Manuscript of the Compression chapter of Five Last Acts 2015.
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## 2. Compression

*Compression in a nutshell*

Compression is a simple method of self-deliverance that relies
on no complicated equipment and does not require drugs.
The main veins and arteries of the neck are compressed in
such a manner that the pressure remains after the person has
fainted. Fainting, and death, is a result of lack of oxygenated
blood to the brain. It is very quick — fainting occurring within
a minute and death following within a few minutes. (In rare
cases death may be accelerated by cardiac arrest after loss of
consciousness.) One of the main methods of achieving
compression is to use a tourniquet around the neck, carefully
positioned so it does not obstruct breathing. Another method
is to use continuous looping, and a third is the introduction of
mechanical devices. Some momentary discomfort is possible,
but brief, and can be minimized with careful forethought.
Material can be planned for, or found at short notice.
Compression can be used in situations of confinement, such
as a hospital stay, or other emergency situations where there is
no possibility of using helium or drugs.

Although it is essentially simplicity itself, roughly half of our
workshop participants over the years were able to grasp the
method properly and the other half struggling to understand
the speed with which it must be accomplished to avoid a
'swollen' feeling. Note that published criticisms in books by
another author were withdrawn when he studied the evidence.
Readers are urged to go through this chapter several times to
understand both the evidence and the application thoroughly.
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Compression — key points

 >A ligature is used to apply pressure evently
 around the neck, tight enough to compress the
 main arteries and veins, but not tight enough
 to interfere with breathing.

 >The ligature is wide enough for comfort, but
 no wider (padding may be used).

 >The ligature it is placed high on the neck to
 avoid discomfort on the windpipe.

 >Pressure is applied by tightening the ligature
 swiftly so that arteries as well as veins are
 compressed, leading to death of the brain from
 lack of oxygenated blood and destruction of
 the brain stem.

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## Introduction

While helium might be a *preferred* way to go by the large
proportion of right-to-die members,¹ we all know that there
are possibilities of being surrounded by others or otherwise
prevented from using a helium tank. Many of us will experi-
ence long periods in hospital before death. Some will be living
with in-laws. Some may just find connecting the equipment
too cumbersome, leave it too late, or not have anywhere to
conceal it.

A favourite question I sometimes ask people at the start of
workshops (held in the function room of a large hotel) is, if
for some reason you decided that you wanted to draw your
life to a close *now* and only had half an hour to get together
everything necessary, could you do it? How would you do it?

After reading this chapter, *anyone* should be able to say 'yes.'
At the end of the chapter, have a look around the room where
you are reading this. Work out what you could use. If you
were in hospital, what do you think you could use? If nothing
comes to mind, could you get it from a 24hr service station or
corner shop? Could you take it into hospital without arousing
suspiction? The answer to all these questions should be 'yes.'

Unlike helium, there is less of a 'one-size-fits-all' about the
compression method. In workshops, we experiment with
different implements once we have got the principles. Find
out what feels comfortable. But be clear: in spite of its great
simplicity, the compression method should *not* be used as a
cry for help. You can pass out very easily, and death follows.
That you can accomplish this with just a piece of binding and

---
¹ Some organisations recommended it as the only method seriously to be considered.
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something to tighten it with does not make it any the less
lethal. (So the good news is: no expensive or cumbersome
materials to buy!)

Some people will feel an aversion perhaps to doing anything
so close to their personal sense of space. A band around the
neck feels different to turning a tap at arm's length. Most
people will keep helium as their number one preference and
compression as their emergency, their 'Plan B.' But if you find
yourself in a desperate situation (such as a nursing home from
which you are not likely to be discharged, or bedridden in
some other way), is it not better to be familiar with how to
take matters into your own hands?

## Main features
Compression provide a simple method of ending one's life
that is not dependent on having previously-acquired equip-
ment or drugs to hand. Properly done, there is little or no
discomfort and it can be performed without arousing too
much unwanted attention. The ease with which it can be
achieved makes it suitable both as a mainstay method, but
particularly also for emergencies should one become confined
to a nursing home or hospital bed and lack complete privacy.
Death results from one of three causes:¹
i) Pressure on the carotid arteries results in loss of conscious-
ness and asphyxia as the brain is denied oxygenated blood.
ii) Pressure on the jugular veins produces 'stagnant hypoxia'
or massive reduction in the circulation of the blood — rather
like a traffic jam. As blood is prevented from flowing away

---
¹ This is a simplified description. For a fuller explanation, please see Stapczynski J,
   Strangulation Injuries, Emerg Med 2010;31(17), (available online,
   www.emreports.com).
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from the head, the pressure prevents fresh blood from
flowing in (similar result as (i) above).
iii) Cardiac arrest due to the so-named 'carotid sinus reflex.'
This is less likely than either of the above causes. Pressure is
required for at least three to four minutes to produce cardiac
arrest — occuring after loss of consciousness.

In all three processes, breathing continues normally until
death. The term 'strangulation' in this context does not mean
a throttling that interferes with breathing — something very
unpleasant. It means a 'strangling' or cutting off of the *blood*
*supply* to the brain. The pressure needed to strangle the
windpipe is much greater and not needed for self-deliverance.

Concerns over the possible survival of the brain stem (which
have occasionally been documented in rare non-suicidal
compression cases involving healthy young subjects) have
sometimes prompted suggestions for the use of a plastic bag
in conjunction with this method. A small bag, such as that
described for helium (a large roasting bag) is suitable. No
other preparation is needed, and such a bag is small enough to
be folded discreetly or even used to hold toiletries and so
avoid suspiction. The only other implements are material with
which to make a tourniquet and some sort of rod with which
to tighten it. Such things can be found impromptu or kept
with one at all times.

