ORIGINAL ARTICLE

Hanging Deaths
A Retrospective Study Regarding 260 Cases
Maria Cristina Russo, MD, Andrea Verzeletti, MD, Mauro Piras, MD, and Francesco De Ferrari, MD
The data analyzed for each case included (1) year, month,
Abstract: Hanging is a form of asphyxia caused by external pressure on and day of the event; (2) information about the victims (sex, age,
the upper airways deriving from a band tightened by the gravitational nationality); (3) manner of death (suicide, homicide, accident);
weight of the body. During a 33-year period from 1983 to 2015, there were (4) place of death; (5) type of hanging (complete or incomplete
260 hanging deaths examined at the Brescia Institute of Forensic Medicine suspension) and ligature mark (typical or atypical hanging, place-
(Northern Italy), which represented approximately 40% of all the asphyxial ment of the ligature); (6) ligature means; (7) external findings (fa-
deaths recorded during this period. Almost all of the cases were represented cial congestion, petechial hemorrhages of the conjunctive, tongue
by suicidal events, 1 case was a homicide event and there also was a case of position); (8) internal findings when autopsy was performed (frac-
sexual asphyxia. Eighty-two percent of the victims were men; 18% were ture of the hyoid bone and laryngeal cartilages; cervical fractures;
women. There was an increasing tendency in the ages between 20 and muscle neck hemorrhages; Amussat sign; petechial hemorrhages
60 years, and the highest number of cases was observed in the 41- to of the pleura, pericardium, and scalp); (9) toxicological examina-
50-year age group (23% of the cases). The most common place chosen tion outcomes (whenever mandated by the law); and (10) psychi-
by the victim was the home setting followed by isolated outdoor places. atric history, when known. The lack of some data (place of death,
The most common ligature material was a rope. The pathological findings type of suspension, ligature material) is because of the prosecu-
were evaluated in all cases. tor's decision that, according to Italian law, does not always require
Key Words: hanging, suicide, asphyxial death, pathological findings, a forensic pathologist at the scene of death. The forensic patholo-
neck injuries gist reached the scene of death in less than 10% of the cases, with
the examination of the place of injury usually being performed by
(Am J Forensic Med Pathol 2016;37: 141–145)
the police forces whose data are not always included in the foren-
sic pathologist's report.
H anging is a form of asphyxia caused by external pressure on
the upper airways deriving from a band tightened by the grav-
itational weight of the body. RESULTS
It is classified as complete when the whole body is suspended
and incomplete when suspension regards only part of the body. Year, Season, Month, and Day of the Event
When the loop of the ligature band lies on the anterior region of In the 33-year period between May 1983 and April 2015, a
the neck and the knot is on the back, hanging is defined typical; total of 11,670 postmortem examinations were carried out in our
all other conditions are defined as atypical. Hanging is a common Institute. Of these, 260 were hanging deaths that represented ap-
method of suicide, although, rarely, a murderer chooses hanging proximately 40% of all the asphyxial deaths. An increasing ten-
to commit homicide. In a few cases, hanging occurs as an accidental dency was recorded in the last 2 decades with a peak between
event. The aim of this study was to describe and characterize all the 2000 and 2002 (approximately 23% of all events) (Fig. 1). The
hanging events reported at the Institute of Forensic Medicine in the highest frequency was registered in November (11%), followed
County of Brescia (Northern Italy) between 1983 and 2015, cov- by April and June (10% of the cases) (Table 1) (Fig. 2); of the
ering a 33-year period, focusing on socioepidemiological factors weekdays, most cases occurred on a Monday (18%).
and pathological findings of forensic interest.
Victims' Characteristics
MATERIALS AND METHODS In 212 hanging cases, the victim was a man (82%), with
We retrospectively analyzed the postmortem examination re- a male-to-female ratio of 4:1. The 31- to 50-year age group
cords from the archive of the Brescia Institute of Forensic Med- accounted for the most number of cases (121 cases, approximately
icine from April 1983 to May 2015. During this period, 260 46%). There were extremes in age, those younger than 20 years
hanging deaths were registered. The County of Brescia is an im- and older than 80 years comprised 5% and 3% of victims, respec-
portant industrial district in Northern Italy (Lombard region), with tively. The youngest victim was a 13-year-old boy and the oldest
a population of more than 1,250,000 (12.8% of the Lombard re- was a 95-year-old man (Fig. 3).
gion's population; 2.2% of the Italian population). According to Most of the victims were Italian (87%); foreigners repre-
Italian law, in all the cases, a forensic medical examination was es- sented 13% of the cases.
tablished by the prosecutor. An external examination was required
in 61 cases; autopsy in 199 cases. Place of Death
This information was not available in 49 cases; for the rest,
Manuscript received October 30, 2015; accepted March 25, 2016. the most common place chosen by the victim was the home setting
From the Istituto di Medicina Legale, Università degli Studi di Brescia,
Brescia, Italy.
(70% of the cases) followed by isolated outdoor places (15%).
The authors declare no conflict of interest. In 8 cases, the suicide event occurred at the workplace; in 6
Reprints: Maria Cristina Russo, MD, Medicina Legale, Istituto di Medicina cases, the victim was a prisoner in the county jail; 5 events oc-
Legale di Brescia, Piazzale Spedali Civili 1, Brescia, Italy. curred in a hospital regarding mostly psychiatric patients; 5 vic-
E-mail: [email protected].
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
tims committed suicide in a public place (eg, railway station,
ISSN: 0195-7910/16/3703–0141 public toilet); whereas 2 truck drivers killed themselves in their
DOI: 10.1097/PAF.0000000000000239 own trucks (Table 2).

