Simon's bleedings as a vital sign of hanging--a literature review

The intervertebral haemorrhages described by Simon in 1968 as a vital sign of hanging have been verified and endorsed by other authors. They occur in 40-50 % of hanging cases, most frequently in the lumbar spine, in younger age groups, and in cases of free suspension. The haemorrhages are not unique to hanging, but may occur in particular as a result of other traumatic elongation or overextension of the spinal column (e. g. in the course of traffic accidents). In cases of decomposition of the body, "false positive" findings are relatively common. As external findings scarcely provide any reliable vital signs of hanging, there is still a high demand for autopsies. In addition to Simon's bleedings, internal findings which are diagnostically conclusive also include microscopic examinations of the lungs and the neck musculature. More recent findings such as haemorrhages in the back and auxiliary respiratory muscles as well as the intestinal wall, if confirmed, could supplement Simon's bleedings. Frei's fibre sample and evidence of histamine in the ligature mark should not be neglected. Finally, it must be emphasized that the forensic assessment of hanging cases should always be based on a criminological and forensic evaluation of all the circumstances of the offence as well as on post-mortem findings.     

Hemorrhages of the tongue in the postmortem diagnostics of strangulation

Hemorrhages of the tongue can be useful for the diagnosis in cases of lethal neck compression. The reported frequencies of tongue bleedings in the literature in cases of suicidal hanging range from 0 to 14% and in homicidal strangulation (str.) from 5 to 37%. This study gives a summary of the incidence and intensity of tongue bleedings in cases of homicidal str. by ligature, manual str., suicidal str. by ligature and suicidal hanging. In 25% of all homicides significant or massive hemorrhages of the tongue were detected. In contrast to this, in suicidal hanging the tongue was unaffected in 95%. The causes of massive hemorrhages here (2%) could be explained by an "abnormal" position of the loop.     

Significance of hemorrhages at the origin of the sternocleidomastoid muscles in hanging

Hemorrhages at the periostal-clavicular origin of the sternocleidomastoid muscles are part of the indirectly induced autopsy findings in death by hanging. In a prospective study of 178 cases of hanging, clavicular hemorrhages were found in 110 cases (a relative frequency of 62%). A statistically significant association between occurrence of hemorrhages and completeness of the victim's body suspension was discovered (P = 0.046) as well as a significant association between the occurrence of hemorrhages and the location of the ligature knot on the neck (P = 0.008). The occurrence of hemorrhages at the clavicular origin of the sternocleidomastoid muscles was independent of age, sex, and weight. This article renews the knowledge of this important vital sign described mainly in the German medicolegal literature.     

Amussat’s Sign in Hanging—A Prospective Autopsy Study

Abstract: Amussat’s sign is typically a transverse laceration of the intimal layer of carotid arteries described in cases of hanging. Subtotal laceration of the carotid artery is not strictly specific for hanging and can be also caused by blunt neck trauma, extreme overstretching, or whiplash‐injuries. In a prospective autopsy study of 178 cases of hanging, Amussat’s sign was found in 29 cases (a relative frequency of 16.1%). A statistically significant association between the occurrence of tears in the intimal layer of carotid arteries and the victims’ age was discovered in the cases studied (the frequency increased with age; p < 0.05). The occurrence of Amussat’s sign was independent of gender, weight, completeness of the victim’s body suspension, and position of the ligature knot on the neck. The study demonstrates the fact that the most probable cause of Amussat’s sign is a combination of direct compression of the artery by the rope and indirect stretching because of the gravitational drag produced by the weight of the body.     

Factors and circumstances influencing the development of hemorrhages in livor mortis

Petechial hemorrhages or ecchymoses in the skin of the face and/or in eyelids and/or conjunctivae are one important feature in postmortem diagnosis of lethal strangulation. On the other hand, petechial bleedings can occur in various causes of death, especially in cases of neck or thoracic compression, they can occur in acute cardiac failure, as a result of blood or skin diseases or as a postmortem phenomenon. The focus of this investigation (retrospective study of 279 corpses, found initially in a prone position or some other face down position) was to analyse the frequency of postmortem (hypostatic) hemorrhages and factors which may influence their development. Petechial hemorrhages in livor mortis in the skin of the trunk and extremities were found in 110 cases (39%). The frequency ranged from 41% in the side position and 44% in the kneeling position to 50% in the prone position. Increasing intensity of livor mortis resulted in an increasing frequency of hemorrhages, up to 59%. In cases with a body-mass-index (BMI) of more than 26 the frequency of hemorrhages increased up to 64%. In cases without livor mortis when the corpses were found as well as in cases with complete movement of livor mortis after turning the corpses, no hemorrhages were found. If hypostasis was partly or completely fixed, the rate of hemorrhages increased up to 50%, without additional increase in longer postmortem intervals. Obviously postmortem petechiae develop neither very soon nor days after death, but within a period of several hours after death.     

