– Ben Franklin

Summary

Hanging and strangulation are effective methods of suicide. Both can be carried out by people with limited physical abilities. Hanging doesn’t require complete suspension. Death occurs within about 5-10 minutes after cutoff of oxygen or blockage of blood flow to the brain (anoxia); however convulsions are common and the noise may attract attention. Pain can be minimized by protecting and padding the front of the neck. Since finding the body will probably be traumatic, care should be given to choosing a location. These are highly lethal methods and cannot be done safely as a suicidal gesture.

Lethal intent: High

Mortality: High, around 80%

Permanent injuries in survivors: Moderately infrequent

What are the pros and cons of hanging as a means of suicide?

• Pros:
  • Quick unconsciousness
    
    
  • Fairly quick death
    
    
  • Easily accomplished with materials found around the house
    
    
  • Can, if necessary, be done without leaving bed
    
    
• Cons:
  • Possibility of brain damage if interrupted
    
    
  • Sometimes a gruesome cadaver, which may be upsetting for whoever discovers the body

Introduction

Suspension hanging is often lumped (and confused) with judicial-type (“drop”) hanging, suffocation, strangulation, and even choking. This is entirely understandable, since the subject is confusing, but there are some important, and sometimes critical, differences between them.

Short definitions of these terms may be helpful in making sense of what follows.

1. Suspension hanging: suspension by the neck, with little or no drop. Death is due to compression of the airway (trachea, or windpipe) and/or the major blood vessels connecting the heart and the brain. These latter are the carotid and vertebral arteries, and the jugular veins. We will use “hanging” to mean “suspension hanging” unless otherwise specified.
   
   
2. Judicial-type (drop) hanging: a several foot drop, with rope attached to the neck. If everything goes right, death is due to a broken neck. While this is quicker than suspension hanging, it may or may-not be less traumatic.
   
   
3. Strangulation: manual compression of the airway and/or blood vessels to/from the brain. In suicide, this generally requires a ligature (rope, wire, cloth, etc.). In homicide, there may be a ligature, or there may be direct pressure from hands or forearm on the neck.
   
   
4. Choking: blockage of the airway by mechanical obstruction, e.g., a lump of food.
   
   
5. Suffocation or asphyxiation: interference with the ability to take in or use oxygen; related to choking, suspension hanging, and strangulation, in that oxygen is prevented from reaching the brain in each case; however there is no direct pressure on the airway in suffocation or asphyxiation. Examples are, use of a plastic bag, or carbon monoxide. This topic is treated in another chapter [See “Asphyxia” chapter].

Demographics:
How many people hang themselves,
and who are they?

Summary

About 4,000 people hang themselves annually in the U.S.¹ More than 95% of these are suicides. This is similar to the hanging rate in Great Britain, though the overall British suicide rate is about 50% lower than in the U.S.²


U.S. National Statistics

There are roughly 30,000 suicides per year in the United States. The annual average number of suicides by hanging, strangulation, or suffocation between 1979 and 1994 was 4,270. This is about 14.4% of official U.S. suicides for those years. Sex, and racial data for U.S. 1994 and 1979-94 are presented below. (More tables and graphs.)

Table 23-1: Suicide by Hanging, E953.0
	1994 Deaths	1994 Population	1994 Rate	1979-94 Rate
Total	4073	260,423,572	1.57	1.62
All Male	3555	127,118,264	2.80	2.77
All Female	518	133,305,308	0.40	0.47
White Male	3005	106,178,839	2.83	2.82
White Female	424	110,371,063	0.38	0.48
Black Male	340	15,500,047	2.19	2.16
Black Female	29	17,189,697	0.16	0.19
Other Male	210	5,439,378	3.86	3.62
Other Female	65	5,744,548	1.13	1.34
Rate is per 100,000 people per year. Source: Centers for Disease Control.

Table 23-2: Suicide by Plastic Bag Asphyxia, E953.1
	1994 Deaths	1994 Rate	1979-94 Rate
Total	422	0.16	0.12
All Male	214	0.17	0.12
All Female	208	0.16	0.13
White Male	206	0.19	0.14
White Female	199	0.18	0.14
Black Male	4	0.02 *	0.02
Black Female	5	0.03 *	0.01
Other Male	4	0.08 *	0.05
Other Female	4	0.07 *	0.05
* = Unreliable Rate is per 100,000 people per year. Source: Centers for Disease Control.

Interestingly, the average (mean) age for suicidal hangings in the U.S. is 34.5 years. In Great Britain it’s 50.2 (with a peak at 50-59)³ and in Denmark, 53.⁴ The reason for these differences is that older people tend to use more lethal methods for suicide attempts. In the U.S., that’s guns; in Europe, where civilian guns are much less common, it’s hanging. Consistent with this notion are data from New York City, where guns are restricted. The N.Y.C. age distribution for hangings was similar to that in Great Britain and Denmark, with a mean age of around 54 years.^{a 5}

Details

To find out more about those who hang themselves, we can take a look at some data on age, sex, race, site, and motive on hanging suicides in parts of Seattle (1978-82) and Atlanta (1979-84).

The Seattle region surveyed had about twice the population as that in Atlanta (1.26 million versus 0.62 million). The Seattle suicide rate was 14.0/100,000; Atlanta averaged 14.6. (The U.S. national rate was around 13/100,000.) Hangings were 9.3% of suicides in Seattle and 10.7% in Atlanta (14.4% in U.S., 1982). The population of the Atlanta area covered was 51% black, 49% white; 53% female, 47% male. In Seattle, the population was about 80% white, 8.5% black, and 11.5% other (mostly Asian or Native American.)

The age range was 14 to 89; average (mean) was 41.3 and median (half above, half below) was 37. A note was found associated with 22 of 61 hangings (36%), considerably higher than the 10-20% of suicides in general. The peak at age 60-69 was attributed to people with health problems.

The study from Atlanta⁶ was a bit more informative in that it compared hangings with other suicides. Age ranged between 12 and 88 years. Average (mean) age was unspecified and median was 31 years, six years less than for all suicide victims. Notes were found in 10 of 56 cases (18%), one as a computer screen display.

In Atlanta, black men hang themselves at twice the rate of their other suicide methods; white women tend to use different means. White men and black women hang themselves at rates corresponding to their overall suicide frequency.

The reason(s) for these differences are unknown, according to the authors of this study. However, as they also point out, 60% (9 out of 15) of jail hangings were among blacks, and twice the percentage of blacks as whites who hanged themselves did so in in jail (38% versus 19%). Since (a) the Atlanta jail population is disproportionately black; (b) the suicide rate among prisoners in the U.S. is several times higher than that of the general population^b; and (c) about 90% of prison suicides are by hanging, this could account for some of the unusual hanging data for black men in Atlanta.⁷

Fifteen of the total of 56 hangings (28%) took place in jails.^c Another 24 (43%) hanged themselves at home, 5 (9%) in woods, 4 (7%) in hotels, 3 (5%) in health care facilities, and 5 (9%) elsewhere.

In looking at the “reasons mentioned,” we find that the reasons/motives are roughly similar to those cited for other suicides, except for the disproportionate number of “arrest” (jail) hangings.

