Analysis of compression injuries over neck: One-year prospective study

Introduction

Death by compression of neck may arise from ligature or manual strangulation, hanging, blow upon neck, arm locks and variety of accidental lesions such as, entanglement with cords or falling on to neck. Although deaths due to compression of neck are classified under asphyxial deaths, yet it is not the sole element involved. This is one of the most complex and controversial areas of asphyxial death, as mechanism is uncertain and frequency of such deaths makes them common problem for both Forensic experts and Jurist.1 Unlike hanging, strangulation should be assumed to be homicidal until contrary is proved. The distinction between hanging and ligature strangulation is utmost important to ascertain the manner of death. Ligature applied to neck within two hours of death will usually produce ligature mark. Postmortem suspension of body may be used by criminals to mislead the investigating agency and to hide the crime. In some cases, hanging may be homicidal and in all such doubtful cases, examination of scene of crime becomes important as a circumstantial evidence.2 A great challenge rests in front of forensic experts in cases of asphyxial deaths to establish the cause and manner of death. The various features of hanging and strangulation deaths that are available from the case history, police investigation, gross findings and internal findings can lead a forensic expert to the conclusion of compression of neck as the cause of death. However, doubtful cases which test the mettle of forensic expert do always exist. In cases with faint or absent ligature mark on the neck and with minimal internal findings it may be difficult to comment about the cause and manner of death. Many times, in forensic practice, cases occur where there is allegation from maternal side of married woman particularly in cases of dowry deaths, where relatives claim that it is a case of post-mortem hanging.3 In such cases there is importance of clubbing the gross findings with histopathological findings. These findings may be helpful in arriving at conclusions in such unsolved and doubtful cases. In this study socio-demographically compared the gross changes in neck structure, gross observation in skin, strap muscle, sternocleidomastoid muscle, common carotid artery and esophagus. Correlation between various ligature materials and internal neck structure also studied.4

Materials and Methods

This observational study was conducted in Department of Forensic Medicine, Government medical college and hospital in year 2017. Total 2781 brought for postmortem examination and amongst them 105 (3.77%) cases were studied as per inclusion criteria of all brought dead cases of unnatural deaths due to compression of neck brought for medico legal autopsy to the mortuary of Government Medical College and hospital. Exclusion criteria were bodies brought with 1) decomposition 2) hospitalization 3) having trauma over neck, extreme overstretching, or whiplash-injuries in vehicular accident, neck surgery, pathological lesion. Standard Performa was designed to collect the information of cases regarding age, sex, occupation, marital status, residence status rural, urban, place of occurrence, circumstances of death, type of ligature material, manner of death. The examination of ligature material, whenever available was carried out in this study.

External and internal examination of neck structure was carried out to note injury over neck, extravasation of blood in soft tissue, muscle, common carotid artery, fracture of throat skeleton was examined in situ in en block. Carotid artery was observed with reference to intimal tear by using Methelyne blue insufflation (Special dye) by naked eye examination and fractured neck structure were dissected with care at autopsy. The study was carried out on medicolegal cases brought for postmortem examination by police with inquest and proper requisition; hence no consent was necessary to obtain from relatives or any other authority in this particular study. However, as per the prevailing mandatory standard procedures of the Institute, the prior permission cum no objection certificate to carry out the study was obtained from Institutional Ethical Committee.

Results and Observations

Occupation

Figure 1 shows common working group found dead due to compression of neck was farmers 29 (27.62%) followed by laborers 23.

Figure 1

showing occupation wise distribution of cases

Place

Figure 2 shows out of 105 cases of compression of neck, the maximum incidence of cases 66 occurred in their home.

Figure 2

Place of occurrence of cases

Type of ligature material

Figure 3 shows the most common ligature material used by victim or assailant for compression of neck was nylon rope in 51 (48.57%) cases followed by soft material like Shela.

Type of ligature material used in compression of neck cases.

Figure 3

Type of ligature material used in compression of neck cases

Discussion

Out of 105 cases of compression around neck we observed 66 males and remaining 39 females. Findings of this current study are similar to the findings of male predominance as observed in the studies Batra et al. (2003)5 (male to female ratio 1: 0.19), Sharma et al. (2005)6 (66.66% males), Ambade et al. (2008),6 Uzun et al. (2007)7 and Sharma et al. (2008)8 but, findings of Naik et al. (2005)9 reported higher number of females in hanging as well as strangulation cases; differ from this study findings.

In this study, almost 75% cases were observed to be from age group 11 to 40 years. Out of which maximum cases (30 cases) were from age group of 21 to 30 years, whereas only few cases were observed in extremes of age groups i.e. 3 cases in age group 00 to 10 and 2 cases in group 61 to 80 years. This was similar to the findings of studies from various parts of India reported by Ambade et al. (2008)10 and Sharma et al. (2008)8 and NCRB report 2015.11 The present finding does not match with Bowen A (1982).12 Who reported high incidence of hanging deaths over age of 50 years in males and in age group of 40-49 years in female.

In this study most of the victims 73 were from urban area and rural area 32. However, we haven’t come across any study regarding distribution of locality with regards to such cases.

