One of the limits about writing about a case that’s sub judice is that we’re limited in what we the public have access to, what we can see. In order to examine the case in terms of the bruising around Susan’s neck, the logical place to start is by examining the photos of those bruises.

I’ve seen Khan’s in court, and I’ve seen some of Perumal’s photos. Unfortunately I can’t reproduce them here while the case is underway. As such I’m a little reluctant to pontificate about bruises without being able to show them.

What I can do is shed a little light on the pathology of bruises, and expose an important problem in this area, regarding Rohde’s version of events.

The image below shows a model that Dr. Perumal used to demonstrate Susan’s ligature strangulation. A ligature isn’t a bruise, a ligature [such as a rope or cord] causes a bruise. A ligature may point to the cause of death [ligature strangulation, asphyxiation] and thus reveal the manner of death [homocide, suicide etc].

The photographs I saw didn’t show a clear line like the one coloured in koki over the mannequin’s neck.

In a genuine hanging, we’d expect the ligature to ride right up against the jaw and the throat in the front and sides and the cervical vertebrae at the rear.

In genuine hangings the u-shaped hyoid bone is often undamaged precisely because the ligature constricts the tissue above it. The hyoid bone is the bone floating in the centre of the throat, just above the adam’s apple. In Perumal’s koki sketch, he appears to have the ligature more or less over the hyoid bone.

When someone is strangled, the hyoid bones is typically injured. Unlike a ligature which cuts off air and blood flow high up on the neck and throat, when human hands or a second person uses a ligature to strangle their victim, it tends to exert force on the middle section of the throat. I’m surprised the state prosecutor hasn’t brought up this important artefact with Perumal yet.

In this case we’re sure about the cause of death [asphixia], but we still have two hypotheses competing for the manner of death. Either Susan strangled herself, or her husband strangled her. It’s important to remind ourselves that even suicide involves the same scenario as murder – there’s a murder weapon, a motive and an opportunity. It’s still murder, it’s just murder of the self.

The pertinent question that materialises when we imagine a staged suicide is whether the neck will bruise post mortem. It’s important to figure this part out in order to exclude or be able to fully or partly exclude the ligature from the cord.

What we want to know is whether the bruises on Susan’s neck involve few or many layers of bruising. If there is a single bruise in a clear line then that suggests suicide. If the bruising is more cloudy and spread out over the neck, it may suggest not only hands around the throat but other objects as well, such as the gown’s belt. Multiple bruises suggest a struggle.

We could also say that the absence of a clear ligature line in a person who bruises easily is a critical absence of critical evidence. But the absence of evidence is also evidence.

Rohde’s story forces us to imagine two Susans and two Jasons. One Susan is suicidal, but that scenario is contingent on an honest and basically good Jason. An imperfect but innocent Jason. In the other scenario, Susan is murdered, and Jason is exposed as not not just deceitful, but murderously deceitful. Not just disgusting, but criminally so. Which is it? Which version is real?

If there’s not a trademark ligature bruise across the throat where there should be one, and one that resembles Perumal’s black line, then it’s easier to come to a decision. There’s also the time of death aspect hidden in the riddle of the bruising. If the bruising switches off in a sense, post mortem, then it might reveal the time of death.

In Season 3 Episode 4 of Sherlock, The Abominable Bride, there’s a scene where a man is beating a corpse in an attempt to figure out post mortem bruising. That man flogging the dead turns out to be Sherlock Holmes.

Bruising is an important and fascinating aspect of true crime. Bruises provide incredibly valuable time sensitive data, color-coded, telling what has happened to a particular person absent their ability to tell us themselves. Before we look at how those colors form and what they mean, let’s look at bruising itself to make sure we understand what it is, and what it isn’t.

Simply put, a bruise is a kind of  internal bleeding. It’s a localised collection of blood floating outside the vessels that usually contain the blood, such as capillaries. When blood breaks through the surface of the skin, or an organ, it’s no longer a bruise, but bleeding.

