Study of morphological changes in the skin of the neck in suicidal cases by hanging
U osob, které spáchaly sebevraždu oběšením, bylo většinou sledování morfologických změn zaměřeno převážně na makroskopické nálezy v místě rýhy od škrtidla.
Seznamujeme s charakteristickými histopatologickými nálezy strangulační rýhy na šíji u třech jedinců, kteř spáchali sebevraždu oběšením.
K hlavním nálezům patří koagulační nekróza celé vrstvy kůže a přiléhajících příčně pruhovaných svalů. V oblasti uzavřené škrtidlem je v cévách patrné městnání krve s mírným zánětlivým perivaskuárním infiltrátem. Mazové a ekrinní žlazky zůstávají zachovalé. Tyto nálezy naznačují, že ani tlak ani hypoxie nejsou dostatečné, aby způsobily nekrózu kožních adnex.
Angel Fernandez-Flores1; Oliva Orduėa2; Veronica Carranza2
Authors place of work:
Service of Cellular Pathology, Clinica Ponferrada. Ponferrada, Spain.1; Legal Medicine Institute of Leon and Zamora, Ponferrada, Spain2
Published in the journal:
Soud Lék., 56, 2011, No. 2, p. 24-26
Purpose: the morphologic changes in specimens from people who have committed suicide by hanging have mainly centered on macroscopic findings. Pour purpose is to inestigate the microscopis changes in the ligature marks.
Methods: we report the histopathologic features of the ligature mark on the neck of three people who committed suicide by hanging themselves.
Results: the main finding was coagulative necrosis of all cutaneous layers and the subjacent striated muscle. In the areas close to the ligature, blood vessels appeared congestive with a mild inflammatory perivasculary infiltrate. In some other areas, we found preserved sebaceous and eccrine glands, underneath the epidermis with marked necrotic changes.
Conclusions: These findings suggest that neither pressure nor hypoxia is enough to induce necrosis in cutaneous adnexa.
Keywords: hanging – ligature mark – coma necrosis
The morphologic changes in
specimens from people who have committed suicide by hanging have
mainly centered on macroscopic findings. Some histopathologic studies
have focused on the morphology of internal organs such as large
vessels and muscles of the neck area. Not many studies on the
cutaneous changes of the ligature mark have been published. In one of
them (1), the
authors studied such changes in people who died several weeks after
the suicidal attempt, so the main histopathologic feature was chronic
inflammation with granulation tissue.
We have histopathologically
studied the cutaneous changes of the ligature mark of three cases of
suicide by hanging from people who died immediately after the
OF THE CASES
An 86-year-old man was found at
home, hanging by a rope. The face had a bluish tone and
after removing the rope, a depressed supraglotic mark was
evidenced (Fig. 1, left).
The autopsy revealed a fracture
of the hyoid bone (right greater and lesser cornu, as well as left
lesser cornu). The internal organs were generally congestive, but no
other pathology was found. The study for toxics and drugs was
negative. The final determination from the coroner was suicide.
The microscopic study of the
supraglotic depression showed compression of all the layers of the
skin, as well as of the subjacent striated muscle (Fig. 2). At this
level, the structures were necrotic, with preservation of the shapes
of the adnexa but with loss of the definition of the cellular details
(Fig. 3). In some areas, we could see how sebaceous glands, as well
as sudoripary ducts were preserved underneath areas of necrotic
dermis and epidermis (Fig. 4). The preserved immediate adjacent
dermis showed congestive blood vessels with mild inflammatory
perivascular infiltrate (Fig. 5).
A 40-year-old woman, who was
under psychiatric treatment, was found dead at home, hanging from
a sheet that surrounded her neck. After removing the sheet, the
neck presented a lineal depression. The necropsy evidenced
fracture of the left lesser cornu of the hyoid. There were also
general anoxic organic alterations, with no other pathology. The
study for toxics and drugs was negative. The autopsy from the coroner
A sample from the depressed
area of the cutaneous lesion of the neck was morphologically studied.
It showed compression of all the layers of the skin, as well as of
the subjacent striated muscle. Necrosis of the adnexa was evidenced,
including sudoripary glands, as well as the pilosebaceous unit (Fig.
6). The dermis close to the necrotic area showed dilated blood
vessels with mild inflammatory chronic perivascular infiltrate.
