Vijay Kautilya D

STUDY OF PATTERN OF NECK INJURIES IN CASES OF HANGING
WITH SPECIAL REFERENCE TO CAROTID INJURIES.

CONDUCTED AT
BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE,
BANGALORE
By
Dr. VIJAY KAUTILYA D
Dissertation Submitted to the Rajiv Gandhi University of Health Sciences,
Karnataka, Bangalore in partial fulfillment of the requirements for the degree of
M. D. (Forensic Medicine)
Guided
By:
Dr. P. K. Devadass.
Co Guide
By
Dr Raghupathi A R
DEPARTMENT OF FORENSIC MEDICINE

BANGALORE MEDICAL COLLEGE AND RESEARCH INSTITUTE, BANGALORE.
2008- 2011
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
i
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation entitled “STUDY OF PATTERN OF NECK
INJURIES IN CASES OF HANGING WITH SPECIAL REFERENCE TO CAROTID
INJURIES.” is a bonafide and genuine research work carried out by me under the guidance
of my guide Dr. P. K. Devadass MD, Professor & Head of Department of Forensic
Medicine and co guide Dr Raghupathi A R MD, professor Department of pathology,
Bangalore Medical College and Research Institute, Bangalore.
Date: Dr. Vijay Kautilya D.

Place:
ii
CERTIFICATE BY THE GUIDE
This is to certify that this dissertation entitled “STUDY OF PATTERN OF NECK
INJURIES IN CASES OF HANGING WITH SPECIAL REFERANCE TO CAROTID
INJURIES.” conducted at Bangalore Medical College and Research Institute, Bangalore, is a
bonafide work done by Dr. Vijay Kautilya D, under my direct guidance and supervision in
the Department of Forensic Medicine, Bangalore Medical College and Research Institute,
Bangalore, in partial fulfillment of the requirement for the degree of M. D. in Forensic
Medicine, examination to be held in May 2011
Date: Dr. P. K. Devadass MD,

Professor & Head
Place: Bangalore. Department of Forensic Medicine,
Bangalore Medical College and Research Institute,
Bangalore.
iii
Certificate by the Co-Guide
bonafide work done by Dr. Vijay Kautilya D, under my guidance and supervision as a co-
guide in the Department of Pathology, Bangalore Medical College and Research Institute,
Bangalore, in partial fulfillment of the requirement for the degree of M. D. in Forensic
Medicine, examination to be held in May 2011.
Date: Dr. Raghupathi A R,

Professor
Place: Bangalore. Department of Pathology,
Bangalore.
iv
ENDORSEMENT BY THE HEAD OF THE DEPARTMENT
INJURIES.” is a bonafide work done by Dr. Vijay Kautilya D, under my overall supervision in
the Department of Forensic Medicine, Bangalore Medical College and Research Institute,
Bangalore in partial fulfillment of the requirement for the degree of M. D. in Forensic
Medicine, examination to be held in May 2011.
Date: Dr. P. K. Devadass MD,

Professor & Head
Bangalore. Department of Forensic Medicine,
Bangalore.
v
ENDORSEMENT BY THE PRINICIPAL
bonafide work done by Dr.Vijay Kautilya D, under direct guidance of Dr. P. K. Devadass
MD , Professor & Head Department of Forensic Medicine and co guide Dr Raghupathi A R

MD, professor Department of pathology, Bangalore Medical College and Research Institute, in
partial fulfillment of the requirement for the degree of M. D. in Forensic Medicine,
examination to be held in May 2011.
Date: Dr. Subash G.T.DM,

Place: Bagalore. Dean and Director,
Bangalore.
vi
COPYRIGHT
DECLARATION BY THE CANDIDATE
I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall
have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic
format for academic / research purpose.
Date: Signature of the Candidate

Place: Bangalore Name: Dr Vijay Kautilya D
 Rajiv Gandhi University of Health Sciences, Karnataka
vii
ACKNOWLEDGEMENTS
I am highly indebted to my mentor and teacher Dr. P. K. Devadass MD, Professor and Head,
Department of Forensic Medicine, Bangalore Medical College and Research Institute,
Bangalore, for his continuous support, inspiration, kind and valuable guidance and
understanding throughout my dissertation and my MD course. His experience and knowledge
have been valuable resource for this work.
I also thank Dr Raghupathi A R MD, professor department of pathology for having found
time in his busy schedule to guide in this work. His extensive knowledge in pathology was in
deed a major guiding force in the completion of this thesis
I am grateful to, Dr. Satish. K. V. MD Associate professor, Department of Forensic Medicine,
Bangalore Medical College and Research Institute, Bangalore, for his constant
encouragement, insight and knowledge through my MD course and helped me a lot in my
dissertation, for which I shall remain obliged.
I sincerely thank Dr Shankar, Professor, department of Neuro- pathology, NIMHANS for
promptly helping me with special stains for the slides of carotid artery.
I am deeply indebted to Professor Dr. K. H. Manjunath MD. DFM, Department of Forensic
Medicine, Bangalore Medical College and Research Institute, Bangalore, for his valuable
suggestions and support.
I am deeply indebted to Dr.Bhimappa Havanur M.D Associate professor, Department of
Forensic Medicine, Bangalore Medical College and Research Institute, Bangalore, for his
valuable support.
I express my deepest gratitude to Dr. S. Venkata Raghava. MD Assistant professor,
Department of Forensic Medicine, Bangalore Medical College and Research Institute,
Bangalore, for his wonderful guidance, support, constant help with wise advice in all aspects
viii
and constructive criticism at every stage of my study and without which this dissertation
would not have been a damn success.
I express my thanks to Dr. C. N. Sumangala MD Lecturer, Department of Forensic Medicine,
Bangalore Medical College and Research Institute, Bangalore, for her Care and support.
I express my deepest gratitude to Dr. Kumar Guru, for his wonderful guidance, support,
constant help with wise advice in all aspects and constructive criticism at every stage of my
study and without which this dissertation would not have been a damn success.
I express my thanks to Dr. Geraldin Sanjay, Department of Forensic Medicine, Bangalore
Medical College and Research Institute, Bangalore, for her support, suggestion and
encouragement.
I thank and express my deepest gratitude to my friend Dr Chandrakanth Kocatanoor PG
in Forensic medicine, for his constant support, suggestion and help throughout this
dissertation
I thank Dr. Subhash. G. T. DM, Director and Dean, Bangalore Medical College and
Research Institute, Bangalore for providing opportunity and support.
My sincere gratitude to my wife Dr. Shruti P Hegde P G in Ophthalmology for her
wonderful support and help at every stage of my study and life.
I express my deepest gratitude to my colleague Dr.Pushpa M G., Dr Hemanth Naik, Dr
Pramodh R K, Dr Sarika, Dr Somashekar P, Dr Rajashekar Myageri for their valuable support
and help.
It’s my pleasure to express thanks to my beloved friends and colleagues Dr.Shylaja,
Dr.Shobhana, Dr.Ravikumar, Dr.Chetan, Dr.Rudresh, Dr.Yogesh, Dr Vinay, Dr Yadukul, Dr
Murali, Dr Raghavendra for their constant support.
I sincerely thank all the mortuary staff and non-teaching staff of the department for their
support and cooperation.
ix
I shall be failing in my duties, if I do not acknowledge the moral support, encouragement and
active help received from my family members.
I am also obliged to police personnel and relatives of the deceased. Finally I bow my head to
pay my obeisance to all who died unnecessarily and prematurely for been the source of data.
Date: Signature of the Candidate

Place: Bangalore. Name: Dr. Vijay Kautilya D.
x
Abstract
PURPOSE: - The internal signs of asphyxia in all its forms is so overlapping that it is very
hard to differentiate them using these alone. The purpose of the study is to determine the
frequency of neck injuries to inner tissues with regard to the type of hanging, hanging
material, position of the knot and weight of the body. This is an attempt to indicate the
mechanism of injury to the organs directly and also to study the carotid intimal tears due to
indirect stretch and the variables influencing it, to also check the association of the intimal
tears with hanging so as to consider its consistency with this form of asphyxia.
METHOD: - A total of 152 cases of hanging were studied in the department of forensic
medicine, Victoria Hospital over a Period of 18 months from December 2008 to May 2010.
Prinsloo and Gordon’s method of dissection of the neck was followed and the injuries in the
neck noted. The carotid arteries were drawn and checked for injuries and tears. Hysto-
pathology was conducted on positive cases of tears and the results documented.
RESULTS: - Contrary to the general belief of the fact that no significant injuries in the neck
are present in cases of hanging, a specific pattern of injuries could be established for neck
injuries in hanging. Hemorrhage into the lower end of sterno mastoid was demonstrated in
27.6% of cases, 4.6% cases showed strap muscle hemorrhage, two cases each had thyroid
cartilage fracture, hyoid bone fracture and vertebral fracture. Transverse Multiple Carotid
Intimal tears were present in 4.6% of cases and their ante-mortem nature could be
demonstrated on histopathology.
CONCLUSION: - Hemorrhage into the lower end of sterno-mastoid and transverse
(horizontal) intimal tears in the carotid artery are classical to the mechanism of hanging and
should be looked for in all cases during autopsy. Histopathology of the carotid arteries can
confirm its ante mortem nature.
xi
Table of Contents
Sl.
Contents Page No.
No.
1. INTRODUCTION 1-2
2. AIMS AND OBJECTIVES 3
3. REVIEW OF LITERATURE 4 – 33
4. MATERIALS AND METHODS 34 – 37
38 -72
5. RESULTS & DISCUSSION
80– 82
6. CONCLUSION
7. SUMMARY 83
8. LIST of REFERENCES 86 -92
93 – 103
9. ANNEXURES
xii
List of Tables
Table no. Name of the table. Page no..

1 Sex 39
2 Age 39
3 Place of occurrence 40
4 Suspension Point 41
5 Ligature Material used 41
6 Type of Ligature Material 42
7 Type of Hanging 42
8 Age and injury pattern in the neck 43
9 Type of hanging and injury pattern 44
10 Weight of the body and injury pattern 46
11 Type of ligature and injury pattern 47
12 Height of suspension and injuries sustained 48
13 Foot ground distance and the injuries sustained 49
14 Period of suspension and injuries sustained 50
15 Position of the knot and injuries sustained 51
16 Ligature Mark and Injury Pattern 52
17 Thickness of the ligature and injury pattern 53
18 Type of Knot and injury pattern 54
19 Sterno mastoid Haemorrhage 55
20 position of the knot and Sterno-mastoid haemorrhage 55
21 Strap Muscle haemorrhage 56
22 Throat skeleton fracture 57
23 Carotid Intimal tears 59
24 Age of deceased and Carotid Injuries 59
25 Weight of the Body and Carotid Tears 61
26 Ligature material and Carotid Injuries 62
27 Ligature material and Carotid Injuries 62
28 Foot Ground distance and carotid injuries 63
29 Period of Suspension and carotid injuries 64
xiii
30 Position of the Knot and carotid injuries 65
31 Ligature mark and Carotid injuries 66
32 Ligature Thickness and carotid injuries 67
33 Ligature loop and carotid injuries 68
34 Cases of carotid Intimal Tears 70
xiv
List of Figures
Figure no. Name of the figure Page no
1 Age and Sex distribution of cases. 39
2 Age, sex and injury pattern in the neck 43
3 Type of hanging and the pattern of injuries 45
4 Weight of the body and injury pattern 46
5 Type of ligature and injury pattern 47
6 Height of suspension and injuries sustained 48
7 Foot ground distance and the injuries sustained 49
8 Period of suspension and injuries sustained 50
9 Position of the knot and injuries sustained 51
10 Ligature Mark and Injury Pattern 52
11 Thickness of the ligature and injury pattern 53
12 Type of Knot and injury pattern 54
13 position of the knot and Sterno-mastoid haemorrhage 56
14 Age of deceased and carotid intimal tear 60
15 Age of deceased and carotid extravasations 60
16 weight of the body and carotid Injury 61
17 Ligature material and carotid injuries 63
18 Foot Ground distance and carotid injuries 64
19 Period of Suspension and carotid injuries 65
20 Position of the Knot and carotid injuries 66
21 Ligature mark and Carotid injuries 67
22 Ligature Thickness and carotid injuries 68
23 Ligature loop and carotid injuries 69
xv
LIST OF PLATES
PLATE PICTURE TITLE PAGE NO.

NO. NO
1 Photograph of a case of suicide by complete
1 hanging with tree as the suspension point
2 Photograph of a case of suicide by partial 73
hanging with a support beam as suspension
point
3 Photograph of a case of suicide by partial
hanging using fan as a suspension point
4 Photograph showing hemorrhage into lower
2 attachment of sterno-mastoid muscle in case of
hanging.
5 Photograph showing hemorrhage into the strap
muscles in case of hanging. 74
6 Photograph showing hemorrhage into the right
side strap muscles in case of hanging.
7 photograph showing hemorrhage into sterno-
mastoid muscle in case of hanging
corresponding to the
8 Photograph showing thyroid cartilage fracture
3 in case of hanging.
9 Photograph showing hyoid bone fracture in 75
case of complete hanging.
10 Photograph showing fracture of the cervical
vertebrae in case of a suicidal hanging in an
aged person.
11 Photograph showing two horizontal intimal
4 tears in the carotid artery in case of complete
hanging.
12 Photograph showing two horizontal intimal
tears in the carotid artery in case of complete 76
hanging.
13 Photograph showing horizontal intimal tear in
common carotid artery in a case of complete
hanging.
14 Photograph showing horizontal intimal tear in
common carotid artery in a case of complete
hanging.
15 photograph showing three horizontal intimal
5 tears in the carotid artery near the bifurcation
16 Photograph showing intimal tear at the root of
the common carotid artery in case of hanging 77
17 Photograph showing intimal tear in the
common carotid artery in case of complete
hanging
xvi
18 Photograph showing complete obstruction of
external carotid artery in case of hanging
19 Photomicrograph of a tissue section of normal
carotid artery (H&E, X40)
20 Photomicrograph of a tissue section of carotid
artery showing a tear extending longitudinally
from the intima to the adventitia splitting the 78
transversely on either sides (H&E, X40)
6
21 Photomicrograph of a tissue section of carotid

artery showing RBC extravasations within the
tear (H&E, X200)
22 Photomicrograph of tissue section of carotid
artery showing intimal tear extending up to the
upper 1/4th of the media with extravasations of
RBC within the tear (H&E, X100)
7 intimal tear with extravasations of RBC within 79
the tear (H&E,X200)