Intramuscular bleeding in deaths from an internal cause: forensically significant differential diagnosis between external trauma and hemorrhages occurring during agony

Five cases of death from an internal cause are described in which bleeding into the muscles of the neck, the region of the shoulder girdle, the back of the thorax and partly the arms occurred during agony. As the cause of death was unclear at first and a violent crime could not be ruled out, a forensic autopsy was ordered in the course of which hemorrhages were detected which raised the differential diagnostic question whether extravasation might have been caused by an impact of blunt force. However, thorough investigation of the macroscopic and especially the microscopic structure of the lesions provided clear evidence that all the hemorrhages were due to internal causes. The pattern of these muscular lesions suggests intensified breathing with dyspnea leading to ruptures of the accessory respiratory muscles. Intramuscular bleedings of this type are a well-known phenomenon in legal medicine in connection with death by drowning, but have not been described in the medicolegal literature in cases of natural death from an internal cause so far.     

Frequency of blood spatters on the shooting hand and of conjunctival petechiae following suicidal gunshots wounds to the head

A total of 103 suicidal and 29 homicidal gunshot fatalities were evaluated. In 42% of the suicides, characteristic findings like blood spatters and/or powder soilings, could be found on the shooting hand by naked-eye inspection indicating the importance of an accurate examination of the deceased's hands at autopsy for a preliminary diagnosis. Petechial hemorrhages of the conjunctivae due to the gas pressure after discharge of the weapon were observed in 22% of those cases with contact shot wounds to the head/neck, but not in cases of distant shot injuries following the use of non-high velocity ammunition. Therefore, conjunctival petechiae can be regarded as an additional but optional sign of contact head shots in cases without alterations possibly influencing the development of conjunctival pin-point bleedings. The evidence of such findings can be of practical importance if the entrance shot wound cannot be examined for whatever reason.     

Death due to unusual position of the body--an explanationfor the consequence of reduced venous reflux to the heart

The article describes the case of a 29-year-old woman who was found dead in her apartment on a bar stool with the body being maximally retroflected in the lumbar region, the head hanging down and the feet and hands barely touching the floor. On external inspection of the body the cuff-like distribution of hypostasis on the forearms and lower legs was consistent with the position in which the body was found. There were no signs of foreign intervention. At autopsy massive congestion was found in the internal organs as well as pulmonary and cerebral edema. In the ventral region of the lumbar intervertebral discs superficial hemorrhages were detected. The alcohol content was 3.40 per thousand in the blood and 4.43 per thousand in the urine. As the essential pathogenetic mechanisms responsible for death reduced venous reflux to the heart in combination with postural asphyxia and the influence of alcohol are discussed.     

Accidental hanging by a sweater: an unusual case

An accidental atypical hanging with the collar of a sweater is reported. A 67-year-old man was found dead in the sitting position with the collar of his sweater hanging off the brake handle of a motorcycle. Autopsy findings revealed a ligature mark on the surface of the neck; hemorrhages in the sternohyoid muscles; submucosal hemorrhages in the left greater horn of the hyoid bone; a large degree of submucosal petechial hemorrhages in the larynx, oral mucosa, and palpebral conjunctivae; and dark-red liquid blood with little clotting in the heart cavities. The alcohol levels in the blood and urine were 2.84 mg/ml and 3.52 mg/ml, respectively. It was concluded that the man had died from hanging by the sweater, and it was speculated that when he became inebriated, he might have lost consciousness and then fell with the collar of his sweater hanging from the brake handle of the motorcycle.     

Observed Characteristics of Suicidal Hangings: An 11-year Retrospective Review

Many studies have been published regarding suicidal hanging deaths, and most forensic pathologists and coroners are very familiar with such causes of death. Forensic pathologists are challenged over their rulings regarding manner of death in part because the general public has a limited scope of knowledge. One such challenge centers on the question of whether a hanging can be a suicide if the individual is not fully suspended. The authors designed a retrospective study to review suspension in hangings and to analyze other criteria used to help in deciding manner of death. We examined 229 suicidal hanging deaths over an 11-year period (1997 through early 2009) using the data from two separate jurisdictions in Ohio. In conclusion, we found that the vast majority (83.4%) of people who hanged themselves were found partially suspended. Among other criteria analyzed, only the presence of petechial hemorrhages and acute neck injury was statistically significant.     