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Russo et al Am J Forensic Med Pathol • Volume 37, Number 3, September 2016

FIGURE 1. Temporal distribution of hanging deaths.

Type of Hanging and Ligature Mark Toxicological Examination Outcomes

Data regarding the type of suspension (complete or incom- Toxicological examinations were performed in 94 cases
plete) were available in 177 cases; of these, complete hanging rep- (47%) of all the autopsies. Among these, alcohol was tested in
resented 71%. In approximately 77% of the cases, the hanging 43% of the cases and was found in half. Illegal drugs were tested
was typical, and the knot was localized on the back of the neck. in 37% of the cases and had a positive result in 30% (68% cocaine,
In approximately 22% of the cases, the knot was located on the lat- 14% cannabinoids, 9% oppioids). Drugs were tested in 56 cases
eral region of the neck, whereas in 3% of the cases, the knot was (28%) and were found in only 6 (almost all antidepressants).
on the front side.
The mark was mostly present as a single loop (95% of the Psychiatric History
cases). In 26% of the cases, the mark was continuous; in all the A history of pathological illness was documented in only 65
other cases, the sign had one or more interruptions (usually in cases (approximately 25%). Frequently, the victims experienced
the back according to the knot position). depression, anxiety, or paranoid schizophrenia.
The mark was usually oblique from bottom to top and from
front to back (96%), and in 62% of the cases, the ligature mark Manner of Death
was above the thyroid cartilages.
Almost all of the cases were represented by suicidal events
(98.8%). There were 2 cases of accidental events and only 1 homi-
Ligature Means cide case (Table 5).
Data regarding the ligature material were available in 156 About the accidental events, 1 could be classified as sexual
cases: of these, rope was the most common material used by the asphyxia: a 50-year-old man died during a bondage sex game.
victims (approximately 58% of the cases); in the other cases, the The man was found naked in his bedroom with a rope tightened
victims chose cables, belts, scarf, foulards, chains, strings, ties, around the neck and fixed to the door handle. Toxicological anal-
sheets, drapes, or clothes (eg, trousers, sweaters) (Table 3). ysis revealed that he was under the influence of alcohol.
The second accidental event involved an old woman while
she was sleeping: it represents an atypical form of external pres-
External Findings sure on the neck by a protective corsage worn by the woman.
Facial congestion was observed in approximately 12% of the Probably, the woman made inappropriate movements during the
cases. Conjunctival petechiae were seen in approximately 11% night that dislocated the corsage, and so she hanged herself by
and protruding tongue in 19% of the cases. the weight of part of her body.
Lastly, the homicide case concerned a young foreign woman
(aged 20 years) who was killed in an isolated place, hanged to a
Internal Findings roof beam using a sweater with her hands tied behind her back.
An autopsy was performed in 199 cases. The study revealed Blunt extracranial injuries were observed on the victim; no alcohol
that 66% of the cases (132) had internal neck structures injuries. was detected in her blood.
Muscle neck hemorrhages were observed in 50% of the
cases, tears of the intimae carotid (Amussat sign) in 17% of the
cases, hyoid bone fractures in 17% of the cases, laryngeal carti-
lages fractures in 15% of the cases, and fractures in the cervical DISCUSSION
vertebrae in 4% (Table 4). Hanging is a form of asphyxial death frequently adopted as a
Petechial hemorrhages were revealed on the scalp in 56% of suicide method. Our retrospective analysis conducted in Brescia
the cases, on the pleura in 34% of the cases, and on the pericar- County in a 33-year period (1983–2015) revealed that almost all
dium in 15%.