Alcohol use seems to be less common in hanging than in some other, e.g., gunshot or leaping from height, suicides. In one study, only 11% showed “legal intoxication.”⁸ Another report showed 18% legally drunk.⁹ A third cited alcohol in 34%, but included levels well below intoxication.¹⁰

By contrast, between 25% and 40% of gunshot suicides have legal intoxication levels above 100 mg alcohol/100 ml blood. Possibly, greater manual dexterity is needed to tie knots than to pull a trigger. Or it may be harder to work up the courage to shoot than hang yourself without alcohol – somehow it seems more final. Or, as always, perhaps “none of the above.”

How Dangerous Is Hanging Compared to Other Methods of Attempted Suicide?

Tables 16-1 through 16-4 show that hanging is one of the more lethal methods of attempting suicide, with reported fatality rates of 78-88%. However, since minor injuries tend to be under-reported, the actual fatality rates are probably lower (but not equally for all methods) than the figures cited.

Somewhat more recent (1978-1990) data give similar results: of 306 hangings (92% were suicides), 59% were found sufficiently dead at the scene that paramedics weren’t called; another 19% were declared dead at the scene by paramedics. 22% were transported alive to hospitals, of whom more than a third (8% of total) died. The overall fatality rate was 86 percent (263/306). Almost all the deaths were due to asphyxia, rather than spinal cord or neck injury.¹¹

Physiology: Just what is “hanging,” and how does it kill?

Short answer. Hanging can kill by four distinct mechanisms: compression of the carotid arteries, compression of the jugular veins, compression of the airway (trachea), and breaking the neck. The first three can result from suspension hanging; the last from drop hanging.

Carotid artery. On the right side of your neck, just under the side of the jaw, is one of your carotid arteries. Put your fingers there and gently feel your pulse. It should be quite strong. (If you can’t find one, either you’re looking in the wrong place or you don’t need this book.) The carotid artery carries much of the blood to your brain, which uses around 15% of the entire blood supply of your body.¹² Anything which interrupts that blood-flow for more than a few seconds will cause loss of consciousness.

Jugular vein. On both sides of the neck, under the angle of the jaw, are the jugular veins, which carry the “used” blood back to the heart. If the jugulars are blocked, blood backs up, much like water in a stream that has been dammed. The carotids and jugulars can be compressed with just a few pounds pressure; a moderately tightened rope will do nicely. Death occurs within a few minutes. There does not need to be any pressure on the airway (trachea or windpipe), though there often is.

Trachea/airway. The airway, down the front-center of your neck, can be blocked internally, (e.g., by inhaling a foreign object), or externally (e.g., by a rope). When the interference is internal, it is termed “choking.” In either case, obstruction of the airway takes a good deal longer to produce unconsciousness than does carotid pressure, and is much more painful. Details are in the “Asphyxia” chapter. Sometimes choking is the cause of accidental death (“cafe coronary”) when a piece of food lodges in the airway and can’t be dislodged – so learn the Heimlich maneuver, don’t make a pig of yourself when eating, and chew your food thoroughly; Ma was right about some things.

“Suffocation” is related to choking, but is an interference with successful breathing, rather than direct blockage of the trachea. Examples include smothering with a pillow or plastic bag, and being killed by a boa constrictor. More on suffocation in the “Asphyxia” chapter.

Pressure on the neck is sometimes a method of homicide, typically by the use of two thumbs against the airway and the other fingers grasped round the back of the neck. If the neck constriction is due to the body’s weight pulling on a ligature, it is called “hanging”; otherwise it is some form of strangulation. This is of some practical significance, since almost all hangings are suicide, accident, or judicial, while most stranglings are homicide.

Hanging. Judicial (drop) hanging is quite a different kettle of worms from suspension hanging. In (properly done) judicial-type hanging, the victim falls several feet before coming to an abrupt halt at the end of a rope. Often, this is the bitter end. Such a precipitous change in velocity is supposed to cause a broken neck and quick unconsciousness and death. However, exhumation of judicial hanging victims has shown that the breaking of the neck was frequently not the cause of death.¹³

An excessively long drop can result in separation of head from body, and is considered bad form by professional hangmen.^d

Suspension hanging can cause compression of the carotid, jugular, and/or airway, depending on how it is carried out.

More detailed answer

There are similarities between suspension-hanging and choking, as well as the previously-mentioned differences. Your blood carries oxygen and nutrients to your brain. Enough pressure on the airway (trachea/windpipe) compresses it and prevents oxygen from reaching the lungs. Your body has built-in reflexes to keep this from happening; pressure against your trachea causes quick pain, and you have an irresistible urge to relieve the pressure and cough; one reflex (pain) gets your attention and tries to get you away from the stimulus – say, someone’s thumbs – and the other reflex (cough) attempts to clear the airway. If these attempts are unsuccessful, blood will continue to be pumped to the brain (and elsewhere) by your heart, but it won’t carry enough oxygen and you will lose consciousness in a couple of minutes.

Time to death. As asphyxia proceeds, first temporary, then permanent, brain damage from lack of oxygen will occur. Death follows in 5-10 minutes (10-20 minutes, according to Polson;¹⁴ however his number seems to be based on the fact that the heart may continue beating for up to 20 minutes after judicial hanging,¹⁵ and ignores that the heart may continue to beat after brain death). While human data are lacking, unanesthetized dogs die after around eight minutes of asphyxia.¹⁶ On the other hand, it’s also true that unconsciousness and death will be delayed if blood-flow to/from the head is only partially obstructed.

Carotid reflexes. Curiously, you don’t have the same protective reflexes along the carotid artery, so that pressure sufficient to block the artery doesn’t elicit much in the way of defensive reaction. In fact, one of the reflexes that is present may be counterproductive: near where the carotids divide are some nerve cells, the “carotid sinus.” These nerve cells have the normally-useful function of maintaining blood pressure at a steady level. They respond to a decrease in blood pressure (e.g. when you stand up) by constricting arteries and telling the heart to beat harder. Without this, you might pass out every time you stood up suddenly, because not enough blood was reaching your brain. (The dizziness many people feel when they stand up suddenly is another way of appreciating how quickly and exquisitely sensitive your brain is to absence of enough blood). Similarly, the carotid sinus responds to an increase in blood pressure by relaxing the arteries and inhibiting the heart.

So far, so good. The problem arises because these pressure-receptor nerves aren’t smart enough to tell the difference between blood pressure and externally-applied pressure – for example a forearm or billy-club across the right-front side of the neck.^e

“Sleeper” hold. Those of you who are wrestling (t.v. variety) fans are probably familiar with the sleeper hold; it is nothing more than a forearm pushed against the right carotid artery, compressing it, and cutting off blood flow to the brain (see “Asphyxia” chapter). This causes unconsciousness in about eight¹⁷ to fifteen¹⁸ seconds.^f

However the sleeper hold is forbidden in tournament wrestling and is faked in the t.v. stuff. The reason is that the amount of pressure needed to compress the artery is enough to cause the carotid sinus to kick into overdrive and send the heart a priority message to SLOW DOWN, which is sometimes enough to stop the heart altogether. Despite being quite aware of this, some police departments continue to use this hold to restrain people they arrest, with the altogether predictable result of infrequent, but entirely unnecessary, deaths.¹⁹

Another hazard with the sleeper hold is that, during a struggle, the constricting forearm can shift from the side to the front of the neck, compressing the airway and becoming a “choke hold” [drawing 4, Reay p256]. This requires greater pressure than the sleeper hold, with a corresponding increase in injuries to neck structures, e.g., fracture of the thyroid cartilage. More dangerously, the lack of oxygen to the heart muscle can trigger fatal cardiac arrest.

