Hanging — A review

A study of 201 cases of death due to hanging, 95% being suicidal in nature and 5% being accidental; in addition there was one judicial hanging. The majority of deaths were in persons over 50 years of age, males predominating particularly in the 50 – 60 age group. In contrast to the Registrar General's annual returns for suicide which show a steady decrease over the past 20 years, deaths due to hanging have increased considerably, particularly in the last decade. This trend could be related to the dramatic fall in carbon monoxide poisoning and more circumspect prescribing of barbiturate drugs.     

Characteristic features of deaths due to decapitation

Deaths due to decapitation are rare in civilian populations. A study in South Australia over 17 years from January 1986 to December 2002 revealed 20 cases (age range, 14 to 72 years; average, 30.7 years; male to female ratio, 15:5). There were 13 suicides consisting of 11 train-related deaths (age range, 14 to 72 years; average, 31.3 years; male to female ratio, 10:1), 1 hanging death, and 1 death using a ligature and a motor vehicle. Five cases related to motor vehicle crashes (age range, 19 to 46 years; average, 30.2 years; male to female ratio, 1:4) and 2 were associated with industrial trauma. Suicidal decapitation accounted for <1% of total suicides and showed a striking male predominance, with the favored method involving trains.     

Ruptured berry aneurysms: a clinical, pathological and forensic review

A retrospective autopsy survey of 583 cases of ruptured berry aneurysm over a period of 25 years with reference to incidence, circumstances and predisposing factors. Over half of the deaths occurred in the 50-80 year age group, the overall male/female ratio being 2:3, the aneurysms being predominately on the middle and anterior cerebral arteries. Most deaths occurred in the home environment without precipitating factors, one fifth being sudden and unexpected in nature. There was no connection between physical trauma and ruptured aneurysm and no instance of a criminal or civil charge. Autopsy and dissection of the cerebral vessels is vital to diagnosis, particularly when deaths are unexpected in nature.     

Asphyxial deaths: a retrospective study and review of the literature

An increasing death rate as a result of violence constitutes a large group in medicolegal autopsies. Specially, deaths due to asphyxia are one of the most important causes in violence deaths.During the 21-year period from January 1984 to October 2004, there were 134 asphyxial deaths autopsied by the Department of Forensic Medicine, Trakya University, Edirne, Turkey. Asphyxial deaths comprise 15.7% of all forensic autopsies; 20.8% of the cases are aged between 30 and 39 years, and the average age was 41.9 years. Males constitute 79.8% of all the cases.The most frequent method of asphyxiation death is hanging (56 cases, 41.8%), followed by drowning (30.5%) and carbon monoxide poisoning (8.2%). More violent methods, such as ligature or manual strangulations, constitute 2.9% and 2.3% of all asphyxial deaths, respectively. Although it was varying according to the methods of asphyxiation, suicide was found to be the manner of death in the majority of the cases.     

Homicidal asphyxia

Homicides due to asphyxia are relatively uncommon. To better understand the presentation of such cases, the files of the Bexar County Medical Examiner's Office were reviewed from January 1, 1985, through December 31, 1998, for all such homicides. A total of 133 cases were found. The largest category was ligature strangulation with 48 deaths (21 male, 27 female). Petechiae were present in the conjunctivae and/or sclerae in 86% of the cases; fractures of the hyoid and/or thyroid cartilage were present in 12.5%. There were a total of 41 deaths from manual strangulation (27 female, 14 male). Petechiae were present in 89% of the cases. In cases of manual strangulation, fractures of the hyoid, thyroid, or cricoid cartilage were found in all the male victims and slightly more than one half of the female victims. Twenty-six cases of suffocation were found; 20 of the victims were < or =2 years of age. Only 1 of these children had petechiae and/or scleral hemorrhage. Five deaths were due to choking. Three of the deaths involved adults who were gagged; 2 deaths involved infants with foreign material pushed into the mouth. Other categories of asphyxia were as follows: 9 deaths due to more than one form of asphyxia; 1 death due to hanging, and 3 deaths due to drowning. Rape was the motive in 66% of the female victims of ligature strangulation and 52% of those due to manual strangulation.     

