A Study Of Ligature Mark In Case Of Hanging Deaths.pdf

Research article

Int J Pharm Biomed Sci 2012, 3(3), 80-84 ISSN No: 0976-5263

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A study of ligature mark in cases of hanging deaths T. Saisudheer1*, T.V. Nagaraja2 1

Department of Forensic Medicine & Toxicology, Kurnool Medical Collage, Kurnool – 500002, Andhra Pradesh, India.

2

Department of Forensic Medicine & Toxicology, Chalmada Ananda Rao Institute of Medical Sciences, Karimnagar-505001, Andhra Pradesh, India.

*Correspondence: Dr. T. Saisudheer Tel: +91 9849027417 Email: [email protected]

Deaths by ligation constitutes a major chunk of asphyxia deaths and corporal evidence in 99% of cases, speaks about suicidal origin. When any case is submitted to autopsy pathologist, without any evidentiary escort and with a valley of questions and allegations regarding the manner of death, it is doctor’s responsibility to come out with a justifiable opinion regarding many questionnaires. Study aims at avoiding the misinterpretation by keen observation of autopsy findings, careful examination of scene of crime, getting reliable information from near and dear of deceased and detailed study of literatures regarding this subject matter by eminent medico legal experts. Detailed study of 200 cases of asphyxia deaths due to ligature pressure over neck was done in the Department of Forensic Medicine, Kurnool Medical College, Andhra Pradesh, India for a period of two years [2010 &2011. After detailed study of all two hundred cases of asphyxia deaths due to pressure over neck by ligature, statistics were discussed in detail to reach justifiable conclusions which is explained in detail. Suicides by hanging are now becoming a preferential mode particularly in urban population and over taking other modalities like poisoning, burning and drowning. Reasons may be the availability of ligature material, easy accessibility to the suspension point in domestic set up and deaths by hanging are considered as painless deaths when compared to other modes. Many victims are middle aged group and post marital deaths are more than before marriage. Partial hanging type predominates over complete hanging and majority is atypical hangings than typical one. In majority cases the ligature material is one of the wearing cloths followed by ropes and wires or chains. Anatomical damage to the internal neck structures is lesser in suicidal hangings when compared with homicidal hangings and other deaths due to pressure over neck. Key words: Asphyxia deaths, Deaths due to hanging, Forensic medicine, Ligature mark, Ligature materials, Suicide

Received: 04 Jul 2012 / Revised: 08 Jul 2012 / Accepted: 09 Jul 2012 / Online publication: 12 Jul 2012

1. INTRODUCTION Deaths by ligation of neck are in practice from the time immemorial and before advent of civilization. In uncivilized societies, the application of ligation for taking away the life of another person was one of the commonest practices which were successfully carried out into the civilized societies. Earliest it was a homicidal method as suicide was considered as a heinous act. More over the impression was ligation leads to wind pipe constriction for which manual violence is needed. But with progression of civilization, ligation has been adopted for self application also. When compared to other modalities of unnatural deaths, death by ligation has found world wide acceptance and is one of the preferred method to take away the life.

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Depending upon the methods of suicide, hanging is one of the commonest modes of death. Virtually all hangings are suicides until unless otherwise proved contrary. As per expert opinion, suicidal hangings are less common in females but now a day’s domestic problems, frustrations, harassments and so many other stress related reasons leading to increased fold of suicides in females when compared with past. But still suicides by hanging are in higher percentage in men than women. Children are victims in many occasions of homicidal hangings when compared with other age group. Many conditions like passion, disappointments, loss of property, misfortune, financial losses, poverty, disgust with life, physical and mental sufferings, religious mania, unhappy love, failures in many aspects, marital problems, jealous, unbearable fear and pain are some of the common known reasons for an individual who were tempted to put an end to www.pharmainterscience.com

