CASE REPORT
Suicide by Ligature Strangulation
Three Case Reports
Serafettin Demirci, MD,* Kamil Hakan Dogan, MD,* Zerrin Erkol, MD, and Gursel Gunaydin, MD*
Abstract: Suicide by ligature strangulation, which gives the initial impres-
sion 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.
Key Words: ligature strangulation, death, forensic medicine
(Am J Forensic Med Pathol 2009;30: 369 372)
S trangulation by ligature is a common method of homicide. If a
victim is found with the ligature still present, the evaluation of
the mode of death (suicide/homicide) can be an extremely complex
objective.1 Suicide by self-strangulation is uncommon, but a review
of the forensic literature revealed that many cases of atypical
strangulations have been described. Despite this, many authors and
criminal investigators continue to believe that self-strangulation is
not possible and that strangulation must therefore represent homi-
cide.2 Ligature strangulation is a type of strangulation carried out
with the use of a ligature.
To confirm ligature strangulation, it is necessary to perform a
detailed investigation of the death scene 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 our study, we present our experiences with suicide by
ligature strangulation by describing 3 cases with the findings of the
death scene investigation.
Manuscript received September 27, 2007; accepted November 15, 2007.
From the *Department of Forensic Medicine, Meram Medical School, Selcuk
University, Konya, Turkey; and Department of Forensic Medicine, Abant
Izzet Baysal University, Bolu, Turkey.
Presented at the 5th Congress of the Balkan Academy of Forensic Sciences, Ohrid,
Republic of Macedonia, June 37, 2007.
All figures can be viewed in color at http://amjforensicmedicine.com.
Reprints: Serafettin Demirci, MD, Department of Forensic Medicine, Meram
Medical School, Selcuk University, 42080 Meram, Konya, Turkey. E-mail:
sdemirci@selcuk.edu.tr.
Copyright 2009 by Lippincott Williams & Wilkins
ISSN: 0195-7910/09/3004-0369
DOI: 10.1097/PAF.0b013e318187e06b
Am J Forensic Med Pathol Volume 30, Number 4, December 2009
CASE 1
A 68-year-old man was found dead in his hut-like home in the
autumn of 2000. There was no sign of forced entry to the door of the
house. The inside of the house was neat and undisturbed. The victim
was lying on his back on the bed and there was a 5 cm-wide, thick
fabric belt around his neck (Fig. 1). A wooden bar passed through the
circle created by the belt on the right side of the neck (ie, the tourniquet
method). The circle was constricted by rotating the bar, thus placing
pressure on the neck. When the fabric was removed from the neck
by cutting the belt, it was seen that there was a 5 cm-wide ligature
mark, which was compatible with the belts shape and horizontal
position around the neck at the level of the thyroid cartilage. On the
right side of the neck, the mark was thin where the belt was folded.
When the folded part of fabric belt was unfolded, it was noted that
the wooden bar had been rotated twice. In the death scene investi-
gation, a suicide note was found indicating that nobody was respon-
sible for the death of the victim.
After his wife had died 2 years earlier, the victim had been
living alone and had been treated intermittently for major depression
at a local hospital during those 2 years. External examination of the
body showed that rigor mortis was present and advanced, and
hypostasis was very clear, dark-purple, and localized to the back.
Autopsy showed the common signs of death resulting from as-
phyxia, including fluid blood, congestion of the vessels of the neck,
and petechial hemorrhages; no traumatic lesions were visualized and
the laryngohyoid complex was intact; the toxicological analysis was
negative.
CASE 2
A 70-year-old woman was found dead by her son on the floor
of the living room in her house in the spring of 2006 with pantyhose
tied around her neck and a pillow under her head. As soon as her son
saw her, he untied the 3 knots of pantyhose under her chin on the
front of her neck (Fig. 2). She had been receiving treatment for
depression and bronchial asthma for 20 years. It was learned that she
had attempted suicide by taking drugs and had been treated in a state
hospital a few weeks previously.
In the death scene investigation, a bloody bread knife was found
near the closet in the bathroom (Fig. 3). There were no signs on the
corpse or at the scene suggestive of an attack by someone else.
In the external examination, it was seen that there were 2, 4
cm-long, parallel, and superficial cuts on the flexor surface of the left
wrist which were perpendicular to the axis of the forearm (Fig. 4).
There was a tail at the beginning and end of the wounds. A 2 cm-wide,
superficial, horizontal ligature mark was noted around the neck.
Rigor was setting in and nonfixed hypostasis was present on
the back. Autopsy showed the common signs of death resulting from
asphyxia, including fluid blood, congestion of the neck vessels, and
petechial hemorrhages, but no traumatic lesions. There was edema
in the larynx and ecchymosis at the radix of the tongue and in the
tonsils (Fig. 5). The laryngohyoid complex was intact. The left radial
vein was completely cut. The toxicological analysis was negative.
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Demirci et al Am J Forensic Med Pathol Volume 30, Number 4, December 2009
FIGURE 1. Tourniquet method (case 1).
