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J O U R N A L

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FORENSIC
A N D L E G AL
ME D IC IN E
Journal of Forensic and Legal Medicine 15 (2008) 298305
www.elsevier.com/jflm

Original Communication

Injuries to neck structures in deaths due to constriction of neck, with

a special reference to hanging
B.R. Sharma MBBS, MD (Professor) *, D. Harish MBBS, MD (Reader),
Anup Sharma MBBS, MD (Junior Resident), Swati Sharma MBBS (Demonstrator),
Harshabad Singh MBBS (Student)
Department of Forensic Medicine and Toxicology, Government Medical College and Hospital, # 1156-B, Sector 32-B, Chandigarh 160 030, India
Received 18 May 2007; received in revised form 10 October 2007; accepted 13 December 2007
Available online 14 March 2008

Abstract
This prospective study aimed at examining various injuries to the neck structures in deaths due to constriction of neck. Neck dissection technique, as advocated by Prinsloo and Gordon was undertaken to study the injuries to the thyro-hyoid complex, strap muscles,
carotid vessels, etc.
Of the 1746 medico-legal autopsies, conducted during the study period, 5% were deaths due asphyxia of which 82% were those of
constriction of neck. The 2130 years age group accounted for the maximum number of cases (57%). Male:female ratio was 2:1. Hanging
(69%) outnumbered other asphyxial deaths ligature and/or manual strangulation, smothering, etc. Injury to the sternocleido-mastoid
muscle (54%) was the commonest injury to the neck structures. The hyoid bone was fractured in 21% cases, while the thyroid cartilage
was fractured in 17% cases. Complete hanging was noted in 68% of cases while the hanging was atypical in 88%. Fixed knot was found to
have been used in 71%. A single loop round the neck was observed in 80% of the cases and it was above the level of thyroid in 58% cases.
Most cases of the fracture of the laryngo-hyoid complex were in the 4160 year age group, 72% and the fracture was on the same side as
the knot in 52% cases. Majority used soft daily wear articles of clothing like a sari (32%) or chunni (24%).
Asphyxial deaths due to constriction of neck being common in all parts of the world, prospective studies in dierent setups to examine
the prole of neck structure injuries are needed so as to dierentiate the suicidal or homicidal nature of such deaths with a greater
certainty.
2008 Elsevier Ltd and FFLM. All rights reserved.
Keywords: Asphyxia; Asphyxial deaths; Hanging; Strangulation; Ligature; Laryngo-hyoid complex; Medico-legal autopsy

1. Introduction
The term asphyxia literally means defective aeration of
blood due to any cause. Bacroft1 using the term anoxia
divided the condition into three groups: (1) anoxic anoxia
meaning prevention of oxygen from reaching the lungs,
(2) anemic anoxia meaning inability of blood to carry sufcient oxygen to the tissues due low hemoglobin content,
and (3) stagnant anoxia meaning lack of oxygenated
*

Corresponding author.
E-mail address: [email protected] (B.R. Sharma).

blood transport to the tissues due to impaired circulation.

Later on, Peters and Van Slyke in 1931 added a fourth
group to it called histotoxic anoxia wherein, though
freely available in the blood stream, oxygen cannot be utilized by the tissues.2 The histotoxic anoxia was further
divided into (1) extra-cellular depicting a fault at the tissue
oxygen enzyme system, as for example, in cyanide poisoning, (2) peri-cellular depicting that oxygen cannot gain
access to the cell because of decreased cell membrane permeability as is seen in lipoid soluble anesthetic agents like
halogenated hydrocarbons, (3) substrate meaning inecient metabolism by the cell on account of inadequate

1752-928X/$ - see front matter 2008 Elsevier Ltd and FFLM. All rights reserved.
doi:10.1016/j.jm.2007.12.002

