Hanging is that form of asphyxia which is caused by suspension of the body by a ligature which encircles the neck, the constricting force being the weight of the body. The whole weight of the body is not necessary, and only a comparatively slight force is enough to produce death. In ‘partial hanging’ the bodies are partially suspended, the toes or feet touching the ground, or are in a sitting, kneeling, lying down, prone or any other posture. The weight of the head (5 to 6 kg) acts as the constricting force. In typical hanging, the knot is situated over the nape of the neck  ligature runs form the midline above the thyroid cartilage symmetrically upward on both sides of the neck to the occipital region other position of knot is called Atypical Hanging. When the body is completely suspended by a Ligature with full weight acting as constricting force it is termed as Complete Hanging,when any part of the body is in contact with the ground it is termed as Partial Hanging.

Ligature: A suicide will use any article readily available for the purpose, like a rope, metallic chains and wires, leather strap, belt, bed sheet, scarf, dhoti, saree, turban, sacred thread, etc. The doctor should note whether the mark on the neck corresponds with the material alleged to have been used in hanging and if it is strong enough to bear the weight and the jerk of the body. He should also note its texture and length, to know whether it was sufficient to hang. Before removing the ligature from the neck, it should be described as to the nature and composition, width, mode of application, location and type of knot. Sometimes, the rope will break or become detached and the deceased will be found lying on the ground with a ligature around his neck.

Symptoms: The first symptoms are loss or power and subjective sensations, such as flashes of light and ringing and hissing noises in the ears. There is intense mental confusion, all power of to logical thought is lost; the individual can do nothing to help himself even if it were possible. These are to followed by loss of consciousness, which is so rapid, that it is regarded as a painless form of death. Then follows a stage of convulsions. The face is distorted and livid, eyes prominent, and there is violent struggling. Respiration stops before the heart, which may continue to beat for about 10 to 15 minutes.

Causes of Death :

1. Asphyxia : The constricting force of the ligature, causes compressive narrowing of laryngeal and tracheal lumina, and forces up the root of the tongue against the posterior wall of the pharynx, and folds the epiglottis over the entrance of the larynx to block the airway. A tension of 15 kg. on ligature blocks the trachea.
2. Venous congestion: The jugular veins are blocked by the compression of the ligature which results in stoppage of the cerebral circulation, and a rapid rise in venous pressure in the head. This occurs if ligature is made up of broad and soft material, which cannot sink into tissue to any depth. The jugular veins are closed by a tension in the rope of 2kg.
3. Combined asphyxia and venous congestion: This is the commonest cause.
4. Cerebral anaemia: Pressure on the large arteries on the neck produces cerebral anaemia and immediate coma. This occurs with ligature made of thin cord, which sinks deeply into tissues. A tension of 4 to 5kg on ligature blocks carotid arteries, and 20 kg. the vertebral arteries.
5. Reflex vagal inhibition form pressure on the vagal sheath or carotid bodies.
6. Fracture or dislocation of the cervical vertebrae.

Delayed Death: Death delayed for several days is rare. Delayed deaths occur due to (1) aspiration pneumonia, (2) infections, (3) oedema of lungs, (4) oedema of larynx, (5) hypoxic encephalopathy, (6) infarction of brain, (7) abscess of brain, (8) cerebral softening.

The secondary effects of hanging in persons who have recovered are sometimes hemiplegia, epileptiform convulsions, amnesia, dementia, cervical cellulitis, parotitis, retropharyngeal abscess, amnesia, and dementia.

Fatal Period : Death occurs immediately if the cervical vertebrae are fractured, or if the heart is inhibited; rapidly if cause is asphyxia, and least rapidly if coma is responsible. The usual period is 3 to 5 minutes.

