J Forensic Sci, 2015 doi: 10.1111/1556-4029.12772 Available online at: onlinelibrary.wiley.com

PAPER PATHOLOGY/BIOLOGY

Vipul Namdeorao Ambade,1 M.D., L.L.B.; Dayanand Kolpe,2 M.D.; Nilesh Tumram,3 M.D.; Satin Meshram,1 M.D.; Mohan Pawar,2 M.D.; and Hemant Kukde,2 M.D.

Characteristic Features of Hanging: A Study in Rural District of Central India

ABSTRACT: The ligature mark is the most relevant feature of hanging. This study was undertaken with a view to determine the characteristic

features of hanging and its association with ligature material or mode of suspension. Of a total medicolegal deaths reported at an Apex Medical Centre, hanging was noted in 4.1% cases, all suicidal with mortality rate of 1.5 per 100,000 population per year. The hanging was complete in 67.7% with nylon rope as the commonest type of ligature material used for ligation. The hanging mark was usually single, situated above thyroid cartilage, incomplete, prominent, and directed toward nape of neck. The mark of dribbling of saliva was seen in 11.8% cases. Facial congestion, petechial hemorrhage, and cyanosis were significantly seen in partial hanging. Though occasionally reported, the argent line was noted in 78.7% hanging deaths with neck muscle hemorrhage in 23.6% cases. Fracture of neck structure was predominant in complete hanging.

KEYWORDS: forensic science, asphyxial deaths, hanging, characteristic features, hanging mark, ligature material In India, hanging is one of the common methods of committing suicide along with poisoning, burning, and drowning (1,2). Over the past 30 years, the incidence of suicide by hanging is on the increase, especially among young adults (3). Most of the time, a ligature mark may be the only evidence available in cases of asphyxial death due to hanging or strangulation. Hence, thorough examination of a ligature mark and ligature material is important to arrive at the most probable cause of death and to differentiate it from strangulation. Against this background, this study attempted to determine the characteristic features of hanging and its association with a ligature mark or mode of suspension. Each case was subjected to a complete autopsy, including toxicological and histological analysis when considered necessary as per the standard autopsy protocol.

medicolegal deaths. Medicolegal deaths are deaths occurring in unnatural (including suicidal, homicidal, and accidental), suspicious, or unknown circumstances. The accompanying police papers provide much of the information regarding age, sex, residence, marital status, date of death, reasons and manner of death, and all other relevant information about the case. A complete standard autopsy was performed for each case to record the relevant details. A total of 3094 medicolegal deaths were reported in this medical center over a period of 5 years. Hanging was noted in 127 (4.1%) cases with a range of 13–39 cases per year with hanging mortality rate of 1.5 per 100,000 population per year. The autopsy was followed by mandatory police inquiry and Magistrate’s verdict report, especially in regard to manner of death. Hence, the police records were again reviewed for confirmation of information.

Materials and Methods The study attempted to review all medicolegal deaths during the period of 5 years from January 2001 to December 2005. All the autopsies had been performed in the mortuary of Forensic Medicine, Government Medical College at Yeotmal, a rural district of Maharashtra, India. The district has a population of 24,58,271 spread in an area of 13,582 km2. The center is an Apex Medical Centre, where about 70% of the total medicolegal autopsies completed across the district are performed. The police department in India is legally bound to arrange autopsies in all 1

Department of Forensic Medicine, Government Medical College, Nagpur, 440 003 Maharashtra, India. 2 Department of Forensic Medicine, Vasantrao Naik Government Medical College, Yeotmal, 445 001 Maharashtra, India. 3 Department of Forensic Medicine, Government Medical College, Nagpur, 440 003 Maharashtra, India. Received 26 Jan. 2014; and in revised form 3 June 2014; accepted 26 July 2014. © 2015 American Academy of Forensic Sciences

Results Age and Gender in Hanging Deaths Age and sex distribution are given in Table 1. In hanging deaths, 84.3% of the victims were male and 15.7% were female with male-female ratio of 5.4:1. The age ranges from 10 to 80 years in male and 13 to 60 years in female. In total, 72.4% of the victims were between the ages of 21 and 50 years with peak incidence at 21–30 years (29.1%) followed by 31–40 years (26%). Only one victim was below the age of 10 years, but 5.5% were above the age of 60 years, and 8.7% of the victims were between the ages of 11 and 20 years, where the numbers of female victims outnumbered the male victims. Marital Status As per Table 2, almost 78% of the victims were married and 19.7% were unmarried. In 2.4% cases, the marital status of the 1

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JOURNAL OF FORENSIC SCIENCES TABLE 1––Age and sex distribution in hanging cases.

