Hanging

In hanging, asphyxia is secondary to compression or constriction of the neck structures by a noose or other constricting band tightened by the weight of the body. There may be either complete or incomplete suspension of the body (Figure 8.13). Incomplete suspension, with the toes or feet (less commonly the knees or buttocks) touching the ground, is extremely common. Virtually all hangings are suicidal. Accidental hangings are uncommon and homicidal hangings very rare. Death is caused by compression of the blood vessels of the neck such that an insufficient amount of oxygenated blood reaches the brain. Obstruction of the airway can also occur, either through compression of the trachea or, when the noose is above the larynx, elevation and posterior displacement of the tongue and floor of the mouth. Blockage or compression of the air passages is not necessary to cause death in hanging. A number of individuals have hanged themselves with the noose above the larynx and a permanent tracheostomy opening below. Fracture of the neck plays virtually no role in non-judicial hangings. It is rare and, in our experience, is usually seen only in individuals with advanced degenerative disease of the cervical spine, such as osteoarthritis, in combination with complete suspension of the body, a sudden drop, and, frequently, obesity.

The amount of pressure necessary to compress the jugular veins is 4.4 lb; the carotid arteries, 11 lb; and the vertebral arteries, 66 lb. Compression of the trachea requires 33 lb of pressure.13 Because of the small amount of pressure necessary to compress the carotid arteries, one can hang oneself

Erotic Hanging Noose
Figure 8.13 (A) Hanging with complete suspension (continued).

sitting, kneeling, or lying down. The weight of the head (10-12 lb) against a noose is sufficient to occlude the carotid arteries and cause death. The authors have seen cases where individuals have hanged themselves from a bedpost while lying in bed next to a sleeping spouse. Hangings in kneeling and sitting positions are common.

Virtually all hangings are suicidal. Depending on the area of the country and the sex of the victim, hanging is either the second or third most popular method of suicide. Rarely, couples hang themselves together, some with the same rope. In hangings, a simple slipknot type of noose is typically used. The noose is constructed from anything that is handy. Most common are ropes, electrical cords, and belts. In jails and prisons, convicts typically tear sheets into strips as well as using T-shirts, undershorts, trousers, or even socks. Occasionally, to prevent a change of mind, the victim ties his hands together. The authors have seen a number of cases where the victims have actually handcuffed their hands behind themselves. (Figure 8.13B )

Larynx Hanging

Figure 8.13 (continued) (B and C) Hanging with (B) hands cuffed behind back (C) incomplete suspension..

The most common point of suspension is the side of the neck, followed by the back and the front. At the time of suspension, the noose typically slips above the larynx, catching under the chin (Figure 8.14). Present on the neck will be a furrow. This furrow generally does not completely encircle the neck, but rather slants upward toward the knot, fading out at the point of suspension — the knot (Figure 8.15). If the knot is under the chin, its site might be indicated by an abrasion or indentation beneath the chin. The clarity and configuration of the furrow depend on the material used. A rope will give a deep, well-demarcated, distinct furrow, often with a mirror-image impression of the twist of the rope on the skin (Figure 8.16A). This furrow initially has a pale yellow parchment appearance, with a congested rim. With time, the furrow dries out and becomes dark brown. If the ligature is a soft material, the groove might be poorly defined, pale, and devoid of bruises and abrasions (Figure 8.16B). In some cases, the lower margin of the groove is pale, with the upper margin red, caused by postmortem congestion of vessels. A towel can give poorly defined superficial areas of abrasion.

In the majority of suicidal hangings, the noose consists of a single loop. Less commonly, there are two loops. This results in two furrows that may be

Pinch Bruises Marks
Figure 8.14 Hanging with point of suspension on (A) side of neck and (B) front of neck.
Hanged Neck
Figure 8.15 Furrow from noose slanting upward toward point of suspension.
Ligature Mark Hanging Fixed Noose
Figure 8.16 (A) Noose mark with pale yellow base and congested rim. (B) Broad pale furrow due to soft noose.

parallel, overlap at points, or follow two completely different paths, e.g., one oblique and the other horizontal. The two loops might pinch the skin between them, producing a hemorrhagic strip of skin (Figure 8.17). If the noose is a belt, there are usually two parallel ligature marks on the neck where the upper and lower edges of the belt dig into the skin (Figure 8.18).