artery showing Intimal Tear with extravasations
of RBC (Arrow) within the tear
artery showing intimal tears with RBC (Arrow)
with in the tear
26 Photomicrograph of tissue section of Carotid
artery showing Intimal tear extending into the
media (Arrow-elastic lamina)
xvii
LIST OF ANNEXURES
Sl.No. ANNEXURES Page No.
1. Proforma 93 - 95
2. Key to Master chart. 96 - 98
3. Master chart. 99 - 103
xviii
Introduction
History of suicide goes back at least to the earliest available human records and human suicidal
behavior has always been a source of dread and wounds to mankind. Globally an estimated
815,000 people kill themselves each year making suicide the 13th most common cause of death.
Suicide is now among the three leading causes of death in the age group of 15-44yrs. It is
estimated that one person commits suicide every 40 seconds. In the recent years, a large portion
of autopsies conducted in various hospitals and institutions in almost all parts of India are
suicides. The incidence of suicide in all metropolitan cities in India is on the rise and Bangalore
as such is not an exception. In India the rates of suicide is least in Kolkata and highest in
Bangalore.
Hanging is now the most common form of successful suicide in most parts of the world.
It is the commonest method of successful suicide in India, Canada, 2nd most common in USA
and most common method of suicide in men in the United Kingdom.
Hanging refers to lethal suspension of a person by a ligature. The Oxford Dictionary
states that-
―Hanging in this sense is specifically to put to death by suspension by the neck, although it
formerly also referred to crusification and death by impalement in which the body would remain
hanging.‖
Hanging is a method of suicide in which a person applies a ligature to the neck and brings
about unconsciousness and then death by means of partial suspension or partial weight bearing
on the ligature.
1
It is in our common experience that hanging in face value goes in favor of being suicidal in
nature. The age of the victim may be anywhere between extremes of life. Partial hanging is
almost always suicidal unless proved otherwise.
The materials necessary for suicide are easily available. It is a deceptively simple yet
highly effective method of suicide. However a careful forensic examination in asphyxia
involving pressure on the neck is of great importance, even in the cases of hanging supposed to
be suicidal, with an aim of ascertaining the ante-mortem character of the lesions and the physio-
pathologic mechanisms of death and excluding the possibility of murder dissimulation.
When confronted to an apparent suicidal hanging the forensic pathologist must keep in
mind the possibility of simulated hanging, a homicidal strangulation followed by a hanging of
the victim in an attempt to cover up the homicide. However this distinction is highly challenging.
The pathologist must take into consideration many pathological findings such as location of the
ligature and noose marks, type of noose, finger nail marks, petechial hemorrhages and signs of
resuscitation or intubation, deep damage to the muscles of the neck.
The scene of death, previous suicidal attempts and oral statements concerning suicidal
thoughts can also enlighten observations made during autopsy. Still, specific criteria to
distinguish suicidal and homicidal strangulation are lacking.
The present study evaluates the internal findings in the neck tissues in cases of hanging to
establish a pattern of injuries so as to help clear the problems during autopsy relating to
confirmation of suicidal hanging. A special importance is given to study the injuries in the
Carotid Arteries and evaluate their ante-mortem nature.
2
Aims and Objectives of the Study
1. To evaluate the incidence of various injuries in the neck in case of hanging.
2. To know the pattern of neck injuries in various types of hanging.
3. To know the association of superficial and deep neck injuries in hanging.
4. To know the incidence of tear in the intima of the carotid in hanging.
5. To study the patterns of carotid intimal tears with variables such as-
 Weight of the body.
 Type of hanging material.
 Position of the knot.
 Ligature material used.
 Height of the fall.
6. To establish the ante-mortem nature of the tears in carotid arteries by microscopy and
staining.
3
Review of Literature
1. Anatomy of the Neck:-
Neck is generally described as the region of human body that extends from the base of the skull
to the top of the shoulders. This small region of the body has long been the concentrated target of
any assault and any fatal accident, reason being the existence of many vital life sustaining
structures like blood vessels, larynx, tracheae, cervical sympathetic ganglion and the spinal cord
arranged compactly in a small area. The neck is supported by the cervical spine with seven
cervical vertebrae [semicircular bones assembled into a column]. The head rests over the atlas
vertebrae which intern forms an articular joint with the articular facet of the Axis vertebra
providing for the motility of the neck. The spinal cord is protected within the vertebral foramen
formed by the vertebrae. The vertebral artery passes through the foramen transversorium of these
vertebras. Between each bone is a disc shapes fibrous structure [Intervertebral disk] which acts
as a shock absorber1.
The muscles that work most closely with the cervical vertebra to provide movement are
the splenius capitis which is positioned in both sides of the neck along the spine and the
trapezius, the muscles that connect the base of the neck to the shoulder. Anteriorly the sterno-
mastoid muscle holds the head to the front of the chest and provides for side to side movement1.
The larynx is relatively protected from trauma in the front of the neck by the
overhanging of the mandible above, the bony prominence of the mandible above, the bony
prominence of the clavicle and sterna manubrium below and by the mass of neck muscles on the
side. The framework of larynx consists of primarily of four cartilages, the thyroid cartilage, the
cricoids cartilage and a pair of arytenoids cartilages. The thyroid cartilage is shaped like a shield
4
and forms a protective casing for the vocal cords. The prominence of the thyroid cartilage in the
neck of men is often referred to as Adam’s apple. The cricoid cartilage sits below the vocal folds
and is shaped like a signet ring. The ring like structure of the cricoids serves as a stent to help
hold open the airway below the vocal folds2.
The hyoid bone is the one and only bone of the throat. It is a horse shoe shaped bone that
lies between the chin and the thyroid ligament. Interestingly the hyoid bone does not connect to
any other bones and is the only bone in the human body to do so. Instead the bone connects
solely to ligaments. The primary function of the bone is to allow the movement of the tongue,
pharynx and larynx by connecting to muscles in the region. Also the bone functions in the
protection of these structures. The hyoid bone has three parts i.e. the body, greater cornuae and
lesser cornuae3.
The anterior surface of the body provides insertion to Genio- hyoid and Mylo-hyoid
muscles and gives origin to a part of Hyo-glossus muscle. The upper border of the body provides
insertion to lower fibers of Genio-glossi and attachment of Thyro-hyoid membrane. The lower
border of the body provides attachment to pretracheal fascia, in front of the fascia the sterno-
hyoid is inserted medially and omohyoid laterally. Below the omohyoid there is the linear
attachment of the Thyro-hyoid, extending back to the lower border of the greater cornua. The
medial border of greater cornua provides attachment to the Thyro-hyoid membrane. The lateral
border of the greater cornua provides insertion to Thyro-hyoid muscles anteriorly. The investing
fascia is attached throughout its length. The lesser cornua provide attachment to the stylo-hyoid
ligament at the tip. The middle constrictor muscle arises from its postero-latral aspect4.
5
In the hyoid bone two mechanisms have been suggested in which the hyoid bone may
be fractured:
 Direct lateral compression.
 Indirect violence.
Direct lateral compression is one mechanism in manual strangulation when pressure is
applied under the angle of the jaw. In the second mechanism the hyoid bone is drawn up and
held rigid by the muscle attachments to its upper and anterior surface, violent downward and
lateral movement of the thyroid cartilage or pressure between the hyoid bone and thyroid
cartilage will exert traction through the Thyro-hyoid ligament and causes fraction of the
hyoid bone5.
The thyroid cartilage may be fractured through the superior cornua or the body. The
superior cornua fracture is the most common and again traction via the Thyro- hyoid
ligament could be a common mechanism. Fracture of the body of the thyroid cartilage is rare.
They are usually vertical and near the junction of the lamina in the midline and are the result
of a direct blow upon the laryngeal prominence or ligature pressing backwards5.
Fracture of the thyroid cartilage and to some extent those of the hyoid bone are more
commonly found in the elderly people with calcified thyroid cartilage and rigidly ossified
hyoid bones and are seldom, if ever seen in young children5.
Calcification and age and oft ossification in the laryngeal cartilage are variable in their
incidence and degree. They increase with age and often occur earlier in men then in women.
Hyoid bone ossifies bye six ossification centers, two for the body and two each for the
cornua. Ossification centers in the greater cornua appear to the end of fetal life, in the body
6
shortly afterwards and in the lesser cornua during the first or second year of life. When the
cartilaginous union between the body and the greater cornua takes place the hyoid bone
becomes more liable to fractutre5.
Carotid arteries:-
The right common carotid artery is a branch of the Brachiocephalic artery. It begins
in the neck behind the right Sterno- clavicular joint. The left common carotid artery is a
branch of the arch of aorta. It begins in the thorax in front of the trachea opposite a point little
to the left of the center of the Manubrium. It ascends to the back of the left sterno-clavicular
joint and enters the neck6.
In the neck both the arteries have a similar course. Each artery runs upwards within
the carotid sheath, under cover of the anterior border of the Sterno-mastoid muscle. At the
level of the upper border of thyroid cartilage the artery ends by dividing into the external and
internal carotid artery at the level of C3-C4 cervical vertebrae6.
The external carotid artery is one of the terminal branches of the common carotid
artery and is the chief artery of supply to the front of the neck and face6.
The common carotid artery can be compressed against the carotid tubercle i.e. the
anterior tubercle of the transverse process of the C6 cervical vertebrae which lies at the level
of the cricoids cartilage6.
The internal carotid artery begins at the level of the C4 cervical vertebrae and ends
in the cranial cavity. It is the main arterial supply to the brain and eyes. The cervical part of
the artery ascends vertically in the neck from its origin to the base of the skull to reach the
7
lower end of the carotid canal. The initial part shows dilation, the carotid sinus which acts as
a Baro- receptor. The lower part of the artery is more superficial than the rest of the artery6.
2. Mechanisms of Death in Pressure on the Neck:-
Pressure on the neck may arise from manual strangulation, ligature strangulation,
hanging, direct blows, arm locks and a variety of accidental lesions such as entanglement
in a cord or falling on to the neck. This form of death previously was thought to cause
death solely by Asphyxia but now the concepts are changing. A number of anatomical
and physiological factors must be considered in analyzing the effect of pressure on the
neck7.
 Airway obstruction: This may occur from direct compression of the larynx or trachea
or from the lifting of the larynx so that the pharynx is closed by the root of the tongue
being pressed against the soft palate and roof of the mouth. The later mechanism is
more likely as the strong cartilages of the neck will resist all but the most extreme
compression. Various experiments have been done to quantify the force needed to
close the airway and blood vessels but it has always been difficult to translate the
force required to do so. Brouard calculated that the force needed to close the trachea
was of the order of 15kgs, far more than that required in blocking the blood vessels7.
 Occlusion of the neck veins: this almost solely is responsible for the classical signs of
asphyxia like congestion, cyanosis, petechiae etc. The external jugular vein is the
most vulnerable but any significant force encircling the neck can block the internal
jugular veins as well. Brouard’s experiments suggest that a ligature with tension of
2kgs blocks the jugular return7.
8
 Compression of the Carotid arteries: This is much less common than the venous
occlusion as the higher internal pressure of the carotid arteries resists occlusion and
they are situated deeply. If this can be achieved then unconsciousness would be
immediately achieved as cortical function would seize without blood supply.
Occlusion of the vertebral arteries by neck compression is seems virtually impossible
though some studies have claimed the contrary. If the carotid circulation is totally
occluded for an unremitting period of 4 or more minutes, then irreversible brain
damage may occur7.
 Nerve effects: pressure on the Baro-receptors situated in the carotid sinuses, the
Carotid sheath and the carotid body can result in bradycardia [slowing of the heart] or
total cardiac arrest. The impulse passes up through the glosopharyngeal nerve to the
10th nerve nucleus in the brain and the parasympathetic stimulation through the vagus
nerve is activated to the brain to cause cardiac arrest7.
 Fracture of the spine: Fractures of the base of the skull and the spine are rarely
observed in case of death by hanging and if so generally only in case of a fall from a
certain height [drop] as in judicial hanging. A fracture at the level of first and second
cervical vertebrae or else ware in the spine is thus described as hangman’s fracture
and can lead to cerebral paralysis and sudden respiratory arrest. A fall from more than
4mts with hanging device such as nylon ropes can result in decapitation because of
the force exerted8.
Measurements have established that a weight of 34N is enough to
obstruct the carotids while the vertebral arteries are obstructed at 160-200N. Human
9
head itself weighs 4-5kgs and is sufficient to exert a constricting force of 100-200N
even in the lying down position8.
Usually depending upon the mechanism of death, in case of judicial hanging or hanging
from a long drop results in injuries to the spinal cord, death is almost instantaneous, respiration
seizes almost abruptly though the heart beats for some time. Similar is the case with vagal
inhibition. In other mechanisms unconsciousness occurs almost instantaneously although death
may not occur for few minutes9.
3. Injuries to the neck structures in hanging:

The general features in hanging depend on the predominance and combination
of mechanisms that have occurred. The general internal appearances are those associated
with an asphyxia death. Internal injuries are remarkably infrequent and when present
suggest that some violence has occurred such as from a drop. In addition to soft tissue
injuries which are infrequent fractures may occur in both larynx and hyoid bone. The
frequency with which these fractures occur varies considerably in different series. Puller
et al in his practice found that fractures of the superior horn of the thyroid cartilage are
approximately equal to the fractures of the greater horn of the hyoid bone. They are
considerably lesser than in case of strangulation and are normally related to the state of
ossification of these structures and therefore related to age of deceased. The infrequency
in his cases perhaps was due to the age of at least two thirds of the victims being below
30yrs10.
In most of the hanging deaths the dissection of the throat and neck organs
and tissues does not reveal any signs of traumatic injury. Fractures of the superior horn of
the thyroid cartilage and hemorrhage in the neck muscles have been occasionally
10
encountered. Rupture of the sterno- mastoid muscles and of the thyroid ligament and
fracture of the cornua of the hyoid bone have been described. Fractures of palate of the
thyroid cartilage and of the cricoids cartilage are rare. In most cases the other organs in
the body do not show characteristic finding aside from the general sign of asphyxia and
congestion11.
In the neck tissues there may be surprisingly little to find, as absence of any
laryngeal fracture or strap muscle hemorrhage is common especially if a soft ligature is
used. However the literature suggests that the average figures for the incidence of soft
tissue hemorrhage would be about 20-30% of cases and for laryngeal fractures
approximately 35-45% of cases. Fracture of both hyoid bone and thyroid cartilage has
been seen. Damage to the intima of the carotid arteries, often in the region of the sinuses,
may sometimes be found on careful dissection. In hanging with an unusually long drop
severe disruption of the larynx can be found12.
Bleeding into the crushed areas of the ligature mark is rare. More frequently
however there are changes of the blood distribution in the retro laryngeal region,
particularly in the deeper layers of cervical muscles anteriorly to the spinal column and
also in the adjacent blood vessels. Bleeding into the lower attachment of the sterno-
mastoid muscle of the clavicle is very typical although bleeding within the muscle bellies
is uncommon. It is particularly evident at the site diametrically opposite to the highest
point of suspension and is due to the pulling effect at the time of suspension. In cases of
fall or jumping into the strangulation device preceding the suspension the cervical
muscles may be torn partially or completely. The sterno-mastoid muscles are affected the
most. Bleeding both in ruptured and non ruptured muscles is minimal13.
11
If the fall is from a height more than 3.5 feet, depending on the weight of the
body and the type of rope used, complete decapitation can occur. Frequency of skeletal
injuries varies in cases of death by hanging. Since the hyoid bone ossifies earlier then the
upper thyroid cartilage horn, a fracture of the hyoid cornua is more likely. Injuries to the
vertebral column are extremely rare in suicidal hanging. Such injuries are more frequent
in judicial execution. Bleeding into the soft part of larynx such as muscles, vocal cords,
epidural bleeding in the spine, intervertebral discs may be seen. Saternus emphasizes that
injuries of the soft part of cervical spine do not typically occur in a case of fall into the
noose, but are a frequent a type of injury occurring in more usual suicidal hanging.
Vertebral arteries are more frequently injured than carotids, mostly with peri- vascular
bleeding but sub intimal bleeding and disruption of the intima can also occur13.
Fractures of the hyoid bone or of the thyroid cartilage or of both together are by
no means uncommon in hanging. The thyroid cartilage usually fractures at the junction of
the superior horn and the lamina and the hyoid at/or near the junction of the greater horn
and the body. The features are usually associated with at least a little hemorrhage but this
is not invariable in hanging and the absence of hemorrhage does not necessarily mean
that the body was suspended after death14.
Occasionally muscle fibers of the platysma and sterno-mastoid may get ruptured
especially in long drops or complete hanging. There is a lack of unanimity of opinion
regarding the frequency of hyoid bone fracture in hanging. Reuter (1901) reported this
fracture to be relatively common, present in 60% of typical cases and 30% of atypical
cases of hanging. Smith and Fiddes (1955) remarked that hyoid bone fracture never
occurs and Weintraub (1961) found the hyoid bone fractured in 9 out of 33 cases. Polson
12
and Gee found the fracture of superior horn of thyroid cartilage in 31 out of 80 cases
(almost 50 %) 15.
Nikolic et al found that most frequent injuries were the muscle hemorrhages
brought by direct pressure as well as indirect stretching of these structures. Frequency of
hyoid bone fractures was more in victims older than 30 yrs (10-87yrs). Factors like age,
point of suspension and width of the ligature carried considerations. Fractures of superior
horns of the thyroid cartilage were most frequent injuries of the solid neck injuries.
Factors like age, location of the knot, location of the ligature, length of the ligature and
possible swing carried considerations16.
Of the 655 cases of hanging studied by Matthew et al 84% were male with a
mean age of 30.3 yrs. 119 of these cases were admitted in the hospital. They suggested
that evaluation and diagnostic priorities should focus on potential injuries to the airway,
cervical & upper thoracic spine, cervical vascular structures and Central nervous system.
459 cases showed at least one injury, 185 cases had multiple injuries, 74% had brain
hypoxic changes on CT scan and spinal injury was documented in 18% of cases. 45 cases
had cervical sprain, 26 cases had vertebral fracture and overall vertebral fracture was
found in 7% of cases. Penn et al reviewed 42 cases of suicidal hanging and found 2 spinal
fractures both in the thoracic vertebra. Matsuyama et al found only 4 cervical fractures in
42 cases studied17.
In a study of 134 cases autopsied in Turkey by Azmak et al over a period of 21
years, hanging was found to be the most common asphyxia death (56cases). 83% of the
cases were male with an age range of 14-97 yrs and the mean age being 41.6 yrs. 67%
cases hanged themselves indoors. 54 of the 56 cases were complete hangings. Prominent
13
ligature mark was present in all the cases and knot was under the occiput in 66% of the
cases. 26 of the 56 cases of hanging had hyoid bone fracture (46.4%). 10 cases had
thyroid cartilage fracture (17.8%). 7 cases had both the fractures (12.5%). 51% cases had
bleeding in the neck muscles. Elfawal and Awad State that, in their study there was no
fracture of the hyoid bone, thyroid cartilage, and cervical spine noted in any of the
victims. There was no relation to injury to solid neck structures and type of the ligature
material or suspension18.
In their study of 67 cases by Nichols et al over a period of 17 years, they noted
that laryngeal fractures and carotid arterial injuries were present in few cases however
cervical spinal fractures were not noted though subluxation were identified19.
Tarequi et al reported a case of a 22 yr old man weighing 87.5 Kgs was
reported who committed suicide by jumping from a bridge over a canal with a nylon rope
tied around the neck with decapitation at C1-C2 level. It is a very rare scenario in suicidal
hanging and is nearly always related to high drop and non extensible ligature material
used 20.
In the 162 cases of suicidal hanging studied by Bennewith et al the most
frequently used ligature materials were ropes, cables and belts. The most common
suspension points were beams, grids and trees commonly available in the local settings.
52% cases were complete hangings, mean age for males was 40.6 years and for females
was 42 years. 64.4% hanged themselves in their homes and 4.3% survive till they
received some treatment. 49% used ropes as ligature material, 13.1% used belts and
11.9% used cables. Roof and ceiling were used as point of suspension in 1/3 rd of cases
14
(35.8%). In outdoor settings trees were the most common choice. In cases of incomplete
hanging 23% had feet touching the ground, 7.4% were kneeling, 8% were seated21.
Given that most fatal hangings are suicidal and occur in locations that have
been selected to conceal this activity (thus maximizing the chances of a lethal outcome),
there has been very little corroboration of the speed with which unconsciousness and
death may occur. A 35-year-old male is reported by Gilbert et al who committed suicide
by hanging immediately after talking to his spouse. Police investigations confirmed her
reliability as a witness indicating that lethal anoxia in this case had occurred within a very
short time (most likely in less than 1 min) of suspension. The speed with which death
may result from hanging not only gives an insight into fatal patho-physiological
mechanisms, but also provides useful information for situations where a lethal outcome is
to be avoided, or is not intended22.
Most of the victims are males younger than 40 years old with a history of suicide
attempts. Unlike judicial hanging, where the body falls from a great height resulting in
certain death, suicide hanging has a rather optimistic survival prognosis, as the fatal spinal
cord and skeletal injuries are rare with a favorable neurologic outcome. Patients with
spontaneous circulation on scene usually survive; therefore, aggressive resuscitation and
management of hanging victims are justified. A case of 44-year-old patient with a history
of a depressive disorder and a previous failed suicide attempt was brought to Costache et
al few hours after a suicide attempt by hanging. . Cervical and thoracic computed
tomography (CT) revealed a complete tracheal rupture starting from the 3rd cervical
vertebrae up to the 5th cervical vertebrae. Complete tracheal section between the cricoid
15
bone and the first tracheal ring associated with a bilateral injury of the superior laryngeal
nerves was noted 23.
A case of accidental autoerotic hanging with 40 cm x 1cm ligature mark with a
blue thin rope running obliquely towards the right mastoid was reported by Memchoubi
et al. Internally, there was fracture of the hyoid and transverse tear of intima of both
common carotid arteries. Viscera were congested. Blood was dark and fluid. Stomach
was full Death was concluded to be due to asphyxia as a result of hanging24.
A case of a typical form of sexual asphyxiation was described by Gilles et al,
involving a young man hanging; in a context of Autoerotic asphyxia. Faint ligature mark
with no internal tissue damage or injury was noted, classically consistent with incomplete
hanging25.
Spence et al in a study of six cases of judicial hanging transverse fracture of the
C1 cervical vertebrae and fracture of the body of the C2 cervical vertebrae in one case was
noted. Three cases showed fracture of the C2-C3 cervical vertebrae. One case showed
fracture of the posterior tubercle of the C5 vertebrae. All cases had the knot in the left sub
aural region26.
In a review of 231 cases of suicidal hanging by Anne Godin et al, 4 cases of
homicidal hanging and 52 cases of strangulation was done. In the cases of hanging 194
were male and 37 were women with a mean age of 34.5 yrs. It showed that in 23.4% of
cases of hanging had neck structure fractures where as in 65.4%cases of strangulation
neck structure fractures were found. Isolated fracture of the hyoid bone was found in
2.6% cases of hanging (6 cases). Isolated fracture of the thyroid cartilage was found in 43
16
cases (18.6%) and combined fracture of the thyroid cartilage and hyoid fracture in 2.2%
(5cases). Thyroid fracture was the most common fractured neck structure in hanging27.
Details of the fractures found in the study are as follows27:-
Thyroid cartilage:
 Left superior horn-35%
 Right superior horn-27%
 Bilaterally in superior horn-31%
 Fracture of the lamina-2%
 Combined lamina and superior horn-4%
Hyoid bone27:
 Left greater horn-27%
 Right greater horn-54%
 Bilateral greater horn-18%
Average age of the fractures was found to be 40.8 years27.
Of the 233 cases of suicidal hanging studied by Samarasekara et al 122 cases
showed injuries to the neck. These injuries were more common in cases of complete
hanging (62%) than in case of incomplete suspension. Prevalence of the neck injuries in
the cases of slip knot (58%) was similar to that in fixed knot (60%). Petechial
haemorrhages as a hallmark of asphyxiation were present in 113 of the 233 cases.
Observable ligature mark on skin is seen in 230 cases of 233 cases (90%) 28.
The vertebral artery was shown to be injured quite frequently (rupture, intimal
tear, sub intimal haemorrhage) namely in 1/4th of the cases and more than half of these
17
had per vascular bleeding. Frequencies of the vertebral artery injury were more common
than carotid intimal injuries29.
Death is usually due to asphyxia as unlike in judicial hangings as the height of
the drop is insufficient to cause spinal injuries in suicidal hanging. 3/4th of the cases occur
at home. Ligature materials used most commonly are ropes, belts and electric cables.
Suspension points used are mainly beams, hooks, or door knobs. 50% of the cases were
complete hangings and of the partial hangings 8% were kneeling, 8 % sitting in
position30.
In their study David Gunnel et al noted that males outnumbered the females.
The ratio was 6.4: 1. The youngest case to commit hanging was about 9 years of age.
Most of the cases were below 40 years of age and above the age of 15 years. The ratios in
other parts of the world are reported as follows: US 4.3:1, India 1.2:1, China 0.9: 1 and
Europe 4.3:131.
In this case report by Donald et al a 31 yr old male committed suicide by
hanging with a 7/8 braided hemp rope with a knot on left side of neck immediately below
the left ear; the height of the jump was 7 feet. Neck dissection showed extensive and
abundant haemorrhage in the muscles and soft tissues. Haemorrhage into the facial planes
in the peri-vascular region was noted. Incomplete tears of the intervertebral ligaments of
the C2-C3 cervical vertebrae. Carotid artery was normal. Midline thyroid cartilage fracture
and fracture left wing of the ossifying hyoid bone was present. Haemorrhage into the
strap muscles was present32.
Sub cutaneous tissue under the ligature mark will be condensed, hardened,
glistening and whitened without any evidence of any extravasations of blood. In 40 % of
18
the cases hyoid bone showed avulsion fracture at the junction of the cornua and the body,
especially in people above 40 years of age. Intimal tears in the carotid artery, transverse
in nature may be present occurring due to stretching of the artery33.
Fibers of the platysma and the stermo-mastoid muscles are torn sometimes
and posterior horns of the thyroid cartilage may be fractured from the pressure on the
thyroid ligament but the hyoid is rarely injured except in cases where the age of the
decease is above 40 years as there is increased calcification and brittleness of the bone.
Such fractures involve the greater cornua at the junction of the inner two third and outer
one third, the broken fragments being displaced outwards. The periosteum is torn only on
the inner side of the fracture. If the suspension has taken place when the person is alive
there usually is hyperaemia of the lymph nodes and larynx. Frictional tears in the intima
of the carotid with sub intimal haemorrhage are also noted in some cases34.
Of the 1746 cases studied by Sharma et al, male to female ratio was 2:1 and the
most common age group was between 21-30 yrs. Majority used a saree or chunni as the
ligature material and in one row (80%).Injury to the sternocledo mastoid muscle was the
most common injury (54%) noted. Hyoid bone was fractured in 21% of the cases and the
thyroid cartilage was found to be fractured in 17% of the cases. 68% of the cases were
complete hanging, 88% were that of atypical hanging and 71% of the cases had fixed
knot. The most common age for fracture was between 41-60 years (72%) and 53% had
the knot placed on the same side as the fracture. Six cases of group had injury to the
carotid arteries35.
Among the hyoid fractures the left greater cornua was the most common to
fracture (69%), stern mastoid haemorrhage was more common in the cases of typical
19
hanging while fracture of the right superior horn of hyoid bone was the more common
injury in both typical and incomplete hanging. In 85% of cases the ligature mark was it or
above the level of the thyroid cartilage35.
It was noted in their study that males were predominantly affected with a male
female ratio of 2:1. Mean age in males was 40.6 years and in females was 29.6 year. Peak
age of attempted suicide by hanging was between 3rd -5th decade36.
In the analysis of two cases of judicial hanging by Ct and MRI it was found by
Wallace et al that in the first case there was disruption of the posterior and anterior
cruciate ligament with fracture of the C5 cervical vertebra transverse process with
associated thyroid cartilage fracture and peri-vascular haemorrhage. Angiography showed
the laceration of both vertebral arteries but carotid arteries were found to be intact. In the
second case posterior subluxation of the C2-C3 inter space was present with the
transaction of the spinal cord at the same level. Haemorrhage into the soft tissue of the
neck was present. Knot of the ligature was placed under the ear in both the cases37.
A comprehensive review of literature over the past 15 years focusing on near
partial hanging cases by Rayson et al showed that laryngeal injuries may occur. Thyroid
cartilage fractures are the most common with fractures of the hyoid bone and cricoid
cartilage seen less often. Damage to these structures is more common in those over 40
years due to calcification and where a narrow ligature has been used. The patterns of
injury in near partial hanging are quite different to those seen in judicial hanging.
Cervical spine injuries are quite rare. Injury mainly arises through pressure on the neck
veins and arteries. Compression of the airway is less common. The external compression
20
causes venous cerebral congestion, hypoxic circulation and reduced arterial cerebral
supply38.
Other described injuries include traction injuries to the carotid arteries where
bleeding into the vessel wall or intima occurs. This can lead to immediate or late
obstruction to blood flow. Hyperthermia, status epilepticus, subarachnoid haemorrhage,
ruptured oesophagus and pneumo-peritoneum have all been described38.
In a survey of 80 cases of suicidal hanging by Simonson et al it was noted that
thyroid cartilage fracture and hyoid bone fracture was noted in 45 % of cases. Cricoids
fracture was not reported in any of the cases of hanging. The frequency of neck skeleton
fracture increased with increasing age of the deceased and no fracture was reported in
cases under the age of 25 years, males hand more predominance of the fracture of the
neck skeleton than females and fracture rate was higher in typical and complete hanging
cases. Incomplete hanging to a very great extent was combined with congestion to the
face, especially if the location of the ligature was atypical. Typical hanging in general did
not produce congestion 39.
In a study of five cases of suicidal hanging by Duband et al, the ligature
mark on the neck was always above the thyroid cartilage prominence. Four cases showed
subcutaneous haemorrhages and 4 cases showed intra muscular bleed and peri vascular
haemorrhage was found in only one case. Hyoid bone fracture was found in one case.
Lymph node bleeding was found in three cases. Epidural and cervical spine bleeding was
found in one case40.
Of the 257 cases of hanging studied by Patil et al 245 had the ligature mark
above and at the level of the thyroid cartilage and there was not a single victim of hyoid
21
bone fracture in hanging. The percentage of hyoid bone fracture varies from 0% to 68%
in case of death due to hanging as reported in some of these proclaimed studies41:
 Routor [1901] - hyoid bone fracture was found in 60% of typical and 30% of
atypical case of hanging.
 Smith and Fiddes- did not report any case of fracture in hanging.
 Wintraub- reported fracture in 27% of cases.
 Modi J P – states that hyoid fracture is rare in cases of hanging.
 Mukharjee J B- did not report any fracture of hyoid bone in 500 cases studied.
 Throat skeleton fracture was reported in 67% of cases by Betz, Panal,
Eissenmenger.
 Apurba Nandi- reports that hyoid bone fracture does not occur in more than 5-10
% of cases of hanging.
 K S N Reddy-says that hyoid b one fracture occurs in 15-20 % of cases of
hanging but also says it is rare below the age of 40 years.
 Nikolic S Et al – reported in a study that 68% cases of hanging had throat skeleton
fractures.
A total of 72 suicidal hanging cases that took place in Konya between 2002
and 2006 were included in the study by Demirci et al. The cases were aged between 12
and 92 years and the average age was 42.5 years. The ratio of male to female was 11:6.
Partial hanging was determined in 12 (71%) cases, whereas hanging was complete in 5
(29%) cases. It was observed that the position of the noose was atypical in 3 (18%) cases,
whereas it was typical in the remaining 14 (82%) cases. No significant injury to any of
the neck structures was noted other than the ligature mark and asphyxia signs42.
22
Of the 307 cases that were studied by Feigin et al over a period of four years,
275 were male and 42 were female. Fractures of the thyroid cartilage, hyoid bone, and/or
cervical spine were found in 29 of these cases; 4 in females (9.5%) and 25 in males
(9.1%).The age range of the cases with neck organ fractures was 12 to 87 years. Sixteen
of the ligatures were one cm in width or less. The remainders were wider than 3cms. Of
the fractures observed, 21 were of the thyroid cartilage, 10 were of the hyoid bone, and 3
were of the cervical spine. Of the thyroid cartilage fractures, 20 were of the greater horn,
and 1 was of the lower quarter. Of the hyoid fractures, 11 were lateral, and 1 had no
description regarding location. The 3 cervical spine fractures were located at C1-2, C3-4,
and C6-7. In no case were there >2 fractures of the neck structures in any one person.
One of the spinal fractures was in a case of a child ages 12 years though he did not have a
high suspension/fall. This points out to the extreme variability in the finding of cervical
spine fractures and the lack of predictability in their occurrence43.
In 73 of 109 investigated cases (67%) by Betz et al, at least a single fracture of
the throat skeleton was found, and the youngest individual with positive findings (boy,
suicide, fracture of the right superior horn of the thyroid cartilage, highest point of the
ligature mark in the left occipital region) was aged 14 years. The oldest individual
without fractures of the hyoid or thyroid horns was aged 81 years44.
In 28 of the 73 individuals (38% of the positive cases), a single fracture of the
hyoid or thyroid cartilage horns was found, and 27 individuals (37%) had two horns of
the throat skeleton broken. In 11 cases (15%), a threefold fracture was observed, and in
seven further individuals (10%), all the four horns of the hyoid and thyroid cartilage were
23
injured. In three cases, the deceased had dropped into the ligature, leading to a rupture of
the intima of the left carotid or a total destruction of the thyroid cartilage, including the
greater horns44.
The largest category of asphyxial homicides was ligature strangulation. There
were 48 such deaths in the study by Dimaio (21 male, 27 female). The large number of
male strangulation victims was a surprise. Internal examination of the structures of the
neck revealed fractures of the hyoid and/or thyroid cartilage in 6 cases (12.5%). Five of
the victims were male and 1 was female. In these 6 cases there were a total of 12
fractures: 7 of the hyoid and 5 of the thyroid. Four of the 6 victims had fractures of both
the hyoid and thyroid, and 2 victims had only fractures of the hyoid. The fractures of the
thyroid cartilage all involved the superior horns45.
The second largest category of asphyxial deaths was manual strangulation. There
were a total of 41 deaths involving 27 female and 14 male victims: a ratio of 1.9 to 1.
Internally, there were fractures of the hyoid, thyroid, or cricoid cartilage in all 14 male
victims and in slightly more than one half (14 cases) of the female victims. The average
age of the male victims was 50 years compared with 33 years for the female victims;
thus, the male victims were more likely to have had calcification of the neck structures.
Of the 14 female victims with fractures, all had fractures of the hyoid, either alone (5
cases) or in combination with other structures (9 cases). The 14 male victims had
fractures of the hyoid, either alone (4 cases) or in combination with other structures (6
cases). Two individuals had fractures limited only to the thyroid cartilage, and 2 had
24
fractures limited to the cricoid cartilage. All the fractures of the thyroid cartilage involved
fractures of the superior horns45.
Among the six cases of judicial hanging studied by Spence et al five cases
showed cervical spine injury. Among the other injuries seen were fractures of the hyoid
cornua, styloid process, occipital bone and cervical vertebra bodies [C2] and transverse
process of C1, C2, C3, and C5. Three cases had relative rotation of the involved vertebra.
One case had C2-C3 dislocation with transaction of the spinal cord due to the ligamentous
disruption46.
Weight ranges for hanging of male persons in different body positions are
presented by Khokhlov et al: in standing posture the ligature is stretched by more than
65% of the body weight, in kneeling position by 64–74%, in sitting by 17–32%, in
recumbent posture by less than 18% of the body weight. In 108 cases of suicidal hanging
trauma to the neck complex (fractures, infractions, fissures) was found in more than 64%
of cases. Vulnerability index hyoid bone/thyroid cartilage was 1.75 in complete hanging
of the body, 0.88 in standing position, and 0.63 in kneeling, 0.33 in sitting, 0.25 in
recumbent posture47.
A total of 19 suicides and 63 homicides were investigated in this study by
Maxeiner et al and it was noted that only 20% of the homicidal victims had no injuries
except those caused directly by strangulation, whereas this was seen in 80% of the
suicides. Less than 20% of all homicides but more than 50% of the suicides had no
internal injuries. In suicides, the sterno-mastoid muscle was the most affected muscle.
Except for one case, not more than one muscle bleeding per case was present. In the
25
suicide group, a single fracture of an upper thyroid horn was found in only two cases, a
fracture of a lower thyroid horn in another case was probably the result of a blunt trauma.
Fractures of the laryngohyoid complex were found in 21 homicides. Even if the factor
―age‖ was considered by excluding young victims and matching homicidal and suicidal
victims with similar age, the prominent difference in the laryngo-hyoid fractures
remained stable, and no clear influence of the type of the ligature material in both groups
resulted48.
In this study of 80 cases of suicidal hanging by Monlid et al careful dissection of
the neck and an X ray cabinet with ready made films in envelops were used to register all
fractures. There were 73% men and 27% women in the study. The proportions of
fractures registered seem to increase with age and possibly also with increasing
suspension time. The highest frequency of the fracture was found in atypical complete
hanging49.
Men attempt hanging 3 times more often than women. Injury to the laryngotracheal
apparatus may be caused by compression or traction of the involved structures. Fractures
of the hyoid bone and thyroid cartilage are seen with some regularity while cricoid
fractures are less common. The incidence of these fractures increases with greater age of
the patient probably due to calcification of the structures. The incidence of thyroid and
hyoid fractures in hanging victims is in the 10 to 15% range; cricoid fractures are rare50.
In the late 19th and early 20th centuries, British postmortem studies of judicial
hanging demonstrated that a minimum drop force (patient weight multiplied by the length
of the drop) was needed to cause a cervical spine fracture. The required drop height varies
26
depending on factors such as the weight of the subject, the neck musculature and the
strength of the bone itself. Although generally a drop height greater than the patient’s
height is required to cause a spinal fracture, in rare circumstances shorter drop heights can
produce these injuries. The minimum reported drop height is 3 feet. The most common
spinal injury with long drops is disjointing of the second from the third cervical vertebra
and bilateral fractures of the second cervical vertebra, the classic Hangman’s fracture. The
position of the knot is important. In typical hangings, the knot is placed under the occiput
and has the greatest ability to cause arterial occlusion rather than a spinal fracture50.
A study was conducted by Sharma et al retrospectively (1994 to 1999) and
prospectively (2000 to 2003) on 108 cases of hanging. Seventy-one per cent of the cases
were male and 29% female, aged between 15 to 60 years. Hanging was typical in 20% of
cases and atypical in 80%; it was complete hanging in 46% of cases and incomplete in
54% of cases. Neck structure fractures were found to be more common in atypical
complete hangings; the incidence was found to be 10% in the retrospective group and
27% in the prospective group. Contusions and lacerations of musculature were found in
20% of cases in the retrospective group and 34% in the prospective group51.
A 33 year old woman as reported by Linnau et al after attempting hanging
sustained cricoid fracture– dislocation and cricotracheal disruption, sequenced CT
angiography of the neck and catheter angiography of the carotid arteries showed
subintimal hematomas in both common carotid arteries. Luminal diameter was narrowed
by 60% on the right side and 30% on the left. With loss of consciousness, decreased
27
muscle tone facilitates arterial obstruction and intimal tears, which are found at the level
of the ligature in about 5% of autopsies of hanging victims52.
There is no specific gold standard to distinguish between ante mortem
hanging and postmortem suspension. However presence of -
• Vertical salivary dribble mark from the dependant angle of mouth.
• The phenomenon of Le Facies sympathique.
• Hyperemia and echymosis of margins of ligature mark.
• Horizontal tear of the intima of carotid artery at level of ligature with infiltration around
are considered as ante mortem features of hanging.
Horizontal tear of the intima of the carotid artery is also very rare
phenomenon observed in 1% cases only. Of the hundred cases of suicidal hanging studied
by Shivasuthan et al Fifty-nine were males and 41 females, ranging from 12 to 78 year
age group. 62 percent of cases showed rupture of the lower attachment of sterno-mastoid
muscles. It is found that in the age group of 32 to 41yrs, the prevalence is significantly
low to the tune of 37% as against 62% generally53.
4. Carotid Artery Injuries:-

