Abstract
Background
Suicide remains a significant global public health challenge, with hanging as the most prevalent suicide method in South Korea. This study aimed to determine diagnostic markers confirming suicidal hanging-associated deaths.
Methods
In this prospective study, hemorrhages at the periosteal-clavicular origin of the sternocleidomastoid (SCM) muscles were compared among suicidal hanging, manual strangulation, and ligature strangulation cases. This study included 211 cases of suicide by hanging, and a control group of 50 individuals who underwent cardiopulmonary resuscitation but died of other causes. Additionally, nine cases of ligature strangulation and six cases of manual strangulation were analyzed. Postmortem examinations were conducted, and clavicular hemorrhages were histologically evaluated. Statistical analyses were performed using the χ2 test.
Results
Hemorrhages at the periosteal-clavicular origin of the SCM were observed in 178 of the 211 hanging cases (84.4%). The highest frequency of clavicular hemorrhage was found in typical hanging cases with complete suspension. Among the 50 control cases, only three showed hemorrhages in the clavicular region, but these were extravasations in the adjoining soft tissue, not in the periosteum. In cases of manual and ligature strangulation, SCM hemorrhages were found within the muscle tissue and were not of periosteal-clavicular origin.
Conclusion
Hemorrhage at the periosteal-clavicular origin of the SCM is a significant finding in suicidal hanging and serves as a potential pathognomonic marker for confirming cases of suicidal hanging. The study revealed a statistically significant association between the type of hanging, completeness of body suspension, and the occurrence of these hemorrhages. Cardiopulmonary resuscitation does not cause a hemorrhage at this location.
Keywords: Hanging, Suicide, Sternocleidomastoid Muscle, Hemorrhage, Clavicle, Forensic Pathology, Strangulation
Graphical Abstract
INTRODUCTION
Suicide is a challenging global public health problem.1 In South Korea, suicide was the sixth leading cause of death in 2022, accounting for 12,906 deaths.2 In Korea, hanging is one of the most common methods of suicide and warrants the performance of an autopsy by a forensic pathologist.
Hanging is a form of asphyxia, in which the force applied to the neck with ligature strangulation, is derived from the gravitational drag of the weight of the body or a part of the body.3 The process of death by hanging involves several anatomical and physiological mechanisms, including blockage of the airway, constriction of the neck veins, compression of the carotid arteries, pressure on the baroreceptors, and vagal cardiac arrest. Death is most likely caused by a combination of different mechanisms.4,5 A crucial aspect of postmortem examination in hanging cases is the identification and documentation of both external and internal injuries. These injuries are essential for determining the manner of death, particularly when there is ambiguity concerning whether the death was due to actual or simulated hanging.
Typical pathological findings in hanging-related deaths include the presence of a ligature mark, injuries to the laryngo-hyoid or thyrohyoid complex, and hemorrhage in the cervical muscles.6,7,8,9 In hanging cases, there is a high frequency of hemorrhages in the sternocleidomastoid (SCM) muscle (Fig. 1).10,11 However, considering the strong association between ligature marks and/or injuries to the laryngo-hyoid or thyrohyoid complex and hanging cases, the diagnostic value of SCM hemorrhage in the periosteal region has not been fully explored for hanging-related deaths.
Fig. 1. Periosteal hemorrhage (indicated by blue arrows) at the clavicular origin of the right sternocleidomastoid muscle in cases of suicidal hanging.
Therefore, in this prospective study, we aimed to identify hanging-specific hemorrhages at the periosteal-clavicular origin of the SCM through descriptive and comparative analyses of hemorrhages at the periosteal-clavicular origin of the SCM observed in hanging victims and victims of other related causes of death, including manual and ligature strangulation.
METHODS
A prospective study was conducted on 211 consecutive postmortem cases of death due to suicide by hanging, which were autopsied by the Department of Forensic Medicine, Seoul National University College of Medicine between May 2011 and April 2024 (156 months). The control group consisted of 50 individuals who had underwent cardiopulmonary resuscitation but died from causes other than hanging. Additionally, for comparative analysis, nine cases of ligature strangulation and six cases of manual strangulation were included.
Hangings were classified based on the position of the ligature mark: ‘typical’ if the ligature mark was located in the front of the neck between the hyoid bone and the thyroid cartilage, with the groove converging upwards towards a point in the midline of the back of the neck; and ‘atypical’ if the angle of the groove was located at the side of the neck or in the front of the neck (Fig. 2).