Ligature Strangulation Suicide
Figure 8.17 Suicide with double loops pinching skin.

If a soft noose, such as a towel, is used and the body is cut down shortly after death, no marks may be present on the neck. With a thin, hard ligature, the groove will be narrow, deep, and distinct. The longer the body remains suspended, the more prominent the mark. The furrow will be shallow and broad with a wide ligature such as a strip of cloth. The ligature mark is deepest opposite the point of suspension. Rarely, scratch marks will be seen above and below the ligature mark, where the victim tried to undo the noose.

In most hangings, the face is pale and the tongue is protruding and "black" from drying (Figure 8.19). Exceptions to this usually involve partially suspended individuals, where the noose is tightened only by the weight of the head or the torso. In these instances, while the carotid arteries and venous

Ligature Hanging
Figure 8.18 Suicide with belt.
Hanging Suicide With Belt
Figure 8.19 Suicidal hanging with protrusion of tongue and drying.

drainage are completely occluded, the vertebral arteries continue to supply blood to the head, producing congestion of the face and petechiae. In hangings, blood will pool in the dependent areas of the body, usually the forearms, hands, and lower legs, secondary to gravity. With time, punctate hemorrhages and Tardieu spots, caused by hydrostatic rupture of vessels, will be seen (Figure 8.20).

Prior to removal of the noose from the neck, its nature and composition, width, mode of application, location, and type of knot should be described in detail. After removal, the ligature mark on the neck should also be minutely described. One should describe the direction of the furrow (obliquely upward, horizontal, etc.), whether it is continuous or interrupted, its color, its dimensions (depth and width), whether there is a distinct imprint to the ligature pattern, the areas of the neck involved, and its relation to local landmarks.

Usually, except for ligature marks, there are no other external marks (injuries) on the body. If some are present, the medical examiner must decide whether they are self-induced, occurred during the convulsive phase preceding death, were produced when the body was cut down or during attempted resuscitation, occurred when a swinging body contacted other objects, or were produced by a second party, making the case a homicide.

On examination of the internal structures of the neck, in more than half of the cases, there are no injuries. Of 83 consecutive hangings examined prospectively, only ten (12%) had fractures. Nine showed fractures of the thyroid

Tardieu Petechiae Face
Figure 8.20 Tardieu spots.

cartilage, specifically the superior horns; none fracture of the hyoid, and one a fracture of the cervical spine (VJM DiMaio, personal communication). This last case involved an obese woman with arthritic changes of the cervical vertebrae who stepped off a ladder, dropping a short distance before being fully suspended. Of the nine cases with fracture of the superior horns of the thyroid cartilage, seven were unilateral and two bilateral. Four of the unilateral fractures were contralateral to the point of suspension, two ipsilateral, and one unknown. Seventeen (20.5%) of the 83 cases, excluding those with fractures, showed hemorrhage in the strap muscles of the neck. Petechiae of the conjunctivae or sclerae were present in 21 of the 83 cases (25.3%) including four with fractures and six with hemorrhage in the neck. Absence of petechiae in most hangings is because there is complete obstruction of the arterial system, so there is no pooling of blood in the head, no increased pressure, and, therefore, no pete-chiae. A dried rivulet of saliva often runs from a corner of the mouth and down the chest. Blood-tinged fluid may be present in the nostrils.

The low incidence of fractures of the neck organs observed by one of the authors (VJMD) was also observed by Feigin.19 In a retrospective study of 307 suicidal and accidental hangings, fractures of the neck organs were present in only 9.5% (29) of cases. In three cases, there were fractures of the cervical spine, C1-2, C3-4 and C6-7 (one in association with a fracture of the thyroid cartilage), 14 cases with fractures confined to the thyroid cartilage, nine fractures of the hyoid and three fractures of the hyoid and thyroid cartilage. No individual had more than two fractures of the neck organs.

