CASE REPORT

A Case of Suicidal Ligature Strangulation by Using a Tourniquet

Method
Mehmet Atilgan, MD

Abstract: Ligature strangulations are usually homicidal. Accidental and

suicidal ligature strangulations are quite rare. In this study, an unusual case
of suicidal ligature strangulation with a tourniquet method using a walking
stick is presented.
A 70-year-old-man was found dead in his room, a piece of cloth wrapped
around the neck, knotted, and tightened by a walking stick. His hand was still
on the walking stick which was seemingly used by him for a tourniquet
effect. Autopsy showed bilateral sternocleidomastoid muscle hemorrhage. A
thorough death scene investigation, detailed corpse examination, and autopsy
are extremely important for determining the manner of death in such ligature
strangulation cases.
Key Words: ligature strangulation, suicide, forensic medicine
(Am J Forensic Med Pathol 2010;31: 85– 86)

FIGURE 1. The original position of the body lying on the bed.

I n forensic practice, most ligature strangulations are homicidal.
Accidental ligature strangulation is occasionally seen, particularly
in children, and suicidal ligature strangulations are quite rare.1– 4 In
a study of 15,000 medicolegal autopsies, Koops and Brinkmann
found only 7 cases of suicidal strangulation by ligature, and it was
estimated that 5% of strangulations by ligature are suicides.5 Ac-
cording to another study by Maxeiner and Bockholdt, approximately
10 homicidal cases and 1 suicide case of ligature strangulation occur
in Berlin per year.6
Self strangulation by unusual ligature (eg, elastic band, twine,
nylon stocking, telephone cord, torn clothing) or by a complex
mechanism has been described in only a few cases in the litera-
ture.6 –12 In this study, an unusual case of suicidal ligature strangu-
lation with a tourniquet method using a walking stick is presented.

CASE REPORT
A 70-year-old-man living with his son and daughter-in-law was
found dead in his room. The body was lying supine on the bed with the
feet touching the floor. A textile-belt-like piece of cloth was wrapped
around the neck, knotted, and tightened by a crook handle walking
stick. His hand was still on the walking stick, which was seemingly
used by him for a tourniquet effect (Figs. 1, 2).
He has a history of coronary artery bypass surgery and
asthma. In the week before death, he had suffered from depression
and felt that he had become a burden for his family.
On external examination, multiple petechial hemorrhages
were seen in the eyelids and conjunctivae. There was no clear
ligature mark. Only a superficial abrasion (0.5 cm in diameter) was
Manuscript received January 5, 2009; accepted May 27, 2009.
From the Department of Forensic Medicine, Akdeniz University Medical Faculty,
Antalya Branch of the Council of Forensic Medicine, Antalya, Turkey.
Presented at the First International Eurasian Congress of Forensic Sciences,
October 8 –11, 2008, Istanbul, Turkey.
Reprints: Mehmet Atilgan, MD, Akdeniz University Medical Faculty, Department
of Forensic Medicine, Antalya, Turkey. E-mail: atilgan@akdeniz.edu.tr.
Copyright © 2010 by Lippincott Williams & Wilkins
ISSN: 0195-7910/10/3101-0085
DOI: 10.1097/PAF.0b013e3181c21c24
FIGURE 2. Close-up of knot.
observed on the left side of the neck (Fig. 3). A 30 cm, midline
surgical scar was present on the chest.
Internal examination revealed bilateral hemorrhage of the
sternocleidomastoid muscles (Fig. 4). There was a submucosal
hemorrhage (1.5 ⫻ 1 cm) in the right side of the hyoid bone,
although no fractures of the hyoid bone or thyroid cartilage were
seen. The lungs were edematous (right lung, 763 g; left lung, 635 g)
with some subpleural petechial hemorrhages. The heart weighed
480 g. All coronary arteries showed severe atherosclerotic stenosis.
There was a single bypass graft to the left anterior descending artery,
which was occluded at the aortic anastomosis. There were large
areas of old myocardial infarction in the anterior and posterior wall
of the left ventricle. No other significant findings were seen. Toxi-
cologic analysis showed subtherapeutic levels of theophylline only.
DISCUSSION
Examples of suicidal strangulations are rare and usually
includes tying a ligature around the neck with additional knots or

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Atilgan
FIGURE 3. View of the neck after removal of the ligature
showing no clear ligature mark. A superficial abrasion is seen
on the left side of the neck (black arrow).
FIGURE 4. Bilateral hemorrhage in the sternocleidomastoid
muscles.
86 | www.amjforensicmedicine.com
Am J Forensic Med Pathol • Volume 31, Number 1, March 2010
tightly wrapping a ligature several times around the neck without
any knot.2,4 Applying a tourniquet, as described in our case also, is
a well known but rarely seen method of ligature strangulation. Only
in 1 case, the tourniquet method was used in a study, which has
examined 82 ligature strangulation cases for a period of 20 years.6
In this method, a stick or similar object is inserted under a ligature
which is wrapped around the neck and twisted to tighten. Clothing
or the individual’s own weight on the stick holds it in place,
maintaining pressure.1– 4 This device is used both in suicidal and
homicidal cases.3,6
The specific pattern of external and internal findings in
suicidal ligature strangulation can be helpful in distinguishing sui-
cide from a homicide.5,6,13 A clear ligature mark and fractures of the
hyoid bone or the laryngeal cartilages are rarely found in suicidal
cases,6 same as our case.
In this case, the absence of any signs of self-defense and a
history of recent depression supported suicide as the manner of
death. Accidental autoerotic death was ruled out by lack of scene
evidence and the rarity of that event in an elderly man.
A thorough death scene investigation, detailed corpse exam-
ination and autopsy are extremely important for determining the
manner of death in such ligature strangulation cases.
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© 2010 Lippincott Williams & Wilkins