2022 YLR 1257
Neck hemorrhage could be caused by internal disease like ischemic heart disease or cardiac failure. Similar suggestion was put to the doctor by the defence in this case but he denied the same due to his little knowledge of medicine. This study further observes that bruising, hemorrhage and abrasion on the face and neck can be occurred during CPR and CPR means Cardiopulmonary resuscitation which is an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest.
Throttling.
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"(2) If fingers are used (throttling), marks of pressure by the thumb and the fingertips are usually found on either side of the windpipe. The thumb mark is ordinarily higher and wider on one side of the front of the neck, and the finger marks are situated on its other side obliquely downwards and outwards, and one below the other. However, the marks are sometimes found clustered together, so that they cannot be distinguished separately. These fingertip bruises, each disc-shaped and 1-2 cm in diameter, look like red bruise (six penny bruises) if examined soon after death, but they look brown, dry and parch ment-like sometimes after death. One should refrain from drawing inference from the direction of curved abrasion, as to how the hand of the assailant might have been applied to the neck of victim. The inherent quality of the victim's skin, the shape and length of the fingernails of the assailant render such inferences extremely tenuous. This linear or crescentic marks produced by the fingernails are occasionally present, if the fingertips are pressed deeply into the soft tissues of the neck. A body, which is wet, may not reveal fingernail marks until drying of the skin of the body. When both hands are used to grasp and compress the throat, the thumb mark of one hand and the finger marks of the other and are usually found on either side of the throat. Sometimes, both thumb marks are found on one side and several finger marks on the opposite side. If the throat is compressed between two hands, one being applied to the front and the other to the back, bruises and abrasions may be found on the front of the neck, as well as on its back.
Besides these marks, there may be abrasions and bruises on the mouth, nose, cheeks, forehead, lower jaw or any other part of the body, if there has been a struggle. Similarly, fractures of the ribs and injuries to the thoracic and abdominal organs may be present, if the assailant kneels on the chest or abdomen of his victim while pressing his throat.
He further commented on appearances due to Asphyxia as follows:--
"The face is puffy and cyanosed, and marked with petechiae. The eyes are prominent and open. In some cases, they may be closed. The conjunctivae or congested and the pupils are dilated. Petechiae are seen in the eyelids and the conjunctivae. The lips are blue. Bloody foam escapes from the mouth and nostrils, and sometimes, pure blood issues from the mouth, nose and ears, especially if great violence has been used. The tongue is often swollen, bruised, protruding and dark in colour, showing patches of extravasation and occasionally bitten by the teeth. There may be evidence of bruising at the back of the neck. The hands are usually clenched. The genital organs may be congested and there may be discharge of urine, faeces and seminal fluid."
Dr. C. K. Parikh in his Textbook of Medical Jurisprudence, Forensic Medicine and Toxicology defines throttling as a form of strangulation effected by the hand, and is therefore often referred to as manual strangulation. He observed that following would be the External signs in case of throttling:--
"The extent and character of these signs will depend in large measure upon the rate of the asphyxial process. In certain cases, signs of asphyxia may be very slight if death has supervened quickly from cardiac inhibition due to pressure on the carotid nerve plexus. However, as is usual, when the constricting force has been considerable, the signs are well marked. In addition, the following signs are also seen: The tongue may be bruised, bitten by teeth, and protruded. Bleeding from the ears due to rupture of the blood vessels of the tympanum may be seen. There may be injuries on the face, chest, etc, indicating a struggle. The face and eyes may show multiple petechial haemorrhages. The body temperature may rise."
He indicates particular injuries found on the neck in case of throttling which are as under:--
"The situation and extent of the bruised area on the neck will depend upon the relative position of the assailant and the victim, the manner of grasping the neck, and the degree of pressure exercised upon the throat. The marks of bruising and ecchymosis are usually found on the front or sides of neck, chiefly about larynx and above it. When one hand is used to throttle, there may be a single bruise on one side due to pressure of the thumb and obliquely directed multiple bruises, one below the other, on the opposite side, due to pressure of finger pads or finger tips. When both hands are used, the bruising pattern depends upon the relative position of the thumbs and fingers and the degree of pressure applied to the throat. The bruising caused by the thumb is generally wider than that caused by the fingers. In addition to bruises, curved impressions. commonly described in books as crescentic abrasions caused by finger nails are also seen. The scratch caused by the thumb nail is deeper and wider as compared to that from finger nails. The distribution of the various marks (bruises and finger nail scratches) may be regular as mentioned above but is more often irregular due to renewed attempts at grasping the neck when the victim struggles to escape."
