how the two free ends of ligature material has been fixed to create constant pressure and constriction of the neck, absences of injuries to other parts of the body, previous history of deceased helps in determining the manner of death. On the perusal of inquest submitted by the investigating officer, the deceased a chronic alcoholic was found in an open field with ligature material present in situ around the neck (Figure 1). The free end of the ligature material was twisted within fingers of his left hand the hand was stretched away from the torso (abducted), made out from the presence of rigor mortis. On further enquiry with the investigating officer, it suggested that one day prior to this fatal incidence; the deceased had carried a sharp cutting weapon (sickle) and threatened to cut his throat in front of his villagers (superficial, parallel incisions noted over the front of neck-hesitation cuts-Figure 4). At that moment, the villagers overcome the deceased and prevented him from getting harmed. Also, the investigating officer could elicit the fact that the deceased suffering from diseases and was thus depressed.
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Suicidal Ligature Strangulation without a Knot - A Case Report
RRMC & H, Mysore Road, Kambipura, Bangalore, Karnataka, India
A R T I C L E I N F O
Keywords:
A B S T R A C T
Strangulation is a form of death due to asphyxia. Suicide by ligature strangulation
is rare & very unique. In suicidal strangulation, the signs of venous congestion
are very well developed above the ligature mark. The above said feature is seen
where the ligature is twisted several times round the neck, which is followed
by a knot. In suicidal strangulation the marks of violence, struggle on other
parts of the body are rare and as a rule absent. The following is an unusual case
of suicidal strangulation where the victim maintained pressure over neck by
pulling the ligature with his left hand. Scene of a crime, relative position of body,
absence of violent marks/struggle marks, entangled thread within the grasp of
the deceased’s hand, past history of suicidal attempt and mental condition of
the deceased assisted in arriving at the manner of death.
*Corresponding author: Kumar PMV, MBBS, MD (Forensic Medicine), RRMC & H, Mysore Road, Kambipura,
Bangalore -74, Karnataka, India
Kumar PMV*, Ahmed N and Rayamane AP
World Health Organization mortality data found that hanging was the most common method used for committing suicide
in most of the countries [1]. Literature search suggests that the suicidal hanging is the most common method used in India.
Self-strangulation by ligature is uncommon [2]. Strangulation is a type of mechanical asphyxia produced by constriction of
the neck by ligature material, without suspending the body [3]. Most of the strangulation deaths are homicidal in nature.
Accidental and self-strangulation death are very rare to meet in practice. In the case of suicidal strangulation, there will
be no signs of struggle & resistance, the neck including the laryngeal cartilages will not show injury and thus can be
differentiated with homicidal strangulation where injuries to the neck musculature are more [2]. Attending the scene of
crime, examination of the neck with respect to the pattern, course, position and the method as to how the two free ends of

of the body, previous history of deceased helps in determining the manner of death.

with ligature material present in situ around the neck (Figure 1). The free end of the ligature material was twisted within

                  

incisions noted over the front of neck -hesitation cuts - Figure 4). At that moment, the villagers overcome the deceased and
   
diseases and was thus depressed.
Citation: Kumar PMV, Ahmed N, Rayamane AP (2014) Suicidal Ligature Strangulation without a Knot - A Case
Report. SAJ Forensic Sci 1(1): 101
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   
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Case Report Open Access
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Introduction
Case report
On external examination, mild subconjunctival hemorrhage noted. Dried blood stains present around oral and nasal region
(due to ant bites). A black thread was present in situ over neck. The free ends of the thread (ligature material) were found

Article history:
Received: 02 June 2014
Accepted: 27 September 2014
Published: 28 May 2015
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
noted. The abrasion over the neck was wound twice around the neck. One completely encircling the neck and another
abrasion was wound 3/4th the circumference of neck with a gap noted on its left side. The abrasions were placed one
below the other. A gap was noted for the length of 10cms on the left side of neck and the free ends of ligature material
 

   

the left hand. Ant bites were seen at places over the body. Other external appearances were unremarkable. On dissection
of neck, strap muscles were intact and unremarkable. Hyoid bone and laryngeal cartilages were intact (Figure 5). All
internal organs were deeply congested. Liver was yellowish with feature of multi nodular cirrhotic changes which was

