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American Journal of Forensic Medicine & Pathology:
doi: 10.1097/PAF.0000000000000074
Case Reports

An Unusual Case of Incaprettamento

Focardi, Martina MD; Pinchi, Vilma; Defraia, Beatrice MD; Norelli, Gian-Aristide

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From the Institute of Legal Medicine, Florence, Italy.

Manuscript received May 2, 2013; accepted November 20, 2013.

The authors report no conflicts of interest.

We did not receive any funding for this work.

Reprints: Beatrice Defraia, Institute of Legal Medicine of the University of Florence, Largo Brambilla 3, 50134, Florence, Italy. E-mail:

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Incaprettamento is a ritual strangulation that represents a method of homicide typical of the Italian Mafia. While the victim is in the prone position, he/she is bound by one end of a rope, creating a slipknot around the throat, while the other end is used to tie the limbs behind the back. Forensic investigations reveal that in most cases, the binding of the extremities and the positioning of the victim are carried out after death due to others means and are intended to hold somebody in contempt and to punish betrayers. When the victim is tied while alive, the death is caused by self-strangulation because it is impossible to maintain the legs in this forced position. Here, we describe in detail a case with a lot of similarities to incaprettamento, although we define it as atypical because of the unusual methods of the actual binding and the circumstances in which death occurred. In fact, the investigation of the crime scene, the external and internal findings, and the histologic examination result show that this is a crime of passion.

Incaprettamento is a ritual vendetta homicide committed by the Italian Mafia that expresses contempt for the victim and constitutes an exemplary warning to other traitors.1–3

Fineschi et al4 were the first authors to describe this ritual in the literature. They described 18 cases of incaprettamento focusing their attention on the essential hallmarks of this murder, especially the particular features of ligature in the neck, back, and limbs.

The typical binding is performed while the body is in prone position, with a rope that is tied in a noose and positioned around the victim’s neck, while the other end is placed around the victim’s ankles and wrists behind the back. In most instances, postmortem examination and police investigation reveal that the binding of the body is carried out postmortem after the victim is murdered with the same rope used for the subsequent macabre ceremony. In a small percentage of cases, death is caused by self-strangulation when it is impossible to maintain limbs in this imposed position; this possibility is identified as a result of the examination of bindings.

For this reason, medical examination is extremely important for determining when the death took place, that is, before or after ligature, and establishing the manner of death because the victim may have been shot and bound after death.4

Incaprettamento can be regarded as a rare variant of ligature strangulation, common in North America and Europe and frequently involving female victims in the context of rape homicide involving positional asphyxia because the body position can interfere with the normal pump function of respiration.5

Finally, there are similarities between incaprettamento and some other positional asphyxias, for example, those that use a hog-tied prone position such as that occurs during law enforcement transportation in the rear compartments of police patrol cars, or during erotic or autoerotic maneuvers.6–8

Starting from the new classification of asphyxia proposed by Sauvageau et al9 in 2010, incaprettamento could be associated for the manner of death, to positional asphyxia because the adoption of imposed body positions causes important consequences such as alveolar hypoventilation and cardiac hyperexcitability due to respiratory acidosis in combination with extensive liberation of catecholamine.

We report a case of this ritual homicide that we define as atypical because of the unusual manner of binding the body and the cause of death. Both the investigation of the crime scene and the histologic examination of external marks, internal findings, and skin lesions were evaluated to reconstruct the case and to establish in particular whether the ligature signs were inflicted antemortem or postmortem.

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The body of a 54-year-old Brazilian homosexual man was found lifeless in his bedroom at home in a submissive position on the floor (Fig. 1). A cotton T-shirt was acting as a tie, with one end wrapped around his neck creating a loop, and the other end bound around the wrists with multiple knots. When the arms were extended, the loop around the neck was pulled taut (Fig. 2). The ankles were fixed into flexed position by binding with a gray wool sweater, double knotted and fixed by a 2-cm-wide white tape (Fig. 3).

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The corpse was surrounded with pornographic materials, and the home was completely turned upside-down, although looking around, there were no signs of tampering.

The victim wore trousers torn in the crotch and a T-shirt over a sweater, which was bloodstained. At the time of the autopsy, the body measured 162 cm in length, seemed malnourished, and was in an initial state of decomposition, with widespread green discoloration of the skin.