Though the sudden vagal inhibition type of death caused by pressure on the
Baro-receptors of the carotid sinus and sheath is quite common it is unusual to find
anatomical confirmation of injury to these structures. There may be deep hemorrhage in
the neck tissue surrounding and adjacent to the bifurcation of the common carotid artery,
28
but this is often absent in case of cardiac arrest and may be prominent in slow asphyxia
deaths. Rarely careful dissection of the carotid arteries may reveal an intimal tear or
bleeding into the wall of the vessels or near the carotid sinus54.
A delicate technique is required and artifactual damage must be carefully
excluded especially that from the point of scissor used to silt open the artery. Such tears
are more often found when a forcible impact or a more focal pressure has been applied,
such as from a thin ligature that can cut deeply and abruptly into neck especially in
hanging54.
In some cases extravasations of blood is present around the carotid arteries and
rarely small transverse intimal tears of the carotid arteries are caused by the thin ligature.
Intimal tears of jugular veins are even less common11.
In cases of hanging where fall or jump into the strangulation device precedes
the suspension, another phenomenon that is found is the disruption of the intima of the
carotid artery and rarely rupture of the media with surrounding hemorrhage can occur.
However vertebral arteries are more frequently injured than carotids, mostly with peri-
vascular but also with subintimal bleeding and disruption of the intima13.
The neck blood vessels injuries are rare; when present there was higher
tendency of their occurrence to the ipsilateral side related to the location of the ligature
knot suggesting their production due to traction rather than direct pressure on the blood
vessels. Damage to the intima of the carotid arteries usually around the region of the
sinuses with extravasations of blood in their walls occurs particularly in case of long
drop15.
29
Blunt carotid artery injuries have been associated with any severe
hyperextension and rotation of the neck, usually resulting in intimal tears and dissection.
Maier et al described a case of bilateral carotid artery occlusion secondary to hanging and
recommended carotid evaluation in all hanging victims17.
Injury to the carotid arteries is caused by hyperextension and rotation of the
head. The carotid artery can be stretched over the transverse process of C2 or compressed
by direct pressure over the transverse process of C6. This result in an intimal tear
.Vertebral artery flow is not affected by direct pressure except at the extremes of rotation
and lateral flexion50.
The an investigation of the neck structures drawn from 145 cases of asphyxia
involving pressure on the neck by Ciprian et al during January 1, 1999, to May 1, 2001,
has pointed out in 3 cases, besides the classic signs already known, a particular lesion
unmentioned yet in the literature, namely, a pericarotid bone splinter, placed in the
proximity of the common carotid artery bifurcation. The bone splinters had dimensions
between 0.25 and 0.7 mm and a certain ante-mortem character, surrounded by
hemorrhagic areas and by fibrin. The 3 cases deal with adult males who had died through
complete hanging, with the knot placed lateral, the hanging mark having the maximum
depth in the later cervical region, correspondent with our finding. This sign appeared
neither at other types of hanging nor at strangulation by hand or by ligature55.
The carotid vessels were the location of many types of lesions. Most frequently,
there were found hemorrhagic infiltrations of the arterial adventice and of the
periadventicial conjunctive tissue, with uni- or bilateral locations. There were also found
30
parietal tears affecting the intima and a part of the media (the Amussat sign), with the
hemorrhagic dissociation of the elastic fibers55.
Hanging was complete but with the knot placed laterocervically. The loops
were made of hard material (wires, rope, and string). The bone splinter was placed at the
level of the carotid bifurcation, unilateral, opposite to the knot of the loop. The ante
mortem character of this lesion was proved by the appearance of hemorrhagic
infiltrations and of fibrin in the soft tissues surrounding the bone splinter excluding, in
this way, its occurrence hanging, traction that is less strong in other types of neck
compression (strangulation) 55.
This study by Wahlen et al highlights two cases of partial hanging with no
signs of any lesion in the carotid artery like intramural bleeding, dissection of the medial
layer or horizontal rupture of the intima, media and adventitia even though vascular
injuries are reported in 5-20% of cases in hanging56.
Blunt trauma can cause carotid artery dissection indirectly by forcing the
head into hyperextension and stretching the internal carotid artery over the bony
processes (transverse) of the cervical vertebra. Blunt trauma accounts for approximately
10% of acute traumatic carotid artery injuries. Stretching of the carotid artery during
hyperextension can give rise to an intimal tear that can dissect and occlude the artery or
serve as a nidus for thrombus formation and subsequent intracerebral embolization. The
presentation of carotid artery dissection is highly variable and nonspecific. Only 10% of
patients display immediate symptoms, 55% demonstrate symptoms within the first 24
hours, and 35% exhibit no symptoms until 24 hours or more after injury57.
31
Here Kiani et al report a case of accidental hanging in a deceased aged 24
years who survived after the incidence and showed bilateral internal carotid thrombosis in
CT scan. No bony or cartilaginous damage was sustained in our patient. The force
required to obstruct the carotids is slightly greater than that needed for the jugular veins;
3.5kgs for carotids compared with 2kg for the jugulars. Traction on the arterial structure
can lead to intimal damage and subsequent thrombosis and obstruction. An autopsy series
of 101 hanging cases failed to demonstrate any intimal tears58.
Traumatic thrombosis of the internal carotid artery is reported as being
caused by one of the four mechanisms:
 Injury to the intrapertous or cavernous part of the carotid artery during basal skull
fractures.
 Injury to the point of emergence of the carotid artery from the cavernous sinus as
the result of shearing strain.
 A direct blow to the neck or trauma to the paratonsillar area by a foreign body in
the mouth.
 Stretching of the carotid artery by hyper extension and lateral flexion of the neck
as can be expected in cases of hanging58.
In manual strangulation cases the histology of the carotid artery shows
extensive hemorrhage surrounding the carotids in some cases. The external
carotid arterial lumen shows rupture with detachment of the tunica intima. These
tears are not transversally oriented to the axis of the common carotid artery as we
can see in Amussat’s sign in cases of hanging. In manual strangulation the intimal
tears run parallel to the longitudinal axis of the carotids. Such tears are more often
32
found when a forcible impact or a focal finger pressure has been applied to the
neck. They are found more often over the anterio-lateral border of the carotid
arteries. In hanging the tears are typically placed transversely (horizontally)
perpendicular to the longitudinal axis of the carotid arteries59.
33
Materials and Methods
The study was conducted in the Department of Forensic Medicine, Victoria Hospital
attached to BMCRI for a period of eighteen months from December2008 to may 2010.
The cases of death due to history of hanging being brought to the Victoria hospital
mortuary were selected for the study. The following criteria was used for the selection of
the cases-
Inclusion Criteria:-
1. All the cases of death due to hanging.
2. Cases belonging to both the sexes.
3. Both treated /untreated cases of hanging.
Exclusion Criteria:-
1. Cases with cause of death suspected as other than hanging.
2. All decomposed cases as the reliability of Internal finding and histopathology
examination in questionable.
A detailed Porforma of the findings to be evaluated was made before the start of
the study to have uniformity in the pattern of collection of data. Meticulous autopsy was
conducted with special reference to neck structures and the findings were tabulated for
further analysis. Further detailed information regarding the deceased, circumstances of
death, position of the body and suspension were collected from the relatives, police, and
examination of scene of occurrence and their photography.
34
Method of neck Dissection:-
For blood less dissection of the neck the Thoraco-abdominal contents and the brain
were removed before proceeding to the neck dissection. A block of 12-20 cm high was
placed under the shoulders to allow for minimal extension of the neck to aid dissection.
After the evisceration neck dissection was undertaken following the protocol of
―Prinsloo and Gorden‖. It is the layer by layer dissection of the neck with first incision
being immediately deep to the skin through the platysma and under surface of each layer
inspected before proceeding further. Then the lower end of Stermo-mastoid muscle was
cut so as to examine the clavicular end and sternal end of the muscle for extravasations of
blood. Further the Omohyoid muscle was resected and the strap muscles cut at the lower
end and lifted up to expose the carotid sheath and thyroid gland along with other
laryngeal cartilages. The surface of all the structure was examined for hemorrhage. The
carotid sheath was opened anteriorly so as to expose the Internal Jugular vein and carotid
artery.
The carotid artery was resected lower down at its origin and the internal and
external carotid arteries cut as distally as possible. Blunt forceps was used to handle the
artery during dissection and care was taken to use as minimal handling as possible
required avoiding art factual injuries.
Further the mouth is opened and the tongue is pushed upwards and backwards.
The knife is inserted under the chin through the floor of the mouth and cut along the sides
of the mandible to the angle of the mandible dividing the neck muscles attached to the
35
lower jaw. At the angle of the mandible the blade is turned inwards and the tongue is
pushed down under the mandibular arch, soft palate is cut including the uvula and the
tonsils with the tongue and other neck organs removed enmass. Posterior attachments
were freed from the per-vertebral muscles.
The vertebral bodies and the inter-vertebral discs are further inspected. The
laryngeal cartilages were also further dissected and inspected for any fracture or
extravasations of blood. The carotid arteries were opened longitudinally on the anterior
surface for inspection of any Intimal injuries or tears and finding duly noted. In cases
where gross tears were found, the carotid arteries were preserved in 10% formalin and
submitted for Histo-pathological examination.
Histo-Pathological examination:-
The drawing of the carotid bifurcation is considered to be very important as this is
a genuine traumatic center in the pressure of the neck. Every drawn organ, when taken to
the pathology laboratory, had its own description of the autopsy findings and a few data
of judicial investigation. The examination in the pathology laboratory took place after a
fixation with formaldehyde for at least 24 hours and comprised 2 stages:
1. Macroscopic stage:-
We measure the length of every carotid artery and the distance between proximal
extremity of the carotid and the bifurcation. The arteries were examined for the presence
of atherosclerotic regions, hemorrhagic lesions, gross tears, intimal disruptions and any
other abnormality.
36
A minimum of three drawings for microscopy was done in the following places
 Four centimeters from the proximal end of carotid arteries.
 Carotid bifurcation.
 At the branches of carotid arteries.
Further drawings for microscopy were done at the site of the tears, carotid
disruption (intima) and hemorrhagic areas if found on examination. A block was cut
perpendicular to the transverse tears, processed and embedded vertically.
2. Microscopic stage:-
This consisted of paraffin inclusions and followed by microtome sections with width of
3-4 micrometers and standard coloration of hematoxylin-eosin was done.
Further special stains were employed for a few selected sections for better differentiation.
Statistical techniques:-
Data was expressed using descriptive statistics such as rates, ratios and
means. The statistical software namely SPSS 16.0 was used for the analysis of the data
and Microsoft word and Excel have been used to generate graphs, tables etc.
37
Results and Discussion
A total of 152 cases of hanging brought to Victoria Hospital Mortuary were studied over
a period of 18 months between December 2008 and May 2010. The sample consisted of
150 cases of suicide, one case of homicide and in one case the manner of death is still
under discussion.
Age, Sex and Distribution of other variables in the study group.
TABLE 1: - SEX
Sex
Cumulative
Frequency Percent Valid Percent Percent
Valid male 97 63.8 63.8 63.8
female 55 36.2 36.2 100.0
Total 152 100.0 100.0
The sample consisted of 97 males (64%) and 55 females (55%), indicating a male: female
ratio of nearly 2:1 in the study. Males are twice as more likely to commit suicide by
hanging. This observation is similar to what was also observed by Mathew J Martin et
al17, Derya Azmak et al18, Victor S Costache et al23 and Anny Godin et al27. However a
much higher male to female ratio was shown in studies by B L Meel et al31 and Demirci
et al42.
38
TABLE 2:- AGE
age
Cumulative
Valid 10-19 18 11.8 11.8 11.8
20-29 72 47.4 47.4 59.2
30-39 37 24.3 24.3 83.6
40-49 18 11.8 11.8 95.4
50-59 5 3.3 3.3 98.7
>60 2 1.3 1.3 100.0
Total 152 100.0 100.0
The above table clearly shows that age group of 20-29 years are most vulnerable to commit
suicide by hanging. Nearly 71% of the cases belong to the age group of 20-49 years involving
the most functional group of any population.
FIGURE 1:- Age and Sex distribution of cases.
39
The graph shows that the distribution of cases among both the sex differs a little. Females show
predominance at a slightly younger age (10-29yrs) to commit suicide by hanging than males (20-
39yrs). The influencing factors for the above distribution could have been unemployment, love
disappointment, marital disharmony, financial problems, dowry harassment etc.
Similar finding were reported by Mathew J Martin et al17, Derya Azmak et al18, Victor S
Costache et al23, Anny Godin et al27, B L Meel et al31 and Demirci et al42.
TABLE 3:- Place of occurrence.
Place of occurrence
Frequency Percent Valid Percent Cumulative Percent
Valid house 140 92.1 94.0 94.0
open 5 3.3 3.4 97.3
hotel 2 1.3 1.3 98.7
prison 1 .7 .7 99.3
Tree 1 .7 .7 100.0
Total 149 98.0 100.0
Missing System 3 2.0
Total 152 100.0
The above table shows that a majority of the people 140(92.1%) attempted suicide indoor in their
house and a very few attempted suicide out door in gardens (3 cases). Especially women nearly
all the cases occurred at home. Similar trends were documented in the studies reported by Derya
Azmak et al18, Olive Bennewith et al21 and David Gunnell et al30.
40
TABLE 4:- Suspension Point
Suspension point
Valid fan hook 63 41.4 41.4 41.4
window pane 9 5.9 5.9 47.4
Staircase 1 .7 .7 48.0
hook/roof 70 46.1 46.1 94.1
Tree 4 2.6 2.6 96.7
Others 4 2.6 2.6 99.3
Not sure 1 .7 .7 100.0
Total 152 100.0 100.0