In one case, a man’s wife

“... sought an involuntary psychiatric commitment order because of his withdrawn behavior and refusal to take medication. The order was granted and two police officers were dispatched to his residence to bring him to the hospital. Coaxing by the police officers proved futile. In an attempt to overcome and handcuff him, one police officer stepped behind the victim and grabbed him about the neck. The hold intended by the officer was the carotid sleeper with the neck of the victim in the crook of the arm and forearm of the officer. After a brief but violent struggle during which both the officer and the victim fell to the floor, the victim became lifeless. He did not respond to cardiopulmonary resuscitation. An electrocardiogram taken during resuscitation showed cardiac arrest. Witnesses including family members stated that the entire struggle lasted only a short time with the neck hold in place several seconds. An inquest jury ruled that the death was natural because of the victim’s previous cardiac history and the brief time during which the neck hold was applied.”²⁰

Pressure needed to compress the carotid. How much pressure is needed to compress the carotid? Surprisingly little. To quote the eminent Doctors Polson and Gee,

“By experiment I have confirmed that the carotid artery is appreciably obstructed by a ligature under low tension. Having first established free flow of fluid between the common carotid artery, exposed in the upper chest, and the internal carotid artery, seen inside the skull after removal of the calvarium, I then applied a ligature with a running noose round the neck. Weights were added and injection was repeated, below the level of the ligature. The tests showed that a pull of as little as 7 lb (3.2 kg) was sufficient to reduce free flow through the artery to a mere trickle.”²¹

Obviously, this will vary from person to person, and also with the width of the ligature; other published values are as high as 11 pounds (5 kg).²² Two problems with these calculations are that, in a living person, (a) the carotids are located deeper in the neck than jugular veins and are shielded by a living sterno-mastoid muscle; (b) blood pressure might open the compressed artery on each heartbeat. More on that in a moment.

Pressure needed to compress the jugular. Since veins operate at lower pressures than do arteries (if you cut an artery, blood spurts out; blood only flows from a severed vein) one might expect the jugular veins to be more easily compressed than the carotid arteries. Experimentally, this is exactly the case, with only around 4.5 pounds (2 kg) pressure needed to block the jugulars.

Pressure needed to compress the airway and other arteries in the neck. About 33 pounds (15 kg) will compress the airway, and 66 pounds (30 kg) the vertebral arteries leading to the face.²³

What this means, practically speaking, is that someone who wants – or wants to avoid – a lethal result should be aware that full suspension is quite unnecessary. Death will occur after only a few pounds of pressure on a neck ligature; a sitting or semi-reclining position is sufficient.

Suspension Hanging. Hanging does not have a very good image. For example:

“The discovery of a grotesquely hanging corpse whose swollen, sometimes bitten tongue protrudes from a bloated blue-gray face with hideously bulging eyes is a nightmarish sight upon which only the most hardened can gaze without revulsion.”²⁴

However, while some look livid, about 60 percent of hangers have a “pale and placid” face.²⁵ Some have small hemorrhages, caused by capillaries leaking (due to high blood pressure in the absence of oxygen), on the face, eyelids, and/or scalp; others don’t.

What accounts for these differences? Basically, it’s a question of how quickly and totally the ligature cuts off blood circulation to and from the head. If suspension is fast and complete, the blood supply both to and from the head will be cut off simultaneously, so there is no excess blood or blood pressure in the head, and thus a more-or-less normal-colored corpse. Similarly, activation of the carotid sinus pressure receptor would cause a decrease in blood flow to the head, leading to paleness in the cadaver.

If, on the other hand, the pressure on the neck gradually increased as consciousness was lost, it’s probable that the jugular veins were shut off before the carotid arteries (and almost certainly before the hard-to-clamp vertebral arteries), since it requires less pressure to do so. Thus, in this case blood would continue flowing into the head while having no way to leave it; hence engorgement and blue/purple color. This is most likely when the suicide is in a sitting or lying position, because there is less (and less sudden) pressure on the neck than when she/he is completely suspended.

Placement of the ligature. An additional variable is the placement of the ligature [drawings in Simonsen, 1988] The least pressure corresponds to the location of the knot in the rope, since that point is pulled up and away from the neck. It is thus possible to avoid compressing the trachea is the knot is along the centerline of the face.

Further complications arise because the noose can be placed high or low on the neck, with potentially different intermediate results. When high, it is less likely to compress the airway because some of the pressure from the ligature may be transferred to the jaw or skull.

Do people die from airway blockage, or from cutoff of blood circulation to the brain? Bodies with little weight on the ligature, e.g., prone or seated, have a greater chance of death from asphyxia, according to a standard forensic text. Since the jugular vein (blood out) is easier to compress than the carotid artery (blood in), enough blood accumulates in the head and neck to compress the airway, leading to asphyxia.^{g 26}

Medical experts disagree about the frequency and importance of airway blockage in hangings. For example, one says, “Occlusion of the air passage by constriction on the neck is probably extremely rare if existing at all.”²⁷ Others hedge their bets: “Suicidal hanging is earmarked characteristically as causing death by compression of the anatomic airway and the blood vessels in the neck.”²⁸ or cover all the bases: “Reports in the forensic literature have stated that death may be due to either asphyxiation, coma, carotid artery or jugular vein injury, or any combination of the above.”²⁹ Certainly, airway blockage is not essential to successful hanging. In one case a woman with a tracheotomy^h killed herself despite attaching the ligature above the site of the breathing hole. She would have continued breathing until dying from lack of blood to her brain.

Airway blockage is more likely when:

• The ligature knot is toward the back of the neck. In this situation the maximum pressure from the rope is then on the front of the neck, where the airway is.
  
  
• The person is seated, semi-reclining, or prone. Due to little weight on it, the rope tends not to slide up the neck. Were it to move up, it would end up being partially supported by the chin, relieving pressure on the airway.
  
  
• The ligature is thin, or attached with a running noose. Such a ligature tends to clamp in place.
  
  
• The ligature is placed low on the neck, where it tends not to slide up high enough to be supported by the chin.

Was it Suicide, Homicide, or Accident?

“ a farmer who, living at a distance from his cattle herd, came to tend the herd alone, only to find the submersible pump in the well which supplied them with water to be broken. He used a piece of angle iron as a bridge across the well head, and a peculiarly flimsy and inadequate piece of rope to lower himself into the well to retrieve the pump: the rope broke and he was drowned – or at least this was the story received by telephone from the local coroner. When the body was received for autopsy the first finding was a ligature mark around the neck; I telephoned the coroner to point out with some acerbity that this was an obvious suicide. ‘But Doc,’ the coroner replied, ‘that was the only way we could pull him out of the well!’”³⁰

There are four possible definite verdicts in a hanging death: homicide, accident, judicial, or suicide.

Homicide

Homicidal hanging is very rare because there are many easier ways to commit murder. Simulating suicidal hanging is generally done to disguise a murder, often an impulsive one. It is also unusual, mostly because it is difficult to pull off without leaving signs of drugging, struggle or improbable injury.

For example, in a notorious case from Great Britain, Sergeant Emmett-Dunne killed a fellow soldier, Sergeant Watters, by a karate-chop to the throat and then suspended the body from a staircase to make it look like a suicidal hanging.

