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

 

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 suicidal^12,20. 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

1. Dogra TD, Rudra A. Lyon’s Medical Jurisprudence and Toxicology. 11th ed. Delhi: Delhi Law House; 2013. pp. 958.
2. Mythri S, Ebenezer JA. Suicide in India: distinct epidemiological patterns and implications. Indian J Psychol Med 2016;38(6):493–8.
3. Modi J P. Medical Jurisprudence and Toxicology, Edited by K Mathiharan and Amrit K Patnaik, Lexix Nexis Publishers, New Delhi, 23rd edition; 2008: 565 – 614.
4. Kamalakar D (2012) A new trend of suicides in India, Countercurrents. org., June 2016.
5. David Gunnell, Olive Bennewith, Keith Hawton, Sue Simkin and Nav Kapur. The epidemiology and prevention of suicide by hanging: a systematic review. International Journal of Epidemiology 2005; 34(2):433-442.
6. Vijaykumar L. Suicide and its prevention: The urgent need in India. Indian J Psychiatry 2007; 49:81-4.
7. Accidental Deaths and Suicides in India 2018 , published by National Crime Records Bureau (Ministry of Home Affairs), Government of India.
8. World Health Organization (WHO) https://apps.who.int/iris/bitstream/handle/10665/324775/WHO-PRP-18.1-eng.pdf (accessed 23 August 2019).
9. World Health Organization (WHO) https://www.who.int/mental_health/publications/action_plan/en (accessed 23 August 2019).
10. Kumar C, Rana N, Goyal AK, Tanna J, Pathak A, et. al., (2015) Epidemiology of cases of hanging at Vadodara, Gujarat. IRPMS. 1(2): 23-26.
11. Udhayabanu R, Toshi S, Baskar R (2015) Study of hanging cases in Pondicherry region. IOSR- JDMS. 4 (7): 41-44.
12. Momin SG, Mangal HM, Kyada HC, Vijapur MT, Bhuva SD (2012) Pattern of ligature mark in cases of compressed neck in Rajkot region: A prospective study. J Indian Acad Forensic Med. 34(1): 40-43.
13. Rawat V, Rodrigues EJ (2015) Medico-legal study of hanging cases in north Goa. Int J Forensic Sci Pathol. 3(5): 110-118.
14. Kumar N, Sahoo N, Panda BB, Dutta A (2016) Demographic profile of hanging cases autopsied in Rims, Ranchi. GJRA-Global Journal for Research Analysis. 5(3): 119-121.
15. Kamalja and Khangar, A statistical study of suicidal behavior of Indians, Egyptian Journal of Forensic Sciences (2017) 7:12
16. Bhosle SH, Batra AK, Kuchewar SV (2014) Violent asphyxia death due to hanging: a prospective study. J Forensic Med Sci Law. 23(1): 1-8.
17. Ahmad M, Rahman FN, Hussain MA, Chowdhury MH, Yasmeen BHN (2015) A medico-legal study of hanging cases at Dhaka Medical College. NIMCH J. 7(1): 110-114.
18. Ajay Kumar S, Chandan V, Rudresh YC, Govindaraju HC, Gouda S (2013) Study of violent asphyxial deaths in Chitradurga district of Karnataka. IJBAR. 4(12): 868-871.
19. Dinesh Rao, An autopsy study of death due to Suicidal Hanging of 264 cases, Egyptian Journal of Forensic Sciences (2016) 6, 248–254
20. Sharma BR, Harish D, Sharma A, Sharma S, Singh H. Injuries to neck structures in deaths due to constriction of neck, with a special reference to hanging. J Forensic Legal Med 2008 Jul;15(5): 298–305.
21. Pradhan A, Mandal BK, Tripathi CB. Hanging: nature of ligature material applied and type of hanging according to point of suspension. Nepal Med Coll J 2012;14(2):103–6.
22. Saisudheer T, Nagaraja TV. A study of ligature mark in cases of hanging deaths. Int J Pharm Biomed Sci 2012;3(3):80–4.
23. World Health Organization (2018). National suicide prevention strategies: progress, examples an indicators. World Health Organization, Geneva.