Are Peripapillary Intrascleral Hemorrhages Pathognomonic for Abusive Head Trauma?*

Abstract: The American Academy of Pediatrics’ Committee on Child Abuse and Neglect, Section on Ophthalmology, acknowledges that searching for retinal hemorrhages (RHs) in infants only in cases of suspected of abuse creates selection bias. However, they also recommend that postmortem eye removal might not be indicated “in children who have clearly died from witnessed severe accidental head trauma or otherwise readily diagnosed systemic medical conditions.” Although infrequently described in the child abuse literature, peripapillary intrascleral hemorrhages (bleeding in the sclera at the optic nerve insertion)—putatively from severe repetitive acceleration/deceleration forces with or without blunt head trauma—have been considered essentially pathognomonic for abusive head trauma (shaken baby syndrome). We present two neonates who sustained accidental, severe in utero head injuries and had associated extensive RHs and optic nerve sheath hemorrhages with peripapillary intrascleral hemorrhages detected at autopsy. Neither neonate had a documented clinical fundal examination in the intensive care unit.     

Apparent partial hanging

A careful analysis of circumstances and investigations of death scene are required before commenting on the manner of death in a case of hanging. Hanging may result from either complete or incomplete suspension of the body. Two cases of hanging are reported where discrimination in eyewitness's account and death scene investigation report was evident regarding type of hanging (complete/partial). The use of term apparent partial hanging is proposed in such cases. Body position in hanging is one of the numerous factors that determine the strength of the neck compression by the ligature and thus should be considered in the evaluation of dying process and pathomorphologic feature of hanging. The cases also put a probable explanation to the higher incidence of partial hangings in different studies. We believe that incidence of true partial hangings may be much lower than that reported in the literature.     

Criminal Case Outcomes, Incarceration, and Subsequent Intimate Partner Violence

Given the centrality of court interventions to the U.S. response to intimate partner violence (IPV), it is crucial to evaluate their impact on reabuse. To do so, this study examined whether female IPV victims’ experiences of abuse in the year following a criminal court case against their partner varied by case outcome or by whether the batterer had or had not been incarcerated. Consistent with prior research, we found no main effect differences in reabuse trajectories by court case outcome or by incarceration. We also examined variables that might moderate the impact of case outcome and incarceration on reabuse and found that although batterer legal history did not affect the impact of case outcome, his age, Time 1 employment status, the couple’s Time 1 living arrangement, and duration of abuse did interact with case outcome. No variables tested moderated the relationship between incarceration and reabuse over time. Findings suggest that in certain cases there may be benefits to case outcomes that leave potential consequences hanging over the offender’s head. These results also add to the growing body of evidence questioning the efficacy of one-size-fits-all approaches to IPV cases.     

The importance of Simon's symptom in cases of hanging (author's transl)

Radiological and patho-anatomical investigations of the spines of 32 corpses of persons who had committed suicide by hanging revealed spine damage in 81% of the cases. The cervical spine was damaged in 69%, the lumbar spine in 56% of the cases. The typical damage of the cervical spine is a loosening of the discs at the dorsal side, usually at the level of C 4/5 to C 6/7. In the region of the lumbar spine, bleeding between the (anterior) ventral ligament and the discs is the most frequently observed damage (Simon's sy;mtpom). Simon bleeding is brought about by traction force and is not dependent on the age at death or on any existing degenerative changes of the spine.     

Value of laryngeal injuries as evidence

Report of two cases: Violations at soft parts of the neck and at larynx pointed to an attack against the throat by strange hand, but local vital reactions showed that the attack had been survived. A 54-year old woman had little excoriations in the skin of the neck, the right great horn of hyoid bone and the left upper process of thyroid cartilage were broken, the fractures were bloodshot. No petechiae in skin and conjunctivitis. Death occurred from a suicidal poisoning of soporifics. The attack against the throat (throttling by hand, conceded by the culprit) had been survived. That was recognizable on a clear cell-reaction in the bleedings within the muscles of the neck. A 87-year old man was found in his rummaged home. Violations of the skin in the face pointed to attacks against mouth and throat; additional maltreatment by gagging and fettering (in the meantime untied) could be supposed. -- Histological examination showed advanced cell-reaction in the wounds, partially even intracellular iron pigment; there was a superposition of old and recent injuries, but even the recent had been survived many hours. The situation of finding the corpse, bleedings inside the iliac muscles, little hemorrhages in the mucosa of the stomach and acetone in blood and urine pointed to a death lately from cold. But complete clearing-up of the case was not yet possible.     

Correlation of circumstances with pathological findings in asphyxial deaths by hanging: a prospective study of 61 cases from Seattle, WA

Correlation of the circumstances of death with the pathologic findings in this prospective study of deaths by hanging affords insight pertaining to certain of the pathophysiologic mechanisms involved in fatalities of this type. The presence of conjunctival and facial/periorbital petechial hemorrhages correlates with increasing levels of body support below the point of ligature suspension. Hyoid bone and/or thyroid cartilage fractures (found in 26% of cases) are most frequently identified in those persons found completely suspended and in victims in the older age ranges. No hyoid bone/thyroid cartilage fractures, internal soft tissue injury, or petechiae were present in 13 (21%) of the study cases.     

