External Examination of Hanging Deaths

Dependent livor is observed in the lower arms and legs depending on the duration of suspension (see Chapter 2, Fig. 9 and ref. 23). Ligature on Neck

Ropes, electric cords, and belts are common (23,24,43,50,57,58). The ligature may be altered, i.e., unraveled or cut by next of kin and investigators (16). The ligature can be wound multiple times (Fig. 8; refs. 5, 24, and 62). The ligature can be simply looped around the neck or there can be an elaborate knot (e.g., multiple loops in a hangman's noose [16,46]). An Australian study showed that when a knot was used, it was fixed in 25% of cases and was a slipknot in the rest (16). A series from Northern Ireland showed that 69.5% used a slipknot, 8.6% used a fixed knot, and 10.5% just looped the ligature around the neck (50). Knot analysis can assist in determination of manner of death (1). Hair caught in a knot is suspicious, although hair can be interposed between the noose and skin (65,67).

Fig. 8. Suicide by hanging. (A) Extension cord wound three times around neck. (B) Resulting furrows on neck.
Fig. 9. Suicide by hanging. The female victim placed a sweater between the ligature and her neck.

The neck can be protected by padding in suicides (Fig. 9; see Subheading and refs. 23 and 46). Clothing can be seen under the ligature (62). Tissue (epidermis, fat from ruptured blisters) can be transferred from the compressed site to the ligature or interposed material (129). Usually a single ligature is used, but the original can break on suspension, resulting in a second ligature being employed (128).

Children Bound With Duct Tape
Fig. 10. Suicide by hanging (ligature—rope). Wrists bound by duct tape. Ligatures on Other Body Sites

Binding of other areas of body is not necessarily indicative of homicide or auto-erotic death (see Subheading and refs. 5,7,130-132). Extremities can be bound (Figs. 10 and 11). Wrists can be tied behind the back, and even handcuffs have been used (131,132). Such bindings are usually loose, have been easily applied or stepped through, and can be easily released (61,131-133). Signs of Compression on Neck and Other Body Sites

A neck "furrow," a result of compression and rubbing, is seen in most cases (23). A furrow is typically yellow or brown with a parchment-like appearance and can appear soon after suspension (in one case report, 25 min from the time last seen alive; see Fig. 12 and refs. 28,29,62, and 134). Red or pink neck marks suggest an antemortem hemorrhage, but this may simply be owing to squeezing of blood postmortem (66,134,135). Abrasions and contusions adjacent to the furrow are suspicious of homicidal ligature strangulation (6). Postmortem blisters have been observed on skin squeezed adjacent to a furrow (Fig. 13 and ref. 62).

The furrow is typically at or above the thyroid cartilage prominence (notch, Adam's apple) in contrast to ligature strangulation, in which the furrow is typically on or below the thyroid cartilage (refs. 7, 8, 15, 16, and 50 and Fig. 12). Some cases of suicidal hanging, however, do show the furrow at the level of the thyroid cartilage (134). Furrow location may be dependent on the type of ligature. One study showed that furrows, in cases of complete suspension with a hard plastic clothesline, were above the thyroid cartilage, but deaths involving cotton cloth and incomplete suspension were

Fig. 11. Suicidal hanging (ligature—electrical cord). Another electrical cord was used to bind the knees (see Chapter 2, Fig. 16).
Strangulation Ligatur
Fig. 12. Suicide by hanging. Typical neck furrow passing over prominence of thyroid cartilage (arrow).
Forensic Hanging Deaths
Fig. 13. Suicide by hanging. Note blisters (arrows) below inferior neck furrow.

below it (5). In some young children suspended from cribs by clothing, a furrow has been observed at the level of cricoid cartilage (29). An abraded area below a furrow may indicate upward slippage of the ligature, more likely seen when suspension is complete (7,16,24). The furrow is typically angled or canted up to the point of suspension, i.e., the knot (Fig. 14; ref. 28). The point of suspension is usually at the side of the neck, but suspension does occur from the front, which results in a horizontal furrow on the back of the neck (Fig. 15; refs. 5 and 24). A ligature may encircle the neck completely and then looped anteriorly or posteriorly, resulting in a horizontal furrow (Fig. 16). A horizontal furrow arouses suspicions of homicidal strangulation (Fig. 17; ref. 136). Decapitated individuals who jump from heights can have a horizontal furrow, if a tough nonslip ligature was used (137). This has also been described in victims who become horizontal relative to the suspension point (e.g., kneeling forward [50,138]).