T. Saisudheer and T.V. Nagaraja, Int J Pharm Biomed Sci 2012, 3(3), 80-84

his or her life by suicide by hanging which is one mode of self killing, after poisoning. Hanging is a form of asphyxia which is caused by suspension of the body by a ligature, which encircles the neck, the constricting force being weight of the body, where whole weight is not necessary. Weight of the head (5kg-6kg) is enough to act as constricting force. So death happens in partial hangings also, which are on toes, feet touching, sitting, kneeling and lying down postures. Many deaths of sexual asphyxias are of partial hangings. A suicide will use any article readily available for the purpose, from sacred thread to sari, dhoti, chunni, rope, towel to bed sheet, chains and wires, like many whichever available for them. Symptoms of hanging starts with loss of power and subjective sensations, followed by flashes of light, ringing and hissing of noises in the ears, mental confusion, loss of consciousness, which is so rapid, thus it is regarded as painless form of death. Stage of convulsions follow and face is distorted and livid, eyes prominent and there is violent struggling. Causes of death in hanging are asphyxia, venous congestion, cerebral anaemia, reflex vagal inhibition and fracture or dislocation of cervical vertebrae. Delayed deaths are rare, if occurs, are due to aspiration pneumonia, infections, oedema of lungs, hypoxic encephalopathy, brain infarction, brain abscess and cerebral softening. In persons who survived, secondary effects like hemiplegia, convulsions, amnesia, dementia, cervical cellulites, parotitis and retro pharyngeal abscess are seen. Usual fatal period in deaths due to hanging is between 3 & 5 minutes in majority cases. Ligature mark depends upon composition of ligature, width and multiplicity of ligature, weight of the body suspended, degree of suspension, tightening of the encircling ligature, duration of suspension, position and type of knot, slipping of the ligature during suspension and height of suspension. Ligature produces a ligature mark as a furrow or groove in the tissue which is pale initially, turns to yellow or yellowish brown and is dry, hard on touch, parchment like due to drying of slightly abraded skin oozing. In partial hangings, constricting force is less and congestive changes are more marked because only veins are occluded. When there is pressure over cervical sympathetic ganglia, the eye on the same side may remain open and its pupil is dilated. Dribbling of saliva from angles of the mouth results from irritation of salivary glands due to compression by ligature over glands. Neck should be examined by reflecting skin flaps by modified Y shaped primary incision, After emptying three cavities i.e., cranial, thoracic and peritoneal cavities, neck region is examined at last to avoid artefacts and misinterpretations. Superficial small haemorrhages in the underlying layers of skin are produced directly by ligature. Vertebral arteries also shows tears and sub intimal ©2012 PharmaInterScience Publishers. All rights reserved.

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haemorrhages. Fractures of hyoid bone are rare below 40 years of age. Generally superior horns of thyroid are fractured. The abdominal organs are congested, but brain may be pale or congested according to mode of death. The term asphyxia means absence of pulsation (pulselessness) and it results from the interference with uptake of oxygen due to any cause which may be mechanical, environmental or toxic. The tissues of the body cannot function without oxygen. Hence many deaths are due to inference of oxygen supply to tissues which is a result of hypoxia or anoxia. The classical signs of asphyxia are 1. Congestion due to decreased venous return. 2. Tardieu spots or Peticheal haemorrhages due to escape of red blood cells from ruptured capillaries leading to formation of small bleeding points. 3. Cyanosis due to reduced haemoglobin in the blood

Fig.1 Pathophysiology of asphyxia

2. EXPERIMENTAL This study is conducted in the department of Forensic medicine and Toxicology, Kurnool medical college, Kurnool, Andhra Pradesh. The period of analytical study of ligature mark in cases of deaths due to hanging is from January 2010 to December 2011. The total number of autopsies on hanging done during 2010 and 2011 years are 205. A detailed study of 200 cases of deaths due to hanging are analysed with special reference to ligature mark. 1. History obtained from relatives 2. Visit to the scene of crime in suspicious cases 3. Description of scene of crime, injuries over body, last seen alive and first seen dead 4. Information from the inquest report 5. Autopsy done in hanging cases personally in mortuary of Kurnool medical college 6. Finding of autopsies in the post mortem reports www.pharmainterscience.com

