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What is Asphyxia?

In the most general sense asphyxia ("a" --without; "sphyzein" (Gr) --to beat or throb violently) is any condition that causes the heart to stop beating by interfering with the body's capacity to inhale or utilize oxygen. Oxygen is ultimately necessary for all human metabolic activity, and its absence is rapidly fatal. Since the brain is the organ most sensitive to lack of oxygen, as a practical matter asphyxia is anything that cuts the brain's supply of, or ability to use, oxygen. Obviously the rest of the body needs oxygen, too; but the brain responds most quickly and catastrophically to its absence.

Looking at the various causes of asphyxia outlined below, one can begin to appreciate that methods as seemingly dissimilar as carbon monoxide poisoning, strangling, and drowning are all fundamentally alike in how they kill.

I. Mechanical interference with oxygen uptake
	A. Compression of neck or chest
		1. Ligature
			a. hanging
			b. strangling
		2. Non-ligature
			a. compression of chest
	B. Obstruction of airway
		1. External
			a. Smothering
		2. Internal
			a. Inhaling foreign object
			b. Swelling (e.g., from allergic reaction or blow)
			c. Depletion of oxygen (e.g., plastic bag, drowning, vacuum)
II. Chemical interference with oxygen uptake or utilization
	A. Replacement of oxygen by non-toxic gas (e.g. helium, methane, nitrogen)
	B. Depletion of oxygen
		1. Fire
		2. Other oxidation (e.g., rusty SCUBA tank)
	C. Interference with utilization of oxygen at cellular level
		1. Carbon monoxide
		2. Cyanide

Some of these topics are treated separately or in more detail in other chapters (hanging, drowning, carbon monoxide, cyanide); others are too rarely encountered in the suicide literature (allergic reaction, inhalation of foreign object) to be worth looking at in detail.

How Many People Kill Themselves by Asphyxia?

U.S. suicide data(340) for 1994 (Table A-1). (More tables and graphs.)
METHOD	TOTAL	M	F	WM	WF	BM	BF	OM	OF
Pipeline gas E951.0	9	8	1	8	1	0	0	0	0
L-P gas E951.1	8	8	0	8	0	0	0	0	0
Motor vehicle CO E952.0	1618	1257	361	1222	352	20	2	15	7
Other CO E952.1	393	317	76	308	74	8	2	1	0
Other gases E952.8-9	15	13	2	12	1	0	1	1	0
Hanging E953.0	4073	3555	518	3005	424	340	29	210	65
Plastic bag asphyxia E953.1	422	214	208	206	199	4	5	4	4
Other related means E953.8-9	249	184	65	169	60	12	4	3	2
Drowning E954	383	254	129	200	107	42	12	12	10
M = Male; F = Female; W = White; B = Black; O = Other; L-P = liquified propane; CO = carbon monoxide
E-numbers are International Classification of Disease (ICD) codes (see website appendix).

Hanging and automotive carbon monoxide accounted for the large majority of these suicides. Drowning is a distant third, though its actual numbers may well be a good deal higher than reported, since it's easier to disguise suicidal intent with drowning than with either hanging or carbon monoxide poisoning.

Plastic bag asphyxia is unusual in that there are as many women than men who use this method.

How and Why is Asphyxia Dangerous?

Death is a process, rather than an event. Different cells and tissues die at different rates; for example, the brain will not normally survive more than a few minutes without oxygenated blood circulation, while connective tissue and muscle cells may remain alive for many hours.⁽³⁴¹⁾ Thus, there is the current medical ability to reattach severed limbs, but not heads.

At a basic level, all asphyxial injury is due to cutting off the brain's oxygen supply. This can happen directly, by interference with breathing (e.g., from pressure on the chest or on the front of the neck) or by removal of the oxygen from the air. The same results occur indirectly if blood can't pick up oxygen (e.g., in carbon monoxide poisoning), or if oxygenated blood is prevented from reaching the brain (e.g., by pressure on the large arteries in the neck). Irrespective of the method,^(342f) complete asphyxia causes quick---typically within 2-3 minutes---unconsciousness, followed by brain damage, ending in death. Since the degree of oxygen depletion varies with method, so does the length of time needed for any given result.

Resuscitation may produce a survivor with brain damage, which is often long-lasting and sometimes permanent. Four to five minutes of circulatory arrest causes brain damage in around half of patients⁽³⁴³⁾ and approximately 5-10 minutes of complete oxygen cutoff is generally fatal (unless body temperature is abnormally low, as in drowning in icy water), though the heart will continue to beat for several more minutes.

Let's look at some of the methods in more detail.

Strangulation

Strangulation causes asphyxia by means of pressure on the neck from a ligature or from someone's hands. The weight of the victim's body plays no part, which is what distinguishes strangulation from hanging. Since manual self-strangulation is unknown and probably impossible (your hands relax when you become unconscious), all cases of manual strangulation are considered homicides. I suppose this also makes manual self-strangulation the perfectly safe suicidal gesture, but, by the same token, it would not likely be taken seriously.

Pressure on the neck can close the airway (trachea, or windpipe) at the front of the neck, or compress the common carotid (both sides of neck) and vertebral (back of neck) arteries or jugular veins (both sides), or some combination of the above.^(344f) The jugular veins are easiest to compress, followed by carotid and vertebral arteries, followed by the trachea. (See 'Hanging' chapter for details.) Much more pressure is needed to close the airway than to close the blood vessels in the neck, and is unnecessarily painful. It is entirely feasible to protect the airway with stiff padding, and still kill oneself by tightening a ligature around the neck, thus shutting off blood flow to or from the brain.

Because they operate at higher pressure, the carotid arteries (blood into the head) require more external pressure to compress than do the jugular veins (blood out). A tight, quickly-applied ligature would squeeze both shut, leaving a body with a dusky, blue-tinged (from de-oxygenated hemoglobin in the blood) face.

Lesser pressure, compressing the major veins but not the arteries, would allow blood into, but not out of, the head. This would result in a swollen, blue-purple head, often leaking blood. It may also be painful, albeit briefly. If aesthetics are an issue, quick and complete compression of the blood vessels is least likely to leave a gruesome corpse.

Suicidal strangulation is uncommon, but certainly not unknown. It is generally done by one of three means: (1) knotting a rope or piece of cloth around the neck in such a fashion that it will not come undone when consciousness is lost; (2) twisting a stick or rod under the ligature so that it tightens, and then stays caught under the jaw or chin after unconsciousness; (3) wrapping multiple turns of cord around the neck without any knot at all, depending on friction to hold it in place.

Pressure on the windpipe is painful, but even lethal pressure elsewhere on the neck may produce little or no distress; thus, if the front of the neck is well padded, none of the following techniques ought to be particularly painful. But all are potentially deadly.

Method one is straightforward: a ligature is wrapped once or twice around the neck and quickly knotted. This often looks similar to a homicidal strangulation, but can usually be distinguished from it by the absence of scratches on the neck (produced either by the attacker or the victim) and of internal neck injuries.

A more-or-less typical case of a suicidal strangulation is described in a forensic medicine text:

"A woman aged 73 was lying full length on the floor of a bedroom, which she shared with another patient in a nursing home. The bedclothing had been thrown back in a manner consistent with getting out of bed. There were no signs of any struggle. She was dressed in a nightgown and a brown stocking was round her neck; the fellow of a pair was seen suspended over the head of the bed. The stocking was applied with a half-knot at the nape on the first turn and with another half-knot at the front of the neck. The first turn was tight, but the second, although close to the first, was easily released. There were no other signs of violence, but a little bleeding, which produced a small stain 1 in. in its diameter, had occurred from the nose; the stain was directly below her nose. Her face and neck, above the ligature, were congested and of purple colour. Bleeding had occurred beneath the conjunctivae [eyelids], but petechial hemorrhages [pinpoint hemorrhages often found in asphyxia] were not seen in the skin of the forehead and face. The tongue protruded, but was not bitten; she had dentures, but these were on her bedside table."

The author goes on to describe the generally mild injuries in detail and concludes,

"The cause of death was asphyxia, following the application of a relatively broad, soft ligature to the neck with sufficient force to obstruct the veins and, to a lesser degree, the arteries of the neck; there was also obstruction of the air passages. The mode of application of the ligature was consistent with self-strangulation, as was all the other evidence."⁽³⁴⁵⁾

Sometimes it's difficult to determine whether death resulted from suicidal or from homicidal strangulation. For example, a soft ligature applied with skill and removed soon after death will create problems at autopsy. In one case a woman strangled her child with her husband's necktie. She tied no knot and held the ends of the necktie instead, until the deed was done, and then removed it.⁽³⁴⁶⁾ As a result, there was no externally-visible neck injury. But she was caught anyway.

It isn't unusual for defense counsel in a case of homicidal strangulation to try to muddy the waters. In one instance, the body of a 42-year-old woman was found in a grave in her well-screened back yard. Clothesline was wrapped twice around her neck and tightened with a half-knot. A man was arrested. At trial, the defense described the ligature as more like a "lover's" knot than a murderer's; but had a hard time explaining the presence of a large piece of cloth forced down her throat, and several additional injuries. Faced with this evidence, counsel admitted that the injuries were the cause of death, but suggested that they were the results of a violent quarrel. The accused's failure to report the death was attributed to his preference for conducting his own funeral arrangements. His contention, that he wanted to give her a "Christian burial," was described by the prosecutor as one of the worst pieces of hypocrisy he had ever heard. The jury was equally unimpressed by his solicitude and convicted him of murder.⁽³⁴⁷⁾

Method two is rather like applying a tourniquet. There is generally a single loop which is attached loosely and usually knotted with a granny or reef knot.⁽³⁴⁸⁾ A rod (still called a "Spanish windlass" in honor of its former use in that country for judicial executions) is placed under the ligature and twisted to tighten. Tightening needs to be accomplished fairly quickly in order to get a few extra twists in before unconsciousness intervenes. This is done because the twist may partly unwind when no longer held in place. But only partly. Usually the rod hangs up on the side of the jaw, and enough compression is maintained to cause death. Occasionally, quite unwieldy rods are used to tighten the ligature, as in a case where a man used a fireplace poker.⁽³⁴⁹⁾ Items this large will certainly prevent the ligature from untwisting, but are hard to tighten rapidly.

Method three, multiple loops, is the least common since, if the ligature is tight, there isn't time to do very many loops; if it is loose, it's ineffective. In one case, however, a 53-year-old man succeeded despite these difficulties. He wrapped twine around his neck 35 times, tied a knot and tightened it. He then bent forward on his knees with his head down, which increased his neck circumference, and thus, pressure from the twine; this is the posture in which he was found. Since this is an unusual position, the police were initially suspicious. However, there was no internal damage to the fairly delicate anatomical structures in the neck, a fact consistent with suicide, but not murder.⁽³⁵⁰⁾

Choking

Choking is the blockage of the internal airway by some foreign object. Some examples are:

(1) Inhaling vomit while unconscious, typically after drug/alcohol overdose. While this may be the actual cause of death, it is unpredictable and rarely, if ever, the intended method.

(2) Aspiration of food. This is a common (and public) enough accidental cause of death that it's been nicknamed the "cafe coronary". The food item is often a chunk of meat, and the victim often is drunk. Sometimes there is no sign of respiratory distress---the victim just sits back on the chair, or falls over, dead. These are cases of cardiac arrest triggered by a bolus of food stuck in the airway. Choking on food is also occasionally seen among some mental patients who try to "wolf" down (a canard---wolves don't eat in this way) their own and/or other inmates' food.

(3) Young children are indiscriminate about what they put into their mouths, and readily insert things that will block breathing if inhaled.

The emergency treatment for life-threatening choking is the "Heimlich maneuver" widely taught in first-aid courses. It consists of holding the victim from behind and putting sudden pressure on her diaphragm by a quick squeeze with your locked hands. An emergency "self-Heimlich" can be done (if you don't panic) by quickly shoving your diaphragm (just below where your ribs come together between your chest and belly) hard against the rounded corner of a table, bannister, or other sturdy object. Falling onto a round object such as a soccer ball or your fists should be similarly effective.

In any case the idea is to dislodge the blockage by a sudden increase in exhalatory air pressure. If this isn't done, or fails, the desperate victim tries harder to inhale, which only wedges the object more firmly. Blood pressure and carbon dioxide levels rise; lack of oxygenated (red) and excess of un-oxygenated (blue) hemoglobin causes the victim to turn bluish; convulsions due to insufficient oxygen and too much carbon dioxide often occur; heartbeat races, falters, then stops.

"Choke" and "sleeper" holds, sometimes used by police and muggers, are discussed in the "Hanging" chapter.

Compression of Chest

If the chest and diaphragm are compressed, the ability to inhale is impaired. Since this can be done with few, if any, external signs of injury, it was once a notorious method of disguising murder. It was popularized^(351f) by two Ulstermen, William Burke and William Hare, who killed a number of derelicts in Scotland by this means. The motive was money: they committed these murders in order to sell the bodies for dissection at the local medical school.

Hare was keeper of the Log's lodging house in Edinburgh. They sold their first corpse, who had died a natural death at the lodging house on November 29, 1827, to a Dr. Robert Knox for 7 pounds, 10 shillings, for dissection at Knox' anatomy school.

Deciding that there was a career opportunity here, over the next 11 months they enticed at least 15 people (one at a time) to the lodging house, got them drunk, and smothered them. One would hold the victim's legs while the other would sit on his or her chest. Hare testified that, in one murder, Burke,

"...got stridelegs on the top of the woman on the floor, and she cried out a little, and he kept in her breath...He pressed down her head with his breast...He put one hand under the nose and the other under her chin, under her mouth..."⁽³⁵²⁾

The technique was given the name "burking" in their honor. After they were caught, Hare turned King's evidence, was eventually released, and disappeared with Burk's former mistress, by then Hare's wife. He supposedly died a pauper in London in 1859. Burke was hanged in 1829; the doctor was never charged.^(353f)

Other than accidents such as car wrecks, construction cave-ins, falling beverage vending machines (surprisingly common, and usually due to people trying to rob the machine, or to irate customers trying to get their money back^(354f)), and stampeding mobs (most frequently soccer or music fans), the main incidence of fatal chest compression is in the course of police arrests. If a prisoner is face down on the ground or in the back of a police car, with hands forced behind in cuffs and the weight of the policeman on his back, there may be lethal results. This is especially, but not only, true if the prisoner is struggling violently or has taken alcohol or other depressant drugs.

Compression is also the method used by "constrictor" snakes to kill their prey: they wrap themselves around their victim a bit more closely each time it exhales. Inhalations become progressively more difficult until the victim dies of asphyxia. It is not "crushed" in the sense of having broken bones, except incidentally. There are four recorded cases of deaths due to constrictor snakes in the U.S. Three were due to large pet snakes; two killed infant children of the owners; one adult was killed while sleeping on the floor. The fourth death was that of a zoo-keeper.⁽³⁵⁵⁾ None were considered suicides; nor is it a recommended method of suicide.

Smothering

"Smothering" is the blockage of the nose and mouth . This is sometimes seen in homicide since it simultaneously minimizes the injuries that generate suspicion of foul play, and noise (screams, gunshots, etc.) that might attract unwanted attention. However, unless there is a major mismatch in strength, the chances of killing someone quickly and without producing visible injury are slim.^(356f)

In the 18th and 19th centuries the accidental smothering of infants was common in England.^(357f) This was called "overlaying" and was attributed (by the upper classes) to widespread drunkenness amongst the lower classes, supposedly due to the availability of cheap gin. Since young children generally shared their parents' bed, if the parents were drunk, they might innocently (or otherwise) lie on and asphyxiate a small child. In our more enlightened time, infants are usually kept in their own cribs, and their occasional mysterious deaths are now attributed to "Sudden Infant Death Syndrome" or SIDS.^(358f)

Sometimes people are gagged in the course of other crimes. If the gag slips upward to also block the nose, or is inhaled, death from asphyxia can result.

Suicidal smothering is rare, requiring extraordinary will power, but is occasionally seen amongst prisoners and mental patients. One prisoner killed himself by stuffing pieces of cloth into his mouth and nose, and holding them in place with a handkerchief.⁽³⁵⁹⁾ Another was found dead in a mental hospital with a pebble lodged in each nostril and mouth stuffed with cloth.⁽³⁶⁰⁾ It's also possible to smother oneself by lying face down on soft bedding or clothing. This is occasionally the cause of death for people who are drunk, or incapacitated for other reasons; but I'm not aware of cases in which a physically and mentally unimpaired adult has committed suicide by this means.

Accidental smothering occurs mostly in small children. Some of these cases are due to an infant being unable to turn over from its stomach. (The recent decrease in SIDS cases in England has been credited to a campaign to get mothers to put their babies face up in cribs.⁽³⁶¹⁾) This situation is made more dangerous by the use of waterproof (and thus airproof) bedding covers. There exist "safety pillows" with holes cut throughout, intended to allow breathing even face down. In one case of infant asphyxia, such a pillow was used---but covered with a plastic liner.

There have been rare, but well-documented, cases of infants being smothered by cats sitting on their faces or chests. In one instance a five-week-old baby was discovered in her baby carriage with a cat lying on her face. Her father got her breathing again with mouth-to-mouth resuscitation, but she died seven months later. Autopsy showed evidence of brain damage consistent with asphyxia.⁽³⁶²⁾

Plastic bags, especially the thin, clinging sort used for garments, are notorious for smothering young children. Though flimsy, they tend to, well, cling. Older children and young adults are sometimes accidentally asphyxiated when sniffing fumes (glue, propane, solvents, etc.) from a plastic bag, if they become unconscious. This is in addition to the sometimes-serious toxicity caused by the vapor itself.

In suicide, a small plastic bag is generally placed over the head and tied or taped around the neck. The oxygen in the bag is used up by rebreathing. This plastic bag technique, however, seems unreliable, since most garden-variety bags are more-or-less easily torn in the course of convulsions or semi-conscious movement. Plastic bag(s) or sheets may instead be wrapped tightly around the nose and mouth, which is faster but more traumatic.

