CASE REPORT

Suicidal ligature strangulation using gymnastics bands

Iliana Tzimas & Thomas Bajanowski & Stefan Pollak &

Kurt Trübner & Annette Thierauf

Received: 24 September 2013 /Accepted: 16 December 2013 /Published online: 16 January 2014# Springer-Verlag Berlin Heidelberg 2014

Abstract Suicidal ligature strangulation is a rare event. Themost important issue to solve in the investigation is whether it isa case of homicide or suicide. The characteristics of suicidalligature strangulation are summarized by Koops andBrinkmann with the emphasis on the nature of the ligatureinstrument(s). In this article, we present two cases of self-strangulation with an almost identical modus operandi usinggymnastics bands. The autopsy findings and the nature of theligature in these cases are depicted and in good accordance withthe described typical observations in suicidal cases. The impor-tance of a broad medico-legal investigation is demonstrated.

Keywords Suicide . Strangulation by ligature . Gymnasticsband

Introduction

Self-strangulation is a rare suicide method. Only 0.1 % of allsuicides in Germany and 5 % of all deaths due to ligaturestrangulation are caused by self-strangulation [1]. From 1973till 2011, at the institute of Legal Medicine in Essen, 23,032autopsies were performed. Among those, 274 cases of homi-cide by neck-compression (manual and/or ligature strangula-tion, strangulation combined with other means of violence,strangulation combined with smothering/gagging) were ob-served and only 20 cases of self-strangulation.

When facing a case of death due to strangulation, the mostimportant question is, whether it is homicidal, suicidal oraccidental [2, 3]. Regarding the latter, autoerotic deaths and

recently the so-called choking game have to be kept in mind[2, 3, 6]. The ‘choking’ or ‘fainting game’ refers to an inten-tionally caused lack of oxygen to the brain, mostly by stran-gulation with the aim of achieving euphoria or a temporarysyncope. It is ‘played’ by adolescents and children [6, 22]. In1982, Koops and Brinkmann summarized the characteristicsof suicide by ligature strangulation with the emphasis on thefeatures of the used utensils [1].

In the absence of non-relocatable knots, these utensils haveto be relatively broad and soft, rough and/or elastic in order toachieve a high sticking friction to ensure further strangulationafter the victim has lost consciousness. In addition to ligaturestrangulation with only one device, combinations of differentutensils and/or complex garroting mechanisms were observed[4]. A number of case studies were published, reporting onremarkable ligature devices or complex suicides [5–17]. Inthis article, we present two cases of suicidal strangulationobserved at the institutes of Forensic Medicine in Essen andFreiburg. In both cases, almost identical ligature instruments,gymnastic bands, were used.

Gymnastics bands are promoted as products for sports, reha-bilitation and fitness. Thera-Bands® are coloured ribbons withdifferent dimensions and resistances. The most distinct differ-ence between a Thera-Band® and a Deuserband® is the fact thatthe latter forms a loop. For both gymnastics bands, the use oftalcum powder is recommended to prevent sticking together.

Case report

Case 1

Case history A 46-year-old woman was found lifeless in bedby her daughter. Around the neck she had an elastic gymnas-tics band (Thera-Band®, Fig. 1) and next to her an emptyblister of ‘Zopiclone’, a modern hypnoticum with an effectsimilar to benzodiazepines, was discovered. An ambulancewas called, and the paramedics cut the band in three pieces

I. Tzimas (*) : T. Bajanowski :K. TrübnerInstitute of Legal Medicine, University Hospital Essen,Hufelandstraße 55, 45122 Essen, Germanye-mail: iliana.tzimas@uk-essen.de

S. Pollak :A. ThieraufInstitute of Legal Medicine, University Medical Centre Freiburg,Albertstraße 9, 79104 Freiburg, Germany

Int J Legal Med (2014) 128:313–316DOI 10.1007/s00414-013-0959-8

and performed attempts at resuscitation, which remainedunsuccessful.