Retrospective Analysis of Hanging Deaths in Ontario

Hanging deaths from investigation standpoint are rarely problematic. Unusual circumstances can on occasion raise suspicion of foul play. Associated neck injuries are reported in the literature with variable frequency (from 0% to 76.8%). This study retrospectively analyzed 755 hanging deaths in Ontario (Canada) to evaluate the demographic features and circumstances of hanging fatalities, and the frequency of hanging‐related neck injuries. A number of cases showed unusual/special circumstances (e.g., complex, double suicides, restraints). Among 632 cases with complete autopsies, hyoid and larynx fractures were present in 46 cases (7.3%) with the most common being isolated hyoid fractures. The incidence of cricoid fractures was 0.5% and cervical spine injuries, 1.1%. A higher incidence of neck injuries occurred among males, long drop hangings, and in cases with complete suspension. There was a tendency for the number of fractures to increase with increasing age and weight of the deceased.     

A survey of buprenorphine related deaths in Singapore

Buprenorphine is available in Singapore as substitution treatment for opioid dependence since 2002. This study surveys buprenorphine related deaths in Singapore between September 2003 and December 2004. The aims are to establish the autopsy prevalence of buprenorphine related deaths and the demographical and toxicological profile of the cases. Toxicological screening was performed for all unnatural deaths, deaths involving known drug addicts, as well as when autopsy revealed no obvious cause of death. Twenty-one cases had buprenorphine detected in post-mortem blood and/or urine samples. Eighteen were sudden deaths. There were two fatal falls from height and one death by hanging. All subjects were male. The age range was 24-48 years. Fourteen subjects were between 30 and 39 years of age. The mean age was 35 years. The majority (62%) were Chinese. Eleven (52%) were known drug abusers. For sudden deaths, two groups were identified. Six cases died from natural causes. Blood buprenorphine levels ranged from undetected (detected in urine) to 3.2 ng/mL (mean 1.4 ng/mL). Twelve cases were attributed directly and indirectly to mixed drug poisoning. Blood buprenorphine levels ranged from undetected (detected in urine) to 17 ng/mL (mean 3.2 ng/mL). Nineteen cases showed concurrent abuse of buprenorphine and benzodiazepine, diazepam being the most frequently detected, followed by nitrazepam and midazolam. The availability of buprenorphine as substitution therapy is associated with an increase in buprenorphine related deaths. The danger of co-abuse of buprenorphine and benzodiazepines is highlighted.     

Autoerotic deaths in the literature from 1954 to 2004: a review

Autoerotic death by hanging or ligature is a method of autoeroticism well known by forensic pathologists. In order to analyze autoerotic deaths of nonclassic hanging or ligature type, this paper reviews all published cases of autoerotic deaths from 1954 to 2004, with the exclusion of homicide cases or cases in which the autoerotic activity was not solitary. These articles were obtained through a systematic Medline database search. A total of 408 cases of such deaths has been reported in 57 articles. For each case, the following characteristics are presented here: sex, age, race, method of autoerotic activity, cause of death, and location where the body was found. Autoerotic death practioners were predominantly Caucasian males. Victims were aged from 9 to 77 years and were mainly found in various indoor locations. Most cases were asphyxia by hanging, ligature, plastic bags, chemical substances, or a mixture of these. Still, atypical methods of autoerotic activity leading to death accounted for about 10.3% of cases in the literature and are classified here into five broad categories: electrocution (3.7%), overdressing/body wrapping (1.5%), foreign body insertion (1.2%), atypical asphyxia method (2.9%), and miscellaneous (1.0%). All these atypical methods are further discussed individually.     

Agrochemical poisoning in Sri Lanka

Mortality resulting from agrochemicals met within the Office of the Judicial Medical Officer, Colombo, which is the premier Medico-legal Institute in Sri Lanka, are analysed over a 3-year period and the morbidity and mortality rates of the entire country are examined over a 10-year period. The number of patients admitted to hospitals in Sri Lanka during the period 1975-1983, stood at around 11,000-15,000 each year, with the year 1983 recording 16,649 admissions. The number of deaths during the same period varied from 900 to 1500 each year, while the year 1983 recording 1521 deaths. About 75% of such cases of poisoning were due to self ingestion while accidental and occupational poisoning formed the balance. Principal agricultural districts like Kurunegala, Jaffna, Vavuniya, Nuwara-Eliya and Badulla recorded the highest incidence of poisoning. The mortality figures of the Office of the J.M.O., Colombo, indicated that 4% of all bodies subjected to autopsy were those of agrochemical poisoning. The male/female ratio was 2:1. Seventy-five percent of deaths from agrochemical poisoning were recorded in the 15-39 year age group, while 33% of deaths belonged to the 20-24 age group. One third of cases of agrochemical poisoning were dead on being brought to hospital, while 50% were dead within 2 h and 60% dead within 24 h. Organophosphates accounted for 57.6% of all cases of agrochemical poisoning, while paraquat accounted for 21.2% of cases. Deaths were also reported from what are called safe chemicals like Carbamates and Pyrethrums due to their lethal additives.     

