HANGING

HANGING

Definition –

Hanging is a process in which the body is suspended with a ligature around the neck which causes constriction of the air passage preventing exchange of air between the atmosphere and the alveoli of lungs, leading to asphyxia and death. The constricting force is either the weight of the whole body or the weight of the head alone.

Types of hanging (on the basis of the position of the knot used) –

1. Typical hanging – In a typical hanging, the knot of the ligature should be at the nape of the neck on the back. Typical hanging is not very common in occurrence.

2. Atypical hanging – In atypical hanging, the knot of the ligature may be at any site other than the nape of the neck. It may be near one angle of the mandible, near the mastoid process, or below the chin.

Hence in case of typical hanging, maximum pressure is exerted in the front of the neck, on the midline, i.e., over the wind pipe. The pressure over the jugular veins and the carotid arteries are comparatively less but equal on both sides.

HANGINGIn atypical hanging, the commonest site for the knot is near one side mastoid process or near the angle of mandible. Occasionally, it may be below the chin. When a knot is on one side, the pressure over the vessels on both side is not equal and it also takes more time for total occlusion of the wind pipe. When the knot is below the chin, there may not be much evidence of asphyxiation as the respiratory tract is not directly compressed.

Types of hanging according to the degree of suspension –

According to the degree of suspension i.e., whether the body is fully suspended or not, hanging may be complete or total and incomplete or partial.

Complete hanging – In this variety, the body is fully suspended and no part of the body touches the ground. The constricting force here is the weight of the whole body. Here the weight of the body is transmitted to the earth, through the point of suspension of the ligature material above, e.g. the trunk of a tree or like, which depends according to the place of suspension.

Incomplete or partial hanging – In this variety the lower part of the body is in touch with the ground. Sometimes only the toes, sometimes the whole foot or feet, sometimes the knees (hanging in kneeling position), sometimes the buttock (hanging in sitting position), may be in touch with the ground. In partial hanging, a part of the weight of the body is transmitted to the ground through the touching part of the body and a part through the point of suspension above. When the body is in inclined position, then the whole of the weight of the body except the weight of the head may be transmitted to the earth through the touching point and in these cases the weight of the head alone acts as the constricting force. It is generally taken that the precise cause of death in partial hanging is due to asphyxia alone, though there are many other causes of death in cases of hanging. Partial hanging is taken to be diagnostic of being suicidal in nature.

The ligature materials in cases of hanging – The ligature material may be anything which may be tied around the neck with some additional length for fixing it to the point of suspension. This may be a rope, electric wire, belt, neck-tie, saree, bedsheet, scarf, dupatta, cycle chain or any such thing.

The knot – The knot may be affixed one (double or more), or it may be a slipping knot or a running noose.

Signs-symptoms of hanging – The signs-symptoms are related with the effects of compression over the neck. Thus, when the pressure over the larynx is prominent, then the signs-symptoms of asphyxia predominates, with evidence of respiratory distress, cyanosis and in the last phase convulsion with mental confusion, ringing in the ear etc. The effects of pressure over the jugular vein may lead to helplessness, a feeling of excruciating pain over the side opposite the side of the knot and there will be appearance of petechial haemorrhagic spots, on the forehead, eyelids and conjunctiva. Pressure over the carotid artery causes immediate unconsciousness followed by failure of the respiratory centre due to cerebral anaemia, when death is rather painless.

Precise causes of death due to hanging – Though a form of violent asphyxia, not in all cases of hanging death occurs due to asphyxia. Any of the followings may be the actual cause of death –

1. Asphyxia along with apoplexy due to simultaneous pressure over larynx and jugular veins. The combined effect of asphyxia and apoplexy is the cause of death in most cases.
2. Asphyxia alone.
3. Apoplexy alone.
4. Cerebral anaemia or ischaemia due to pressure over carotid and vertebral arteries.
5. Vagal shock. This may occur due to inhibition of the heart due to irritation of the carotid sinus.
6. Fracture dislocation of the 2nd and 3rd cervical vertebrae, which causes injury to the medulla and the upper part of the spinal cord, as in case of judicial hanging.

