Table of Content - Volume 14 Issue 3 - June 2020
Study of deaths due to hanging in ABVIMS and Dr Ram Manohar Lohia Hospital New Delhi
Arindam Chatterjee1, Vinka Maini2
1Senior Resident, Department of Forensic Medicine and Toxicology, ABVIMS and Dr Ram Manohar Lohia Hospital New Delhi, INDIA. 2Senior Resident, Department of Forensic Medicine and Toxicology, Government Medical College Jammu, Jammu and Kashmir, INDIA. Email: drvinkamaini@gmail.com
Abstract Background: Hanging is a form of violent asphyxial death produced by suspending the body with a ligature around neck and the constricting force being the weight or part of the body weight. Hanging is a common cause of suicide world-wide, along with poisoning and self-immolation in rural regions of India. Hanging is being common method of suicides while strangulation as one of methods in homicide. A total of 1,34,516 suicides were reported in the country during 2018 showing an increase of 3.6% in comparison to 2017 and the rate of suicides has increased by 0.3 during 2018 over 2017. Present study was undertaken to Study of deaths due to hanging in ABVIMS and Dr Ram Manohar Lohia Hospital, New Delhi. Material and Methods: Present study was prospective and observational, conducted in Department of Forensic Medicine and Toxicology ABVIMS and Dr Ram Manohar Lohia Hospital New Delhi, in cases which had history of death by hanging as reported by the police inquest. Results: In present study, total 118 cases of hanging were autopsied. All cases were related to suicidal deaths. Male cases (55 %) were more than female (45 %), male to female ratio was 1.2:1. 15-29 years age group was most common (48%), followed by 30-44 years age group (24%) and 45-59 years age group (19%). We noted that 63% cases had typical hanging. Nylon rope (35 %) was most common ligature material used in hanging, followed by dupatta/chunni (26%) and jute rope (16%). Common predominating suicidal motivating factors were domestic. Out of 33 cases of domestic cause, 16 were dowry related and rest were due to other domestic causes. Dowry deaths in young females is very distressing (14 %). Other motivating factors were financial (21%) , love relationship (17%) , disease related (15%), work related (10%) and education/career (8%). Conclusion: Different and multiple stress factors are increasingly reported to be associated with hanging, Identification of precipitating factors of suicide among younger victims and necessary sociological interventions are need of hour to prevent these premature deaths and socioeconomic burden on our society. Keywords: Hanging deaths, Ante-mortem hanging, Ligature material, Pre‑disposing factor
INTRODUCTION Deaths due to compression of neck by ligature are one of the most important unnatural deaths encountered by forensic experts in mortuary. Hanging is a form of violent asphyxial death produced by suspending the body with a ligature around neck and the constricting force being the weight or part of the body weight. Hanging is a common cause of suicide world-wide, along with poisoning and self-immolation in rural regions of India. Hanging is being common method of suicides while strangulation as one of methods in homicide. All cases of hanging are considered to be suicidal until the contrary is proved.3 Many cultural and socio-economic factors are responsible for the causation of hangings. Rapid urbanization, industrialization and emerging family systems are resulting in social upheaval and distress.4 Over the past 30 years the incidence of suicide by hanging is on increase, especially among young adults.5 The fact that 71% of suicides in India are by persons below the age of 44 years imposes a huge social, emotional and economic burden on our society.6 A total of 1,34,516 suicides were reported in the country during 2018 showing an increase of 3.6% in comparison to 2017 and the rate of suicides has increased by 0.3 during 2018 over 2017.7 The reduction of suicide mortality has been prioritized by the World Health Organization (WHO) as a global target and included as an indicator in the United Nations Sustainable Development Goals (SDGs) under target 3.4, the WHO 13th General Programme of Work 2019-20238 and the WHO Mental Health Action Plan 2013-2030. 8Present study was undertaken to Study of deaths due to hanging in ABVIMS and Dr Ram Manohar Lohia Hospital, New Delhi.