Fig. 2. Classification of hanging types according to knot position: typical (posterior) and atypical (anterior, right lateral, and left lateral).
Hanging cases were divided into two subcategories: ‘complete hanging,’ where the entire body was off the ground and full body weight was supported by the neck, and 'incomplete hanging,' where any part of the body was touching the floor or another support. The ligatures were categorized into two groups: hard materials (e.g., rope, steel rope, cable, belt, strap, duct tape, wire, laundry wire, and garden hose) and soft materials (e.g., bedsheet, clothes, towel, bathrobe belt, and headscarves).12
Postmortem examinations were conducted through comprehensive dissection in both the cohort and control groups. To diagnose the ante-mortem findings, we evaluated hemorrhages in the soft tissues of the neck structures. To confirm the hemorrhage as antemortem (true) bruising, the neck was examined following head and neck drainage. Anterior cervical muscles were dissected into different layers. The SCM muscles were detached directly from the clavicles, following the standard protocol. The tendons were exposed, the clavicular periosteum was split, and the hemorrhage was recorded. To prevent artifacts, periosteal hemorrhages from the regions of origin of the SCM muscles were histologically examined.
Descriptive statistics were used to analyze all the variables. Comparisons between the hemorrhage and non-hemorrhage groups were performed using the chi-square test. We also conducted logistic regression analysis, including odds ratios and 95% confidence intervals, to investigate the impact of hanging and suspension types on the occurrence of bilateral clavicular hemorrhage compared to non-bilateral cases. All statistical analyses were performed using SAS software (version 9.4; SAS Institute Inc., Cary, NC, USA). Statistical significance was set at P < 0.05.
Ethics statement
The study protocol was reviewed and approved by the Institutional Review Board (IRB) of Seoul National University Hospital, and the requirement for informed consent was waived (IRB number: E-2406-029-1540).
RESULTS
Table 1 summarizes the demographic characteristics of the study cohort (n = 211). The study cohort comprised 211 cases of suicidal hanging (53 women and 158 men) aged between 18 and 87 years (mean age: 62 years). The control group consisted of 50 individuals (11 women, 39 men) aged 19–73 years (mean age: 57 years) who had undergone cardiopulmonary resuscitation but died from causes other than hanging. Forty-six deaths in the control group were caused by natural diseases, of which 32 (69.6%) were attributed to ischemic heart disease, including acute myocardial infarction. Eleven patients (23.9%) had other cardiac diseases, including suspected conduction disorders and dilated cardiomyopathies. Three individuals (6.5%) had chronic alcohol-related diseases, based on the pathological findings of chronic liver diseases, including liver cirrhosis. The remaining four cases in the control group included two self-inflicted cervical injuries and two patients with head injury (subdural hematoma).
Table 1. Demographic characteristics of the study cohort (N = 211).
| Variables | Values | |
|---|---|---|
| Sex | ||
| Female | 53 (25.1) | |
| Male | 158 (74.9) | |
| Age, yr | ||
| ≤ 24 | 4 (1.9) | |
| 25–44 | 62 (29.4) | |
| 45–64 | 66 (31.3) | |
| ≥ 65 | 79 (37.4) | |
| Obesity | ||
| Underweight (BMI < 18.5 kg/m2) | 21 (10.0) | |
| Normal (BMI ≥ 18.5 and < 23.0 kg/m2) | 93 (44.1) | |
| Overweight (BMI ≥ 23.0 and < 25.0 kg/m2) | 81 (38.4) | |
| Obese (BMI ≥ 25 kg/m2) | 16 (7.6) | |
Values are presented as number (%).
BMI = body mass index.
Among the 50 cases that underwent cardiopulmonary resuscitation, three cases (6%) showed hemorrhages in the clavicular region of the SCM. However, histological examination revealed that these hemorrhages were extravasations found in the adjoining soft tissue and not in the periosteum. Thus, there were no periosteal hemorrhages at the SCM attachment site in the control group.
Hemorrhage at the origin of the SCM was observed in 178 of the 211 cases (84.4%). The hemorrhages were exclusively located at the periosteal-clavicular origin of the SCM. In all cases, hemorrhage was not detected at the sternal origin of the SCM.