Figure 1: Position of the Body at the Scene of Crime
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Figure 2: Ligature Material In Situ
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Figure 3: Winding of Ligature around Fingers of Left Hand
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Figure 4: Hesitation Cuts
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Figure 5: Internal Findings of Neck Structures
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Discussion

with strangulation [3]. Death by strangulation is homicidal in nature, rarely suicidal or accidental. The distinction between

investigators hastily conclude that self-strangulation is not possible and thus makes it a suspicious death. This may be
true in terms of manual self-strangulation as the constant pressure over the neck cannot be maintained due to loss of
consciousness.
A rudimentary knowledge of neck anatomy is critical in order to understand adequately the clinical features of strangled
victim. The occurrence and degree of mechanical injuries are generally reported to be less marked in suicide, than in
homicide—which is consistent with our case [5].



or ventrolateral position of the knot, the lack of a clear ligature mark, and the absence of defense injuries all characterize a

phenomena: namely, “impaired and obstructed venous return in the presence of continued arterial input” and that “no
relationship exists between the development of petechiae and the presence or absence of asphyxia” [7].
Suicidal neck compression generally has minimal injuries of deep neck structures when compared to the case of homicidal

internal neck injuries like hemorrhages especially surrounding the carotid arteries [9]. As a general rule during post
mortem examination, if a hyoid bone is found fractured the death will be a homicide from strangulation until proven
otherwise [10]. Fracture of the hyoid bone or the laryngeal cartilages are rarely found in suicidal cases and are restricted to
only one broken upper thyroid horn in most instances [11]. A study by Maxeiner showed that fractures of the laryngohyoid
structures seen both in homicidal and suicidal cases, although, in suicidal cases, this is rare and usually limited to the upper
thyroid horn(s) of the laryngeal cartilage [8]. In our case injury to the neck structures and laryngohyoid structures were
absent due to the ligature material being thin and placed well above the laryngohyoid structures.
5
Volume 1 | Issue 1
References
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
35: 294-302.



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
12. Di Nunno N, Costantinides F, Conticchio G, Mangiatordi S, Vimercati L, et al. (2002) Self-strangulation: an uncommon but not unprecedented suicide

SAJ Forensic Science
The use of more than one ligature has been repeatedly reported in suicides as well as multiple turns [5,8]. It is very
important to examine the knot or other means used to exert pressure over neck and to document its position [12]. In our
case, ligature material was winding twice around the neck with a small gap on the left side. Most of the authors argued that
the presence of knot, half knots as well as double knots should be present in cases of suicidal strangulation. In our case,
constant pressure over the neck was maintained by the ligature which was pulled by the deceased with is left hand. The

This fact was clearly appreciated during autopsy, by the presence of out stretched left arm and the ligature being wound
 