Force of constriction necessary for causing these effects –

1. For closure of the jugular vein a pressure of 2 Kg. is sufficient.
2. For causing obliteration of the carotid arteries the constricting force should be equivalent of 3 – 5 Kg. For closure of the trachea, a force of about 15 Kg. is necessary, and that for the vertebral arteries it is about 18 Kg.

Fatal period  When death occurs due to fracture and dislocation of the cervical vertebrae and injury to the medulla, the process of fatality is said to be the speediest, due to failure of the respiratory centre. Death in case of closure of the carotid and the vertebral arteries occurs very quickly due to cerebral anaemia, but not as quick as in case of injury to the cervical vertebrae. When death is due to asphyxia resulting from the pressure over the larynx, the fatal period varies according to the level of the ligature. When the ligature is placed at the level of the cricoid cartilage, complete asphyxiation occurs earliest. When the level of the ligature is slightly above i.e., over the larynx, the fatal period is slightly more. Fatal period is maximum when the ligature is between the chin and the hyoid. In case the subject is released from suspension and there is some degree apoplexy, then death may be delayed even for a few days depending on the site of damage in brain, having residual signs like amnesia, mental confusion and neurogenic disturbance.

Treatment – immediate – artificial respiration and then in hospital – rest, stimulant and symptomatic.

POSTMORTEM APPEARANCE

A. External Findings –

1. The ligature mark –  In most cases of death due to hanging, the ligature mark around the neck is very much conspicuous. The ligature mark in a case of hanging is oblique, non-continuous, placed high up around the neck, is grooved, parchmentised and abraded at places. The upper margin of the ligature mark has a line of postmortem staining, all around above the ligature mark. This is due to settling of blood, from head and neck above the level of constriction, caused by the ligature material. The ligature mark is non-continuous because of a gap at the nape of neck due to hair intervening between the ligature material and the skin underneath. There may also be some gap near the site of the knot due to the pull on the knot from the point of suspension above. When the knot is in contact with the skin, it is usually inverted “V” shaped, due to extension of ligature material downward on both sides from the knot above. The point of contact of the skin with the knot if present may leave a deep parchmentised “A” shaped abraded impression.

Factors which influence the appearance of ligature mark –

(a) The ligature material – If the ligature material is tough and narrow, then the ligature mark is deep and prominent. If on the other hand the ligature material is soft and broad, then the ligature mark is less prominent and less deep.

(b) Period of suspension – If the period of suspension is more, then the ligature mark will be prominent, deep and parchmentised.

(c) Degree of suspension – Ligature mark becomes deep and prominent in case of total suspension of the body. In case of partial hanging, it may be less prominent or prominent on one side only.

(d) If something, say, the collar of the shirt intervenes between the ligature material and the skin of the neck then the ligature mark will not be prominent.

(e) The weight of the body of the deceased – The ligature mark will be more prominent and deep if the weight of the body is more.

(f) Tightness of the ligature – A tight ligature keeps a deeper impression.

(g) Slipping of the ligature material – If the ligature is originally fastened at a lower level of the neck, then, during suspension when the body slips downward, the ligature gets a higher position. This may prevent formation of a deeper ligature mark at the original site of the ligature. On the other hand in such cases, wider abraded area may be noticed due to the effect of such frictional displacement of the ligature material. Deep mark is produced where the ligature material settles after slipping.

(h) When the ligature is applied in multiple turns, then there will be multiple, parallel, grooved ligature marks.

(i) Design of a ligature material, e.g. of a rope or a cord may get imprinted on the ligature mark.

(j) The ligature material may be in situ around the neck or may be sent along with the dead body or may be absent altogether.

2. The dimensions of the neck – Due to prolonged suspension, the neck becomes slender and increases in length. This however will not be seen in suspension for a short period.

3. Bending of the neck – The neck gets flexed to the side, opposite the side of the knot. The state of bending will continue until the onset of decomposition.

4.  The face may be pale or flushed or congested.

5. Tardieu’s spots may be present on the forehead, over the eyelids, under the conjunctiva and sometimes near the temple.

6. Tongue may be partly protruded out in between the lips and during the stage of rigor mortis may also be bitten in between the jaws.