In 102 cases (48.3%), hanging was classified as ‘typical’ (Fig. 2, Table 2). Among the typical hanging cases, 91 (89.2%) had clavicular hemorrhage. Among the 48 cases of atypical left-side hanging, 38 (79.2%) were positive for hemorrhage. Of the 56 cases of atypical right-sided hanging, 48 (85.7%) exhibited hemorrhages. Among the five cases of atypical anterior hanging, only one case was positive for hemorrhage. Thus, the highest relative frequency of clavicular hemorrhage was observed in typical and atypical right-sided hanging cases, whereas atypical anterior hanging cases had the lowest relative frequency of clavicular hemorrhages. In atypical hanging, hemorrhages were more frequent on the ipsilateral side of the ligature suspension, with 50.0% of the right-sided hangings showing right clavicular hemorrhage and 39.6% of the left-sided hangings showing hemorrhage on the left side (Fig. 3). The highest rate of bilateral hemorrhage was observed in the typical hanging cases (Table 2). The presence of bilateral clavicular hemorrhage was significantly more frequent in the typical hanging group than in the atypical hanging (P < 0.001) group.
Table 2. Distribution of hemorrhages at the origin of the sternocleidomastoid muscles based on type of hanging.
| Type of hanging | Clavicular hemorrhage (N = 211) | ||||
|---|---|---|---|---|---|
| Left | Right | Bilateral | None | Total | |
| Typical (on the back) | 24 (23.5) | 21 (20.6) | 46 (45.1) | 11 (10.8) | 102 |
| Atypical (on the left) | 19 (39.6) | 11 (22.9) | 8 (16.7) | 10 (20.8) | 48 |
| Atypical (on the right) | 8 (14.3) | 28 (50.0) | 12 (21.4) | 8 (14.3) | 56 |
| Atypical (on the front) | 1 (20.0) | 0 | 0 | 4 (80.0) | 5 |
| Total | 52 (24.6) | 60 (28.4) | 66 (31.3) | 33 (15.6) | 211 |
Values are presented as number (%).
Fig. 3. Distribution of clavicular hemorrhages by type of hanging.
Overall, there were 68 cases (32.2%) of complete hanging and 143 cases (67.8%) of incomplete body suspension. Among the complete hanging cases, 42 were male (male-to-female ratio, 1.6). In contrast, 116 of the incomplete hanging cases were male (male-to-female ratio, 4.3). Hemorrhages at the origin of the SCM were found in both complete and incomplete body suspension hangings (Fig. 4; Table 3). In the complete hanging group, clavicular hemorrhages were observed in 64 cases (94.1%). Among the incomplete hangings, clavicular hemorrhages were identified in 114 cases (79.7%) (Table 3). A χ2 test confirmed a significant association between the occurrence of hemorrhages at the origin of the SCM and complete body suspension during hanging (P = 0.007). The logistic regression analysis results in Table 4 also indicate that the probability of bilateral clavicular hemorrhage is significantly higher in cases with a typical hanging type (P < 0.001) and complete suspension (P = 0.008) compared to non-bilateral cases (adjusted odds ratio [aOR], 3.82; 95% confidence interval [CI], 1.90–7.71; aOR, 2.61; 95% CI, 1.29–5.27). There was no significant association between the sex of the victim, age distribution, obesity, or occurrence of hemorrhages at the origin of the SCM (Table 4).
Fig. 4. Distribution of clavicular hemorrhages by body suspension.
Table 3. Distribution of hemorrhages at the origin of the sternocleidomastoid muscles based on completeness of suspension of the victim.
| Suspension | Clavicular hemorrhage (N = 211) | ||||
|---|---|---|---|---|---|
| Left | Right | Bilateral | None | Total | |
| Complete hanging | 13 (19.1) | 19 (27.9) | 32 (47.1) | 4 (5.9) | 68 |
| Incomplete hanging | 39 (27.3) | 41 (28.7) | 34 (23.8) | 29 (20.3) | 143 |
| Total | 52 (24.6) | 60 (28.4) | 66 (31.3) | 33 (15.6) | 211 |
Values are presented as number (%).