FIGURE 2. Untied pantyhose (case 2).
CASE 3
A 30-year-old woman was found unconscious in the room of
her house in the summer of 2006. Her brother immediately took her
to the hospital. The physician reported that he removed a scarf from
around the neck, which included 3 knots at the front of the neck area,
by cutting it. It was learned that the woman had been under
treatment due to schizophrenia for 6 years.
A 4 cm-wide, superficial, horizontal ligature mark was ob-
served around the neck (Fig. 6). Additionally, cutaneous needle
punctures related to the medical therapy in the hospital were present
over the antecubital veins. In the hospitals document, it was
specified that She was taken into the hospital due to a loss of
conscious. Her general situation was bad. A ligature mark was noted
on the patients neck. She was connected to a mechanical ventilator.
Gastric lavage was performed due to a question of intoxication.
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FIGURE 3. Bloody bread knife near the closet in the bath-
room (case 2).
FIGURE 4. Superficial cuts on the left wrist (case 2).
Hypoxic brain syndrome was diagnosed. However, she died after
1 day of hospitalization.
It was seen on the external examination that rigor mortis was
setting in and nonfixed hypostasis was present on the back. Autopsy
showed the common signs of death resulting from asphyxia, includ-
ing fluid blood, congestion of the neck vessels, subpleural and
subepicardial petechial hemorrhages, and acute pulmonary edema.
Ecchymosis on the left side of the radix of the tongue and a fracture
with ecchymosis on the left upper horn of the thyroid cartilage were
present (Fig. 7). The toxicological analysis was negative.
DISCUSSION
There are many different methods for committing suicide, but
few are likely to be confused with homicide.3 Self-strangulation is one
of those methods that, at least at first sight, may easily be mistaken for
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Am J Forensic Med Pathol Volume 30, Number 4, December 2009
FIGURE 5. Ecchymosis at the radix of the tongue (case 2).
FIGURE 6. Ligature mark (case 3).
homicide because many investigators and forensic pathologists believe
that it is impossible to carry out self-strangulation as a means of
suicide.2,4 7 This is due to the misconception that strong pressure is
needed on the neck to occlude the airways and the arterial vessels of the
neck. Polson8 has brilliantly demonstrated that a force of only 3.2 kg is
necessary to occlude the airways, whereas a force of 2 kg is enough to
occlude the venous system. Moreover, to stimulate the vagal reflex,
even minimal pressure may suffice.9 In the current report, death in all
3 cases was due to pressure of both the airway and venous system.
2009 Lippincott Williams & Wilkins
Suicide by Ligature Strangulation
FIGURE 7. Fracture of the thyroid cartilage (case 3).
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 cases 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.2,57,11 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
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
found in all of our cases.
Fractures of the hyoid bone or the laryngeal cartilages are
rarely found in suicide cases and are restricted to only 1 broken
upper thyroid horn in most instances. Rothschild and Maxeiner12
reviewed 116 suicide ligature strangulation cases in which sufficient
details were available. They found that the number of laryngohyoid
fractures generally was low and the involvement of the hyoid bone,
as well as major injuries (eg, a fracture of the cricoid cartilage), was
extremely uncommon. Maxeiner and Bockholdt1 analyzed 47 homi-
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Demirci et al Am J Forensic Med Pathol Volume 30, Number 4, December 2009
cide and 19 suicide death cases by ligature strangulation. They
reported that there was bleeding on the tongue in 25 homicide and 19
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
left upper horn of thyroid cartilage in the third case only.
The term garroting or tourniquet method is the tightening
of a noose around the neck by twisting a rod within the ligature.9
The tourniquet method was used in our first case. We could not find
in any similar cases in which the tourniquet method had been used
in the literature during the last 50 years. It is our opinion that this
method is important as a finding of suicide in strangulation cases.
There were not any findings which were suggestive of homi-
cide in the death scene investigation in any of our 3 cases. There
were no defensive wounds on any of our corpses. A suicide note was
found in the first case. The actions in all of our cases were carried
out with common, personal goods (ie, a belt, pantyhose, and a scarf).
It was concluded, based on all of the above stated findings, that the
cause of death in each of the 3 presented cases was suicide.
The third case had a chronic psychiatric disorder (schizophre-
nia), whereas the first and second cases had depression, similar to
reports in the literature.2,6,13
As in all cases of ligature-related asphyxiation, the type of
knot is important. Therefore, the ligature should be removed with
care, leaving the knot intact. In the investigation of the death scene
in the first case, the tourniquet and the ligature on the victims neck
were examined by a forensic pathologist. In the second case, the
ligature was removed by the victims son, who untied the knots. In
the third case, the ligature was removed by the physician in the
hospital who cut the binding and protected the knot.
It should be emphasized that collaboration and transfer of
information among investigators and the forensic pathologist will
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facilitate and expedite the correct interpretation of the cause of death
in cases like those presented herein.
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