A small bag is said to become unpleasantly warm; if so, some ice, wrapped in a towel and resting on the head or neck, should help. My experiments with larger bags have not found heat to be a problem; but one might as well be comfortable.

A more gradual asphyxia can be achieved by use of a large plastic bag. A would-be suicide could combine drugs with this slow asphyxia to cause death less traumatically, more rapidly, and more reliably than either method could do alone.^(363f) The seal around the neck doesn't need to be painfully tight---rubber bands, elastic, or velcro will do---and small air leaks are not significant, at least in the 30-gallon and tube tent sizes. In fact, there are examples of fatalities where the bottom of the bag was not closed at all.⁽³⁶⁴⁾

Interestingly, there is often no sign of asphyxia---the faces are pale and uncongested---after plastic-bag suicides. This may be important in assisted-suicide, where the assistant wishes to avoid legal entanglements. It also suggests that the mechanism of death is not always, or not entirely, hypoxia, but rather cardiac arrest set off by hypoxia.⁽³⁶⁵⁾

The combination of asphyxia and drugs would decrease one of the major difficulties with drug overdose as a suicide method: besides being unreliably lethal, most drugs take a long time, making a suicide attempt subject to intervention. But if one were to use a drug(s) that quickly induced unconsciousness, simultaneous use of a large plastic bag or a tube tent would substantially increase the chance of a lethal result. (Obviously, this is counterproductive if one wants to survive the suicide attempt.)

And the time-window for permanent injury would be smaller than with the drug alone: done properly, if one were interrupted within, say, 20 minutes, there would be good chance of full recovery (since the drug dosage alone could be sublethal and there would be enough air for about a half an hour in a 30 gallon bag); after an hour or so, it would be too late.

However, there are some practical problems with combining plastic bag asphyxia with drug overdose. For example, the huge number of available drugs⁽³⁶⁶⁾ and doses makes it difficult to know what and how much to use to achieve unconsciousness. In addition, the effects of drugs are somewhat uncertain for many reasons, among which are individual sensitivity and the possibility of vomiting part of the swallowed dose; and most oral drugs are unpredictable in how long they take to cause insensibility.

Thus, simultaneous use of a small plastic bag might cause you to run out of oxygen while still conscious. This is not a big deal if you're alert---open the bag and try again---but may cause panic and bag tearing or removal during semi-conscious movement. Waiting to use the bag until the drug(s) start to take effect does not seem like a entirely reliable alternative, but may be your best bet here, unless you have help available.

Multiple-bagging, thicker plastic, or wearing gloves will decrease the chance of tearing or removing the bag in the course of involuntary movements. If you are terminally ill, you may have friends or family who are willing to assist by sealing the bag and restraining your hands after you lapse into unconsciousness; however this will have legal repercussions if detected.

Since thin plastic bag material tends to fall onto your face (especially if you're lying on your back), wearing a brim-hat or a dust (or painters') mask (cut holes in it for easier breathing), is recommended.

Most of these problems can be avoided by using a plastic tube tent instead of a small plastic bag: it's cooler, unlikely to drop onto your face, less critically dependent on drug speed, and will cause asphyxial death after roughly 4-5 hours.

One could even build a coffin with an easily lifted lid. Having taken some unconsciousness-inducing drug, one might lie in the coffin, holding the lid open. Upon losing consciousness, the lid would fall, cutting off the air supply and leading to asphyxial death a few minutes later. If the drug dose was insufficient, or for any other reason one woke unexpectedly, it would be an easy matter to open the lid.

However, note that while the combination of sedative drugs and large plastic bag (or functional equivalent) might seem to allow time and opportunity to change your mind, as a practical matter such drugs will likely prevent you from making, or acting on, any coherent decision once they start to take effect.

Exclusion of Oxygen

The effects of oxygen depletion have been described as consisting of four distinct stages.⁽³⁶⁷⁾ However, the following oxygen percentages are only approximate and vary from person to person.

(1) "Indifferent" stage: arterial blood is more than 90% saturated with oxygen; only effect is decreased night vision;

(2) "Compensatory" stage: 82-90% oxygen saturation; body compensates by increase in heart and breathing rate; lower pH -->change in Hb dissociation curve: check [tedeschi [I] p76] [may also increase anaerobic glycolysis: check]--> this level of oxygen saturation causes no additional difficulties in people in good health; those with heart, lung, or blood problems may show early symptoms of:

(3) "Disturbance" stage: 64-82% oxygen saturation; increasing air hunger, headache, exhaustion, dizziness, confusion;

(4) "Critical" stage: less than 60% oxygen saturation; unconsciousness in a few minutes, followed by brain damage and death. This corresponds to 6-8% oxygen in the breathing mixture (normally 21%).

Oxygen can become unavailable to the body by four general means:

Let's examine each of these in more detail.

Displacement of oxygen from the breathing mixture

Many gases that are more-or-less non-toxic can cause asphyxia by replacing oxygen from the breathing mixture. Some common ones include acetylene, argon, butane, carbon dioxide, freons, helium, hydrogen, liquified petroleum gas (LPG), methane, neon, nitrogen, and propane. As a result, they are dangerous in enclosed areas or via gas mask, but not otherwise. People start showing signs of asphyxia when the concentration of these gases is around 30%; severe symptoms at around 50%; death at around 75%.⁽³⁶⁸⁾

In the above list, argon, butane, carbon dioxide, freons, and LP gas are heavier than oxygen, and may displace it from the bottom of closed spaces, and, occasionally, even open spaces that are protected from wind.

Tunnels that are open only through manhole covers occasionally contain lethal concentrations of carbon dioxide. Someone entering such a location unknowingly would become unconscious within a couple of minutes---perhaps within seconds⁽³⁶⁹⁾---and dead after five to ten minutes. A standard gas mask is useless under these circumstances; supplemental oxygen is necessary.

A mass asphyxia occurred near Lake Nyos in Cameroon, in August 1986. A large amount of cold, dissolved carbon dioxide exists in the bottom layers of this volcanic lake water. Probably as a result of turbulence from a mudslide, this carbon dioxide-rich water rose. As a result, the pressure on it from water above was decreased. The result was like opening a soft drink bottle: bubbles of carbon dioxide gas left the water.

People living in the valley below were engulfed by an invisible wave of carbon dioxide gas which, being heavier than oxygen, displaced it. There was no warning. Everything that needed oxygen died within minutes: human beings, domestic and wild animals, even insects. Birds that were on the ground or flew too low perished. People dropped like flies (so did the flies) in the midst of whatever they were doing. The human death toll was over 1700. [For a link to a recent newspaper article, click here.]

However, for the purpose of suicide, carbon dioxide would be an unpleasant choice, since its presence stimulates both breathing reflexes and the sensation of smothering.

The hydrocarbons methane, butane, liquified petroleum gas (LPG), and propane, while readily available as fuel gases, are normally mixed with bad-smelling "warning" gases (mercaptans), related to skunk scents.

Acetylene is used for gas welding and is easy to acquire, but contains somewhat-toxic acetone. Don't bother making your own acetylene from calcium carbide (formerly and still occasionally used in carbide lanterns for caving), because it contains an ammonia-like contaminant, phosphine (PH3).

Freons are bad for the ozone layer and neon is expensive.

Hydrogen is flammable (remember the Hindenberg) and raises the pitch of your voice.

The remaining gases, argon, helium, and nitrogen, are your best bets in this category. They are all tasteless, odorless, non-irritating, and under these conditions, chemically and physiologically inert. In fact, nitrogen comprises about 80 percent and argon 1 percent of sea-level air, while a roughly 90 percent helium-10 percent oxygen mix (precise ratio depends on dive depth) is used for deep-water diving (to avoid the intoxicating effects of high pressure nitrogen, called "nitrogen narcosis" or, more poetically, "rapture of the deep").

Since these inert gases are not poisonous and your lungs have something to inhale, such asphyxias will be minimally traumatic. That is, they will not cause feelings of suffocation (which are due mostly to carbon dioxide buildup, rather than lack of oxygen) or hemorrhages (caused by high blood pressure from blocked jugular vein or struggling to breathe against a closed airway).

Most medical use of inert gases is for animal euthanasia,⁽³⁷⁰⁾ however there have been human fatalities from them, too. For example, face masks were mistakenly hooked up to inert gas (generally nitrogen) cylinders instead of to oxygen at least ten times during the 1980s in the U.S. The fact that these people died without attracting attention is consistent with non-traumatic death.⁽³⁷¹⁾

Argon is commonly used for inert-gas electric welding and helium for balloons. Nitrogen has a variety of uses and may be purchased either as a gas or as a cold (-196 deg C; -321 deg F) liquid. All of these are available from industrial gas suppliers. Helium can also be found at party-supply stores, and argon at welding suppliers. None of these gases are dangerous^(372f) unless they displace oxygen from the breathing mixture.

Probably the easiest way to use inert gases for suicide is to enter a tube tent with a gas cylinder, flush the tent with any of the three gases, and seal the ends of the tube. The volume of a tent is such that you won't produce enough carbon dioxide to stimulate breathing reflexes before dying. Since there's little or no residual oxygen in the breathing mixture, minimal amounts of carbon dioxide ought to be exhaled, suggesting that a large inert-gas-filled plastic bag over the head should work as well as the tube tent.

Only slightly more complicated is hooking up a gas delivery mask (available at military surplus or medical supply stores) to a cylinder of compressed inert gas. This may, in fact, be the easiest method if you're using supplemental oxygen, and have a gas delivery system already in place.

The main hazard of this (and all) asphyxia is the possibility of brain damage if the process is interrupted due to intervention, running out of gas, or tearing or removing the gas mask, plastic bag or tube tent while unconscious. This can be minimized by using a high concentration of the anoxic gas, which causes most rapid loss of consciousness. These gases are not a danger to others in anything but a small, sealed space; however it's important that a gas cylinder not be mis-labeled, lest it imperil subsequent users.

In experiments, animals (dogs, cats, rabbits, mink, chickens) show little or no evidence of distress from inert gas asphyxia,⁽³⁷³⁾(374f) become unconscious after 1-2 minutes, and die after about 3-5 minutes.^(375f)

Thus, use of any of these three gases, combined with a plastic bag, should be less traumatic than plastic bag asphyxia alone, since there will be little discomfort from carbon dioxide buildup and unconsciousness will be swift.

Removal of oxygen from the breathing mixture

Oxygen can be removed either physically, by pumping it out along with the other components of air; or chemically, by combining it with other substances and so making it unavailable to the body.

Physical removal of oxygen may become a means of suicide in the future, if there is space travel through the near-vacuum between planets. I'm not familiar with any use of hard vacuum to commit suicide on earth (though there at least one instance of suicide in a high-altitude test chamber). Don't try to become a footnote in the Guinness Book of World Records by being the first: if a vacuum was generated quickly, your blood would boil most unpleasantly from the low pressure before you had time to die from asphyxia.^(376f)

Using up the available oxygen is often the cause of accidental death, as when children are trapped in abandoned refrigerators and asphyxiate. Despite laws in every state and widespread publicity, the Consumer Product Safety Commission (CPSC) reported 76 of these deaths between 1980-88.⁽³⁷⁷⁾

Similarly, glue sniffers who use plastic bags are at risk of unexpected unconsciousness, followed by death in the absence of prompt intervention.

Rough calculations 100 mol air --> 21 mol oxygen --> 28 mol Fe x 56 gm/mol=1.6 kg Fe=3.5 lbs Fe--> show that it's possible for much of the oxygen in a SCUBA tank to be used up if the inside of the tank rusts severely; so don't go diving with old air in your tanks. The same hazard exists in other iron tanks, such as ship's holds. Here, also, the damp steel walls can rust enough to use up the available oxygen. Such deaths tend to occur too quickly to be directly due to hypoxia; instead, the immediate cause seems to be sudden cardiac arrest, brought on by lack of oxygen.

Carbon monoxide poisoning

Until recently, in Europe you could open the oven gas valve (unlit), stick your head into the oven, and be fairly confident of dying quickly. (Death from opening the stove-top valves was much slower since the entire room needed to reach a lethal gas concentration, unless your head was near the unlit burner.) Yet if you tried this in the U.S., it would hardly ever work.

The reason is that the U.S. and Europe used different gases for household heating. In the U.S. "natural" gas---composed largely of the non-toxic hydrocarbon methane---is cheap and plentiful; Western Europe, until discovery of the North Sea oil and gas fields in the nineteen sixties, had very little. In Europe, the gas generally used was a mixture of hydrogen, hydrocarbons, and (7-15 percent) carbon monoxide. The hydrogen is as non-toxic as methane, but carbon monoxide is deadly.^(378f) This mixture was called "water gas" or "coal gas", and is a perfectly good fuel except for its deplorable tendency to kill anyone in the same (or sometimes even a nearby) room as a gas leak, deliberate or accidental.

As various parts of the world switched from a water-gas based mixture to natural gas (no carbon monoxide), the head-in-the-oven method of suicide became much less frequent. For example, between 1946 and 1996, the fraction of U.S. households using natural gas increased from 45 percent to 98 percent. During the same span, the household-gas suicide rate decreased twelve-fold, from 0.926/100,000 to 0.079/100,000.⁽³⁷⁹⁾ In England, the number of suicides due to gas fell from 2368 (plus another thousand or so accidental deaths) to 11 between 1963 and 1978.⁽³⁸⁰⁾ Similarly, in West Germany the percentage of suicides by household gas fell from 11.6% to 0.3% from 1963 to 1976; meanwhile, however, the percentage of suicides due to drugs/poisons went from 24.4% to 36.5%.⁽³⁸¹⁾

It is possible that some Americans (including the poet Sylvia Plath^(382f)) who were familiar with low-lethality natural gas died by accident/mistake in Europe when they intended a suicidal gesture with methane and died from carbon monoxide. This may also account for the common misconception that natural gas contains toxic amounts of carbon monoxide: it doesn't (though a mis-adjusted natural gas burner that produces a yellow or sooty flame is generating significant carbon monoxide).

There was a bizarre case where a man tried to commit suicide by the head-in-the-oven method. Since the gas was methane, this wasn't working well. After a while, the man got bored, took his head out, and lit a cigarette. The match ignited the gas/air mixture and he was killed by the explosion. The legally-interesting question arose, was this a suicide or an accident? The inquest ruled it a suicide.⁽³⁸³⁾

Household gas does have a bad-smelling additive (methyl mercaptan) intended to warn you if there's a gas leak. This "warning gas" is also added to bottled gas for the same purpose. However, old and internally corroded propane and butane tanks absorb the mercaptans, leaving an odorless explosive gas, which probably won't be detected if it leaks.

A second factor that lowered the frequency of head-in-the-oven suicide attempts has been the general introduction of ovens containing thermocouples and either pilot lights or electronic igniters. Instead of manually lighting the oven with a match, these devices, unless disabled or defective, will light the oven moments after gas enters it. This makes gas asphyxia unlikely and substantially decreases the chance of an explosion caused by filling a room with an unburned gas mixture waiting only for a spark or flame to blow sky high. However, the stove-top burners will continue to emit gas if, for whatever reason, they fail to light or blow out.

Comparison of carbon dioxide, carbon monoxide, and hydrogen cyanide: How do these gases work? (See, also, "Drug" chapter)

There's a lot of confusion concerning these poisonous gases.

Carbon dioxide (CO2) is the product of the complete combustion of carbon by oxygen, and is non-toxic at low concentrations. Your exhaled breath is normally 4-5 percent CO2. Inhaling CO2 does increase the acidity of your blood, and cause you to breathe faster, but at high CO2 concentrations these don't have time to become serious problems.

CO2 kills by two different mechanisms: (1) it displaces oxygen (and most other atmospheric gases, since carbon dioxide is denser than almost all of them), leaving you with nothing else to breathe. (2) Carbon dioxide in concentrations of 30 percent or more is also a rapid anesthetic, causing unconsciousness within 1-2 minutes, and death in about 5 minutes, without much evidence of distress in experimental animals.⁽³⁸⁴⁾

It is widely used for theatrical "fog" (ever notice how it stays near the ground? and a good thing, too) and as a portable refrigerant in its frozen state, "dry ice". There is at least one case report of a death from transporting dry ice in an enclosed car. As the dry ice evaporated, a dangerous concentration of gaseous carbon dioxide was created. ⁽³⁸⁵⁾

In addition to dry ice, CO2 also is available as a compressed gas. (You need a special CO2 valve for these tanks, as standard valves freeze up.) Carbon dioxide gas has the additional merit of being non-explosive, cheap, and will put out most fires.

Carbon monoxide (CO) is colorless, odorless, and tasteless; it has one fewer oxygen atom than carbon dioxide (CO2). It will be produced by any carbon-fueled flame that doesn't get enough oxygen. If a flame is yellow or puts out visible soot, you can be sure it's also generating carbon monoxide; if a flame is blue, carbon dioxide is the principal carbon oxide. You may have noticed that the outer part of a candle flame is blue, while the inside is yellow. This is because the outer portion burns hotter due to its greater oxygen supply.

Carbon monoxide's biological effects are mostly due to the fact that it's 200-250 times more strongly attached to the oxygen-transporting molecule in red blood cells, hemoglobin, than is oxygen. And a hemoglobin molecule can't carry both carbon monoxide and oxygen. Thus a low concentration of CO in the air can occupy a large fraction of your hemoglobin. For example, 0.01%, 0.02%, 0.10% and 1.0% CO in the breathing mixture would tie up 11, 19, 54, and 92%, respectively, of a person's hemoglobin at equilibrium.⁽³⁸⁶⁾

Carbon monoxide is also directly toxic to cells by interfering with their ability to use oxygen, by binding to a number of iron-containing enzymes and other proteins. Carbon monoxide causes blood to be a bright, cherry red, which produces a ruddy corpse. This unusual coloration can be used for preliminary identification of CO poisoning.

