.I Indian Acad ForensicMed, 31(3)

Originals and' Papees:

Histopathological changes in skin and subcutaneous tissues at ligature site-in-cases

of hanging and strangulation

Anil Yad~v 'I; & B.M. Gupta- ** -" ,

Abstract94 'cases of deaths due tohanqinq and strangulation were studied prospectively during July

2007 to December 2008 .at S.M.s. Medical. College, Jaipur.' Autopsy was conducted' in all casesencompassing a detailed external and' internal examination including histopathology of' skin andsubcutaneous tissues from ligature site. Out of 94 cases, -91were of hanging and 3 of strangulation. -lnhanging, no gross haemo_rrhage·was-detected whereas it 'was detected in all cases of stranqulation.Congestion and Compression were present in 100% cases of 'strangulation whereas in 28.5% and43.95% cases of hcmging respectively. Breaking of skin was present in 35.16% cases of hanging whilein 33.3% cases, of strangulation. Wrinkling of skin was not observed in any case of strangulation butobserved in 46.15% cases of hanging. These findings indicate the importance of histopathology ofligature mark in documenting antemortem nature of hanging and strangulation in doubttul cases.

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Key words: Subcutaneous tissue; ligature merk, neck 'comptessien. ,-' , :

examination of. skin and .subcutaneous tissueIntroduction from ligature _ site with the routine autopsy

Hanging is a form of ligature strangulation procedure. These findings may be helpful inin which the force applied to the neck is derived elucidating the circumstances of death infrom the gravitational drag of the weight of the conditions where the circumstances may be asbody or the part of the body'. It is a common yet unsolved or are later found to be fabricated.method of suicide in India. Strangulation is The ligature mark itself is not necessarilyanother entity representing death by compression the deciding factor. It is clear that the mark whichof the neck from the external force by ligature, is usually seen on the neck where hanging tookhuman hand or by other means like stranglehold, place during life may be produced also by afoot and some solid substances 2. A great ligature applied within 24 hours, or even later afterchallenge rests in front of forensic experts in . death .consequently. This kind of mark is notcases of asphyxial deaths to establish the cause conclusive proof that the hanging took placeand manner of death. The various features of the during the life 3. A detailed microscopichanging and strangulation deaths that are examination of the mark may confirm theavailable from the case history, police presence of effusion of red cells, possibly withinvestigation, gross findings and internal findings separation of fibrin and cellular elements, but nolead a forensic expert to the conclusion of evidence of tissue reaction 3.

compression of neck as the cause of death.However, doubtful cases which test the mettle of Material and Methoda forensic expert do always exist. Here, lies theimportance of clubbing the histopathological

This study was carried out at Departmentof Forensic Medicine, S.M.S. Hospital, Jaipur incollaboration with the Department of Pathology,S.M.S. Medical College, Jaipur. 94 cases ofasphyxial deaths were studied over the periodfrom July .2007 to December 2008. Out of the 94cases included in this study, in 91 cases the

* Corresponding author- Final Year Resident,** Sr. Professor & Head, Department of ForensicMedicine & Toxicology S.M.S. Medical College,Jaipur.

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Yadav & Gupta .' lIP changes & ligature siie

death was due ,to hanging, while- in rest.vthree irat S'.M.S.'Hospital,~-Jaipur.Amongst the,94 casescases the death was due to strangulation (two of ,hanging and strangulation, 68 subjects weremanual. and one ligatur:e strangulation). After, males (72-,3%) and 26 were females (27.7%). Thiscompleting 'all, medico . legal 'formalitie~, the' showsthat the number of malecases were 2.p'autopsy was conducted at the mortuary of our' times, more than females. In the present study,department with standard technique. Thorough death due to strangulation among males was notexternal examination was carried out pertaining to observed.the features such as rigor mortis, post mortem As per table-2, maximum number of deathhypostasis; detailed examination of the ligature cases i.e.' 42 (44.68%) cases of hanging andmark and other significant findings' -Were strangulation were reported in the age group ofrecorded. ' 21-30 years. Out of 91 'cases of hanging, 68

Dissection of thoraco-abdorninal and (74.73%) were males and 23 (25.27%) werecranial cavities. was carried out following the females died due, to· hanging. In 3 cases ofstanda-rd technique, and lastly the dissection of strangulation, no male was reported dead i(l anyneck was carried out with Y-shaped. incision age group. All the 3 cases otstranqulation weremethod i.e. two incisions, commencing on either reported in females. No case of. hanging' andside of neck from 2-3 cm behind the lobe of each strangulation deaths Was reported in 0-10 yearsear which met at manubrium sterni and then age group.,continued as single incision down to the pubic In our .study, In 40 out of 91 cases ofsymphysis, carried out in reverse' manner. This hanging; compression changes were observed inincision is suitable for detailed dissection of neck. the skin while compression of the skin wasLayer by layer dissection was carried out of the present in all 3 _cases of strangulation. Theneck structures beneath the ligature mark and breaking of skin was present in 32- out of 91gross findings were noted. A portion' of the skin cases of hanging and in only 1 outof 3 cases ofand subcutaneous tissue from the ligature site strangulation. The wrinkling of skin was present inwere preserved in 10% tormalln for 42 (46.15%) out of 91 cases of hanging deathshistopathological, examination with microscopy while this ,histopathological feature of the skinunder H & E stain of suitable sections. was absent in all 3 cases of strangulation.