Table 4. Association between bilateral clavicular hemorrhage and hanging type and suspension by logistic regression analysis results.
| Variables (ref) | Bilateral (N = 66)a | |||
|---|---|---|---|---|
| aORb | 95% CI | P value | ||
| Sex (female) | ||||
| Male | 1.35 | 0.65–2.82 | 0.421 | |
| Age, yr (under 24) | ||||
| 25–44 | 0.24 | 0.01–4.72 | 0.347 | |
| 45–64 | 0.23 | 0.01–4.63 | 0.338 | |
| ≥ 65 | 0.17 | 0.01–3.22 | 0.233 | |
| Obesity status (normal) | ||||
| Obesity | 0.43 | 0.11–1.64 | 0.213 | |
| Overweight | 0.56 | 0.27–1.16 | 0.118 | |
| Underweight | 0.64 | 0.18–2.33 | 0.497 | |
| Type of hanging (atypical) | ||||
| Typical | 3.82* | 1.90–7.71 | < 0.001 | |
| Suspension (incomplete) | ||||
| Complete | 2.61* | 1.29–5.27 | 0.008 | |
aOR = adjusted odds ratio, CI = confidence interval.
aReference: non-bilateral Clavicular Hemorrhage.
bAdjusted for age, sex, and obesity status, but not adjusted for knot type because at least one table cell has 0 frequency.
*P < 0.05.
Hard materials, including ropes, cables, and belts were used in 60.7% (n = 128) of cases. Soft materials such as clothes, robe belts, linens, and headscarves were used in 39.3% (n = 83) of the cases. No significant differences in clavicular hemorrhage were observed between the hard and soft materials.
Hemorrhage of the SCM was observed in two of six manual strangulation victims. However, these hemorrhages were never located in or under the periosteal clavicular origin of the SCM but were always within the muscle tissue itself (Fig. 5). In nine cases of ligature strangulation (three suicidal and six homicidal), SCM hemorrhage was detected in two cases. Consistent with the findings of manual strangulation, hemorrhages in the ligature strangulation cases were located within the muscle tissue itself and not at the periosteal-clavicular origin.
Fig. 5. Hemorrhages at the sternocleidomastoid muscles (indicated by white arrows) in victims of manual strangulation.
DISCUSSION
Although hanging is a common method of suicide, each case, regardless of the circumstances of the death, should be carefully differentiated from homicidal hanging and staged suicide. The most frequently observed injuries in hanging cases are muscle hemorrhages, which are attributable to both direct pressure and indirect stretching of the affected structures.13,14 However, forensic investigations into cervical structures in hanging cases may reveal a surprisingly limited number of observable findings, particularly when the neck is compressed by a soft object such as a scarf. Several studies have suggested a correlation between hemorrhage at the periosteal-clavicular origin of the SCM and hanging induced death.10,11,15
Since Walcher16 first reported a 66% incidence of clavicular hemorrhage in hanging induced deaths, subsequent retrospective autopsy studies have found that the relative frequency of hemorrhages at the origin of the SCM ranges from 30% to 62%.10,17,18 Although the frequency of hemorrhages in the SCM suicidal hanging cases has been studied, owing to the infrequent occurrence of extensive stretching of the neck muscles, these hemorrhages are not recognized as reliable indicators of hanging.19
In this study, hemorrhages at the periosteal-clavicular origin of the SCM were observed in 178 of the 211 hanging cases (84.4%). Compared to previous retrospective studies,10,17,18 we found a higher frequency of clavicular hemorrhages. These hemorrhages were observed not within the muscle itself, but in the periosteal region of the clavicle, which requires meticulous dissection. Consequently, in prospective studies, the frequency of hemorrhages at the origin of the SCM ranges from 70% to 98%. Therefore, consistent with our study findings, hemorrhages at the periosteal-clavicular origin of the SCM muscle are a significant finding in suicidal hanging.
Our study indicates that cases with typical hanging exhibit a significantly higher occurrence of bilateral clavicular hemorrhage than other types. These results suggest a fundamental mechanism for the genesis of the hemorrhage: direct stretching and elongation of the SCM along the longitudinal axis. The highest tensile stress occurs at the origins of these muscles, specifically at their junctions with the clavicle.
Our findings also demonstrated that unilateral hemorrhages were predominantly observed in atypical hangings, especially when the ligature knot was positioned laterally on the neck. In such cases, the hemorrhage is more frequently noted on the ipsilateral side, which corresponds to the location of the ligature knot.
This finding further supports the hypothesis that these hemorrhages resulted from traction. The ipsilateral side of the neck experienced a greater traction force. Moreover, in such cases, severe longitudinal traction is exacerbated by the violent lateral flexion of the head, as previously reported.11
Mechanical stress at the clavicular origin due to neck extension is considered the primary factor in the development of hemorrhages, which are often anticipated in cases involving urgent resuscitation efforts.11 However, in the 50 cases analyzed in this study, of cardiopulmonary resuscitation, cardiac massage, and pharyngeal intubation, periosteal hemorrhages at the clavicular origin of the SCM muscles were not observed. Keil et al.11 also proved that cardiopulmonary resuscitation has no essential influence on the formation of hemorrhages at the clavicular origin of SCM.