The toxicity of carbon monoxide is shown by a case in which a car accident victim was put on a stretcher, which was placed 8-10 feet behind the tailpipe of an idling ambulance while another person was attended to. Upon reaching the hospital, the first man was discovered to be dead from carbon monoxide poisoning. His other injuries were minor.

Since smoldering tobacco contains about 4% carbon monoxide,⁽³⁸⁷⁾ pack-a-day smokers have 5-6% of their hemoglobin tied up by carbon monoxide. This level causes small, but measurable, impairment of both physical and mental performance.⁽³⁸⁸⁾ Frequent cigar smokers have peak carbon monoxide blood levels of around 20%.⁽³⁸⁹⁾ A 50% carbon monoxide blood level is often fatal, but levels as low as 15 percent may also kill those with heart or lung problems.⁽³⁹⁰⁾

It takes about five and a half hours of breathing fresh air to remove half the carbon monoxide from hemoglobin, another way of showing the high affinity between the two; 100% oxygen reduces this to 80 minutes; 100% oxygen at three atmospheres pressure gets rid of half the carbon monoxide in 23 minutes,⁽³⁹¹⁾ but may cause permanent eye damage. However, even 23 minutes is often too long: a few minutes of asphyxia is enough to cause brain damage which may be fatal, and has a good chance of being permanent.

These injuries include dementia, psychosis, paralysis, cortical blindness, memory deficits, and parkinsonism; the latter two are the most common. The frequency of permanent injury from carbon monoxide overdose ranges from 0.3% to 43% in various studies,⁽³⁹²⁾ even if high-pressure oxygen used. "Some survive [in] a coma for weeks or months before succumbing to infection."⁽³⁹³⁾

Alcohol and other central nervous system depressants (e.g. sedatives) may increase the toxic effects of carbon monoxide. A 0.20% blood-alcohol concentration combined with a serious (but generally not fatal in a healthy individual) 35-40% carbon monoxide saturation of the blood has been fatal.⁽³⁹⁴⁾ However, this is association is controversial.⁽³⁹⁵⁾ Carbon monoxide is also hazardous to unprotected rescuers, and will explode should CO concentration reach 10 percent and there is a spark or flame present. This concentration will not be reached from combustion, but may be achieved from compressed CO (in tanks) or chemically-generated CO.

Automotive carbon monoxide poisoning is becoming less frequent in the U.S. The reason is that car engines are required to get better gas mileage and produce fewer toxic emissions than in the recent past. A new, well-tuned engine may emit 0.06% carbon monoxide, compared to 6-9% from an engine of the 1960's, a hundred-fold decrease. As a result, it takes longer to kill yourself by filling a garage with carbon monoxide from a tuned engine. It can be done, but is no longer either fast or certain.

How long does this take? For a given-volume garage, it depends primarily on the age, state-of-tune, and size of the engine. If a "clean" 2-liter engine idles at 750 rpm, then it will take about an hour for 20 x 20 x 8 (feet) garage to reach 0.06% carbon monoxide. This is not a reliably lethal concentration.

What would happen if the exhaust gases are piped directly into the car (garden or vacuum-cleaner hose is commonly used)? It would take about 3 min to reach 0.06% atmospheric carbon monoxide. However, the atmospheric CO concentration can't be greater than that of the exhaust mixture; it just takes less time to get there. Once again, not reliably lethal.

If we had a "dirty" engine of the same size with 6% carbon monoxide emissions (100x clean engine), it would take about 35 seconds for the garage to reach 0.06% carbon monoxide; 70 seconds for 0.12%, 140 seconds for 0.24%, and so on. Thus, a lethal concentration of CO would be produced in a minute or two. Death could occur in less than a half an hour. Note that, while running such exhaust into the car would generate a lethal concentration of CO within a few seconds, one would have to continue breathing it for a fatal result.

These calculations are illustrative rather than precise because (a) garages differ widely in size and leakiness to gases; (b) most cars emit somewhere between 0.06% and 6% CO.

Alternatively, one may be able to buy a small tank of carbon monoxide from a chemical, science supply, or industrial gas supply company (you will need a gas regulator/valve, too). Loosely sealing yourself in a plastic tube tent, car, or functional equivalent, and releasing the gas should be quickly (5-15 min) fatal.^(396f)

A simple and reliably lethal source of carbon monoxide is a charcoal grill, hibachi, or other burner. If charcoal (or any other handy carbon fuel, like wood or coal) is burned in one, a deadly CO concentration will be quickly generated in any small, enclosed space, such as a tent. Using this method inside a building is a bad idea, both due to fire hazard and because of the CO danger to other people.

Dr. Kevorkian's current suicide apparatus consists of a gas mask attached to a tank of carbon monoxide. The gas flow is controlled by a valve that is opened by the patient, who is wearing the mask. Under these conditions, death should occur in less than 5 minutes. The advantage is that the gas concentration will probably be higher than with a tent, with faster results. The disadvantage is that the hookup is a bit more elaborate, and is correspondingly more likely to require someone else's help.

Effects of carbon monoxide: A century ago the eminent British scientist J.B.S. Haldane studied the effects of carbon monoxide on himself---a time-honored, but sometimes hazardous, medical tradition. While sitting and taking notes, he breathed a 0.21% carbon monoxide mixture for 71 minutes. A summary of his observations follows: after 20-34 minutes he had a slight feeling of fullness and a throbbing of the head; 17% of his blood hemoglobin was tied up by carbon monoxide as carboxyhemoglobin. After 40-45 minutes the headache was worse, his breathing was slightly fast and he felt abnormal (39% carboxyhemoglobin). After 59-65 minutes, he was breathing fast, looked pale, was starting to become confused, and couldn't move in his chair without feeling worse (44.5% carboxyhemoglobin). After 71 minutes his vision was dim, he couldn't get up without help, and he stopped the experiment (49% carboxyhemoglobin). There were no long-term ill effects.⁽³⁹⁷⁾ A chart showing the correspondence between CO concentration, duration, and symptoms is shown in the Website Appendix Table A-3.

As always, there is individual variability: in 7% of fatal CO poisonings, less than 40% of the victim's hemoglobin was tied up by CO.⁽³⁹⁸⁾ Another study found that 0.32% CO for an hour caused unconsciousness; 0.45% caused death.⁽³⁹⁹⁾

In animal experiments, carbon monoxide is about as fast as inert gases: unconsciousness occurs in 1-2 minutes and death after around 5 minutes, using 4-8 percent CO.⁽⁴⁰⁰⁾ Death is preceded by convulsions and muscle spasms, but the fact that there are frequent accidental carbon monoxide poisonings among sleeping people shows that it doesn't cause enough discomfort to reliably awaken someone. However, first taking enough of a sedative (e.g., alcohol, opiate, barbiturate) to achieve unconsciousness would probably result in an easier death.

If low concentration of CO is anticipated, such as from new-car exhaust, it may be useful to premedicate with anti-nausea (e.g. some antihistamines) and anti-seizure (e.g. Valium) drugs, but this is speculative. Better is to avoid this situation: don't use CO for a suicidal gesture and don't use low concentrations for suicide.

We close this section with a suicide note from Japan, written while a car was filling with carbon monoxide.⁽⁴⁰¹⁾ The first 11 items of the note were personal messages and instructions for the disposal of assets. The last entries are quoted below, in translation:

"12. Although I had attempted suicide with several methods, I could not commit it yesterday. I hope I am successful in killing myself today.

13. I have written too much. Finally, goodbye my life! I believe in Rin-ne [Buddhist concept of reincarnation as human or animal, depending on one's conduct in the most recent life.]

[At 6:15 p.m.] The inhalation of exhaust gases is begun.

[After 7 minutes] My eyes and throat are slightly irritated. Put on a bathing towel. There are tremendous water drops on the door glasses [This is condensation of water vapor from the exhaust]. The tank is full of gasoline.

[After 8.5 min] Slight shortness of breath. Ha-ha-ha. The powers of Nissan's engine are great!

[After 10 min] Swallowed a cup of Japanese sake [rice wine]. I could not control myself to stay in the cabin [of the mini-van] at this level of shortness-of-breath yesterday.

[After 11 min] To the mistress of a grocery store: "Yes, you were right. The size of this hose, 30 mm in outer diameter and 25 mm in inner diameter, fits the exhaust pipe perfectly."

[After 12.5 min] Swallowed another cup of sake. I wish I could have a can of beer. I wonder what the concentration of carbon monoxide is now.

[After 14 min] Breathing can only be done by mouth.

[After 15 min] Water is pouring out of the hose.

[After 16 min] Goodbye, Mum and Papa! [and a list of six people].

[After 17 min] Still I am living. It is asthmatic breathing. Now, I will sleep."

This was the last entry.

Cyanide is one of the fastest acting poisons [see "Drug" chapter for more information], though sources differ with regard to just how long (mostly between 1 and 15 minutes in large (1500 mg) doses, longer with lower doses⁽⁴⁰²⁾) it takes to kill. The lethal dose is estimated to be 50-300 mg;⁽⁴⁰³⁾ however much larger amounts have been survived with prompt medical attention.

The gaseous forms, hydrogen cyanide and cyanogen, are rarely used in suicide, but, in high concentration, should act more quickly than the oral poison; solid cyanide salts (potassium, sodium, and calcium cyanide) are the commonly sold forms, but hydrogen cyanide gas can be easily made by mixing a solid cyanide and a liquid acid (e.g., hydrochloric [muriatic] acid); this is what is done in gas chambers.

Cyanide works by causing asphyxia at the cellular level; it binds to iron ions found in some enzymes and makes them unavailable for cellular respiration, essentially strangling your cells. The cells try to survive by switching to a non-oxygen-requiring metabolic pathway (the same one your muscles use when you're exercising faster than you can breathe in oxygen), but this quickly builds up lactic acid to toxic levels. The fastest-metabolizing tissues, brain and heart cells, are most quickly affected; and if they die, so do you. Cyanide also has a direct poisonous effect on the central nervous system and depresses breathing, but this is overkill. As with carbon monoxide, some survivors have permanent nervous-system injury, such as memory deficits and tremor.

If you use cyanide, it would be a good idea to leave a conspicuous note to that effect, because of possible hazard to rescuers who might otherwise apply mouth-to-mouth resuscitation---some people lack the ability to detect the almond-like smell of cyanide.

Thus, all three substances, carbon dioxide, carbon monoxide, and cyanide are asphyxiants: carbon dioxide displaces oxygen, keeping it from getting to your lungs; carbon monoxide prevents your red blood cells from picking up oxygen and also blocks cellular respiration directly; and cyanide stops your cells from "breathing" despite plenty of available oxygen in the air and in your red blood cells.

Conclusion

1. None of the methods discussed in this chapter should be used for a suicidal gesture; all are potentially lethal and don't give enough warning of unconsciousness to allow you to count on being able to change your mind.

2. Strangulation, like hanging, is quickly fatal. If the front (throat/airway/trachea) part of the neck is well-protected, it should not be particularly painful. Quick and complete compression of the neck arteries will prevent engorgement of the head with blood. For someone who is terminally ill, has no help available, and is bed-ridden, strangulation may provide the best combination of speed, ease of application, and lethality.

3. Carbon monoxide is probably the only readily-available toxic gas worth considering for suicide, but internal combustion engines are highly variable as sources for this gas. This is relevant either if you are contemplating filling a garage with a lethal carbon monoxide concentration, or running a hose from the exhaust pipe into a sealed car. A charcoal grill is more reliably lethal. In general, carbon monoxide is both slower and probably more subject to interruption than hanging or strangulation, and has caused brain damage in some survivors.

4. Perhaps the least traumatic of these methods consists of achieving unconsciousness with drugs, combined with plastic-bag, carbon monoxide, or inert gas asphyxia. However, this requires arranging and coordinating two methods, which may be difficult to do without help, particularly for people who are severely ill. Finding the right drug(s)/doses is also sometimes a problem.

Especially in the absence of sedative drugs, either carbon monoxide or inert gas (nitrogen, helium, or argon) will probably make plastic-bag asphyxia less unpleasant since they speed unconsciousness and minimize carbon dioxide buildup.

"Many are cold, but few are frozen." --Anon.

Introduction Hypothermia (hypo=low, thermia=temperature) is an effective, but infrequently used suicide method. It is a poor choice for a suicidal gesture, unless one is sure of timely intervention.

Fatality rate: More than 30%

Permanent injury: Moderately likely

What are the pros and cons of hypothermia for suicide?

Pros

Cons

What is hypothermia?

The freezing point of water, under standard conditions, is 32 degrees F (0 degrees C) and its boiling point is 212 degrees F (100 degrees C). Normal human body temperature is around 98.6 degrees F (37 degrees C), and is tightly regulated by a variety of physiological mechanisms. Even a 3.6 degrees F (2 degrees C) change is significant; a 5.4 degrees F (3 degrees C) fever is a medical emergency.

Systemic hypothermia is generally defined as a body temperature below 95 degrees F (35 degrees C). Severity is rated by how low the core body temperature falls: 89.6-95 degrees F (32-35 degrees C) is "mild" hypothermia; 80.6-89.6 degrees F (27-32 degrees C) is "moderate"; below 80.6 degrees F (27 degrees C) is "severe".

Hypothermia is also divided into "acute" and "chronic" categories. Acute hypothermia occurs quickly, roughly within two or three hours; chronic hypothermia takes longer. While the boundaries are fuzzy, the distinction is more than academic, since both treatment and prognosis differ between the two. This will be discussed in more detail in the "Rate of cooling" section.

What causes hypothermia?

Hypothermia occurs when the quantity of body heat lost to the external environment substantially exceeds the heat generated from metabolism. This can be caused by a decrease in heat production, or an increase in heat loss, or both.

Heat production

Low heat production is usually due to insufficient food, illness, injury, or some drugs.

An average resting body gives off about 50 kilocalories (kcal) or "kitchen" calories---the "calories" you see on food labels---of heat per square meter of skin per hour. Multiplied by the average person's 1.7 square meters of skin and 24 hours, you lose around 2000 kcal per day to the outside world, which is about the amount that you generate at rest from the food that you've eaten. This is called "basal metabolism".

If your muscles are working, metabolic heat production goes way up. For example, while you're shivering, you generate roughly five time as much heat as when sitting quietly; while exercising, ten times as much.⁽⁴⁰⁴⁾

However, exercise is a two-edged sword in hypothermia. While it produces heat, which is needed to keep body and mind functioning, it also increases blood flow to your active muscles, and thus heat loss from them. In addition, it uses up energy stores quickly. The decision whether to exercise in a potentially hypothermic situation depends on the circumstances: how long the conditions are expected to last, availability of food and shelter, and need for clear thinking.

To some degree there is no choice in the matter: shivering is a form of involuntary exercise. It increases heat production by 200-700%,⁽⁴⁰⁵⁾ but is accompanied by an increase in blood flow to/from the muscle, resulting in about a 25% increase in heat loss, too. Shivering is an effective means of generating heat, until muscles run low on energy.

The common warning against going to sleep in the cold is certainly appropriate if you're in the process of walking out of trouble; but that is not always the right thing to do. For example, someone with reasonable cold-weather clothing caught in a mountain blizzard might be better off building a snow-hole or shelter, staying as dry and warm as possible, and sleeping through the storm.

Heat loss

Excessive heat loss is due to cold surroundings or to a failure in the body's temperature regulating mechanism.

There are four physical mechanisms of heat loss:

(1) convection: heat loss by means of molecular transfer of energy via air or water currents.

(2) conduction: heat loss by touching something that's colder than you are. This is, fundamentally, the same process as convection, but mostly applies to solids.

(3) radiation: heat loss from invisible infrared-wavelength energy you give off.

(4) evaporation: heat loss from the cooling effect of changing a liquid into a gas.

Looking at these in more detail:

Convection and conduction

Most heat loss in hypothermia is from contact with cold air or cold water: you're always generating a micro-environment of warm air (or water, if that's where you are) around your body, but this is easily stripped away by air/water currents or your own movements. You can easily demonstrate this by putting your hands into a container of cold water, and holding them still for a few seconds. If you then move your hands, they will feel suddenly colder, as unwarmed water contacts them.

At a molecular level, what happens is that cold air/water molecules hit your skin, pick up some heat (energy) and bounce off, leaving cooler skin behind (hot air/water warms you by the same process, with the hot molecules transferring energy to your skin). This cooler skin, being in contact with the rest of the body, is in turn warmed by the body core, which is thereby cooled. The colder the air/water molecules, the faster this occurs.

The rate of convective heat loss also depends on the density of the moving substance (heat loss in water is much faster than in air of the same temperature) and the velocity of the moving substance (the faster the air/water current, the faster the heat exchange).

Another variable in heat loss is surface area. The more surface area, the more heat transfer. Curling up in the fetal position minimizes heat exchange by minimizing surface area, and thus evaporation, radiation, and convection. It may also be comforting for atavistic reasons.

With cold air, some of the variables that affect heat loss are: temperature, wind speed, insulation, and humidity. We'll look at their effects in a bit more detail.

Wind

Wind speed is the cause of the often-misunderstood "wind chill factor". "Wind chill" is just a practical demonstration of air convection, and is nothing more complicated than wind removing the warmed (by you) air molecules from near your body and replacing them with cold ones. This results in your body being hit by more cold air molecules per minute, and so being cooled more. For example, 0 degrees F (-18 degrees C) with no wind causes heat loss at the same rate as 30 degrees F (-1 degrees C) and 25 mile-per-hour (40 kilometer-per-hour) breeze.⁽⁴⁰⁶⁾ However, the latter case would not drop below 30 degrees F (-1 degrees C), in the absence of evaporative effects.

Evaporation

A second consideration, which is not technically part of wind chill factor calculations but may be biologically important, is that more wind will cause faster evaporation of sweat. This will remove from your body around two a half kilocalories per teaspoon of sweat, if any is present, and thus additional cooling.