Post-mortem Appearances :

External: The ligature mark in the neck is the most important and specific sign of death from hanging. Ligature mark on the neck depends on: 1) Composition of ligature: The pattern and texture is produced upon the skin, e.g., if thick rope is used, its texture may be impressed in the form of superficial abrasion. 2) Width and multiplicity of ligature : When ligature is narrow, a deep groove is made because much more force per sq. cm. Of ligature is directed inwards. A broad ligature will produce only a superficial mark. If the ligature is passed twice round the neck, a double mark, one circular, and the other oblique may be seen. The ligature may have one, two or more layers. There may be multiple congested areas where the skin has been caught between the various layers. 3) The weight of the body suspended and the degree f the suspension: Heavier he body and greater the proportion of the body suspended, the more marked is the ligature impression. 4) The tightness of encircling ligature: The ligature impression is deeper opposite the point of suspension, but it may tail off vary rapidly if ligature consists of loop rather than a noose. If the noose tightness completely around the neck, the ligature mark will be seen completely encircling the neck. 5) The length of time body has been suspended: Longer the suspension, deeper is the groove. Even a soft, board ligature can cause a clear-cut groove if suspended long. If the ligature is cut down within a short time and a soft broad ligature has been used, there may be no external mark. 6) Position of the knot: The main force applied to the neck b ligature is opposite to the point of suspension. If the point of suspension is in occipital region, front of the neck is involved. If in front, the depth of the groove is limited posteriorly by cervical spine. 7) Slipping of ligature during suspension: Frequently, only the portion adjacent to the knot moves. There is a tendency for the ligature to move upwards, this being limited by the jaws. The upward movement may produce double impression of ligature. The lower mark is usually very superficial and is connected by fine abrasions, caused by the slipping ligature, to the mark made by ligature in its final position.

Knot: It is frequently in the form of a simple slip-knot to produce a running noose or fixed by granny or reef-knot; occasionally a simple loop is used. The knot is usually on the right or left side of the neck, ligature usually rising behind the ear to the point of suspension. Sometimes, the knot is in the occipital region and rarely under the chin. After suspension in hanging, the knot is at higher level than the remainder of ligature, the movement of knot being due to the act of suspension. The involvement of another party may be suggested by certain types of knots and nooses. Removal of the noose from the neck is done by cutting the noose away from e knot and tying the cut ends with string or wire.

Ligature Mark: The ligature produces a furrow or groove in the tussue which is pale in colour, but it later  becomes yellowish or yellowbrown and hard like parchment, due to the drying of the slightly abraded skin. The course of the groove depends on whether a fixed or running noose has been used, when the loop is arranged with a fixed knot, the curse of the mark is deepest and nearly horizontal on the side opposite to knot, but as the arms of the ligature approach the knot the mark turns upwards towards it. This produces an inverted ‘V’ at the site of the knot, the apex of the ‘V’ corresponding with the site of the knot. An impression from a knot any be found if the ligature is tight on the skin, usually on one or other side of the back and occasionally beneath the chin. A slip-knot may cause the noose to tighten and squeeze the skin through the full circumference of the neck. In the case of a fixed loop with a single knot in the midline at the back of the head, the mark is seen on both sides of the neck and is directed obliquely upwards towards the position of the knot over the back of the neck. In the case of a fixed loop with a single knot in the midline under the chin, the mark is seen on the back and both sides of the neck, and is directed obliquely forwards towards the position of the knot over the front of the neck. In the case of fixed loop with the knot in the region of one ear, the mark differs on each side of the neck. On the side of the knot, the mark is directed obliquely upwards to the knot, and on the other side it is directed transversely. If the ligature is in the form of a loop, the mark will be most prominent on the part of the neck to which the head has inclined and less marked over the region of the open angle of the loop. When a running noose is applied, the weight of the body will cause the noose to tighten in a mainly horizontal position. The mark is seen on both sides of the neck, and is usually directed transversely across the front of the neck resembling that of a ligature mark in strangulation, except that it is likely to be seen above the level of thyroid cartilage. If a running noose fails to tighten, the mark may resemble one produced by a fixed loop. If the noose is a belt dig into the skin. In hanging from a low point of suspension, the groove produced by the ligature is less well marked, and may be at about the level of the upper border of the larynx and more horizontal. In partial hanging when the body leans forward, a horizontal ligature mark may be seen. The ligature mark usually encircles the entire neck except for the place where the knot was located. The firmer muscular tissues at the back of the neck do not show clear and deep grooves, as are teen of the depression, a thin line of congestion or haemorrhage will be seen above and below the groove at some point, usually the deepest, if not throughout its course. Ecchymoses alone have no significance as to whether hanging was caused during life or not, but abrasions with haemorrhage are strongly suggestive of suspension taking place during life.