TABLE 4––Month wise distribution of hanging deaths.

Age Groups

M

%

F

%

T

%

01–10 years 11–20 years 21–30 years 31–40 years 41–50 years 51–60 years 61–70 years 71& > Total

1 4 34 27 20 14 2 5 107

0.9 3.7 31.8 25.2 18.7 13.1 1.9 4.7 84.3

0 7 3 6 2 2 0 0 20

0.0 35.0 15.0 30.0 10.0 10.0 0.0 0.0 15.7

1 11 37 33 22 16 2 5 127

0.8 8.7 29.1 26.0 17.3 12.6 1.6 3.9 100.0

TABLE 2––Distribution of marital status. Marital Status Married Unmarried Not known Total

M

%

F

%

T

%

87 17 3 107

81.3 15.9 2.8 100.0

12 8 0 20

60.0 40.0 0.0 100.0

99 25 3 127

78.0 19.7 2.4 100.0

victim was not known. In unmarried cases, 40% of the victims were female and only 15.9% were male.

Month and Season March April May June Summer Season July August September October Rainy Season November December January February Winter Season Grand total

M

%

F

%

T

%

8 6 15 11 40 11 6 8 9 34 7 8 9 9 33 107

20.0 15.0 37.5 27.5 37.4 32.4 17.6 23.5 26.5 31.8 21.2 24.2 27.3 27.3 30.8 84.3

0 2 2 1 5 3 0 2 3 8 1 1 2 3 7 20

0.0 40.0 40.0 20.0 25.0 37.5 0.0 25.0 37.5 40.0 14.3 14.3 28.6 42.9 35.0 15.7

8 8 17 12 45 14 6 10 12 42 8 9 11 12 40 127

17.8 17.8 37.8 26.7 35.4 33.3 14.3 23.8 28.6 33.1 20.0 22.5 27.5 30.0 31.5 100.0

TABLE 5––Distribution of condition of body and identity. Condition/Identity

M

%

F

%

T

%

11 96 101 6

10.3 89.7 94.4 5.6

0 20 20 0

0.0 100.0 100.0 0.0

11 116 121 6

8.7 91.3 95.3 4.7

Place of Hanging

Decomposed Nondecomposed Identified Unidentified

As per Table 3, the most number of victims preferred to hang themselves in their home (63.8%), followed by the farm (15.7%), barren land (9.4%), and the forest (6.3%). Only two victims were recovered elsewhere; one at a hostel and another at a hospital. None of the female victims of hanging were found in barren land and only one female victim was recovered from the forest.

None of the female victims have decomposed while 10.3% male victims were decomposed. In hanging deaths, 95.3% of the victims were identified and 4.7% were unidentified, all males recovered from the forest in advanced decomposition. Initially, eight victims of hanging were unidentified, but later on during the course of police investigation, two of them were identified.

Seasonal Variation

Types of Hanging (Depending Upon Mode of Suspension)

As shown in Table 4, no significant seasonal variation was noted in hanging deaths, but there were more incidences in the summer season, peaking in the month of May (17 cases) followed by July (14 cases). Male preponderance was seen in summer season and female in rainy season.

As shown in Table 6, complete hanging was seen in 67.7% cases and partial (incomplete) hanging in 32.3% cases.

Condition of Body and Identification The condition of the body in hanging cases is shown in Table 5. The cases were recorded as decomposed if there was significant discoloration, smell, marbling, purging of putrefactive fluids, insect activity (like maggots, larva, or eggs over body), peeling of skin, passing of rigor mortis, and bloating or a combination of two or more. In hanging deaths, only 8.7% of the cases were decomposed and 91.3% were nondecomposed (fresh). TABLE 3––Distribution of bodies as per place of hanging. Place of Hanging Home Hostel Farm Barren land Forest Hospital Prison/Police Station Total