A bruise tends to form where tissue has experienced trauma or sustained enough damage to cause blood to leak through cracks or ruptures in tissue. It’s important to remember that usually bruises only form where excessive and unusual force is applied. What makes Susan Rohde’s case a little unusual, is that she bruised easily, a hereditary condition she shares with one of her daughters. What I find quite frustrating with this case is that despite having two pathologists in court, we still don’t have a medical diagnosis for Susan’s bruising condition. I mean, is it telangiectasia, run of the mill ecchymosis, what is it? If it was such an obvious condition, why wouldn’t someone use the proper expert term for it?

Speaking of terms, pathologists use a different lexicon to describe various pathological features: a bruise is a contusion but it may involve other terms such as a hematoma and hemorraging. Both these words focus on the blood side of the equation, whereas the contusion focuses on the optics – because something appears injured on the face of it. It comes from the Latin contusionem which means ‘to beat’.

Bruising is usually associated with superficial injury, but any capillary damage, whether subcutaneous or deeper inside the body cavity produces bruising. One can bruise one’s brain [cerebral contusion], heart [cardiac contusion] or even lungs [pulmonary contusion]. For our purposes we’re only going to refer to the bruising of Susan’s neck and throat.

Now, I don’t want to confuse the issue by adding too much fluffy data to the discussion, but it’s worth noting that petechia [also petechiae] may resemble bruising but it’s not necessarily the same thing. The simplest way to describe petechia is that it’s a kind of micro-bruising. Someone who cries a lot may develop petechia in their face. It can also be caused by coughing, weightlifting or sunburn. One sees very tiny red threads [tiny burst capillaries] on the surface of the skin, or even in the eyes. These injuries are a bugger to deal with, 1) because it’s difficult to draw the line between injuries building up to a case of death, and the peri mortem [at the time of death] petechia injuries taking place during the act of dying and 2) because petechial injuries and bruises are so similar. It should be easy – the one is a smaller form effectively than the other.

This may seem a fine line, but stay with me on this. In order to understand bruising, we also need to navigate the fine line of what isn’t bruising.

To figure this out let’s look at a brief dialogue on the subject, referring to murder [as it turned out] by strangling of fifteen-year-old Diane Oarlock. This transcript is courtesy of CNN:

GRACE: You have quite a reputation as a very powerful defense attorney. What is the defense in this case?

ROBERT NUTTALL, ATTORNEY FOR DEFENDANT (VIA TELEPHONE): Well, hello, everyone. This is not a case of who did it. It`s a question of what happened. There`s no question that he killed her. The question was whether or not he murdered her. And to turn a killing into a murder, you need murderous intent, and that inference had to be drawn from the forensic evidence. So what it came down to was really not so much a battle but a disagreement between the forensic pathologists.

GRACE: About the throat, Clark Goldband.

GOLDBAND: Well, Nancy, authorities say they believe that she was, in fact, strangled manually, and that`s how this girl died.

GRACE: So Robert Nuttall, there was a manual strangulation. How does that fit into your theory?

NUTTALL: Not necessarily. The original pathologists found that the cause of death was unascertained. And quite frankly, there was very, very little evidence of trauma either to her body or any evidence of struggle in her room.

GRACE: Wait a minute. Didn`t she have multiple hemorrhages in the eyes? That would be the petechiae, which is a direct indication of strangulation?

NUTTALL: You`re quite right. Those are petechial hemorrhaging, and petechial hemorrhaging is a very strong indicator that, one, the blood`s been cut off, which is pressure to the neck, or more — for our point of view, more importantly, that the air has been cut off either by way of a bizarre mechanism called berking  and perhaps positional asphyxia.

If he choked her, if he squeezed her neck, there`s murderous intent, guilty of second degree. And in our country, because there was a sexual assault, it`s constructive first, and so it moves right up to first degree.

If, on the other hand, he was sitting on her chest while was sexually excited and perhaps her head was against the wall in a position of positional asphyxia, he could very, very well through his unlawful act have cut off the air to her brain. And so therefore, he would be guilty of manslaughter but not guilty of murder.

And the real issue became what was seen in the neck. Was it real bleeding, or whether it was, as the forensic pathologists say, post-mortem lividity or post-mortem pooling, an artifact created after death? And that`s what the jury had to think about.