Autopsy findings Autopsy was performed 71.5 h after resus-citation attempts had been terminated. Numerous petechiaewere observed in the conjunctivae, the palpebrae, the mucosaof the lips, the facial skin and behind the ears. No strangula-tion marks were found, but pale areas within the livoresaround the neck (Fig. 2). On the thorax, marks caused by adefibrillator were discovered, and there was an old scar justabove the pubic area of 13.0 cm length. On both legs small,older bruises were seen, and on the arms, needle marks causedby the paramedics were found. No internal strangulation markand no injuries of the hyoid and laryngeal cartilages werediscovered, but haemorrhages were observed within the neckmuscles as well as a 3.0 cm×1.0 cm measuring haemorrhagewithin the soft tissue of the jugular fossa. Furthermore, inten-sive bleeding within the tongue muscles and under the surfaceof the tongue root was seen. No visible residues of medicationin the stomach were detected.

Toxicological investigations Applying the GC-method in pe-ripheral venous blood, no alcohol was detected. In the GC/MS

and HPLC/DAD, no drugs or medication, includingZopiclone, could be detected in heart blood and stomachcontents.

Police inquiries The victim had a known history of depres-sion and had recently broken up with her husband. A suicidenote was found next to her. She worked as a psychiatric nurseand about a month prior to her death, she had participated in aseminar about suicidal tendencies of patients.

Case 2

Case history A79-year-oldmanwas found dead by his wife inthe former nursery of the house. The body was in supineposition; around the neck (Fig. 3), a gymnastics band(Deuserband®, Fig. 4) was twined tightly. The original sitewas changed by the wife, who had removed the gymnasticsband, which was not knotted.

On both sides of the man's hips, surgery had been performed.The left hip was inflamed and another operation was planned.The man left a suicide note that mentioned fear of pain due tothe newly planned surgery as a motive.

Autopsy findings Autopsy was performed 27.5 h after thebody was discovered. The external investigation yielded mas-sive congestion of the upper parts of the neck and the head(Fig. 3). There was a distinct borderline to the pale lower partsof the neck. Multiple petechial haemorrhages were found inthe skin of the palpebrae, the conjunctivae of the eyes, thefacial skin, in the skin behind the ears and the oral mucosa.There was a bleeding from the left ear, caused by massivecongestion [4]. No haematomas or abrasions were found in theskin of the neck.

On both hips, there were old scars. The left hip showed asoft swelling; when cut open, purulent fluid drained off.

Fig. 1 Case 1: Thera-Band® used as a ligature instrument

Fig. 2 Case 1: lateral view of the neck Fig. 3 Case 2: lateral view of the neck

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Congestive bleedings were additionally found in the pala-tine tonsils and the pharynx. There were haemorrhages in theorigins of both sternocleidomastoid muscles, but no furtherbleedings or injuries of the neck. The lungs showed oedemaand discrete hyperinflation. The heart muscle was concentri-cally hypertrophic; sclerosis was found in the coronaryarteries.

Both hip joints were artificial: on the left side, theendoprothesis was made of ceramics and on the right side,there was a metal artificial hip joint. The left side was mas-sively inflamed and swollen. As mentioned above, the jointand the surrounding tissue contained a purulent fluid.

Toxicological investigations Using gas chromatography andan ADH method, in peripheral venous blood and urine, noethanol was detected. Further toxicological investigationswere not performed.

Discussion

Without any doubt, both cases were classified as ligaturestrangulations; further effort was performed to clarify thecircumstances of death, particularly to distinguish betweensuicide and homicide. Accidents were not considered.

For several reasons, the cases were classified as rare typesof suicide by self-inflicted ligature strangulation. First of all,both corpses showed no signs of an assault. The negativeresult of the toxicological examinations in the first case

suggested capacity to act when the strangulation was inflicted,and obviously, both victims were in a good physical conditionand fit for protecting themselves [18]. Therefore, defenceinjuries would have to be expected, if they had been thevictims of an assault. There was no indication of a dynamicinteraction between two fighting people, and the findings wereall consistent with self-infliction [19].