Eyelid petechiae and conjunctival hemorrhage after cardiopulmonary resuscitation]

In the last few years, some reports claim that petechial bleedings found in the eyelids and conjunctivae of corpses may be resp. are caused by resuscitation efforts (= RES). Nevertheless, the numbers of cases were small and the selection of the cases presented to demonstrate this relation in our opinion was not convincing. In the material of our institute, the rate of autopsies in which the victims had been tried to resuscitate by professionals increased up to ca. 25%, including a substantial number of victims of homicides. If RES alone would cause petechial bleedings, serious problems would arise for the medical expert. We analyzed all cases of a period of 5 years, which were examined by 1 investigator. Among 474 autopsies, RES was done in 144 cases (31%). 19% of these victims presented petechial bleedings, predominantly in the conjunctivae, compared to only 11% in the non-RES group. However, this was not a consistent finding in all subgroups: If the group of acute cardiac deaths of middle-aged persons was taken separately, in the remaining material a statistically significant difference in the petechial rate between cases with and without RES was not present. The analysis revealed an influence of the following factors in the development of petechial bleedings: cause of death, age, constitution (body mass index). In the RES subgroup with the highest rate of petechial bleedings (acute cardiac deaths of persons between 40-60 years; n = 23; rate of petechiae = 50%) the frequency of petechiae could be explained by a combination of such factors. As a second way we investigated all persons in which RES was done in our Medical School during a period of 5 months. In no surviver petechiae were present; in the group of non-survivers (predominantly cardiac deaths), the petechial rate was 16%. According to the statements of the treating physicians, a development of petechial bleedings under RES was not striking in these cases or according to their general experiences. Although such a statement is of restricted value (because petechial bleedings are mostly not obvious without a special look for them), the complete absence of information of this aspect in the clinical literature is striking. If petechial bleedings would be a common consequence of RES, this finding should be well known in intensive care units. According to our experience, a clear causal relation between resuscitation efforts and petechial bleedings in the face is not likely.     

MRI detects hemorrhages in the muscles of the back in hypothermia

Morphological findings in death due to hypothermia are variable and predominantly unspecific. Goal of this study was to check the usefulness of post-mortem cross-sectional imaging methods in the diagnosis of externally invisible findings in death due to hypothermia. Three consecutive forensic cases that died due to hypothermia were examined using post-mortem multi-slice computed tomography (MSCT) and magnetic resonance imaging (MRI) prior to autopsy. MSCT excluded traumatic skeletal and fatty tissue injury. Using MRI, it was possible to detect hemorrhages within the muscles of the back in all three cases, a so far unknown finding in death due to hypothermia. MRI also allowed the detection of hemorrhages in the iliopsoas muscles. Wishnewsky spots remained radiologically undetected using the present examination techniques. In conclusion, hemorrhages of the muscles of the back might serve as a new sign of death due to hypothermia; however, additional studies on their specificity are necessary. Post-mortem MRI is considered as a good diagnosing tool for muscular hemorrhages, with a great potential for examination and documentation.     

Fatal accidental hanging by a high-chair waist strap in a 2-year-old girl

High chairs are commonly used to feed children after 6 months. Related injuries are oftentime minor and rarely leading to death. We describe a case of a 2-year-old female child who used to jump alone on her high chair and also had the habit to fasten the straps by herself. Her mother found her hanging by the waist straps. A thorough investigation showed that she climbed her high chair and fastened the waist straps but not the crotch one. The girl slid down into the seat, trapping her neck in the waist straps and thus resulting in hanging. In here, we concluded that the victim's death was caused by asphyxia, itself, caused by accidental hanging. The present case is of a special interest because of the rare similar cases reported. This case suggests that a correct restraint use and a close supervision would have prevented such a fatal issue.     

A triad of laryngeal hemorrhages in strangulation: a report of eight cases

The results of histological studies on larynges from eight cases of manual strangulation, all that had intracartilaginous laryngeal hemorrhages, a recently described and under-recognized lesion associated with strangulation, are reported. Formalin-fixed larynges were examined in serial section using a standardized protocol. In all cases, intracartilaginous laryngeal hemorrhages were associated with subepithelial laryngeal hemorrhages, and intralaryngeal muscular hemorrhages forming a "triad of hemorrhages." In five cases, the triad was found in the presence of laryngeal cartilage microfractures. Since cartilage microfractures can be causally related to mechanical injury to the neck, it is likely that the triad of hemorrhages has diagnostic value as an independent morphological criterion for the postmortem diagnosis of strangulation. Since a proportion of cases of strangulation lack characteristics that are self-evidently due to violent application of pressure on the neck, recognition of the triad may have important implications for the postmortem diagnosis of strangulation.