The mark is situated above the level of thyroid cartilage, between the larynx and the chin in 80 percent of cases. It may be at the level of the cartilage in about 15 percent, and below the cartilage in about 5 percent cases, especially in partial suspension. The width of the groove is about, or slightly less than the width of the ligature. Any well-defined pattern in the ligature is match of patterns. When fresh, the ligature mark is less clear, but becomes prominent after dying for several hours. A portion of skin and deeper tissue in relation to ligature should be examined microscopically for evidence of tissue reaction, which if present indicated ante-mortem hanging. The absence of tissue reaction does not exclude ante-mortem hanging (Gordon, et al). however, hanging may occur without visible marks on the victim’s neck. If there is a beard. Or if a portion of clothing is caught between the ligature and the skin, no ligature mark any be found under it.

When a folded cloth has been used, there may be great difference between the appearance of the neck mar and the size of the ligature. When fabric is pulled tight, certain parts of it become raised into ridges, which form the ligating surface, and only these may be reproduced on the skin. When nylon, silk or terylene fabrics are used, they may leave a mark only 2 to 3 mm wide. A loop made of soft material e.g., towel, scarf, etc. may not produce a ligature mark, but the knot may produce an abrasion due o its firmness. If there is no ligature, the mark should be taped, as it may pick up some fibers by the ligature and facilitate the identification of the material of which the ligature was made. The ligature mark of hanging may be reproduced by dragging a body aong the ground with ligature passed round the neck soon after death. decomposition obliterates the ligature mark. The ligature mark may disappear after several bourns following removal of the ligature.

In obese persons or infants, skin folds on the neck may resemble a ligature mark, especially after refrigeration of the body has caused coagulation of the subcutaneous fat. When there is swelling of the neck tissues due to decomposition, marks may be produced by jewellery or clothing.

Partial Hanging: Hanging may occur simply by leaning against the noose secured to a chair or door knob, the leg of a table, a bedpost or rail, or the handrail of a staircase, which is slightly higher than the position of the head, the deceased being in a kneeling position, or fall back or forward and lie prone with only the face and chest off the ground. In these cases, the constricting face is less and congestive changes are more marked. Hanging may occur when pressure is applied only at the font of the neck, e.g. by the arm of a chair, rung of a ladder, etc. in such case, the marks on the neck may be indistinct or absent.

Other Signs : Asphyxial signs are present in about half the cases of death due to hanging. The neck is stretched and elongated and the head is always inclined to the side opposite to the knot. The face is usually pale, due to cerebral ischemia or vagal inhibition, but is sometimes congested and swollen (swelling often disappears when the body is cut down), f the veins were constricted before the arteries. Occasionally, the congestion drains away from the head, inspite of the ligature being still in position. This probably occurs through the vertebral venous plexus, which is not easily compressed as the jugular veins. The brain is often drained of blood in this way. The petechial haemorrhages in the skin and conjunctivae remain, as they are extravascular. The signs of asphyxia are most marked in cases in which the noose as placed high up on the throat. Obstruction of the jugular veins, while the arteries remain patent, leads to severe engorgement of the head and neck. Slow asphyxia is the exception in hanging and is likely to occur only when the point of suspension is a low one, or ligature exerts pressure below the chin and does not encircle the neck. When suspension is in complete or in the standing posture, asphyxial signs are slight, petechial haemorrhages are relatively uncommon due to the complete obstruction of the arterial system, but are usually present when hanging has been from low point. Sometimes, they are so minute and diffuse that the head and neck have a dusky appearance which may be mistaken for congestion, especially when petechiae are in subcutaneous  tissues. They may be completely than usual due to congestion. Te conjunctive are open, and the pupils are usually dilated. If the ligature knot presses on cervical sympathetic, the eye on the same side may remain open and its pupil dilated. It indicates ante-mortem hanging (le facile sympathique). The tongue is usually swollen and blue especially at the base, and usually forced against the teeth when the jaw is shut, or the tip may be found projecting between the lips. The protruding part of the tongue is usually dark-brown or even black due to drying. The lips, and the mucous membrane of the mouth are blue. Saliva may be found dribbling from the angle of mouth when the head is drooping forward. This is due to the increased salivation before death due to the stimulation of the salivary glands by the ligature. Slight haemorrhage or bloody froth is sometimes seen at the mouth and nostrils, and some blood may be found under the head. This results from rupture of engorged blood vessels, and should not be mistaken for evidence of foul play. Occasionally, haemorrhage into the middle ears is seen due to excessive congestion. The hands are clenched, especially in violent hanging. Engorgement of the penis with blood occurs from hypostasis’ it may be semierect, and semen may be found at the tip. Urine and faeces may escape due to relaxation of the sphincters. If the body has been suspended for sometime, post-mortem hypostasis is seen in the legs, feet, hands and forearms, while the upper part of the body will be pale. Petechial haemorrhages may be found in the skin of the legs in 2 to 4 hours. If the body in removed within 4 hours after death and is placed in supine position, post-mortem hypostasis in the limbs will fade and new areas of lividity will appear along the back and buttocks.