B.R. Sharma et al. / Journal of Forensic and Legal Medicine 15 (2008) 298305

energy (food), and (4) metabolite where end products of

the cellular respiration cannot be removed thereby preventing further metabolism as in uremia or CO2 poisoning.
Adelson3 dened asphyxia as the physiological and
chemical state in a living organism in which acute lack of
oxygen available for cell metabolism is associated with
inability to eliminate excess of CO2. Despite the dierences
of opinion regarding the term asphyxia in medical literature, it is widely used for medico-legal purposes and is categorized as mechanical asphyxia meaning that the ow
of air into the body is interfered through some physical
impediments, and non-mechanical asphyxia taken to
mean physiological impediments where there occurs exclusion of oxygen by its depletion and replacement by another
gas or by chemical interference with its uptake and utilization by the body itself or where there is insucient oxygen
in the atmosphere itself.
Asphyxial deaths may be caused by dierent methods,
such as hanging, strangulations (manual and ligature), suffocations (environmental, smothering, choking, mechanical, and suocating gases), chemical asphyxia (carbon
monoxide CO, hydrogen cyanide, and hydrogen sulde),
and drownings.4 Additionally, in some cases, the victim
dies as a result of the combination of dierent mechanisms
of asphyxia. A case study from Romania5 indicates that a
victim was killed by three dierent mechanisms of
asphyxia: smothering with the hand, manual strangulation
with the other hand, and traumatic asphyxia by thoracic
compression with the knees. Autoerotic asphyxial
deaths,69 positional asphyxial deaths,10,11 and neck
holds12 are some other reported unusual forms of asphyxial
deaths in forensic practice.
Asphyxial death is a common incident in forensic practice, and determination of the manner of death that may be
accidental, suicidal, homicidal, or natural is of utmost signicance. In such deaths, a detailed and meticulous
autopsy plays a major role to solve the case while the scene
investigation and collection of samples have their own signicance.4 The purpose of this study was to investigate
some features of asphyxial deaths in the Chandigarh region
of Northern India and to compare them with other studies.
2. Materials and methodology
This prospective study was conducted at the Department of Forensic Medicine and Toxicology, Government
Medical College Hospital, Chandigarh, during the period
from January 2001 to December 2005. Ninety-ve cases
of deaths due to asphyxia subjected to medico-legal
autopsy were the subjects of the study. The information
regarding identication of the deceased and the type of
asphyxial death was obtained from the police and detailed
interviews of the relatives of the deceased. Various injuries
to the neck structures in dierent cases of compression of
the neck (hanging, ligature strangulation, manual strangulation/throttling) and the dierent types of hanging were
carefully noted at the time of conducting the autopsy using

299

a standardized technique that included specic attention to

the ligature mark on the neck, a layered dissection of the
neck tissues and careful assessment of other injuries on
the body surface.
Neck dissection was undertaken after evisceration of the
other body organs, following the protocol of Prinsloo and
Gordon (a layer by layer dissection of the neck with the
rst incision being immediately deep to the skin, through
the platysma and inspection of each layer before dissection.
The thyroid gland is exposed by blunt dissection, and the
larynx, trachea, pharynx and esophagus are mobilized
and dissected for thorough inspection).13 In this way careful attention to the soft tissues of the neck could be made,
thereby dening the presence of internal neck injury. The
type of injuries that were specically sought included
bruises of the thyroid capsule or gland, injuries to the
thyro-hyoid membrane, bruises of the soft tissue or strap
musculature, intimal injury in one of the carotid arteries
and laryngeal fracture (hyoid bone and/or thyroid cartilage
and/or cricoid cartilage).
Blood samples taken from the left chamber of the heart
and tissue samples were collected for systemic toxicological
analysis according to regular procedures. All samples were
sent to the Forensic Science Laboratory/Chemical analyzer
to determine/rule out use of drugs, poison, and ethanol.
Histopathological examinations of all cases were done at
the Department of Pathology. The data so obtained from
detailed history, postmortem examination, chemical analysis and histopathological examination was analyzed and
compiled.
3. Results
A total of 1746 medico-legal autopsies were conducted
during the period under study, of which 95 (5%) were
asphyxial deaths. Male victims (63) were twice the number
of female victims (32). Considering the asphyxial deaths in
general, hanging was the commonest mode observed in 66
(69%) cases, followed by drowning in 10 (11%) (Fig. 1).
The age group 2130 years, accounted for the maximum
number of cases, 54 (57%), followed by the age group 31
40 years, 15 (16%) cases. Extremes of age, the less than 15
years and the more than 60 years groups, comprised 2%
victims, each (Fig. 2).
Among the dierent cases of death due to constriction of
neck, injury to the sternocleido-mastoid and other muscles
was the commonest injury observed in the 33 (42%), followed by the fracture of the hyoid bone, 16 (21%) cases
(Table 1).
Among those having fracture of the hyoid bone, fracture
of the left greater horn was more common, 11 (69%) cases.
As regards the fracture of dierent parts of the hyoid bone
in dierent forms of constriction of neck, it was noted that
fracture left lesser horn was more common, nine (14%) followed by the fractures of left greater and right lesser horns,
eight (12%) each in cases of hanging; while left greater horn
was found fractured more commonly in ligature strangula-

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B.R. Sharma et al. / Journal of Forensic and Legal Medicine 15 (2008) 298305
Different Types of Asphyxial Deaths
50
46

Males

45

Females

40
35
30
25
20

20
15

11

10
6

0
Hanging

Ligature Strangulation

Throttling

Drowning

Suffocation

traumatic Asphyxia

Fig. 1. Dierent types of asphyxial deaths.

