Forensic Science International 301 (2019) e44–e48

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Forensic Science International

journal homepage: www.elsevier.com/locate/forsciint

Case Report

Differentiation of homicidal or suicidal strangulation

E. Doberentz* , P. Markwerth, B. Madea
Institute of Legal Medicine, University of Bonn, Stiftsplatz 12, 53111, Bonn, Germany

A R T I C L E I N F O A B S T R A C T

Article history: Hanging can be suicidal, accidental, or homicidal, and these backgrounds must be discriminated by police
Received 25 April 2019 and forensic pathologists. We herein report a case involving a 33-year-old man who was found dead on
Received in revised form 29 May 2019 the floor behind the entrance door of an apartment house. The man’s brother declared that he had found
Accepted 31 May 2019
him hanging in the gap between the stairs on the top floor. When his brother tried to cut him down, the
Available online 8 June 2019
victim fell three floors down through the gap between the stairs. Autopsy was performed to confirm
suicidal hanging and a postmortem fall into the narrow gap. In this case, however, a homicide was
Keywords:
suspected, and the version of events told by the victim’s brother was initially doubted. Homicidal hanging
Fall
Hanging
may be uncommon, but intensive scene investigation and thorough autopsy are necessary in hanging
Homicide cases to rule out homicide.
Strangulation © 2019 Elsevier B.V. All rights reserved.
Suicide

1. Introduction whose offenders have superior physical force [8,14,22]. However,

postmortem hanging after homicide is also possible [14,18,23,24].
About 95% of all hanging cases have a suicidal background [1]. This Such cases may involve hanging of the victim in the agonal period,
can be problematic because although the number of suicidal hangings but before death [20].
is much higher than that of accidental or homicidal hangings, many The classification of a suicidal, accidental, or homicidal hanging
cases of non-suicidal hanging nevertheless point toward suicide, and can be challenging, especially in cases of ambiguous circumstances
the external postmortem examination and police investigation may [12,16,19,25,26]. We herein present an unusual case of suicidal
therefore be inadequate. Furthermore, a court order to perform an hanging that led immediately to the suspicion of homicide. This
autopsy may be omitted in these ‘clear’ cases. case demonstrates the importance of a thorough crime scene
Accidental hanging [i.e., Refs. [2–9]] accounts for approximately investigation and cooperation between police and forensic
5% of all hanging cases [1,10]. Most such cases involve infants, and pathologists at the crime scene as early as possible.
some involve adults engaging in autoerotic behaviour. All three
types of hanging (accidental, homicidal, and suicidal) occur in 2. Case report
children, but infants can also commit suicide [11]. It is sometimes
very difficult or even impossible to clarify the manner of death 2.1. History
[12]. In cases of accidental sexual asphyxia, the place of discovery
and typical findings such as pornographic equipment may point to The police were called, and a man reported that he had found his
an autoerotic death. These cases could have legal relevance brother hanging in the staircase outside of his apartment. When the
because another person is likely involved in autoerotic behaviours police officers arrived at the scene, the man’s 33-year-old brother
and homicides may simulate sexual asphyxia [13]. was found dead behind the entrance door of an apartment house on
Homicidal hanging is very rare. A German study performed 35 the ground floor (Fig. 1). The man declared that he had found his
years ago estimated a homicidal hanging incidence of 1:1000 [14]. brother hanging in the gap between the stairs (Fig. 2). A belt had been
The estimated number of undetected cases might be higher, which attached to the handrail of the banister on the top floor where the
may be caused by the low autopsy rate. A few cases of homicidal man’s apartment was located. When trying to cut his brother down,
hanging have been reported in both older and more recent the victim fell three floors down through the gap between the stairs.
literature [8,10,14–21]. Hanging can be the form of homicide itself; The man was questioned by the police. He said that his brother
this is mainly found in children, incapacitated people, or victims was on a visit and that they had been drinking alcohol the previous
evening and went to sleep before midnight. He did not see his
brother until he found him at 05:00 the next morning. In contrast,
* Corresponding author. neighbours told the police that they still heard the two brothers
E-mail address: edoberentz@uni-bonn.de (E. Doberentz). speaking in the early morning.

https://doi.org/10.1016/j.forsciint.2019.05.058
0379-0738/© 2019 Elsevier B.V. All rights reserved.
 E. Doberentz et al. / Forensic Science International 301 (2019) e44–e48 e45

Fig. 1. Original position of body at the time of discovery. The body was in the supine position directly behind the entrance door. Parts of a belt were present beside the head.