The above table shows that fan (41.4%) and Hooks on the roof (46.1 %) were the most
commonly used suspension points to tie the ligature. Few cases used trees, window panes and
one case staircase was used. Similar findings were reported by Derya Azmak et al18, Olive
Bennewith et al21 and David Gunnell et al30.
TABLE 5:- Ligature Material used
Ligature material
Cumulative
Valid bed sheet 5 3.3 3.3 3.3
cable 3 2.0 2.0 5.3
lungi 10 6.6 6.6 11.8
rope 31 20.4 20.4 32.2
saree 65 42.8 42.8 75.0
towel 4 2.6 2.6 77.6
veil 33 21.7 21.7 99.3
others 1 .7 .7 100.0
Total 152 100.0 100.0
41
TABLE 6:- Type of Ligature Material
Material
Cumulative
Valid cotton 35 23.0 23.0 23.0
Jute 5 3.3 3.3 26.3
nylon 26 17.1 17.1 43.4
synthetic 82 53.9 53.9 97.4
wool 1 .7 .7 98.0
others 3 2.0 2.0 100.0
Total 152 100.0 100.0

The above tables indicate that most of the subjects used sarees (42.8%) or ropes
(20.4%) as ligature material. Synthetic material were the most commonly used by the study
group (53.9 %) followed by cotton material (23%). The material which are commonly available
at home or the materials available at the time of impulse to commit suicide are commonly used.
This finding is also documented in the studies conducted by A Traequi et al20, Olive Bennewith
et al21 and David Gunnell et al30.
TABLE 7:- Type of Hanging
Type of hanging
Cumulative
Valid complete 91 59.9 59.9 59.9
incomplete 61 40.1 40.1 100.0
Total 152 100.0 100.0
This table shows that 91(59.9%) cases were that of complete hanging with the body completely
suspended . this seems to be consistent with the fact that the suspension point most commonly
42
being hook or fan in the room providing sufficient height for suspension. This is a fact consistent
with other studies reported by Derya Azmak et al18, Olive Bennewith et al21, David Gunnell et
al30 and B R Sharma35.
Association of pattern of injuries and the variables under study.
TABLE 8:- Age, sex and injury pattern in the neck
Sterno-mastoid strap muscle thyroid# hyoid # vertebral #

Male Female Male Female Male Female Male Female Male Female
10-19yrs nil 2 nil nil nil nil nil nil nil nil
20-29yrs 14 8 6 nil 1 nil 1 nil nil nil
30-39yrs 7 2 nil nil nil nil 1 nil nil nil
40-49yrs 6 Nil 1 nil 1 nil nil nil nil nil
50-59yrs 2 Nil nil nil nil nil nil nil 1 nil
>60yrs 1 Nil nil nil nil nil nil nil 1 nil
FIGURE 2:- Age, sex and injury pattern in the neck
From the table and graph it is interesting to note that no noticeable injuries are noted in the age
group of 10-19 years. Hemorrhage into the lower end of Sterno-mastoid was the most common
hemorrhage occurring in 42(27.6%) of 152 cases. In men occurrence of sterno-mastoid
43
hemorrhage is quite consistently present in all ages above 20 years with the maximum of 14
cases showing hemorrhage in the age group of 20-29 years. In women the hemorrhage is more
commonly present in younger ages with maximum of 8 cases showing hemorrhage in the age
group of 20 -29 years.
Hemorrhage into the strap muscles was relatively less occurring in only 7 cases (4.6%)
of 152 cases. All the cases were males in the age group of 20-29 yrs [6 of the 7 case occurred in
this group].
Throat skeletal injuries like thyroid cartilage fracture, hyoid bone fracture and vertebral
injuries occurred significantly in older aged men. No fracture of thyroid cartilage or hyoid bone
was found in women. Vertebral injuries (2 cases) were found in cases above 50 years of age.
These findings are consistent with the results of studies reported by P Pullar10,
Nikolic et al16, Anny Godin et al27, R Basu et al33, B R Sharma35, Feigin et al43, H Maxeiner et
al48, Leon D Sanchez et al50.
TABLE 9:- Type of hanging and injury pattern
Type of Sterno- Strap muscle platysm thyroid Hyoid # Vertebra caroti carotid
hanging mastoid haemorrhag a cartilag l# d extravas
haemorrhag e e# intima ations
e l tears
Complet 24 4 1 2 2 1 5 14
e
hanging
partial 18 3 1 nil nil 1 2 5
hanging
44
FIGURE 3:- Type of hanging and the pattern of injuries
From the above graph and table it is clear that the extent of injury sustained to the neck is
consistently higher in cases of complete hanging rather than in partial hanging probably due to
the higher fall or complete body weight acting on the body. Throat skeleton fracture was also
found in only complete hanging except for one case of cervical fracture in partial hanging as the
person had landed on his buttocks adding to the height of fall.
Also it is very interesting to note that carotid intimal tears are significantly found in
cases of complete hanging (5 cases: 2cases). This shows the importance of complete suspension
in the occurrence of this injury.
These findings are similar to what was demonstrated by Krishna Vij15, John D Gilbert et
al22,Gillies Tournell et al25, Tanuj Kanchan et al36, Phil Rayson38, and Demirci et al42.
45
TABLE 10:- Weight of the body and injury pattern
Sterno- strap platysm thyroid thyroid disc vertebra

mastoid muscle a gland cr# hyoid# hemorrhage l#
heavy 33.30% 5.50% 0 0 0 0 5.50% 5.50%
moderat
e 27.50% 2.50% 2.50% 0.86% 1.70% 1.70% 0.00% 0.86%
light 22.20% 0 0 0 0 0 0 5.50%
FIGURE 4:- Weight of the body and injury pattern
Sterno-mastoid hemorrhage (33.3%), strap Muscle Hemorrhage (5.5%), Intervertebral disc
Hemorrhage (5.5%) and vertebral fracture (5.5%) are all noted to be common in heavier subjects
but throat skeleton fracture (1.7%) is significantly noted in cases of moderate weight deceased
probably because of the effect of the type of hanging (partial/ complete) influencing the amount
of weight of the body acting as the constricting force.
These findings are similar to the description of Francis E Camp14 and Valdislav et al47.
46
TABLE 11:- Type of ligature and injury pattern.
sterno strap
mastoid muscle platysma thyroid# hyoid# vertebral#
rigid material(42) 18(42.8%) 2(4.7%) 1(2.35%) Nil nil 1(2.35%)
stretchable
material(110) 24(21.8%) 5(4.5%) 2(1.8%) 2(1.8%) 2(1.8%) 1(0.9%)
FIGURE 5:- Type of ligature and injury pattern
The above graph and table show that percentage of injuries sustained in the neck are persistently
higher in cases using rigid ligature material. Strap muscle hemorrhage occurs in 42.8% cares
with rigid ligature material compared to 21.8% in soft material indicating that the type of ligature
used has a significant influence on the soft tissue injuries of the neck. These findings are similar
to the findings reported by Francis E Camps14, Derya Azmak et al18, A Traequi et al20 and B R
Sharma35.
47
TABLE 12:- Height of suspension and injuries sustained.
sterno strap thyroid Intervertebra vertebral

mastoid muscle platysma gland thyroid# hyoid# l disc #
>15ft 33% 0% 0% 0% 0% 0% 0% 0%
10-14ft 30% 6% 4% 1% 1% 1% 0% 0%
5-9ft 26% 4% 0% 0% 1% 1% 1% 3%
FIGURE 6:- Height of suspension and injuries sustained.
From the above table and the graph we do not note any significant difference in the pattern of
injuries sustained with the change in the height of suspension point. But it was noted that
complete suspension of the body and the percentage of body weight acting as the constriction
force is more important determinant of the injuries sustained as also demonstrated by W
Eisenmenger13, Francis E Camps14, Nikolic et al16and D Y Patel et al44.
48
TABLE 13:- Foot ground distance and the injuries sustained
sterno strap thyroid Intervertebral Vertebral

mastoid muscle Platysma gland thyroid# Hyoid # disc #
<half feet 32.10% 0 0 0 0 0 0 0

1/2-1 ft 24.13% 10.34% 0 0 6.80% 6.80% 0.00% 0.00%
> 2ft 25.70% 2.80% 0 0 0 0 0 2.80%
partial
hanging 28.33% 5% 5% 1.60% 0 0 1.60% 1.60%
FIGURE 7:- Foot ground distance and the injuries sustained
From the above graph and table though there is not much of a difference in the pattern of sterno
mastoid hemorrhage other injuries show a dominant increase in occurrence with the increase of
foot and ground distance after suspension. If this indicator is taken as a measure of the height of
49
jump then it can be concluded that the occurrence of neck structure injuries increase with the
increase in the height of jump. This is a finding similar to that shown by W Eisenmenger13,
Francis E Camps14, D Y Patil et al44 and Leon D Sanchez et al50.
TABLE 14:- Period of suspension and injuries sustained
sterno strap Intervertebral

mastoid muscle platysma thyroid# hyoid# disc vertebral#
<30min 22.70% 4.50% 0% 0% 0% 4.50% 4.50%
30min-
1hr 29.10% 0% 0% 0% 0% 0% 0%
1-5hrs 27.10% 6.70% 1.30% 1.30% 1.30% 0.00% 0.00%
>5hrs 32% 4% 8% 4% 4% 0% 0%
FIGURE 8:- Period of suspension and injuries
From the above graph and table it can be noted that there is a gradual increase in the percentage
of cases showing sterno mastoid hemorrhage with increase in the period of suspension and also
the throat skeleton fractures were noted in cases with period of suspension more than 1 hour.
50
This is a finding similar to the study done by Morild et al49. But the study by Derya Azmak et
al18 did not demonstrate any relation of the period of suspension with the injury pattern.
TABLE 15:- Position of the knot and injuries sustained

chin 42.80% 0% 0% 0% 0% 0% 14.20%
ch-left ear 0% 0% 0% 0% 0% 0% 0%
left ear 28% 0% 8% 0% 0% 0% 0%
left occipital 67% 0% 0% 0% 0% 0% 0%
occipital 23% 6.60% 1.10% 2.20% 2.20% 0% 0%
right occipital 20% 0% 0% 0% 0% 20% 20%
right ear 38% 4.70% 0% 0% 0% 0% 0%
FIGURE 9:- Position of the knot and injuries sustained
From the above graph and table it can be noted that sterno mastoid hemorrhage is consistently
present in all knot positions and being most common (67%) in left occipital position of the knot.
However the throat skeleton fracture was only present in cases with the knot being at the
51
occipital position and causing the fracture by backward pressure on the neck. Also it is noted that
the vertebral fracture were present when knot was under the chin or the right side indicating an
element of hyperextension and rotation in the mechanism of fracture. These findings are similar
to the findings of Parikh C K34, B R Sharma35and Leon D Sanchez et al50.
TABLE 16:- Ligature Mark and Injury Pattern

prominent 31.50% 4.20% 2.50% 0% 0.84% 0.84% 1.60%
faint 14.70% 5.80% 0% 5.80% 2.90% 0% 0%
FIGURE 10:- Ligature Mark and Injury Pattern
From the above table and graph it can be clearly noticed that the injuries to the neck structures
corresponds well with the prominence of the ligature mark as all the injuries occur at a higher
rate in cases of prominent ligature mark on the neck. However thyroid cartilage and hyoid bone
fractures are present at a higher rate in cases with faint ligature mark probably due to the softer
52
material with wider surface area like a saree, veil being used which can cause a wider surface of
pressure on the neck. These findings are similar to that reported by nikolic et al16 and Gilles
Tournel et al25.
TABLE 17:- Thickness of the ligature and injury pattern

<0.5cms 100% 0% 0% 0% 0% 0% 0%
1cms 25% 6.20% 0% 0% 0% 0% 0%
2-3 cms 30.50% 4.80% 5.60% 2% 2% 1% 1.20%
>4 cms 22.60% 3.60% 5.60% 0% 0% 0% 1.80%
FIGURE 11:- Thickness of the ligature and injury pattern
From the above table and graph it can be made out that soft tissue injuries like Sterno mastoid
and strap muscle hemorrhages are more common in thin ligatures but with wider ligatures the
chances for throat skeleton to fractures are more. In nearly all cases of ligature < 0.5 cms there
53
was sterno-mastoid hemorrhage. This is a finding similar to the results of studies by Francis E
Camps14 and Nikolsci et al16.
TABLE 18:- Type of Knot and injury pattern

fixed loop 25.50% 5.60% 1.88% 0.94% 0.94% 0.94% 0.94%
running loop 32.60% 2.20% 2.20% 2.20% 2.20% 0.00% 2.20%
FIGURE 12:- Type of Knot and injury pattern
From the above graph and table it is noted that there is a uniform distribution of injuries in cases
of both running loop and fixed loop and no specific pattern could be noted. Hence it can be
concluded that the pattern of injuries in the neck is not influenced by the type of loop. It is a
finding consistent with studies by Francis E Camps14, Nikolsci et al16 and Gilles tournel et al25.
54
TABLE 19:- Sterno mastoid Hemorrhage
Sterno-mastoid hemorrhage
Valid bilateral 28 18.4 18.4 18.4
bilateral and middle 1 .7 .7 19.1
left 6 3.9 3.9 23.0
no hemorrhage 110 72.4 72.4 95.4
right 7 4.6 4.6 100.0
Total 152 100.0 100.0

Of the 152 case of hanging studied sterno- mastoid hemorrhage was present in 42 cases (27.6%).
Bilaterally hemorrhage was present in the lower end in 28 cases (18.4%) followed by on the
lower end on the right side (4.6%).
TABLE 20:- position of the knot and Sterno-mastoid hemorrhage
left right-
chin chin-left left ear occipital occipital occipital right ear
bilateral 4.60% 0% 14.20% 0% 33.30% 2.30% 14.20%
right
side 2.30% 0% 2.30% 0% 9.50% 0% 2.30%
left side 0% 0% 0% 4.60% 7.10% 0% 2.30%
55
FIGURE 13:- position of the knot and Sterno-mastoid
hemorrhage
Sterno mastoid hemorrhage is significantly present bilaterally in most of the cases especially
when the knot is placed occipital (33%) and under the chin (4.6%) probably due to the direct
traction or hyper extension of the neck respectively. Also when the knot is placed on the sides
the hemorrhage is present on the same side as the knot. This is a finding consistent with
publications of Milton Helpern11, Bernard Knights12, W Eisenmenger13, Krishna Vij15, Nikolic et
al16, Derya Azmak et al18, B R Sharma35, H Maxeimer48 and Sivasuthan et al53.
TABLE 21:- Strap Muscle hemorrhage
Strap-muscles
Valid bilateral 1 .7 .7 .7
left side 4 2.6 2.6 3.3
right side 2 1.3 1.3 4.6
no bleed 145 95.4 95.4 100.0
Total 152 100.0 100.0
56
Strap-muscle hemorrhage was present in only 7 (4.6%) of the 152 cases of hanging studied. Of
these four cases showed hemorrhage on the left side, in two cases it was present on right side and
in one case on both sides. Strap muscle hemorrhage is more commonly expected in cases of
strangulation rather than hanging contrary to hemorrhage in the lower end of Sterno-mastoid
which is more classical of hanging. This is in line with studies by Bernard Knights12 and Donald
T Ready32.
TABLE 22:- Throat skeleton fracture
variables Hyoid bone fracture Thyroid cartilage fracture

Case1 Case2 Case1 Case2
Pm number 1508/09 3175/09 1508/09 1607/10
Sex Male Male Male Male
Age 20-29yrs(25yrs) 30-39yrs(38yrs) 20-29yrs(25yrs) 40-49yrs(41
yrs)
Weight Moderate Heavy Moderate Moderate
Type of hanging Complete Complete Complete Complete
Suspension point Hook of roof Hook of roof Hook of roof Fan
Height of suspension 10feet 9feet 10feet 9feet
Foot-ground 1 foot 1foot 1 foot 1feet
distance
h/o jump Yes Yes Yes Yes
Period of suspension 1hour 5hours 1hour 4 hours
Loop type Fixed loop Running Fixed loop Running
Ligature material Saree Saree Saree Veil
Ligature mark Faint Prominent Faint Faint
Ligature thickness 3cms 2.5 cms 3cms 2.5 cms
Knot position Occipital Occipital Occipital Occipital
Associated injuries Satrap-muscle Sterno-mastoid Satrap-muscle Sterno-
haemorrhage, haemorrhage, strap- haemorrhage, hyoid mastoid
thyroid cartilage muscle bone fracture. haemorrhage,
fracture. haemorrhage. strap-muscle
haemorrhage.
57
The above table shows the various variables studied in the three (1.97%) cases of throat skeleton
fracture found in the 152 cases of hanging studied. All the cases were male with the average age
of 33 years. Saree was used as the ligature material used in two cases with veil used in the third
case showing with the average thickness of the ligature material 2.8cms indicating that broader
the ligature material more is the chance of thyroid cartilage fracture. In all the cases the knot was
placed in the occipital region which is consistent with the broad ligature pressing on the throat
cartilages backwards leading to the compression of these structures between the ligature and the
vertebral column.
All the cases being complete hanging had a high suspension point (hook/ fan) and gave a
history of jump during the attempt of hanging. The throat skeleton fractures were associated with
soft tissue hemorrhages like Sterno -mastoid hemorrhage and strap muscle hemorrhages. These
findings are consistent with those reported by Francis E Camps5, P Pullar10, Milton Helpern11,
Nikolic et al16, Mathew J Martin et al17, Anny Godin et al27, B R Sharma35, D Y Patil41, Smith
and Fiddes41, Modi J P41, Mukharjee J B41, Apurba Nandi41 and Leon D Sanchez et al50. But
Bernard Knights12, Krishna Vij15, W Eisenmenger13, Nikolic s et al19, Derya Azmak et al18, smith
and fiddles41, Routor41, Wintraub41 and K S N Reddy41 reported a much higher percentage of
throat skeleton fracture in cases of hanging ranging from 15 to 68%.
Injuries to the Carotid Arteries
Carotid arteries were evaluated for the presence of intimal tears, extravasations of blood around
and in the carotid artery and dissection of the carotid arteries. In no case was dissection of carotid
noted The position, number and the pattern of the Intimal tears were studied and the case where
gross tears were made out, hysto-pathology examination was conducted.
58
TABLE 23:- Carotid Intimal tears
Carotid intimal tear
Cumulative
Valid tear present 7 4.6 4.6 4.6
no tear 145 95.4 95.4 100.0
Total 152 100.0 100.0