Sudden infant death in a tropical environment: Singapore's experience

A total of 206 cases of sudden infant deaths examined at the Institute of Science and Forensic Medicine, Singapore, over a 5 year period (1989–1993) were identified to assess the pattern of sudden death in this age group, which was subdivided into the neonatal and post-neonatal periods. A total of 34% (70) of infant deaths occurred in neonatal life and the remaining 66% (136) in the post-neonatal period; 90% of the neonatal deaths were natural, of which over half were due to congenital heart disease and complications of prematurity. Unnatural deaths in this period were uncommon, there being only seven such deaths. In the post-neonatal period, unnatural deaths constituted 25% of the total with trauma and aspiration heading the list. Natural deaths in the post-neonatal period are predominantly due to infections (34%) and a group of sudden natural deaths with minimal findings (31%). The latter group may arguably represent cases of Sudden Infant Death Syndrome (SIDS). The yearly incidence of this group in our study varied between 0.08 to 0.2 per 1000 live births, which is considerably lower than the incidence quoted for Western populations. The criteria for the classification and the impact of sudden infant deaths in Asian countries are discussed.     

Metal Railing Fences and Accidental Death

Two cases of accidental deaths caused by the sharp ends of fence or gate posts are reported. Case 1: A 47‐year‐old man was found hanging by his ankle in an inverted position on fencing. He had attempted a shortcut to a railway platform by climbing over a metal rail fence. He had slipped and been impaled through his ankle by the sharp end of the fence post, resulting in death from positional asphyxia. Case 2: An 18‐year‐old male slipped while climbing over a gate and died after being impaled on a spear tip finial, which had lacerated his external iliac vein. Death was due to exsanguination. These cases demonstrate two rare examples of accidental deaths from impalement by the ends of sharp fence posts. Mechanisms of death in such circumstances involve suspension with positional asphyxia and vascular injury with exsanguination.     

Prison Suicides in South Australia: 1996–2010

Forty‐eight deaths occurring in prisons in South Australia were identified between January 1996 and December 2010, including 25 cases of suicide (mean age = 37 years; median age = 34 years; age range = 24–70 years). Most suicides were due to hanging (23/25; 92.0%) with victims using bedding, belts, or shoelaces attached to cell shelves, air vents, doors, or other accessible projections. There were no suicides attributed to drug overdose or sharp force injury. Over a third of all suicides (39.1%) occurred during the first month of confinement, with 26.1% of cases occurring within the first week. There was one suicide reported after 2 years of imprisonment. Given that suicide in state prisons currently occurs at a rate approximately eight times that of the general South Australian community, it appears that the subset of incarcerated individuals represents a group in need of effective preventive strategies to enable more appropriate provisions of existing prisoner resources.     

Methods of Choice in Completed Suicides: Gender Differences and Review of Literature

Abstract:  Suicide is an important public health hazard worldwide. A 4-year retrospective study from January 2000 to December 2003 was conducted to identify the favored methods in realized suicides among males and females in the west coastal region of India. During the study period, a total of 539 cases of suicidal deaths were autopsied. Males were predominantly affected (male: female—1.9:1). The age of the victims ranged from 13 to 90 years in males (mean = 40.1 years, median = 37.0 years) and 15 to 85 years in females (mean = 36.6 years, median = 32.0 years). Most favored method of suicide amongst males and females was hanging (36.9%, n  = 199) followed by poisoning (34.7%, n  = 187). Male dominance was apparent for each method of suicide except for self-immolation. Males were relatively more likely to use hanging and poisoning while females were more likely to prefer drowning and self-immolation as methods of suicide. Relatively younger females (mean   = 33.0 years, median = 32.0 years) preferred hanging as a method of suicide when compared to males (mean = 42.4 years, median = 40.0 years). Among females, significantly younger females resorted to hanging when compared to older females who preferred drowning. On investigating the various theories proposed for choice of suicide methods in males and females in different regions we conclude that preference of method of suicide in men and women is complexly determined. In this region, availability, accessibility, popularity, and socioacceptability seem to be the major determinants in the choice of methods among males and females rather than violence associated and lethality of the method. Females were as likely to use lethal and violent methods as males in this region.     