M

%

F

%

T

%

67 1 16 12 7 2 2 107

62.6 0.9 15.0 11.2 6.5 1.9 1.9 84.3

14 1 4 0 1 0 0 20

70.0 5.0 20.0 0.0 5.0 0.0 0.0 15.7

81 2 20 12 8 2 2 127

63.8 1.6 15.7 9.4 6.3 1.6 1.6 100.0

Ligature Material Used in Hanging Types of ligature material used for hanging are shown in Table 7. Different types of ligature materials are used for hanging. The most common type of ligature material used for hanging was of hard material like rope (nylon rope, jute rope, and electric wire) which was seen in 70.9% of hanging deaths. This is followed by soft material like cloth (dupatta, sari, odhani, shirt, lungi, bed sheet) in 23.6% and firm material like cotton rope, pipe, and machine belt in 5.5% hanging deaths. In total, nylon rope was the most used type of ligature material used for hanging in 63% cases followed by odhani (10.2%), jute rope (6.3%), and dupatta and sari (5.5% each). Other types of ligature material used for hanging were cotton rope, electric wire/cable, plastic water pipe, shirt, lungi, bed sheet, and machine belt. Nylon rope as ligature material for hanging was preferred by TABLE 6––Distribution of suspension of hanging. Type of Suspension

M

%

F

%

T

%

Complete Hanging Partial Hanging Total

73 34 107

68.2 31.8 100.0

13 7 20

65.0 35.0 100.0

86 41 127

67.7 32.3 100.0

AMBADE ET AL. TABLE 7––Distribution of ligature material used for hanging. Types and Nature Ligature Material 1. Hard Material Nylon rope Jute rope Electric wire 2. Soft Material Dupatta Sari Odhani/Chunni Shirt/lungi/bed sheet 3. Firm Material Cotton rope Plastic water pipe Machine belt-cotton Grand total

M

%

F

%

T

%

72 8 2 82

67.3 7.5 1.9 76.6

8 0 0 8

40.0 0.0 0.0 40.0

80 8 2 90

63.0 6.3 1.6 70.9

7 5 4 3 19

6.5 4.7 3.7 2.8 17.8

0 2 9 0 11

0.0 10.0 45.0 0.0 55.0

7 7 13 3 30

5.5 5.5 10.2 2.4 23.6

3 2 1 6 107

2.8 1.9 0.9 5.6 100.0

1 0 0 1 20

5.0 0.0 0.0 5.0 100.0

4 2 1 7 127

3.1 1.6 0.8 5.5 100.0

Dupatta = a scarf worn around the head by Indian males Odhani/chunni = a long scarf worn around the neck by Indian females. Lungi = a rectangular piece of cloth encircling around the waist and lower limbs in one long piece worn by males.

both sexes, but odhani and sari were more preferred by female victims. Features of Ligature Mark Around the Neck As per Table 8, the ligature mark around the neck was usually single (72.4%), situated above the level of the thyroid cartilage (83.5%) and incomplete (78.7%). It was faint in 20.5% and prominent in 79.5% cases. But the mark was grooved in 38.6% cases of hanging deaths. The direction of the ligature mark was known from the position of knot. The knot was commonly placed over the back of the neck in 37% of which the knot was at the occipital protuberance in 10.2% cases (typical hanging). The knot was situated on the left side of neck (left mastoid) in 33.9% cases and right side of neck (right mastoid) in 24.4% cases. The knot on the front of the neck (chin) was found in only 2.8% cases. However, the ligature mark was usually double in hanging by jute rope and electric wire. The mark was mostly faint in hanging by odhani, dupatta, and sari. External Features of Hanging As shown in Table 9, the stain marks of dribbling of saliva either over the body or on clothes were noted in only 11.8% cases of hanging. The face was congested in 39.4% and petechial hemorrhage over face/conjunctiva in 26% hanging deaths. The nails or lips were cyanosed in 42.5% cases. The stocking and gloves type of lividity is considered as “typical” postmortem lividity in hanging cases. It was present in 22% cases, almost five times more common in males. Internal Features of Hanging The whitish glistening subcutaneous tissue underneath the ligature mark was seen in 78.7% cases of hanging. Any visible hemorrhage in at least one of the neck muscles underneath the ligature mark or in the thyroid gland or salivary gland is considered as positive findings in this study. In total, 23.6% cases of

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STUDY OF HANGING DEATHS IN CENTRAL INDIA