Autopsy showed an unusual fracture of the cartilage around the thyroid gland, and vertical tears in the carotid artery that are typical of drop-type (judicial, not suspension) hangings where there is sudden force applied to the neck. Despite this, a verdict of suicide was rendered by an inexperienced army pathologist due to lack of any other suspicious circumstances.

Nevertheless, military gossip persisted about a relationship between Emmett-Dunne and Watters’ widow, which was reinforced when, six months later, they married. It was not until a year later that the military police reopened the investigation (as well as the body). Photographs of the original scene showed that blood had pooled both above and below the ligature, in the head, neck and upper chest regions, which is inconsistent with hanging. There were no tiny hemorrhages which are often found in asphyxiation.

Under questioning, Emmett-Dunne’s half brother (Emmett) came undone and confessed to helping Emmett-Dunne suspend the body. Further circumstantial evidence was discovered, Emmett-Dunne was convicted of murder and sentenced to life imprisonment.

He was saved from hanging because of jurisdictional quirks: he was a citizen of the Irish Republic serving in the British army. The crime had taken place in Germany. The question arose as to where, and under what laws, he should stand trial. Eventually it was decided that there was no authority to send him to England; he was tried, convicted, and sentenced to death by British military court in Dusseldorf in June, 1955. However, there was no death penalty in the Federal Republic of Germany, (though there was in England at that time), nor, by treaty, could military executions be carried out in German territory. The sentence was commuted to life in prison; he was, however, released after 7 years, when passions had cooled.³¹

Accident

How often are hanging deaths due to accident? Combining four studies of hanging³², we find that 96% (range 94-98%) were suicidal, and 4% (range 2-6%) accidental.

Of the 19 accidental deaths, 5 were children. For the most part, they were toddlers snagged by crib slats and/or their own clothing. The remaining 14 were all males who had gotten wrapped up in auto-erotic asphyxiation. To quote from an interesting review of hanging:

“Add sexual perversion to the woes of mankind. When men or women try to improve on nature’s biological methods, they not only become frustrated, but worse, act unnaturally, and usually to their own detriment. Any sexual behavior that strays from the confines of normal physiological compatibility is considered to be a perversion. One may add to the list another deviation, described by the Marquis de Sade: self-induced asphyxia as a means of ejaculatory gratification in the form of masturbation. When propelled by concupiscence, the unfortunate person with autoerotic propensities does not suspect that death lurks nearby.”³³

It seems that increased sexual gratification can be had by partial interruption of oxygen to the brain. There may also be elements of masochism here. Whatever the motivation, the trick is to make sure the interruption is, and remains, partial. The problem is that unconsciousness can occur without warning; if it does, and if the ligature doesn’t slip off or loosen, death follows.

These are accidental deaths. The victims are alleged to share some psychological traits with suicides: depression, death fixation, and isolation.³⁴ However the circumstances and details of the hangings are usually quite different; in autoerotic hanging:

1. There are often signs of masturbation.
   
   
2. Women’s clothing, either worn by the victim or found near him, is common.
   
   
3. Erotic literature is frequently found at the site.
   
   
4. There is often a history of successful partial hangings, evidenced by a diary, a collection of ligatures, or wear marks from the rope on the rafter, door, or other attachment point.
   
   
5. Typically, the neck is protected by padding.
   
   
6. Feet are usually on the floor and/or there is furniture nearby for support.
   
   
7. There are sometimes mirrors or cameras for viewing the (often bound) genitalia.
   
   
8. Generally, there is no history of suicidal attempts.
   
   
9. The victims are almost always (more than 99%) male, for reasons unknown.ⁱ

Note, especially, points 5 and 6; these people die because they lose consciousness quickly and unexpectedly.³⁵

Some of the case reports are truly bizarre,³⁶ but interestingly, asphyxia as a means of sexual arousal is a centuries-old practice documented by anthropologists.³⁷

For example, Eskimos (Inuit) apparently choke one another as part of their normal sexual repertoire, and Eskimo children suspend themselves by the neck in play.

“The state of unconsciousness is so important and so familiar to the Eskimos that even the children play at it. It is a favorite pastime of theirs to hang themselves by their hoods. When these tighten about their necks, the blood is kept from their heads, and in time they lose consciousness. The other children in the house take them down when their faces turn purple. But they say that the state of unconsciousness is so delightful that they play this game over and over again.”³⁸

Legal consequences The distinction between suicidal and accidental hanging (or other means of death) has legal, as well as emotional, ramifications. Most life (i.e., death) insurance policies, understandably enough, have limitation or total exclusion of payments for suicidal death, at least for the first two years.

Some pay extra in case of accidental death, for no obvious reason.^j Is autoerotic hanging an accident or suicide? We must go back to the definition of “accident”. To quote an attorney:

“The legal definition of accident has not always been the same. Variations have been stated legally in different court decisions. Among these are that an accident is:

1. Any event that take place without the foresight or expectation of the person acted upon or affected thereby;
   
   
2. A happening or coming by chance or without design; casual, fortuitous, taking place unexpectedly, unintentionally, or out of the usual course of events; and,
   
   
3. Something unforseen, unexpected, or extraordinary.
   
   

The word, accident, is derived from the Latin verb, accidere, signifying “fall upon,” “befall,” “happen,” “chance,” or “unexpected.” In a etymological appraisal, anything that happens can be interpreted as an accident. In its more formal accepted meaning, accident is defined as a fortuitous circumstance, event, or happening. It is an event happening wholly or partly through human agency, an event which, under the circumstances, is unusual and unexpected by the person to whom it happens. An accident is an untoward occurrence in the usual course of events. It may be without known or assignable cause. In its proper use, the term excludes negligence.”³⁹

After all this, it should be no surprise to learn that insurance companies differ as to whether autoerotic hanging qualifies as an “accident,” and will examine such a death very closely. So, if you go in for that sort of thing, read your life insurance policy carefully.

Should you be in the military, “If the injury or death was incurred as a result of erratic or reckless conduct or other deliberate course of conduct without regard for personal safety,^k or the safety of others, it was incurred not in the line of duty, but was due to misconduct.” and the deceased can expect to be court-martialled for destruction of government property.


Judicial Hanging

“My father could dispatch a man in the time it took the prison clock to strike eight – leading him from his cell on the first stroke and having him suspended dead on the rope by the last stroke. That seemed a very worthy intermediate ambition for me.”⁴⁰

One hesitates to ask what his ultimate ambition was. In any event, Albert Pierrepoint followed in his father’s footsteps and became one of the small number of “qualified executioners” in Great Britain.

The art of hanging was taught both by apprenticeship and by schooling at some British prisons. There was widespread need for this skill, since as late as 1832, 220 separate crimes, including poaching, and picking pockets, were punishable by death. Hangings were public cautionary spectacles and were covered by the newspapers. There are accounts of executioners – sometimes family and friends – pulling on the legs of young boys who were not heavy enough to be successfully hanged in order to add sufficient weight to strangle them.

The theory of deterrence-by-example was in vogue. It was satirized by a contemporary painting of a public hanging in which a pickpocket was working the crowd.⁴¹ As a result of critical newspaper reports of botched hangings, the Home Office prepared a standard table of drops in 1888. The formula was basically:

1260 divided by the weight of prisoner in pounds = length of the drop in feet.

