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Hanging - Forensic Medicine: Complete Overview

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1. DEFINITION

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2. TYPES OF HANGING

Based on Position of Feet (Suspension)

The weight of the head (5-6 kg) is sufficient to produce a fatal result. A person can therefore die even in a partially suspended posture.

Based on Position of the Knot (Noose Position)

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3. MODE OF HANGING

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4. MANNER OF HANGING

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5. CAUSE OF DEATH

Primary Causes

Key fact: The most common cause of death in most hangings is compression of neurovascular bundles, NOT asphyxia by airway obstruction. Evidence: suicidal hangings have been documented in persons with tracheostomy below the level of the noose; vomitus is found in bronchi below the neck constriction.

Fatal Period

• Judicial hanging (long drop) - death may be instantaneous from spinal cord transaction
• Ordinary hanging - 5 to 8 minutes if airway blockage is incomplete
• Heart may continue beating for 8-20 minutes even after death in judicial hanging

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6. POSTMORTEM APPEARANCES

External Appearances

1. Neck: Stretched and elongated due to upward pull
2. Head: Inclined toward the side opposite the knot (gravitational effect)
3. Face: Usually pale (due to arterial occlusion); congested and swollen with petechiae if venous obstruction predominates
4. Eyes: Eyeballs prominent (congestion); conjunctival petechiae
5. Tongue: Turgid, protruding, clenched between teeth; exposed tip turns dark brown/black due to drying
6. Saliva: Dribbling from the corner of the mouth opposite the knot - important sign of antemortem hanging (stimulation of salivary glands by ligature)
7. Hands/nails: Cyanosed
8. Genitals: Involuntary micturition/defecation; seminal discharge (erection in males)
9. Postmortem lividity: Dependent - on arms, legs, lower limbs; also on face and neck above ligature

Ligature Mark (Most Important External Finding)

• Appears as a groove/furrow on the neck
• Does NOT completely encircle the neck - slants obliquely upward toward the knot (inverted "V" shape)
• Direction: Obliquely upward, toward the point of suspension
• Position: In 80% cases, above the thyroid cartilage; 15% at the level; 5% below (common in partial hanging)
• Color: Initially pale/yellowish; later becomes yellowish-brown, dry, hard, parchment-like after drying
• Characteristics: Pale/waxy center, congested/hyperaemic margins; abrasions and bruises at knot site
• A rope produces a deep, well-demarcated furrow, often showing the rope's weave pattern
• Soft material (dupatta, towel, scarf) may leave a poorly defined or absent mark
• Saliva fibres from the ligature may adhere to skin

Ligature Mark vs. Strangulation Mark (Key Difference)

Internal Appearances

1. Neck dissection (done after removing brain and abdominal/thoracic organs to drain blood and avoid artefacts - Schrader's technique):

• Tissues under mark: dry, white, glistening (due to pressure necrosis)
• Ecchymosis in neck muscles (sternomastoid); muscle hemorrhages
• Hemorrhage or rupture of intima of carotid vessels
• Fractures of hyoid bone (greater cornu) and thyroid cartilage - may be seen; considered antemortem when blood is found at the fracture site
• Vertebral artery intimal tears possible

1. Brain: Congested; cerebral edema
2. Lungs: Congested, edematous; Tardieu spots (petechial hemorrhages) on visceral pleura; bloody froth in trachea
3. Heart: Petechiae on epicardium; right heart distension
4. Stomach: Sometimes vomitus, supporting role of vagal reflex
5. Spinal cord: In judicial hanging - fracture-dislocation C2-C3 with cord transection; bilateral fracture of pedicles/laminae of C2/C3/C4 arch

In DiMaio's prospective study of 83 consecutive cases, no internal neck injuries were found in >50% of hanging deaths - therefore absence of internal neck injuries does NOT exclude hanging as cause of death.