T. Saisudheer and T.V. Nagaraja, Int J Pharm Biomed Sci 2012, 3(3), 80-84

7. Suicide notes, if any, present 8. Study of case sheets, where death occurs in hospitals, as a complication of hanging. 3. RESULTS The total numbers of autopsies done in the mortuary of Kurnool medical college, Kurnool between the periods of 2010 to 2011 were [1487+1385] 2872, out of which total number of autopsies done on cases of hanging were 205. A detailed study of 200 cases of death due to hanging are analysed with special reference to ligature mark. About identity of deceased, out of 200 cases of hanging, victim identified cases were 194 (97%) and victim unidentified cases were 06 (3%). The most common age group of victim was fallen between 20 to 40 years. Out of 200 cases of hanging 136 (68%) were female victims and 64 (32%) were male victims and regarding marital status incidence of hanging is more common in married persons i.e. out of 200 cases of hanging in 164 cases (82%), the victim were married and unmarried victims were 30 (15%) and in 6 cases (3%) the marital status was unknown. Regarding socioeconomic status of the victims, out of 200 cases of hanging, the incidence is more common in middle income group 156 (78%), next common is in lower income group 34 (17%) and least common is in higher income group 04 (2%) and not known in 6 (3%) cases. Regarding motive for committing the suicide in hanging, in males family disputes were most common motive 36 (18%), next common motive was ill health 18 (9%) and least common motive was financial problems 10 (5%). In females the most common motive was harassment particularly in married women 102 (51%), next common motive was family disputes 22 (11%) and least common motive was ill health 12 (6%). Regarding type of hanging, complete hanging cases were about 128 (64%) and partial hanging cases were about 72 (36%). About posture of the body in partial hanging, feet touching cases were 88 (44%), sitting posture cases were 4 (02%) and kneeling posture cases were 34 (17%) and in lying posture are 02 cases(01%). Regarding nature of ligature material, out of 200 cases hanging, in 172 cases (86%) the ligature material was soft, in 16 cases (08%) it was firm, in 4 cases (02%) it was hard and in 08 cases (4%) the nature of ligature material was not known. Regarding level of the mark over the neck, out of 200 cases, in 176 cases (88%) the mark was present above thyroid cartilage, in 20 cases (10%) it was present over the thyroid cartilage and in 4 cases (2%) it was present below the thyroid cartilage. Regarding grooving of the ligature over the skin of neck, out of 200 cases, in 108 cases (54%) grooving was present and in 92 cases (46%) it was not present. Regarding position of the knot, out of 200 cases of hanging, in 122 cases (61%) the knot was in left side of neck, in 56 cases (28%) it was in right side of neck, in 22 cases (11%) it was on the back of neck. Regarding encircling of the mark around the neck, out of 200 cases, there was incomplete encircling of the ©2012 PharmaInterScience Publishers. All rights reserved.

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mark in 164 cases (82%) and complete encircling of the mark was present in 36 cases (18%). Regarding presence of pattern of ligature over the skin, out of 200 cases, pattern was present in 20 cases (10%) and absent in 180 cases (90%). Regarding type of knot, out of 200 cases slip knot was present in 118 cases (59%), fixed knot was present in 64 cases (32%) and in 18 cases (09%) there was no particular type of knot. Regarding presence of injuries other than ligature mark, out of 200 cases, in 186 cases (96%) injuries were absent and in 14 cases (4%) injuries were present. Regarding fracture of hyoid bone and thyroid cartilage, out of 200 cases, there were no fractures in 192 cases (96%) and in 08 cases (4%) fractures were present. Soft tissue injury of neck region is observed in 56 cases (28%) on dissection. 4. DISCUSSION Out of all cases, percentage of hanging cases is 12% in cumulative total of PMEs in years 2010 and 2011. As an assistant professor I personally observed about 200 cases of deaths from hanging in the mortuary and studied in detail in the above direction, to ascertain the positive and negative fall outs and pit falls, possibilities of misinterpretations, masquerades, artefacts etc., in the interest of administration of justice. In my study, establishment of the identity of deceased is near total 97% in deaths. Majority of the deceased have fallen in the age groups of 20-40 years where compromise and adjustment to the then circumstances leads to more stress. This is followed by the period of adolescence. Incidence of female sex is more in adolescent age group; this may be due to early physical and mental maturity with influence of emotional factors, in female sex. The incidence of hanging deaths is minimal in the extremes of age. In the early childhood (below 10 years) the deaths are either homicidal or accidental in nature as emotions have no important role to play. In contrast, in other extreme of age i.e. old age, the low incidence is due to comprise and acclimatization to the factors leading to suicide. In my study the incidence of hanging deaths are more common after marriage comparative to premarital life and clearly indicates the influence of marriage on human behaviour and institution of family. The incidence of hanging is more in female sex than male sex and in 82% cases female victims were married. This clearly shows the increased vulnerability of female sex after marriage. In my study hanging deaths whether suicidal or homicidal are rare in upper income group. This is accordance with the general trend of criminal profile which originates from the roots of environmental and psychological factors. This why, the maximum incidence of the hanging deaths are seen in middle income group, who never compromise or accept the reality. In contrast, the lower income group shows the same trend, but on a lesser scale, which indicates the incidence of hanging deaths, more of psychological in origin. www.pharmainterscience.com

