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Case Report

Suicide by Ligature Strangulation

Three Case Reports

Demirci, Serafettin MD*; Dogan, Kamil Hakan MD*; Erkol, Zerrin MD; Gunaydin, Gursel MD*

Author Information
The American Journal of Forensic Medicine and Pathology: December 2009 - Volume 30 - Issue 4 - p 369-372
doi: 10.1097/PAF.0b013e318187e06b
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Strangulation 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 homicide.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.


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 belt's 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 investigation, a suicide note was found indicating that nobody was responsible for the death of the victim.

Tourniquet method (case 1).

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 asphyxia, 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.


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.

Untied pantyhose (case 2).

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.

Bloody bread knife near the closet in the bathroom (case 2).

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.

Superficial cuts on the left wrist (case 2).

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.

Ecchymosis at the radix of the tongue (case 2).


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 observed 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 hospital's 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 patient's neck. She was connected to a mechanical ventilator. Gastric lavage was performed due to a question of intoxication. ”Hypoxic brain syndrome“ was diagnosed. However, she died after 1 day of hospitalization.”

Ligature mark (case 3).

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, including 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.

Fracture of the thyroid cartilage (case 3).


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 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.

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 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 homicide 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 homicide 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 (schizophrenia), 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 victim's neck were examined by a forensic pathologist. In the second case, the ligature was removed by the victim's 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 facilitate and expedite the correct interpretation of the cause of death in cases like those presented herein.


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ligature strangulation; death; forensic medicine

© 2009 Lippincott Williams & Wilkins, Inc.