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.     

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.     

Suicidal hanging in Cardiff--a 15-year retrospective study.

A retrospective study of 84 cases of suicidal hanging was undertaken in which petechial haemorrhages or congestion were seen in 27%, soft tissue haemorrhage in 29% and fracture of the hyoid or laryngeal cartilages in 36%. Fractures were found to be related to increasing age and were not found when a soft ligature had been employed. Petechial haemorrhages and congestion were related to the completeness of suspension. Apart from the lack of fractures in the soft ligature group any of these findings, either singly or in combination, was found to occur without regard to age, suspension type or ligature type. No evidence was found of clustering or seasonality. The findings are compared to other series and discussed with regard to the mechanisms of causation.     

Correlation of circumstances with pathological findings in asphyxial deaths by hanging: a prospective study of 61 cases from Seattle, WA

Correlation of the circumstances of death with the pathologic findings in this prospective study of deaths by hanging affords insight pertaining to certain of the pathophysiologic mechanisms involved in fatalities of this type. The presence of conjunctival and facial/periorbital petechial hemorrhages correlates with increasing levels of body support below the point of ligature suspension. Hyoid bone and/or thyroid cartilage fractures (found in 26% of cases) are most frequently identified in those persons found completely suspended and in victims in the older age ranges. No hyoid bone/thyroid cartilage fractures, internal soft tissue injury, or petechiae were present in 13 (21%) of the study cases.     

Neck markings and fractures in suicidal hangings

Over a 10-year period in which both a retrospective and prospective study of suicidal hangings was made, fractures of the thyroid cartilage alone, or the hyoid bone alone, or of both together were noted in 20% of the cases. In the prospective study, an incidence of 46% was found. This contrasts sharply with the incidence of 15% in the retrospective study. This wide discrepancy indicates the need for longer periods of a controlled prospective study by properly trained prosectors. Fractures were found in all age groups above 19 years of age and occurred whether suspension was complete or incomplete, whether the ligature was soft or hard, narrow or wide, and whether decedents did or did not jump from a platform. The higher incidence of fractures occurring among women is unexplained. The presence of reddish or pink bands or linear streaks (with or without superimposed abrasions) along one side of the neck, separated by bands of pale skin, canting upwards towards the back of the neck and revealing the imprint of a folded cloth permits the diagnosis of ante-mortem hanging in the absence of very strong proof to the contrary. As in any type of Medical Examiner's case, a knowledge of the circumstances and investigation of the scene are required before a final determination of the cause and manner of death can be considered.     

Analysis of neck injuries in hanging

Retrospective study of suicidal hangings was made on 175 cases (133 male victims, 42 female victims) for a 5-year period. The mean age was 47.33 +/- 17.51 years. The sample was divided in 4 groups according to the position of the ligature knot (anterior, right, left, and posterior hanging). The authors analyzed all visible injuries of soft tissues and bones and cartilage of the neck, and in 150 cases (85.7%), we established that there was at least one injury of these structures (hematoma or fracture for example). The most frequent injury was to sternocleidomastoid muscles. Fracture of throat skeleton was detected in 119 cases (68%). The proportion of fractures increases with age of the deceased. There was no clear correlation between frequency of neck injuries and type of hanging.     

A meta-analytic review of the frequency and patterning of laryngohyoid and cervical fractures in cases of suicide by hanging

The frequency and distribution of fractures are commonly utilized to assist in interpreting the manner of death. In cases of alleged suicide by hanging, however, the evidence base for the frequency and patterning of laryngohyoid and cervical vertebrae fractures resulting from such blunt force traumatic events is limited and so fractures cannot be reliably used to assist in interpreting the manner. Using meta-analytic techniques, this study aimed to estimate frequency and distribution of fractures in the context of relevant intrinsic and extrinsic variables. A systematic review of the literature identified 20 studies with relevant data (8523 cases of suicide by hanging). Meta-analyses identified the frequency and distribution of fractures present and how fracture frequency was affected by the subgroups of age, sex, completeness of suspension, ligature knot position and study design. Results indicated that fracture frequency was variable, there was no unique patterning, and high levels of heterogeneity were present in all variable sub-groups. Age was the only subgroup to show differences. Findings suggest that neck fracture frequency is inconsistent and cannot be predicted by the chosen variables. Subsequently, neck fractures in isolation should not be given weight in medico-legal interpretations of a hanging death as suicidal.     

Immunohistochemical studies on postmortem lividity

An immunohistochemical investigation of postmortem lividity was performed to illuminate localization of hemoglobin (Hb) and the mechanism of fixed lividity. The fixed lividity was defined as an unfading phenomenon by thumb finger pressure. Skin specimens were taken from 68 autopsy cases 7.5–336 h (2 weeks) postmortem. Localization of Hb of the specimens was examined by a labeled streptabidin biotin (LSAB) method using polyclonal (rabbit antihuman hemoglobin antibody) and monoclonal (mouse anti-human hemoglobin monoclonal antibody) antibodies. Positive staining for Hb was observed in various sites of the skin, i.e. in only intravascular erythrocytes, in vascular walls and perivascular tissue including sweat glands and sebaceous glands, in the dermal connective tissue, and in almost all of skin tissue except the horny layer. The diffusion of Hb into skin tissue was observed in 20 of 41 displaceable lividity cases (49%) and 11 of 27 fixed lividity cases (41%). Compared to displaceable lividity, superficial plexi in fixed lividity were filled with erythrocytes, which were markedly immunodetected. These findings support the hypothesis that the fixation of lividity is not due to diffusion of Hb into skin tissue but hemoconcentration in blood vessels.     