In 26 out of 91 cases of hanging and allthe 3 cases of strangulation congestion. in theskin were present. Rest other had no congestion.Cellular infiltration in the skin was' present in 30out of 91 cases of Hanqinq and 1 out of 3 cases

ObservationsDuring· the period from July 2007 to

December 2008, a total of 94 cases of asphyxialdeath due to compression of neck were autopsy

::;;.-

"Table -1: Age and sex-wise distribution of deaths due to hanging and strangulation-s:No. --- -A-g;;-grouj;--- ~-H~nging----- Strangulation Total -----

-------·-·-T-----!-----,·--------I--·---------jMale Female Male Female No. (%). (%) ..(%) (%) (%)

--'--:--1---1- 0-10 - --c-rr-~r 0 0 0 - ----'-0-',..-. -,--,------ - . -----, . .._-_ ---- - _.-.:...-- -.-----'<:0----

,~ ,2 '11-20 1'-;l,(15,38) ~4(4.39) 0',. 1 (33.33) _ 19(20.21) ,- ' 3 21-30 ---r27(29-:67r 14 (15.38) 0 ,1-(~:t33)_ '--,' 42 (44.6.8)•..

\."~':.'-4~ ::--:·~46---;~i~'22'(24:17) '3 (3.'29) I---o-~~-'...0' .: _.~5 (26:59)--,~. 5"" y "" 41":50 J '~5;(5A9) -- 2 (2.'1'9) 0 ---0---'---7(7.44)- .. ---'.'.;:~~.--;"'-" --;'51~60~~O-::-'-;"- 0 0 ,., •.~ \33:33) . 1 (1.0(;»)---7-- ;~t~T'T' '--:-g8(74r-- --23 (26) e_ 0 3 '(tab) 94' (1bO)'~~

J Indian.Acad Forensic Med, 31(3)

. Table-z: Incidence and distribution 6f .histopathological changes in skin in 'hanging and, strangulation deaths

Type of Compression . Breaking " . Wrinkling - . Congestion Cellular Infiltration 'death Present Absent Total Present Absent. Total Present Abse.nt Total· PresenAbsent Total Present Absent Total

Hanging 40 51 91 32 59 91 42 49 91. ,26 . 65 91 .30 61 91. (43.95% (56.05% hOO%) (35.16% 64,84% 00%) 46.15% (53:85% (100%) (28.5% 7f5%) (100%)(32.96% (67.04%) (100%)Strangulation '3 " 0 ' 3., 1 '2 3 -,0 . " 3 3 . 3 ! 0 i: :3 2 1 . 3 '

(100%) 00%) (33.3%) (66.6%) 00%). '(0%)· (100%) (100%) (100%) (100%) (66.6%) (33.3%) (~OO%)

Table-3: Incidence and distribution of histopathological changes in the ~nderlying subcutaneous tissue in'., . ." hanging and strangulation . .' .

Changes in the subcutaneous, tissue . Hanging Strangulation., Congestion - '. 48 (52.7%) 3 (100%)

Haemorrhage J " . 19 (20.8%) - 3 (100%)·" Cellular Infiltration ,. 30 (32.9%) 0(0%)

AILabove mentioned findihgs absent . , 107'(18.6%) 0(0%)of strangulation.

In hanging, ,48 (52.7%) out of 91 caseshad congestive changes in underlyingsubcutaneoustissue i.e, thyroid, muscles, fibroustissue and Iymphnodes, and in 19 (20.8%) caseswere having, haemorrhagic changes. Cellularinfiltrationswere present in 30 cases. None of thehistopathological changes seen in ·17 out of 91cases of Hanging.

In strangulation .all three cases- hadcongestion and haemorrhagic chanqes, but 'noneof the case· had cellular infiltration: "in Flgure- 2:-Section of skin from ligature site (IOOx).subcutaneous.tlssue. showing in case of hanging showing wrinkling,

breaking in epithelium, infiltration in subepithelium region and congestion in ;dermal region;

1

. ,Figure-I: S.ectionof skin from ligature site (IOOx)showing multiple breaks and congestion in dermal

region.

.. Figure- 3:.Section-of skin from ligature site (IOOx)

.'"showing breaking, compression in epithelium, focalcongestion in sub epithelial, region and haemorrhage

, in dermal region.. .. i:.:,"),

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Figure-4: Section of skin from ligature site (lOOx)ina case of strangulation showing br.eaking,

compression with focal congestion. '

Figure- 5: Section of Subcutaneous tissue (thyroidlOOx)showingdilated capillaries with congestion.