knot is not necessary to maintain the pressure over the neck, as the ligature were held in place by the hands, or by winding
around lower limbs [5,9].
Conclusions
Based on the factors that have to be observed, visit the scene of crime, presence of more than one turn around neck, mode
of application of constant pressure over neck, type of ligature material and past history of the deceased are important to
arrive at the manner of death.
www.scholarena.com
A thorough death scene investigation, meticulous postmortem examination, past history of the deceased, is essential in
arriving at the manner of death in cases of ligature strangulation. Concluding the manner of death as suicidal has to be
done with precision and upon exclusion of other possible causes.
... 13 Absence of marks of violence or struggle in strangulation is prima facie of suicidal act. 14 Suicidal self-strangulation has minimal or no deep neck structure injuries as when compared to homicidal strangulation. [15][16] Ligature mark at the level of thyroid cartilage devoid of thyroid horn fracture or laryngeal soft tissue injury points to suicidal manner of death as in our case. ...
... 10 Presence of knot is not mandatory in cases of self-strangulation by a ligature. 14 SM Claydon (1990) noted that ligature in selfstrangulation is either knotted or tightened like a tourniquet. 17 Self-strangulation by ligature is very likely to raise an initial suspicion of homicide. ...
... 17 Self-strangulation by ligature is very likely to raise an initial suspicion of homicide. 11,14,17 No any signs of struggle posed by the victim or presence of any abnormal evidences like footmarks etc. at the death scene excluded the possibility of homicide. It appeared that the deceased had put the wires around his neck and jumped from a slightly raised platform in the space between two buildings. ...
Article
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A case of ligature strangulation where circumstances into the manner of death were doubtful is reported for its rarity. Detailed death scene investigations and autopsy could unravel the mystery posed in this case of ligature strangulation without a knot in the noose. © 2016 South India Medico-Legal Association. All rights reserved.
... Para se determinar a circunstância relacionada ao estrangulamento, se homicídio ou suicídio, ou até mesmo acidente, é fundamental que se faça um exame detalhado da cena do crime, analisando-se, cuidadosamente, o tipo de ligadura que foi feita no pescoço da vítima, o número de voltas ao redor do pescoço, a forma do nó e o método empregado 2 . Outro aspecto importante é avaliar como o material empregado na ligadura foi utilizado para manter a constrição e a pressão constantes no pescoço 3 . Zorro (2014) 4 reforçou, ainda, que além das análises da ligadura e do nó efetuados, é necessário que se faça uma avaliação da cena no sentido de identificar sinais de participação de terceiros e avaliar se os ferimentos constatados, como sulcos, escoriações, poderiam ser autoinflingido. ...
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Os métodos de suicídio mais comuns são enforcamento, uso de armas de fogo, ou de armas brancas, e envenenamento. O suicídio por meio de estrangulamento não é comum, havendo poucos casos descritos na literatura. Objetiva-se relatar três casos de suicídios atípicos onde o método utilizado foi o estrangulamento. Os casos foram classificados como suicídios, baseando-se nos elementos constatados no local da ocorrência, como a habilidade e possibilidade da vítima em efetuar um laço que seja letal, e ausência de vestígios que indicassem a participação de terceiros. Os achados necroscópicos e o trabalho da investigação criminal também foram considerados no escopo da classificação dos casos de suicídio. Tendo em vista que os relatos de casos de suicídio por estrangulamento são escassos na literatura, o presente artigo corrobora o auxílio de estudos e atuação de Peritos Criminais, Médicos Legistas, bem como outros profissionais inseridos em todo o contexto da investigação criminal.
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ABSTRACT: Self strangulation by ligature which gives the initial impression of a homicide, is distinctly uncommon. Strangulation by ligature is a common method of homicide in forensic field. Sometimes it may be accidental, particularly in the context of occupational accidents but very rare & unusual method of suicide. Self-strangulation must be separated from homicidal and accidental strangulation. To confirm manner of ligature strangulation, the initial assessment of the case must start with detailed investigation of the death scene, ruling out signs of violence & struggle and examine the type of ligature around the neck of the victim, the number of wrappings around the neck, the shape of the knot and the method of ligature application. In this report we present our experience with suicide by ligature strangulation by describing a case with the findings of the crime scene investigation, where a 25 year old female was found dead inside her room. Room was bolted inside and was neat & undisturbed. The victim was lying on her back on the bed and there was a 1.0 cm wide, thick waistband (Nada) wrapped thrice around her neck.
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To summarize the published forensic pathology evidence base in deaths concluded to be the result of suicidal ligature strangulation, an uncommon entity. Four electronic bibliographic databases Medline Ovid, Embase, Scopus, HEINonline were screened for relevant literature. No date restrictions were applied. All English language case reports or case series were included. Articles were evaluated and key data extracted according to predefined criteria. A total of 1554 references eventually yielded 24 papers with 31 eligible case reports. The location of the deaths and background circumstances and history mirror broadly those of suicide generally. The range of ligature types was diverse. 19/31 cases reported one or more knots present. In the remaining 12 cases, the ligatures did not lend themselves to knots. In only one case were laryngeal fractures reported, but the available material does not justify confidence in that report given the significance of the finding. This systematic review has identified and synthesized the evidence from 31 case reports of suicidal ligature strangulation. A forensic pathologist faced with a possible case can locate it within the spectrum of reported cases and therefore identify its common and distinguishing features. Inherent difficulties for research in forensic pathology mean that case reports are an important source of learning and evidence for the discipline. Opportunities for improvement exist especially in harmonizing terminology and standardizing techniques generally, and in reports of suicidal ligature strangulation in particular.