In 1982, Koops and Brinkmann published characteristicsof suicidal strangulation by ligature [1, 20]. They specifiedthose cases by the nature of the ligature and by the morpho-logical findings at the neck and due to congestion.

For the noose used in suicidal cases of ligature strangula-tion, a firm knot or high static friction was considered asprecondition. This criterion is met by a broad, soft and elasticinstrument with an adhesive surface. In the two cases present-ed, gymnastics bands were used. The woman in case 1 applieda so-called Thera-Band®, and in the second case, a so-calledDeuserband® was noosed around the neck. Both are elasticrubber bands, made of latex or rubber. The main difference isthat the Deuserband® forms a ring, while the Thera-Band® isstraight. The adhesive feature of these bands was utilized toinduce pressure to the neck for self-strangulation. Both gym-nastic bands attain the requirements Koops and Brinkmannhave summarized.

The bands' feature of strong adhesion was exerted in bothcases; both ligatures showed several turns and the bands werenot knotted. Due to the nature of the bands, there was neitheran outer nor an inner ligature mark, but only a circular streakwithout hypostasis.

Apart from the used ligature material, twisting and multipleenlacements are other possible characteristics for suicidalligature strangulation described by Koops et al. [1, 20].Furthermore, the authors reported on typical findings in sui-cidal cases of ligature strangulations: often, a distinct conges-tion of the head can be found; while the neck compressionhardly ever is sufficient to fully occlude the carotid arteries,the blood flow in the cervical veins is usually impaired. Thisleads to massive congestion in the body regions above theligature. Both presented cases showed a very distinct conges-tion of the head and multiple petechial bleedings in the pref-erential sites. An increase of the neck diameter, as pictured byKoops et al. [1, 20], was not observed, though.

One further criterion for suicidal ligature strangulations wasrealized in both cases [1, 20]: The assumed leading pathophys-iological mechanism implicates a moderate pressure on theneck structures. Laryngeal injuries or fractures of the hyoidare uncommon. Both cases did not show such injuries.

In both cases, congestive bleedings in the tissue of thetongue root and the palatine tonsils were found. Ropeladder-like haemorrhages in the tongue muscles were notfound. The latter were observed by Pollak and Missliwetz innine out of ten cases of homicidal manual and/or ligaturestrangulation [21].

Fig. 4 Case 2: Deuserband® used as ligature instrument

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After careful consideration, a synopsis of all informationrevealed no indication of a homicidal act; the findings in bothcases were consistent with suicidal ligature strangulation. Incase 1, intoxication had been ruled out; no drugs or medica-tion, including Zopiclone, was found, using GC/MS anHPLC/DAD. In the future, it may be possible to investigatebiomarkers to correlate the cause of death with suspectedsuicide particularly in cases with unclear mechanism ofdeath [2].

Conclusion

Two cases of suicidal ligature strangulation are presented.Both cases emphasize the importance of broad medico-legalinvestigations including a forensic autopsy to evaluate thecircumstances of death. Only the synopsis of all findingspermits a sound assessment of the circumstances of deathand the clarification of homicide/suicide.

Concerning the reported cases, the assumption of suicidalself-infliction seems justified for the following reasons:

& The absence of defence injuries is in line with a suicidalact.

& No findings indicate a physical inability to act when thestrangulation was inflicted.

& The nature of the ligature is in accordance with typicalobservations in suicidal cases.

& The cases show neither a ligature mark nor bony laryngealinjuries.