Figure- 6: Section from muscle underlying theligature mark (lOOx),showing areaot'haemorrhages

. • . f' ;' in 'muscle: ,'. .

Yadav & Gupta: HP changes & ligature site

Figure- 7: Section from subcutaneous tissue(fibrous tissue lOOx) showing congestion.

Figure- 8: Section of muscle (lOt}x)in a case ofstrangulation showing the destroyed architecture of

muscle fibres.

Discuss~onIn our study, we studied 10 control cases.

There was no compression, breaking, wrinkling,congestion and haemorrhage on gross andmicroscopic studies carried out on skin andsubcutaneous tissue from the neck region incases other than hanging and strangulation,where there was no trauma to the. neck regionpresent.

Inclusion criteria were to include thosecases of asphyxial deaths, where there washistory of, hanging or strangulation as per theinvestigating agency and where there was noother external injury or -any other ev~nt Out oftotal.s t cases of hanging, 74% cases were maleas against 84% cases in study carried out byLuke e~al. \-.10 stranqulation; al!.3, cases werefemalesandno malevictim.ofstrangulationwas .

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observed during the period of study. Thisindicates that hanging is a more common methodof committing suicide ""in males. Maximumnumbers of cases of hanging in our study ",belongto the age group of 21- 30 years i.e. 45.05%(29.67%males and 15.38%females). Theobservation of Luke et al" was 26% (23% malesand 3% females) in this age group. Leastcommon age group in the cases of hanging in ourstudy was 41-50 years as against 10-19 years inthe study done by Luke et a14• In the presentstudy, we observed that death due to hanging ismore common in males as compared "to'females.Whereas in strangulation, all victims were femalesand no male was victim in our study. ,

A detailed dissection of the tissue of theneck should be made to detect injury of thedeeper structures",

In strangulation the degree and characterof injury to the deeper tissues of the neck aredependent on the amount of violence used inapplication of ligature5. The underlying musclesfrequently show some degree of extravasationdue to rupture of capillary vessels".

An "array of characteristic changes wasobserved in microscopy of the skin andsubcutaneous tissues of ligature site in cases ofhanging and strangulation.' These includecompression, breaking wrinkling, congestion andhemorrhage. Compression is the decreasedthickness of skinlayers with increased basophilia.

The term Breaking means discontinuity ofepidermal and/or dermal layers of the skin.

Wrinkling is the term which indicates 2.increased waviness of the epidermis: Theseparation between the layers associated withother features i.e. compression were observed ln' 3. Taylor AS. Principles and Practice of Medical100% cases of strangulation deaths compared to Jurisprudence. Edited by Keith Mant A. 13thhanging death i.e. 43:95%. Breaking was ed., 1994: 316. "observed' in 33.3% cases of stranqulation death 4. Luke J L .Correlation of circumstances withas 'compared to 35.10% cases of hanging death. pathological findings in Asphyxial deaths byCongestion was present in all three cases i.e, "100% of strangulation as compared to hanging 5." hanging, J For Sci. 198§; 30: 1140-1147,

Glaister R. Medical Jurisprudence andwhere itwas present in' 28:5% cases. Cellular TqxicoIOgy.14thed., 1966.:170-173.. ,infiltration 'was present in 2(66.6%) out of' three "

6 Reddy KSN." The ""essential of Forensiccases of strangulation "as' compared to hanging c' "

deaths (32.96%). Wrinkling was observed in 42 Medicine and Toxicology. 2002: 291,

.T Indian Acad Forensic 'Med,"31 (3)

(46.15%) cases of hanging deaths while thisparticular feature was absent in all 3 -eases ofstrangulation. in the subcutaneous tissues,congestion and hernorrhaqe were observed in52.7% and 20.8% cases of hanging respectivelywhereas: both these features were documentedin 1OO%, cases of strangulation.The various features of mechanical cutaneousalteration either alone or in combination are highlysuggestive to determine ante mortem aspectssince these" histopathological features indicatethat the violent compression of neck took place.

A portion of the skin and deeper tissue inrelation to the ligature mark should be examinedmicroscopically for evidence of tissue reaction,which if present indicates ante mortem hanging.The absence of tissue reaction does not excludeante mortem. hanging (Gordon et al) 6.

The present" study emphasizes theimplementation of histopathological examinationof skin in all the cases of violent asphyxial deathwhere violent compression of neck took place, asa routine procedure.

The present study concludes that adetailed evaluation of the gross andhistopathological findings of the neck structures,if undertaken as a routine would be moreconclusive in establishing the cause and mannerof death to aid the administration of justice.

References1. Knight B. Forensic Pathology,

379.2nd ed., 1996:

Vij K. Text book of Forensic 'Medicine &Toxicology : Principles and Practice. 4th ed.Elsevier. 2008: 170.

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