Medico-legal study of strangulation cases in Varanasi district

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 929 IJAMSCR |Volume 6 | Issue 4 | Oct - Dec - 2018 www.ijamscr.com Research article Medical research Medico-legal study of strangulation cases in Varanasi district Satish Kumar Khalkho 1 Manoj Kumar Pathak 2 1 Junior Resident JR-III Department of Forensic Medicine Institute of Medical Sciences Banaras Hindu University Varanasi Utter Pradesh 2 Professor Department of Forensic Medicine Institute of Medical Sciences Banaras Hindu University Varanasi Utter Pradesh Corresponding Author: Satish Kumar Khalkho Email id: satishkhalkho81gmail.com ABSTRACT Introduction The term asphyxia may be defined as a state in which the body lacks of oxygen because of some mechanical interference with the process of breathing. Strangulation is a form of violent asphyxial death caused by constricting the neck by means of ligature or by any other means without suspending the body. Materials and methods The study was conducted in Department of Forensic medicine Institute of Medical Sciences Banaras Hindu University Varanasi Utter Pradesh. It is a prospective study. The study was conducted during October 2016 to March 2018. Results Total 150 out of 2976 medico-legal deaths were identified to be due to violent asphyxia with incidence rate of 5. Most common age group involved was 21-30 years. Strangulation was the most common method of asphyxial homicidal death constituting 4.67.cases smothering 0.67 cases. Fracture of hyoid bone is noted in 2 cases. Conclusion Ligature strangulation is more frequently used method of homicidal asphyxial death. If hyoid bone fracture is detected it has to be confirmed whether it is ante-mortem fracture or an artefact of post-mortem fracture occurred during autopsy as it has medico legal importance while giving the opinion regarding the cause of death. Keywords: Mechanical asphyxia Ligature strangulation Manual strangulation Hyoid bone. INTRODUCTION Strangulation is a form of violent asphyxial death caused by constricting the neck by means of ligature or by any other means without suspending the body. Strangulation is considered to be a form of mechanical asphyxia. The term strangulation is specifically used to indicate the external pressure applied to the neck either by means of a ligature or the hands. The mechanisms of death in strangulation include airway occlusion resulting in hypoxia occlusion of the neck vessels or compression of the carotid arteries leading to cerebral ischemia and carotid sinus reflex leading to cardiac arrest. 1 ISSN:2347-6567 International Journal of Allied Medical Sciences and Clinical Research IJAMSCR

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 930 Homicidal asphyxial death most commonly includes strangulation smothering. 2 Ligature strangulation is usually homicidal in nature involves women children and the elders but accidental and suicidal occur as well. Manual strangulation is the most common form of strangulation used in the domestic violence cases. 3 Strangulation occupies less than 1 of all the medico-legal deaths and 5-10 of criminally violent deaths 4. In a study from 2009 to 2012 in Peshawar ligature strangulation was the most common method of violent asphyxia. 5. Strangulation cases were also on the rise in honour killing victims in a study done by Human Rights Commission 6. Fracture of hyoid bone and thyroid cartilage may be seen in some cases. However hyoid fractures are not common because the level of ligature is below the hyoid bone and traction on the thyro-hyoid ligament is not much acting. Moreover if broad ligature material is used with considerable force hyoid bone or thyroid cartilage may be fractured 7 8. Similarly the hyoid bone or thyroid horns may be fractured especially where the ligature rides at the level of the thyro-hyoid ligament or above. 1 So observation of hyoid bone becomes one of the most important parts of examination during autopsy of mechanical asphyxial deaths due to pressure over the neck. . MATERIALS AND METHODS The present study was conducted in Department of Forensic Medicine Institute of Medical Sciences Banaras Hindu University Varanasi for medico-legal autopsies done on bodies brought from the various Police Stations of Varanasi and surrounding areas. Total 07 cases of asphyxial death due to strangulation were studied during October 2016 to March 2018 and percentage study was done on that. For this study those cases were selected which were died due to violent asphyxial death and were confirmed to be so after the post- mortem examination. Also those cases which were reported by police as not being the case of violent asphyxial death but came out so after post-mortem examination were also included in present study. OBSERVATION AND RESULTS Table 1: Incidence of Violent Asphyxial Deaths amongst all Autopsied cases October 2016 to March 2018 No. of Autopsy Percentage Asphyxial deaths 150 5 Other 2826 95 Total 2976 100 Figure 1: Distribution of cases of Violent Asphyxia Death on the basis of the type of death. 57 5 1 1 24 12 Type of death Hanging Strangulation Throttling Smothering Drowning Traumatic asphyxia