For example, the calculated drop for a 154 pound person would be 8.2 feet, a bit less than the 9 feet in the drop table shown below.

Another source⁴² provides similar data:

Table 23-3: Hanging Drop Heights
Culprit’s Weight (Imperial)	Culprit’s Weight (Metric)	Drop (Imperial)	Drop (Metric)
14 stone (196 lbs)	89kg	8ft 0in	2.44m
13.5 stone (189 lbs)	86kg	8ft 2in	2.49m
13 stone (182 lbs)	83kg	8ft 4in	2.54m
12.5 stone (175 lbs)	79kg	8ft 6in	2.59m
12 stone (168 lbs)	76kg	8ft 8in	2.64m
11.5 stone (161 lbs)	73kg	8ft 10in	2.69m
11 stone (154 lbs)	70kg	9ft 0in	2.74m
10.5 stone (147 lbs)	67kg	9ft 2in	2.79m
10 stone (140 lbs)	64kg	9ft 4in	2.84m
9.5 stone (133 lbs)	60kg	9ft 6in	2.9m
9 stone (126 lbs)	57kg	9ft 8in	2.95m
8.5 stone (119 lbs)	54kg	9ft 10in	3m
8 stone (112 lbs)	51kg	10ft 0in	3.05m

These numbers apply to people of average build with no unusual physical characteristics. The author (James “Hangman” Barry) noted that when executing “persons who had attempted suicide by cutting their throats to prevent reopening the wounds I have reduced the drop by nearly half.” This would probably not cause a broken neck, however, and the victim of Mr. Barry’s aesthetic sensitivities would then be left to strangle, very unpleasantly, over several minutes.

Pierrepoint notes,

“A master executioner is responsible for every detail of his craft. He has to come to his own decision on the length of the drop based on the Home Office table, varied by his own experience, and adjusted to the weight of the prisoner, his height, his age, and an estimate of the musculature and tensile strength of his neck.”

In order to carry out a perfect hanging, the noose must, of course, be properly applied:

“Draw it firm and tight with the free end of the rope emerging from the metal eye just under the jawbone. There is no knot. That fancy cowboy coil of a ‘hangman’s noose (knot)’ is something we abandoned to the Americans a hundred years ago. In Britain, the rope runs free through a pear-shaped metal eye woven into the rope’s end, and the operative part of the noose is covered with soft wash-leather. Always adjust it to the left, because with the pull of the drop the noose gyrates a quarter-circle clockwise and the tug of the rope finishes under the chin. This motion throws the neck back and breaks the spinal column, separating it at about the third vertebra of the neck. Adjust it on the right and it gyrates to the back of the neck, throwing the head forward, not breaking the neck, eventually killing by suffocation.”

At this point I should mention that one had best not use mountain-climbing rope for a drop hanging, since it is designed to stretch in case of a fall. Thick manila rope is a much better choice.

It is commonly believed that a black bag is placed over the condemned’s head just before execution. Alas, contrary to all the movies, the bag is white.

Actually, there’s a bit more to say about it. The bag,

“...has been used in British executions from the later days of batch-strangulation^l in public, long before the introduction of the long drop designed to sever the cervical vertebrae and cause spontaneous death. Its original purpose was to mask the contortions of slow strangulation, which were considered too horrible even for the ghoulish British public to witness, although the logic that public executions were a public deterrent against crime might have been followed strictly by exposing the ultimate horror in order to achieve the maximum deterrence.”⁴³

The number of capital crimes was reduced to 15 in 1837, and, “In 1861, the death penalty was reduced to the offences of murder, treason, piracy with violence, and arson in the Sovereign’s vessels, arsenals, or dockyards.” Further restrictions ended judicial executions in 1964.

More recent events, especially those related to Northern Ireland, have led the British public to favor the reintroduction of the death penalty for terrorism and other violent crimes. Interestingly, this was rejected by the House of Commons despite the largest Conservative majority in modern parliamentary history and the support of then Prime Minister Margaret Thatcher (who, it should be noted, freed members of her party from party discipline (she wasn’t known as “The Iron Maiden” for nothing) to vote their consciences). The result was due to an unusual alliance between those opposed on humanitarian grounds and those who wished to avoid producing martyrs for the IRA.⁴⁴

Pierrepoint looked back on his career with very mixed emotions:

“I believed with all my heart that I was carrying out a public duty. I conducted each execution [about 400] with great care and a clear conscience. I never allowed myself to get involved with the death penalty controversy. I now sincerely hope that no man is ever called upon to carry out another execution in my country. I have come to the conclusion that executions solve nothing and are only an antiquated relic of a primitive desire for revenge which takes the easy way and hands over the responsibility for revenge to other people. It is said to be a deterrent. I cannot agree. There have been murders since the beginning of time and we shall go on looking for deterrents until the end of time. If death were a deterrent, I might be expected to know. All the men and women whom I have faced at the final moment convince me that in what I have done I have not prevented a single murder.”

Suicidal hanging

Scene. Since over 95% of non-judicial hangings are suicides, there is sometimes a predisposition on the part of investigators to see hangings through suicide-colored glasses. This can lead to overlooking or misinterpreting evidence. The previously mentioned case of Emmett-Dunne is cautionary.

Ligature. Most suicidal people are not very picky, and use whatever is handy. Household clothesline remains a big favorite except in the wealthier population that owns electric or gas clothes dryers.^m On the other hand, amongst people lacking clotheslines, use of electric cords sometimes takes up the slack.

Articles of clothing are also perennially popular. People have used belts, suspenders, shoelaces, scarves, handkerchiefs, neckties, shirtsleeves, pantlegs, and undershirts, among other things.

As previously noted, death occurs after 5-10 minutes of complete brain anoxia. A broad ligature, such as a pant leg, may not produce enough pressure to fully cut off blood flow to the brain, let alone air through the trachea, and thus may take much longer to be fatal.

Though a forensic medicine text warns, “Unusual ligatures arouse suspicion [of foul play]”,⁴⁵ it is not clear why that should be so, given the tendency to use whatever is available at the moment. Indeed, the same authors cite a case of a man who hung himself using some of the roots of a pine tree as the ligature, looped over a low branch of the same tree.

Two studies, one of 61 consecutive hanging deaths in Seattle, Wa.,⁴⁶ and the other of 106 hangings in New York City⁴⁷ show the range of materials used:

Table 23-4: Ligatures Used in Suicidal Hangings
	Luke, 1985 Seattle, Wa. n=61	Luke, 1967 New York City n=106
Material
Rope or clothesline	32 (52%)	49 (46%)
Leather belt	8 (13%)	15 (14%)
Soft belt or necktie	7 (11%)	7 ( 7%)
Length of sheet or other cloth	6 (10%)	7 ( 7%)
Electric cord	—	8 ( 8%)
String or twine	—	5 ( 5%)
Not specified by coroner	—	8 ( 8%)
Other (dog leash, venetian blind cord, clothing, etc.)	8 (13%)	7 ( 7%)
Width
One inch or less	46 (75%)	—
More than one inch	7 (11%)	—
Not reported	8 (13%)	—
Number of wraps around neck
One	52 (85%)	—
Two	6 (10%)	—
Three or more	3 (5%)	—

If the suspension point is inconveniently high, ligature material, similar or dissimilar, may be tied together. For example, bed sheets may be torn into strips and connected by knots.

