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Suicide is an exceptionally important medical and social problem of modern society. Suicide methods differ and depend on the particular region, but on a global scale, in most countries, within the general structure of suicidal deaths, hanging takes first place [1, 3, 8, 9, 14]. Varying information is reported about some of the countries on the Balkan peninsula regarding the relative share of the suicidal hangings committed. In the region of Mures (Republic of Romania) they are 85.4%, in the Republic of Serbia – 57%, and in the region of Trakya (Republic of Turkey) they are 41.8% [1, 2, 10, 11].

In the Republic of Bulgaria, the relative share of committed suicidal hangings has increased over the years [12, 13]. Despite the high rates reported, there is insufficient detailed characterization of the specific nature of the suicidal act, and lack of a description of the injuries found during the forensic medical autopsy. Forensic medical investigations related to the postmortem diagnostics, genesis and stages of occurrence of death in the cases of suicide could help in the prevention of suicides.

The aim of this study is to examine the characteristics of suicidal hangings and the injuries caused by them.

Material and method: The object of this study are the suicides committed by hanging, registered at the Departments of Forensic Medicine of St. George University Multi-Profile Hospital for Active Treatment EAD and Plovdiv Multi-Profile Hospital for Active Treatment AD, Plovdiv, over the period 2000-2009. For the collection of input  information has been used a historical method of choice. Alternative, variation, non-parametric and graphical analysis has been used in the statistical processing of information [4, 5].

Results: Over the period 2000-2009, 480 suicidal hanging deaths were registered in the region of Plovdiv, but forensic medical autopsy was conducted in 405 of them.

In reference to body position, 17 cases (4.19±0.49%) of atypical hanging and 389 cases (95.81±0.49%) of typical hanging have been established. In the cases of atypical hanging, suicides either have their feet touching the ground or their knees bent in a sitting or lying position. The distribution of suicides by gender in the atypical hangings shows a preponderance of men, who are 11 (64.70±2.37%), and women are 6 (35.30±2.37%).

Atypical hanging in reference to the position of the noose – lateral or anterior, is observed in 141 cases (34.81±2.38%). In the remaining 264 cases (58.76±2.45%), suspension is typical. No information is available about 26 cases (6.42±1.22%) of suicidal hanging.

The distribution of suicides by gender and type of suspension is presented in diagram 1.

Diagram 1. Distribution of suicides by gender and position of the noose

Comparative analysis of the data presented in Diagram 1 shows that typical posterior suspension is the most common with both gender suicides.

In the predominant part of the suicidal hangings – 368 people (90.86±1.43%), a soft noose was used. It has been established that only 11 people (2.72±0.81%) used a hard noose, with only one woman among them. No information is available about 26 cases (6.42±1.22%) of suicidal hanging. Information about the specific type of noose used is available about 155 cases only. Hard nooses were mainly made from electric cables or metal wire, whereas soft nooses were made from rope, bands, towels, bed sheets, etc. (Diagram 2).

Diagram 2. Distribution of hanging suicides by the type of noose used

The analysis of the suicides committed by hanging has established that the most frequently used noose is the single-coil one, which is observed in 292 cases (72.10±2.23%). Two-coil, four-coil and multiple-coil nooses are also used.

With all suicides are found the typical hanging external characteristics – spotted hemorrhages on the eyelid conjunctiva and sclera (ecchymoses), presence of strangulation mark on the neck. During the forensic medical autopsy of the suicides, in all of the cases were found the spotty hemorrhages under the epicardium and the pleura (Tardieu spots), characteristic of mechanical asphyxiation, and in some of the cases were established fractures of the hyoid bone, thyroid cartilage and neck muscle hemorrhage. Traumatic injuries in the neck which are typical of this kind of suicides only have been examined.

Fractures of the hyoid bone were found in 42 cases (10.37±1.51%). Fractures of the thyroid cartilage only were found in 19 cases (4.69±1.05%), and in 52 cases (12.84±1.66%), both were fractured (Diagram 3).

Diagram 3. Types of fractures in hanging suicides

Fractures of the hyoid bone may affect the left horn, the right horn, both horns or the body (Diagram 4).

Diagram 4. Types of fractures of the hyoid bone

Fractures of the thyroid cartilage may affect the left or the right horn individually, both horns or its body (Diagram 5).

Diagram 5. Types of fractures of the thyroid cartilage

The bruises caused by hanging are most frequently located in the muscles surrounding the fractures or in certain areas of the neck muscles (Diagram 6).

Diagram 6. Distribution of bruises in hanging suicides


This study has established that there is an atypical position of the body in 4.20% of the cases of suicidal hanging only, unlike the reported 50% in England and Wales, or 16% in Australia [3, 8]. This shows the preference of suicides for the typical position of the body during the act of hanging. Accidentally, in the event of impossibility to commit hanging, suicides resort to atypical methods of suicidal hanging.

Occipital suspension is predominant in most of the suicidal hangings not only in the region of Plovdiv, but also in the region of Trakya (Republic of Turkey) and in the Republic of Serbia [2, 11]. This shows that there exist no significant differences in the method of committing the suicide in the cases of suicidal hanging in the Balkan peninsula region.

The analysis of the data has revealed that suicidal hangings in the region of Plovdiv occur in their majority without fracture of the hyoid bone or the thyroid cartilage. In the cases when fractures occur, they are mostly in the hyoid bone horns or in the thyroid cartilage body. A considerable part of the fractures is found with the cases of posterior typical suspension. The cases of hyoid bone and thyroid cartilage fractures and soft tissue injuries found in this study concur with the data reported by other authors [3, 6, 7, 11].


  1. Atypical hanging according to body position is rarely found and most frequently consists in the feet touching the floor.
  2. Suicides mostly use soft ligature and single-coil noose.
  3. With suicides from both sexes, the typical posterior suspension is the most common.
  4. The injuries sustained as a result of hanging are found in less than half of the cases and they are most frequently expressed in fractures of the hyoid bone and the thyroid cartilage, in most cases accompanied by hemorrhages.


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    Suicide is a particularly important medical and social problem. Hanging is the most common suicide method. The characteristics of committing suicidal hangings and the injuries caused by them have been studied. 405 cases of suicidal hanging committed in the region of Plovdiv, Republic of Bulgaria, in the period 2000-2009 were investigated. It has been established that in reference to body position in 95.81±0.49% of the cases hanging was typical. The most common position of the knot is posterior (58.77±2.45%), and the most frequently used is the soft noose (90.86±1.43%). Injuries sustained in the act of hanging are found in less than half of the cases. These are most frequently fractures of the hyoid bone and the thyroid cartilage, accompanied in the majority of the cases by bruises.
    Written by: Marin Kostadinov Baltov, Ekaterina Lyubenova Raykova, Iliya Petrov Bivolarski
    Date Published: 05/22/2017
    Edition: ЕВРАЗИЙСКИЙ СОЮЗ УЧЕНЫХ_ 30.01.2015_01(10)
    Available in: Ebook