TABLE 1. Distribution of Cases According to Season

Season No. Cases %

Spring 73 28
Summer 67 26
Autumn 67 26
Winter 53 20
Total 260 100
FIGURE 2. Distribution of hanging deaths per month.

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Am J Forensic Med Pathol • Volume 37, Number 3, September 2016 Hanging Deaths

TABLE 3. Ligature Material Used to Hang

Ligature Material Number %

Rope 91 58.3
Cable 17 10.9
Soft tissue (eg, sheets, drapes) 10 6.4
Belt 10 6.4
Scarf 7 4.5
FIGURE 3. Distribution according to age groups. Shutter belt 5 3.2
String 4 2.6
the hanging deaths that occurred were suicide events (257 cases), Bathrobe belt 2 1.3
according to other international studies.1–8 Chain 2 1.3
In 2 cases, hanging was an accidental event, and 1 case was Clothes 2 1.3
represented by homicidal hanging. As reported in the literature, Foulard 2 1.3
homicidal hanging is a rare event8–12; it is usually used by a mur- Tie 2 1.3
derer after strangulation to simulate a suicidal event committed by Tube 1 0.6
the victim. Corsage 1 0.6
Moreover, accidental hanging is not a frequent event. Many
Total 156 100
authors described accidental autoerotic hanging deaths13–15 (sim-
ilar to the case we reported) and accidental hangings in the pediat-
ric population16,17 (no cases involving children happened during Most of the victims were Italians (87%); foreigners repre-
the considered period). sented 13% of the cases. The first foreign victim was reported in
The phenomenon of hanging has been increasing in the last 1997, and the number has gradually grown according to the in-
2 decades, with a peak in the early years of the 21st century. A creasing migratory flow, reaching a peak in 2009.
similar trend was observed in other countries, whereas there The most common place of death was the victim's own home
was a decreasing trend in other Italian counties (Roma)18 and followed by isolated outdoor places, according to other similar
international countries.19,20 studies.2,19,24,25 When a person decides to kill himself or herself,
In most of the cases, the victim was a male adult. The male- 2 scenarios usually are recurrent: when the need for a familiar
to-female ratio was 4:1, showing that a higher tendency to commit place or the wish to be found by relatives or friends to hit or shock
suicide by hanging was associated with the masculine sex as what them is prevalent, the home setting is the place of choice; when in-
has resulted in almost all published studies.4,6,19–24 stead, guilt, shame, or the need for isolation are the main sensa-
Generally, hanging increases with age, with a higher percentage tions, the victim prefers outdoor places far from home.
in the 31- to 50-year age group both for men and women. The age Complete suspension was the leading manner of hanging.
groups between 21 to 30 and 61 to 80 years displayed a markedly This finding is consistent with what is described in other re-
different trend between sexes with a much higher male-to-female ports2,4,19,22,26: complete hanging seems to better assure death
ratio (approximately 10:1). The preponderance of adult male vic- because it requires a single act, differing from incomplete sus-
tims reflects the findings of most international reports.6,19–24 pension that seems more difficult to realize and apparently re-
There was no significant seasonal variation. We registered a quiring a stronger will and a prolonged act.
higher number of victims in spring and a slight decrease in winter. In approximately 77% of the cases, the hanging was typical.
Most of the victims committed suicide on a Monday (18%), as This is in contrast to information reported by Sharma et al22 and
noted by Suárez-Peňaranda et al.4 It could be explained by the Dean et al.23
feelings connected to the beginning of the working week: fatigue Usually, the ligature mark was oblique from bottom to top
caused by the need for planning the whole week, busyness, and and from front to back (96%) and was above the thyroid cartilage
the distance from weekend rest for the working population. For (in 62% of the cases). This finding reaffirms itself as one of the
unemployed people, other factors might play a role like stress re- main pathognomonic signs of hanging differing from ligature
lated to the search for a job or depression caused by the absence of
an active role in society.
TABLE 4. Internal Neck Structure Injuries (199 Cases)

TABLE 2. Distribution of the Cases According to Place of Death Neck Structure Injuries No. Cases %
Hyoid bone fractures 34 17
Place of Death Number %
Hyoid bone 5
Home 148 70 Greater horns 27
Outdoor place 31 15 Lesser horn 2
Workplace 8 4 Thyroid cartilage fractures 30 15
Jail 6 3 Body 9
Indoor place 6 3 Superior horns 20
Public place (eg, railway station) 5 2 Lesser horn 1
Hospital 5 2 Muscle injuries 100 50
Truck 2 1 Tears to the intimae carotid 34 17
Total 211 100 Vertebral fractures 7 4