MATERIAL AND METHODS Present study was prospective and observational, conducted in Department of Forensic Medicine and Toxicology, ABVIMS and Dr Ram Manohar Lohia Hospital, New Delhi over a period of 15 months study from June 2018 to September 2019. Institutional committee approval was taken. Strict confidentiality was kept regarding identity, medical and forensic details of study subjects. The materials taken for this study are those autopsy cases which had history of death by hanging as reported by the police inquest. Cases suggestive of strangulation were not included. We thoroughly scrutinized information gathered from Police, inquest report and hospital treatment records. Regular autopsy examination is done with special attention to thorough examination of the neck structures. Necessary information for the study such as autopsy related documents, history from relatives of the deceased, hospital records, concerned investigating agencies and laboratory report of viscera and their contents, fluids, deceased tissues and organs and other relevant suspicious samples, was collected. Skin samples are taken from the ligature mark and also corresponding area of the underlying carotid vessels and sent for histopathological examination along with control. Collected data was entered in Microsoft excel. The result so obtained was then subjected to statistical analysis. Statistical analysis was done using descriptive statistics.
RESULTS In present study, total 118 cases of hanging were autopsied. All cases were related to suicidal deaths. Male cases (55 %) were more than female (45 %), male to female ratio was 1.2:1. 15-29 years age group was most common (48%), followed by 30-44 years age group (24%) and 45-59 years age group (19%).
Table 1: Age wise Distribution of Suicides during Study Period
We noted that 63% cases had typical hanging. Most cases had features of complete and atypical hanging (57 %) , partial and atypical hanging (33 %). Only 6% had features of Complete and typical hanging.
Table 2: Incidence of Type of Hanging
Nylon rope (35 %) was most common ligature material used in hanging, followed by dupatta/chunni (26%) and jute rope (16%). Other ligature material used were lungi/khudei (8%), sari (6%), cable wire (4%), curtain (3%) and bed sheet (2%). Table 3: Ligature material used
Most common characteristic features noted at ligature mark were grooving (97%), color change i.e. blackening (97%), heaping of epithelium in margins at ligature mark (97%), abrasion/excoriation at ligature mark (96%), leathery hard and pale ligature mark (96%), oblique shaped ligature mark (86%), incomplete ligature mark (discontinuity noted) (83%) and ligature mark above the thyroid cartilage (81%).
Table 4: Findings at the ligature mark.
During post-mortem examination, various internal trauma in neck noted. Trauma to Sternocleidomastoid muscle (60%), Carotid artery (36%), Cervical vertebra (19%) were common amongst them.
Table 5: Internal trauma in the neck
For each suicidal case one or more motivating factors were present. Common predominating suicidal motivating factors were domestic. Out of 33 cases of domestic cause, 16 were dowry related and rest were due to other domestic causes. Dowry deaths in young females is very distressing (14 %). Other motivating factors were financial (21%) , love relationship (17%) , disease related (15%), work related (10%) and education/career (8%).
Table 4: Motivating Factors*.
(* - finalised after reviewing all case details) DISCUSSION Hanging is a serious area of concern to community, so as for forensic experts. In present study male cases (55 %) were more than female (45 %), male to female ratio was 1.2:1. Kumar et al.10, Udhayabanu et al. 11, and Momin et al. 12, reported a male: female ratio of about 2:1. Rawat and Rodrigues13 reported 78.22% cases of male and 21.78% cases of female with male to female ratio of approximately 3:1. Kumar et al.14, reported male to female ratio of about 2.1:1. The overall male: female ratio of suicide victims for the year 2018 was 68.5:31.5, which remains same as compared to year 2017 (68.5:31.5). The proportion of female victims were more in ‘Marriage Related Issues’ specifically in ‘Dowry Related Issues’, and ‘Impotency/Infertility’. The age group (18 and above - below 30 years) and persons above 30 years - below 45 years of age were the most vulnerable groups resorting to suicides. These age groups accounted for 34.9% and 31.6% suicides respectively7.Males are 2.52 times and 2.08 times more likely than females to commit suicide by hanging and poisoning respectively, whereas females are 1.5 times more likely to commit suicide by fire/self-immolation15. As observed in our study, 15-29 years age group was most common (48%), followed by 30-44 years age group (24%) and 45-59 years age group (19%), represents the most active and productive section of the society. Our study is in agreement with study of Udhayabanu et al.11, Rawat and Rodrigues13, Kumar et al. 14, Bhosle et al.16, Ahmad et al.17 and Ajay Kumar et al.18 where majority of the victims were in the age group of 21-30 years. The age group (18 and above - below 30 years) and persons above 30 years - below 45 years of age were the most vulnerable groups resorting to suicides. These age groups accounted for 34.9% and 31.6% suicides respectively. 