Methamphetamine-related deaths in San Francisco: demographic, pathologic, and toxicologic profiles

A study was undertaken to develop demographic, toxicologic, and pathological profiles of methamphetamine-related deaths. Anatomic and toxicologic findings in 413 deaths where methamphetamine was detected were compared with findings in a control group of 114 drug-free trauma victims. The number of cases per year did not change significantly over the course of the study. Mean age was 36.8 years, but 11% were over the age of 50. Decedents were overwhelmingly male (85.2%) and Caucasian (75%). Blood concentrations of methamphetamine and amphetamine were indistinguishable in cases where methamphetamine was related to the cause of death (MR) and cases where it was not (non-MR) (2.08 vs. 1.78 mg/L, p = 0.65, and 0.217 vs. 0.19 mg/L, p = 0.82). Coronary artery disease, ranging from minimal to severe multivessel, was identified in 79 of the 413 drug users, but in only six of the 114 drug-free controls (p = 0.0004), and MR decedents had enlarged hearts compared with controls. There were also ten cases of subarachnoid and intracranial hemorrhage in the MR group. Abnormalities of the liver (34%) and lungs (24.7%) were frequent. In 65% of these cases, death was due to accidental methamphetamine toxicity. In the remaining cases, methamphetamine was an incidental finding. We conclude that, in our jurisdiction, neither the rate of detection nor the number of methamphetamine deaths has increased significantly in the past 13 years. Decedents are almost all Caucasian males, and many were approaching middle-age. Methamphetamine use is strongly associated with coronary artery disease and with subarachnoid hemorrhage.     

Observed Characteristics of Suicidal Hangings: An 11-year Retrospective Review

Many studies have been published regarding suicidal hanging deaths, and most forensic pathologists and coroners are very familiar with such causes of death. Forensic pathologists are challenged over their rulings regarding manner of death in part because the general public has a limited scope of knowledge. One such challenge centers on the question of whether a hanging can be a suicide if the individual is not fully suspended. The authors designed a retrospective study to review suspension in hangings and to analyze other criteria used to help in deciding manner of death. We examined 229 suicidal hanging deaths over an 11-year period (1997 through early 2009) using the data from two separate jurisdictions in Ohio. In conclusion, we found that the vast majority (83.4%) of people who hanged themselves were found partially suspended. Among other criteria analyzed, only the presence of petechial hemorrhages and acute neck injury was statistically significant.     

Suicides in hospitals of Vienna (author's transl)]

An analysis of the autopsies ordered by the Viennese Forensic and Health Authorities between 1967 and 1976 has shown that 2.3% of all suicides were committed in hospitals. Two thirds of the 77 examined cases were carried out by males. Thirty-five patients were in stationary psychiatric treatment; their average age was 50.7 years. In all other kinds of hospitals 42 (mostly male) patients committed suicide at an average age of 65.3 years. Preferred methods of performance were jump and fall from height (44.1%) and hanging (40.3%). Rare methods used were one case of abdominal incisions (harakiri), one self-strangulation, and one case of suffociation in plastic bags. The act was usually accomplished early in the morning or in the late afternoon. Among the suicidal patients who were hospitalized because of organic diseases those with malignant neoplasms [18] and cardiovascular diseases [12] were predominant. Also taking the suicides outside hospitals into consideration the numerical ratio between natural deaths due to cancer and the suicides of cancer patients is about 1:1,000. Amont the suicides in psychiatric institutions schizophrenics [11] and endogenous depressives [7] were the most numerous. In 4 cases the suicide was preceded by acts of injury or homicide.     