A 25-year-old woman was
found at home, hanging from the ceiling, with a rope around her
neck. The depression under the rope showed vital signs. The depressed
area reached the submaxillary area. Both sternocleidomastoid muscles
showed albus line. The left jugular vein showed Otto sign (internal
jugular wall torn) and the left carotid artery presented Amussat sign
(internal carotid wall torn). No signs of violence were found and the
coroner’s autopsy determined suicide. The study for toxics and
drugs was negative.
A sample from the cutaneous
wrinkle in the middle part of the neck was histopathologically
studied (Fig. 1, right). Coagulative necrosis of the epidermis,
dermis, hypodermis and striated muscle, was seen. Under the areas of
necrotic epidermis, we found some sudoripary glands which were only
mildly involved by the compression, and did not appear necrotic (Fig.
7). The dermis showed dilated blood vessels with mild inflammatory
chronic perivasculary infiltrate.
The macroscopic findings of the
ligature mark(s) in the neck of people
who have committed suicide by hanging themselves, have been
previously described in literature (2).However, the
microscopic features of such lesions have rarely been reported (1,3).
Even so, most of the histopathologic studies have centered on the
morphologic changes of the internal structure, such as vessels
(Amussat and Otto signs) (4). The dermal changes are less frequently
described. In the report by Vock et al., two cases were presented,
and while granulation tissue was described in one, a normal
corion was evidenced in the other (1). In both cases, death occurred
approximately a month after the suicidal attempt. The reason why
in one case the granulation tissue was formed and not in the other
was, according to the authors, the difference in the degree of
strangulation. Our report includes a microscopic study of three
cases in which suicidal death was the immediate result from hanging.
In that respect, this contains information never published before, to
the best of our knowledge.
The changes observed by us were
typical of an extreme ischemic area
of skin with infarcted zones. We did not see signs typical of burns,
although rope burns are sometimes associated to the ligature mark.
When the latter are present, they have forensic value, since they
indicate an antemortem nature of hanging (2).Such an abrasion is
due to compression (5). A different meaning can be attributed to
the bullous changes of the skin as well as to the ridge ecchymoses
which can be found between the ligature burns. Although once thought
to be an antemorten sign, we now know they can appear as a post
mortem sign (6).
From a histopathologic point
of view, the inflammatory infiltrate at the compressed area, is
considered as a premortem sign (3). We saw a mild
perivascular inflammatory infiltrate in the 3 cases, but it was seen
in the non-necrotic dermis.
In our study, we could see
sebaceous glands as well as sudoripary ducts, which appeared
preserved underneath the necrotic dermis and hypodermis. This
contrasts with the findings in the cutaneous lesions of coma, where
the eccrine seat coil, as well as the sweat duct and the sebaceous
glands appear necrotic (7–11). Pressure and hypoxia have been
considered in literature as determinant factors in cutaneous necrosis
due to coma (10), and it was once emphasized how the lesions were
more commonly found on pressure areas, such as the extremities and
trunk (12). Moreover, similar lesions are found in patients with
generalized hypoxia due to carbon monoxide intoxication (13).
Nevertheless, such a claim has not been consensus, and others
have suggested how other factors could be responsible (8).Certain facts
supporting this latter option are that coma-lesions also appear in
non-pressure areas. Also, the eruption is sometimes widespread and
distributed in an irregular pattern (8).
Moreover, the outer layer of the
eccrine duct is more metabolically active than the inner one, but
nevertheless, the latter is altered earlier in the necrosis due to
coma than the former (8).Even in cutaneous
changes in non-drug-induced coma, alterations in the eccrine glands
are seen (13,14), and
an immunologic pathogenesis has been suggested for this (15). Our
study is a good model for observing the changes which are
present in extreme pressure and hypoxia located on a specific
area of the skin. Since differences with the changes in coma-lesions
are obvious, this supports the claim that other factors contribute to
the changes seen in coma-induced cutaneous alterations.
The microscopic features of
ligature marks from sucide cases from hanging were mainly coagulative
necrosis of the epidermis, dermis, hypodermis and striated muscle.
Some adnexal glands were only
mildly involved by the compression, and did not appear necrotic.
Neither pressure nor hypoxia are
enough to induce necrosis in cutaneous adnexa.
The epidermis and superficial
dermis are damaged in some areas earlier than the subjacent adnexal
when pressure on the skin is extreme and constant.
The sequence of events in
necrosis, due to external mechanical pressure, seems different to the
one seen in coma-induced necrosis, as some have already suggested