7. Dribbling of saliva – It is a very constant and important finding in a case of death due to hanging. Dribbling of saliva occurs from the angle of the mouth which is at a lower level i.e., from the angle opposite the side of the knot. When the knot is on the nape of the neck it occurs across the middle of the lower lip. When the knot is under the chin, then it occurs through either or both angles of the mouth. The saliva drops down in front of the chest when the body is bare or it stains the clothes in front, when the deceased is dressed. When dried or partly dried, it becomes quite fixed and cannot be easily removed or rubbed out. However, placing the dead body inside the cooling chamber and rough handling may remove the stain.

Dribbling of the saliva is considered a very important phenomenon in support of death due to antemortem hanging, as because, excessive salivation is an antemortem reaction which occurs due to irritation of the submandibular salivary glands during life, due to the pressure and friction caused by the ligature material.

8. Peculiar distribution of the postmortem staining – As the body remains suspended in the upright position after death, the postmortem staining will be present over the lower limbs, lower parts of the upper limbs and the upper margin of the ligature mark, which are actually the lower parts of different body, segments in this posture. Occasionally, in the lower limbs, there may be multiple haemorrhagic spots due to rupture of the capillaries, due to being over-distended by blood. This distribution of the postmortem staining is however not confirmatory of the death being due to hanging. It only speaks that the body was in a state of suspension in upright position for a considerable period after death. Thus, if a dead body is placed after death, in upright position in a state of suspension with a ligature around the neck, then similar distribution of postmortem staining will be there, provided that sufficient time has been allowed to pass, in that position of the body.

9. The hands are usually clenched. Sometimes the hands may show presence of fibres, like that of jute when a jute rope has been used.

10. Fingertips, nailbeds, and lips show sign of cyanosis.

11. In males there may be involuntary discharge of semen.

12. In both sexes there may be involuntary discharge of faecal matter and urine.

13. In addition, there may be some abrasions at places like lateral aspects of shoulder, due to friction with a wall or a post or pillar, which occurs during suspension, particularly during the last phase of life when there is convulsion.

14. In some cases, the right side eye remains open with more dilatation of the rt. pupil, whereas the left eye remains closed and left pupil less dilated. This is known as(“Le facie Sympathique”.)

B. Internal findings –

1. In some cases, the tongue is slightly protruded out and in others the tongue is pushed back.
2. Larynx and trachea are congested. There may be Tardieu’s spots under the mucus membrane of the trachea and larynx.
3. Lungs are congested. There will be presence of Tardieu’s spots on the undersurface of the pleura which are particularly abundant at the interfaces of the lobes. This is another finding which along with dribbling of saliva is diagnostic of death due to hanging.
4. All the organs are congested.
5. Brain is congested, oedematous with presence of haemorrhagic spots. Similar findings are present in the layers of meninges.
6. Maximum findings are available in the TISSUE OF THE NECK.

(a) The subcutaneous tissue underneath the ligature mark is dry, white,  firm and glistening. The platysma and the sternomastoid muscle may show haemorrhages and are even occasionally ruptured.

(b) The hyoid bone may be fractured in persons, more commonly above the age of 40 years. Though early authors have claimed that, fracture of hyoid bone occurs in hanging deaths in about 25% cases, in the experience of the present author, it does not occur in more than 5 – 10% cases. Contrary to the findings recorded by other authors, Poison and Gee found fracture of thyroid cartilage in about 50% of cases. But, so far the present author is concerned, fracture of thyroid in hanging cases seems to be a rarity.

In hanging, hyoid bone fracture may be due to any of the three reasons –

1. Antero-posterior compression
2. Side wise compression
3. Fracture due to traction, also known as avulsion fracture.

In antero-posterior compression, the fracture commonly occurs at the midpart with tear of the soft tissue at the inner surface, with haemorrhage in the surrounding tissue.

In sidewise compression, either or both cornu may be fractured due to compression from one or both sides.

In avulsion fracture, traction due to pressure on the thyro-hyoid or crico-hyoid ligament is primarily responsible.

(c) Many authors noticed transverse tear of the intima of the carotid arteries. But to my experience, ordinarily the intima of carotid artery is expected only in some cases, to show hyperaemia in young individuals and minor degree tear in elderly subjects.