Age and Gender distribution of asphyxial deaths

30

Males
25

Females

24

20

15

14

11

10

9
7
5

4
3

2
1

<15 years

16-20 years

21-25 years

26-30 years

31-40 years

41-50 years

51-60 years

>60 years

Fig. 2. Age and gender distribution of asphyxial deaths.

tion, two (67%) and right greater horn in cases of throttling, two (67%) (Table 1).
Among the injuries to the thyroid cartilage, bruising of
the capsule was found in seven (11%) cases of hanging
and four (100%) cases of throttling while both bruising of
the capsule in association with the fracture of the body
were found in four (50%) cases of ligature strangulation.
Fracture of the body of thyroid cartilage was found in
six (9%) cases of hanging and three (75%) cases of throttling (Table 1).
Overall, 45 (68%) cases were of complete hanging and 58
(88%) cases were of atypical hanging (suspension point
being at a place other than the nape of neck, as against

the typical hanging having suspension point at the nape

of neck as seen in judicial hanging in India).
Petechiae were observed in a total of 28 (42%) cases of
which 21 (75%) were of incomplete hanging and seven
(25%) were atypical complete hanging. However, petechial
hemorrhages were not found in either ligature or manual
strangulation (Tables 1 and 2).
Considering the neck structure injuries in dierent types
of hanging, it was observed that injury to the sternocleidomastoid and other muscles was more common in cases of
typical and complete hanging, three (60%), while fracture
right superior horn of hyoid bone was the more common
injury in cases of typical and incomplete hanging, two

B.R. Sharma et al. / Journal of Forensic and Legal Medicine 15 (2008) 298305

301

Table 1
Neck structure injuries in cases of compression of neck
Neck structure injuries

Compression of neck
Hanging (n = 66)

Ligature strangulation (n = 08)

Throttling (n = 04)

Total (n = 78)

No.

No.

No.

No.

Injury to hyoid bone (n = 16)

# Hyoid bone
# Left greater horn of hyoid bone
# Right greater horn of hyoid bone
# Left lesser horn of hyoid bone
# Right lesser horn of hyoid bone

10
8
6
9
8

15.2
12.1
9.1
14.1
12.1

3
2
1
0
0

37.5
25.0
12.5
0
0

3
1
2
1
0

75.0
25.0
50.0
25.0
0

16
11
9
10
8

20.5
14.1
11.5
12.8
10.3

Injury to thyroid cartilage (n = 15)

# Body of thyroid cartilage
# Superior horn of thyroid cartilage
Bruising of the thyroid capsule

6
2
7

9.1
3.0
10.6

4
1
4

50.0
12.5
50.0

3
2
4

75.0
50.0
100.0

13
5
15

16.7
6.4
19.2

28
6
28

42.4
9.1
42.4

4
2
0

50.0
25.0
0

1
0
0

25.0
0
0

33
8
28

42.3
10.3
35.9

Injury to muscles and vessels

Injury to sternocleido-mastoid and other muscles
Injury to blood vessels
Petechial hemorrhages

Table 2
Neck structure injuries in dierent types of hanging
Neck structure injuries

Types of hanging
Typical complete
(n = 05)
No.

Typical incomplete
(n = 03)
No.

Injury to hyoid bone

# Body of hyoid bone
# Left greater horn of hyoid bone
# Right greater horn of hyoid bone
# Left lesser horn of hyoid bone
# Right lesser horn of hyoid bone

1
1
0
1
0

2
0
0
1
2

5
4
5
5
4

2
2
1
2
2

10
7
6
9
8

Injury to thyroid cartilage

Bruising of thyroid capsule
# Superior horn of thyroid cartilage
# Body of thyroid cartilage

1
0
1

0
0
0

5
1
4

1
1
1

7
2
6

Injury to muscles and vessels

Injury to sternocleido-mastoid and other muscles
Injury to blood vessels
Petechial hemorrhages