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Russo et al Am J Forensic Med Pathol • Volume 37, Number 3, September 2016

the characteristics of the ligature sign is very important to diag-

TABLE 5. Summary Characteristics of Hanging nose hanging. According to these results, the ligature mark has
to be considered as the leading forensic sign to diagnose and dif-
Variable No. cases %
ferentiate the different manners of suffocation.
Manner of death
Suicide 257 98.8 REFERENCES
Accident 2 0.8 1. Al Madni OM, Kharoshah MA, Zaki MK, et al. Hanging deaths in
Homicide 1 0.4 Dammam, Kingdom of Saudi Arabia. J Forensic Leg Med. 2010;17(5):
Type of suspension 265–268.
Complete 126 71 2. Azmak D. Asphyxial deaths: a retrospective study and review of the
Incomplete 51 29 literature. Am J Forensic Med Pathol. 2006;27(2):134–144.
Ligature material 3. Meel BL. A study on the incidence of suicide by hanging in the
Rope 91 58 sub-region of Transkei, South Africa. J Clin Forensic Med. 2003;10(3):
Other 65 42 153–157.
Type of hanging 4. Suárez-Peňaranda JM, Alvarez T, Miguéns X, et al. Characterization of
Typical 197 76 lesions in hanging deaths. J Forensic Sci. 2008;53(3):720–723.
Atypical 63 24 5. Atreya A, Kanchan T. Clinico-epidemiological study of near-hanging
Number of ligature marks cases—an investigation from Nepal. J Forensic Leg Med. 2015;33:35–38.
Single 247 95 6. Kurtulus A, Yonguc GN, Boz B, et al. Anatomopathological findings
Two or more 13 5 in hangings: a retrospective autopsy study. Med Sci Law. 2013;53(2):
Ligature mark position 80–84.
Above the thyroid 161 62 7. Dogan KH, Demirci S, Deniz I. Why do people hang themselves on trees?
Other 99 38 An evaluation of suicidal hangings on trees in Konya, Turkey, between
Neck structures injuries 2001 and 2008. J Forensic Sci. 2015;60(Suppl 1):S87–S92.
Muscle hemorrhages 100 50 8. Sauvageau A. True and simulated homicidal hangings: a six-year
Tears of the intimae carotid 34 17 retrospective study. Med Sci Law. 2009;49(4):283–290.
Hyoid bone fractures 34 17 9. Monticelli FC, Brandtner H, Kunz SN, et al. Homicide by hanging: A case
Laryngeal cartilages fractures 30 15 report and its forensic-medical aspects. J Forensic Leg Med. 2015;33:
71–75.
Cervical vertebrae fractures 7 4
10. Sharma L, Khanagwal VP, Paliwal PK. Homicidal hanging. Leg Med
(Tokyo). 2011;13(5):259–261.
strangulation, the closest manner of asphyxial death in which the 11. DiMaio VJ. Homicidal asphyxia. Am J Forensic Med Pathol. 2000;
band is tightened by forces other than the gravitational weight of 21(1):1–4.
the body,27 so that the ligature mark runs lying horizontal and of-
ten under the thyroid cartilage. 12. Leth P, Vesterby A. Homicidal hanging masquerading as suicide. Forensic
Sci Int. 1997;85(1):65–71.
In our retrospective analysis, as in most others reported,20,24,26
ropes were the most common tools used by the victims. Rope is 13. Breitmeier D, Mansouri F, Albrecht K, et al. Accidental autoerotic deaths
easy to find, cheap, and resistant enough to suspend the body between 1978 and 1997. Institute of Legal Medicine, Medical School
weight till death. Hannover. Forensic Sci Int. 2003;137(1):41–44.
Not every case underwent autopsy. Among autopsies per- 14. Janssen W, Koops E, Anders S, et al. Forensic aspects of 40 accidental
formed in our institute (199 cases), internal neck structure injuries autoerotic deaths in Northern Germany. Forensic Sci Int. 2005;
were observed in more than half of the cases: muscle neck hemor- 147(Suppl):S61–S64.
rhages were observed in 50% of the cases, tears of the intimae ca- 15. Tournel G, Hubert N, Rougé C, et al. Complete autoerotic asphyxiation:
rotid (Amussat sign) in 17% of the cases, fractures in the hyoid suicide or accident? Am J Forensic Med Pathol. 2001;22(2):180–183.
bone in 17% of the cases, fractures in the laryngeal cartilages in 16. Gok E, Cetin S, Baduroglu E, et al. Two accidental hanging cases of
15% of the cases, and fractures in the cervical vertebrae in 4%. children. J Pak Med Assoc. 2015;65(7):790–792.
The low incidence of internal neck fractures in hanging is reported
17. Wöllner K, Kernbach-Wighton G, Madea B. Suicide in childhood or
by many authors.19,21,23,28–32 Based on these results, the presence
accidental hanging? A case report [article in German]. Arch Kriminol.
and the shape of the ligature mark has to be considered the most
2015;236(1-2):43–50.
important forensic sign to establish the manner of suffocation.
In conclusion, during a 33-year period from 1983 to 2015, 18. Umani Ronchi G, Bolino G. Asfissie Meccaniche Violente. Milan, Italy:
the Institute of Forensic Medicine of Brescia registered 260 hang- Giuffrè Editore; 2006. Capitolo XVIII: I decessi da asfissia meccanica
violenta nella casistica del dipartimento di medicina legale dell'università
ing deaths. In most of the cases, the victim was an Italian man,
degli Studi di Roma “La Sapienza” (anni 1990–2005).
aged between 30 and 50 years, who usually committed suicide
in his home by complete hanging with a rope as ligature material. 19. Abd-Elwahab Hassan D, Ghaleb SS, Kotb H, et al. Suicidal hanging in
This profile is in line with data from international reports. The Kuwait: retrospective analysis of cases from 2010 to 2012. J Forensic
high percentage of suicides among hanging deaths confirms hang- Leg Med. 2013;20(8):1118–1121.
ing as a typical manner of suicide death. 20. Kanchan T, Menezes RG. Suicidal hanging in Manipal, South
The ligature mark on the neck was observed in all cases with India—victim profile and gender differences. J Forensic Leg Med. 2008;
different characteristics (position, direction, depth, continuity, 15(8):493–496.
thickness); on the other hand, internal neck fractures were ob- 21. Jayaprakash S, Sreekumari K. Pattern of injuries to neck structures in
served in only a few cases. The ligature mark was easily detectable hanging—an autopsy study. Am J Forensic Med Pathol. 2012;33(4):
through external examination: a careful and complete analysis of 395–399.