That’s why I really dislike the petechial side of things, because it’s an injury that can be argued both ways. It can be argued that it occurred naturally during death, or as part of the criminal intent and execution. Either way, it’s difficult to prove, but easy to invoke reasonable doubt.

The word “lividity” also needs explanation, but we’ll deal with it a little further down in this post.

Now let’s get down to brass tacks. Bruising is a color-coded record of injury, that’s the beauty – in a manner of speaking – of this injury. It can reveal a lot. Wikipedia provides the following mechanism for how bruises evolve and devolve.

Increased distress to tissue causes capillaries to break under the skin, allowing blood to escape and build up. As time progresses, blood seeps into the surrounding tissues, causing the bruise to darken and spread. Nerve endings within the affected tissue detect the increased pressure, which, depending on severity and location, may be perceived as pain or pressure or be asymptomatic. The damaged capillary endothelium releases endothelin, a hormonethat causes narrowing of the blood vessel to minimize bleeding. As the endothelium is destroyed, the underlying von Willebrand factor is exposed and initiates coagulation, which creates a temporary clot to plug the wound and eventually leads to restoration of normal tissue.

During this time, larger bruises may change color due to the breakdown of hemoglobin from within escaped red blood cells in the extracellular space. The striking colors of a bruise are caused by the phagocytosis and sequential degradation of hemoglobin to biliverdin to bilirubin to hemosiderin, with hemoglobin itself producing a red-blue color, biliverdin producing a green color, bilirubin producing a yellow color, and hemosiderin producing a golden-brown color.^[9] As these products are cleared from the area, the bruise disappears. Often the underlying tissue damage has been repaired long before this process is complete.

Just as we don’t want to confuse bruises with petechia, we don’t want to get mixed up between bruises and lividity. Lividity, also known as livor mortis [livor=”bluish colour” + mortis=”of death”] is a staining of the interior of the body with blood, as it collects in the lower regions drawn by gravity. Since the body is dead, no blood circulation occurs, and so the blood pools. Livor mortis is fairly distinctive to bruising. It’s a much stronger purple-blue or red, and the color tends to occur in large blotches, especially where the body rests against an object.

Superficially, it’s possible to confuse bruises with lividity, especially where the bruises occur within the same reddened or discoloured areas. So it’s important to try to separate bruises suffered in life, and peri mortem, from lividity.

In Susan Rohde’s case this is fairly easy because there’s no lividity around the front of her neck or throat. The fact that she was in an upright position and then lay on her back, means the “mixed signals” between bruises and lividity in the throat area are virtually absent.

In order to show how similar lividity is to the appearance of a bruise, or redness, this image from the Rebecca Zahua case [below] is worth examining. Notice the redness in the back and how the right arm is darker than the left. Zahua was found hanging from a red rope over a balcony, fully naked, hands bound with a shirt wrapped around her neck and its sleeves stuffed into her mouth. She was cut down and allowed to lie on the lawn on her right side for most of the day as helicopter crews buzzed overhead, filming the scene.

Did the shirt have anything to do with the cause of death? What was also missing in the Zahau case were the ligature marks around the neck one would expect from hanging. Just as in the Rohde case, the Zahau case involved two pathologist, and two autopsies. The second actually involved exhuming her coffin in order to perform the vital second autopsy.

Here’s the pertinent information from the pathologist in the Zahau case, courtesy of the San Diego Tribune:

Several months after Rebecca Zahau’s body was found bound and hanging at a Coronado mansion, a well-known forensic pathologist went on the “Dr. Phil” show to announce that while he couldn’t say with certainty that the woman had been killed, his findings during a second autopsy raised serious questions about the death.

That same pathologist, Dr. Cyril Wecht, was much more definitive while testifying in Zahau’s wrongful death lawsuit on Monday. “In my opinion, Rebecca Zahau’s death was a homicide,” he said in San Diego Superior Court. “She was manually strangled and it was set up to look like a suicidal hanging.”

Initially, Wecht determined that Zahau’s cause of death was asphyxiation due to hanging, and her manner of death to be “undetermined.” When he went on the Dr. Phil show, he said he was strongly leaning toward the death being a homicide.