Usually a single simple loop is used, but multiple loops are not grounds for suspicion; quite the contrary, for the presence of more than one loop is unusual in murder, taking longer to apply and being harder to tighten.

Type of knot. Most common are the running noose (loop at one end, through which the other end is pulled) and the fixed noose with a granny or reef knot.

Multiple knots are uncommon: “A ligature which is knotted firmly at the first turn and then knotted again after a second turn is unlikely to have been applied by a suicide; it is possible but rare.”⁴⁸

Position of the knot. The location of the knot is just about evenly distributed between left side, right side, and back of the neck; rarely is it in front. Some data on this are shown in Table 23-5.

Table 23-5: Location of Knot in Suicidal Hangings49
Left side of neck	20 (33%)
Right side of neck	17 (28%)
Back of the neck	17 (28%)
Front of the neck	3 ( 5%)

In one case, a 57-year-old man hanged himself with a rope whose knot was in the front of the face at eyebrow level. All of the pressure was thus on the back, and to a somewhat lesser extent, sides of the neck, as can be seen by the location of the post-mortem rope grooves. The exact cause of death was not clear. There was no sign of asphyxia, which is understandable since the airway was not obstructed, but pressure on the carotid arteries probably cut off the blood supply to the brain; or pressure on the carotid pressure receptors might have caused the heart to stop.

The position of the ligature around the neck provides some distinction between hanging and strangulation, and thus clues to distinguish suicide (mostly hanging, rarely strangulation) from murder (almost always strangulation). In most suicides, the victim’s weight causes the ligature to slide up to the top of the neck, under the jaw. Exceptions can usually be accounted for if:

1. The position of the body doesn’t put much weight on the ligature. This can occur if the body is partially supported by, say, a chair. Similarly, if the victim was in a reclining position, there is little tendency for the ligature to move towards the top of the neck.
   
   
2. The victim has a particularly large thyroid cartilage (Adam’s apple), which will limit the upward movement of a ligature.
   
   
3. A quickly-tightening running noose, or a thin ligature, may clamp down pretty much where it was originally placed.

In two studies of 279 suicidal hangings, the ligature was above the thyroid cartilage in 215 (77%), at the level of the thyroid cartilage in 43 (15%), and below in 19 (7%).⁵⁰

Suicidal hanging typically causes a “caret” (inverted v) shaped ligature mark. The tip of the caret is at the site of the knot, since the weight of the body normally causes the knot to be the highest point of a loop around the neck. This will not be seen if the body was at a reclining angle, and the ligature mark will make the death look like a strangulation. A running noose can also produce a horizontal mark, because it tightens quickly. If a soft, wide ligature is used, e.g., a t-shirt, and the victim is cut down soon after death, there may be no visible external marks at all.

Legal consequences can hinge on the ligature marks. In one case a man walked into the house and found his wife who had hanged herself. To avoid the social stigma of suicide, he cut her down and hid the cord, before calling the police and telling them that he had found her collapsed on the floor. Had the rope marks on her neck not been clearly suicidal, he might well have been charged with murder.

The ligature does not have to go entirely around the neck, as long as it compresses either the sides (blocks blood circulation to the brain) or the front (blocks airway) of the neck. In fact, there does not need to be a flexible ligature at all: people have died from resting their necks on stair tread edges, car steering wheels, and sofa or chair arms.

In one case a 60-year-old man was found dead in a kneeling position with the bottom of his chin balanced on the arm of a chair . The compression mark on his neck matched the chair arm, and extended to the carotid arteries. There was no bruising of neck muscle, or injury to neck cartilage or bones. There was no evidence of alcohol or other drugs, nor of injury or debilitating illness. He had a history of severe coughing, and death was attributed to an attack of violent coughing or choking that had caused him to crouch down and then be unable to rise.⁵¹

Point of suspension. As with their indiscriminate choice of ligatures, suicidal people suspend themselves from whatever site is handy. Stair rails are popular, as is tying one end of the ligature to a doorknob and tossing the other end over the top of the door. Hooks and nails are useable, but may bend or pull out if not sturdy, and firmly attached. Often a chair that the victim stood on is nearby, but total suspension is quite unnecessary; a majority of such suicides have their feet touching the ground.⁵²

It’s not generally appreciated that even low suspension points are sufficient; a table leg, door knob, or bedpost have all been used. In one case a 77-year-old woman hanged herself from the leg of a table, with the rope tied only 17 inches off the floor. She was found lying face-down.⁵³ In another case, of a completely suspended woman, the seeming absence of a platform caused the police to suspect her husband. Luckily, the victim’s footprints were found on top of a sewing machine near the body.⁵⁴

Position of the body. In one study, 37% (30/80) of hanging victims were completely suspended; 63% (50/80) were in contact with the ground⁵⁵ This is credible, since all it takes to carry out a standing hang is to bend the knees enough to tighten the ligature. In 261 cases of incomplete suspension, 64% (168) had both feet touching the ground, 16% (42) were on their knees, 11% (29) were lying down, 7% (19) were sitting, and 1% (3) were huddled or squatting.⁵⁶

Suicide pacts and hanging. While suicide pacts are not uncommon, dual hangings are rare. In one case, two men were found dead in their hotel room, one on either side of the closet door. The bedsheet had been tossed over the door and opposite corners tied to their necks. Each had been on a chair and had stepped off simultaneously.⁵⁷ In another instance a woman and a man, despondent lovers, tied a rope to a branch of the tree under which they were sitting. They attached the free ends to their necks and leaned back.⁵⁸ Acts like these require planning, coordination, and trust.

Suicide by hanging combined with other methods. There exist several reports where a person attempted to commit suicide by one method, became impatient, and finished the job by hanging. In one instance a man drank ammonia (Not Recommended) and then hung himself. Presumably the ammonia was too slow or too painful.⁵⁹

In another case, a 53-year-old woman was found hanged in a loft. There was considerable blood, widely scattered, from a depressed skull fracture and other scalp wounds. She had apparently first cut herself with a knife, found in her pocket, followed by a blow to the head from the butt of a hatchet. Pouring blood (scalp wounds tend to be messy), she found a rope, formed a running noose, and hanged herself.⁶⁰

Finally, there was a 48-year-old man who slit his left wrist and throat. The wrist injury was deep but the throat cuts were too shallow to be fatal. He followed this by two gunshots, one through his left palm and the other to the right temple. This latter bullet did not penetrate the skull. Understandably frustrated, he then hung himself from the stairs.⁶¹

Strangulation
Strangulation is defined as pressure applied to the neck without suspension of the victim. It is uncommon in suicide, but not unknown. Nevertheless, most strangulations are homicide, and will be treated as such by medical examiners and police, in the absence of clear evidence to the contrary. Strangulation was used as a method of execution in some countries, e.g., Turkey and Spain. In Spain, the sitting victim was tied to a post. A metal collar was placed around the neck and the post, and then tightened. In one version, a metal spike stuck out of the post and was forced into the base of the prisoner’s neck by the pressure of the tightened collar.

The physiology of strangulation is essentially the same as that of suspension hanging, and needs not be treated separately. In self-strangulation, the ligature is applied more slowly and less tightly than in suspension hanging. As a result, the jugular veins are more constricted than are the carotid arteries, leading to a blue, swollen, head. Neck injuries, however, are rare. Because the ligature cannot slide up the neck or be supported by the chin, compression of the airway is more likely than in suspension hanging.