Characterization of lesions in hanging deaths

Hanging is a common method of committing suicide and a routine task in medico-legal autopsies. The hanging mark is the most relevant external sign and its characteristics are well known, but, for unknown reasons, there are major differences in reports on internal findings. We retrospectively studied 228 consecutive cases of hanging deaths. A complete standard autopsy was performed for every case. We investigated the association between the characteristics of the hanging mark and the frequency of bone, cartilage, soft tissue, and vascular injuries with the mode of suspension. Most cases (75.3%) presented some kind of bone or cartilage fracture, but these were unrelated to any of the variables studied. Vascular lesions are clearly more infrequent: intimal injuries were found in the carotid artery (9.1%), the jugular vein (2.2%), and ruptures of the carotid adventitial layer (21.7%). These could be partially associated with the use of a hard fixed noose and body weight.     

Bleedings into the Anterior Aspect of the Intervertebral Disks in the Lumbar Region of the Spine as a Diagnostic Sign of Hanging

Abstract: Simon’s hemorrhages are ventral intervertebral hemorrhages located beneath the anterior longitudinal ligament that have been described in cases of hanging and tend to appear in the lumbar region of the spine. There are also reports of Simon’s hemorrhages in cases of blunt trauma, asphyxia, drowning, and putrefaction. In a prospective analysis of 2226 autopsies, we found Simon’s hemorrhages in 65 out of 178 cases of hanging and also in 17 cases in a group of 350 controls with various causes of death. The relative frequency of occurrence of Simon’s bleedings in cases of hanging was 37%. Simon’s hemorrhages can be considered an objective vital finding, which is not absolutely specific for hanging. The absence of hemorrhages in intervertebral disks does not exclude death by hanging. This study suggests that Simon’s bleedings in cases of hanging are more frequent in rather young individuals, in cases with free body suspension, and in individuals with minimal degenerative changes in the lumbosacral part of the spinal column.     

Aspiration of gastric contents in hanging with typical position of the strangulation cord and free suspension]

Among 193 cases of hanging from the years 1978 to 1991 examined in the institute of Forensic Medicine of the Freie Universit?t Berlin 8 cases with an aspiration of stomach contents had been reported. Herefrom 3 cases were hanging in a "typical" position (suspension point at the back of the head, free suspension of the hanging body) and did not undergo resuscitation. By free suspension of the hanging body the observed massive aspiration of gastric contents only can be explained by an at least partly open connecting passage between the laryngeal entry and the entrance of the oesophagus. The post mortem flowing in of stomach contents as well as a post mortem gastro-oesophageal peristalsis seem not to be able for explicating the findings. Differences in important parameters (e.g. gastric contents, alcoholization) to the cases of hanging without aspiration were not found. Even by free suspension of the body, running noose and point of suspension in the back of the neck sometimes the connection between larynx and oesophagus may stay open, especially when by emesis a high pressure is produced by the stomach.     

Calculation of tension exerted on a ligature in incomplete hanging.

The study is devoted to one of the numerous factors (namely, body posture), which determine the strength of the neck compression in hanging. Mathematical modeling method and achievements of biomechanics were used. Human body was supposed to consist of 16 freely joined hard parts. The possibility of ligature tension calculation in any position in incomplete hanging is shown. Weight ranges for hanging of male persons in different body positions are presented: in standing posture the ligature is stretched by more than 65% of the body weight, in kneeling position by 64-74%, in sitting by 17-32%, in recumbent posture by less than 18% of the body weight. The importance of the accurate recording of a corpse posture at the place of accident is emphasized, as well as the necessity of the corpse mass evaluation. Significance of the work for medico-legal practice is illustrated by the study of the neck organocomplex trauma in 108 cases of suicidal hanging. Injuries were revealed stereomicroscopically after the complete preparation of the hyoid bone and laryngeal cartilages, preliminary fixed in the formalin solution. Trauma to the neck complex (fractures, infractions, fissures) was found in more than 64% of cases, differences in many of the groups compared are significant, P<0.05. Vulnerability index hyoid bone/thyroid cartilage was 1.75 in complete hanging of the body, 0.88 in standing position, 0.63 in kneeling, 0.33 in sitting, 0.25 in recumbent posture. Results of the study may be used for investigation of dying processes and morphology of hanging.     