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Hanging is the most common asphyxial method of suicide, whereas suicide by strangulation is unusual. Here, we are reporting a particular methodology of the asphyxial method of suicide in which a case of self-strangulation culminated into partial hanging. A 30-year-old male wrapped one end of the cable wire around his neck. He then passed the other end over a curtain rod and tied that end around the right hand. He pulled the hand down, using the curtain rod as a fulcrum, to tighten the noose around the neck in an attempt to strangulate himself. However, he lost consciousness during the process and the body slipped down, pulling the right hand up which got stuck at the curtain rod. This led the body hanged in the kneeling position. This bizarre scenario raised suspicion of homicide but the crime scene, autopsy and victim characteristics were in favor of suicide.
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Suicide by ligature strangulation, which gives the initial impression of a homicide, is very rare. In this article, 3 suicidal death cases caused by ligature strangulation in Konya between 2001 and 2006 are presented. The first victim was a 68-year-old man who suffered from depression and lived alone in a cottage house. He terminated his life by applying a tourniquet to his neck after leaving a suicide note. The second victim was a 70-year-old woman who was found dead on the floor of the living room in her house. After she cut the vessels in her wrist, she tied pantyhose with 3 knots around her neck. It was reported that she had been intermittently receiving treatment for bronchial asthma and depression for 20 years. The third victim was a 30-year-old woman who suffered from schizophrenia for 6 years. She tied a scarf around her neck with 3 knots and died in the hospital after 1 day due to "hypoxic brain syndrome." As a result of the death scene investigations, autopsies, and judicial inquiries, it was concluded that death was by suicide in all 3 cases. Because the use of the ligature strangulation method, and particularly the tourniquet method, in suicidal cases is extremely rare in the literature, our aim is to present and discuss these cases.
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Accurate information about preferred suicide methods is important for devising strategies and programmes for suicide prevention. Our knowledge of the methods used and their variation across countries and world regions is still limited. The aim of this study was to provide the first comprehensive overview of international patterns of suicide methods. Data encoded according to the International Classification of Diseases (10th revision) were derived from the WHO mortality database. The classification was used to differentiate suicide methods. Correspondence analysis was used to identify typical patterns of suicide methods in different countries by providing a summary of cross-tabulated data. Poisoning by pesticide was common in many Asian countries and in Latin America; poisoning by drugs was common in both Nordic countries and the United Kingdom. Hanging was the preferred method of suicide in eastern Europe, as was firearm suicide in the United States and jumping from a high place in cities and urban societies such as Hong Kong Special Administrative Region, China. Correspondence analysis demonstrated a polarization between pesticide suicide and firearm suicide at the expense of traditional methods, such as hanging and jumping from a high place, which lay in between. This analysis showed that pesticide suicide and firearm suicide replaced traditional methods in many countries. The observed suicide pattern depended upon the availability of the methods used, in particular the availability of technical means. The present evidence indicates that restricting access to the means of suicide is more urgent and more technically feasible than ever.
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OBJECTIVE: Accurate information about preferred suicide methods is important for devising strategies and programmes for suicide prevention. Our knowledge of the methods used and their variation across countries and world regions is still limited. The aim of this study was to provide the first comprehensive overview of international patterns of suicide methods. METHODS: Data encoded according to the International Classification of Diseases (10th revision) were derived from the WHO mortality database. The classification was used to differentiate suicide methods. Correspondence analysis was used to identify typical patterns of suicide methods in different countries by providing a summary of cross-tabulated data. FINDINGS: Poisoning by pesticide was common in many Asian countries and in Latin America; poisoning by drugs was common in both Nordic countries and the United Kingdom. Hanging was the preferred method of suicide in eastern Europe, as was firearm suicide in the United States and jumping from a high place in cities and urban societies such as Hong Kong Special Administrative Region, China. Correspondence analysis demonstrated a polarization between pesticide suicide and firearm suicide at the expense of traditional methods, such as hanging and jumping from a high place, which lay in between. CONCLUSION: This analysis showed that pesticide suicide and firearm suicide replaced traditional methods in many countries. The observed suicide pattern depended upon the availability of the methods used, in particular the availability of technical means. The present evidence indicates that restricting access to the means of suicide is more urgent and more technically feasible than ever.
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In judicial and police circles - sometimes even in circles of medical professionals - it is still often thought that suicidal strangulation by ligature is impossible. Reviewing the forensic literature we could find more than 200 cases that have been published earlier. We report another 4 cases of suicidal strangulation. The main problems of criminalists and medical examiners in such cases are discussed. Primary investigation of the corpse in original position by a forensic scientist is of high importance.
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Self-strangulation by ligature is distinctly uncommon. It is distinct from self-suspension in cases of hanging, the latter being a far more common form of suicide. Self-strangulation must be separated from homicidal strangulation and from accidental sexual asphyxia. The ligature in suicidal strangulation may be knotted or tightened like a tourniquet. As the ligature is tightened the face and neck may become congested due to slow venous compression. Laryngeal fractures are rare and injuries are mild and often confined to the single ligature mark around the neck. The three cases discussed here were initially treated by the police as suspicious. Detailed examination of the scene and of the deceased person, along with investigation of the circumstances leading to the death, produced clear verdicts of suicide in all three cases.
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