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 931 Figure 2: Age and sex wise distribution of victims of Strangulation Photograph-1: showing localized multiple contusions over left side of face along with congestion suggestive of strangulation with/without ligature Photograph-2: showing left lateral view – Multiple enlarged focal contusions with cresentric abrasion over nose adjacent left cheek and chin face suggestive of struggle during Strangulation with ligature 0 10 20 30 40 50 60 0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 0 0 60 40 0 0 0 0 0 0 50 0 0 0 50 0 Percentage Age in years Males Females

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 932 Photograph-3: showing intensely congested eyes with subconjunctival haemorrhage suggestive of Strangulation Photograph-4: showing horizontal ligature mark over neck at thyroid cartilage level Photograph-5: showing horizontal ligature mark all around neck at the level of thyroid cartilage along with abrasion around the ligature mark and bruised neck muscles

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 933 Photograph-6: showing intensely congested eyes with Sub-Conjunctival haemorrhage Photograph-7: showing congested face due to manual strangulation along with haemorrhages over neck and chest wall Photograph-8: showing manual strangulation – Internal neck dissection in an attempt to examine hyoid bone fracture as this was a case of manual strangulation Throttling

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 934 Table 2: Incriminating factors as observed in Homicidal death. Factors Frequency Percentage Property / Money Quarrel 3 30 Family Quarrel 4 40 Sexual Jealous 0 0 Sexual Assault 1 10 Not Known 2 20 Total 10 100 Table 3: Types of strangulation Type Number Percentage Ligature strangulation 5 71.43 Manual strangulation 2 28.57 Total 7 100.00 Table 4: Place of incidence of strangulation cases Places Males Females Total No. No. No. Home 2 66.67 1 33.33 3 42.86 Work place 2 100 0 0 2 28.57 Forest 1 50 1 50 2 28.57 Table 5: Characteristic features of ligature mark Features Number Percentage Continuous 7 100 Above thyroid cartilage 1 14.24 At thyroid cartilage 5 71.43 Below thyroid cartilage 1 14.24 Not visible 0 0 Ecchymosis 7 100 Table 6: Observation of neck structures Neck structure Number of patients Percentage Laryngeal congestion 7 100 Tracheal congestion 7 100 Fracture of hyoid bone 2 28.57 Sterno-cleidomastoid muscle contusion 5 71.42 Laryngeal contusion 6 85.71 Tracheal contusion 6 85.71 Nail marks / Abrasion 3 42.86 Contusion / Laceration wound 5 71.42 Table 1: Incidence of violent asphyxial death in our study was 5 the total number of autopsies conducted during the study period was 2976 out of which 150 were mechanical asphyxial death Figure 1: The incidence of various types of violent asphyxial deaths was recorded and out of 150 asphyxial death cases hanging was found to be the commonest of all 86 cases 57.3 followed by drowning 36 24.0 strangulation 74.67 throttling 21.33 smothering 1 0.67 respectively and accidental finding of relatively higher proportion of traumatic asphyxia 18 12 number of cases. Figure 2: Age and sex wise distribution of victims of Strangulation – The study cases were distributed on the basis of their age and gender. 4