Amussat’s Sign in Hanging—A Prospective Autopsy Study

Abstract: Amussat’s sign is typically a transverse laceration of the intimal layer of carotid arteries described in cases of hanging. Subtotal laceration of the carotid artery is not strictly specific for hanging and can be also caused by blunt neck trauma, extreme overstretching, or whiplash‐injuries. In a prospective autopsy study of 178 cases of hanging, Amussat’s sign was found in 29 cases (a relative frequency of 16.1%). A statistically significant association between the occurrence of tears in the intimal layer of carotid arteries and the victims’ age was discovered in the cases studied (the frequency increased with age; p < 0.05). The occurrence of Amussat’s sign was independent of gender, weight, completeness of the victim’s body suspension, and position of the ligature knot on the neck. The study demonstrates the fact that the most probable cause of Amussat’s sign is a combination of direct compression of the artery by the rope and indirect stretching because of the gravitational drag produced by the weight of the body.     

The occurrence of cervical fractures in victims of judicial hanging.

Cervical vertebrae from 34 victims of judicial hanging were examined. In only six cases was there a fracture of the axis and only one other fracture was seen in the series. The fractures were of two types. Three were the traditional 'Hangman's fracture' whilst three were of a type previously unreported. The incidence of fracture was unassociated with drop, date age or hangman. The results of the post mortems on these subjects were reviewed and found to be grossly inaccurate with regard to fractures. The results indicate that the traditional hangman's fracture occurred in only a small proportion of cases of judicial hanging. The cause of fractures and cause of death in judicial hanging are discussed with a brief history of judicial hanging in this country.     

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.     

Significance of hemorrhages at the origin of the sternocleidomastoid muscles in hanging

Hemorrhages at the periostal-clavicular origin of the sternocleidomastoid muscles are part of the indirectly induced autopsy findings in death by hanging. In a prospective study of 178 cases of hanging, clavicular hemorrhages were found in 110 cases (a relative frequency of 62%). A statistically significant association between occurrence of hemorrhages and completeness of the victim's body suspension was discovered (P = 0.046) as well as a significant association between the occurrence of hemorrhages and the location of the ligature knot on the neck (P = 0.008). The occurrence of hemorrhages at the clavicular origin of the sternocleidomastoid muscles was independent of age, sex, and weight. This article renews the knowledge of this important vital sign described mainly in the German medicolegal literature.     

Epidemiology of suicide by hanging in Transkei, South Africa

To describe the epidemiology of suicide by hanging, in Transkei region of South Africa. This is a record review of the autopsy register from 1993 to 2003. There is an increasing trend of hangings from 5.2 per 100,000 to 16.2 in 2003. The highest was in the 20- to 29-year age group. The least number of hangings of 2.2 per 100,000 was in those over 70 years of age. Males (86.4%) outnumber females. The ratio of male to female suicide is 6.4:1. The 2 youngest suicide victims were also males aged 9 years. Peak of these hangings is in May and November and least in September. There is increasing trend of hanging especially among young adults between 20 and 29 years old.     

Histologic appearance of fractured thyroid cartilage and surrounding tissues

Histological appearances of the fractured superior horns (SH) of the thyroid cartilage and their surrounding tissues were reviewed, with particular reference to signs of vital origin of the fracture. Twenty-nine autopsies with either histories or findings indicating asphyxial neck compression, with a total of 39 fractured SHs, and three autopsies with history of suicidal jump from height with a total of two SH fractures, were examined. Fifteen autopsies with finding of 19 artefactually fractured SHs while removing neck organs at autopsy were used as controls. In the cases of neck compression and victims of jump from height haemorrhages, retraction of fractured SH fragments with invagination or squeezing of the perichondrium, contraction bands, contraction band necrosis and 'opaque fibres', in the adjacent muscle fibres could be seen. Fibrin deposition and/or leucocytic reaction were noted in cases where circumstances of death indicated prolonged death struggle (as in incomplete hanging, resuscitation or homicidal neck compression). However, retraction of fractured fragments and invagination of perichondrium between artefactually fractured SH fragments were observed in both control cases and cases with antemortem trauma to the larynx. Many of these histological findings, including haemorrhages and fractures had not been evident at gross examination. We conclude that histological examination of SHs may not only uncover macroscopically overlooked injuries but also may facilitate the clarification of an injury's vital origin.     

Petechiae in hanging: a retrospective study of contributing variables

Petechiae, one of the classic signs of asphyxia, are thought to be more frequently observed in cases of hanging where part of the body is supporting the victim's weight, ie, cases of incomplete hanging. However, there is very little evidence-based medicine to support this claim. The present study is intended to evaluate the relationship between petechiae and the type of hanging (complete vs. incomplete). Furthermore, several other variables were analyzed to determine if they contribute significantly to the presence of petechiae. An 8.5-year retrospective study of 206 cases of death by hanging reviewed autopsy reports for the presence of petechiae. For each case, the following information was also compiled: gender and age, height and weight, body mass index, the type of hanging (complete or incomplete suspension), the type of ligature used (narrow or wide), and whether or not the victim had received cardiopulmonary resuscitation maneuvers. Statistical analysis revealed that the incidence was higher among incomplete hanging victims compared with cases of complete suspension and that the incidence of petechiae varied inversely with the height of the victims. The other factors were not shown to contribute significantly to the presence of petechiae.