T. Saisudheer and T.V. Nagaraja, Int J Pharm Biomed Sci 2012, 3(3), 80-84

In this study, in 85% of cases of death, precipitatory factors are attributed, which revolves around 3 ‘M’ – Money, Mental illness and Mal treatment. In males family disputes are leading cause, where as in females, harassment is the leading cause, particularly in married women. Male sex is more vulnerable to matters concerned with money, where as it is least important for females sex. With regard to other factors like personal affairs ill health and mental illness the trend is same for the both sexes. In my study, in hanging deaths, preferred mode is complete hanging, compared to partial hanging. In case of partial hanging in majority of cases, feet are seen touching the ground followed by sitting position. Low point of suspension is not a must for partial hanging because in present study, in majority of cases where feet are touching the ground, the point of suspension is high. Reasons for it are faulty assessment by the deceased before the application of noose around the neck, stretching of the of the ligature material after suspension and stretching of the neck after death. With regard to nature of ligature material, the preferred choice is a soft material like cloth made followed by firm materials like rope. Hard material likes iron wires, cable wires, etc, are used very rarely and the victims are almost always of male sex only. But considered sex wise in case of males the choice for soft and firm materials for ligation is almost same, in contrast, in females the choice of material is a softy only, with an occasional firm material like rope. The preferred soft material for married group is the saree. In contrast in unmarried group, dhoti, door curtain, bed sheets or chunni are the preferred softies for use. In the present study, typical hangings are rare and 22 cases, which are brought with intact noose around the neck, the knot is on left side in 122 cases, the knot is on right side in 56 cases and in 22 cases the knot is seen on the back of neck. Knot below the chin is very rare. The commonest type of knot applied is slip knot or loop, followed by reef or granny knot. In this study, whenever a broad ligature material like a cloth or thick rope is used for ligation, the noose is made with a single round around the neck. In contrast, when thin materials like cables, metallic wires are used, they are applied around the neck with more than one round. With regard to course of ligature, in 82% cases it is partial in nature with interruption either over nape of the neck or on the side of the knot. In 18% of cases, it is complete in nature around the neck with knot of slip variety only. In this study, usual position of the ligature mark is above the thyroid cartilage (88%), whether it is complete or partial hanging, followed by mark over thyroid (10%). Only in 2% cases, it is seen below the thyroid cartilage. This contradicts the misconception that in partial hangings the ligature mark is seen at a lower level, compared to complete hanging. This is due to the application of slip knot in majority of cases where final tightening of ligature occurs after the noose reaches its final destination, i.e. upper part of the neck. ©2012 PharmaInterScience Publishers. All rights reserved.

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About pattern of ligature, which is observed in 10% of cases of hanging deaths, even though a patterned ligature material was used it is not a hard and fast rule that patterned abrasion should be produced by a patterned ligature material. Hence the presence of pattern indicates that a firm or hard material is used for ligation, but absence of pattern cannot exclude a firm material. Hence presence of pattern has positive value but its absence has no negative value, because the imprint of pattern over skin depends on a number of factors like texture of material, design of pattern, area of contact, time of suspension, type of hanging etc. grooving was present over ligature mark in 54% of hanging cases. In our study, clinching and protrusion of tongue is seen 50% of cases of hanging deaths whether it is complete hanging or partial hanging. Apart from ligature mark over neck, other body injuries are seen in 7% of cases of hanging and they are sustained prior, during and later to actual act of hanging and their magnitude is not enough to indicate the struggle, resistance or incapacitation, thereby raising the finger towards the possibility of a homicide. In this study damage to the internal tissues of neck is minimal in hanging cases. Soft tissue damage was observed with ante mortem fractures of hyoid bone and thyroid cartilage, in 4% cases. In 74% of cases of hanging, the internal neck structures were free from the evidence of trauma. The presence of underlying tissue damage is not an indicator for the manner of death in case of hanging. In the present study, 97% of hanging deaths are suicidal in origin; the remaining 3% are either homicidal or accidental in nature. In all the four cases of homicidal hanging, the victims are children who were below 10 years and the perpetrator are the parents, who subsequently committed suicide by same mechanism. In the two cases of accidental hanging the victims are children while playing and an adult under the influence of alcohol. 5. CONCLUSIONS In ligation deaths, suicide by hanging is fast developing as a preferential mode, particularly in urban areas, over taking other modalities like poisoning, burning and drowning etc. as it is considered as a pain less death and can be accomplished with minimal effect and ligature material is readily available. Ligation deaths from hanging are most common in middle age group, the period of an emotional outlet and outburst, and almost are suicidal in nature. In contrast, hanging deaths in child hood are mostly accidental or homicidal in nature and in old age is suicidal. In ligation deaths by hanging, male preponderance is seen but this does not confirm the increased suicidal tendency in male sex because the preferred mode for female sex is conflagration. The abnormally high post marital incidence of hanging deaths shows the tell – tale signs and influence of marriage on human behaviour, but this is the only factor which cannot www.pharmainterscience.com