Fig. 2. View through the gap between the stairs to the top of the staircase where the brother found the man strangulated and freely hanging in the gap.
e46 E. Doberentz et al. / Forensic Science International 301 (2019) e44–e48

The police officers were suspicious because of the contradictory touched over the mediastinum. Both upper horns of the laryngeal
information regarding the time of death. Additionally, it seemed cartilage were fractured and exhibited minor haemorrhage. The
impossible to fall more than three floors from the top to ground hyoid bone was intact, and no haemorrhage was present in the
floor through the very narrow gap between the stairs (Fig. 3) and tissue of the neck. Simon’s bleedings were not present.
land in the position in which the deceased was found. Moreover,
the back of the victim’s head showed an injury (Fig. 4). A homicide 2.3. Further investigation results
was therefore suspected, and the version of events provided by the
victim’s brother was doubted. Forensic pathologists were imme- Histological examination of organs taken at autopsy revealed
diately called to the scene. lung congestion and chronic hepatitis. Immunohistochemical
investigation of the ligature mark showed an intense positive
2.2. Autopsy findings reaction of aquaporin 3 staining in the epidermis and dermal blood
vessels (Fig. 5).
The deceased was a man with a body weight of about 80 kg and The alcohol concentration was 0.89m in the femoral venous
a body length of 176 cm. He had a normal stature. blood and 1.21m in the urine. Chemico-toxicological investigation
At the scene, livores were present on the face and back of the revealed no influence of psychoactive drugs.
body, and the legs showed a stocking-like appearance of livores. The time of death was determined to be around midnight.
During the autopsy, intense livores were found on the back of the
body, and a few livores were present on the front of the legs. The 3. Discussion
external examination revealed a single semi-circular strangulation
mark on the neck, rising to the right back aspect of the neck. This In Germany, 4512 people died of suicide by hanging,
mark corresponded to the structure of the belt and contained strangulation, or suffocation in the year 2015 [27]. Of these
reddish–brownish dried excoriations due to the prominent belt people, 80.42% were male and ten were aged 10–15 years. Schmidt
margins and the metallic eyelets (Fig. 4). The man had a pale face et al. [28] described a 10-year-old girl who committed suicide by
without petechial haemorrhage in the facial skin, conjunctivae, or hanging, and the parents simulated homicide to hide the suicide.
oral mucosa. The tongue was protruded between the teeth. Interestingly, in both males and females, the incidence of suicidal
A 1-cm reddish-livid excoriation was found on the top of the strangulation increases with age and peaks between 50–60 years,
head. The right back region of the head exhibited a transversal 4- then decreases.
cm-long linear and deep laceration of the scalp (Fig. 4). The upper Hanging results in strangulation with compression of the neck
margin of the wound was undermined for 1 cm. Haemorrhage was and disturbance of the cerebral blood flow due to the victim’s own
absent from the subcutaneous tissue of the scalp, particularly in body weight. Various factors must be considered when investi-
the area of the laceration. gating hanging cases to discriminate among suicidal, accidental,
The front of the right shoulder and the left calf contained and homicidal hanging, such as:
reddish-livid haematomas of 1.5 cm. The right lower leg beneath
the patella showed small whitish shreds of the epidermis with the  Motive of suicide
direction of the impact towards the head without subcutaneous  Reconstruction of the mechanism of strangulation and proof of
haemorrhage. The skin of the lower right tibia was also excoriated the possibility of self-strangulation
with epidermal shreds with basis in direction toward the head and  Determination of the cause of death
with without subcutaneous haemorrhage.  Proof of vital strangulation
The internal examination revealed a small area of haemorrhage  Assessment of all injuries
in the right temporal muscle. The brain weighed 1.440 g. The lungs  Further chemico-toxicological analysis regarding the ability to
were emphysematous and congestive (left, 610 g; right, 530 g) and act

Fig. 3. The narrowest diameter of the gap was 22 cm.

 E. Doberentz et al. / Forensic Science International 301 (2019) e44–e48 e47

Fig. 4. Strangulation mark corresponding to the belt and pale face. The right side of the back of the head contained a linear laceration.

Fig. 5. Ligature mark, aquaporin 3-positive reaction, 200.

In the present case, the brother’s story and the odd fall into a narrow exhibited isolated laryngeal fractures without involvement of the hyoid
gap of a staircase led to the suspicion of homicide. The inspection of the bone. The wide ligature mark on the neck corresponded to the belt with
scene by forensic pathologists was useful to reconstruct the circum- the highest pointof suspension at the right aspectof the backof the head.
stances of death. The original suspension was not objectively witnessed Histological examination of the ligature mark revealed intense
by anyone but the man who found his strangulated brother. The suicide staining of the water channel aquaporin 3 in the epidermis,
was unexpected and apparently without motive. The man had used his indicating a vital injury to the skin of the neck [30,31]. Ishida et al.
own belt of about 90 cm in length, which was reportedly attached to the immunohistochemically investigated 56 cases of neck compres-
handrail of the banister on the top floor. Traces of material such as paint sion and found markedly intense positive signals in dermal
that had rubbed off on the handrail were not found. The ligature mark keratinocytes in the compressed regions. Depending on the case,
rose to the back of the head. Livores were present in a circular pattern on the ligature mark can show vital reactions if the victim was still
the dependent body parts, which is consistent with a suspended alive when suspended during the agonal period [20].
position. The pale face without congestion and the protruded tongue The gap between the stairs was only about 22 cm wide. Thus,
corresponded to typical hanging. Broken upper horns of the laryngeal the man had to climb over the banister and lower himself into the
cartilage with slight surrounding haemorrhage are also typical findings narrow gap. In postmortem hanging, the corpse has to be moved
in suicidal hanging [29]. In a recent study, 33.7% of 178 hanging victims and placed in the position of strangulation. The body is heavy, and
e48 E. Doberentz et al. / Forensic Science International 301 (2019) e44–e48

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