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The great variability of appearances potentially impedes the classification as to the manner of death (suicide, accident, homicide). The significance of some signs formerly considered to prove vital suspension could not always be confirmed in more recent studies. Therefore, traditional conception passed on from generation to generation must be critically questioned and, if necessary, replaced by evidence-based knowledge derived from systematic evaluations of relevant case material and laboratory tests, where appropriate. Bearing in mind the numerous possible misinterpretations, a dogmatic view must be avoided in favour of a cautious and holistic assessment. 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