In suicidal hanging, people generally use the materials at hand. Women tend to use stockings or scarves; men most often use cord. In one case a man strangled himself with two bow ties.⁶² In another instance, a man, mistaking himself for a bobbin, wrapped 35 turns of twine around his neck, tied a knot, and attached the free end to his right thumb in order to increase pressure. Blood alcohol level was 0.26 percent. ⁶³

Two or more turns tied with a half knot or half hitch (double knots are more characteristic of murder) is strong evidence of suicide, but there are exceptions. The murdered 42-year-old woman described in the “Asphyxia” chapter was such a case.

More typical of self strangulation were two women who killed themselves with stockings. In one case, a 73-year old woman, depressed and about to be committed to a mental hospital, wrapped a stocking twice about her neck. There was a half-knot at each turn. Because the ligature was only tight enough to compress the jugular vein (blood out) but not the carotid artery (blood in), her face was purple and congested. In the other example, a similar stocking was pulled more tightly and the face was not engorged or cyanotic.

It’s possible for a person to strangle him/herself with one arm: a woman with incapacitating burns on her right hand rolled a shawl and scarf into a ligature, wrapped it two-and-a-half times around her neck and tied two knots.⁶⁴

Another method is use of a tourniquet. A single loop of rope is loosely tied around the neck with a good knot, e.g., square or reef knot. A rod is put between the ligature and the neck and is then twisted until the desired degree of tightness is achieved. The rod tends to unwind a bit when the person becomes unconscious, but usually snags on the side of the jaw, maintaining enough tension to cause death. See “Asphyxia” chapter for details.

Consequences: What are the effects of hanging?
There is not much information from survivors for two reasons: (1) there are not many survivors, and (2) often, survivors have more-or-less complete amnesia. In one case, a woman tried to hang herself from the foot of her bed, while in jail. She was saved by a fellow prisoner. She later mentioned having had severe pain, followed by unconsciousness.⁶⁵

In another instance a public entertainer, who hung himself briefly as part of his act, made a mistake of timing. He said (afterwards) that he could not breathe – quite understandable, under the circumstances – and felt as if a heavy weight was on his feet. He quickly lost consciousness before he could move his hands to release himself.⁶⁶

There is additional information from experimental hanging. In one description, the subject mentioned flashes of heat and light, and deafening sound. Legs were numb and weak. Pain was not severe and unconsciousness was sudden.⁶⁷

More detailed information came from another self-experimenter named Minovici. With 5 kg (11 lbs.) pull on the ligature, loss of consciousness was rapid. When he leaned on the rope (incomplete suspension), within 5-6 seconds his eyes blurred, he heard whistling, and his face turned red-violet. With the knot on the side instead of the back of the neck, these effects took 8-9 seconds to appear.

When he tried complete suspension, as soon as he left the ground, he couldn’t breathe or hear his assistant. He experienced such severe pain that he immediately stopped the test. Within 10 minutes, many small hemorrhages could be seen near the site of the rope; these remained visible for 8-11 days. For 10-12 days later he had watering eyes, trouble swallowing, and a sore throat.⁶⁸

After unconsciousness, convulsions follow. In thrashing around, the victim may make enough noise to attract attention, wanted or unwanted. For instance,

“A man aged 20 made a noose with a silk stocking and hung it on a hook behind the door of his room. He climbed on to a chair, put his head through the noose and stepped off ‘to see if his feet would touch the floor.’ He found his feet were a few inches short. The slip knot tightened and he was unable to release the pressure on his throat. During his struggles he kicked a chair over and, when his mother heard the noise, she went to discover the cause. The man was then unconscious but she had the presence of mind immediately to cut the stocking. After a brief stay in hospital he was able to return home.”⁶⁹

External appearances. The face color can range from pale to cyanotic blue, depending on whether or not much blood was trapped in the head region. If the ligature put only enough pressure on the neck to close the jugular veins but not the carotid arteries, a swollen, blue, blood-congested face is the result.

The tongue may be swollen for similar reasons. In 14 of 40 (35%) cases, the tongue protruded from the mouth.⁷⁰

The small hemorrhages previously mentioned occur in about 10% of cases, generally the same ones that have blood-engorged faces.

Interestingly, the faces of many (21 of 40) hanging victims were described as placid, in contradistinction to those strangled, choked or smothered.⁷¹ And, curiously, sometimes the right eye stays open and has a large (dilated) pupil while the left eye is closed and pupil constricted.⁷² The reason for this is not understood.

Consequences: What happens to hanging survivors?
Short answer

Drop (Judicial-type) Hanging. There are no survivors of a properly-done drop hanging; the broken neck (similar to some car-crash neck injuries) is invariably fatal. Even when the neck is not broken, injury is severe and debilitating, and the victim strangles.

Suspension Hanging. Since only around 1% of suicidal hangings are of the drop type,⁷³ there are correspondingly few spinal cord injuries. In suspension hangings, damage to neck structures occurs about 1/3 to 1/2 of the time, but is not normally life-threatening.

Both death and permanent injury are due to cutting the oxygen supply to the brain. The severity of brain damage depends on how completely and how long the brain is oxygen-starved. Mild hypoxia (not enough oxygen) causes behavior resembling drunkenness: physical and verbal incoordination, but no permanent harm.

With complete anoxia (no oxygen taken in, but heart and blood circulation uninterrupted), unconsciousness occurs after about two minutes and coma in about five. If blood circulation to the brain is totally stopped, loss of consciousness follows in 8-15 seconds.⁷⁴ Recovery may take minutes to days, and may not be total. After about four to five minutes of anoxia, permanent brain damage becomes increasingly likely.⁷⁵ Five of 39 people rescued from near-hanging had such persistent injury.⁷⁶

On the positive side, there are rare, but well-documented, cases of spontaneous remission of depression after near-hanging.⁷⁷

Longer answer

Drop Hanging. Drop hanging may not be instantly fatal and, “the possibility of briefly retained consciousness in some cases appears quite real.”⁷⁸ You might be wondering how this was determined. In a study of 34 skeletons of people who had been judicially hanged between 1882 and 1945, a substantial number did not have a broken neck. Interestingly, the average drop for this group was 83 inches; for those whose neck was broken the average drop had been only 74 inches.⁷⁹ Thus, “the length of the drop, though important, does not produce expected or consistent results.”⁸⁰

In the event of miscalculation leading to an inadequate fall, the victim will undoubtedly suffer some more-or-less severe neck injury, but will die within 5-10 minutes of asphyxiation, carotid/jugular compression, or tears of the vertebral arteries (leading to massive hemorrhage).

Suspension Hanging. In addition to brain damage, there may be heart and/or lung injury. For example, there is a syndrome found, among other cases, in hanging survivors; it’s called Adult Respiratory Distress Syndrome (ARDS) and is characterized by progressive respiratory failure that is hard to treat and is not helped much by supplementary oxygen administration. The cause is not well understood: it may be due to brain injury from lack of oxygen; an alternative explanation is that fluid fills the lungs (edema) because of the high negative pressure in the lungs due to trying to inhale against a blocked airway; other possible mechanisms have been proposed.⁸¹ In any case, various types of lung damage are the most frequent cause of delayed death in near-hangings.⁸²

Some case reports may be useful.