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 935 57.14 subjects belonged to age group 21-30 years were commonest to be found where females and males were 1 50 and 3 60 respectively. This was followed by 2 28.58 subjects in 31-40 age groups with 2 40.0 males and 17 and no females. 114.28 subjects were observed 61-70 years of age group. Table 2: Incriminating factors for homicidal deaths-Precipitation factors in homicidal deaths were observed. Family quarrel was commonest in 4 40 subjects followed by property quarrel in 3 30.0 subjects. Factor of death in 2 20.0 was not known Table 3: Types of strangulation: Maximum cases presented with ligature strangulation 5 71.42 in number followed by manual strangulation 2 28.57 in number respectively. Table 4: Place of incidence of strangulation cases: In the present study maximum death of strangulation cases occurred at home which were 3 42.85 in number followed by at work place and forest in 2 28.57 cases each Table 5: Characteristic features of ligature mark In our study Maximum incidence of strangulation case ligature mark was present at level of thyroid cartilage overriding 5 71.43 followed by above thyroid cartilage 114.24 1 14.24 present below thyroid cartilages. Ecchymosis present in 7100 cases. Table 6: Observation of neck structures: In our study laryngeal and tracheal contusions were found in 6 85.71 cases laryngeal and tracheal congestion in 7 100 cases sterno-cleidomastoid muscle contusion in 5 71.42 cases and fracture of hyoid bone was found in 2 28.97 cases. DISCUSSION Table no.1 comprises the data about the incidence of violent asphyxial death in our study which was 5 the total number of autopsies conducted during the study period was 2976 out of which 150 were mechanical asphyxial death. Similar observations were reported by Sharma et al 2008 5 9 Singh A et al 2003 5.26 10 Patel A et al 2013 5.63 11 Arif M 2015 5.9 12 Tirmizi S Z et al 2012 7.08 13 Murty OP et al 2000 10 14 And Ajay Kumar S et al 2013 10.50. 15 Figure 1 depicts the data about the incidences of strangulation deaths in our study was constitutes 4.7 of all asphyxial deaths. . Similar findings were observed in the study done by Sharma et al in a 10 year retrospective study on unnatural deaths in northern India Chandigarh that strangulation constitutes 0.6 of all unnatural deaths.9 Azmak D studied asphyxial deaths during the period of 21 year from 1984 to 2004 in turkey. Strangulation death constitutes 2 to 3 of all asphyxial deaths. 16 Singh et al. reported that incidences of strangulation and hanging is 42 and 51 respectively. 17 Verma and Lal reported that strangulation constitutes 1.17 cases of out of 8385 Forensic autopsies in a retrospective study between 1993 and 2002 in Delhi. 18 Satish et al. conducted a 10 year retrospective study about violent asphyxia deaths in East Delhi and found that incidences of strangulation in all violent asphyxia deaths contributes 14.33 cases with overall incidence of strangulation at 1.2 in total autopsies. 19 Figure 2 shows the age and gender-wise distribution among cases of strangulation In our study cases were distributed on the basis of their age and gender. 4 57.14 subjects belonged to age group 21-30 years were commonest to be found where females and males were 1 50 and 3 60 respectively. This was followed by 2 28.58 subjects in 31-40 age groups with 2 40.0 males and no females. 114.28 subjects were observed 61-70years. Similar findings were observed in the study done by Dimaio V J 2000 in America has reported 41 deaths due to manual strangulation out of which 27 were females and 14 males.20 Azmak D studied asphyxial deaths during the period of 21 year period from 1984 to 2004 in turkey 20.8 of the cases were aged between 30 and 39 years and males constitute 79.8 of all the cases.16 Chandrasekhara rao P et al. Highlighted in their study that the incidences of mechanical asphyxial death is highest in the second decade 20-29 years of age in both sexes. The incidence was lowest in 6 th decade of life age group 60-69 years. 21 In study done by Chand et al. Maximum numbers of cases 51.72 were seen in the age group of 20-29 years followed by 30-39 years of age group 15.51 in both the sexes. The minimum numbers of cases were seen in extremes of age i.e. below 10 years and above 60 years. Male predominance was seen in most of the age groups except age group below 10 years. Male- to-female ratio is 2:1. During the study one case