But when asked to review those findings for the wrongful death suit, and after doing additional research, the pathologist took a stronger stance — that Zahau had been killed. Wecht discussed several of his autopsy findings to support that conclusion.

The first was the presence of four hemorrhages on the right side of Zahau’s scalp. Wecht determined the injuries were caused by blunt force trauma suggesting Zahau may have been bludgeoned with a hard, possibly rounded object that could have led to her losing consciousness before her death.

Dr. Jonathan Lucas, the San Diego County deputy medical examiner who performed the initial autopsy, had previously called those wounds “relatively minor,” adding that they may have been caused by her head striking the building after she fell from the balcony.

Wecht also said that a fractured band of cartilage in Zahau’s neck [the hyoid bone] wouldn’t have been injured in a hanging death, but it could have been during strangulation. There were other injuries to the muscles and skin of Zahau’s neck that also suggested someone used their hands to strangle her, he said.

The pathologist also questioned how her neck remained unbroken, despite falling 9 feet from the balcony. “If she had simply gone over the balcony railing with the body hurtling down, the force that would have been generated would have resulted in a… fracture,” Wecht said.

There were several other injuries, including a bruise between Zahau’s ribcage that was indicative of blunt force trauma and possibly of a struggle.

The answer to the question: can a body bruise after death is no. One obvious reason for that is lividity. If the blood drains out of tissues in the direction of gravity, there is no blood to rupture out of it when the person is dead, and especially not after they’ve been dead for some time.

In Susan’s case, a lot of her blood had collected in her stomach, lungs, the lower extremities and the dorsal [back] side of her body. If Susan bruised easily, then yes, the cord should have left a clear ligature impression – but only if she really committed suicide.

If the suicide was staged, and the cord was placed over the neck post mortem, then what we don’t see, in terms of the missing ligature contusion line around the throat, well it’s exactly what we expect not to see.

The Rohde defence seem to me to want it both ways. Susan bruised easily, which explains why she was covered in bruises and various [apparently defensive] injuries. Susan didn’t have a clear cord bruise on her neck because the cord was tight, but not very tight, although it might even have been loose…

Besides this, it ought to have been obvious to everyone that Susan was dead immediately when they saw her. When CPR was performed on her, blood immediately splattered out of her mouth, as it was forced out of her lungs. Rohde himself did a little CPR then sat back, saying nothing, as Mark Thompson testified:

As he got to the room, cleaning staff told him there was a “white man inside and a white woman who tried to hang herself”. He saw Susan’s body lying on the bathroom floor and Rohde sitting next to her.

“I was in a bit of shock and Jason looked up and said, ‘Mark help me, Mark help me’.”

Thompson said he immediately started compressing her chest and blew into her mouth. He forgot to block her nose. It became clear to [Thompson] that she was dead because her body was cold, she was “porcelain white” and her lips were blue.

He felt he could not let Rohde and everyone else down so he carried on performing CPR for 30 to 45 minutes. At one stage, he said Rohde got up and blew into her mouth once before sitting down again. Thompson got excited when blood came out of her nose because he thought her heart was pumping again. He recalled telling Susan’s husband, “Jase, Jase, I think we got her back”. He apparently did not respond. Thompson wiped the blood away a few times…

In some cases, the manner of death is clear, but the cause of death is unclear. A good example is the Casey Anthony case. The events of this ten year old “cold case” played out from mid-June onwards, in 2008.

Casey Anthony left the family’s home on June 16th, 2008, taking two-year-old Caylee with her. Casey didn’t return home for 31 days, and when she did, Caylee was gone. Caylee was found on December 11th so badly decomposed investigators had to take soil samples to find her remains. Her DNA was salvaged and positively identified from the centre of her bones.  For reasons I won’t go into here, the manner of death was fairly clear but not absolutely clear – homocide, possibly accidental death. Someone had gone to the trouble to hide a child away. and then lied about it for months.

The cause of little Caylee’s death remains unknown, or at least unclear. But that’s not the case with Susan Rohde, much as her widower wants us to think it is.