The pattern of the ligature can be reproduced in the furrow (Fig. 18) (15,29,128). Its width approximates that of the ligature (28). Ligature fibers can be transferred to the skin of the furrow and be taped from the surface (62). A ligature that is obliquely situated on the neck exerts consistent pressure in the antero- and posterolateral areas (139). The furrow and other compression marks may be incomplete, faint, or absent (28). A furrow is absent if a person is promptly "cut down," has material interposed between the ligature and skin, survives for a period of time allowing healing to occur, uses soft material, or employs a broad ligature (Fig. 19; refs. 3,5,6,16,23, and 78). Signs of compression are lacking if death is by vagal stimulation

Suicide Partial Suspension
Fig. 14. Suicide by hanging. Suspension point posterior. Furrow angled or canted up (arrow) behind the left ear.

(5,90,140). Pressure marks, initially present, may disappear in several hours following ligature removal (134). If there is neck lividity, pallor is localized to areas of compression (93). Care must be taken not to mistake neck creases and resuscitation efforts for furrows (Fig. 20).

Signs of compression can be seen on other areas of the body (e.g., axilla from vest restraints, bound extremities; see Subheading 2.1.4. and ref. 96).

Cyanosis of the face and neck is caused by venous congestion and incomplete carotid artery occlusion (e.g., use of a fixed knot, partial suspension; see refs. 5, 7, 23, 50, and 78). In contrast, facial pallor is noted when there is total arterial blockage (e.g., full suspension; see Fig. 21 and refs. 23, 50, and 78). This is more frequent (50). There can be congestion and edema of the conjunctivae (7). Dried blood-stained mucus may come from nostrils, corner of mouth, and ears (7,78). The tongue can protrude (Fig. 21; refs. 23 and 128). Petechiae

Distribution of petechiae is typically on the eyes and on the skin of the face and neck above the ligature site (Fig. 22; ref. 29). Eyelid petechiae were seen in 27% and conjunctival/scleral petechiae in 33% of hangings in one study (16). Both sites were involved in 18%. Petechiae are an indication that a victim was alive when suspension occurred (129). Their presence varies in partial and full suspension of adults and children (5,7,15,24,28,29,61,123,128,141). The evolution of petechiae depends on a number of factors, such as the tightness and the duration of initial application of the ligature before

Horizontal Furrow
Fig. 15. Suicidal hanging. (A) Suspension point (knot) above larynx. Anterior furrow angled. (B) Horizontal furrow, posterior neck.

pressure due to the full body weight is exerted and the absence of a slipknot in cases of partial suspension (24). For those completely suspended, angling of the head and neck away from the knot may result in only partial reduction of arterial blood flow (24). Petechiae have been described in sitting individuals asphyxiated by a vest restraint (96). Other Signs of Trauma

The hands may be near the ligature, but injuries indicating attempted relief of the applied pressure are usually not seen, underscoring the rapid loss of consciousness (Figs. 23 and 24; ref. 57). Fingernail abrasions on the neck are possible (3).

Trauma unrelated to the fatal event may have preceded the suicide and arouses suspicion (16). There may be coexistent acute, healing, or old nonfatal self-inflicted

Ligature Mark Neck
Fig. 16. Ligature looped around neck, crossed posteriorly and extended across cheeks resulting in horizontal neck furrow. (Courtesy of Dr. E. Rowe, St. Thomas-Elgin General Hospital, St. Thomas, Ontario, Canada.)

injuries (e.g., "hesitation" incised wounds; see refs. 16, 50, 61, 66, and 68). Some injuries are more worrisome (e.g., superficial stab wounds; see ref. 128). Self-mutilation (e.g., excision of male genitalia) can be observed in psychotics and transsexuals (7). Bruises can occur in the axillae and lower legs when a living victim is lifted onto a stretcher (78). A gag may have been inserted in the mouth (132). Postmortem trauma results from careless handling of the deceased (e.g., victim cut down striking a hard surface), resuscitation, and animal predation (Fig. 25; refs. 66, 68, 78, and 90).

Strangulation Ligatur
Fig. 17. Young girl. Homicidal ligature strangulation masquerading as suicidal hanging. Note two furrows on posterior neck (arrow)—faint hanging furrow canted up; arrowhead—horizontal furrow from strangulation. (Courtesy of the Office of the Chief Medical Examiner, Chapel Hill, NC.)

Injuries occur during hanging (e.g., thrashing; see refs. 50, 66, and 65). In homicidal hangings, other trauma (e.g., facial and scalp bruises) is absent if the victim has been incapacitated (66,68). Signs of external blunt trauma, strangulation, or sharp force injury may be seen in homicides disguised as suicides (6,7,28,68).

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