He was of the view that following could be the internal appearances in case of throttling:--
"In the usual case where the constricting force has been considerable and the signs of asphyxia are well marked. subcutaneous tissues of the neck show extravasation of blood beneath the injured areas. However, generally, haemorrhage in the subcutaneous tissues and in the muscles underlying nail marks is usually scant as compared to the external injuries. Conversely, the absence of externally visible neck injury does not preclude the possibility of underlying fatal trauma. Sometimes, all that is found is a single small area of bruising in any muscle of the neck but commonly on either side of the midline and usually over the thyroid cartilage or the hyoid bone. The weak areas liable to fracture due to trauma are the projections of the laryngeal cartilage and the ends of the hyoid bone, also known as horns. Occasionally, there are no fractures but only submucosal haemorrhages of the larynx. Fracture of the laryngeal cartilages and hyoid may be present in persons above 40 years of age. Fracture of the hyoid seldom occurs in hanging or strangulation by ligature. It is strongly in favour of throttling. When found, it is in the region of greater cornuae, which are generally squeezed violently during the process, the broken ends being commonly displaced inwards. Bruising (haemorrhage) at the base of the tongue may sometimes be the only evidence of throttling."
He has well defined the seat of injury in case of pressing of throat and strangulation of hyoid bone in following diagram:--
He concluded that if the death is caused by throttling, following would be the medico-legal aspects:--
"Evidence of violent compression of the neck during life is obtained from bruising due to thumb and fingers, nail marks, and swelling and lividity of the face. In addition, further evidence is provided by bruising and laceration of larynx, windpipe, and muscles and vessels in front and sides of the neck, and fracture of the cornuae of the laryngeal and occasionally the hyoid."
In this respect a study was also conducted by scientists of Tehran University and published a paper in International Journal of Medical Toxicology and Forensic Medicine, 20131; relevant excerpts are as follows:--
Causes of Death Accompanying by Soft Tissue Neck Hemorrhage by Akhlaghi M, Okazi A, Ghorbani M,
Taghaddosi-Nejad F, Mazinani R, Mehdizadeh F, Sanjari Kh.
Department of Forensic Medicine, School of Medicine, Tehran
University of Medical Sciences, Tehran, Iran.
Forensic Medicine Organization, Tehran, Iran observed as under:-
"In this study, in addition to the expected causes of neck hemorrhage, some other causes have been observed. Out of 86 autopsies with neck hemorrhage, only half had died due to asphyxia and neck traumas. In 40.7% (n=35) of cases, neck hemorrhage was observed with other causes of death such as drug overdose, respiratory insufficiency, Co-poisoning, electrocution and drowning. The cause of death in 9.3% (n=8) of cases which had no symptom of trauma to any parts of the body especially the neck, could not be established in spite of various investigations. However, our cases were selected among files that were referred to the highly specialized centers of legal medicine, so the frequency of causes of death and sex may not conform to the normal population.
Our study included 11 cases of death caused by advanced cardiac diseases such as ischemic heart disease or cardiac failure and 4 cases of respiratory failure. All of them underwent CPR in hospitals. Although neck hemorrhages are not commonly observed in natural deaths, little has been reported in earlier studies. Lach et al have reported 5 cases of hemorrhage in gross and microscopic investigations of neck muscles, shoulder girdle, and the back of the thorax. All of these cases showed no signs of violent crime or trauma to the neck, and the cause of death in all were associated with internal diseases. Their study suggests the intensified breathing with dyspnea leading to accessory respiratory muscles rupture and hemorrhage.
Bruising, hemorrhage and abrasion in the face and neck can occur during CPR. Raven e al reported 64% laryngeal and tracheal mucosal injury, 14% strap muscles hemorrhage, and 4% cutaneous injury of the neck in 50 cadavers who had been resuscitated. Yoshiko Hashimoto et al have also reported post-CPR neck hemorrhages with hyoid bone and thyroid cartilage fractures.
Conclusion:
Soft tissue hemorrhage of the neck occurs in some known causes of death like multiple traumas or asphyxia death, but it may happen in other causes of death without any direct trauma or neck compression. More studies on atypical causes of death with neck hemorrhage are required to prevent ambiguous judgments about cause of neck hemorrhage in suspected cases."
This study highlights that neck hemorrhage could be caused by internal disease like ischemic heart disease or cardiac failure. Similar suggestion was put to the doctor by the defence in this case but he denied the same due to his little knowledge of medicine. This study further observes that bruising, hemorrhage and abrasion on the face and neck can be occurred during CPR and CPR means Cardiopulmonary resuscitation which is an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest. The witnesses took the deceased to the hospital when he was unconscious and there is a probability that they might have resorted to CPR to bring him back to life which might have resulted to a little inside injury to hyoid bone as observed by histopathologist in his report (Ex.PJ).
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