3

hanging shows visible hemorrhage in the neck muscles, 17.3% in thyroid gland, and 7.9% in salivary gland. The fracture of the hyoid bone was noted in 10.2% and fracture of the thyroid cartilage was seen in 3.1% cases, predominantly seen in males. In one case, there was fracture of cervical vertebra. The visceral organs were congested in 91.3% cases and subpleural petechial hemorrhage was present in 30.7% cases. The brain was edematous in 77.2% cases of hanging (Table 10). Correlation Between Features of Hanging with Complete or Partial Hanging As per Table 11, facial congestion, petechial hemorrhage, and cyanosis were seen in both types of hanging, but were significantly more common in partial hanging. These features were seen in 65.9%, 43.9%, and 68.3%, respectively, in partial suspension as compared to 26.7%, 17.4%, and 30.2%, respectively, in complete hanging. In contrast to the above features, the internal features such as argent line, neck muscle hemorrhage, and fracture of hyoid/thyroid were more common in complete hanging. Subpleural petechial hemorrhage were predominantly seen in partial hanging, but congestion of organs and brain edema were commonly found in both partial and complete hanging. Toxicological and Histological Analysis In this study, toxicological analysis was carried out in 24 (18.9%) cases of hanging including eight decomposed cases. The toxicological analysis does not reveal any intoxicant in the decomposed cases. Alcohol was detected in sixteen cases (12.6%), all males, and the concentration was more than 85 mg % in all cases. Histological examination was performed in only five cases (3.9%) of hanging deaths. The samples were preserved mostly to confirm the pathological findings and not for the cause of death. Discussion The methods of suicide vary in different countries and even in same countries in different regions. Hanging is the preferred method of committing suicide in many countries such as Galicia —Spain (4), Saudi Arabia (5), and Hungary (6), constituting 65.6% of all suicides. It is also the leading method of suicides in Belgium (7), Norway (8), England and Wales (9), North Yorkshire (10), Turkey (11), Lithuania (12), Germany (13), and Japan (14). In United States, despite the fact that the suicide patterns differ according to the states, hanging was reported to be the second leading method of suicide after firearms (15–17). It is the also the second most common means of suicide in Sri Lanka (18) and in Portugal (19). In India, hanging is reported as third/ fourth most common methods of suicide (2). Joseph et al. (20) found hanging as the second leading method of suicide after intoxication. But, Sahoo et al. (21), Pradip et al. (22), and Mohanty et al. (1) reported hanging as the most common means of suicide in India. In the present study, out of the total 3094 medicolegal autopsies reported in this medical center, hanging was noted in 4.1% of deaths, all suicidal, with hanging mortality rate of 1.5 per 100,000 population per year in this rural region of central India. Amandeep (23), Sharma et al. (24), and Patel et al. (25) reported 1.3%, 3.4%, and 4.6% hanging deaths, respectively, in total medicolegal autopsies. Al Madni et al. (26) noted hanging mortality rate of 0.85 per 100,000 population per year in Saudi Arabia.

0 8 4

7 1

3 5

2 2 2 1 0 0 1

7.5 92.5 53.8

82.5 17.5

23.8 76.3

8.8 30.0 28.8 27.5 1.3 1.3 2.5

OP, Occipital protuberance. Shirt/L/BS = shirt, lungi, bed sheet.

0 6 2

73.8 25.0 1.3

25.0 25.0 25.0 12.5 0.0 0.0 12.5

37.5 62.5

87.5 12.5

0.0 100.0 50.0

0.0 75.0 25.0

%

No

No

%

Jute Rope (8 + 0 = 8)

Nylon Rope (72 + 8 = 80)

No of wrap/turns around neck Single 59 Double 20 Multiple 1 Impression of ligature mark Faint 6 Prominent 74 Grooved 43 Level of mark Above thyroid 66 At level of thyroid 14 Completeness of mark Complete 19 Incomplete 61 Position of knot/direction OP 7 Back of neck 24 Left mastoid 23 Right mastoid 22 Left mandibular 1 Right mandibular 1 Chin 2

Feature of Ligature Mark

1 0 3 0 0 0 0

1 3

4 0

1 3 0

3 1 0

No

25.0 0.0 75.0 0.0 0.0 0.0 0.0

25.0 75.0

100.0 0.0

25.0 75.0 0.0

75.0 25.0 0.0

%

Cotton Rope (3 + 1 = 4)

0 1 4 2 0 0 0

1 6

5 2

5 2 0

7 0 0

No

0.0 14.3 57.1 28.6 0.0 0.0 0.0

14.3 85.7

71.4 28.6

71.4 28.6 0.0

100.0 0.0 0.0

%

Dupatta (7 + 0 = 7)

1 1 2 3 0 0 0

2 5

6 1

3 4 0

4 3 0

No

14.3 14.3 28.6 42.9 0.0 0.0 0.0

28.6 71.4

85.7 14.3

42.9 57.1 0.0

57.1 42.9 0.0

%

Sari (5 + 2 = 7)