Hemorrhage at the periosteal-clavicular origin of the SCM muscles could be caused by manual strangulation.20 In our study, we investigated SCM hemorrhage in six cases of manual strangulation. Hemorrhage in the SCM was observed in two victims; however, these hemorrhages were located within the muscle tissue itself, not in or on the periosteum of the clavicle.
The occurrence of hemorrhage at the clavicular origin of the SCM in cases of ligature strangulation remains underexplored. A limited number of ligature strangulation studies have reported hemorrhage in the SCM,21 , 22 but none has documented hemorrhage of clavicular origin. In our analysis, which included nine cases of ligature strangulation (three suicidal and six homicidal), SCM hemorrhage was detected in two cases. Consistent with the findings of manual strangulation, hemorrhages in the ligature strangulation cases were located within the muscle tissue itself and not at the periosteal-clavicular origin.
These findings indicate that in both manual and ligature strangulation, SCM hemorrhage occurs within the muscle tissue but not at the periosteal-clavicular origin. This finding suggests that SCM hemorrhage in the clavicular periosteal region serves as a potential diagnostic marker, particularly in cases of suicidal hanging. Further prospective studies are necessary to validate the diagnostic value of SCM hemorrhage in suicidal hangings.
In conclusion, our study showed a high relative frequency (84.4%) of hemorrhages at the origin of the SCM in 211 suicidal hanging cases. A statistically significant association between the type of hanging, completeness of body suspension, and occurrence of bilateral hemorrhages at the origin of the SCM was revealed in this study. Furthermore, cardiopulmonary resuscitation did not cause hemorrhage at the origin of the SCM. Although the diagnosis of suicidal hanging requires meticulous dissection techniques, our results indicate that hemorrhages at the origin of the SCM, as observed during complete autopsy, could confirm the diagnosis of suicidal hanging.
ACKNOWLEDGMENTS
We thank all the members of the National Forensic Service for their assistance in providing facilities in the autopsy room for this study.
Footnotes
Disclosure: The authors have no potential conflicts of interest to disclose.
- Conceptualization: Yoo SH.
- Data curation: Yoo SH.
- Investigation: Lim S, Son MJ, Kim MK, Chun H, Kim MK.
- Writing - original draft: Lim S, Son MJ, Yoo SH.
- Writing - review & editing: Yoo SH.
References
- 1.World Health Organization. Suicide Worldwide in 2019: Global Health Estimates. Geneva, Switzerland: World Health Organization; 2021. [Google Scholar]
- 2.Lim D. Trends in suicide methods in Korea; 1997–1999 and 2017–2019. J Health Info Stat. 2023;48(1):76–80. [Google Scholar]
- 3.Saukko P, Knight B. Knight’s Forensic Pathology. 4th ed. London, UK: CRC Press; 2015. [Google Scholar]
- 4.Clément R, Redpath M, Sauvageau A. Mechanism of death in hanging: a historical review of the evolution of pathophysiological hypotheses. J Forensic Sci. 2010;55(5):1268–1271. doi: 10.1111/j.1556-4029.2010.01435.x. [DOI] [PubMed] [Google Scholar]
- 5.Russo MC, Verzeletti A, Piras M, De Ferrari F. Hanging deaths: a retrospective study regarding 260 cases. Am J Forensic Med Pathol. 2016;37(3):141–145. doi: 10.1097/PAF.0000000000000239. [DOI] [PubMed] [Google Scholar]
- 6.Hellier C, Connolly R. Cause of death in judicial hanging: a review and case study. Med Sci Law. 2009;49(1):18–26. doi: 10.1258/rsmmsl.49.1.18. [DOI] [PubMed] [Google Scholar]