Ten years of "body packers" in New York City: 50 deaths

We reviewed all 50 body packer deaths in New York City from 1990 to 2001. The majority (37/50) of deaths were caused by acute intoxications due to open or leaking drug packets in the gastrointestinal tract. The number of packets recovered ranged from 1 to 111 (average 46). The weight of the combined packets ranged from 9.4 to 1,200 g (average of 377). The age ranged from 19 to 57 years (mean 37.1). The decedents were: 82% male, 66% Hispanic, 24% Black, and 10% White. The manners of death were 47 accidents, 1 homicide, 1 natural, and 1 undetermined. The causes of death included 42 acute intoxications, 5 intestinal obstructions/bowel perforations, 1 gunshot wound, 1 intracerebral hemorrhage due to hypertensive disease, and 1 undetermined. Of the 50 decedents, 42 were transporting opiates, 4 cocaine, and 4 both opiates and cocaine. There were 9 deaths from 1990-1995 and 41 from 1996-2001. Of the 41 deaths between 1996 and 2001, only 6 involved cocaine. In New York City there has been an increase in body packer deaths from the early 1990s to the late 1990s. Along with this increase is a marked predominance of opiate body packer deaths with few cocaine deaths.     

Causes of unexpected death in patients with multiple sclerosis: a forensic study of 50 cases

To determine the cause of death (as a result of neurologic or nonneurologic complications or accidents) in patients with multiple sclerosis (MS), we reviewed the autopsies of 50 subjects with MS from the Office of the Chief Medical Examiner of Maryland (OCME) between 1982 and 2004. The series included 32 females and 18 males (mean age, 45.8 years; range, 25-69 years) and the causes of death were classified into 3 categories: (A) neurologic complication directly related to MS; (B) nonneurologic complications or other medical causes; and (C) accidents, etc. Of the 50 cases, in 43 there was a history of MS, but in 7 subjects there was not, and the diagnosis was established by neuropathologic examination. In Group A, 21 (42%) cases, deaths were directly related to a neurologic complication; in Group B, 14 (28%) cases were related to the following nonneurologic and medical causes: ASCVD 9 (18%), metabolic disorder 1 (2%), pulmonary embolism 3 (6%), and bronchopneumonia 1 (2%); and in Group C, 15 (30%) cases, deaths were due to trauma, 9 (18%); intoxication, 5 (10%); and thermal injury, 1 (2%). Thus, among the 50 subjects, in 26, deaths occurred naturally; and in 24, from accidents, homicides, suicides, or undetermined causes. Pathologically, the majority of cases showed either chronic inactive (66.7%) or chronic active (15.6%) demyelinating lesions, mainly in the cerebral hemispheres. In some cases, it appears that demyelinating lesions, involving brain regions that regulate cardiorespiratory activity, could be considered as the immediate cause of death, but a large proportion appears to be due to other causes such as accidents and trauma. Thus, it seems likely that taking specific precautions could prevent some deaths in MS.     

Deaths in custody in Shelby County, Tennessee, January 1970-July 1985

The purpose of this study is to review retrospectively the deaths that have occurred in the Shelby County detention center from 1970 to 1985. The Shelby County data are compared and contrasted with other studies to discern significant and preventable causes of death in custody. This study confirmed natural causes as most prevalent; however, suicide accounted for greater than 20% of all deaths (15-50-fold greater than the general population). Suicide occurred by hanging in greater than 90% of cases. This is a preventable cause of death while in custody, and means of prevention are addressed.     

Characteristic Features of Hanging: A Study in Rural District of Central India

The ligature mark is the most relevant feature of hanging. This study was undertaken with a view to determine the characteristic features of hanging and its association with ligature material or mode of suspension. Of a total medicolegal deaths reported at an Apex Medical Centre, hanging was noted in 4.1% cases, all suicidal with mortality rate of 1.5 per 100,000 population per year. The hanging was complete in 67.7% with nylon rope as the commonest type of ligature material used for ligation. The hanging mark was usually single, situated above thyroid cartilage, incomplete, prominent, and directed toward nape of neck. The mark of dribbling of saliva was seen in 11.8% cases. Facial congestion, petechial hemorrhage, and cyanosis were significantly seen in partial hanging. Though occasionally reported, the argent line was noted in 78.7% hanging deaths with neck muscle hemorrhage in 23.6% cases. Fracture of neck structure was predominant in complete hanging.