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 936 was seen kinner in 20-29 years of age. 22 The findings of present study are different from the study of Singh et al the study reflected female predominance in ligature 63.63 and manual strangulation 75. This is in accordance with a study from Patiala India which reported that female victims constituted 66.66 of violent asphyxial deaths caused by ligature. 17 Table no. 2 concludes the data about the incriminating factors for homicidal deaths- In our study family quarrel was commonest in 4 40 subjects followed by property quarrel in 3 30.0 subjects. Factor of death in 2 20.0 was not known. These findings were similar to study done by Srivastava and Rajesh K who reported a fairly equal distribution among various motives with maximum contributions from family quarrel and dispute over property. 423 El-Hady et al. reported that the most common motives for homicide were robbery and defence for honour 3 cases of each 20 followed by psychological problems of the assailant revenge family problems and after the rape 2 cases of each 13.3. 24 Table no 3 emphasises the type of strangulations In our study maximum cases presented with ligature strangulation 5 71.42 in number followed by manual strangulation 2 28.57 in number respectively. Similar findings were observed in the study done by Suffla et al Ligature strangulation is reported as the more frequently recorded method of asphyxial homicide.25 Ambade et al conducted retrospective study during 1996to 2005 on homicidal asphyxia deaths in south Delhi and found that ligature strangulation makes the most frequently used method 67.2. 26 In the study done by Chand et al only 6.84 of cases manual strangulation and 1.36 of cases of ligature strangulation contribute to deaths due to asphyxia. 22 Arif M 2014 Ligature strangulation 36.97 was the leading cause of violent asphyxial deaths in the study. 12 Table no 4 highlights the Places of incidence of strangulation cases: In the present study maximum death of strangulation cases occurred at home which were 3 42.85 in number followed by at work place and forest in 2 28.57 cases each. Similar observations were reported by Punitha et al. that place of occurrence was indoor in 27 cases 79.4 and outdoor in 04 cases 11.7. 27 In study by Wahlsten P majority of the offences 59 took place in a private residence. 28 In a study conducted by Mohanty M.K. majority of homicides took place outdoors on in contrast with our study results. 29 Table no 5 summarises the features of ligature marks in strangulation: In our study in maximum number of strangulation cases ligature mark was present at level of thyroid cartilage overriding 5 71.43 followed by above thyroid cartilage 114.24 114.24 present below thyroid cartilages. Ecchymosis was present in 7100 cases. Similar findings were observed in the study done by Gordon et al ligature strangulation usually the level of constricting force is at the level of or below the level of thyroid cartilage.30 Sharma et al reported the presence of ligature above the level of thyroid in 58 of cases 27.3 of cases at the level of the thyroid cartilage and in 15.2 of cases below the level of thyroid cartilage.9 Chand et al the ligature mark was present above the level of thyroid cartilage in 50 of cases at the level of thyroid cartilage in 48.07 of cases and 1.92 below the level of thyroid cartilage. 22 Table no 6 concludes the data about the internal injuries in case of strangulation: In our study laryngeal and tracheal contusions were found in 685.71cases laryngeal and tracheal congestion in 7 100 cases sterno-cleidomastoid muscle contusion in 5 71.42 cases and fracture of hyoid bone was found in 2 28.97 cases. Similar findings were observed in the study done by Dinesh Rao 2016 70.83 n –187 of cases damage to neck muscle fibres and haemorrhage at the Sternal end of the Sterno-cleidomastoid muscle were present.31 According to Polson CJ Nandi A and V.V. Pillay in cases of throttling as the constricting force is more in magnitude involving larger area and directly acting upon the hyoid bone itself hyoid bone is most vulnerable to fracture. 7322 In study done by Nikolic S the incidences of fractures of hyoid bone varies in different studies from 0 to 68 which also varies with types of mechanical asphyxia like hanging strangulation and throttling.33 In study done by Uzun et al. found muscle haemorrhage only in 13.79 of total cases including all the cases of manual strangulation and 5.76 of cases of hanging.34 These incidences are lower than that reported in literature 55.8 by Suárez-Peñaranda et al.35 42 by Sharma et al.9 and 100 by