Internal: The neck should be examined after removal of the brain and viscera from the chest and abdominal cavities. Superficial incision of the groove may show small haemorrhages in the underlying layers f skin, caused by the direct trauma produced by the ligature. The tissues under the mark are dry, white and glistening with occasional ecchymses in the adjacent muscles. In most cases, there is no bruising of strap muscles or other soft tissues, the muscles of the neck, especially the platysma and sternomastoid are ruptured (5 to 10%), if violence has been considerable. In some cases (5 to 10%), the intima of he carotid arteries show transverse splits with extravasation of blood in their wall due to stretching and crushing. Several horizontal intimal tears scattered along the carotid arteries at different levels are sometimes found in hanging associated with a long drop. To demonstrate these tears, the carotid arteries should be opened to the level of mandible. The vertebral arteries show rupture, intimal tears, and subintimal haemorrhages in some cases. Opinion varies regarding the frequency of fracture of the hyoid bone. Estimates range from 0 to 60%, but the average is 15 to 20%. Fractures are rare below 40 years because of the elasticity of the cartilage and mobility of the joints. The fracture is common in persons above 40 years and involves the great horns, at the junction of inner two-thirds and outer one-third. The fracture is usually a direct result of the ligature, but it can be a traction or “tua” fracture. The superior horns of the thyrohyoid may be fractured from pressure on the thyrohyoid ligament in about 40% of cases above 40 years. Injury to the trachea is unusal. Petechial haemorrhages may be found on the epiglottis, in the larynx and trachea. The trachea is usually congested. The lungs are congested, oedematous, and exude bloody serum on section in cases of constriction occurring at the end of expiration; but they are pale if constriction occurred at the end of inspiration. Subpleural ecchymoses may be found. The abdominal organs are usually congested. The brain is usually normal, but may be pale or congested according to the mode of the death. subarachnoid effusions are common.

Diagnosis:

1. Ligature mark around the neck,
2. Presence of abrasions, ecchymoses and redness about the ligature mark,
3. Trickling of saliva from the mouth,
4. Ecchymoses of the larynx or epiglottis,
5. Rupture of the intima of the carotid, and
6. Post-mortem signs of asphyxia.

The Circumstances of Death: Scene of Crime: Note the posture of the body, any signs of violence or disorder of furniture, etc., and the condition of the clothing of the deceased. The texture and length of ligature should be noted to know whether it was sufficient to hang. If the ligature had broken and the victim is found on the ground, free ends of the ligature should be compared to know whether they coincide and that a break had occurred.

Accidental hanging: Accidental hanging may occur [1] during play or at work, and [2] in sexual deviation. It is seen in children during play while imitating judicial hanging or in athletes who are in the habit of exhibiting hanging. Some padding between ligature and neck suggests accident. Workmen in falling from scaffolding may be hanged by becoming entangled in ropes. When boys climb trees or railings they may loose their foothold and in falling, some garment is caught by branch of tree or bar and is drawn tight round the neck. Infants wearing restraining apparatus may wriggle partly out of it, and become asphyxiated by its tightening around their neck as they try to crawl away or fall over the side of the bed. The ligature need not completely encircle the neck to cause death. It is sufficient if it is applied beneath the chin so as to compress the sides of the neck, e.g. suspension of the chin by the steering wheel of a motor car, the tailboard of a lorry or cart, the edge of a sofa, or the arm of chair. A person who slips when descending a ladder may be suspended by one of its rungs, or a slip on a staircase may result in suspension on the edge of one of the treads. It may be associated with abnormal sexual behavior.