From the above table it is noted that carotid intimal tears were found in seven out of 152 cases of
hanging giving an overall incidence of 4.6%. This consistent with the varied incidence of 1 to 9
% reported in various studies by Bernard Knights12, W Eisenmenger13, Milton Helpern11,
Mennchobi P H24, Satrenus et al29, B R Sharma35, Sharon K Wallace37, Betz et al44, Bianca et
al56 and S H Kiani et al58.
TABLE 24:- Age of deceased and Carotid Injuries
intimal tears carotid extravasation

male female Male female
10-19yrs
(18) 0 0 1(25%) 1(7.1%)
20-29yrs
(72) 3(6.90%) 0 6(13.9%) 2(6.8%)
30-39yrs
(37) 0 1(14.8%) 3(10.3%) 0%
40-49yrs
(18) 1(6.60%) 1(33.3%) 3(20%) 2(66.6%)
50-59yrs (5) 0 0 1(25%) 0%
>60yrs (2) 1(100%) 0 0% 0%
59
FIGURE 14:- Age of deceased and carotid intimal tear
FIGURE 15:- Age of deceased and carotid extravasations
From the above table and graphs it can be noted that the frequency of carotid intimal tears
increases with increase in the age of the deceases. Tears were absent in the age group of 10-19
years , in the age group of 20-29 yrs tears were present in 6.9% of males, in the age group of 30-
39 yrs it was 14.8% in females , in the age group age group of 40-49 yrs it was 33.3% and
present in the only male in the age group >60yrs. This predisposition could be due to various
60
factors like atherosclerosis etc decreasing the pliability of arteries with age. However no
significant change with the extravasations of blood around the carotid artery was noted with
increasing age. This is a fact which is also documented by Phil Rayson38 and Sivasuthan et al53.
TABLE 25:- Weight of the Body and Carotid Injuries
carotid
intimal carotid
tears extravasations
Heavy(18) 2(11.1%) 1(5.5%)
Moderate(116) 5(4.3%) 17(14.6%)
Light(18) 0 0
FIGURE 16:- weight of the body and carotid Injury
61
From the above graph it can be noted that intimal tears were present in 11.1% of cases having a
heavy built and in 4.3% of cases having a moderate built. No intimal tears or extravasations of
blood in the carotid artery were noted in cases with light built. There is a nearly linear decrease
in the incidence of tears with decrease in the weight of the body. However no significant relation
of the weight of the body and extravasations in and around carotid arteries was noted. These
findings match with the results of the studies by Krishna Vij15, R Basu et al33, Phil Rayson38,
Valdislav et al47 and David B Levy et al57.
TABLE 26:- Ligature material and Carotid Injuries
carotid carotid
rigid 4 10
stretchable 3 8
TABLE 27:- Ligature material and Carotid Injuries
carotid carotid
tears extravasation
Bedsheet 20% 0%
Cable 34% 0%
Lungi 0% 0%
Rope 6.40% 32.30%
Saree 1.50% 10.70%
Towel 0% 0%
Veil 6.10% 3%
others 0% 0%
62
FIGURE 17:- Ligature material and carotid injuries
From the above tables and graph we can observe that carotid intimal tears were present in 34%
cases using cables, in 20 % of cases using Bed sheets and 6.4% of cases using ropes as the
ligature material. Carotid extravasations were also present in 32% of cases using ropes as
ligature material. This makes it obvious that rigid material used in hanging are more efficient in
resulting in tears and extravasations of blood in the carotid arteries then soft and stretchable
material. These findings are similar to those found by Bernard Knights54.
TABLE 28:- Foot Ground distance and carotid injuries
carotid tears carotid extravasations

<half ft 7.20% 25.20%
1/2-1ft 0% 10.30%
>2 ft 8.50% 11.40%
partial hanging 3.30% 8.30%
63
FIGURE 18:- :- Foot Ground distance and carotid injuries
From the above table and graph we can note that tear is documented in 3.30%, 7.20% and
8.50%of cases of partial hanging and foot ground distance < half feet, >2 feet respectively. If his
factor can be considered as a measure of the height of fall in the case it would not be wrong to
conclude that the chance of tear in the carotid arteries increases with the height of fall into the
noose of the ligature. However there is a nearly uniform occurrence of extravasations of blood
around the carotid arteries. These findings are similar to the studies by P Pullar10, Bernard
Knights12, W Eisenmenger13, Krishna Vij15, Betz et al44 and Leon D Sanchez et al50.
TABLE 29:- Period of Suspension and carotid injuries

<30 min 9% 23.50%
30min-1hr 3.20% 16%
1-5hrs 4.10% 12%
>5hrs 4% 8%
64
FIGURE 19:- Period of Suspension and carotid injuries
From the above table and graph it can be observed that intimal tears were present in 9% of cases
suspended for <30min and then uniformly from 3 to 4 % in cases suspended longer. Even carotid
extravasations the incidence is higher in cases suspended for < 30min (23.5%). This indicates
that carotid injury is an acute phenomenon and is not related to the period of suspension of the
body. This is similar to the results got by R Basu et al33 and contradicting those got by Morild I
et al49.
TABLE 30:-Position of the Knot and carotid injuries

chin 0% 0%
chin-left ear 0% 42.80%
Left ear 0% 12%
left occipital 0% 0%
occipital 4.40% 9.90%
right occipital 20% 0%
right ear 9.40% 13.10%
65
FIGURE 20:-Position of the Knot and carotid injuries
From the above graph and table it can be made out that 24.40% of cases with knot located near to
the occipital region showed tear in the intima and 42.80% of cases with knot near to the chin
showing extravasations of blood in the carotid. This probably supports the idea that traction,
shearing force and hyper extension of the neck being responsible for the intimal tears and carotid
extravasations respectively. This is also reflected in the studies by B D Chaurasia6, Krishna Vij15,
Mathew J Martin et al17, R Basu et al33, Parikh C K34, Sharan K Wallace et al37, Leon D Sanchez
et al50 and Ciprian Lupascus et al55.
TABLE 31:- Ligature mark and Carotid injuries
carotid carotid
Prominent 5.90% 15.20%
Faint 0% 0%
66
FIGURE 21:- Ligature mark and Carotid injuries
From the above table and graph it is clear that a prominent is a good indicator to correspond to
the internal vessel injuries in the neck in cases of hanging. Intimal tears were found I 5.9% cases
with prominent ligature mark and were totally absent in cases with faint ligature. Prominent
ligature mark is an indicator of the amount of traction on the neck thus supporting the
mechanism of their causation. These findings are similar to those seen by R Basu et al33, Parikh
C K34, Bernard Knights54 and Ciprian Lupascus et al55.
TABLE 32:- Ligature Thickness and carotid injuries

<0.5cms 0% 0%
1cms 0% 31.20%
2-3cms 4.80% 8.50%
>4cms 5.60% 11.30%
67
FIGURE 22:- Ligature Thickness and carotid injuries
From the above graph and table it can be noted that carotid intimal tears occurs in 4.8% of cases
with ligature thickness of 2-3cms and in 5.6 % of cases with ligature >4cms. This does not reveal
a significant influence of ligature thickness on the incidence of tear. Similarly in carotid
extravasations is found in 31.2% cases with ligature thickness 1cm and in 9% and 11% of cases
with thickness 2-3cms and >4cms revealing no appreciable pattern similar to the study of Cipran
Lupascus et al55.
TABLE 33:- Ligature loop and carotid injuries
carotid tear carotid extravasations

Fixed loop 5.64% 11.28%
Running loop 2.20% 15.40%
68
FIGURE 23:- Ligature loop and carotid injuries
From the above table and graph it can be noted that carotid intimal tears occur in 5.64% of cases
with fixed loop and 2.2% in cases of running loop. Carotid extravasations are found in 15.4% of
cases with running loop and in 11.28% present of cases with fixed loop. This indicates that a
fixed loop has a higher incidence of intimal tear than running loop. But no specific pattern is
shown in case of carotid extravasations similar to what was shown by Cipran Lupascus et al55.
69
TABLE 34:- Cases of carotid Intimal Tears.
variables Case1 Case2 Case3 Case4 Case5 Case6 Case7

Pm number 941/09 1245/09 1476/09 1898/09 2122/09 2666/09 3119/0
9
Sex Female Male male male Female male male
Age 5( 45yrs) 3(28yrs) 7(70yrs) 3(25yrs) 4(35yrs) 5(45yrs) 3(29yrs
)
Weight Moderate Moderate heavy heavy Moderate Moderate Modera
te
Type of complete Complete Incomplete Incomplet complete complete complet
hanging e e
Suspension Fan Fan Hook Hook Hook Fan hook
point
Height of 9feet 8.5feet 8feet 8feet 8feet 8feet 12feet
suspension
Foot ground 1feet Half feet Buttocks soles 3feet 2feet 2feet
distance
H/o Jump Yes Yes yes yes yes yes yes
Loop Fixed Fixed fixed fixed fixed fixed Runnin
g
Period of 30min 2hrs 1min 2hrs 3hrs 1hrs 6hrs
suspension
Knot occipital Occipital Right Right ear Right ear occipital occipita
position occipital l
Ligature prominent prominent prominent prominent prominen prominen promin
mark t t ent
Ligature Saree Veil Cable Bed sheet Veil Rope Rope
material
Carotid Yes Yes yes yes yes yes yes
tears
Number of One Two One One One on Three Three
tears each side
Location of Bifurcation Right Right Left B/l Right Left
tears left side Bifurcation bifurcation common carotid
common carotid
external carotid
Bifurcation
Pattern of horizontal horizontal horizontal horizontal horizonta horizonta horizon

tears l l tal
Associated Carotid Sterno- Sterno- Nil Nil Nil nil
injuries extravasations. mastoid haemorrhage,
mastoid haemorrhage,
carotid extravasations Vertebral
fracture &
Intervertebral disc
haemorrhage.
70
From the above table of cases of carotid intimal tears it is noted that five of the cases were male
and two cases were female with the average age for intimal tears coming to be 39.57 years. Five
of the cases were complete hangings and two were partial hangings. All the cases had high
suspension point and even in the case of partial hanging the cases were of heavy built which
would have resulted in the tear. One case of partial hanging showed that the buttock was in
contact with the ground adding to the height of fall to the ground. All the cases gave a history of
jump which is an important factor leading to tears.
Most of the cases (4) used a rigid ligature material leading to a prominent
ligature mark. Six of the cases showed a fixed loop and the knot were placed occipitally or in the
right side. In two cases of occipital knot the tears were at the right common carotid bifurcation an
in two cases on the left common carotid bifurcation. In one case of knot on the right side tear was
on the opposite side and in one case on the same side. One cases of right side knot tear was
present in right external carotid. In one case of occipital knot the tear was bilaterally present. The
tears number varied from single to three and all the tears were transversely (horizontally) placed.
In three cases the tears were associated with other injuries like sterno mastoid hemorrhage and
vertebral injuries.
These finding are consistent with the expected norms reported by Bernard Knights12, 54
, W
Eisenmenger13, Milton Helpern11, Krishna Vij15, Mathew J Martin et al17, Mennchobi P H24,
Satrenus et al29, R Basu et al33, B R Sharma35, Sharon K Wallace37, Phil Rayson38, Betz et al44,
Valdislav et al47, Leon D Sanchez et al50, Bianca et al56, David B Levy57 and S H Kiani et al58.
71
Histo-pathology of the carotid arteries:-
Hematoxylin and eosin stained sections of the carotids demonstrated wedge shaped tears in the
intima extending to varying depths of the carotid artery in scanning view(X40). Further details
could be observed by increasing the magnification(X200). The in few specimens the tears
extended into the media. In one case the tear extended till the adventitia. The base of the tear on
careful observation demonstrated erythrocytes indicating hemorrhage into the wound. This could
be an indicator of its ante-mortem nature. Athermatous plaques were demonstrated in most of the
carotid artery specimens studied. These findings were similar to that demonstrated by Grafia et
al59.
72
PLATE 1
Picture 1:- Photograph of a case of suicide by Picture 2:- Photograph of a case of suicide by
complete hanging with tree as the suspension partial hanging with a support beam as
point suspension point
Picture 3:- Photograph of a case of suicide by

partial hanging using fan as a suspension point
73
PLATE 2
Picture 4:- Photograph showing hemorrhage Picture 5:- Photograph showing

into lower attachment of sterno-mastoid hemorrhage into the strap muscles in
muscle in case of hanging. case of hanging.
Picture 6:- Photograph showing hemorrhage Picture 7:- photograph showing

into the right side strap muscles in case of hemorrhage into sterno-mastoid muscle in
hanging. case of hanging corresponding to the
ligature mark.
74
PLATE 3
Picture 9:- Photograph showing

hyoid bone fracture in case of
complete hanging.
Picture 8:-photograph showing thyroid cartilage

fracture in case of hanging.
Picture 10:- Photograph showing fracture of the cervical

vertebrae in case of a suicidal hanging in an aged person.
75
PLATE 4
Picture 11:- Photograph showing two horizontal Picture 12:- Photograph showing two
intimal tears in the carotid artery in case of horizontal intimal tears in the carotid artery
complete hanging. in case of complete hanging.
Picture 13:- Photograph showing horizontal Picture 14:- Photograph showing

intimal tear in common carotid artery in a case horizontal intimal tear in common
of complete hanging. carotid artery in a case of complete
hanging.
76
PLATE 5
Picture 15:- photograph showing three Picture 16:- Photograph showing intimal
horizontal intimal tears in the carotid artery tear at the root of the common carotid
near the bifurcation artery in case of hanging
Picture 17:- Photograph showing intimal Picture 18:- Photograph showing

tear in the common carotid artery in case of complete obstruction of external carotid
complete hanging artery in case of hanging
77
PLATE 6
Picture 20:- Photomicrograph of a tissue