T. Saisudheer and T.V. Nagaraja, Int J Pharm Biomed Sci 2012, 3(3), 80-84

be overcome and which has to be bore as long as the institution of marriage at stake. The incidence of suicidal hanging deaths is more common in middle income group as they are the fulcrum of the society with wavering or oscillating mentality. The leading predisposing factor for mortality is harassments in case of females, family and financial problems in case of males, leading to physical or mental stress in both sexes. Irrespective of sex, partial hanging is more common than complete hanging where in majority cases are feet are touching the ground. Soft materials are the preferred choice for ligation, particularly sari in married group. Bed sheets, dhotis and chunnis in unmarried group. Hence the marital status of the deceased and the nature of the ligature material can also be used as indicator in arriving to the manner of death. Atypical hangings are more particularly with knot on left side. There by typical hangings with knot over the occipital region or under the chin usually allow suspicion as it is a deviation from normalcy. The course of ligature mark over the neck is influenced by the type of knot applied which itself has no medico legal bearing. An interrupted ligature mark over and above thyroid cartilage is diagnostic of hanging. It is not customary to get an imprint of ligature mark with a patterned ligature material. The presence of pattern over ligature mark has a positive value but its absence has more negative value. The grooving of the skin produced by ligature material depends more on its texture, pattern, weight of the body and duration of suspension rather than the other influencing factors. Symptoms like clinched teeth or protrusion of tongue can be considered as indicator rather than specific for hanging.

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The extent of the damage to the internal structures of the neck are nil or minimal in case of hangings when compared with other modes of asphyxia deaths. REFERENCES [1] Adelson L. The Pathology of homicide. Charles C Thomas Publisher, Springfield 1974, pp.547-553. [2] Apurba Nandy. Priciples of Forensic medicine Including Toxicology. New Central Book Agency (P) Ltd, London pp.315-322. [3] Gardner E. Mechanism of certain forms of sudden death in medico-legal practice. Medico-Legal and Criminological Review 1942, 10, 120. [4] Rutherford Birchard Hayes Gradwohl, Francis E. Camps, Ann E. Robinson, Bernard G. B. Lucas. Gradwhol’s Legal Medicine, 3rd Edn, Year Book Medical Pub, 1978. [5] Sydney Alfred Smith, Harvey Littlejohn. Forensic Medicine, a Textbook for Students and Practitioners, J. and A. Churchill Publisher, 1943. [6] Wiggins CE, Luke JL. The pathology, diagnosis and medical-legal aspects of death by drowning. Journal of the Oklahoma State Medical Association 1970. [7] Keith Simpson. Forensic medicine, 5th Edn., Edward Arnold, Ltd., London, and Williams and Wilkins Co., Baltimore 1964. [8] Knight B. Knight's forensic pathology, 3rd Edn., Saukko P, Knight B (Eds.), Arnold Publishers, London 2004. [9] Last RJ. Human anatomy, pp.134-139. [10] Lyons. Medical jurisprudence and toxicology, Delhi Law House, 2008 [11] Modi JP. Modi’s text book of medical jurisprudence, Mathiharan K, Patnaik AK (Eds.), 23rd Edn. Eastern Book Company, Lucknow 2005. [12] Moritz AR, Crawford Morris R. Hand book of Legal medicine, Saint Louis, Mosby 1975. [13] Parikh CK. Law in relation to medical men. in: Parikh's textbook of medical jurisprudence and toxicology, 5th Edn. CBS Publishers and Distributors, 1995. [14] Pillay VV. Medical law and ethics. in: Textbook of forensic medicine and toxicology, 15th Edn, Paras Medical Publisher, Hyderabad 2004. [15] Polson CJ, Gee DJ, Knight B. The essentials of forensic medicine, Pergamon Press, NewYork 1985. [16] Simpson K. Death from vagal inhibition, Lancet 1949, 1, 558. [17] Sydney Smith, Harvey Littlejohn. Forensic medicine: A textbook for students and practitioners, 6th Edn, J. & A. Churchill Ltd Publisher, London 1983. [18] Taylor AS. Taylor’s Principles and Practice of Medical jurisprudence, Mant AK, 13 Sub Edn. Churchill Livingstone, Edinburgh 1984. [19] Tedeschi CG, Eckert WG, Tedeschi LG, eds. Forensic medicine: a study in trauma and environmental hazards, Philadelphia, WB Saunders, l977, pp.199-210.

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