Fractures were not associated with height of suspension, sex, or the width of the ligature. The likelihood of fractures did increase with age.

The best way to examine the interior of the neck in strangulation deaths, whether manual or caused by hanging or ligature, is to remove the viscera from the chest and abdominal cavities and then remove the brain. After there has been drainage through the cranial and chest cavities, the neck can be dissected in a relatively blood-free field. Fractures of the thyroid cartilage, the cricoid cartilage or the hyoid bone can only be considered antemortem if there is blood at the fracture site. In the authors' opinion, blood detectable only microscopically at a fracture site is insufficient to prove that the fracture was antemortem.

Homicidal hanging is very rare. It is virtually impossible for one of two healthy adults, equally matched physically, to hang the other unless the victim was beaten unconscious or rendered helpless by alcohol or drugs. In the first instance, one would suspect homicide by virtue of the injuries on the victim. In the second scenario, or if the victim was rapidly subdued by two or more stronger assailants, there might be no marks on the body except the noose mark or possible contusions of the arms, inflicted while being forcibly restrained by the assailants. If there is also a marked disproportion in strength between the assailant and victim, for example, an adult and a child or a large man and a small woman, it would also be possible to hang an individual without marks of violence. A person might also be ligature strangled and then strung up. But in this instance, the neck markings would not have the classic inverted-V configuration of a hanging. The authors, however, have seen suicidal hangings involving incomplete suspension where the noose mark overlaid the larynx and was horizontal, not sweeping upward to the point of suspension in an inverted-V configuration. To rule out any violence that might not be visible and to make sure the individual was not drugged, in all alleged suicidal hangings, a complete toxicologic screen should be performed and, in most instances, a complete autopsy.

Accidental hangings usually involve children who are playing at hanging or get entangled in a rope, or adults engaging in the practice of sexual (erotic) asphyxia (see Sexual Asphyxia). Rarely, infants will accidentally hang themselves from a pacifier suspended around their neck on a cord or get entangled in a toy or mobile placed above their cribs.20 Accidental hangings of infants and toddlers have also been reported with venetian-blind cords and drawstrings on clothing.21,22

In all deaths from hanging, the police agency involved should notify the medical examiner's office immediately. If the victim is obviously dead, the body should not be cut down, so that proper photographic documentation and investigation of the scene can be made. The noose should never be cut from the body, but left intact for transport with the body to the morgue.

When the medical examiner removes the noose from the neck, the knot should not be untied. The noose should either be slipped off the head or cut opposite to the knot and the cut ends secured together with tape.

Research has been performed on the hanging of dead bodies. Between 1817 and 1855, Casper performed 23 experiments to determine the effect of hanging on a dead body.23 He concluded that the noose marks seen on the neck in hanging during life could be produced by a ligature applied to a neck within 2 h or if not later after death. Thus, noose marks on the neck do not necessarily mean that an individual was alive when he was hanged.

In judicial hangings, death is caused by fracture-dislocation of the upper cervical vertebrae with transaction of the cord. The knot is placed under the left ear or, less commonly, under the chin. A trapdoor is sprung and the prisoner falls a specific distance determined by his weight. If he falls an insufficient distance, he strangles rather than breaking his neck; if he falls too far, he is decapitated. In properly performed judicial hangings, the victim abruptly stops at the end of his fall when his head is jerked suddenly and violently backward, fracturing his spine. Ideally, one then has the classical hangman's fracture — fracture through the pedicles of C2 with the posterior arch remaining fixed to C3. C1, the odontoid process and the anterior arch of C2 remain in articulation with the base of the skull. This injury pattern is caused by hyperextension and distraction and results in injury of the cord at C2-3. This classic fracture does not always occur in hangings. Thus, in an anthropologic study of six judicial hangings by Spence et al., there were fractures of the hyoid, the styloid processes, and occipital bones as well as the cervical body of C2 and the transverse processes of C1-3 and C5.24

In a report by Hartshorne and Reay on two recent hangings, they found bilateral vertebral artery lacerations with associated basilar subarachnoid hemorrhage; fractures of the hyoid and thyroid cartilage and hemorrhage into the cervical muscle.25 In one of the cases, there was also a fracture or separation at C2 and C3 with complete transection of the cord, bilateral carotid intimal tears and a subdural hematoma. In this latter case, the fall was 5.5 feet, with the knot slipping to the subaural area. In the other case, the fall was 7 feet, with the knot secured in the subauricular area.