'Family Problems' (2,236), ‘Failure in Examination’ (1,529), ‘Love Affairs’ (1,131) and ‘Illness’ (932) were the main causes of suicides among children (below 18 years of age)7. Suicide by ‘Hanging’ (51.5%), Consuming ‘Poison’ (26.7%), ‘Drowning’ (4.9%) and ‘Self-Immolation’ (4.4%) were the prominent means of committing suicides during 2018. During the year 2018, share of ‘Hanging’ (from 49.8%in 2017 to 51.5% in 2018), have increased during 2018 over 20177.With regard to precipitating/causative factors in committing suicide, domestic cause (29 %), Other motivating factors were financial (21%) , love relationship (17%) , disease related (15%), work related (10%) and education/career (8%). Dowry deaths in young females is very distressing (14 %). Rawat and Rodrigues13 who noticed physical illness as the most common cause in 22.77% cases followed by poverty in 21.78% cases and drug addiction in 16.83% cases. Udhayabanu et al.11, noticed family disputes like marital disharmony and quarrel with spouse in 52.25% cases followed by mental illness in 23.87% cases. ‘Family Problems’ and ‘Illness’ were the major causes of suicides which accounted for 30.4% and 17.7% of total suicides respectively during 2018. ‘Marriage Related Issues’ (6.2%), ‘Drug Abuse/Addiction’ (5.3%) ‘Love Affairs’ (4.0%), ‘Bankruptcy or Indebtedness’ (3.7%), ‘Failure in Examination’ and ‘Unemployment’ (2.0% each), ‘Professional/Career Problem’ (1.3%) and ‘Property Dispute’ (0.9%) were other causes of suicides7. The means adopted for committing suicide varied from the easily available and effective means such as consumption of poison, jumping etc. to more painful means such as self-inflicted injuries, hanging etc. Like previous year, ‘Hanging’ (51.5%), consuming ‘Poison’ (26.7%), ‘Drowning’ (4.9%) and ‘Fire/Self- Immolation’ (4.4%) were the prominent means/mode of committing suicide7.In present study, nylon rope (35 %) was most common ligature material used in hanging, followed by dupatta/chunni (26%) and jute rope (16%).In a study by Dinesh Rao19, the commonest choice of ligature material used was female dress (soft) material [(Stole (n – 79) and Sari (n – 68)] constituting to 55.68% (n – 147) cases and the least preferred choice was the Waist Belt, reported in only 2 cases (0.76%). Sharma et al. 20, they had opined 47% and 56% of their victims respectively preferred Soft ligature material like sari, Stole, shawl. These results were contrary to the observations made by Pradhan et al.21 wherein they had observed that only 9.09% (n – 4) used sari. Whereas the study conducted by Saisudheer and Nagaraja22 concluded with 86% of Soft material used for ligature. This wide nature of deviations in the choice of ligature material can be explained by the dressing fashion of the population and occupation. We noted that 63% cases had typical hanging. Sharma et al.20 and Saisudheer and Nagaraja22 in their study, 68% and 64% of the cases respectively were due to Complete Hanging. This highlights the regional influence, lifestyle and to a certain extent the type of residence. Dribbling of saliva from the angle of mouth is supposed to be a sure sign of ante-mortem hanging. It could be because of congestion and mechanical stimulation of salivary glands consequent upon friction by ligature6. It is also well known fact that discontinuity along the course of the ligature mark is another important criterion while describing the ligature mark of hanging or ligature strangulation. Other most important finding of ligature mark are level, obliquity of the ligature mark, etc. which differentiate hanging from ligature strangulation. However, it is a fact that not all these differentiating features are present simultaneously in all cases of hangings and strangulations. In practice, the distinction between the two groups important because strangulation is usually homicidal and hanging in vast majority is considered to be suicidal12,20. Suicide is a complex multifactorial phenomenon that makes it difficult to estimate the specific contribution of effective suicide prevention strategies or other changes on societal, community or individual rates. Further action and strengthening of ongoing efforts in the implementation of key effective suicide prevention interventions (i.e. restricting access to means of suicide, interaction with the media for responsible reporting, training young people in their life skills, and early identification, management and follow-up) as described in the LIVE LIFE strategy (WHO, 2018) are crucially needed, to save lives lost to this serious public health issue23.
CONCLUSION Different and multiple stress factors are increasingly reported to be associated with hanging, Identification of precipitating factors of suicide among younger victims and necessary sociological interventions are need of hour to prevent these premature deaths and socioeconomic burden on our society.
REFERENCES
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