2 4 5 1 1 0 0

0 13

13 0

10 3 0

13 0 0

No

15.4 30.8 38.5 7.7 7.7 0.0 0.0

0.0 100.0

100.0 0.0

76.9 23.1 0.0

100.0 0.0 0.0

%

Odhani (4 + 9 = 13)

0 1 1 1 0 0 0

0 3

2 1

1 2 0

3 0 0

No

0.0 33.3 33.3 33.3 0.0 0.0 0.0

0.0 100.0

66.7 33.3

33.3 66.7 0.0

100.0 0.0 0.0

%

Shirt/L/BS (3 + 0 = 3)

TABLE 8––Distribution of features of hanging mark around neck in relation to ligature material.

0 1 0 1 0 0 0

1 1

2 0

0 2 2

0 2 0

No

0.0 50.0 0.0 50.0 0.0 0.0 0.0

50.0 50.0

100.0 0.0

0.0 100.0 100.0

0.0 100.0 0.0

%

Elect Wire (2 + 0 = 2)

0 0 3 0 0 0 0

0 3

1 2

0 3 0

3 0 0

No

0.0 0.0 100.0 0.0 0.0 0.0 0.0

0.0 100.0

33.3 66.7

0.0 100.0 0.0

100.0 0.0 0.0

%

Pipe/Belt (3 + 0 = 3)

13 34 43 31 2 1 3

27 100

106 21

26 101 49

92 32 3

No

10.2 26.8 33.9 24.4 1.6 0.8 2.4

21.3 78.7

83.5 16.5

20.5 79.5 38.6

72.4 25.2 2.4

%

Sum Total 127

4 JOURNAL OF FORENSIC SCIENCES

AMBADE ET AL. TABLE 9––Distribution of external features of hanging. External Features of Hanging

M

%

F

%

T

%

Salivary stain mark Congestion of face PH of face or conjunctiva Cyanosis of nailbed or lips Typical postmortem lividity

13 41 26 43 27

12.1 38.3 24.3 40.2 25.2

2 9 7 11 1

10.0 45.0 35.0 55.0 5.0

15 50 33 54 28

11.8 39.4 26.0 42.5 22.0

PH, Petechial hemorrhage.

Similar to the present study, it has been found that male predominance was seen to peak at the age of 21–30 years (8, 17, 22–25, 27–29). Similarly, other studies also reported males account for most of the deaths by hanging, confirming that violent death is more commonly associated with males (30–33). But Ahmad and Hossain (34) noted female preponderance in hanging. Moens et al. (8) reported it as the most frequent means of suicide used by females in Belgium. Saisudheer and Nagaraja (35) reported most of the victims in age group of 20–40 years, followed by the period of adolescence, more particularly in females. This may be due to early physical and mental maturity with influence of emotional factors in the females. In our study also, suicides by the females in the age group of 11–20 years almost doubled as compared to the males. The incidence of hanging was minimal in the extremes of ages consistent with that reported by Saisudheer and Nagaraja (35). However, victims above 60 years of age were almost five times more common than the victims below 10 years of age. But these findings are contrary to that of Bowen (36) and Scott (37) who reported a high incidence after the 50s and under 20s age group, respectively. In present study, the incidence of hanging deaths was more common in married people as compared to unmarried ones, with male predominance. This is in sharp contrast to that reported by Saisudheer and Nagaraja (35) in which 82% of the female victims were married. Vijayakumari (29) reported 69.2% of the victims were married. The home is the most common place for committing suicide by hanging. This is probably due to the secluded environment and easy accessibility of different ligature material available at home for ligation. In the present series, the home (63.8%) was the most common place for hanging followed by agricultural farm (15.7%), barren land (9.4%), and forest (6.3%). However, the female preferred the home and the farm more as compared to the male for committing suicide by hanging. This is clear from the incident wherein only one case, a female body was found either in the forest or in barren land. Vijayakumari (29) and Ahmad and Hossain (34) reported more than 95% of victims preferred the home for committing suicide by hanging.

.