Picture 19:- Photomicrograph of a tissue section
section of carotid artery showing a tear
of normal carotid artery (H&E, X40)
extending longitudinally from the intima to
the adventitia splitting the transversely on
either sides (H&E, X40)
Picture 21:- Photomicrograph of a tissue section Picture 22:- Photomicrograph of tissue

of carotid artery showing RBC extravasations section of carotid artery showing intimal
within the tear (H&E, X200) tear extending up to the upper 1/4th of the
media with extravasations of RBC within
the tear (H&E, X100)
78
PLATE 7
Picture 23:- Photomicrograph of tissue Picture 24:- Photomicrograph of tissue section

section of carotid intimal tear with of carotid artery showing Intimal Tear with
extravasations of RBC (Arrow) within extravasations of RBC (Arrow) within the tear
the tear (H&E, X200) (MTS, X 100)
Picture 25:- Photomicrograph of tissue Picture 26:- Photomicrograph of tissue section

section of carotid artery showing intimal of Carotid artery showing Intimal tear
tears with RBC (Arrow) with in the tear extending into the media (Arrow-elastic
(MTS, X200) lamina). (VG, X 100)
79
CONCLUSION
A total of 152 cases of hanging brought to Victoria Hospital Mortuary were studied over a period
of 18 months between December 2008 and May 2010. The conclusions from the study are as
follows:
Characteristic Features of the Soft Tissue Injuries to the neck found-
 Soft tissue injuries of the neck were more common in younger age group subjects (10-29
yrs) where as throat skeleton fracture and vertebral fractures were found in higher age
group above 40 yrs.
 The extent of injuries sustained to the neck were more in cases of complete and typical
hanging compared to cases of partial hanging.
 Heavier individuals and individuals using rigid ligature material like cables ropes etc had
a higher chance of soft tissue injuries and vertebral fractures.
 There is a definite increase in the rate of occurrence of injuries with the increase in the
height of jump in cases of hanging.
 With increase in the period of suspension of hanging above >5hrs there is a gradual
increase in the frequency of the soft tissue injuries occurring.
 Hemorrhage into the lower end of sterno- mastoid muscle occurred in 27.6% of cases of
hanging and in 18 % of cases it was bilaterally located making it a good indicator to
confirm death by hanging. In most of the cases the knot was occipitally located. Strap
muscle hemorrhage was present in only 4.6% of cases which is much more common in
cases of strangulation.
80
 Throat skeleton was fractured in 1.97% of cases with the average of fracture being 33yrs.
All the fractures were in cases of complete and typical hanging.
 67% of cases with knot placed occipitally had sterno- mastoid hemorrhage indicating that
the stretch of the muscle causes these hemorrhage and vertebral fractures occurred in
cases of knot under the chin as hyper extension of the neck could be the primary
mechanism causing the injury.
 Prominent ligature mark corresponded well with the internal injuries. And broader
ligature mark corresponded well with throat skeleton fractures.
Carotid artery injuries:
 Carotid intimal tears were found in 4.6% of cases of hanging. The incidence of tears
increased with the age of the deceased with the average age being 39.57 yrs. No tears
were found in the age of 10-19 yrs.
 There was a linear increase in the occurrence of intimal tears in carotid artery with the
increase in the weight of the deceased (11.1% cases with heavy built had Intimal tears).
 Rigid ligature material like Cables, Ropes, Bed sheets were more likely to cause intimal
tears. 34% of cases using cable had tear. 5.9% of cases with prominent ligature mark had
tears.
 Higher the jump more is the frequency of tears. This was noted by the fact that 8.5% of
cases with foot and ground distance on suspension had tears compared to partial hanging
cases (3.3%).
 Knot was place occipitally in nearly 24% of cases with tear. And 42 % of cases with knot
under the chin had extravasations around the carotid. This indicates that the stretch of the
carotid arteries is what causes the injury.
81
 No relation of the period of suspension and tear in the carotid was made out indicating it
is an acute phenomenon.
 All the tears were transversely and circumferentially located most commonly in the
common carotid artery and at the bifurcation. In one case tears were bilaterally located.
Number of tears varied from one to three.
 Ante-mortem nature of the carotid intimal tears could be further confirmed by histo-
pathology using plain Hematoxylin and eosin staining by demonstrating erythrocytes in
the tears indicating ante-mortem hemorrhage.
82
SUMMARY
This study was conducted in the department of forensic medicine, Victoria Hospital over a
period of 18 months from December 2008 to may 2010. A total of 152 cases of hanging were
studied. The aim of the study was to determine the pattern of neck tissue injuries in cases of
hanging and also to study in specific injuries to the carotid arteries in cases of hanging. Carotid
arteries were carefully dissected to look for intimal tears and to check their ante-mortem nature
by hysto- pathology examination.
Of the 152 cases studied the male to female ratio was nearly 2:1 with the mean age of
the deceased being between 20-39 yrs. 60% of the cases were complete hanging. Sterno-mastoid
hemorrhage in the lower attachments was the most common hemorrhage in the neck occurring in
27.6% of cases. This was classically due to sudden stretch of the muscle and can be used to
specifically confirm suspension of the body. Strap muscle hemorrhages were less common
occurring in 4.6% cases. Hyoid bone was fractured in two cases and thyroid cartilage was
fractured in two cases making the incidence of throat skeleton fracture to 1.97%. Vertebrae were
fractured in two cases.
Intimal tears in the carotid artery occurred in 4.6% of the cases of hanging. When present
the tears were transversely and circumferentially located in the common carotid artery or the
bifurcation. Tears were present in heavy individuals with complete hanging. Most common knot
position was occipital. Carotid artery extravasations were present in 42% of cases with knot
under the chin. Ante mortem nature of the tears could be confirmed on hysto- pathology.
Extravasations of RBC were demonstrated in the tears by H-E stain indicating the ante-mortem
nature of the injury and so also confirming the history of Hanging.
83
LIMITATIONS OF THE STUDY
1. Study confined to a particular area.
2. Information regarding the deceased is based only on the history provided by police,
relatives, panchanama and photograph of the scene of occurrence.
3. Hysto-pathology of carotid Arteries was not done for the presence of microscopic tears
and disruptions.
84
Recommendations
 In this study though the frequency of intimal tears in the carotid arteries was less (4.6%)
its presence confirmed the suspension of the body as transverse circumferential tears can
only be cause by stretching of the carotid arteries as it occurs in hanging. Hysto-
pathologic confirmation of their ante-mortem nature helps confirm the ante-mortem
nature of hanging. Hence it is recommended that in all cases of hanging careful dissection
of the carotids should be done to check for tears and if present hysto-pathology of the
artery should be done.
 Hemorrhage into the lower end of sterno mastoid was the most common soft tissue
hemorrhage found and can be a very effective indicator for suspension of the body and
sudden jerk on the neck structures and also ante-mortem nature of hanging.
 Injuries to the neck tissue are not uncommon in case of hanging and hence should be
carefully interpreted in cases of hanging. The patterns of injuries which occur in hanging
are different from those of strangulation.
 Careful dissection of the neck by a layer by layer approach after achieving a blood less
field should be carried out in all cases of hanging to avoid art factual injuries.
 Carotid artery histopathology could be considered to prove the ante-mortem nature of
injuries and also to demonstrate microscopic hemorrhage into the artery.
85
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Forensic Leg Med.2008 July; 15(5): 298-305.
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profile and gender differences. J Forensic Leg Med. 15(3); 2008 November: 493-496.
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38. Phil Rayson. Near Hanging. Emerg Med. 1999; 11:17–21.
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40. S. Duband, Timoshenko, R. Mohammedi, M. Prades, Barral, Debout, Péoc’h. Study of
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Pathol. 1999 December; 20(4): 309-322.
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92
PROFORMA
STUDY OF PATTERN OF NECK INJURIES IN CASES OF HANGING WITH SPECIAL REFERANCE TO CAROTID
INJURIES.
- vijay kautilya
1. Name:- PM/NO:-
2. Sex: - M/F. Date:-
3. Age:-
4. Occupation:-
5. Educational status:-
6. Socio economical status:-
7. Height:-
8. Approximate weight:-
9. Triceps skin fold thickness:-
10. Place of occurrence: - house/ work place/ open field/ hotel/ hut/ school/ prison/ others
HANGING PROPER:
1. Mode of hanging: - accidental /suicidal/ homicidal.

2. Type of hanging: - complete/ incomplete.
3. Type of suspension point: - hook/ windowpane/ frame of the door/others
4. Height of suspension point from the ground:-
5. Distance pf ground from the foot:-
6. Lowest part of the body in contact with the ground:-
7. H/O jump if any: - yes/ no.
8. Treated / not treated.
9. Approximate period of suspension:-
HANGING MATERIAL
 Length :-
93
 Length from knot to suspension:-
 Loop fixed / running
 Stretchable or rigid
 Material:-rope/saree/bed sheet/belt/cable/scarf/ veil/tape/ others??
 Material made of:-synthetic/ nylon/ metal/ cotton/ wool/leather/others.
AUTOPSY
LIGATURE MARK: - faint/prominent
1. thickness:-
2. Length:-
3. above /below the thyroid cartilage:-
4. position of the knot:-
5. Complete / incomplete.
6. intervening material in between LM and neck:-
Scarf/ hair/ shirt collar/ veil/ others??
INTERNAL FINDINGS:-
SL NO NAME RIGHT LEFT
1 Sternomastoid muscle:-
2 strap muscles
3 Platysma
4 jugular vein
5 thyroid gland
6 thyroid cartilage
7 hyoid bone
8 LARINX/TRACHEA
94
9 Intervertebral disc
10 vertebrae
11 others
CAROTID ARTERY
1) INTIMAL TEARS:- YES/NO
RIGHT LEFT
1 NUMBER
2 LOCATION
3 PATTREN
2) CAROTID SHEATH EXTRAVASATION
3) DISSECTION
 MODE OF DEATH:- ASPHYXIA/ CEREBRAL ANOXIA/Others??

 HISTOPATHGOLOGICAL EXAMINATION REPORT:-
 FSL REPORT:-
95
KEY FOR THE MASTER CHART
General information
 A)Sex: -
 male- M
 female- F
 B)Age:-
 0-9 ……………..1
 10-19…………..2
 20-29 …………3
 30-39…………..4
 40-49----------5
 50-59………….6
 60+……………..7
 C)Weight:-
 Light- L
 Moderate- M
 Heavy- H
 D)Place of occurrence
 House- H
 Open-O
 Hotel-m
 Prison-P
 Others – E
Hanging proper
 E)Mode of hanging-
1. Accidental- A
2. Suicidal- S
3. Homicidal- H
 F)Type of hanging
 Complete- C
 Incomplete- I
G) Suspension point
 Fan hook- F
 Window pane- W
 Staircase –S
 Hook/ roof plate-H
96
 Tree –T
 Others-O
H) Height of suspension
I) Foot Ground distance(feet)

J) Lowest part of body in contact with ground
 Foot – F
 Toe- T
 Knee- K
 Others-O
K) H/o jump
 Yes- Y
 No- N
L) Period of suspension :-
M) Knot -Suspension
Hanging material
N) Loop
i. Fixed-F
ii. Running-R
O) Stretch in material
i. Stretchable- S
ii. Rigid- R
P) Material
i. Saree-S
ii. Veil-V
iii. Rope- R
iv. Lungi- L
v. Bed sheet-B
vi. Others- 0
Q) Material make
i. Synthetic-S
ii. Nylon-N
iii. Cotton-C
iv. Wool-W
v. Leather-L
vi. Others- O
97
Ligature mark
R) Ligature mark
 Faint- F
 Prominent-
S) Thickness
T) Location
 Above- A
 Below-B
U) Position of the knot
 Right ear- R
 Left ear-L
 Chin-C
 Occiput-O
V) Complete
 Complete-C
 Incomplete-I
W) STERNOMASTOID HEMORRHAGE AF) Vertebral Injuries