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 937 Uzunet al.34 In study done by Chandrasekhara Rao et al fractured hyoid bones were noted in throttling. Out of 6 cases of throttling fracture of hyoid bone were noticed in 5 cases amounting to 83.3. No fractures were seen in cases of ligature strangulation with zero fractures out of 9 cases of ligature strangulation and very few fractures were noticed in cases of hanging that is 2 hyoid bone fractures in total of 75 hanging cases. 21 In the study done by Dinesh Rao hyoid bone was damaged in 6.06 n – 16 of the victims. 31 According to Chand et al. hyoid bone fracture occurs in all the cases of strangulation. In manual strangulation cases 360 out of 5 cases showed presence of hyoid bone fracture and all cases of ligature strangulation showed this finding. 22 In a study Chand et al. highlighted that fractures of both greater cornua of the right and left sides were seen in 2 50 cases of manual strangulation. The fracture left greater cornu was seen in 2 50 cases one in Manual Strangulation and one in Ligature Strangulation.22 The results were comparable to other Indian study by Naik S K with fractures of hyoid bones 4 out of 5 in throttling. 36 CONCLUSION Medico-legal autopsies provide an important statistical data related to criminal incidents of that particular area. The violence in the form of asphyxia also contributes to the increased number of deaths in this world about 10 overall and in our context it was the fourth commonest cause of unnatural death after Road Traffic Accident burn and poisoning. Strangulation is that form of asphyxia which is caused from constriction of the neck by a ligature without suspending the body. Pulling a U-shaped ligature against the front and sides of the neck while standing at the back can cause death. It is of two types: 1 strangulation by a ligature and 2 manual strangulation or throttling. 3 Garroting. 4 Mugging. 5 Bansdola. If hyoid bone fracture is detected it has to be confirmed whether it is ante-mortem fracture or an artefact of post-mortem fracture occurred during autopsy as it has got immense medico-legal importance while giving the opinion regarding the cause of death. Strangulation with or without ligature as well as manual strangulation Throttling is quite a common method of homicide after firearm and stab wound in our place as well as in our country. How- so-ever strangulation of all types is always homicidal unless proved otherwise. Acknowledgement Authors would like to thank faculty and staff of department of Forensic Medicine IMS BHU Varanasi for their valuable support and full help in data collection from the autopsied cases. I would also like to pay sincere tribute to all the victims whose details have been incorporated in the present study after their sad demise. Conflict of Interest: Nil Source of Funding: This research was not financially supported by any funding agencies. Ethical Clearance The present study was approved by “Institutional Ethical Committee” of Institute of Medical Sciences Banaras Hindu University Varanasi. All the information has been taken under consideration of medical ethical committee Statement of Informed Consent As this case report was prepared from medico- legal autopsy done at our departmental mortuary hence we had statutory authorization to do post- mortem examination as well as to publish the findings in the field of scientific journals for literary benefit of young and budding Forensic Science as well as Forensic Medicine aspirants. As per the rules of consent described in Forensic medicine textbooks as well as different scientific literatures of Forensic Medicine informed consent is needed only in pathological autopsy not in medico-legal autopsy. Statement of Human and Animal Rights: No human right and animal right is violated in this case. REFRENCES 1. Saukko P Knight B. Suffocation asphyxia fatal pressure on the neck immersion deaths. In: Knight’s Forensic Pathology. Arnold London. 3 2004 352-411.