STUDY OF HANGING DEATHS IN CENTRAL INDIA

5

In general, incidences of suicide happened more in the summer season, peaking in the month of April and May (38), particularly in this region. Similarly, in hanging deaths, most of the victims were found in summer season with peaks in the month of May. However in females, most number of cases were found during the rainy season. These results were closely similar to a South African study, which showed a highest total number of hanging incidents in summer (39) and another study in Lithuania having a distinct annual rhythm with peaks in summer season (40). Al Madni et al. (26) also reported most hangings in the summer, peaking in June. On the other hand, this pattern is not coinciding with the seasonal variation in the Northern Hemisphere countries (41). Identification is one of the main concerns of investigating agencies, particularly in decomposed or skeletonized/mutilated bodies. Fingerprints and dental comparisons represent the most scientifically reliable methods of identification (42). In India, police actually establish the identity of a dead body with the help of relatives and friends. The clothes of the deceased and their belongings help in the identity of the decomposed bodies along with tattoos, scar, and other peculiar features (43). In general, the decomposed bodies make up only a small percentage of medicolegal autopsies (43). Nowadays, DNA profiling may be useful for identification in such circumstances from the bones and teeth (44). However in the present series, most of the bodies were nondecomposed and identified. The bodies were decomposed in 8.7% cases and were unidentified in 4.7% cases, all recovered from the forest in the stage of advanced decomposition. Saisudheer and Nagaraja (35) also reported that the establishment of the identity of the deceased was about 97% of the hanging deaths. As found in the present study, complete hanging predominated over the partial hanging (45,46). Saisudheer and Nagaraja (35) and Penaranda et al. (47) also reported complete hanging in 64% and 62.4%, respectively, and feet touching the ground in most of the cases of partial hanging. Ahmad and Hossain (34) found 97.2% complete hanging, whereas Sharma et al. (48) found 46% complete and 54% partial hanging. With regard to the nature/type of ligature material, the preferred choice was of hard material (70.9%) followed by soft material (23.6%) and firm material (5.5%). In total, nylon rope was the commonest type of ligature material used for hanging followed by odhani and jute rope. However, the females preferred odhani and nylon rope for ligation over the neck. Saisudheer and Nagaraja (35) and Patel et al. (25) reported soft material like cloth followed by firm material like rope as the preferred choice of ligature material for hanging. Sharma et al. (24) noted chunni as the most common ligature material used followed by

TABLE 10––Distribution of internal features of hanging. Internal Features of Hanging

M

%

F

%

T

%

White glistening S.C.T (argent line)* Neck muscle hemorrhage Thyroid gland hemorrhage Salivary gland hemorrhage Fracture of hyoid Fracture of thyroid cartilage Fracture of vertebra Congestion of organs Subpleural PH Brain edema

84 26 19 9 12 4 1 96 34 87

78.5 24.3 17.8 8.4 11.2 3.7 0.9 89.7 31.8 81.3

16 4 3 1 1 0 0 20 5 11

80.0 20.0 15.0 5.0 5.0 0.0 0.0 100.0 25.0 55.0

100 30 22 10 13 4 1 116 39 98

78.7 23.6 17.3 7.9 10.2 3.1 0.8 91.3 30.7 77.2

PH, Petechial hemorrhage. *S.C.T = Subcutaneous tissue underneath the ligature mark.

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JOURNAL OF FORENSIC SCIENCES

TABLE 11––Correlation between features of hanging with partial and complete hanging. Partial Hanging (n = 41)

Complete Hanging (n = 86)

Features of Hanging

No.

%

No.

%

Salivary stain mark Congestion of face PH of face or conjunctiva Cyanosis of nailbed or lips White glistening S.C.T (argent line)* Neck muscle hemorrhage Fracture of hyoid/thyroid Fracture of vertebra Congestion of organs Subpleural PH Brain edema

5 27 18 28 24 7 2 0 41 17 34

12.2 65.9 43.9 68.3 58.5 17.1 4.9 0.0 100.0 41.5 82.9

10 23 15 26 76 23 16 1 75 22 64

11.6 26.7 17.4 30.2 88.4 26.7 18.6 1.2 87.2 25.6 74.4

PH, Petechial hemorrhage. *S.C.T = Subcutaneous tissue underneath the ligature mark.

