Silent while living, speaks when dead- A case report of manual strangulation

Introduction

Throttling is a mean of producing asphyxia by application of pressure on the neck with the palms & fingers of hands. Most commonly it is homicidal in nature. In majority of the cases death results almost immediately but, it may be delayed in some instances. Death may be delayed due to variety of causes as mentioned by various authors.1, 2 In cases where victim survives for some time after the incident, he/she may not be conscious or able to speak for giving history, but the injuries produced by application of pressure by palms and fingers may speak by themselves about the incident, if examined carefully. Here is a case where, a 52 years old female was brought by the relatives in anxious state with difficulty in breathing & swallowing along with inability to speak and bilateral upper & lower limb weakness. The only sign the clinicians could find was swelling in the neck and subcutaneous emphysema in neck and upper chest, but no injury was mentioned in clinical records. Medicolegal autopsy conducted on 5^th day of hospitalization revealed important evidence of throttling in form of typical finger nail abrasions on both the sides of neck & deep muscle bruising, along with collapsed lungs on histopathology, which were suggestive of death as a result of complications of pressure over neck due to throttling. The injuries could have healed & no evidence even at autopsy could have been found regarding the offence when victim had survived for some more time and if unfortunately after that death had resulted. Meticulous autopsy played vital role in revealing the pathognomonic evidence, which was missed while patient was alive in the hospital. This case report stresses the need of multi-disciplinary approach at the time of treatment of the patient with suspicious history to have some different angle of view with regards to medico legal concerns.

Case Presentation

A 52 years old female was brought to the casualty of GCS hospital, Ahmedabad (previous workplace of authors) by her relatives in anxious state with complaints of difficulty in breathing & swallowing along with inability to speak and all four limbs weakness. Past history of cholecystectomy before 1 month was revealed. No any other history of any trauma was given by the chaperones. Patient was immediately attended by casualty medical officer and oxygen was started as oxygen saturation was 76%. After thorough clinical examination, clinicians could only find swelling in the neck region with subcutaneous emphysema in neck and upper chest & quadriparesis. No mark of any external injury was mentioned in the case papers. As the clinicians found the history to be suspicious, they asked the victim about the incident again and even with quadriparesis, almost after 16 hours of admission, she revealed that her son tried to throttle her by nodding her head in response to the leading questions asked by the doctors, as she could not speak. The diagnosis put was “? Strangulation” and medico legal case was issued.

Multi Slice Computed Tomography (MSCT) scan of cervical spine didn’t show any definite erosion, sclerosis, fracture or collapse. MSCT scan of brain was normal. High Resolution Computed Tomography (HRCT) scan of thorax found bilateral pneumothorax (more on right side) - ? tension type, pneumomediastinum and bilateral subcutaneous emphysema. Inter-costal drainage tube was inserted on right side. Patient used to maintain oxygen saturation with supplemental oxygen during the course of treatment but, suddenly in the morning of 5^th day of hospitalization, she started developing difficulty in respiration and bradycardia for which cardio-pulmonary resuscitation was started but it failed and patient died. The speech could not be revived till end. Medico legal autopsy was advised. Police in inquest mentioned that death occurred due to breathlessness as a result of some disease as they dint find any evidence of throttling in clinical records.

Autopsy findings

Autopsy was conducted on 5^th day of hospitalization. External examination of neck showed abrasions with brownish scab (confirming the 5 days old abrasion)3 over following areas of the body.

Over left side of neck (Figure 1), (1) Linear, 2.5 x 0.1 cm sized, but in the lower half cm of its length, it was 0.4 cm wide, the upper end of which lied 6 cm below & 5 cm lateral to mid of chin, going obliquely downwards and laterally, (2) Crescent shaped with its convexity upwards & medially, 0.4 cm long, situated 3 cm below and 0.5 cm left to mid of chin, (3) Linear, 0.1 cm long, located 5.5 cm below & 4.8 cm lateral to mid of chin.

Figure 1

Injuries over left side of neck

Over right side of neck (Figure 2), (4) Linear, 0.5 cm long, situated 2 cm below & 4 cm lateral to mid of chin, oblique with upper end medially, going downwards and laterally, (5) 0.3x0.2 cm sized, situated 5.5 cm below & 5.5 cm lateral to mid of chin, (6) 0.1x0.1 cm sized, located 5.8 cm below & 8 cm lateral to mid of chin,. A surgically stitched wound of inter-costal drainage was found on right lateral side of chest (therapeutic).

Figure 2

Injuries over right side of neck

Internal examination showed hematoma of 1 cm diameter in deep muscle of neck (Thyrohyoid) on left side (Figure 3), but no any fracture of hyoid bone, thyroid or any other cartilage or cervical vertebra. Both lungs were oedematous.

Figure 3

Internal examination of neck structures

Histopathology showed oedema, congestion, emphysematous changes with evidence of collapse in both the lungs. Rest of the vital organs showed congestion while atheromatous changes were noted in aorta and coronaries.

Respiratory failure as a complication of pressure over neck due to throttling was concluded to be the cause of death.

Discussion

Delayed death in case of throttling is rare but not impossible. Evidence of injuries suffered by the victim as a result of throttling apart from the history forms a solid substance for framing the charge on the suspect. Absence of any external or internal injury although rare in throttling, can be there when victim is unconscious and amount of pressure to the neck is minimal but, generally some injury is always present.4 Two unique cases are reported by Sharma A et al., where the history was suggestive of some illness but actually they were revealed to be the cases of throttling associated with poisoning. Here, the external injuries resulting due to throttling in form of multiple abrasions, contusions were not noticed by the clinicians in a hustle to treat the patient, but were significantly noted during autopsy.5 In present case as well, even after the history of throttling was given by the victim by gestures after 16 hours of admission, clinicians failed to notice any external injury. We found typical signs of throttling at autopsy even on the 5^th day of hospitalization, which could have been easily examined in fresh state and some more information regarding medico legal proceedings could have been derived if Forensic Medicine experts were called at the time of admission. Similarly, Badkur DS et al. have reported that they discovered typical fingernail abrasions on 7^th day of hospitalization of a patient of attempted throttling and the same were confirmed on the 19^th day when autopsy was performed.1

Probable reasons for failing to note the injuries by Clinicians during treatment:

Conclusion

Multidisciplinary approach in the patients with suspicious history can be fruitful in medico legal cases. The system of referral of medico legal cases should be developed in tertiary care level hospitals where all the medico legal cases should be scrutinized with medico legal point of view by Forensic medicine experts while treatment of such patients is going on by the department concerned. This can help in collecting the valuable evidence related to the crime that can be lost if more time has elapsed after the incident. This evidence ultimately can be proved useful in future court proceedings.

Sources of Funding

None.

Conflict of Interest

None declared.