In the present study, out of total 105 cases, 68 individuals were married and 34 individuals were unmarried. This study coincides with studies of Vijayakumari (2011)13 Bardale et al. (2011)14 and T Saisudheer et al (2012).15

As per as occupation of victims is concerned farmers were found to be most affected group contributing 29 (27.62%) out of total 105 cases. According to NCRB 2015, 13% of total suicide victims were from the group engaged in Farming/Agricultural activities.11

In the present study out of 105 cases of compression of neck, 62.85% of cases occurred at the house of residence of deceased. Similar findings were observed by Cooke et al. (1995),16 Uzen et al. (2007).7

In present study most commonly encountered ligature material in the form of nylon rope which was observed in 51 (48.57%) cases. These findings coincide with the study of Dixit et al. (2001)17 and Cooke et al. (1995).16 However, our findings differ from study by, Sharma et al. (2005)6 Shaw and Danielle M. (2005).18

Complete ligature mark was found to be more prevalent than incomplete ligature mark i.e. in 60 and 45 cases respectively. Out of 60 cases where incomplete ligature mark was found, in most of the cases (37) noose was found to be fixed whereas out of 37 cases of incompletely ligature mark fixed knot was observed only in 11 cases. Sharma et al (2005)6 reported lower incidence of completely encircling ligature mark (16.48%). Text books authors like Reddy1 states that the ligature mark completely encircling the neck is usually common with running type of noose because the noose moves towards the neck due to weight of body and thus completely constricting the neck; giving complete ligature mark. In presence study running knot was found to be most commonly associated with complete ligature mark around the neck.

As we have come across maximum number of hanging cases in our study, ligature mark was found to be above the level of thyroid cartilage 81 (77.14%) cases. As far as direction and depth of the ligature mark is concerned it was obliquely placed in 97 (92.38%) cases and was deeply situated in that of 79 (75.24%) cases. Similar findings were reported by Sharma et al. (2005)6 Elfawal et al. (1994)19 Dixit et al. (2001).17

Out of 93 cases of hanging, dribbling of saliva was present in 36(38.70%) cases. These observations in this regard are consistent with observations of textbook authors like KSN Reddy.1 In the present study, cyanosis was present in 75 cases. Congestion and edema of internal organs was present in 92 of the cases. Fluidity of blood was observed in 96 cases. Forensic textbooks like Nandy A20 K S N Reddy1 that post-mortem fluidity of blood is not characteristic of asphyxia or any other cause of death for that matter, but rather the result of a high rate of fibrinolysis and may be found in other many conditions. External or internal petechiae were found in 90% of cases, Petechial hemorrhages beneath the pleura and pericardium were regarded by Tardieu [1866] Luke and his colleagues (1985)3 observed that petechiae were common with incomplete hangings. In textbooks of Reddy1 quoted that petechiae were common with incomplete hangings. The hemorrhages were reported in muscles in 32 (30.47%) cases, which correlate with Nikolic et al (2003)21 33.70%, Sharma et al (2005)6 34.00% cases, However Samarasakera and Cooke (1996)22 reported higher number of cases with hemorrhages (52.00%). The hemorrhages were reported in this study, which correlate with Dixit et al (2001)17 included all 11 cases of strangulation had soft tissue hemorrhage (100%) correlating with findings of Verma et al (2006), Dixit et al (2001)17 Intimal tear of carotid artery was evident in 11 (11.82%) cases of hanging, which likely correlates with that of Nikolic et al. (2003)21 7.43%, but not correlates with Jani and Gupta (2003)23 reported high incidence of tear in carotid artery (47.8%).

In the present study, fracture of hyoid bone alone was found in 11 cases, of which 06 cases were in hanging, 05 cases were in strangulation and in no any case of throttling. Which correlate with that of Dixit et al. (2001)17 Morild I (1996).24 The present study findings do not correlate with Sheikh et al. (2001)25 Azmak (2006)26 Fracture of thyroid cartilage alone was found in 03 case cases of which both cases were of strangulation and one case of throttling which correlating with Feigin (1999)12 but does not correlate with Morild I (1996)24 Dixit et al. (2001)17 Elfawal et al (1994)19 Bowen BA (1982)27 Naik et al. (2005)9 did not find any fracture of hyoid bone or thyroid cartilage in their study. In our study, 87 cases of hanging and 04 cases of strangulation were no fracture found which coincides with study of T Saisudheer (2012).15

Conclusion

The most common manner of neck compression is suicidal. Hanging (88.57%) is the most common among death due to compression of neck studied. One case of throttling observed in present study. No case of accidental hanging was reported in present study. Eleven case of ligature strangulation found in present study including one case of accidental strangulation. Hanging is one of the preferred methods of suicide by males than females. Male cases outnumbered in female cases in hanging but in strangulation female cases outnumbered male cases. The highest number of cases was found in the age group 21-30 years. Economic Problems, unemployment, failure in love, failure in examination, alcohol addiction and emotional instability were the alleged reasons for committing suicide in this age group.

More number of cases was found in farmers. Poverty, failure of crops either due to floods or droughts coupled with chronic psychiatric problems related to chronic alcoholism contribute to higher incidence of suicides in farmers.

Any secluded place is preferred to commit suicide by hanging. In our study, the most commonly preferred place of hanging was home. In this study commonly used ligature material is nylon rope (48.57%). In each and every case of ligature compression death, which was studied it was found with at least one of the classical signs of asphyxia however decomposed cases were excluded in present study. Signs of asphyxia are not pathognomic of violent asphyxia, but they still should recall this possibility, especially so in doubtful cases with faint or no ligature mark over neck.

In this study, the ligature mark in most of the cases was directed obliquely (92.38%). Fracture of throat skeleton is common in completely suspended bodies than partially supported bodies and resulted from rapid and forceful constriction of the neck, the ligature supporting the entire body weight and the more force acting on the throat skeleton in this type of hanging. There was no significant difference in hyoid bone horn fracture in relation to position of knot. The most common internal neck finding in neck compression deaths is sternocleidomastoid hemorrhage. In 11 cases of strangulation hemorrhages were observed on gross. Carotid artery injury was present in 11.82% cases of hanging.

Source of Funding

None.

Conflict of Interest

None.