nylon rope and jute rope. But, Patel et al. (25) and Ahmad and Hossain (34) reported dupatta as the commonest ligature material used for hanging. The hanging mark is typically single and lying above the thyroid cartilage, which has been reported in many literature (42,49) and this fact was further corroborated by our own study. Penaranda et al. (47), Saisudheer and Nagaraja (35), Patel et al. (25), and Sharma et al. (24) also reported the same findings. However, when thin material like jute rope or electric wire was used, they were wrapped around neck more than once. The hanging mark was incomplete in most of the cases as reported in other literature (24,35,47) with interruption either over nape or side of neck at the position of knot. In 23.3% cases, the mark was complete around the neck, more common with slip type of knot. The mark was faint in 20.5% hanging deaths. It is more frequent with soft broad ligature and where the ligature material was removed immediately after the hanging. The ligature mark around neck was grooved in 38.6% cases, more frequent in hard material like nylon rope or jute rope. Saisudheer and Nagaraja (35) noticed grooving in 54% cases of hanging. In the present study, knot was commonly placed over back of neck (37%), but typical hanging was seen in 10.2% cases. The knot was on the left side of neck in 33.9% and right side of neck in 24.4% cases. These findings are in consistence with that reported by Penaranda et al. (47). Saisudheer and Nagaraja (35) and Sharma et al. (24) found that the knot was commonly placed on left side of neck followed by right side and back of neck. But, Ahmad and Hossain (34) noted the knot more commonly on right side followed by left side of neck. The findings of facial congestion, petechiae, and cyanosis have been considered as a classical sign of an asphyxial mode of death, but its real significance has been challenged (49,50). In the present series, facial congestion and cyanosis were present in about 40% cases each and petechiae in 26% hanging deaths. Penaranda et al. (47) found congestion of face in 42.9% and petechial hemorrhage in 23.4% cases. Sharma et al. (48) noted facial congestion in 42% cases and Elfawal and Awad (45) noted petechial hemorrhage in 29.5% cases. However, Patel et al. (25) and Simonsen (51) reported facial congestion in 77.5% and 52.5%, respectively. Clement et al. (52) noted petechial hemorrhage in 46% cases. Some authors affirm that these findings are more frequent in partial hanging (42,49) as com-

pared to complete hanging. We have also found such association in the present series. Luke et al. (53), Elfawal and Awad (45), and Clement et al. (52) noted significantly higher incidence of petechial hemorrhage in partial suspension as compared to complete hanging. Similarly, Simonsen (51) and Elfawal and Awad (45) found predominance of facial congestion in partial suspension. However, Penaranda et al. (47) did not find any correlation between facial congestion and petechial hemorrhage with the type of suspension. Evidence of dribbling of saliva from the angles of mouth, considered as one of the most important antemortem sign of hanging (50,54,55), was noticed in only 11.8% cases. Such lower percentage is probably due to wiping of the stain or giving water to the victim by the relatives after immediate removal from the hanging position or due to a resuscitation attempt to revive the victim of ligation. Patel et al. (25) found salivary stains in 71.3% hanging deaths. In the present study, typical postmortem lividity was noted in 22% cases, more in males. Patel et al. (25) also observed typical lividity in 17.5% cases of hanging. This type of lividity suggests that the body was in the suspended position for more than 4–6 h (25). With regard to internal features of hanging, a common finding in our series was the whitish glistening subcutaneous tissue underneath the ligature mark seen in 78.7% hanging deaths, more common in complete hanging. It is due to the condensation of the subcutaneous fat under the furrow, known as an argent line, and was only occasionally reported in the literature (56,57). Patel et al. (25) observed white glistening subcutaneous tissue in all cases of hanging deaths. However, Penaranda et al. (47) found such “argent” line in 76.6% hanging deaths, but no association was noted with mode of suspension. Hemorrhage in at least one of the neck muscles was present in 23.6% hanging deaths, more commonly found in complete hanging as compared to partial hanging. Saisudheer and Nagaraja (35), Dixit et al. (58), and Luke et al. (53) noted neck muscle hemorrhage in 28%, 26%, and 24.5% hanging deaths, respectively. However, Penaranda et al. (47) and Nikolic et al. (28) found neck muscle hemorrhages in 55.8% and 60.1% cases, but no correlation was found with partial or complete hanging. Hemorrhages were more common in males, probably due to greater body weight, greater muscular mass, and consequently greater traction to the neck (47), but no such correlation were found in the present study. In the present study, hemorrhage in the thyroid gland and salivary gland was present in 17.3% and 7.9%, respectively. Dixit et al. (58) also reported hemorrhage in 20% and 9%, respectively. But Luke et al. (53) reported thyroid gland hemorrhage in 37.7% hanging deaths. In the present series, hyoid bone was fractured in 10.2% and thyroid cartilage in 3.1% hanging deaths, predominantly seen in males. Some studies have shown that these fractures of neck structures were more frequent in women (59) and others in contrast state the same for men (51), while still others inform that no gender association was found (60). Dixit et al. (58) noted these fractures in 14% and 15% cases, respectively. Morild (7) found such fractures in 16% and 12.5% cases, respectively. Luke et al. (53) noted these fractures in 24.5% and 26.2% cases, respectively. Ahmad and Hossain (34) observed these fractures in 26.9% and 18.6% cases, respectively. However, Penaranda et al. (47) reported such fractures in 48.4% and 47.1% cases, respectively. But Feigin (61) observed fracture of thyroid and hyoid in 9% cases of hanging, and Saisudheer and Nagaraja (35) reported fracture of hyoid and thyroid cartilage in only 4% hanging deaths. Sheikh et al. (62) noted hyoid bone fracture in 5.1% cases of