3
0
0

1
0
3

16
6
7

8
2
18

28
8
28

(67%). Again, injury to the sternocleido-mastoid and other

muscles was found to be more common in atypical and
complete 16 (40%) as well as atypical and incomplete hanging eight (44%) cases (Table 2).
Sari was the commonest ligature material used by the
males, 14 (30%), while females preferred chunni nine
(45%) followed by the sari seven (35%). In 53 (80%) cases
a single loop around the neck was noted while the ratio
of single:multiple loops was 3.6:1 for males and 5.7:1 for
females (Fig. 3).
Slipknot was found in 19 (29%) cases of hanging and
xed-knot in the rest. The knot was more often placed
in the right posterior aspect of the neck, 21 (32%) cases.
The ligature mark was above the level of the thyroid in
38 (58%) cases. In cases of both the slip knot and the

Atypical complete
(n = 40)
No.

Atypical incomplete
(n = 18)
No.

Total
(n = 66)
No.

xed knot, the hanging was mostly atypical and complete,

15 (79%) and 25 (53%), respectively, implying thereby that
the hanging was more often atypical and complete 40
(61%) (Table 3).
The laryngo-hyoid complex was fractured in 25 (33%) of
the total 78 cases, maximum cases belonged to the age
group 4160 years, 18 (72%), followed by the 2140 years
age group, four (16%). The male:female ratio was 2.5:1.
The fracture was on the same side as the knot in 13
(52%) cases, opposite side in 10 (40%), and both sides in
two (8%) cases. The hyoid bone alone was involved in 12
(48%) cases, thyroid cartilage in nine (36%) while both were
involved in four (16%) cases (Table 4).
On chemical analysis and histopathological examination, nothing specic/contributing towards death was

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B.R. Sharma et al. / Journal of Forensic and Legal Medicine 15 (2008) 298305
Ligature Material Used
16

Males

14

14

females

13

12

10
9

8
7

4
3
2

0
Chunni

Sari

Pajama/Pant

Rope

Electric Cable

Fig. 3. Ligature material used.

Table 3
Relationship of the type of knot to the position of the knot and the type of hanging
Position of the knot

Type of the knot

Slip knot (n = 19)
No.

Fixed knot (n = 47)

Total (n = 66)

No.

No.

3
4
5
7

15.8
21.0
26.3
36.8

7
12
16
12

14.9
25.5
34.0
25.5

10
16
21
19

15.2
24.2
31.8
28.8

Level on the neck

Above the thyroid cartilage
At the level of the thyroid
Below the thyroid cartilage

11
5
3

57.9
26.3
15.8

27
13
7

57.5
27.7
14.9

38
18
10

57.6
27.3
15.2

Type of hanging
Typical complete
Typical incomplete
Atypical complete
Atypical incomplete

3
0
15
1

15.8
0
79.0
5.3

2
3
25
17

4.3
6.4
53.2
36.2

5
3
40
18

7.8
4.5
60.6
27.3

Side of the neck

Right side (anteriorly)
Left side (anteriorly)
Right side (posteriorly)
Left side (posteriorly)

found in all the cases except the detection of alcohol in

eight (16%) male victims.
4. Discussion
Asphyxial deaths are caused by the failure of cells to
receive and/or use oxygen.4 Brain is most sensitive to oxygen deprivation, and it is the organ mostly aected in all
types of asphyxial death. However, cardiac function usually continues for several minutes after respiratory arrest.12
Petechiae are commonly recognized as a fundamental,
albeit non-specic, feature of asphyxiation. Their mechanism of formation is problematic, but focal extravasation
may result from a combination of elevated venous pressure

and hypoxic injury to endothelial cells. In this series of 95

asphyxial deaths, external and internal petechiae were seen
with an overall prevalence of 42%, most commonly on or
around the eyes. The nature of the ligature knot, whether
a slipknot or xed knot made little dierence to this gure.
This is in contrast with Davison and Marshall14 who suggested that a xed knot, resulting as it may in incomplete
constriction of the neck, may be expected to result in more
facial petechiae than a slipknot. Other series have reported
the incidence of petechiae as between 10%15 and 68%.16 If
the gures of four published series that specically address
this point are combined, then out of a total of 311 cases,
external petechiae were seen in 90 (29%).10,14,17,18 In each
of these series was the observation that petechiae were

B.R. Sharma et al. / Journal of Forensic and Legal Medicine 15 (2008) 298305
Table 4
Particulars of laryngo-hyoid complex fractures
Particulars

No.