Evaporation cools you because energy (heat) is always required to change a liquid into a gas. If the liquid is on or near your skin (sweat, water, or wet clothing), the heat comes from you, leaving you cooler. This is handy in the desert, but not so good if you're trying to keep from freezing. Thus, a dry body will cool faster in the presence than absence of wind ("wind chill"), but it won't get below ambient temperature. A wet body in the wind will cool both faster and further, and may drop far below ambient temperature.

Radiation

Another way heat is lost is by radiating it away in the form of infrared (electromagnetic) energy.^(407f) This requires a temperature difference between you and the outside world. The greater the difference, the larger and faster the heat loss (or gain, if the environment is at a higher temperature).

Infrared wavelengths are longer than the unaided human eye can detect, but electronic enhancement permits these wavelengths to be "translated" into our visible range.^(408f) One sort of night-vision goggles is sensitive to infrared wavelengths, allowing you to see things that are at a different temperature than their background. (Another kind amplifies existing light.) Since about a fifth of the heart's output of blood goes to the head (15% to the brain)⁽⁴⁰⁹⁾, it's not surprising that in cold weather an uncovered head may be responsible for more than half the body's total heat loss.⁽⁴¹⁰⁾ Under these circumstances a bare head shows up, on an infrared detector, like a beacon.

Insulation

External insulation consists of clothing and shelter. In cold climates both function to keep the air nearest your body, which you have spent precious calories warming, from leaving quickly and being replaced by cold air.

Sweating increases heat loss in two ways: in addition to causing heat loss from evaporation, it replaces some trapped air in clothing and blankets. Since water conducts heat about 25 times faster than does dry air, this will increase heat loss under cold conditions.⁽⁴¹¹⁾

Some materials,^(412f) like wool and a variety of synthetics (Fiberfill, Holofil, Capilene, Thermax, etc.) maintain their loft (and thus insulating ability) better than others (cotton, down) that mat down when they get wet.^(413f) Nevertheless, any clothing that gets wet or even damp will allow faster heat loss than would the same item dry, both because water conducts heat better than air does, and from increased evaporation.

Internal insulation involves fat and bulk. It is not an accident that mammals in cold climates are, as a rule, larger than closely related warmer-environment species.^(414f) They also have a smaller surface-to-volume ratio; are rounder, and have smaller ears, nose, and tail, and thus less heat loss. You can see these differences if you compare, say, cold- and warm-region rabbits or bears.

Fat is very useful in cold climates. Because fat tissue has relatively low blood flow, it acts as a good barrier to heat loss from important core organs. Equally important, it also is a concentrated metabolic energy (heat) source, providing about 9 kilocalories per gram, compared to some 4 kcal per gram of protein or carbohydrate.

Humidity

The low humidity level of frigid air can play a role in hypothermia. On the one hand, the higher the humidity (gaseous water molecules), the more particles will be available to snatch heat from the skin (though this is offset by the lower density of warm air). On the same side of the equation, humidity will decrease the insulating properties of clothing. However, the humidity is limited by the temperature. For example, the maximum possible humidity at 32 degrees F (0 degrees C) is only one tenth the maximum at 98 degrees F (36.6 degrees C). Thus, at temperatures below the freezing point of water there simply isn't enough gaseous water in the air for these processes to matter much.

On the other hand, low humidity increases the net evaporation of sweat, which is a major cooling mechanism (and which is why people are much less comfortable on a hot, humid day than a hot, dry one). Low atmospheric humidity can also contribute to dehydration for other reasons, since (1) the body sweats to keep skin from drying out (a humidity level of 70% nearest the skin is ideal); (2) exhaled air is close to 100% relative humidity. (The condensation you see from your breath on a cold day is a visual reminder of this.) I estimate the daily amount of water lost in breath at freezing temperatures to be about 1.3 pints (0.6 liters). ~0.4 gm water/min --> ~0.6 L/day...... x 600 kcal/L to heat & evaporate -->~~350 kcal/24 hrs If the heat capacity of air is ~ 1/1,000 that of liquid water (check) 1L x 10 br/min x 60 x 24 x 1mol/20L = 720 mol air.... x .018gm/mol x 40 (delta T) =~ 0.5 kcal/24 hrs. Thus, very little heat is used to warm up the air that you breathe. Whew! -->

Demographics: who dies from hypothermia?

In a recent study of 234 cases of hypothermia in Switzerland, 43 (18 percent) were attempted suicides; 141 were due to accidents or mountaineering-related; the rest to a variety of causes. Three quarters occurred in cold air; the others in cold water. 68 (29%) of the 234 died. The coldest survivor had a core temperature of 63.5 degrees F (17.5 degrees C) and the longest heart stoppage (in a survivor) was 4.75 hours⁽⁴¹⁵⁾.

Hypothermia is not uncommon among the elderly, who often are in frail health, frequently live alone, and may not be able to afford adequate heating or food. These people are at high risk of dying of cold. In some British studies, 3-4% of elderly admissions to hospitals were hypothermic⁽⁴¹⁶⁾. Similar circumstances apply to the homeless; in Chicago, 8 of 22 (36%) hypothermia deaths were among the homeless⁽⁴¹⁷⁾. In the U.S. there were an average of 780 annual deaths attributed to hypothermia between 1979-1990⁽⁴¹⁸⁾; however only a handful (less than ten a year) are officially suicides.

You might be surprised---I certainly was---at the geographical distribution of the top ten hypothermic-death-rate States in the U.S.⁽⁴¹⁹⁾ While Alaska and Illinois are northern states with severe winters, the others are not: Alabama, South Carolina, North Carolina, Virginia, Arizona, New Mexico, Oklahoma and Tennessee.

What's going on here? Cold weather turns out to be only one of several relevant factors. Another is how quickly and unpredictably temperatures change, due to unstable weather patterns, as in the Carolinas and Virginia. High elevation and clear skies cause large temperature drops from day to night time; this is the situation in New Mexico and Arizona (23 people died of hypothermia in New Mexico during the 1993-94 winter). It may also be that people in the South have little experience with severe cold and underestimate its danger. Two other inter-related factors are poverty, such that people can't afford adequate shelter and heat, and a high proportion of older residents; older folks are more susceptible to cold injury, more likely to be poor, and more likely to live alone and unnoticed. Half of hypothermia deaths in this country are among people 65 or older.⁽⁴²⁰⁾

What are the physiological effects of cold?

Temperature regulation

Central temperature regulation in mammals is located in the anterior hypothalamus section of the brain. It is sensitive to blood temperature changes of as little as 1 degree F (0.5 degrees C) and also reacts to nerve impulses sent from nerve endings in the skin. Injury or tumors in the hypothalamus can lead to fatal loss of thermal control even at room temperatures.

Heat conservation

In cold conditions, heat is first conserved by decreasing blood flow to the skin and skeletal muscles, and is controlled by the "sympathetic" nervous system.

Interestingly, some marine mammals, such as seals, have an additional full-time heat conservation method called "countercurrent" blood flow. Normally, warm-blooded creatures in cold water would be expected to lose a lot of heat from their flippers and fins, which have and need a large surface area for propulsion. However this heat loss is decreased because the arteries and the veins in the flippers/fins run right next to each other. This allows heat transfer between the two and means that some of the heat contained by the arterial blood warms the returning venous blood rather than being wasted in warming the seawater. Very crafty.

In humans, typical blood flow to the skin is 300-500 ml/min. Maximum physiological constriction can decrease this to around 30 ml/min. One of the consequences of this is that blood will pool in the core organs at higher-than-normal pressure.

This, in turn, forces the kidneys to increase urine output ("cold diuresis"), which is only a minor heat loss, but may be a significant cause of dehydration, and increases the load on the heart because the blood is more viscous. Nothing has only one effect.

Heat generation

Additional heat is generated by shivering. This reflex is set off by lowered temperature either in the skin or deeper in the body. The fact that it is not under voluntary nervous control is shown by its existence in paraplegics and in people temporarily paralyzed by curare.⁽⁴²¹⁾(422f) Shivering continues down to a core temperature of around 90 degrees F (32 degrees C), but falters below there, and stops altogether at around 86 degrees F (30 degrees C)⁽⁴²³⁾. It also ceases, during slow hypothermia, if muscles use up their energy stores (glucose/glycogen); this occurs after a few hours. In either case, body temperature drops precipitously after the shivering reflex fails.

"Goosebumps" (piloerection), which lift hairs or feathers away from the body, increase the amount of trapped air---insulation---near the skin. Unfortunately, since humans are more-or-less hairless^(424f) over most of their bodies, this process doesn't do us much good. But it was a fine idea when we were furry and is still an interesting sensation.^(425f)

Rate of heat loss

As a practical matter, most hypothermia is the result of contact with either cold air or cold water. Since air has a much lower ability to remove heat than does water, hypothermia in air normally takes many hours and is usually "chronic" or "slow". "Acute" (fast) hypothermia, generally in or due to water, has some significantly different characteristics from the chronic variety.

In slow, as compared to fast, hypothermia, the body has more time to make some physiological responses: blood flow to the limbs and skin decreases, blood pools in the core organs, and shivering continues until metabolic energy supplies are depleted. People develop the physical and mental lethargy commonly associated with hypothermia.

One of the hazards specific to fast hypothermia is a phenomenon called "afterdrop" in which the core temperature continues to fall even after a person has been taken to a warm place. This is because blood vessels in the arms and legs get larger (dilate) as they start to be rewarmed. As a consequence:

(1) blood moves from the core into the limbs (which, despite warming, are still colder than the core), and gets chilled further. This results in more cold blood moving from the periphery into the core, further decreasing core temperature, which can be lethal;

(2) redistribution of blood from the core to the periphery decreases blood pressure, and may lead to heart failure ("shock");

(3) the stagnant blood from the limbs is very acidic (from lactic acid and carbon dioxide buildup) which may cause cardiac arrhythmias and death.

Afterdrop can best be avoided by not rewarming the periphery until after warming the core. This was observed by one of Napoleon's army doctors during the retreat from Moscow, when he noticed that the hypothermic soldiers placed closest to warming fires tended to die more often than those further away.

Fatal chilling may occur before physical and mental abilities are seriously retarded: in 1980, 16 Danish fishermen spent about one-and-a-half hours in the North Sea when their boat went down. When rescued, all could climb into the cargo net, and walk across the deck of the rescue vessel. They went below to the galley for hot drinks (good idea) and to warm up quickly (bad idea). Every one of them died of afterdrop hypothermia.⁽⁴²⁶⁾

Susceptibility to cold

There are age, racial and gender differences in susceptibility to cold. Infants and the old are much more likely to be injured than are young adults. Fat people are less subject to hypothermia than are thin ones. Fashion models drop like flies. Men are more vulnerable to hypothermia than are women, even though they are larger, because women have more subcutaneous fat, which is better insulation (less blood flow) and energy store (more calories per gram) than muscle. Blacks seem more sensitive to cold than are Inuit or caucasians.⁽⁴²⁷⁾ Interestingly, Australian Aborigines apparently lower their body temperature (and, as a result, metabolism and food needs) to around 95 degrees F (35 degrees C) on cold nights.⁽⁴²⁸⁾(429f)

Effects of cold

Behavior and reflexes

In slow hypothermia, by the time body temperature drops to 90 degrees F (32 degrees C) both the central and peripheral nervous systems are impaired, primarily due to decreased blood flow to the brain (6-7% per degree C⁽⁴³⁰⁾): people are physically and mentally clumsy, show decreased sensitivity to pain, have slowed reflexes, and may hallucinate. Thus, a medical school mnemonic for hypothermia symptoms: "stumbles, mumbles, fumbles, and grumbles", which summarizes changes in motor coordination and consciousness.

Sleepiness ("cold narcosis") occurs at around 86 degrees F (30 degrees C) core temperature. At around 81 degrees F (27 degrees C), people stop responding to verbal commands, and some reflexes (such as the reaction of eye pupils to light) stop working entirely. Knee jerk is the last reflex to go,^(431f)(432) at 79 degrees F (26 degrees C). The body's temperature regulating mechanisms also fail and there is quick cooling until the body reaches ambient temperature. However, there is the usual individual variability, with recorded reflexes as low as 68 degrees F (20 degrees C).⁽⁴³³⁾

Heart

The heart's response to hypothermia is usually the actual cause of death. Initially, the heart merely slows down and shows some electrocardiograph changes. Dehydration---blood really is thicker than water---makes it harder for the heart to pump increasingly viscous blood. Ventricular fibrillation is often---but not always---seen below 89.6 degrees F (32 degrees C), and reaches a maximum between 82.4-86 degrees F (28-30 degrees C).⁽⁴³⁴⁾

Ventricular fibrillation occurs when different parts of the muscle surrounding the main pumping chambers beat in a chaotic, unsynchronized fashion; as a result the heart can't send blood through the arteries---with fatal consequences unless reversed. In hypothermic conditions fibrillation may easily be set off by even minor exertion. If the heart escapes fibrillation, it slows further as the temperature drops. In one case, a woman had a pulse of four beats per minute (room-temperature normal is around 75 per minute) with a body temperature of 52 degrees F (11 degrees C), and the heart stopped pumping entirely at 51 degrees F (10.5 degrees C). Her heart restarted when she was rewarmed.⁽⁴³⁵⁾

Brain

At normal body temperature, brain damage starts in about five minutes, in the absence of blood flow; at lower temperatures the length of time before brain (and other organ) injury is substantially longer. This is because cellular metabolism and oxygen needs drop sharply with lowered temperature. For example, oxygen consumption is reduced by 50% at 82.4 degrees F (28 degrees C); 75% at 71.6 F (22 degrees C); 92% at 50 F (10 degrees C).⁽⁴³⁶⁾

However, people whose bodies cool down faster than they run out of oxygen (e.g. fast hypothermia in air, drowning in icy water), can be revived longer. Those who run out of oxygen faster than their temperature drops (e.g. avalanche, drowning in warmer water) will not be revivable as long. Some hypothermic people have been given CPR for up to 3.5 hours and have recovered without neurological damage.

Cause of death

Death is generally from circulatory failure: the heart either goes into ventricular fibrillation or slows down and stops altogether. In people who have survived the first couple of days after rescue, organ failure, particularly of the pancreas, may lead to delayed death.⁽⁴³⁷⁾ A wide range of other organs also may show acute damage from cold, but these injuries, while sometimes severe, are not usually fatal.

Signs and symptoms of hypothermia associated with specific temperatures

Looking at signs and symptoms in relation to temperatures, rather than by organ systems, give a somewhat different perspective.

The following chart⁽⁴³⁸⁾ shows the body core temperature and corresponding signs and symptoms. Not all hypothermic people exhibit all of these symptoms, which will also change as the person's core temperature changes.

Core temperature Signs and symptoms

99 to 97F (37 to 36C) Normal temperature range, shivering may begin.

97 to 95F (36 to 35C) Cold sensation, goose bumps, unable to perform complex tasks with hands, shivering mild to severe, skin numb.

95 to 93F (35 to 34C) Shivering intense, muscle incoordination becomes apparent, movements slow and labored, stumbling pace, mild confusion, may appear alert, unable to walk straight.

93 to 90F (34 to 32C) Violent shivering persists, difficulty speaking, sluggish thinking, amnesia starts to appear and may be retrograde, gross muscle movements sluggish, unable to use hands, stumbles frequently, difficulty speaking.

90 to 86F (32 to 30C) Shivering stops in chronic hypothermia, exposed skin blue or puffy, muscle coordination very poor with inability to walk, confusion, incoherent, irrational behavior, but may be able to maintain posture and the appearance of awareness.

86 to 82F (30 to 27.7C) Muscles severely rigid, semiconscious, stupor, loss of awareness of others, pulse and respiration slow, pupils can dilate.

82 to 78F (27 to 25.5C) Unconsciousness, heart beat and respiration erratic, pulse and heart beat may be unobtainable, muscle tendon reflexes cease.

78 to 75F (25 to 24C) Pulmonary edema, failure of cardiac and respiratory centers, probable death. DEATH MAY OCCUR BEFORE THIS LEVEL

What are the clinical signs of hypothermia?

In addition to the behavioral symptoms mentioned, there is often swelling, especially of the face and ears, as fluid leaks out of the circulation. This is another cause of viscous blood, which overworks the heart. Blood pressure is low and sometimes unmeasurable, as are pulse and respiration. There may be no signs of life whatsoever below temperatures of 64-81 degrees F (18-27 degrees C)⁽⁴³⁹⁾. And with good reason: most of these people are dead. However, there have been occasional cases of survival despite extreme temperatures. Perhaps the most astonishing was that of a man found with a body temperature of 32 degrees F (0 degrees C), who felt frozen and had no signs of life⁽⁴⁴⁰⁾. Yet, when thawed, he revived.^(441f) Thus, in the felicitous phrase of Dr. R.T. Gregory, "No one is dead until warm and dead."⁽⁴⁴²⁾

Some risk factors for hypothermia: alcohol, other drugs, exercise

Alcohol

The role of alcohol in hypothermia is controversial. On the one hand, it predisposes to hypothermia by several mechanisms:

(1) It produces an increase in blood flow (and thus heat loss) near the skin ("cutaneous vasodilation"). Since the skin contains many temperature receptors, drinking alcohol generates a sensation of warmth, but this comes at the expense of internal heat;

(2) Alcohol causes hypoglycemia (low blood sugar), which decreases the body's ability to produce heat;

(3) As a central nervous system (CNS) depressant, alcohol slows metabolism and promotes sleepiness;

(4) And certainly alcohol impairs judgment, which may be critical under adverse conditions.

Many hypothermia victims have blood alcohol concentrations (BAC) ranging from 0.13 to 0.25 gm/100 ml blood⁽⁴⁴³⁾. "Legally impaired" in most of the US is 0.08-0.10 gm/100 ml BAC. Since exercise also increases blood flow to the skin, the combination of alcohol with strenuous exercise would seem to cause maximum heat loss.

On the other hand, alcohol appears to protect the heart against fibrillation (and has been used for that purpose during low-temperature medical operations, at levels of 0.40 gm/100 ml blood⁽⁴⁴⁴⁾). Perhaps this protective effect causes the observed higher survival rate in hypothermics who had been drinking, compared to those who were sober.⁽⁴⁴⁵⁾

In addition, alcohol protects limbs against frostbite (freezing) by increasing their blood flow, but again, this is at the expense of core temperature.