AMBADE ET AL.

hanging. Patel et al. (25) observed fractured in none of the cases, probably due to the use of soft material like cloth in 80% of hanging deaths. Fractures of the neck structures were more common when a hard-fixed noose was used (47) and in complete hanging (58). In the present study too, fracture of neck structure was predominantly seen in complete hanging as compared to partial suspension. Sharma et al. (48) and Simonsen (51) also found these fractures predominantly in complete hanging. However, Peneranda et al. (47) noted that the incidence of these fractures was independent of the mode of suspension. In contrast to hyoid bone and thyroid cartilage fracture, it is very unusual for cervical spine to be fractured in suicidal hanging unless there is a long drop, which usually occur when the victim selects a branch of a high tree as the point of suspension for hanging (34). Otherwise, this fracture is commonly observed in judicial hanging cases (63). In the present series, fracture of cervical vertebra was seen in 0.8% cases and no association with any variables studied was found. It is probably due to the presence of fracture in only one case, an old male victim hanged with nylon rope from the branch of tree in the forest. Feigin (61) found cervical spine fracture in 0.9% cases of hanging. Whereas, Penaranda et al. (47) noted this fracture in 3% cases, all male. Congestion of organs, subpleural petechial hemorrhage, and edema of brain are the important findings in hanging deaths (54,55). In our series, organs were congested in 91.3% and brain was edematous in 77.2% cases of hanging. But subpleural petechial hemorrhage was noted in only 30.7% hanging deaths. All these internal features were more common in partial hanging as compared to complete hanging. Elfawal and Awad (45) noted petechial hemorrhage in the internal organs in 78.7% cases of hanging, more commonly seen in partial hanging. In the present study, toxicological analysis was carried out in 18.9% cases in contrast to 3.9% histological examination. Toxicological analysis was negative in all decomposed cases. Alcohol was detected in 12.6%, all males. Uzan et al. (11) also reported ethyl alcohol in 11.9% victims of hanging in Istanbul, Turkey. However in Saudi Arabia, alcohol was detected in the blood of only 6.8% of victims (26). This is because in Saudi Arabia, trading, manufacturing, and consumption of alcohol beverages are prohibited and there is firm execution of severe penalties against abusers and traders according to the law. However, drugs such as amphetamine and cannabinoids were found in almost 5.2% hanging deaths, which is in sharp contrast to the present study. Vijayakumari (29) does not found blood alcohol or other drug in any of the victim of hanging. References 1. Mohanty S, Sahu G, Mohanty MK. Suicide in India – a four year retrospective study. J Forensic Leg Med 2007;14(2):185–9. 2. Ambade VN, Keoliya AN, Wankhede AG. Availability of means of suicides. Int J Med Toxicol Leg Med 2012;14:83–9. 3. Gunnell D, Bennewith O, Hawton K, Simkin S, Kapur N. The epidemiology and prevention of suicide by hanging: a systematic review. Int J Epidemiol 2006;34(2):433–42. 4. Cerdeira S, Lopez E, Vazquez E, Hervada X. Distribucion geografica y tendencia de la mortalidad por suicidio en Galicia 1976–1996. Gac Sanit 1999;13S:20. 5. Elfawal M. Cultural influence on the incidence and choice of method of suicide in Saudi Arabia. Am J Forensic Med Pathol 1999;20:163–8. 6. Jegesy A, Harsanyi L, Angyal M. A detailed study on suicides in Baranya County (Hungary). Int J Legal Med 1995;108:150–3. 7. Morild I. Fractures of neck structures in suicidal Hanging. Med Sci Law 1996;36(1):80–4. 8. Moens GFG, Loysch MJM, Honggokoesoemo S, Vande Voorde H. Recent trends in means of suicide. Acta Psychiatr Scand 1989;79:207–15.

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