References

1. Koops E, Brinkmann B (1982) Selbsterdrosselung. Z Rechtsmed 88:221–231

2. Costanza A, D'Orta I, Perroud N, Burkhardt S, Malafosse A, ManginP, La Harpe R (2013) Neurobiology of suicide: do biomarkers exist?Int J Legal Med. doi:10.1007/s00414-0835-6

3. Meyer FS, Trübner K, Schöpfer J, Zimmer G, Schmidt E, Püschel K,Vennemann M, Bajanowski T, Asphyxia Study Group (2012)Accidental mechanical asphyxia of children in Germany between2000 and 2008. Int J Legal Med 126:765–771

4. Thierauf A, Pollak S (2013) Strangulation. In: Siegel JA, Saukko PJ(eds) Encyclopedia of Forensic Sciences, 2nd edn. Adacemic Press,Waltham, pp 19–26

5. Sauvageau A, Racette S (2006) Autoerotic deaths in the literaturefrom 1954 to 2004: a review. J Forensic Sci 51:140–146

6. Centers for Disease Control and Prevention (CDC) (2008)Unintentional strangulation deaths from the “choking game” amongyouths aged 6-19 years – United States, 1995-2007. Morb MortalWkly Rep 57:141–144

7. Watanabe-Suzuki K, Suzuki O, Kosugi I, Seno H, Ishii A (2002) Acurious autopsy case of a car crash in which self-strangulation andlung collapse were found: a case report. Med Sci Law 42:261–264

8. Zhao D, Ishikawa T, Quan L, Li DR, Michiue T, Maeda H (2008)Suicidal vehicle-assisted ligature strangulation resulting in completedecapitation: an autopsy report and a review of the literature. LegMed (Tokyo) 10:310–315

9. Patel F (1997) Undetected ligature self-strangulation: disadvantage atthe scene of a decomposed body. J Clin Forensic Med 4:41–43

10. Schmidt P, Haarhoff K, Hoffmann E (1991) Sekundär kombinierterSuizid unter den Augen der Ehefrau. Arch Kriminol 188:65–71

11. Di Nunno N, Costantinides F, Conticchio G, Mangiatordi S,Vimercati L, Di Nunno C (2002) Self strangulation: an uncommonbut not unprecedented suicide method. Am J Forensic Med pathol23:260–263

12. Palmiere C, Risso E, van Hecke O, La Harpe R (2007) Unplannedcomplex suicide by self-strangulation associated with multiple sharpforce injuries: a case report. Med Sci Law 47:269–273

13. Doberentz E, Hagemeier L, Madea B (2009) Cable tie used forsuicidal ligature strangulation – a case report. Arch Kriminol 224:17–25

14. Germerott T, Jaenisch S, Hatch G, Albrecht UV, Guenther D (2010)Planned complex suicide: Self-strangulation and plaster ingestion.Forensic Sci Int 202:e35–e37

15. Sorokin V, Persechino F, DeRoux SJ, Greenberg MJ (2012) Suicidalligature strangulation utilizing cable ties: a report of three cases.Forensic Sci Med Pathol 8:52–55

16. Badiadka KK, Kanchan T, D'Souza DH, Subhash K, Vasu S (2012)An unusual case of self-strangulation by ligature. J Forensic LegalMed 19:434–436

17. Turkmen N, Eren B, Uyaniker ZD, Ergonen AT (2012) An uncom-mon suicide method: sel-strangulation. Med Arh 66:423–424

18. Pollak S, Saukko PJ (2000) Defense wounds. In: Siegel JA, SaukkoPJ, Knupfer GC (eds) Encyclopedia of forensic sciences. AcademicPress, London, pp 374–378

19. Shaw D, Fernandes JR, Rao C (2005) Suicide in children andadolescents: a 10-year retrospective review. Am J Forensic MedPathol 26:309–315

20. Koops E, Kleiber M, Brinkmann B (1982) Über Befundmuster undbesondere Befunde bei homicidalem und suicidalem Erdrosseln.Beitr Gerichtl Med 40:129–133

21. Pollak S, Missliwetz J (1985) Hämatome in der Zungenmuskulaturbei Angriffen gegen den Hals. Beitr Gerichtl Med 43:109–116

22. Andrew TA, Fallon KK (2007) Asphyxial games in children andadolescents. Am J Forensic Med Pathol 28:303–307

316 Int J Legal Med (2014) 128:313–316