(d) For findings in larynx, see no. 2 of the internal findings.

(e) In case of JUDICIAL HANGING or where there is a drop from a reasonable height, the ligature around the neck causes a forceful jerky impact on the neck at the end of the fall. In such cases there will be fracture dislocation of the C2 and C3 or C3 and C4 vertebrae. In case of fracture C2 and C3 the fractured piece of the odontoid process of the C2 vertebra causes damage to the medulla. In other cases there is corresponding injury to the meninges and the spinal cord.

(f) In a few cases, posterior wall of the oesophagus may show congestion due to compression against the cervical vertebrae.

MEDICOLEGAL ASPECTS OF HANGING

A. Suicide – Hanging in its face value goes in favour of being suicidal in nature. The age of the victims may be anywhere between extremes of ages, i.e. between 10 to 80 years. Both sexes are equally prone and incidents in both sexes are more or less same. In suicidal hanging, any of the things mentioned earlier may be used as a ligature material. The place of occurrence is secluded. The point of suspension remains approachable to the suicide. Partial hangings are almost always suicidal in nature. There may be a suicidal note left behind. There should be a motive for committing suicide. Often a suicide failing in other methods to end life, may lastly adapt this method successfully. In these cases evidence of some other adapted methods may be present on the body. The fibres of the ligature material e.g., jute fibre in case of use of a jute rope, may be present in the clenched hand.

B. Homicide – Homicidal hanging is rare. It is not ordinarily possible with an adult victim, if he is not intoxicated or not made unconscious by some other means, like head injury. Alternatively, the victim is either a child or a very debilitated person. Usually the rope is first fastened around the neck and then it is pulled over a high point of suspension. Hence, there will be presence of evidence of pulling or dragging of the victim on the ground as also presence of evidence of friction at the point of suspension, with the ligature material. The hand of the victim may show presence of foreign material like foreign hair or button. The hands, feet and the mouth of the victim may be tied. Signs of struggle may be present on the body of the victim and at the place.

Lynching is an example of homicidal hanging. Here persons enraged by an offence committed by another person kill him publicly by hanging to demonstrate the punishment given to him. This method of punishment wag common in South America, where a black rapist was used to be lynched by angry white mob. Now this term is used more liberally, for any type of killing of a social offender, publicly by a mob.

C. Accidental hanging –

The following circumstances of accidental hanging may be encountered –

1. In factories, a worker working at a height if falls accidentally, may get hanged oh a sling or rope. Similarly, if during such a fall the necktie gets fixed at some point, then the victim may die due to the effect of hanging.

2. Similar deaths may occur in case of a trapeez player when his grips slip and his chin gets entangled on the swinging sling.

3. When a person on the top of a ladder suddenly misses a step, in course of falling down, his head may get fixed in between two steps and he may die due to constriction of the neck in suspension.

4. Infants while accidentally slipping down in between the side grills of the crib, may die due to constriction of the neck with the body being in a suspended position.

5. Children while playfully acting judicial hanging, may actually be hanged to death.

6. In course of masochistic practice the victim may accidentally die due to hanging. Such person gets sexual gratification by partial asphyxiation. He arranges the situation by placing a noose around his neck and creates a state of partial asphyxiation in himself by pulling the other end of the rope, across a pulley type arrangement. After getting sexual orgasm he releases the pull on the rope. In course of such practices the victim may fail to release the pull and die due to hanging. Males are the exclusive victims. The circumstance in such a case is sufficient to indicate the actual nature and mode of death. The victim is found either naked or in female dress with pornographic pictures at the place of occurrence. Often, some soft cloth is placed around, in between the rope and the neck.

D. Postmortem hanging –

Often a victim is killed by some other means and then hanged to simulate a suicidal death. As in case of homicidal hanging, there will be evidence of dragging of the body on the ground and friction at the point of suspension of the ligature material, as the ligature is first tied around the neck of the dead body and then the body is hanged. The unapproachability of the point of suspension by the victim, the signs of disturbance and the evidence of the actual cause of death, present on the dead body, are the other features which make the fact (post mortem hanging) clear.