144 www.amjforensicmedicine.com © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Am J Forensic Med Pathol • Volume 37, Number 3, September 2016 Hanging Deaths

22. Sharma BR, Harish D, Sharma A, et al. Injuries to neck structures in deaths 27. Sauvageau A, Boghossian E. Classification of asphyxia: the need for
due to constriction of neck, with a special reference to hanging. J Forensic standardization. J Forensic Sci. 2010;55(5):1259–1267.
Leg Med. 2008;15(5):298–305. 28. Godin A, Kremer C, Sauvageau A. Fracture of the cricoid as a
23. Dean DE, Kohler LJ, Sterbenz GC, et al. Observed characteristics of potential pointer to homicide. A 6-year retrospective study of neck
suicidal hangings: an 11-year retrospective review. J Forensic Sci. 2012; structures fractures in hanging victims. Am J Forensic Med Pathol. 2012;
57(5):1226–1230. 33(1):4–7.
24. Üzün I, Büyük Y, Gürpinar K. Suicidal hanging: fatalities in Istanbul 29. Green H, James RA, Gilbert JD, et al. Fractures of the hyoid bone and
retrospective analysis of 761 autopsy cases. J Forensic Leg Med. 2007; laryngeal cartilages in suicidal hanging. J Clin Forensic Med. 2000;7(3):
14(7):406–409. 123–126.
25. Bhosle SH, Zanjad NP, Dake MD, et al. Deaths due to hanging among 30. Feigin G. Frequency of neck organ fractures in hanging. Am J Forensic Med
adolescents—a 10-year retrospective study. J Forensic Leg Med. 2015; Pathol. 1999;20(2):128–130.
29:30–33. 31. Paparo GP, Siegel H. Neck markings and fractures in suicidal hangings.
26. Ambade VN, Kolpe D, Tumram N, et al. Characteristic features of hanging: Forensic Sci Int. 1984;24(1):27–35.
a study in rural district of Central India. J Forensic Sci. 2015;60(5): 32. James R, Silcocks P. Suicidal hanging in Cardiff—a 15-year retrospective
1216–1223. study. Forensic Sci Int. 1992;56(2):167–175.

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