1. A 33-year-old man was jailed for shoplifting. He tried to hang himself with his shirt and was cut down after an undetermined time. Examination two hours later showed deep coma which did not change over 12 hours. Gradual improvement occurred over the next two days, and he became awake and alert; however an EEG (electroencephalogram) after 5 days showed residual brain injury. On the seventh day, lung damage appeared; potentially fatal infection followed quickly. Two weeks of intensive care saved his life. A month after the initial admission he was committed to a state mental hospital.⁸³
   
   
2. A 29-year-old man was jailed for assault on his ex-wife and a police officer. Later that night he hung himself with a t-shirt “for several minutes” before being cut down. He was also in a deep coma and unresponsive to deep pain. On the second day he began to improve, but his speech was, and remained, halting and often incoherent. After 12 days he was committed to a state mental hospital.⁸⁴
   
   
3. A 14-year-old boy was found hanging from bleachers by (means of) a jacket he had wrapped around his neck. He was released after being suspended for an estimated 5-10 minutes. He opened his eyes spontaneously, but had no verbal or motor response to painful stimuli. In the hospital his coma score improved (he responded to pain), but lung damage quickly appeared. After four days he was transferred to another hospital, but his neurological improvement at that time was limited to opening his eyes when told to.⁸⁵
   
   
4. Finally, there is a fascinating case in England from 1650.ⁿ Anne Green was a 22-year-old maid in the house of Sir Thomas Read. She became pregnant by Sir Thomas’ grandson, Geoffrey, and gave birth to a stillborn boy. She hid the baby’s body, was discovered, convicted of murder, and hanged. She was suspended for half an hour during which time some of her friends were “hanging with all their weight upon her legs, sometimes lifting her up, then pulling her down again with a sudden jerk, thereby the sooner to dispatch her out of her pain” until forced to stop by the under-sheriff who was worried about the rope breaking. When she was considered dead the body was removed, put into a coffin, and taken to a nearby house.
   
   

When the coffin was opened, she was seen to take a breath. The physicians, intending a dissection, tried to revive her instead. Because of (and despite some of) their efforts, she recovered fully, except for amnesia about some of the events of the hanging. She was subsequently pardoned, in an attempt to co-operate with what was taken to be divine intervention. She eventually went back to the country, taking along her coffin as a souvenir. She married, had three children, and lived another fifteen years.

Practical Matters: How To Do It
If you intend to hang yourself, the next major decision is whether to do a drop (judicial-type) or suspension job. Each has some advantages and disadvantages.

Suspension.

1. Can be done with a wide range of ligature materials – most anything will work;
2. Can be carried out by invalids, without leaving their room;
3. Is fairly quick, probably not painless (but unconsciousness is rapid), but may have severe consequences – brain damage – if interrupted;
4. Doesn’t require much knowledge to accomplish.

To carry out a suspension hanging, you can simply tie one end of the ligature to a fixed point (doorknob, hook, rafter, etc.) and the other end to your neck. You can and should protect the airway from unnecessary compression and pain by firmly padding the front quarter of the neck and (better) by placing the knot high and at the front of your face.

Complete suspension is unnecessary and is probably more painful than partial suspension; however, standing on and kicking away a chair is sometimes done in the same spirit as diving, rather than wading, into icy water. Unconsciousness occurs quickly and without enough warning to count on time to change your mind: this is a lethal method and is not suitable for a “suicidal gesture”.

You need an uninterrupted twenty minutes (half an hour to take into account last-minute vicissitudes) to be sure that you won’t be cut down and “saved” with permanent brain damage. Since you may thrash around while unconscious, take into account the possibility of attracting unwanted intervention because of the noise. Because the cadaver is sometimes gruesome and always shocking, consider not hanging yourself where loved ones will find the body. If you use a hotel or motel, leave a good tip for the cleaning person.

Drop.

1. Requires a strong, low-stretch rope. Manila (sisal) or hemp works;
2. Requires a 5-15 foot drop (see drop table or calculations);
3. Is quick, possibly painless – nobody really knows, and none of the questionnaires have been returned – and generally cannot be interrupted once set into motion;
4. Requires detailed knowledge of how and where to attach rope, how and how far to jump (down, but not out), and a place to jump from. To execute a drop hanging, the drop distance can be estimated as follows,
   
   drop in feet = 1260 divided by your weight in pounds

The type of knot is not important as long as it doesn’t loosen. However, its position is, unlike in suspension hanging, critical. The knot should be as near the chin as convenient, and in any case no further back than the cheekbone. Note which way the knot rotates when pulled up, and adjust it to the side of your head so that it will rotate toward the chin and snap the head backwards. If it ends up behind the ear, it will be much less likely to produce a cleanly broken neck, and may leave you to strangle unpleasantly.

The drop should be as close to straight down as possible; don’t take a running jump.

The rope should be at least an inch thick and must not be one intended to stretch in order to ease a fall, e.g., mountain-climbing rope. Attach it (the other end) to something that won’t break or come loose.

This method is harder to get the hang of than is suspension, and is not recommended unless you’re confident that you fully understand its details. Mistakes usually transpose into some unappealing form of suspension hanging, unless the rope breaks.

Suicidal strangulation

If, for some reason, there is no attachment point available for a ligature, strangulation is a possibility. This method consists of wrapping a cord around your neck and tightening it. The disadvantages are: (a) depending on the amount of tension applied, it may compress your airway as well as the major blood vessels (carotid and/or jugular) unless you protect the front of the neck; (b) since there is no weight on the ligature, it may loosen when you become unconscious. Some methods to solve this latter problem are:

• Use a high-friction ligature that will stay in place;
  
  
• Use a double knot;
  
  
• Wrap thin cord, as many times as possible in 5-10 seconds, around your neck, relying on friction to maintain the tension. A slip knot is helpful, but may loosen unless wrapped;
  
  
• Make a loose loop around your neck. Insert a thin, rigid item, e.g. mixing spoon or pen, between the neck and the loop, and twist the rod until it tightens the ligature; then tuck the end of the rod between the neck and the cord to keep it in place. If you use a bar that is around 8 inches (20 cm) long, there is a good chance that it will stay in place under your chin even if not tucked in;
  
  
• The most reliable of these methods is to buy a ratcheting “tie down.” These are available at auto, motorcycle, and some hardware stores for between US$5 and US$10 and are generally used for attaching cargo. Once tight, a spring-loaded cam release (or equivalent) must be pressed to remove tension. The main caveat is that, if you’re not familiar with them, it may take a few minutes to figure out how the ratcheting mechanism works. A friction-actuated version is easier to use and is also easier to release but can’t be tightened as much, which doesn’t matter for this use.

In all cases,

1. Bending forward increases the diameter of the neck, and thus the constrictive effect of the ligature;
2. If a friend or cadaver is not available, you may wish to practice on your leg to see if the ligature stays in place.

Conclusion
Drop hanging, suspension hanging, and ligature strangulation are effective and lethal means of suicide, and are not suitable for a suicidal gesture. Drop hanging requires knowing what you’re doing and is unforgiving of mistakes; its main virtue is that it is quick and, allegedly, painless. Suspension or ligature asphyxia needs about an uninterrupted half hour, does not require complete suspension, and can be carried out by people with limited physical abilities. Pain can be minimized by protecting the front of the neck. Since finding such a cadaver may be traumatic, care should be given to choosing a location.