Other drugs

Some other drugs that have central nervous system depressant effects can also produce hypothermia, for example barbiturates, opiates, and the "major tranquillizer" chlorpromazine and related compounds; but also some non-sedatives like acetaminophen (Tylenol) and lithium ion (used to treat manic-depressive behavior). A more complete list is found in Appendix Table C-1. These drugs interfere with temperature regulation at the hypothalamic regulatory center in the brain, and may cause hypothermia even at room temperatures. Of 103 consecutive Intensive Care Unit drug overdose admissions, 27 were hypothermic⁽⁴⁴⁶⁾.

Survival factors

In the Swiss study of 234 cases of hypothermia,⁽⁴⁴⁷⁾ some of the factors that tended to be associated with the death of the victims were, in decreasing order of importance: (1) asphyxia (e.g. in avalanche); (2) invasive rewarming methods; (3) slow rate of cooling. Positive survival factors were (1) fast cooling rate; (2) presence [sic] of ventricular fibrillation in cardiac arrest cases; (3) presence of alcohol and/or narcotics in the body.

What are the medical treatments for hypothermia?

Treatment depends on the severity of the hypothermia, it's underlying cause, and the age and general condition of the patient. In the mildest cases, warm, non-alcoholic drinks, food, and a few blankets are enough.

If the hypothermia is moderate, or if the patient has low heat production due to exhaustion, illness, drugs, or malnutrition, more active warming is appropriate. This usually involves heating pads/blankets, hot water bottles, or other external sources of heat applied to the trunk. In wilderness situations, the best emergency rewarming may consist of sandwiching the (dried) hypothermic person in between two warm people, all inside or under a sleeping bag.

In severe or acute hypothermia "active core rewarming" (ACR) is often used. There are many varieties of ACR. For example, heated liquids may be circulated around the stomach by a tube running through the nose, or heated IV fluids may be administered. In the most critical cases, those whose hearts have stopped, blood is often withdrawn from the femoral vein^(448f) (the largest vein in the leg, conveniently close to the surface near the groin), heated to 104 degrees F (40 degrees C) and oxygenated, and reinjected into the femoral artery⁽⁴⁴⁹⁾

How long do people survive under cold stress?

In one recent study, 8 of 11 people with deep hypothermia and cardiac arrest were resuscitated⁽⁴⁵⁰⁾. Five of the eleven had no heartbeat and six had ventricular fibrillation. None were breathing and all were clinically dead with wide, non-reactive pupils, and were supported by external heart massage and ventilation (CPR). The average (mean) length of exposure to the cold in the survivors was 4.4 hours, and average core temperature was 72.5 degrees F (22.5 degrees C). All three of the patients who died had also been asphyxiated (1 avalanche, 2 drownings).

Cold Water

Data from shipwrecks and accidents suggest that a well-nourished man can survive roughly two hours in water at 39 degrees F (4 degrees C).⁽⁴⁵¹⁾ At 32 degrees F (0 degrees C) survival time is only about a half an hour.^(452f)(453) Since swimming, like other exercise, increases heat loss (as well as heat production) due to increasing blood flow near the skin, this may account for some accidental "drownings" in cold water amongst good swimmers. On the other hand, at temperatures above around 68 degrees F (20 degrees C), fit swimmers can continue for many hours. Swimmers attempting the English Channel, which has summer water temperatures in the mid-to-upper 50s F (13 to 15 degrees C) coat themselves with grease (more for insulation and to decrease water absorption than for buoyancy), and take hot drinks and quick-energy carbohydrate foods provided by their support boat every half hour or so.

However, if one is not exercising and taking in lots of calories, the same water temperature can be deadly: in March, 1995, four US Army Rangers died of hypothermia in Florida after spending several hours in water between 52-59 degrees F (11-15 degrees C) while training. Similarly, a man died of hypothermia after getting stuck in the mud of a 15-foot-diameter pond, nowhere more than 3 feet deep.⁽⁴⁵⁴⁾ Air temperature was 70 degrees F (21 degrees C) and water temp was 52 degrees F (11.5 degrees C). Even warm (e.g., 95 degrees F, (35 degrees C)) water will chill you after an hour or so unless you are actively exercising.

As always, there is substantial variability between people. For example, the lowest temperature water in which different young men and women at rest could maintain a steady body temperature ranged from below 53.6 degrees F (12 degrees C) to 89.6 degrees F (32 degrees C). This depended on both insulation (primarily thickness of the fat layer on the trunk) and metabolic heat production. Each of these factors was about equally important: fast metabolizers could maintain body temperature in water 18 degrees F (10 degrees C) colder than slow metabolizers who had the same amount of body fat.⁽⁴⁵⁵⁾

Cold air

Immersion in cold water seems to cause loss of body heat about twenty-five to thirty times as fast as air at the same temperature.^(456f) As a result, survival time in cold air is much longer than in water of the same temperature. Consequently, secondary factors, such as wind speed, precipitation, and amount and type of clothing worn, are more important in cold air than in cold water.

Cold Comfort: how to do it

On land: Make arrangements so you won't be looked for: e.g., tell people you're going away for a few days. Go to a cold, secluded spot where you won't be seen. Drink alcohol and/or take sedatives. You can speed up the process by removing clothing and/or getting wet. Obviously, the amount of time needed will also be very dependent on temperature and wind conditions, and your size, weight, and fat content. These are too many variables to make even rough time estimates.

Use of a home freezer has been recommended⁽⁴⁵⁷⁾ but the air supply in such freezers is so limited that asphyxia will occur long before hypothermia. Commercial freezers are a possibility, but the risk of untimely discovery must be considered.

In water: Since heat loss in water is much faster than in air of the same temperature, the amount of time that one is subject to being saved is correspondingly less. The main concern will be to avoid being seen, both to avoid unwanted rescue and to prevent risk to potential rescuers. Depending on the temperature of the water and your physical condition, fatal hypothermia can occur in as little as 30 minutes or so; less after alcohol and/or sedatives. Be aware that unless the water is very shallow (and even then if you end up face down), you are likely to actually die of drowning while insensible from cold, rather than from hypothermia.

Summary

Hypothermia is an under-appreciated means of suicide: it is relatively painless, though certainly uncomfortable, and generally fatal if not interrupted. The main disadvantage is that it normally takes several hours on land (but much less in water), during which time permanent injury is quite possible if rescue occurs. A second major disadvantage is that the availability of hypothermia is limited by climate and season.

As a suicidal gesture, hypothermia is a bad choice, because the length of time is so dependent on both weather and individual variables. And while, in principle, you can change your mind, in practice you lose too much capacity to think and/or act rationally when hypothermic for this to be a reliable survival net.

"We must all hang together, or assuredly we shall all hang separately." --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?

Pro:

Con:

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.⁽⁴⁵⁸⁾ 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.⁽⁴⁵⁹⁾

U.S. National Statistics

There are roughly 30,000 suicides per year in the U.S.. The annual average number of suicides by hanging, strangulation, or suffocation between 1979-1994 was 4270. 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 H-1 Suicide by Hanging, E953.0 Rate is per 100,000 people per year.
	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
OtherFemale	65	5,744,548	1.13	1.34

Suicide by Plastic Bag Asphyxia, E953.1 Rate is per 100,000 people per year.
	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
E-numbers are International Classification of Disease (ICD) codes. 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)⁽⁴⁶⁰⁾ and in Denmark, 53.⁽⁴⁶¹⁾ 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 NYC age distribution for hangings was similar to that in Great Britain and Denmark, with a mean age of around 54 years.⁽⁴⁶²⁾(463f)

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 vs 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 per cent of suicides in general. The peak at age 60-69 was attributed to people with health problems.

The study from Atlanta⁽⁴⁶⁴⁾ 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% (9/15) of jail hangings were among blacks, and twice the percentage of blacks as whites who hanged themselves did so in in jail (38% vs 19%). Since (a) the Atlanta jail population is disproportionately black and; (b) the suicide rate among prisoners in the U.S. is several times higher than that of the general population^(465f) 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⁽⁴⁶⁶⁾

Fifteen of the total of 56 hangings (28%) took place in jails.^(467f) 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".⁽⁴⁶⁸⁾ Another report showed 18% legally drunk.⁽⁴⁶⁹⁾ A third cited alcohol in 34%, but included levels well below intoxication.⁽⁴⁷⁰⁾

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.⁽⁴⁷¹⁾

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.⁽⁴⁷²⁾ 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.⁽⁴⁷³⁾

An excessively long drop can result in separation of head from body, and is considered bad form by professional hangmen.^(474f)

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;⁽⁴⁷⁵⁾ however his number seems to be based on the fact that the heart may continue beating for up to 20 minutes after judicial hanging,⁽⁴⁷⁶⁾ 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⁽⁴⁷⁷⁾). 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.^(478f)

"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 eight⁽⁴⁷⁹⁾ to fifteen⁽⁴⁸⁰⁾ seconds.^(481f)

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.⁽⁴⁸²⁾

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."⁽⁴⁸³⁾

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."⁽⁴⁸⁴⁾

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).⁽⁴⁸⁵⁾ 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.⁽⁴⁸⁶⁾

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."⁽⁴⁸⁷⁾

However, while some look livid, about 60 percent of hangers have a "pale and placid" face.⁽⁴⁸⁸⁾ 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.⁽⁴⁸⁹⁾(490f)

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."⁽⁴⁹¹⁾ 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."⁽⁴⁹²⁾ 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."⁽⁴⁹³⁾ Certainly, airway blockage is not essential to successful hanging. In one case a woman with a tracheotomy^(494f) 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:

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!' "⁽⁴⁹⁵⁾

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.⁽⁴⁹⁶⁾

Accident

How often are hanging deaths due to accident? Combining four studies of hanging⁽⁴⁹⁷⁾, 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."⁽⁴⁹⁸⁾

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.⁽⁴⁹⁹⁾ However the circumstances and details of the hangings are usually quite different; in autoerotic hanging:

Note, especially, points 5 and 6; these people die because they lose consciousness quickly and unexpectedly.⁽⁵⁰¹⁾

Some of the case reports are truly bizarre,⁽⁵⁰²⁾ but interestingly, asphyxia as a means of sexual arousal is a centuries-old practice documented by anthropologists.⁽⁵⁰³⁾

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."⁽⁵⁰⁴⁾

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.^(505f) 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."⁽⁵⁰⁶⁾

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^(507f), 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."⁽⁵⁰⁸⁾

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.⁽⁵⁰⁹⁾ 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 source⁽⁵¹⁰⁾ provides similar data:

Hanging Drop Heights

Culprit's Weight	Drop
14 stone (196 lbs)	8ft 0in
13.5 stone (189 lbs)	8ft 2in
13 stone (182 lbs)	8ft 4in
12.5 stone (175 lbs)	8ft 6in
12 stone (168 lbs)	8ft 8in
11.5 stone (161 lbs)	8ft 10in
11 stone (154 lbs)	9ft 0in
10.5 stone (147 lbs)	9ft 2in
10 stone (140 lbs)	9ft 4in
9.5 stone (133 lbs)	9ft 6in
9 stone (126 lbs)	9ft 8in
8.5 stone (119 lbs)	9ft 10in
8 stone (112 lbs)	10ft 0in

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^(511f) 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."⁽⁵¹²⁾

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.⁽⁵¹³⁾

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.^(514f) 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]",⁽⁵¹⁵⁾ 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.,⁽⁵¹⁶⁾ and the other of 106 hangings in New York City⁽⁵¹⁷⁾ show the range of materials used:

Table H-6 Ligatures used in suicidal hangings
	Luke, 1985	Luke, 1967
	Seattle, Wa.	New York City
	n=61	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."⁽⁵¹⁸⁾

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 H-7.

Table H-7 Location of knot in suicidal hangings(519)
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%).⁽⁵²⁰⁾

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.⁽⁵²¹⁾

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.⁽⁵²²⁾

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.⁽⁵²³⁾ 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.⁽⁵²⁴⁾

Position of the body In one study, 37% (30/80) of hanging victims were completely suspended; 63% (50/80) were in contact with the ground⁽⁵²⁵⁾ 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.⁽⁵²⁶⁾

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.⁽⁵²⁷⁾ 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.⁽⁵²⁸⁾ 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.⁽⁵²⁹⁾

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.⁽⁵³⁰⁾

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.⁽⁵³¹⁾

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.⁽⁵³²⁾ 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.⁽⁵³³⁾

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.⁽⁵³⁴⁾

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.⁽⁵³⁵⁾

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.⁽⁵³⁶⁾

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.⁽⁵³⁷⁾

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.⁽⁵³⁸⁾

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."⁽⁵³⁹⁾

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.⁽⁵⁴⁰⁾

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.⁽⁵⁴¹⁾ And, curiously, sometimes the right eye stays open and has a large (dilated) pupil while the left eye is closed and pupil constricted.⁽⁵⁴²⁾ 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,⁽⁵⁴³⁾ 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.⁽⁵⁴⁴⁾ 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.⁽⁵⁴⁵⁾ Five of 39 people rescued from near-hanging had such persistent injury.⁽⁵⁴⁶⁾

On the positive side, there are rare, but well-documented, cases of spontaneous remission of depression after near-hanging.⁽⁵⁴⁷⁾

Longer answer

Drop Hanging. Drop hanging may not be instantly fatal and, " the possibility of briefly retained consciousness in some cases appears quite real."⁽⁵⁴⁸⁾ 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⁽⁵⁴⁹⁾ Thus, " the length of the drop, though important, does not produce expected or consistent results."⁽⁵⁵⁰⁾

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.⁽⁵⁵¹⁾ In any case, various types of lung damage are the most frequent cause of delayed death in near-hangings.⁽⁵⁵²⁾

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.⁽⁵⁵³⁾

(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.⁽⁵⁵⁴⁾

(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.⁽⁵⁵⁵⁾

(4) Finally, there is a fascinating case in England from 1650.⁽⁵⁵⁶⁾ 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:

(1) use a high-friction ligature that will stay in place;

(2) use a double knot;

(3) 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;

(4) 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;

(5) 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 $5 and $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, (a) bending forward increases the diameter of the neck, and thus the constrictive effect of the ligature; (b) 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.

Suicide remains paradoxical: it is legal to do but illegal to assist; and if you express the intention to carry out this legal action, you will, most likely, find yourself locked up.

As of this writing (early 1999), the central legal, legislative, and ethical suicide issue is Physician-assisted suicide (PAS). PAS is the most reliable and least traumatic approach to suicide, and has been carried out since at least the time of the early Greeks. (Hippocrates' Oath was partly in response to this practice.) The current ethical arguments, for and against it, were laid out in the early 1870s and have changed remarkably little.⁽⁵⁵⁷⁾ Meanwhile, medical ability to prolong dying has increased to the point where the public is often more afraid of dying than of death. This is the driving force for legalization of assisted suicide.

The ethical situation is not entirely clear-cut; both sides have valid points. Under the circumstances, there is really no way of knowing if PAS opponents' fears will come to pass. Thus, the ongoing experience with PAS in Oregon will be of great importance and interest, and should answer some of the questions of potential abuse. The three-decade-long history of PAS in the Netherlands is also generally reassuring, though the differences between Dutch and American society makes extrapolations tentative.

I do not expect many of the already-decided to change their position quickly as a result of the information from Oregon starting to trickle in; people are quite capable of reaching divergent conclusions from the same data. The debate will continue, as it should; but we will, at last, have some facts and evidence to guide us.

The literature on suicide is immense. I mention here only a few of the books available that I found particularly valuable.

General

Alvarez, A. The Savage God, [Random House, 1972]. A brilliantly-written study of suicide, somewhat schizophrenically divided into an opening essay about Sylvia Plath, and material about everything else.

Colt, George Howe, The Enigma of Suicide [New York: Summit Books, 1991]. Readable and erudite. Much of the book is in the form of stories of the suicides of young people, interspersed with interviews and research findings. The historical material is especially well done.

Hendin, Herbert Suicide in America. [New York: W. W. Norton, 1982, 1995]. One of the best general works on American suicide. More medically and psychiatrically oriented (and less anecdotal) than Colt. I prefer the 1982 edition, because I feel it's more evenhanded than the 1995 revision. They are interesting to read side-by-side.

Forensic Medicine

Polson, Cyril J., Gee, D.J., Knight, Bernard The Essentials of Forensic Medicine, [4th ed. 1985. Pergamon]. The best single book on the subject.

Knight, Bernard, Forensic Pathology, [2nd ed. 1996, Oxford Univ Press] and Spitz W.U., Fisher, R.S. Medicolegal Investigation of Death [3rd ed, 1993, Thomas, Springfield Ill.] are more up-to-date and have better printing (useful for photographs), but can't match the breadth of Polson.

Medicine

Blumenthal SJ and Kupfer DJ, eds Suicide Over the Life Cycle [American Psychiatric Press, 1990]. Excellent academic study of risk factors, assessment, and treatment. Articles written by some of the leading researchers in the field.

Sociology

Lester, David Why People Kill Themselves: a 1990s summary of research findings on suicidal behavior, [3rd ed. Springfield, IL; Thomas, 1992]. You want numbers, correlations, associations? Look no further.

Philosophy/Ethics

Opposing Viewpoints Series Greenhaven Press. Consists of several books on bioethics (Suicide, Medical Ethics, Euthanasia, Death and Dying), all in the same format: 1 to 10 page excerpts or articles (and an occasional cartoon), paired up as "opposing viewpoints". They treat the topics fairly and understandably, if not in great depth. Perhaps the best place to get an overview of the issues, as presented by their advocates.

Medical Ethics Series [Indiana University Press] Smith DH and Veatch RM (eds) covers the same material as the preceding series, but in much greater depth and academic focus. About twenty volumes as of 1998.