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7. DIAGNOSIS OF ANTEMORTEM HANGING

1. Vital reaction in the ligature mark (histology: inflammatory infiltrate, hemorrhage)
2. Salivary staining - dribbling from angle of mouth (stimulation of salivary glands by ligature, antemortem)
3. Ecchymosis of larynx or epiglottis
4. Fracture of hyoid bone or thyroid cartilage with blood at fracture site
5. Rupture of intima of carotid vessels

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8. AUTOPSY TECHNIQUE IN HANGING

Scene Examination (Before Removal of Body)

• Document height of suspension, platform height, point of attachment
• Note posture; photograph and videograph from all angles
• Examine and document the knot and noose type (running vs. fixed) - never undo the knot; if cut, preserve both pieces separately
• Examine the ground beneath and around the body
• Examine the scene for signs of struggle, whether door was bolted from inside
• Note dribbling of saliva, color of face

Autopsy Protocol

1. External examination:

• Photograph the body with ligature in situ
• Before removing noose: measure its position, document knot type, material, width, location
• Slip noose off (do not cut) OR cut well away from the knot, preserving the knot intact
• Describe ligature mark in full: location (above/at/below thyroid cartilage), direction (oblique/horizontal), continuity, dimensions, color, depth, pattern impressions

1. Open cranial cavity first, then thoracic and abdominal cavities
2. Remove brain and viscera to drain neck veins (Schrader's method) - prevents artefactual hemorrhage in neck dissection
3. Neck dissection (in situ in a blood-free field):

• Layer by layer: skin, subcutaneous fat, platysma, strap muscles, vessels, larynx, hyoid
• Examine for hemorrhages in neck muscles, vessel intimal tears, hyoid and thyroid cartilage fractures

1. Toxicological samples: Blood (femoral), urine, vitreous humor (complete toxicology screen mandatory in all alleged suicidal hangings)
2. Histological sections from ligature mark (vital reaction), lung, brain

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9. MEDICO-LEGAL ASPECTS - MANNER DIFFERENTIATION

Suicidal Hanging

• Most common manner; preferred method in India (especially males)
• Scene: room bolted from inside; body found in isolated area
• Suicide note may be present
• History of depression, prior attempts, financial/social stress
• Ligature: knot accessible to the deceased; often self-tied
• No other significant injuries (unless self-inflicted)
• Fixed or running noose tied to ceiling fan, roof beam, window frame, tree

Homicidal Hanging

• Extremely rare; possible only when victim is:
• A child
• Unconscious or rendered helpless (intoxicated, drugged)
• Very frail or disabled
• Signs suggesting homicide:
• Marks of violence on body (bruises, lacerations)
• Horizontal ligature mark (not oblique upward)
• Toxicology positive for drugs/alcohol
• Signs of struggle at scene (disturbed furniture, room unlocked)
• Ligature knot was tied by another person (not accessible to victim)
• Sometimes: individual first strangled then hanged (two ligature marks or mark not in classic inverted-V configuration)

Accidental Hanging

• Children simulating hanging while playing; clothing caught in branches
• Autoerotic/sexual asphyxia in adults
• Women's dupatta entangled in vehicle
• Fall from staircase with neck caught in railing
• Intoxicated person accidentally suspended from arm of chair

Judicial Hanging

• State-sanctioned execution
• Long drop (~5 m), face covered with dark mask
• Knot on left side of jaw near chin; trapdoor falls
• Death: fracture-dislocation at C2-C3 (or atlanto-occipital/atlanto-axial joint)
• Immediate unconsciousness; heart may beat 8-20 more minutes

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10. IPC AND BNS (LEGAL PROVISIONS)

Indian Penal Code (IPC) - Old Provisions

Bharatiya Nyaya Sanhita (BNS) 2023 - New Provisions (Effective 1 July 2024)

Key Legal Point: Decriminalization of Suicide Attempts

Medico-Legal Case (MLC) Considerations Post-BNS

• Cases of attempted hanging should still be registered as MLC when there is:
• Suspicion of abetment (BNS 107/108)
• Foul play or evidence suggesting homicidal hanging
• A suicide attempt made with intent to coerce a public servant (BNS 226)
• Dowry-related deaths within 7 years of marriage (BNS 117 presumption)

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11. QUICK REFERENCE - DIFFERENTIATING HANGING FROM LIGATURE STRANGULATION

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• PC Dikshit Textbook of Forensic Medicine and Toxicology
• Parikh's Textbook of Medical Jurisprudence, Forensic Medicine and Toxicology
• DiMaio's Forensic Pathology, 3rd Edition
• BNS-IPC Comparative Table, UP Police / India Code (2024)
• PMC Article: BNS 2023 Implications for Forensic Psychiatry (PMID via PMC11572553)