- 7.Zátopková L, Janík M, Urbanová P, Mottlová J, Hejna P. Laryngohyoid fractures in suicidal hanging: a prospective autopsy study with an updated review and critical appraisal. Forensic Sci Int. 2018;290:70–84. doi: 10.1016/j.forsciint.2018.05.043. [DOI] [PubMed] [Google Scholar]
- 8.Nikolić S, Zivković V, Babić D, Juković F, Atanasijević T, Popović V. Hyoid-laryngeal fractures in hanging: where was the knot in the noose? Med Sci Law. 2011;51(1):21–25. doi: 10.1258/msl.2010.010016. [DOI] [PubMed] [Google Scholar]
- 9.Sharma BR, Harish D, Sharma A, Sharma S, Singh H. Injuries to neck structures in deaths due to constriction of neck, with a special reference to hanging. J Forensic Leg Med. 2008;15(5):298–305. doi: 10.1016/j.jflm.2007.12.002. [DOI] [PubMed] [Google Scholar]
- 10.Hejna P, Zátopková L. Significance of hemorrhages at the origin of the sternocleidomastoid muscles in hanging. Am J Forensic Med Pathol. 2012;33(2):124–127. doi: 10.1097/PAF.0b013e31820b8fb8. [DOI] [PubMed] [Google Scholar]
- 11.Keil W, Forster A, Meyer HJ, Peschel O. Characterization of haemorrhages at the origin of the sternocleidomastoid muscles in hanging. Int J Legal Med. 1995;108(3):140–144. doi: 10.1007/BF01844825. [DOI] [PubMed] [Google Scholar]
- 12.Balcı Y, Göçeoğlu ÜÜ, Kıymet ME, Seçkin Ç. Autopsy findings of suicidal hanging in Mugla, Turkey. Med Sci Law. 2022;62(2):105–112. doi: 10.1177/00258024211049594. [DOI] [PubMed] [Google Scholar]
- 13.Nikolic S, Micic J, Atanasijevic T, Djokic V, Djonic D. Analysis of neck injuries in hanging. Am J Forensic Med Pathol. 2003;24(2):179–182. doi: 10.1097/01.PAF.0681069550.31660.f5. [DOI] [PubMed] [Google Scholar]
- 14.Suárez-Peñaranda JM, Alvarez T, Miguéns X, Rodríguez-Calvo MS, de Abajo BL, Cortesão M, et al. Characterization of lesions in hanging deaths. J Forensic Sci. 2008;53(3):720–723. doi: 10.1111/j.1556-4029.2008.00700.x. [DOI] [PubMed] [Google Scholar]
- 15.Schulz F, Buschmann C, Braun C, Püschel K, Brinkmann B, Tsokos M. Haemorrhages into the back and auxiliary breathing muscles after death by hanging. Int J Legal Med. 2011;125(6):863–871. doi: 10.1007/s00414-011-0622-1. [DOI] [PubMed] [Google Scholar]
- 16.Walcher K. Beitrag zum anatomischen Befund bei Erhängten. Munch Med Wochenschr. 1935;82:1273–1275. [Google Scholar]
- 17.Madro R, Tomaszewska Z, Lagowski S. Haemorrhages in the inferior insertions of the sternocleidomastoid muscles in the hanging. Arch Med Sadowej. 1982;32:33–38. [Google Scholar]
- 18.Könczöl F. In: Ersticken: Fortschritte in der Beweisführung Festschrift für Werner Janssen. Brinkmann B, Püschel K, editors. Berlin, Germany: Springer Verlag; 1990. Lokale Läsionen im Halsbereich von Erhängten; pp. 145–150. [Google Scholar]
- 19.Maiese A, Del Duca F, Santoro P, Pellegrini L, De Matteis A, La Russa R, et al. An overview on actual knowledge about immunohistochemical and molecular features of vitality, focusing on the growing evidence and analysis to distinguish between suicidal and simulated hanging. Front Med (Lausanne) 2022;8:793539. doi: 10.3389/fmed.2021.793539. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Das Erwurgen PO. Forensische Medizin. Berlin, Germany: Volk und Gesundheit; 1975. p. 116. [Google Scholar]
- 21.Maxeiner H, Bockholdt B. Homicidal and suicidal ligature strangulation--a comparison of the post-mortem findings. Forensic Sci Int. 2003;137(1):60–66. doi: 10.1016/s0379-0738(03)00279-2. [DOI] [PubMed] [Google Scholar]
- 22.Ma J, Jing H, Zeng Y, Tao L, Yang Y, Ma K, et al. Retrospective analysis of 319 hanging and strangulation cases between 2001 and 2014 in Shanghai. J Forensic Leg Med. 2016;42:19–24. doi: 10.1016/j.jflm.2016.05.001. [DOI] [PubMed] [Google Scholar]