In judicial hangings, consciousness is lost immediately, though the heart may continue to beat for 8-20 min and there may be muscular contractions of the facial muscles, twitching and convulsions of the limbs and trunk, and violent respiratory movements of the chest. In non-judicial hangings, where the mechanism of death is strangulation, if there is complete suspension with occlusion of both the carotid and vertebral arteries, based on the experiments of Rossen et al., the victim should lose consciousness in 5-11 sec, with half losing consciousness in 6 to 6.5 sec. If the suspension results only in occlusion of the carotid arteries, unconsciousness may not occur for 10-15 seconds.

Fat Embolism Petechiae

Color Figure 3.13

Meningococcemia. Blotchy erythematous rash with petechiae and purpura.

Color Figure 3.13

Meningococcemia. Blotchy erythematous rash with petechiae and purpura.

Color Figure 4.9

Laceration with bridging.

Color Figure 4.9

Laceration with bridging.

Color Figure 4.6

Patterned contusions caused by the end of a flashlight.

Color Figure 4.6

Patterned contusions caused by the end of a flashlight.

Contusions KnotsPetechiae And Strangulation

Color Figure 5.7

Avulsive injury of left thigh with transection of femoral artery (inset).

Color Figure 5.7

Avulsive injury of left thigh with transection of femoral artery (inset).

Strangulation Neck Scratches

Color Figure 7.15

Stab wound from blade with serrated edge.

Color Figure 7.15

Stab wound from blade with serrated edge.

Color Figure 8.11

A 5-month-old infant killed by python. No petechiae, hemorrhage, or bruising of body.

Puncture marks on face have a semicircular configuration and are caused by the needle-like teeth of the python.

Pictures Manual StrangulationManual Strangulation

Color Figure 8.24

Manual strangulation with fingernail marks and scratches on sides of neck.

Color Figure 8.24

Manual strangulation with fingernail marks and scratches on sides of neck.

Color Figure 9.11

Acid burns of face from ruptured battery.

Color Figure 9.11

Acid burns of face from ruptured battery.

Strangulation PetechiaeInternal Examination Judicial AutopsyOsteoarthritis Air Bubble

Color Figure 19.2

Air bubbles in epicardial veins of heart in death caused by air embolism.

Color Figure 19.2

Air bubbles in epicardial veins of heart in death caused by air embolism.

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Responses

  • lorenzo
    How to compress carotid artery suicide?
    7 years ago
  • Greg
    How to tie a noose how to figure the correct number of loops for victim?
    3 years ago
  • santeri
    How to suicide knot the hang?
    2 years ago
  • george
    How to compress carotid artery for hanging suicide?
    2 years ago
  • DEBRA
    How to tie a noose with a belt?
    2 years ago
  • anne
    How to hang wIth belt from bedpost?
    2 years ago
  • annemari
    How to tie a noose from towels?
    1 year ago
  • alfredino iadanza
    How do you hang yourself while kneeling?
    11 months ago
  • ruby
    How to make hanging rope for suicide?
    11 months ago
  • awate
    How to tie a low suspension hanging knot?
    9 months ago
  • kisanet
    What are tardieu spots?
    9 months ago
  • bellisima
    Where on neck to hang yourself?
    4 months ago
  • trahand
    How to tie a slip knot for hanging?
    4 months ago
  • Carola Hyssälä
    How to hang yourself lying down?
    3 months ago
  • sabrina
    How to kill yourself by partial strangulation?
    2 months ago
  • Ralf Bar
    How to position the rope on your neck when hanging yourself?
    2 months ago
  • carla
    How to make suspension hanging successful?
    2 months ago

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