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 938 2. Pillay VV. Text book of Forensic medicine Toxicology. Paras medical publisher Hyderabad. 16 2011 260- 275. 3. McClane GE Strack GB Hawley D.A review of 300 attempted strangulation cases part 2: Clinical evaluation of the surviving victim. Journal of Emergency Medicine 213 2001 311-315. 4. Srivastava A.K. Study of violent asphyxial deaths in medico-legal autopsies MD thesis Dept of Forensic medicine IMS Banaras Hindu University Varanasi 1984 5. Khalil ZH Naeem M Adil M Khan MZI Abbas SH Alam N. Asphyxial deaths : a four year retrospective study in Peshawar.J Potgrad Med Inst 281 2014 24-6. 6. Nasrullah M Haqqi S Cummings KJ. The epidemiological patterns of honour killing of women in Pakistan. Eur J Public Health 19 2009 193-7. 7. Polson CJ Gee DJ Knight B. The Essentials of Forensic Medicine. New York NY: Pergamon 1985 357-388. 8. Vij k Textbook of Forensic Medicine and Toxicology. Reed Elsevier India Pvt. Ltd New Delhi 5 2011 125- 129 9. Sharma BR Harish D Sharma S Singh H. Injuries to neck structures in deaths due to constriction of neck with a special reference to hanging. J Forensic Leg Med 15 2008 298-305 10. Singh A. A study of demographic variables of violent asphyxial death. Journal of Punjab Academy of Forensic Medicine and Toxicology. 3 2003 32-34. 11. Patel A P Bhoot R R Patel D J Patel K A. Study of Violent Asphyxial Death. International Journal of Medical Toxicology and Forensic Medicine. 32 2013 48-57. 12. Arif M. Ligature mark on the neck How elucidative Professional Med J. 22 2015 798-803 13. Trimizi SZ Mirza FH Paryar HA. Medicolegal investigation of violent asphyxial deaths – an autopsy-based study. J Dow Uni Health Sci 6 2012 86-90 14. Murty OP Agnihotri AK. Homicidal Deaths in South Delhi. J Ind Acad Forensic Med. 22 2000 9–11. 15. Ajay K Handan V Rudresh YC Govindaraju HC Gouda S Study of violent asphyxial deaths in Chitradurga district of Karnataka IJBAR. 412 2013 868-871 16. Azmak D. Asphyxial deaths: a retrospective study and review of the literature. AM j Forensic Med Pathol 2 2006 134-144 17. Singh A Gorea RK Dalal JS Thind AS. A study of demographic variables of violent asphyxia death. JPFMAT 3 2003 22-25 18. Verma SK Lal S. Strangulation deaths during 1993-2002 In East Delhi India Leg Med Tokyo 8 2006 1-4. 19. Satish VK Sonne L. Strangulation deaths during 1993- 2002 in East Delhi India. Leg Med. 81 2006 1-4 20. DiMaio VJ. Homicidal asphyxia. Am J Forensic Med Pathol. Mar 211 2000 1-4 21. Chandrasekhararao P Krishnamurthy V Reddy TTK Sivakameswara R. A study of hyoid bone fractures in Mechanical asphyxial deaths International Journal of Contemporary Medical Research 311 2016 3316-3319 22. Chand S Rishi S Aggrawal A Dikshit PC Ranjan R. Neck structures post mortem finding in asphyxia death International Journal of Scientific Study 5 2017 248-256. 23. Rajesh K R Tripathi S K Manoj K A study of violent asphyxial death case MD thesis Dept of Forensic medicine IMS Banaras Hindu University Varanasi 199 2010. 24. El Hady RH Thabet HZ Ghandour NM. Medico-legal study of violent asphyxia in assist governorate Egypt Journal of Forensic Toxicology and Medicolegal Analysis 12 2016 34-39. 25. Suffla S Niekerk AV Arendse N. Female homicidal strangulation in urban South Africa: BMC Public Health 8 2008 363. 26. Ambade VN Godbole HV Kukde HG. Suicidal and homicidal deaths: A comparative and circumstantial approach. J Forensic Leg Med 14 2007 253-60. 27. Punitha R Pradeep Kumar M.V Jagadeesh N.H Jayapakash. A cross sectional study on homicidal asphyxial deaths. JKAMLS. 261 2017 9-12. 28. Wahlsten P Koiranen V Saukko P. Survey of Medico legal Investigation of Homicides in the City of Turku Finland. Journal of Clinical Forensic Medicine 145 2007 243-252. 29. Mohanty M.K. Variants of Homicide - A Review. Journal of Clinical Forensic Medicine. 114 2004 214-218. 30. Gordon I Shapiro HA Berson SD Forensic medicine – A guide to principles. New York Churchill Livingstone 3 1988 95-127.

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Satish K K et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-64 2018 929-939 939 31. Dinesh Rao. An autopsy study of death due to Suicidal Hanging – 264 cases. Egyptian Journal of Forensic Sciences 6 2016 248–254. 32. Nandi A. Principles of forensic medicine New central book agency Ltd. 2nd edition. 2007 315-343. 33. Nikolic S Micic J Atanasijevic T. Djokie V Djonic D. Analysis of neck injuries in hanging. Am J Forensic Med Pathol 24 2003 179-82. 34. Uzun I BuYuk Y Gurpiner K. Suicidal hanging: Fatalitirs in Istanbul Retrospective analysis of 761 autopsies. J Forensic Leg Med 147 2007 406-409. 35. Suárez-Peñaranda JM Alvarez T Miguéns X Rodríguez-Calvo MS de Abajo BL Cortesão M et al. Characterization of lesions in hanging deaths. J Forensic Sci 53 2008 720. 36. Naik S K. A study of fracture of hyoid bone in cases of asphyxial deaths resulting from constricting force around neck. Journal of Indian Academy of Forensic Medicine. 273 2005 149-153. How to cite this article: Satish Kumar Khalkho Manoj Kumar Pathak. Medico-legal study of strangulation cases in Varanasi district. Int J of Allied Med Sci and Clin Res 2018 64: 929-939. Source of Support: Nil. Conflict of Interest: None declared.

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