Humber-JM, Almeder-RF, and Kasting-GA (eds) Physician-assisted Death in Biomedical Ethics Reviews (series), [Totowa NJ, Humana Press, 1993]. Intermediate in depth and range between the two preceding titles.

Hastings Center Reports/Magazine [Hastings-on-Hudson, New York] looks at topics in biomedical ethics through a quarterly magazine. Timely coverage and thoughtful articles.

Maguire, Daniel C. Death by Choice. [New York: Schocken Books, 1984]. A thoughtful, wide-ranging set of essays, examining the concept of "death by choice" as it applies to suicide, abortion, capital punishment, and war.

Rachels, James The End of Life [Oxford Univ. Press, 1986]. This is a straight-up philosophy book, tightly reasoned and clearly laid out. It examines the question of why killing is wrong, and under what circumstances it might not be.

Battin, M Pabst and Lipman, A. G. (eds) Drug Use in Assisted Suicide and Euthanasia, [New York : Pharmaceutical Products Press, 1996]. The title is a bit misleading; the book is a good collection of essays covering a wide range of issues related to physician-assisted suicide: legal, ethical, and medical.

Battin, M. Pabst. The least worst death: essays in bioethics on the end of life [New York, Oxford University Press, 1994]. This book provides a timely and cross-cultural perspective on end-of-life issues.

1f. The tone of some of the footnotes (and occasionally text) may strike readers as inappropriately flippant, given the nature of the subject. On the other hand, you might find it a therapeutic respite from page after page of unrelentingly earnest examination and preachy advice. (back to text)

2f. I will use male pronouns for most suicides and female ones for most suicide attempts. This reflects the relative male/female numbers in each category, as well as the lack of grammatically "correct" sex-neutral pronouns in the English language. (back to text)

3. Phillips DP; Sanzone AG "A comparison of injury date and death date in 42,698 suicides." Am J Public Health 1988 May; 78(5):541-3. (back to text)

4. Miller, Ted R. Databook on nonfatal injury : incidence, costs, and consequences Washington, D.C. : Urban Institute Press, 1995. (back to text)

5. Langone, John Dead End p2. (back to text)

6f. Final Exit recommended plastic-bag asphyxia or drug overdose for suicide. It was published in 1990 and became a best-seller. Comparing the number of suicides by those methods in 1990 and 1991, we find that plastic-bag asphyxias increased from 334 to 437 (up 31 percent), and intentional overdose deaths increased from 3,143 to 3,314 (up 5 percent). However, the total number of suicides decreased from 30,906 to 30,810. This is consistent with the idea that the book influenced the method used by a few people, but certainly did not unleash a wave of suicide, as some had predicted. The issue was debated by Derek Humphry and P.M. Marzuk [Marzuk PM; Tardiff K; Leon AC "Increase in fatal suicidal poisonings and suffocations in the year Final Exit was published: a national study [see comments]" Am J Psychiatry 1994 Dec;151(12):1813-4 COMMENT: Am J Psychiatry 1995 Dec;152(12):1832-3], but curiously neither side mentioned (or perhaps noticed) that twice as great an increase in plastic bag suicides (up 70 percent) occurred between 1985 and 1986---5 years before Final Exit. (back to text)

7f. To give you some idea, "Over the past two centuries people have committed suicide by jumping into volcanoes, vats of beer, crocks of vinegar, retorts of molten glass, white-hot coke ovens, or slaughterhouse tanks of blood; by throwing themselves upon buzzsaws; by thrusting hot pokers down their throats; by suffocating in refrigerators or chimneys; by locking themselves into high-altitude test chambers; by crashing airplanes; by jumping from airplanes; by lying in front of steamrollers, by throwing themselves onto the third [high voltage] rail; by touching high tension wires; by placing their necks in vices and turning the handle; by hugging stoves; by freezing to death; by climbing into lions' cages; by blowing themselves up with cannons, hand grenades, or dynamite; by boring holes in their heads with power drills; by drinking hydrochloric acid or Drano; by walking in front of cars, trains, subways, and racehorses; by driving cars off cliffs or into trains; by swallowing poisonous spiders; by piercing their hearts with corkscrews or darning needles; by starving themselves; by swallowing firecrackers; by holding their heads in buckets of water; by beating their heads with hammers; by pounding nails or barbecue spits into their skulls; by strangling themselves with their hair; by walking into airplane propellers; by swimming over waterfalls, by hanging themselves with grapevines; by sawing tree limbs out from under themselves; by swallowing glass; by swallowing underwear; by stabbing themselves with spectacles sharpened to a point; by cutting their throats with hand saws, sheep sheers, or barbed wire; by forcing teams of horses to tear their heads off; by decapitating themselves with homemade guillotines; by exposing themselves to swarms of bees; by injecting themselves with paraffin, cooking oil, peanut butter, mercury, deodorant, or mayonnaise; by crucifying themselves." [Colt, G.: The Enigma of Suicide, p235]; by swallowing coins; by swallowing crucifixes; by hanging themselves with tree roots from the branches of the same tree; by cutting their wrist with their teeth; by cutting off their arm with a kitchen knife; by stuffing rags into their mouth and pebbles up their nose; by exploding a stick of dynamite in their mouth; by sawing their skull with a band saw; by inhaling talcum powder; by injecting themselves with HIV-positive blood. (back to text)

8. Stengel, Erwin Suicide and Attempted Suicide, [Baltimore, Penguin] 1964, p73. (back to text)

9. Retterstol, N Suicide: A European Perspective, [Cambridge Univ P] p IX; 1990; trans: 1993. (back to text)

10. US Mortality Stats, 1994. CDC [Centers for Disease Control] web site. http://wonder.cdc.gov (back to text)

11f. The 1980-91 U.S. age-adjusted suicide rate averaged 12.5 per 100,000 population per year. During the same period the homicide rate was 10.2 per 100,000 per year. [Statistical Abstract of the US, 1994, #128] (back to text)

12f. There are many reasons these estimates vary widely. In addition to social and economic disincentives for people to seek help, medical data is both scanty and unreliable. For example, of 72 people who reported suicide attempts in an anonymous survey, only 18 (25 percent) sought medical care and 7 (10 percent) were hospitalized. [Meehan, 1992] In addition, hospital records are notoriously unreliable. [Lee RK, 1991; Birkhead, 1993; Blanc, 1993] (back to text)

13. Miller, Ted R. Databook on nonfatal injury: incidence, costs, and consequences Washington, D.C. : Urban Institute Press, 1995. pp166-7. (back to text)

14. Colt, G The Enigma of Suicide 1991, p373 [Summit, NY]. (back to text)

15. Miller, 1995, Databook p167. (back to text)

16. Nat Center for Heath Stats, 39 Monthly Vital Stats Nov 28, 1990; Table 125, CDC, 1992 data. (back to text)

17f. While in most of the world about 3 males kill themselves for each female suicide, in China, India and much of Southeast Asia a majority of suicides are female. The mid-1980s Chinese rates were 17.7 for males and 24.3 for females (per 100,000 population per year); the corresponding US rates were 20.7 and 5.4 (1986). [Li, 1991; Pritchard, 1996] (back to text)

18. Clark, DC, " `Rational' suicide and people with terminal conditions or disabilities." Issues in Law and Medicine 1992 Fall 8(2); p147-66. (back to text)

19f. Comparative international suicide data are particularly unreliable. Religiously devout societies that consider suicide a major sin have low official rates of suicide, but it is unclear how much of this is due to unwillingness to report suicides, especially at the local level. For example, the official suicide rate in Egypt is 0.0/100,000; yet the rate of suicide attempts in Cairo is 38.5/100,000, leading the researchers to state, "Official government records are misleading & do not represent the true rate." [Okasha, 1979] Similarly, the suicide rate in India (1972 data) was 7.8/100,000 but varied by State: from 0.70 in Muslim Jammu and Kashmir to 20.5 in Hindu Kerala. [Headley, p216] (back to text)

20. Phillips DP; Ruth TE "Adequacy of official suicide statistics for scientific research and public policy." Suicide Life Threat Behav 1993 Winter; 23(4):307-19. (back to text)

21. Litman, Robert in Curran, W.J. et al Modern Legal Medicine Psychiatry and Forensic Science [Davis, 1980] p842. (back to text)

22. Stengel, E. Suicide and Attempted Suicide 1964, p39.// Shneidman, E.S. & Farberow, N.L. Clues to Suicide, [New York: McGraw-Hill] 1957, p197-215.// Tuckman, J. "Emotional Content of Suicide Notes" Am J Psychiatry, 1959, 116, p59-63.//Lester, D. The Cruelest Death: the enigma of adolescent suicide, [Phil., Charles Press] 1993, p35. (back to text)

23. Cooper-PN; Milroy-CM "The coroner's system and under-reporting of suicide." Med-Sci-Law 1995 Oct; 35(4): 319-26. (back to text)

24f. A well-known fictional example is the suicide of Willy Loman, in Arthur Miller's Death of a Salesman, who killed himself in a car crash in order to provide life insurance money for his family. (back to text)

25f. A probably apocryphal Irish coroner came up with a verdict of "accidental death" in a self-inflicted gunshot death: "Sure, he was only cleaning the muzzle of the gun with his tongue." [Alvarez, p82] (back to text)

26f. This is the International Classification of Death (ICD) category 797-799. There were ten times as many of these deaths as there were `undetermined' (ICD 980-989) ones, 8.3 times as many as single motor vehicle deaths, and more than the total number of official suicides. Until recently, these `ill-defined' deaths were "systematically overlooked" in suicide studies, as were pedestrian deaths. [Phillips-DP, 1993] (back to text)

27. Wallace, SE and Eser, A, eds. Suicide and Euthanasia, [Knoxville, U Tenn. Press] 1981, p74-76. (back to text)

28f. In prisons, some "suicides" are probably murders committed by guards [Smith, R, 1984]; however, there are also misclassifications in the other direction. For example, in one study of Ohio prisons, L.M. Hayes found 46 suicides in 1981-2; prison records showed 22. [Hayes, 1989] (back to text)

29. Diekstra-RF, Gulbinat W "The epidemiology of suicidal behaviour: a review of three continents." World Health Stat Q 1993 46(1) p52-68. (back to text)

30. Rich, CL et al "San Diego Suicide Study: I. Young vs. Old Subjects" Arch Gen Psychiatry 1986, v43, p577-8. (back to text)

31. Baker SP, The Injury Fact Book [NY, Oxford U Press] 2nd ed, 1992, p65.// Weissman, MM "The epidemiology of suicide attempts, 1960 -1971." Arch Gen Psych 1974 v30 p737-46.//Bland-RC; Newman-SC; Dyck-RJ "The epidemiology of parasuicide in Edmonton." Can-J-Psychiatry. 1994 Oct; 39(8): 391-6. (back to text)

32. Flanders, Stephen Suicide, Published by Facts on File, 1991, p21. (back to text)

33. Garrison-CZ "The study of suicidal behavior in the schools." Suicide-Life-Threat-Behav. 1989 Spring; 19(1): 120-30. (back to text)

34. Colt, Enigma p96. (back to text)

35f. Of several hundred homicides examined, over 25% were overtly victim-provoked or "suicide by means of victim-precipitated homicide." [Wolfgang, 1959][Wolfgang, M "Suicide by means of victim-precipitated homicide." J Clin Experimental Psychopathology and Quarterly Review of Psychiatry and Neurology 1959, v20; 335-49.][Also in Resnik, 1968, pp90-104] (back to text)

36. Hendin, Herbert Suicide in America, 1st ed. 1982, p49 [Norton, NY]. (back to text)

37. Menninger, Karl Man Against Himself, [Harvest/Harcourt, NY], 1938. (back to text)

38. Carroll, James The Winter Name of God [KC, Sheed and Ward] 1975, pp87-8. (back to text)

39. Dunkel, Tom "A Brief Handhold on a Dream" Wash Post, pE1 May 14, 1996. (back to text)

40. Alvarez, A. The Savage God [Weidenfeld and Nicholson, London] 1971, p253. (back to text)

41. Breasted, JH Development of Religion and Thought in Ancient Egypt [NY, Scribner's Sons] 1912, pp163-9. (back to text)

42f. Samson, Saul, Saul's armor-bearer, Abimelech, Zimri, Razis, and Achitophel. The precise number (3-to-11) and identity depend on the definition of suicide, whether the Apocrypha are included, and which version of a death one accepts. [Barraclough, 1992] (back to text)

43f. Origen's father was a martyr and he (Origen) reportedly wanted to carry on the family tradition. Dissuaded from this course of action by his mother, he did, however, perform a self-castration. [Rosen, G, 1975] Her views on that are unknown. (back to text)

44. Alvarez, Savage God p49. (back to text)

45. Matthew 5:39; 43-4. (back to text)

46. Tertullian, De Corona, p11, quoted in Rachels, James. The End of Life: Euthanasia and Morality. Oxford and New York; Oxford University Press, 1986, p10. (back to text)

47f. Curiously, the most adamantly anti-suicide religions---Islam, Christianity and Judaism---have had no trouble in coming up with exceptions to the "Thou shalt not kill" principle. Equally interesting is that about the time Christianity came out against suicide, its pacifistic opposition to war and capital punishment also flip-flopped. The price of becoming the Roman State Religion was to defend the State. Thus arose the doctrine of the "just war" and the redefinition of "murder" to mean only the killing of the "innocent". We also eventually arrived at the concepts of "proportionate" and "collateral" damage, whereby even the innocent could be justifiably slaughtered if there were a sufficiently important military objective. There were some nit-picky limitations, but these have been ignored whenever they were inconvenient.

Augustine's justification of killing in war and capital punishment is based on the argument that such killing is either commanded directly by God (e.g. Abraham's sacrifice of Isaac), or by God's divinely constituted authority on Earth, that is, lawful government. At the same time, "private killing" of self (or in self-defense, it would seem) is forbidden.

However, this argument can be turned around not only to permit suicide (e.g. Samson pulling down the pillars, presumably after an ok from God ["And when Samson destroyed himself, with his enemies, by the demolition of the building, this can only be excused on the ground that the Spirit, which performed miracles through him, secretly ordered him to do so." [Augustine, City of God]]), but to require suicide under some circumstances (e.g. Socrates' drinking poison, as demanded by the Athenian court [" one who accepts the prohibition against suicide may kill himself when commanded by one whose orders must not be slighted." [Augustine, ch 26]). This, of course, makes hash out of the blanket Christian condemnation of suicide. [Battin, 1994, pp210-11]

There is also the problem of distinguishing a genuine divine command from a diabolical one, or from a psychotic delusion; but that's another issue. (back to text)

48f. Alvarez, Savage God p49. For a more detailed (and acerbic) discussion, see Amundsen, DW "The significancce of innaccurate history in legal considerations of physician-assisted suicide" in Weir, RF (ed) Physician-assisted Suicide 1997, Indiana Univ Press, pp3-32. (back to text)

49. Alvarez, Savage God p50. (back to text)

50f. The stake was to keep the restless ghost from escaping and going back to haunt its old neighborhood; the crossroads were to confuse any ghost---they apparently weren't very good at reading road signs---that escaped the stake, so that it couldn't find its way back home. Busy crossroads were preferred, because the traffic was supposed to discourage the evidently timid ghost from coming out. [Alvarez, part 2, chap 1] In fact, the increase in vehicle traffic due to the automobile has decreased ghost sightings to an all-time low. The last recorded crossroads-cum-stake burial in England was in 1823, when a certain Mr. Griffiths was interred at the intersection of Eaton Street, Grosvenor Place, and King's Road in London [Stengel, 1974 p69]. (back to text)

51f. News from London newspapers around 1860, in a letter from Nicholas Ogarev to his mistress, quoted in E.H. Carr The Romantic Exiles, [MIT Press, 1981; originally London, Gollancz, 1933], p389; cited in Alvarez p43 [Random House ed] (back to text)

52f. Odin, proprietor of Valhalla, was both the God of War and the God of the Hanged. (There was a sacred grove of Odin in Scandinavia where people went to hang themselves, and several popular jump sites on cliffs.) He also held the Poetry and Wisdom portfolios. Valhalla (which apparently functioned like Hilbert's Hotel---always room for one more guest) had 540 doors, and every day its heroes would go out and do battle; every night they would feast and drink and listen to sagas. The Valkyries (Norse maidens who are invariably large blond sopranos in Wagner operas) would serve at the banquets, but also got to ride through the air and visit battles and suicide spots. With their spears, they would choose who were to die and carry them back to Valhalla to take part in the festivities. (back to text)

53. Durkheim, Emile. Suicide: A Study in Sociology, 1897 (English trans, 1951) p218 [Glencoe, Ill. Free Press]. (back to text)

54. Alvarez, p65 [RH]. (back to text)

55. Alvarez, p67 [RH]. (back to text)

56f. The actual situation was, as always, much more complicated. It seems to have been precipitated by a dispute in Roman North Africa over whether a man, who had evaded martyrdom by co-operating with the authorities, should be a member of the commission that was choosing the local bishop. The faction later known as Donatists said `no' and installed their own candidate.