Suicidal Hanging: Hanging is a common method of committing suicide. A typical method of self-suspension is to attach a rope to a high point, such as a beam, window-casing, ceiling fan, branch of a tree, etc. The lower end is formed into either a fixed loop or a slip-knot which is placed around the neck. The victim stands on a stool, chair or other platform and jumps off or kicks away the support, due to which the body is suspended. The body must be in a position compatible with self-suspension. It is important to examine the point of attachment and the surrounding area. If the point is high, then it is likely that there will be recent disturbance of dust caused while attaching the ligature. The deceased’s hands and sometimes part of his clothing may also show the presence of corresponding dust marks. There may also be disturbance of dust from the attached cord or from an abraded area particularly if a beam has been used to attach the ligature. Complete suspension of the body is the absence of any platform is unusual in suicide. Unusual positions, e.g., where the parts of the body touched the ground, kneeling or reclining, are almost diagnostic of suicide. The hands and feet himself, to prevent a change of mind. The position of the ligature with reference to the knot and the manner in which it is attached to the support must be compatible with self-suspension. Determination of purpose will often compensate bodily infirmity. Blindness or age is no bar to hanging. The victim might pull away the ligature to free himself from the constriction and if he had long nails, nail marks may be inflicted on the neck. Sometimes, the upward movement of the rope at the time of suspension may scratch the skin. In an attempted resuscitation, scratches or nail marks on the neck may be produced by another person. Sometimes a person may hang himself after other forms of suicide, e.g., cutting the throat or wrists, stabs, firearm wounds, ingestion of poison, etc., have failed to produce death. suicide pacts effected by hanging are rare.

Homicidal Hanging: It is extremely rare. It is difficult for a single assailant to carry it out unless the victim becomes unconscious by injury or by a drug, or is taken unawares, or is a child or a very weak person. Homicide should be suspected (1) where there are signs of violence or disorder of furniture or other objects, (2) where the clothing of the deceased is torn or disarranged, (3) where there are injuries, either offensive or defensive. Any definite scratches, especially crescentic nail marks point to manual strangulation, and if associated with bruising of neck structures and fracture of larynx, the probability of murder is strong. In all doubtful cases, circumstantial evidence is important.

Lynching : It is homicidal hanging. Sometimes a suspect, accused or enemy is hanged by a rope from a tree, etc., by the mob.

Post-mortem Hanging: A person may be murdered, and the dead body suspended to simulate suicide. Look for signs of dragging to the place of suspension. When a dead body is suspended, the rope is usually tied first around the neck, and then around the beam, branch of a tree, etc. The beam shows evidence of the rope having moved from below upwards as the body has been pulled up. In true suicidal hanging, the rope moves from above downwards. Further, fibers from the rope may be found on the hands of the victim in suicidal hanging, but not in case of post-mortem hanging. The rope should be examined for presence or absence of any paint similar to one on the beam. In most cases, the internal signs are clearly not those of hanging, although in most cases ligature mark cannot be distinguished. Rarely, for motives of revenge, fraud or for some other reason, a victim arranges his suicide to appear to have been a murder.

Judicial Hanging:  The face of the person is covered with a dark mask, and he is made to stand on  a platform above trapdoors which open downwards when a bolt is drawn. A rope to allow a drop of 5 to 7 metres according to the weight, age and build of the person, is looped round the neck, with the knot under the angle of the jaw. The placement of the knot beneath the chin, in the submental position is said to be more effective. On drawing the bolt, the person drops to the length of the rope. The sudden stoppage of the moving body associated with the position of the knot causes the head to the jerked violently. This causes fracture-dislocation usually at the level of the second and third, or third and fourth cervical vertebrae. Less commonly, dislocation of the atlanto-occipital joint or odeontoid process of the axis vertebra occurs causing pulping of the spinal cord and transection of the cervical spine, causing the neck to be lengthened considerably. The upper cervical cord is stretched or torn across, and sometimes the medulla is torn at the border of the pons. It results in immediate unconsciousness, but heart beats and respiratory movements may continue up to 10 to 15 minutes and spasmodic muscular jerking may occur for a considerable time. The pharynx is usually injured and the carotid arteries may be torn transversely, either partly or completely.

 

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