Age in years
<20
2140
4160
>61
Total

0
4
18
3
25

0
16.0
72.0
12.0
100 (32.0)

Sex
Male
Female

18
7

72.0
28.0

Position of knot (on the side of neck)

Ipsilateral
Contralateral
Bilateral

13
10
2

52.0
40.0
08.0

Structures involved
Thyroid cartilage
Hyoid bone
Thyroidhyoid combined

9
12
4

36.0
48.0
16.0

more frequently seen when suspension was not complete, a

comment conrmed in this series with external petechiae in
75% of those incompletely suspended compared with 25%
of those completely suspended. Emphasizing this point further, Luke et al.17 noted a direct correlation existing
between the extent of body support and the likelihood of
nding petechiae, a nding conrmed by us with the highest percentage being in those who were kneeling or sitting
(59%). However, complete absence of petechiae has been
reported in ve of 48 cases even in homicidal strangulation
by ligature without further discussion of the conditions
explaining this.19
A ligature mark to the skin of the neck was present in
98% of the cases, about the same as seen by others.16,17
Mostly the mark, in cases of hanging, crossed the midline
of the front of the neck above the laryngeal prominence
in 58% cases, in agreement with others.14,17,20 Luke
et al.,17 described the high position of the ligature as a factor in the likelihood of laryngeal fracture, but the association has been denied by others.20 It has been reported that
when the ligature mark was narrow, there was a much
greater likelihood of laryngeal fracture, probably reecting
greater force per unit of surface area with a narrow ligature,21 however, we could not conrm the observation. In
a minority of cases there was indication of movement of
the ligature over the skin of the neck, as evidenced by the
presence of a slipping abrasion of the skin. As might be
expected, this nding was more likely to be seen with complete suspension than with incomplete suspension.
In 29% of the cases when a knot was described it was of
the slip-type, forming a running noose, in general agreement with other workers.14,22 However, irrespective of
the type of knot, the prevalence of internal neck injury
was much the same, being seen in 58% of those with a slip
knot and 60% of those with a xed knot. In 53% cases the
knot was located on left side of the neck; there was how-

303

ever, no correlation with location of a laryngeal fracture,

with 52% cases having ipsilateral fracture and 40% cases
having a contralateral fracture. In 8% cases, bilateral laryngeal fractures were present. It would appear then that no
useful comment can be made about the type or location
of a ligature knot from an isolated consideration of the
internal neck injuries.
Of the 78 cases of deaths due to constriction of neck in
this series, injury to the laryngo-hyoid complex was seen in
25 (32%). There is close similarity between our results and
those of Simenson23 who demonstrated fracture of the thyroid cartilage in 37% of cases (12% of the total and 36% of
those having laryngo-hyoid complex injury in our series),
fracture of the hyoid bone in 9% of cases (14% of the total
and 48% of those having laryngo-hyoid complex injury in
our series) and a fracture of both hyoid bone and thyroid
cartilage in 9% of cases (5% of the total and 16% of those
having laryngo-hyoid complex injury in our series). The
other series give more widely disparate results; there is
some consistency however in the rate of hyoid bone fracture (generally around 10%), with a generally greater prevalence of thyroid cartilage fracture. In two series22,23 no
laryngeal injury was demonstrated in any of the cases.
Bowens series24 was an apparently retrospective analysis
of 201 cases; he mentions, ... no fractures of the laryngeal
cartilage, which we interpret to mean the thyroid cartilage
being uninjured. Specic mention of the other structures
including the hyoid bone is not made. It appears likely that
the absence of fracture in any of these cases reects the retrospective nature of the study. Elfawal and Awads series
from Saudi Arabia22 was of 61 cases, apparently studied
prospectively, in which no injury was demonstrated. There
was no ready explanation for this nding. The absence of
injury seems particularly unusual as the majority of the
cases were completely suspended (48 of the 61 cases) and
many were older than 40 years of age (13 of the 61 cases).
We found a greater proportion of males to have laryngeal injury 33% (eight out of 54) than females 29% (seven
out of 24), a dierence not explained by a gender dierence
in the degree of suspension. It is possible that the dierence
is a consequence of greater plasticity of the female throat
structures.13 Simenson23 agrees with this gender dierence,
with 52% of males of his series having a laryngeal fracture,
compared with 34% of the females. Paparo and Siegel however, found that fractures were at least twice as common in
females, this dierence being more signicant in the retrospective component of their series.20
We noted a greater prevalence of laryngeal injury in
those over the age of 40 years, irrespective of the degree
of suspension (incomplete 58% compared with 28% for
those less than 40 years; complete 75% compared with
44% for those less than 40 years). Luke et al.,17 reported
a similar age-related increase in prevalence of laryngeal
injury, particularly for those who were incompletely suspended (50% injury rate for those over the age of 40, compared with 10% for those less than 40 years). In their
combined retrospective and prospective series, Paparo