Apart from the generic signs of asphyxia (ie, conjunctival, pericardial and subpleural petechiae, cyanosis of the face and neck, and acute blood congestion and emphysema of the lung), the surface examination revealed multiple injuries that were localized to the head, neck, and limbs. On the head, there were a lot of contusions and abrasions of different shapes that measured approximately 2 cm in length, as well as multiple vital fractures of the maxilla; there were a considerable number of contusions on the limbs and abrasions of different size and length; whereas in the neck, there was a soft ligature mark that was approximately transverse, measuring 3 cm in height and approximately 10 cm in length. The external features of the ligature marks on the wrists and ankles were rendered unclear by clothing.

The internal findings were massive blood infiltration of the galea capitis, especially at the level of the frontal bones, multiple fractures of the maxillary and nasal bones, and blood staining of the upper neck muscles. During the autopsy, we took blood samples from both the femoral artery and the heart cavities for toxicologic analysis that turned out to be negative for drugs and alcohol.

Microscopic observation demonstrated stasis of the organs and, in particular, typical signs of asphyxia in the lungs such as acute emphysema, edema, and extensive hemorrhages with massive underlying hyperemia.

In addition, we took samples of bruised skin from the limbs and neck for immunohistochemical analysis to evaluate the vitality of the wounds by analyzing the distribution and number of mast cells. After fixing in Bouin or Carnoy fluid,10 all of the specimens were dehydrated in ethanol, embedded in Paraplast, and 5 sections were cut per block. Before bright field microscopy, sections were stained with hematoxylin-eosin and 0.1% toluidine blue at pH 4.3 (Carlo Erba, Milan, Italy).11 Before fluorescence microscopy was carried out, sections were stained with an indirect immunohistochemical method for tryptase and chymase antibodies (Chemicon, Rome, Italy).12,13 They were also stained with fluorescein isothiocyanate–labeled avidin (Sigma, Milan, Italy)14 diluted to 1:400 in 1% albumin (Sigma). Primary mouse monoclonal antibodies, antitryptase, and antichymase were diluted to 1/1000 and applied at 4°C. All primary antibodies were diluted with phosphate-buffered saline. Antimouse polyclonal goat fluorescein isothiocyanate–labeled antibodies were used as secondary antibodies (Sigma).15 Fluorochrome-stained sections were examined with a Nikon Microphot-Fx microscope (Tokyo, Japan) equipped for epifluorescence (Fig. 4).

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In each case, a negative section of the skin from the neck and limbs was processed simultaneously to act as a control for the ligature marks.

Histologic and immunohistochemical evaluations revealed that abrasions to the limbs occurred after death by the bindings, whereas the wound to the neck was vital so that the death of the man was attributed to a combination of asphyxia due to strangulation and multiple bony fractures of the head. Thus, the atypical bindings of the extremities applied after death were able to demonstrate the homicidal nature of the event. Autopsy results, together with investigations carried out by the police and the evaluation of crime scene, allowed us to conclude that the homicide of the man was committed by another homosexual man, which resembled a ritual execution. It is actually impossible to ascertain if it was an intentional simulation.

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The present case has a significant number of similarities with, as well as differences from, cases of classic incaprettamento. The most significant similarities consist of the prone position of the body, the complex binding involving the neck and wrists, and the binding together of the ankles with a sweater.

The principle differences are that the binding of the ankles was not incorporated into the same unique ligature together with the neck and upper limbs, clothes were used as the material for the rope, and many disseminated blunt injuries were present in association with a soft ligature mark on the neck, which was not related to the fractures of the neck structures. The presence of widespread subcutaneous and muscular hemorrhage of neck tissue supports the theory that strangulation occurred as a result of the in situ ligature before death that was caused by a combination of ligature strangulation and multiple bony fractures.

The histamine content in vital wounds is known to increase, with a zenith after 3 hours and then decrease until 24 hours after wounding. We analyzed the distribution and number of mast cells because they represent the main source of this cytokine. Immunohistochemical evaluation of tissues allows a differentiation between vital lesions of the neck and postmortal wounds of the limbs suggesting that the victim was blunt injured and strangled and then bound with his clothes to simulate a ritual crime.16,17

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17. Bacci S, DeFraia B, Romagnoli P, et al. Advantage of affinity histochemistry combined with histology to investigate death causes: indications from sample cases. J Forensic Sci. 2011; 56: 1620–1625.


positional asphyxia; incaprettamento; strangulation; asphyxia

Copyright © 2014 by Lippincott Williams & Wilkins


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