More generally, the Donatists were natives of North Africa (so was St. Augustine, who was a Libyan Berber, educated in Carthage) who were resisting Roman domination, and the religious aspect was one facet of the conflict. The modern-day Coptic Church in Egypt is a descendant of these early nativist Christians. (back to text)

57. Flanders, Suicide, p10. (back to text)

58. Shakespeare, W. Antony and Cleopatra IV, XV:80-82. (back to text)

59. Battin, M.P. The least worst death: essays in bioethics on the end of life [NY, Oxford Univ Press] 1994, p190. (back to text)

60. Clark, N. The Politics of Physician Assisted Suicide 1997, p35-6 [NY, Garland press]. (back to text)

61f. Goethe's Sorrows of Werther (1774) was found so often with bodies of suicides that Goethe was accused of being a murderer, the book was banned in Leipzig, and the whole Italian edition printing was bought up (and, presumably, destroyed) by the Catholic Church in Milan. [Clarke & Lester, p87] (back to text)

62f. It should be noted that psychological views had appeared previously, as far back as Hippocrates (430-377 b.c.), who argued that people's mental state and character, among other attributes, were due to their predominant "humor" (choleric, melancholic, phlegmatic, or sanguine); but most notably Robert Burton's Anatomy of Melancholy in 1621. He wrote, "In other diseases there is some hope likely, but these unhappy men are born to misery, past all hope of recovery, incurably sick; the longer they live the worse they are, and death alone must ease them." [part of this quote is in Alvarez, p161]

Burton was also the first Christian in many centuries known to advocate treating suicides with sympathy and charity: " .what shall become of their souls, God alone can tell .We ought not to be so rash and rigorous in our censures, as some are: charity will judge best: God be merciful unto us all!" [Alvarez, p162] (back to text)

63f. Similar arguments have been made about criminal behavior, both in the U.S. and elsewhere. Thus in the Soviet Union, political dissidents were sometimes committed to psychiatric hospitals to be "cured" rather than jails to be "punished". This had the added benefits of allowing a wide range of "treatment", and indefinite incarceration. For a critique of psychiatric imprisonment, see Thomas Szasz, e.g., The Manufacture of Madness, 1977]. (back to text)

64f. It is ironic that killing other people (who, presumably, would prefer not to be killed) often generates less moral disapproval than killing oneself; indeed, some varieties of killing-of-others, such as war, are frequently considered heroic. (back to text)

65f. Or perhaps not. In August, 1995, Oklahoma prison officials found a death-row inmate unconscious from a drug overdose suicide attempt. Robert Brecheen was taken to a hospital where his stomach was pumped. After regaining consciousness, he was returned to the prison, where his scheduled execution was carried out, only two hours late.

Corrections spokesmen claimed they were required to revive Brecheen, citing a 1986 Supreme Court decision specifying that the condemned "has to be aware of his execution, and he has to know why he is being executed." ["Inmate Survives Overdose, Is Sent Back for Execution" Wash Post, Aug. 12, 1995, Sec A, p3.] (back to text)

66f. We don't live in a philosophical age. (back to text)

67. Droge AJ; Tabor JD, A Noble Death: Suicide and Martyrdom Among Christians and Jews in Antiquity 1992 [HarperSanFransisco, SF]. (back to text)

68f. As a curious aside, there are consistently high suicide rates in both Hungary and Finland, which share the same rare linguistic heritage, Finno-Ugric. (back to text)

69. Retterstol, European 1990, p26. (back to text)

70. Retterstol, European 1990, p14. (back to text)

71. Friedman, P. (ed.) On Suicide p110, [NY, International Universities Press], 1967; quoted in Colt, p194. (back to text)

72. Colt, p58-9. (back to text)

73. Minkoff, K-, Beck AT and Beran RE. "Hopelessness, depression, and attempted suicide." American journal of psychiatry 130:455-459. (back to text)

74. Beck, A.T. et al "Hopelessness and eventual suicide: a 10-year prospective study of patients hospitalized with suicidal ideation." American journal of psychiatry 142:559-563, 1985. See also, Breitbart, W. "Suicide Risk and Pain in Cancer and AIDS Patients," in Current and Emerging Issues in Cancer Pain: Research and Practice, C. R. Chapman and K. M. Foley, eds. (New York: Raven Press, 1993), p49-65. (back to text)

75. Greist, JH et al "A Computer Interview for Suicide Risk Prediction" Am J Psychiatry 130 (12), 1973, pp1327-32. (back to text)

76f. Lest the anti-psychiatry crowd get too smug, note that some anti-depressant drugs (e.g. maprotiline) seem to increase suicidal behavior, as do some tranquilizers (e.g. alprazolam). [Rouillon, 1989; Gardner, 1985] (back to text)

77. Moller, HJ "Efficacy of different strategies of aftercare for patients who have attempted suicide." J R Soc Med. 1989 Nov; 82(11): 643-647.// Montgomery SA, et al "Pharmacotherapy in the prevention of suicidal behavior" J Clin Psychopharmacol 1992 Apr; 12(2 Suppl):27S-31S; comment: J Clin Psychopharmacol 1993 Apr; 13(2):159-60]. (back to text)

78. Hale, AS "Juggling cost and benefit in the long-term treatment of depression." Postgrad Med J 1994, v70 (supp2), s2-s8. (back to text)

79. Haberlandt, W ["Contributions to the Genetics of Suicide"] Folio Clin Int, 1967, 17:319-22 //Hafen, Brent Q and Kathryn J Frandsen Youth Suicide, depression and loneliness" Cordillera Press, 1986, p22.// Little KY, Sparks DL "Brain markers and suicide: can a relationship be found?" J Forensic Sci Nov;35(6):1393-1403. (back to text)

80. Kety, S "Genetic Features in Suicide: Family, Twins, and Adoption Studies" in Blumenthal, SJ and Kupfer DJ, eds Suicide Over the Life Cycle: risk factors, assessment, and treatment of suicidal patients [Am. Psychiatric Press, Wash DC], 1990, pp127-33. (back to text)

81. Langone, J. Dead End, [Little, Brown; Boston] 1986, p32. (back to text)

82. Asberg, M. et al "Biological Factors in Suicide" in Roy, Alec (ed.) Suicide 1986 [Baltimore, Williams and Wilkins].//Asberg, M. in Meltzer, H. (ed.) Psychopharmacology: The Third Generation of Progress, 1987, pp655-668 [NY, Raven Press]. (back to text)

83. Montgomery, SA et al, "Differential effects on suicidal ideation of mianserin, maprotiline and amitriptyline." Brit. J. Clinical Pharmacology 1978;5 (suppl 1), pp 77S-80S.//Inman, WHW. "Blood disorders and suicide in patients taking mianserin or amitriptyline." Lancet 1988; ii pp 90-2. (back to text)

84. Retterstol, European p132. (back to text)

85. Lester, David Why People Kill Themselves: a 1990s summary of research findings on suicidal behavior, 3rd ed [Springfield, Thomas] 1992. (back to text)

86. Retterstol, N. "Norwegian data on death due to overdose of antidepressants." Acta Psych. Scand. 1989, v80 (supp 354) pp61-68. (back to text)

87. David C. Clark, quoted in NY Times April 5, 1994. (back to text)

88. Salk, L et al "Relationship of maternal and perinatal conditions to eventual adolescent suicide." Lancet 1985 Mar 16;1(8429):624-7. (back to text)

89. Jacobson, B et al "Perinatal origin of adult self-destructive behavior." Acta Psychiatrica Scandinavica 1987, v76 pp364-371. (back to text)

90f. For a lucid description of the genetic basis for altruism, see Richard Dawkins, The Selfish Gene (1976) and E.O. Wilson On Human Nature, 1978. For its specific application to suicide there is a good NY Times Science article ["Quest for evolutionary meaning in the persistence of suicide"] by Natalie Angier from April 5, 1994. (back to text)

91f. The difference between committing suicide by ramming one's plane into an enemy ship and other hazardous military missions (say, flying in an American bomber over Germany in 1942 or being part of a U-boat crew) may be more one of intent than of result. Only one out of seven German submariners survived the war. (back to text)

92f. The Buddhists were also protesting what they considered the anti-Buddhist laws and policies of the (Catholic) Diem regime. The first self-immolation was sparked by the Diem government's revocation of draft deferments for Buddhist seminary students. (back to text)

93f. More recently, stubborn British authorities have allowed several equally-pigheaded IRA (Irish Republican Army) prisoners to starve themselves to death over such critical issues as what kind of clothing they were to wear in jail. The British wanted them to wear standard prison garb; the prisoners wanted uniforms consistent with their claimed status as prisoners-of-war. (back to text)

94. Hyde, Margaret and Forsyth, Elizabeth Suicide: the Hidden Epidemic 1986, ch 4 [Minneapolis, CompCare]. (back to text)

95f. "The Jews are a frightened people. Nineteen centuries of Christian love have broken their nerves." ---Israel Zangwill (1864-1926) (back to text)

96. Coleman, Loren. Suicide Clusters, 1987 p18 [Boston and London, Faber and Faber]. (back to text)

97. Coleman, Clusters p17. (back to text)

98. Wolfgang, Marvin. Patterns in Criminal Homicide 1958 [Phil. U Penn. Press]. (back to text)

99. Marzuk PM; Tardiff K; Hirsch CS "The epidemiology of murder-suicide [see comments]" JAMA 1992 Jun 17; 267(23):3179-83; COMMENT: pp3194-5; [Marzuk, 1992a]].//Holinger Paul C et al Suicide and Homicide among Adolescents, 1994 [NY, Guilford]. (back to text)

100. Marquis, Thomas Keep the Last Bullet for Yourself, 1976; Spencer, JD "George Custer and the Battle of the Little Bighorn: Homicide or Mass Suicide?" J Forensic Sci v28, 1983; Scott, DD "Post-mortem at the Little Bighorn" Natural History v95 (6), June, 1986. (back to text)

101. Colt, Enigma p44. (back to text)

102. Hafen, Youth Suicide p107. (back to text)

103f. Data from Australia show that 103 of 509 suicides (20.2 percent) had blood alcohol levels of at least 0.08 mg/100 ml blood, the "legally-impaired" level.

At autopsy there were usually higher alcohol levels in urine than in blood (1.3 to 1 ratio), implying " that in the great majority of cases alcohol had been consumed some hours before, and that in only four instances [out of the 29 studied] was the alcohol most likely to have been taken just prior to death the act had been committed either during, or in the early hours of the morning following a period of alcohol consumption." [James, 1966] (back to text)

104. Goodman, RA et al "Alcohol and fatal injuries in Oklahoma." J Studies on Alcohol 1991, v52;2, pp156-161. (back to text)

105. Nielsen-AS et al "Attempted suicide, suicidal intent, and alcohol." Crisis. 1993; 14(1): 32-8. (back to text)

106. Hendin, Suicide in America 2nd ed, 1995, p42. (back to text)

107. Avis, SP, Hutton CJ "Dyadic suicide. A case study." Am J For Med Path 1994, v15(1) pp18-20. (back to text)

108. Fishbain, DA, Aldrich TE "Suicide pacts: international comparisons." J Clin Psychiat 1985, v46, pp11-15. (back to text)

109. Coleman, Loren Suicide Clusters 1987. (back to text)

110. Gould, M.S. "Suicide Clusters and Media Exposure"; in Blumenthal, Suicide Over the Life Cycle pp517-532. (back to text)

111. Coleman, Loren Suicide Clusters pp107-109. (back to text)

112. Fekete-S, et al. ["The role of imitation in suicidal behavior"] "Az utanzas szerepe az ongyilkos magatartasban." Orv-Hetil. 1992 Jan 5; 133(1): 25-8] (back to text)

113. Karlson-Stiber-C; Persson-H, "Ethylene glycol poisoning: experiences from an epidemic in Sweden" J-Toxicol-Clin-Toxicol. 1992; 30(4): pp565-74. (back to text)

114. Phillips DP; Carstensen LL "Clustering of teenage suicides after television news stories about suicide." N Engl J Med 1986 Sep 11; 315(11):685-9. (back to text)

115. Radecki, Thomas "Deer Hunter Deaths Climb to 43" National Coalition on Television Violence News 7:1-2, Jan-Mar 1986; for a contrary view, see Phillips DP; Paight DJ "The impact of televised movies about suicide. A replicative study." N Engl J Med 1987 Sep 24; 317(13):809-11. (back to text)

116. Yoshida, K et al ["Clustering of suicides under age 20--seasonal trends and the influence of newspaper reports"]. Nippon Koshu Eisei Zasshi, 1991, May; v38(5) pp324-32. (back to text)

117. Jobes DA et al "The Kurt Cobain suicide crisis: perspectives from research, public health, and the news media." Suicide Life Threat Behav 1996 Fall; 26(3):260-69; discussion 269-71. (back to text)

118. Busse, E W., Pfeiffer, E. (eds) Mental illness in later life American Psychiatric Association, 1973 [Am. Psych. Press, Wash, DC]. (back to text)

119. Colt, Enigma, p98. (back to text)

120. Dolce, L. Suicide, p23 [NY, Chelsea House] 1992. (back to text)

121. Henry, A.F. Short, J.F. Jr Suicide and Homicide: Some Economic, Sociological, and Psychological Aspects of Aggression 1954 [Free Press, Glencoe, Ill]. (back to text)

122. Lester D "The association between the quality of life and suicide and homicide rates." J Soc Psychol 1984 Dec;124 (2nd half) :247-248 [1984a].// Lester, D Patterns of Suicide and Homicide in the World, 1996, 45-57 [Commack NY, Nova Science]. (back to text)

123. Lester, D "The Quality of Life and Suicide" J Social Psychology v125, pp279-280, 1985; more on the relationship between economics, suicide and homicide in Gibbs, J. P., Martin, W. T. Status Integration and Suicide: A Sociological Study. Eugene, Oregon: University of Oregon Press, 1964. (back to text)

124. Lester, D. and Danto, B. Suicide Behind Bars: prediction and prevention 1993, pp17-20 [Charles press, Phil.]. (back to text)

125f. An alternative explanation for the low suicide rate in concentration camps is that a prisoner who wanted to die would not have to do anything---just stop eating or draw the attention of the guards. (back to text)

126. Kwiet, K. Leo Baeck Institute Yearbook, v 29, pp135-168, 1984. [NY, Leo Baeck Inst.] (back to text)

127f. This is also the situation in South Africa, where blacks have higher homicide rates and whites higher suicide rates [Lester, D. " South Africa." 1989] (back to text)

128. Stengel, Erwin Suicide and Attempted Suicide, 1974, p28 [J. Aronson, NY]. (back to text)

129. O'Carroll, Patrick "Suicide Causation; Pies, Paths, and Pointless Polemics" in Suicide and Life-Threatening Behavior 23(1), 1993, pp27-36. (back to text)

130. Shneidman, E. in Bongar, B (ed) Suicide: guidelines for assessment, management and treatment [Oxford Univ Press, NY] 1992, p6. (back to text)

131. Winslow, F. The Anatomy of Suicide [London, Renshaw], 1840; cited in Alvarez, Savage God p212. (back to text)

132. Stengel, E., Cook, N. Attempted Suicide: Its Social Significance and Effects, 1958, p19 [Greenwood Press, Westport Conn.]. (back to text)

133. Dublin, L. I. Suicide.- A Sociological and Statistical Study. New York: Ronald Press, 1963. (back to text)

134. Litman, Robert in Curran, W.J. et al Modern Legal Medicine Psychiatry and Forensic Science [Davis], 1980 p844. (back to text)

135. Dublin, Statistical Study p10-12. (back to text)

136. Ettlinger, RW, Flordh, P "Attempted Suicide" Acta Psychiatrica et Neurologica Scandinavica, Supplement, 103, 1955; in Stengel p75. (back to text)

137. Plutchik-R et al "Is there a relation between the seriousness of suicidal intent and the lethality of the suicide attempt?" Psychiatry-Res. 1989 Jan; 27(1): 71-9.// Greer S et al "Subsequent progress of potentially lethal attempted suicides" Acta Psychiat Scand 1967, v43 p361.// Peterson, LG "Self-inflicted Gunshot Wounds: Lethality of Method Versus Intent" Am J Psychiatry 1985, 142(2) pp228-31.// Card, JJ "Lethality of Suicidal Methods and Suicide Risk: Two Distinct Concepts" Omega 1974 v5 pp37-45. (back to text)

138. Mann-JJ et al "Neurochemical studies of violent and nonviolent suicide." Psychopharmacol-Bull. 1989; 25(3): 407-13. (back to text)

139. L.A. Times, Sept 20, 1991. (back to text)

140. Garrison-CZ "The study of suicidal behavior in the schools." Suicide-Life-Threat-Behav. 1989 Spring; 19(1): 120-30. (back to text)

141. "Fatal and nonfatal suicide attempts among adolescents--Oregon, 1988-1993." MMWR-Morb-Mortal-Wkly-Rep. 1995 Apr 28; 44(16): 312-5, 321-3. (back to text)

142. Marttunen-MJ et al "Suicide among female adolescents: characteristics and comparison with males in the age group 13 to 22 years." J-Am-Acad-Child-Adolesc-Psychiatry. 1995 Oct; 34(10): 1297-307. (back to text)

143. Wilber, CG "Some Thoughts on Suicide" Am J For Med and Path, 1987, 8(4), pp302-8. (back to text)

144. The Centers for Disease Control and Prevention MMWR-Morb-Mortal-Wkly-Rep. April 20, 1995. (back to text)

145. Runyan, C. and Gerken, EA "Epidemiology and Prevention of Adolescent Injury: A Review and Research Agenda," Journal of the American Medical Association 1989:262, p2273-79. (back to text)

146. Males, M. "Teen suicide and changing cause-of-death certification, 1953-1987." Suicide and Life Threatening Behavior. 1991; 21(3): 245-259.//Males M. `Reply to Kim Smith, PhD, on "Teen suicide and changing cause of death certification, 1953-1987" ' (SLTB, 21-3). Suicide and Life-Threatening Behavior. 1991; 21(4): 402-405. (back to text)

147. Leary, W. "Young people who try suicide may be succeeding more often" NY Times April 21, 1995, Sec A, p15. (back to text)

148f. To put it mildly. I quote from the abstract of a journal article:

"Suicide rates between 1960 and 1989 were explored for eight predominantly English speaking countries with similar national characteristics. New World countries showed significant similarities but differed from Old World countries. The two North American (NA) New World countries showed more similarity to each other than the two Australasian New World countries. The NA countries showed an unique plateau in the 1980s for males aged 15-29 years. Old World males of all ages showed common rises, suggesting a partial sex-specific influence in the young. However, trends among the 15- to 19-year-olds were significantly different to trends among the 20- to 29-year-olds in both sexes suggesting a substantial youth-related contribution to the rises. Rates among 15- to 19-year-old females rose in the early 1960s, ahead of males but in parallel with rises among older females, suggesting part of the rise was sex- as opposed to age-related. Although rates among the 15- to 19-year-old females showed little change since 1970, this may be partly a function of sex-related improvements observable in older females disguising unfavourable youth-related influences. Possible aetiological factors are suggested but remain speculative." [Cantor, 1996]

