Internal Examination of Hanging Deaths

Internal injuries are absent in many hangings, even with complete suspension, which underscores that hanging is a "gentle" form of asphyxia, particularly when self-inflicted (4,7,15,16,23,24,28,50,93,128). Consciousness is lost rapidly, with little time for purposeful activity (125). Vagal stimulation leading to sudden cardiac arrest could also be a factor (90). Internal neck injuries were seen in about 60% of hanging deaths in one series (16). There was a higher frequency of trauma in complete compared with incomplete suspensions (62 to 46%).

Fig. 18. Suicides by hanging. Examples (A,B) of patterned furrows.

2.1.7.1. Soft-Tissue Hemorrhage

Soft-tissue or muscle hemorrhages are seen in a minority of cases. In various series, the range is from about 3% to about one-third (16,23,24,50,57). Soft-tissue hemorrhages in the neck indicate that the individual was alive when the injuries were inflicted (17,18,129). Hemorrhage adjacent to fracture sites supports the supposition that they occurred antemortem. Hemolysis from decomposition decreases visible hemorrhage (142). Alternatively, the postmortem origin of a hemorrhagic focus cannot be entirely excluded, especially when there is decomposition (see Chapter 2, Subheading 3.3. and ref. 142). No correlation between the presence of soft-tissue hemorrhages and hyoid/lar-ynx fractures has been noted (24). The amount of hemorrhage is usually insufficient to cause death (see Subheading 2.1.7.2.). In certain situations (e.g., following extraction of teeth), extensive hemorrhage in the neck musculature has caused asphyxia (143).

Firrow Hanging Suicide
Fig. 19. Suicides by hanging. (A) Hanging furrow absent. Suspension less than 20 min. (B) Furrow fading (arrows). Survival several days.

2.1.7.2. Sites of Hemorrhage

Sites of hemorrhage may include the following:

• Sternocleidomastoid muscles underlying compression site (Fig. 26; ref. 28).

° Extensive hemorrhage combined with glottic edema and bleeding can interfere with breathing (144).

• Thyrohyoid membrane.

• Connective and muscle tissue adjacent to thyroid cartilage (Fig. 26; ref. 15).

• Soft tissue adjacent to intact hyoid bone and thyroid cartilage (superior horns [28]).

• Soft tissue adjacent to fracture sites (hemorrhage is absent if site artifactually fractured after death or neck compression totally compromised circulation; see Fig. 26 and ref. 145).

• Periosteum, with or without muscle involvement, at inferior insertion of sternocleido-mastoid muscle as a result of neck hyperextension (tendency for hemorrhage to be seen on side of highest ligature mark [107,129,146]).

Ligature Mark
Fig. 20. Hanging. (A) Pale furrow (arrow) created by pressure of ligature in area of lividity. Three pale neck creases inferiorly. (B) Pale "furrow" in area of lividity created by soft tie fastened to an endotracheal tube. More inferior linear horizontal pale area is a neck crease.
Ligature Strangulation
Fig. 21. Hanging. Facial pallor; protruding tongue darkened by drying.
Endometriosi Pathology Conjunctiva
Fig. 22. Hanging. (A) Cutaneous petechiae above furrow. (B) Conjunctival and periorbital petechiae.

° Hemorrhage may not be seen grossly but can be observed with microscopic sections (see Subheading 2.4 and ref. 142).

• Hemorrhage in the posterior cricoarytenoid muscles is a nonspecific finding from various causes (146-148).

2.1.7.3. Petechiae

Petechiae have been described on the buccal mucosa, base of tongue, and epiglottis (15,28). One series noted that epicardial petechiae were seen in 19% of hangings and visceral pleural petechiae in 6% (16). Both sites were involved in 4%. Internal petechiae were observed in 10% of cases when hanging was complete, 19% when incomplete.

2.1.7.4. Fractures

The incidence of anterior neck fractures in hangings increases with age although they do occur at a young age and are absent in older individuals (e.g., 14-yr-old boy with fracture of superior horn of larynx; no fractures in 78-yr-old despite considerable ossification of thyroid cartilage [24,134,145,152-154]). The frequency of fractures depends on the diligence and dissection method used (57,134,145,149,154-156). Radiological assessment increases the yield (145,153,157). Stereomicroscopic examination has documented hyoid and larynx injuries in almost three-fourths of suicidal hangings, a higher yield than those obtained by using the conventional methods of palpation, radiograph imaging, and dissection (156).

Strangulation Ligature Mark
Fig. 24. Hanging. (A) Swollen and blistered fingertips because of hand placement under constricting ligature. (B) Fingertip impression (arrow) in area of livor mortis and adjacent to furrow (arrowhead).

The most common fracture in suicidal hanging involves the superior horn of the larynx (see Table 1; Fig. 26; and ref. 16). Fractures of the laryngeal lamina are uncommon and are associated with either complete suspension or a long drop (16). Generally, a higher incidence of fractures of the hyoid/larynx is noted in manual and ligature

Fig. 25. Deceased hanging victim cut down at scene; head struck concrete floor. (A) Scalp laceration, left occiput exposed by shaving hair. (B) Left occipital bruise (arrowhead) on undersurface of scalp. Removal of dura from base of skull revealed linear fracture (arrow).

strangulation (109). In a review by Betz and Eisenmenger of 109 accidental and suicidal hangings, 37% had two superior horns fractured; 15% had both superior horns and a hyoid cornu (greater horn) broken; 10% had both superior horns and hyoid cornu fractured (including a 28-yr-old [155]). In another series, hyoid fractures were typically associated with thyroid cartilage fractures (16). The pattern of external neck injuries, damage to the hyoid-larynx complex, and associated hemorrhages raises the possibility of homicidal neck compression (68,155,158). Ubelaker's review of the literature determined the following fracture frequencies in homicidal ligature and manual strangulation:

Ligature Neck Compression

Fig. 26. Soft-tissue hemorrhages in suicidal hanging. (A) Hemorrhage in left sternocleidomastoid muscle. (Courtesy of the Office of the Chief Medical Examiner, Chapel Hill, NC.)

(B) Larynx, anterior view. Hemorrhage in muscle adjacent to right thyroid cartilage.

(C) Fractured left superior horn of larynx (arrowhead). Foci of hemorrhage (arrows).

Fig. 26. Soft-tissue hemorrhages in suicidal hanging. (A) Hemorrhage in left sternocleidomastoid muscle. (Courtesy of the Office of the Chief Medical Examiner, Chapel Hill, NC.)

(B) Larynx, anterior view. Hemorrhage in muscle adjacent to right thyroid cartilage.

(C) Fractured left superior horn of larynx (arrowhead). Foci of hemorrhage (arrows).

thyroid cartilage, 32% (ligature) and 34% (manual); hyoid, 11% (ligature) and 34% (manual); and cricoid, 9% (ligature) and 1% (manual [149]).

The hyoid bone, a mobile structure, is protected anteriorly by the mandible and soft tissue, and posteriorly by the cervical spine (Fig. 27). Hyoid fracture is uncommon clinically (144,159). A number of factors determine whether a hyoid bone fractures in strangulation and hanging deaths. The shape, i.e., the curvature, of the greater horns means that fractures usually occur in the posterior and middle parts (160). Most hyoid bones are symmetrical (136). Although different dimensions and shapes—i.e., hyperbolic (breadth = length) and parabolic (breadth > length)—have been related to fracture

Table 1

Fractures: Hanging Suicides

Table 1

Fractures: Hanging Suicides

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