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B.R. Sharma et al. / Journal of Forensic and Legal Medicine 15 (2008) 298305

and Siege20 had a similar nding with 26% of those over 40

years having laryngeal injury, compared with 10% for those
less than 40 years. Simenson was the most recent worker to
conrm this trend,23 with 52% of those over 40 years having laryngeal injury, compared with 34% for those less than
40 years. There was no age-related dierence in the degree
of suspension or type of ligature in our series in conformity
wiht OHalloran and Lundy25. Presumably then, the dierence in rate of laryngeal injury between these two age
groups reects increasing brittleness of the laryngeal structures with increasing age.26,27
We found a greater incidence of fracture of the body of
thyroid (17%), as compared to the fractures of superior
horn (6%). This comparatively unusual nding in our study
could be attributed to the type of ligature material used for
hanging sarees and chunnis, both being soft material
capable of producing a broad ligature and as such exerting
the pressure on neck structures in a manner dierent from
that produced on a narrow ligature.
Few of the reviews1422,28 have specically addressed the
question of the presence of other injuries on the body. In
our study, fresh injuries to the body surface (excluding
those of medical intervention) were present in 2% of cases,
the majority being fresh-appearing injuries. Davison and
Marshall14 reported that such injuries are seen occasionally. They found multiple blunt force supercial injuries
in three cases, fresh-appearing, self-inicted wounds in
two cases, incisions on the fronts of the wrists in ve and
penetrating (stab) injuries to the chest and abdomen in a
further one case. Other workers have similarly commented
on the unusual nature of such self-inicted injuries in hanging deaths.16,26
Paparo and Siege20 noted that retrospective collection of
data cannot be entirely relied upon. This view is reinforced
by our earlier study29 because each of the factors specically examined for in the prospective study may be
reported with less frequency in the retrospective group of
cases. In some cases there may be a disturbing lack of specicity regarding the presence or absence of injury, and its
nature if present. Accordingly, studies of this type require
not only prospective collection of data but also pre-study
standardization of dissection technique, particularly where
there is involvement of dierent prosecutors. Furthermore,
the physical forces involved in hanging depend to an extent
on the size and weight of the body, the completeness or
otherwise of the drop, the age and sex of the deceased
which have a bearing on the degree of calcication or
otherwise on bony components, and therefore the brittleness of the neck structures, the restrictions of space where
the hanging took place and the intrusion into this space of
other objects and so on also need to be taken into
consideration.
5. Conclusion
A careful forensic examination in asphyxia involving
pressure on the neck with ligature material is of great

importance, even in the case of hanging supposed to be suicidal, with the aim of ascertaining the antemortem character of the lesion and the physio-pathological mechanism of
death and to exclude the possibility of murder dissimulation. Furthermore, the ligature mark being mainly a postmortem phenomenon, any inner neck structure injury
indicating ligature mark intravitality is to be identied to
establish the antemortem hanging. However, a critical
analysis of the postmortem diagnostic criteria for asphyxia
leads to a diculty that has signicant implications for the
forensic pathologist. The diculty is that there are no universally recognized pathognomic signs of asphyxia and the
pathologists frequently make this diagnosis based on
observations that individually have indeterminate signicance but combined together, in the appropriate context,
have diagnostic value. Still-further, the signs of strangulation form a spectrum of degree from minimal to marked
and there is no consensus as to the minimal number and
nature of lesions that is required to make the diagnosis of
strangulation. There are occasions when the injury to the
neck structures caused by hanging or ligature strangulation
may become dicult to appreciate for the doctor conducting autopsy and as such there is need for studies in dierent
setups to examine the prole of neck structure injuries so as
to dierentiate the suicidal or homicidal nature of such
deaths with a greater certainty.
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1920;106:127.
2. Peters JP, Van Slyke DD. Quantitative clinical chemistry, vol.
1. Baltimore: Williams and Wilkins; 1931. p. 539661.
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