Whew. (back to text)

149. Lester, D "Youth Suicide: A Cross-Cultural Perspective" Adolescence 1988, v23, pp955-58. (back to text)

150. Lester-D "Changes in the methods used for suicide in 16 countries from 1960 to 1980." Acta-Psychiatr-Scand. 1990 Mar; 81(3): 260-1. (back to text)

151. Colt, Enigma p48. (back to text)

152. Shneidman, E. Definition of Suicide. [Wiley-Interscience, NY] 1985, p229; in Colt, p312. (back to text)

153. Colt, Enigma, p47. (back to text)

154. Colt, Enigma, p47. (back to text)

155. Pinguet, M. Voluntary Death in Japan, [Polity Press] 1993, p35. (back to text)

156. Busse, E., Pfeiffer, E. Mental Illness in Later Life American Psychiatric Association report, [Am. Psych. Press, Wash DC] 1973, p123-6. (back to text)

157. Leenaars, A in Maris, RW (ed) Pathways to Suicide: A survey of Self-Destructive Behaviors, 1981 [Baltimore, JHU Press], p35. (back to text)

158. McIntosh, J. L. "Suicide Among the Elderly: Levels and Trends" American Journal of Orthopsychiatry, 1985, 55(2), p288-93. (back to text)

159. Hendin, Suicide in America 2nd ed. 1995, p81. (back to text)

160. Conwell, Y. and Caine, E.D. "Rational Suicide and the Right to Die: Reality and Myth," New England Journal of Medicine 1991, 325: p1100-1103. (back to text)

161. Meehan, P.J. et al "Suicide Among Older United States Residents: Epidemiologic Characteristics and Trends," American Journal of Public Health 1991, 81: p1198-1200// Nat Center for Health Stats, 39 Monthly Vital Stats Nov 28, 1990. (back to text)

162. Osgood, Nancy J. Suicide in later life : recognizing the warning signs New York : Lexington Books, 1992, p15. (back to text)

163. Cooper-PN; Milroy-CM "The coroner's system and under-reporting of suicide." Med-Sci-Law 1995 Oct; 35(4): p319-26. (back to text)

164f. However the use of guns, the most lethal method, is fairly constant in different age groups in the U.S.:

Age	Percentage of suicides by gunshot
15-24	61
25-34	56
35-44	53
45-54	59
55-64	60
65-74	63
75+	61

(back to text)

165. Conwell-Y, Caine-ED, Olsen-K, "Suicide and cancer in late life." Hosp Community Psychiatry. 1990 Dec. 41(12): p1334-9. (back to text)

166. Patel, NS "A study on suicide." Med, Sci, Law v14:2, pp129-136, 1973. (back to text)

167. Eisele JW, et al "Teenage suicide in King County, Washington. II. Comparison with adult suicides." Am J Forensic Med Pathol 1987 Sep;8(3):210-6.// Rich, CL et al "San Diego Suicide Study: I. Young vs. Old Subjects" Arch Gen Psychiatry 1986, v43, pp577-8. (back to text)

168. Dorpat, 1960, 1968; Miller, 1979.

Dorpat, T.L., W.F. Anderson and N.S. Ripley. "The Relationship of Physical Illness to Suicide." in H.L.P. Resnik, ed., Suicidal Behaviors: Diagnosis and Management., 1968// Dorpat, T.L. and N.S. Ripley. "A study of Suicide in the Seattle Area" Comprehensive Psychiatry 1960, v1 pp349-59.//Miller, M Suicide after Sixty: The Final Alternative [NY, Springer] 1979. (back to text)

169. Barraclough, Brian Suicide: Clinical & Epidemiological Studies. [Routledge Chapman & Hall, Croom Helm UK], 1987. (back to text)

170. Lee MA; Ganzini L "Depression in the elderly: effect on patient attitudes toward life-sustaining therapy" [see comments] J Am Geriatr Soc 1992 Oct; 40(10):983-8; comment: J Am Geriatr Soc 1993 Mar; 41(3):345-6. (back to text)

171. Cicirelli VG "Relationship of psychosocial and background variables to older adults' end-of-life decisions." Psychology and Aging 1997 Mar;12(1):72-83. (back to text)

172. Ganzini L. et al "The effect of depression treatment on elderly patients' preferences for life-sustaining medical therapy" [see comments] Am J Psychiatry 1994 Nov; 151(11):1631-6. (back to text)

173. Lester, David; Tallmer, Margot Now I lay me down : suicide in the elderly Philadelphia : Charles Press, 1994; p9. (back to text)

174. Shneidman, E. S., Farberow, N. L. (eds.). Clues to Suicide. New York: McGraw-Hill, 1957.// Leenaars AA "Suicide across the adult life-span: an archival study." Crisis 1989 Oct;10(2):132-151. (back to text)

175. Trends in Indian Health www.tucson.ihs.gov. (back to text)

176. Phillips DP; Ruth TE "Adequacy of official suicide statistics for scientific research and public policy." Suicide Life Threat Behav 1993 Winter; 23(4):307-19. (back to text)

177. Stengel, E. Suicide and Attempted Suicide 1974, p23. (back to text)

178. Kreitman, N., and Platt, S. "Suicide, unemployment, and domestic gas detoxification in Britain." Journal of Epidemiology and Community Health, 1984, v38, pp-1-6. (back to text)

179f. Perhaps it would be more useful to turn the question around and ask, under what circumstances is suicide rational. G. C. Graber argues that suicide is rationally justified "if a reasonable appraisal of the situation reveals that one is really better off dead." [Graber, p65] Indeed. (back to text)

180. Drake, R.E. et al "Suicide among schizophrenics" Journal of Nervous and Mental Disease 1984; v17; pp 613-617. (back to text)

181. Guze, S.B. and E. Robins, "Suicide and primary affective disorders" British Journal of Psychiatry 1970, v117, pp437-448. (back to text)

182. Clark, DC Issues in Law and Medicine 1992 p147-66// higher alcohol figure from F. Lemere, "What Happens to Alcoholics" Am. J. Psychiatry 1953, v109, p674-6// 2-3.4% in Murphy, GE, and Wetzel, R. "The Lifetime Risk of Suicide in Alcoholism" Arch Gen Psych, 1990 (Apr), v47, pp383-392. (back to text)

183. Clark, DC. Issues in Law and Medicine 1992 p147-66// Mackenzie TB "Medical Illness and suicide" in Blumenthal SJ and Kupfer DJ, eds Suicide Over the Life Cycle Am. Psych. Assn. Press, 1990, p205-232.// Whitlock, FA "Suicide and Physical Illness" in Roy, Alec (ed) Suicide, 1988.//Danto, Bruce in Wallace, SE and Eser, A, eds. Suicide and Euthanasia, 1981, pp26-35.// Dorpat, T.L., W.F. Anderson and N.S. Ripley. "The Relationship of Physical Illness to Suicide." In H.L.P. Resnik, ed., Suicidal Behaviors.// Miller, 1979. (back to text)

184. Quill, TE "Physician-assisted death: progress or peril?" Suicide and Life-Threatening Behavior 1994, 24;4, p317. (back to text)

185. Ellis, Frederick, NY Times, Sept 23, 1995. (back to text)

186. David Eddy, JAMA July 20, 1994; Vol. 272(3), pp179-181. (back to text)

187. Maris, RW in Leenaars, A (ed) Pathways to Suicide: A survey of Self-Destructive Behaviors, 1991, p35. (back to text)

188. Barraclough BM, et al "A Hundred Cases of Suicide: Clinical Aspects", Brit. Journal of Psychiatry 1974, 125, pp355-73. (back to text)

189. Robins, E. The Final Months: a study of the lives of 134 persons who committed suicide [New York : Oxford University Press], 1981. (back to text)

190. Leonard, CV Understanding and Preventing Suicide, [Springfield, Ill. Thomas] 1967. (back to text)

191. Temoche, A. et al "Suicide Rates Among Current and Former Mental Institution Patients" J Nerv and Mental Disease, 1964 v138, pp124-130. (back to text)

192f. Actually, 93 percent [Barraclough, 1974] or even 100 percent [Leonard, p273]. (back to text)

193. Colt, p 343.// Hendin pp189-90// Temoche, A. et al "Suicide Rates Among Current and Former Mental Institution Patients" J Nerv and Mental Disease, 1964 v138, pp124-130. (back to text)

194. Lann, IS et al (eds) "Strategies for studying suicide and suicidal behavior." Suicide and Life-threatening Behav v19, pp1-146, 1989. (back to text)

195f. One historical impetus for this view is that both European (and European-colonized) states and the Catholic Church inflicted severe penalties for suicide (confiscation of property and unconsecrated burial, respectively)---unless the deceased was insane. Thus, there was a tendency for sympathetic coroners (and later, psychiatrists) to find that, in English common-law language, the individual killed himself "while the balance of his mind was disturbed."

And while suicide is associated with mental illness in the West, "In numerous other non-western cultures the association of suicide with mental illness seems to be much less strong. and in some cultures is quite low." [Battin Issues, p6] These are societies where philosophic or institutional suicide is common, e.g. Japan, or India. [Farberow, 1975]

It is also cautionary to remember that until 1973 homosexuality was classified as a psychiatric pathology---a mental disease in need of treatment---by the American Psychiatric Association. (back to text)

196. Green, BR; Irish, DP (eds) Death Education: Preparation for Living [Cambridge MA, Schenkman] 1971, p120; quoted in Colt, Enigma p343. (back to text)

197. Robins, E. et al "Some Clinical Considerations in the Prevention of Suicide Based on a Study of 134 Successful Suicides" A J Pub Health, 1959, v49, pp888-99. (back to text)

198. Szasz, T. "The Ethics of Suicide" The Antioch Review, Spring, 1971, v31 pp7-17. (back to text)

199. Slater, E "Choosing the Time to Die" in Battin M and Mayo D (eds) Suicide: the Philosophical Issues [NY, St.Martin's] 1980, p202-3. (back to text)

200. Hendin Suicide in America, 1982 p224-5. (back to text)

201. Langone, John Dead End 1986 p146. (back to text)

202. Michel K; Valach L; Waeber V "Understanding deliberate self-harm: the patients' views." Crisis 1994; 15(4):172-8. (back to text)

203. Stengel, Erwin Suicide and Attempted Suicide, 1964 p113, supra note 4. (back to text)

204. Hendin, Suicide in America, 1982 p211. (back to text)

205. Rosen, DH "Suicide survivors. A follow-up study of persons who survived jumping from the Golden Gate Bridge and the San Francisco-Oakland Bay Bridge" Western Journal of Medicine 1975, v122, p289-94.//Rosen, DH "The Serious Suicide Attempt: Five Year Follow Up Study of 886 Patients" JAMA, 1976, v235(19), p2105-09. (back to text)

206. Dahlgren, KG "Attempted Suicides 35 Years Afterward" Suicide and Life-threatening Behavior, 1977, 7(2); p75-79. (back to text)

207. Hafen, Brent Q and Kathryn J Frandsen Youth Suicide, depression and lonliness, 1986, p 20. (back to text)

208. van Aalst, JA et al "Long-term follow-up of unsuccessful violent suicide attempts: risk factors for subsequent attempts." J-Trauma. 1992 Sep; 33(3): 457-64. (back to text)

209. 80 percent figure in Hafen, B. Youth Suicide, 1986; 40% in G. M. Asnis et al., "Suicidal Behaviors in Adult Psychiatric Outpatients, I:Description and Prevalence," American Journal of Psychiatry, 1993, v150: 108-12. Other data in Colt, p98; more refs in Hendin, (1995) [23,24] p291; Rich, CL Arch Gen Psychiatry v43, 1986 pp577-8; Robins, E in Roy Suicide 1986, p129. (back to text)

210. Colt, p238. (back to text)

211. Hendin, 1982 p219. (back to text)

212. Scheinin, Anne-Grace "The Burden of Suicide" Newsweek 1983, Feb 7, p13; in Colt, p229. (back to text)

213f. Lithium is an interesting drug---a simple metal ion like sodium or potassium---that seems to work for reasons that aren't understood. The effect of lithium on suicide rates is in dispute. Some studies found the death rate for long term lithium-treated manic-depressive or schizo-affective patients to be about the same as, or lower than, that of the general population. Without treatment their mortality rate is 2-3 times higher. [Muller-Oerlinghausen, 1992; Coppen, 1991]

Unfortunately, their findings are contradicted by other data showing that both natural- and suicide-deaths were higher in the lithium-using group. [Vestergaard, 1991]

There's a fascinating study from Texas that claims the rates of suicide, homicide, rape, robbery, burglary, and theft are all significantly lower in counties whose drinking water is high in lithium. The authors suggest that lithium moderates aggressive behavior, which is consistent with some other reports, and go on to suggest adding lithium to municipal (and prison) water supplies as a means of crime reduction. They may have found a path to world peace---or to Brave New World [Schrauzer, 1990] (back to text)

214. Colt, p229. (back to text)

215. Shaffer, D.J. "The Epidemiology of Teen Suicide: An Examination of Risk Factors" Journal-of-Clinical-Psychiatry; 1988, 49, supplement, Sept, 36-41. (back to text)

216. Motto, J.A., D.C. Heilbron and R.P. Juster. "Development of a clinical instrument to estimate suicide risk." American Journal of Psychiatry 142:6; 1985; 680-685. (back to text)

217f. One major problem with identifying potential suicides is that any current screening test or combination of tests that picks up a significant number of people intending suicide generates too many "false positives". (This is a general problem in the use of screening tests for uncommon occurrences. [Rosen, 1954]) Thus any currently-available screen that will detect, say 80 out of 100 future suicides will also (besides missing 20 suicides) wrongly identify many non-suicidal people as suicidal for each correct identification.

The problem is one of designing tests with both high selectivity and high sensitivity. A highly selective screen is one that distinguishes people intending suicide from all others. An example of a selective screen population might be the set of all people standing on the edge of a cliff, holding a gun to their head. A large fraction of such people are probably suicidal; there will be few false positives. The difficulty with such a selective screen is that it is not very sensitive---it might only pick up one suicide in a thousand since few meet the screen's criteria.

On the other hand a highly sensitive filter, for example, one that picks out all people who are one or more of: schizophrenic, depressed, alcoholic, lonely, hopeless, elderly, a psychiatrist or female physician, have made a previous attempt, or have a family history of suicide, might pick up 90 percent of suicides---but also scores of non-suicidal people for each genuinely suicidal one. Such a sensitive test is too unselective to be very useful. (back to text)

218. Pokorny AD "Prediction of suicide in psychiatric patients. Report of a prospective study."Arch Gen Psychiatry 1983 Mar; 40(3):249-57; also cited in Colt, p310. (back to text)

219. Greist, JH et al "A Computer Interview for Suicide Risk Prediction" Am J Psychiatry, 1973, 130 (12) pp1327-32; also in Colt, p311. (back to text)

220. Mack, J. E., Hickler, H. Vivienne.- The Life and Suicide of an Adolescent Girl. Boston: Little, Brown, 1981. (back to text)

221. Colt, G The Enigma of Suicide 1991, p39. (back to text)

222. Stoney, G `FAQ'. [greyham@research.canon.com.au OR www.grohol.com/helpme.htm] (back to text)

223f. However, note the non-parallel language here: "Two wished to survive two said they did not, but one of the latter two who professed to be furious " [Italics added.] (back to text)

224. Hendin, 1982, p210. (back to text)

225. Seiden, RH "Where are they now? A follow-up study of suicide attempters from the Golden Gate Bridge." Suicide and Life-threatening Behavior v8 1978, pp203-16, quoted in Colt, p333;// also Seiden, R "Suicide Prevention: A Public Health/Public Policy Approach" Omega, 1977, v8, pp267-76. (back to text)

226. Rosen, DH "Suicide Survivors: Psychotherapeutic Implications of Egocide" Suicide & Life-Threatening Behavior, 1976-b, 6(4), p209-15 [quoted in Colt, p333]; "Death Watch at the Golden Gate" Wash Post, July 7, 1995, Sec A, p3; Rosen 1975; Rosen 1976-a. (back to text)

227. Heimerzheim, W [1933], cited in Choron, Suicide [NY, Scribner's Sons], 1972, p50. (back to text)

228. Retterstol, N Suicide: A European Perspective, 1990, p188-9. (back to text)

229. Farberow, NL Genetic Psychology Monographs 1950, 42, pp3-79; Hendin, H. "Suicide" in "Psychiatric Emergencies" in Freedman, A.M. et al, (eds) A Comprehensive Textbook of Psychiatry, 1967, p1173. (back to text)

230. Hendin, 1995, p198. (back to text)

231. Colt, p311. (back to text)

232. Doyle, B.B. "Crisis Management of the Suicidal Patient" in Blumenthal SJ and Kupfer DJ, eds Suicide Over the Life Cycle Am. Psych Assn Press, 1990, p382. (back to text)

233. Rosen, DH "View from the Bridge" JAMA, 1985, 254:3314; quoted in Blumenthal, p382. (back to text)

234. Robins, E. et al "Some Clinical Considerations in the Prevention of Suicide Based on a Study of 134 Successful Suicides" Am. J. Public Health v49, 1959, pp888-898. (back to text)

235. Barraclough BM, et al "A Hundred Cases of Suicide: Clinical Aspects", 125 Brit. Journal of Psychiatry, 1974 pp355-73.// Obafunwa-JO; Busuttil A "Clinical contact preceding suicide." Postgrad Med J 1994 june; 70(824) pp428-32. (back to text)

236. Michel K ["Suicide and suicide prevention. Could the physician do more? Results of a questionnaire of relatives of suicide attempters and suicide victims"] Schweiz Med Wochenschr 1986 Jun 7; 116(23):770-4. (back to text)