X) Strapmuscle hemorrhage AG) other injuries
AH) Carotid Intimal Tears
Y) Platysma
AI) Tear Number
Y) Jugular vein
AJ) Tear Location
AA) Thyroid gland
AK) Tear Pattern
AB) Thyroid cartilage
AL) Carotid Extravasations
AC) Hyoid Bone
AM) Carotid Dissection
AD) Larynx
AE) Intervertebral Disc
98
99
Sl/ A A A A A A A A
no A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A AB C D E F G H AI AJ K AL AM
1. m 13 m h s i f 10 - b n 6 - F r b c F 8 A o i b - - - b - - - - - - n - - - - -
m m
2 4 h s i f 12 - f y 2 2 f s s s p 4 a o i n n p n n n n n n n n n - - - b -
m m
3 3 h s c h 12 1 - y 4 2 r r r n p 4 a l c b - p - - - - - - - - n - - - - -
m
4 f 5 h s c f 10 2 - y 3.5 2 f r s s p 3 a o i n n n n n n n n n n n n - - - r -
m m
5 3 h s c h 12 0.5 - y 2 3 f r b c f 2 a l i n n n n n n n n n n n n - - - - -
m m
6 2 h s c f 12 0.5 - y 1 3 f r r n p 2 a l i n n n n n n n n n n n n - - - r -
m
7 f 2 h s c f 9 2in - y 2 1 f s s s p 6 a o i n n n n n n n n n n n n - - - b -
m
8 f 5 h s c f 9 1in - y 0.5 3.5 f s s s p 4 a o i n n n n n n n n n n n y 1 bf rt hor r -
m m
9 4 h s c f 10 2 - y 0.5 2 f r r j p 1.5 a c c n n n n n n n n n n n n - - - b -
m m w
10 3 p s c 8 0.5 - y 2 1 f s t c p 3 a o i n n n n n n n n n n n n - - - - -
m
11 f 3 h s c h 12 1 - y 6 1 f r r j p 2 a o i r n n n n n n n n n n n - - - - -
m m
12 3 o s c t 9 1in - y 4 2.5 r r r j p 4 a o i n n n n n n n n n n n n - - - b -
m m
13 4 h s i f 12 - k n 24 5 r r r n p 1.5 a o i b n n n n n n n n n n n - - - -
m m
14 4 h s i h 9 - t y 2 n f s s s f 3 a l i b n n n n n n n n n n n - - - - -
m m
15 3 h s i h 8 - t y 2 2.5 r r r c p 1 a o i n n n n n n n n n n n n - - - b -
m m
16 3 h s c f 10 3 - y 1 f r s s p 4.5 a l i b n n n n n n n n n n n - - - - -
m m
17 3 h s c f 8.5 0.5 - y 2 2 f s v s p 5 a o i b n n n nn n n n n n n y 2 bf lft hor l -
m
18 5 h h h i f 10 - k n 3 4 r s r c p 2.5 a r i b n n n n n n n n n n n - - - - -
m
19 f 3 h s c h 10 0.5 - y 1 - f s v s p 2.5 a o i n n n n n n n n n n n n - - - - -
m
20 f 2 h s c f 12 1 - y 2 - f s v n p 2.5 a l i b n n n n n n n n n n n - - - - -
m m
21 4 h s c f 10 1 - y 0.5 3 f s v s f 3 a r i n n n n n n n n n n n n - - - - -
m
22 f 4 h s c h 8 1 - y 1 2 f s s s p 3 a o i n n n n n n n n n n n n - - - - -
m
23 3 h h s c h 12 2 - y 3 4 r r r n p 1 a c c b n n n n n n n n n n n - - - r -
m 1 c1-
24 7 h h s i h 8 - b y m 3 f r c o p 2 a or i b n n n n n n n #? c2# n y 1 bf lft hor - -
m m
25 4 h s c h 12 1 - y 1 3 f r r n p 3.5 a o i n n n n n n n n n n n n - - - b -
m
26 f 3 h s c h 10 1 - y 1 4 f s s s f 2 a o i n n n n n n n n n n n n - - - - -
m m
26 3 h s c h 10 1 - y 1 3 f s s s f 3 a o i n b n n n # b/l #gr n n n n - - - - -
r
m /
28 f 3 h s c h 10 1 - y 2 3 f r s n p 2 a o i b n n n n n n n n n n n - - - - -
m
29 5 l h s c h 10 0.5 - y 6 3 f s s n p 7 a ro i n n n n n n n n n n n n - - - - -
m m
30 3 h s i h 8 - t y 3 4 f s s s p 4 a o i b n n n n n n n n n n n - - - - -
m m
31 5 o s c t 20 5 - y 4 4 r r r j p 2.5 a l c b n n n n n n n n n n n - - - b -
32 m 3 h h s c h 12 2 - y 3 4 f s s n p 2 a o i n n n n n n n n n n n n - - - - -
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m m
33 3 h s c h 12 3 - y 3 4 r s r c p 1 a c i n n n n n n n n n n n n - - - - -
m
34 3 l o s c h 12 4 - y 3 3 f s v s p 3 a o i n l n n n n n n n n n n - - - -- -
m m
35 3 h s c h 10 2 - y 4 3 f s l c p 3.5 a o i n n n n n n n n n n n n - - - - -
m m
36 3 h s c h 12 0.5 - y 1 3 f s s s p 4 a o i b n n n n n n n n n n n - - - - -
m
37 f 3 h s i h 8 - t y 1 3 f s v s f 3 a l i n n n n n n n n n n n n - - - - -
m
38 f 3 h s c h 8 0.5 - y 1 3 f s s s p 3 a r i b n n n n n n n n n n n - - - b -
m m
39 3 h s i h 6 - k y 3 3 f s l c p 2.5 a o i n n n n n n n n n n n n - - - - -
m
40 3 l h s i h 6 - f y 8 4 f s s c p 5.5 a o i n r n n n n n n n n n n - - - - -
41 f 5 h h s c f 10 0.5 - y 0.5 5 f s s s p 2.5 a o i n n n n n n n n n n n n - - - - -
w
42 f 7 l h s i 7 - k n 2 3 r r r n p 1 a o i n n n n n n n n n n n n - - - - -
m
43 4 l h s c f 9 1 - y 2 3 f r c o f 2.5 a o i n n n n n n n n n n n n - - - - -
m
44 f 3 h s i h 7 - f y 1 4 f s s s p 4 a o i b n n n n n n n n n n n - - - l -
m
45 3 l h s c h 10 4 - y 1 3 f s s s f 3 a o i n n n n n n n n n n n n - - - - -
m
46 f 2 h s c h 12 3 - y 3 4 f s v s f 3 a o i n n n n n n n n n n n n - - - - -
m
47 3 h h s i h 8 - f y 2 3 f s b c p 4 a r i n n n n n n n n n n n y 1 lft hor - -
m
48 4 l h s i h 10 - f y 3 4 f s v n p 5 a o i n n n n n n n n n n n n - - - - -
m
49 f 3 h s i f 8 - k n 8 4 f s s s 0 6 a o c n n n n n n n n n n n n - - - - -
m
50 f 2 h s i f 12 - s n 2 6 f s s n p 4 a o i n n n n n n n n n n n n - - - - -
m m
51 6 h s c f 8 1in - y 1 4 r s r c p 1 a l i b n n n n n n n n n n n - - - b -
m
52 f 3 h s i h 8 - f n 0.5 4 f s s s p 4 a o i n n n n n n n n n n n n - - - - -
m m
53 3 h s c f 9 2 - y 1 3 f s s c p 2 a o i n n n n n n n n n n n n - - - - -
m m
54 3 h s c f 10 0.5 - y 1 3 f s l c f 1 a ro i n n n n n n n n n n n n - - - - -
1
m on
55 f 4 h s c h 8 3 - n 3 2 f r v s p 2 a r i n n n n n n n n n n n y eah Bl cm hor - -
56 f 2 l h s c f 12 3 - y 1 4 f s s s f 1.5 a o i n n n n n n n n n n n n - - - - -
m m
57 3 h s i f 10 - k y 1 5 r s l c p 4 a c i n n n n n n n n n n n n - - - - -
m w
58 f 4 h s i 7 - k y 1 3 f s v c p 2.5 a o i l n n n n n n n n n n n - - - - -
m m
59 3 o s c t 11 1 - y 3 5 f r r n p 1 a o i n l n n n n n n n n n n - - - - -
m ?
60 f 3 h h c h 10 2 - y 8 5 r s s s p 3 a r i n n n n n n n n n n n n - - - - -
m
61 f 4 h s c f 9 1 - y 1 3 f s s s p 6 a o i n n n n n n n n n n n n - - - - -
m m
62 4 h s i h 9 - t y 2 5.5 f r r c p 1.5 a o i n n n n n n n n n n n n - - - - -
m
63 f 3 h s i f 9 - k y 1 5 r r v s p 2 a ro i n n n n n n n n n n n n - - - - -
m w
64 f 3 h s c 11 0.5 - y 0.5 4 r s v s p 2 a l i n n n n n n n n n n n n - - - - -
m m
65 2 h s c h 10 3in - y 4 4 r s v s p 4 a r c n n n n n n n n n n n n - - - - -
m m
66 4 h s c f 10 2 - y 2 3 r s s c p 3 a l i n n n n n n n n n n n n - - - - -
101
m w
67 f 3 h s c 8 0.5 - y 2 2.5 r s s s p 3.5 a r i n n n n n n n n n n n n - - - - -
m m
68 4 h s i o 10 - f n 1 2 r r v s p 1.5 a cl i n n n n n n n n n n n n - - - - -
m w
69 f 3 h s i f 10 - f y 2 1 f s v p 4 a o i n n n n n n n n n n n n - - - - -
m
70 4 h h s c f 10 1 - n 0.5 2.5 r s l c f 1.5 a l i n n n n n n n n n n n n - - - - -
m m
71 3 h s i o 20 - k n 1 1 f r l c f 3.5 a o i n n n n n n n n n n n n - - - - -
m w
72 f 4 h s i 8 - k n 4 3.5 r s s s p 2.5 a o i b n n n n n n n n n n n -- - - - -
m
73 3 h h s i f 8 - t n 1 3 f s s s f 3 a l i n n n n n n n n n n n n - - - - -
m m
74 4 h s c h 8 2 - y 4 2 r s s s p 3 a o i n n n n n n n n n n n n - - - - -
m m
75 5 h s c h 9 1 - y 10 3 r r r n p 2 a o i n n n n n n n n n n n n - - - - -
m
76 f 3 h s c f 10 2 - y 1 3 f s v s p 3.5 a l i n n n n n n n n n n n n - - - - -
77 f 2 l h s c h 8 .2 - y 5m 3 r s v s p 3 a o i n n n n n n n n n n n n - - - - -
m m
78 3 h s i h 10 - f y 1 4 r r r n p 3 a o i b n n n n n n n n n n n - - - - -
m m
79 5 h s c f 10 0.5 - y 3 1.7 r r r c p 2 a o i b n n n n n n n n n n n - - - - -
m m
80 3 h s i f 8 - f y 3 3 r s s s p 4 a o c n n n n n n n n n n n n - - - - -
m m
81 4 h s c f 12 1 - y 6 5 r s s s p 4 a l c n n n n n n n n n n n n - - - - -
m
82 f 3 h s c f 8 1.5 - y 12 2 f s v c p 4 a o i n n n n n n n n n n n n - - - - -
m m w
83 3 s i h 9 - f n 6 1.5 f s t c p 4.5 a o i n n n n n n n n n n n n - - - - -
m m
84 3 h s i h 9 - t y 1 1.5 f r c o p 3.5 a l i n n n n n n n n n n n n - - - - -
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85 f 3 l h s i 7 - f n 3 3 f s v c p 3 a lo i l n n n n n n n n n n n - - - - -
m
86 f 3 h s i h 8 - f n .5 4 r s s n f 2 a o i n n n n n n n n n n n n - - - - -
m
87 f 2 h s i f 11 - f n 3 2 f s s s f 8 a l i n n b n n n n n n n n n - - - - -
88 f 2 l h s i h 8 - t y 2 5 f s s s p 3 a o i n n n n n n n n n n n n - - - -
m m
89 5 h s i f 12 - t y 2 5 f r s s f 3 a l i n n n n n n n n n n n n - - - - -
m m
90 5 h s c f 8 2 - y 1 2 f r r n p 2 a o i n n n n n n n n n n n y 3 rt ex hor - -
91 f 4 h h s c h 10 3 - y .5 2 f s s s f 3.5 a o i n n n n n n n n n n n n - - - - -
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92 f 2 h s s c 8 8 2.5 - y 2 2 f s s s f 3 a o i n n n n n n n n n n n n - - - -- -
m m w
93 5 h s i 6 - k n 3 2 r r r j p 4 a r c n n n n n n n n n n n n - - - - -
m m
94 3 h s c f 10 2 - y 6 2 f s s s p 4 a o i n n n n n n n n n n n n - - - - -
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95 5 h h s i h 8 - s y 4 3 r r r n p 2 a l i n n n n n n n n n n n n - - - - -
96 f 6 l h s c f 7 0.5 - y 12 1 f s s s p 4 a l i n n n n n n n n n n n n - - - - -
m m
97 3 h s i h 9 - b y 5m 2 f s r c f 1 a o i n n n n n n n n n n n n - - - - -
98 f 3 h h s c f 10 2 - y 0.5 3 f s s s f 4 a o i l n n n n n n n n nn n n - - - - -
m
99 2 l h s c h 8 2 - y 4 2 f r r n p 2.5 a ro i n n n n n n n n n n n n - - - - -
m
100 6 h h s c f 12 2 - y 2 3 f s s s p 5 a o i n n n n n n n n n n n n - - - - -
m m
101 6 h s i h 9 - f y 6 4 f r t c f 9 a o i n n n n n n n n n n n n - - - - -
m m
102 4 h s c h 8 2 - y 3 3 f s v s p 4 a r i n n n n n n n n n n n n - - - - -
102
m
103 f 3 h s i h 9 0.5 - y 2 3 r r v s p 4 a r i r n n n n n n n n n n n - - - - -
m m
104 3 h s c f 8.5 1.5 - y 1 2 f s s s p 4 b o i n n n n n n n n n n n n - - - - -
15
105 f 4 h h s i f 8.5 - b y min 2 f s s s p 3.5 a l i n n n n n n n n n n n n - - - - -
106 f 3 h h s i f 8 - f y 3 3 f r r n p 2.5 a l i n n n n n n n n n n n n - - - - -
m m
107 3 h s c h 12 2 - y 6 3 r r r n p 2 a o i b n n n n n n n n n n y 3 /bif hor - -
m m
108 6 h s i h 8 - t y 6 3 f r r n p 2 a lo i l n n n n n n n n n n n - - - - -
m m
109 4 h s i h 10 - f y 1 4 f s v s p 4 a c i b n n n n n n n n n n n - - - - -
m
110 f 2 h s c f 10 1.5 - y 9 3 f s s s f 2 a o i n n n n n n n n n n n n - - - - -
m m
111 5 h s c h 10 2 - y 4 3 f s s c p 2 a o i r n n n n n n n n n n n - - - - -
m h w
112 8 l o s i 5 - f n 3 2 f s o c p 3 a o i r n n n n n n n n n n n - - - - -
m m
113 3 o s c t 20 10 - y 6 4 r s b c p 5 a r i n n n n n n n n n n n n - - - - -
m
114 f 2 h s c h 8 1 - y 1 2 r s s s f 3 a o i n n n n n n n n n n n n - - - - -
m
115 4 l h s c h 8 1 - y 2 2 r s s s p 4 a o i l n n n n n n n n n n n - - - - -
m
116 4 l h s i h 7 - f y 2 2 r s l c p 3 a o i n n n n n n n n n n n n - - - - -
m m
117 4 h s c f 8 1 - y 2 3 r s s s p 2 a o i n n n n n n n n n n n n - - - - -
m
118 f 3 h s c f 10 3 - y 3 2 r s s s p 5 a o i n n n n n n n n n n n n - - - - -
m
119 3 l h s i o 10 - f n 4 3 f s v s p 3 a r i l l n n n n n n n n n n - - - b -
m m
120 4 h s c h 9 .1 - y .5 3 f s v s p 3 a l i n n n n n n n n n n n n - - - - -
121 f 3 l h s i h 7 - f y 2 3 f s s s p 4 a lo i n n n n n n n n n n n n - - - - -
m m w
122 5 s c h 11 1 - y .5 3 f r r n p 1.5 a c c r n n n n n n n n n n n - - - b -
m
123 f 2 h s c f 10 2 - y .5 3 f s v s f 4 a r c b n n n n n n n n n n n - - - - -
m
124 f 3 h s i f 10 - f y 3 2 f s v c f 3 a c i n n n n n n n n n n n n - - - - -
m m
125 5 h s i h 8 - b y 2 3 r s s s p 4 a o i n n n n n n n n n n n n - - - r -
m m
126 2 h s c f 9 1 - y .5 2 f s v s f 3 a o i n n n n n n n n n n n n - - - - -
m m
127 3 h s c o 7.5 1 - y 5 1 r r r n p 3 a r i b n n n n n n n n n n n - - - b -
m m
128 3 h s c h 10 0.5 - y 10 2 f s v s p 3 a r i b n n n n n n n n n n n - - - - -
m m 30
129 5 h s i s 6 - f y min 1 f s l c p 3 a o i n n n n n n n n n n n n - - - - -
m m
130 3 h s c f 7 1 - y 6 2 f s l c p 4 a l i n n n n n n n n n n n n - - - - -
m m
131 4 h s c f 10 1 - y 1 3 f s s s p 3 a o i n n n n n n n n n n n n - - - - -
132 f 3 h h s c h 12 1.5 - y 2 3 f s v s p 1.5 a r i n n n n n n n n n n n n - - - - -
30
133 m 4 m h s c h 10 2 - y min 3 f s s s f 2.5 a p i n n n n n n n n n n n n - - - - -
103
134 f 2 m h s i f 8 - t y 2 3 f s v s p 4 a p i n n n n n n n n n n n n - - - - -
135 f 3 m h s c f 9 0.5 - y 13 3 f s s s f 4 a p i n n n n n n n n n n n n - - - - -
136 f 3 m h s i h 7 - f y 3 3 f s s s p 4 a p i n n n n n n n n n n n n - - - - -
137 m 4 m h s c h 12 5 - y 3 3 f s b c p 2.5 a p i b n n n n n n n n n n n - - - - -
138 f 3 m h s c f 8 0.5 - y 3 3 f s s s p 2.5 a r i b n n n n n n n n n n n - - - - -
139 m 5 m h s i f 8 - k n 2 4 r s s s f 4 a r i n n n n n n n n n n n n - - - - -
140 f 2 m h s c f 9 1 - n 3 3 r s v s f 3 a p i n n n n n n n n n n n n - - - - -
141 m 4 m h s c f 10 2 - y 3 2 f s s s p 8 a p i n n n n n n n n n n n n - - - - -
142 m 4 m h s c f 10 1 - y 6 2 f s l c p 5 a r i n n n n n n n n n n n n - - - - -
143 m 3 h h s i h 8 - b y .5 3 f r r n p 0.5 a p i bl lft n n n n n n n n n n - - - - -
144 m 3 m h s i f 9 - f y 1 4 f s t c p 2.5 a p c n n n n n n n n n n n n - - - - -
145 m 4 m h s c f 9 0.5 - y 2 3 f s s s f 5 a r i n n n n n n n n n n n n - - - - -
146 m 4 m h s c h 9 2 - y 3 4 r s s s p 3 a p i b n n n n n n n n n n n - - - - -
147 f 2 m h s c h 9 2 - y 3 3 f s v s p 5 a p i n n n n n n n n n n n n - - - - -
148 m 4 m h s c h 10 1 - y 3 3 r s s s p 6 a p i n n n n n n n n n n n n - - - - -
149 m 3 m h s c h 9 1 - y 3 3 f s s s p 3 a p i n n n n n n n n n n n n - - - - -
m
150 m 5 s c f 9 1 - y 4 2 r s v s f 2.5 a p i r r n n n gr cn rt n n n n n n - - - - -
151 m 4 m h s i f 9 - f y 3 3 r s s s p 4 a p i n n n n n n n n n n n n - - - - -
152 m 3 m h s i f 9 - k n 1 4 f r r n p 2 a l i r n n n n n n n n n n - - - - -

Vijay Kautilya D

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Vijay Kautilya D

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STUDY OF PATTERN OF NECK INJURIES IN CASES OF HANGING

WITH SPECIAL REFERENCE TO CAROTID INJURIES.

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences,

Karnataka, Bangalore in partial fulfillment of the requirements for the degree of

DEPARTMENT OF FORENSIC MEDICINE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

I hereby declare that this dissertation entitled “STUDY OF PATTERN OF NECK

INJURIES IN CASES OF HANGING WITH SPECIAL REFERENCE TO CAROTID

of my guide Dr. P. K. Devadass MD, Professor & Head of Department of Forensic

Medicine and co guide Dr Raghupathi A R MD, professor Department of pathology,

Bangalore Medical College and Research Institute, Bangalore.

Date: Dr. Vijay Kautilya D.

This is to certify that this dissertation entitled “STUDY OF PATTERN OF NECK

INJURIES IN CASES OF HANGING WITH SPECIAL REFERANCE TO CAROTID

INJURIES.” conducted at Bangalore Medical College and Research Institute, Bangalore, is a

Bangalore, in partial fulfillment of the requirement for the degree of M. D. in Forensic

Medicine, examination to be held in May 2011

Date: Dr. P. K. Devadass MD,

INJURIES IN CASES OF HANGING WITH SPECIAL REFERANCE TO CAROTID

INJURIES.” conducted at Bangalore Medical College and Research Institute, Bangalore, is a

Bangalore, in partial fulfillment of the requirement for the degree of M. D. in Forensic

Medicine, examination to be held in May 2011.

Date: Dr. Raghupathi A R,

This is to certify that this dissertation entitled “STUDY OF PATTERN OF NECK

INJURIES IN CASES OF HANGING WITH SPECIAL REFERANCE TO CAROTID

Bangalore in partial fulfillment of the requirement for the degree of M. D. in Forensic

Medicine, examination to be held in May 2011.

Date: Dr. P. K. Devadass MD,

This is to certify that this dissertation entitled “STUDY OF PATTERN OF NECK

INJURIES IN CASES OF HANGING WITH SPECIAL REFERANCE TO CAROTID

INJURIES.” conducted at Bangalore Medical College and Research Institute, Bangalore, is a

MD , Professor & Head Department of Forensic Medicine and co guide Dr Raghupathi A R

partial fulfillment of the requirement for the degree of M. D. in Forensic Medicine,

examination to be held in May 2011.

Date: Dr. Subash G.T.DM,

DECLARATION BY THE CANDIDATE

format for academic / research purpose.

Date: Signature of the Candidate

 Rajiv Gandhi University of Health Sciences, Karnataka

Department of Forensic Medicine, Bangalore Medical College and Research Institute,

understanding throughout my dissertation and my MD course. His experience and knowledge

have been valuable resource for this work.

deed a major guiding force in the completion of this thesis

I am grateful to, Dr. Satish. K. V. MD Associate professor, Department of Forensic Medicine,

encouragement, insight and knowledge through my MD course and helped me a lot in my

dissertation, for which I shall remain obliged.

I sincerely thank Dr Shankar, Professor, department of Neuro- pathology, NIMHANS for

I am deeply indebted to Professor Dr. K. H. Manjunath MD. DFM, Department of Forensic

suggestions and support.

I am deeply indebted to Dr.Bhimappa Havanur M.D Associate professor, Department of

I express my deepest gratitude to Dr. S. Venkata Raghava. MD Assistant professor,

Department of Forensic Medicine, Bangalore Medical College and Research Institute,

would not have been a damn success.

I express my thanks to Dr. C. N. Sumangala MD Lecturer, Department of Forensic Medicine,

I express my thanks to Dr. Geraldin Sanjay, Department of Forensic Medicine, Bangalore

I thank and express my deepest gratitude to my friend Dr Chandrakanth Kocatanoor PG

Research Institute, Bangalore for providing opportunity and support.

My sincere gratitude to my wife Dr. Shruti P Hegde P G in Ophthalmology for her

wonderful support and help at every stage of my study and life.

I express my deepest gratitude to my colleague Dr.Pushpa M G., Dr Hemanth Naik, Dr

Pramodh R K, Dr Sarika, Dr Somashekar P, Dr Rajashekar Myageri for their valuable support

It’s my pleasure to express thanks to my beloved friends and colleagues Dr.Shylaja,

Dr.Shobhana, Dr.Ravikumar, Dr.Chetan, Dr.Rudresh, Dr.Yogesh, Dr Vinay, Dr Yadukul, Dr

Murali, Dr Raghavendra for their constant support.