There are a number of variations on the 'compression tech-
nique' depending on personal preferences and availability of
equipment. Marjorie's story illustrates the Tourniquet Method
(the most common method in this category). Another major
variation is the Ratchet Tie-Down, explained in detail later in
this chapter, and also Continuous Looping — which is only
recommended if you are too weak to use any other variation.
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*Ligatures (tourniquet)*

## Marjorie's story
It had happend quite unexpectedly. What had seemed like a
routine trip to hospital suddenly developed into something
serious. They would do everything they can, but Marjorie was
not expected to recover. Her careful plans to make sure the
end was at a time of her choosing were not going quite as
expected. In hospital, she had no access to pills or helium. She
lay awake for a couple of nights making her plants. going over
all the possible materials and making her choice. It didn't take
too much to ask the nurse bring her handbag for her so she
could get one or two small items. She wanted her mirror and
her lipstick, but most importantly she knew that in the inside
zipped compartment were a pair of stockings. She had also
managed to hide a spoon from dinnertime — a good metal
spoon, proper cutlery, not like the stuff you got in some of
the places she had been in.
(Image description start)
A suicide using tourniquet compression, as found by police.
 The actual pathology photograph (ie, taken after death.)
(Image description end)
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(Image description start)
  Diagrams showing the correct and incorrect way of tying a knot that doesn't slip
Reef knot (correct) Granny knot (wrong)
(Image description end)

Marjorie made sure her 'implements' were in a place where
she could get at them easily, without making any noise that
would attract attention, and not somewhere the nurse might
find them and wonder what on earth this quiet little lady was
going to do with them. She waited until the early hours of the
morning when the ward was quietest until she made her
move. Under the cover of the bedclothes, she made her
(Image description start)
             Close up of the tourniquet in the previous photograph
(Image description end)
preparations. This was where all the dress-rehearsals would
now come in handy! If she hadn't practiced many times
beforhand when she was fit and healthy, working it all out
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now may well have been beyond her: but she knew what she
was doing. Taking one of the stockings, she knotted it loosely
but comfortably around her neck. She wanted to allow about
three or four inches when the loop was pulled tight and the
elastic of the stocking was at its full stretch. Too much and
the process would be cumbersome. Too little and the stocking
would be uncomfortable even before she started. she tied it in
a good knot that couldn't slip — a 'reef knot' I believe they
called it, she reminded herself.

She remembered the many times she had practiced the
technique, using her thigh at first so she could see what she
was doing. If you started with the stocking looped around
your thigh, one end in each hand, then knotted it — right over
left and tuck it under, that was the natural way to do it. The
second knot, the one that made it so it wouldn't come
undone, started the opposite way: it went, left over right and
(Image description start)
   Not all compression suicides use a tourniquet. This 66-yr-old woman, used two
           knotted nylons. (Actual pathology photograph taken after death.)
(Image description end)
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tuck it under. (If you did two 'rights over lefts', you ended up
with a 'granny knot' or slipknot.)

Carefully she positioned the loop around her neck so it was
high up, well above where a man's Adam's apple would be.
She knew that having it low on the neck would cause discom-
fort, since pressure lower down would compress the wind-
pipe, and this was not her intention. Marjorie decided to slip
part of the pillowcase under the loop as well — not strictly
necessary, but when the nylon was tightened it could dig in to
the skin a bit so might as well make it comfy with some
padding. Next she slipped the spoon between her neck and
the nylon of the stocking. Then she tightened the nylon loop
as if tightening a tourniquet or turning the hands of a clock. In
the practice sessions she had used a variety of implements that
came to hand, some were a bit longer, some the length of a
spoon. She had experimented turning the spoon in one
direction and then the other to see which suited her best.
After several turns she could feel it was quite tight — not far to
go now. The spoon would not unwind itself — it tended to
catch on the jaw or collarbone — but Marjorie would be lying
down so there was also the bed there and she could be sure
that, once the desired pressure had been achieved, it would
remain.

Marjorie spent a few minutes lying quietly and pausing. Once
more, she warmly reviewed all the wonderful things she had
enjoyed in her life. She thought of her loved ones, and the
sealed letter she had placed in her bag addressed to them,
making sure they knew she was ending her life in the way she
wanted, and that it was her decision alone, her wish.

Then she swiftly tightened the tourniquet some more until the
woozy feeling started to come over her. One more turn. The
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pressure was compressing the carotid arteries. Marjorie lay on
her side, inclined downwards, breathing calmly as she fainted.
No fresh blood reached her brain. Five minutes later, Marjorie
was had breathed her last.

## Recommended materials for the loop
A wide range of materials are suitable, according to personal
preference and availability. The best material we have found is
rufflette, sold in haberdashers or easily obtained over the
Internet. Rufflette (or 'cotton webbing' or 'rufflette heading
tape') is often used for edging when making your own
curtains. It is a sturdy strip of material, but softer on the skin
than that typically used for ratchet tie-downs or the strapping
used for securing luggage. A recommended width is 25mm.
(Image description start)
         Cotton rufflette is an excellent material for a tourniquet loop
(Image description end)
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When looking at fabric strips, test the material to be sure it
doesn't tear when you pull it hard. For instance, a polyester
necktie won't have much 'give' — but a silk one may not be so
strong. When looking in haberdashers to select fabric tape,
rufflette is similarly stronger than 'bias binding tape.' The
fibres of the latter being at 45 degrees to the length of the
strip, making it stretchier as well as more fluid compared to a
strip that is cut on the grain.

## Recommended materials if you need padding
Sometimes the only available materials will be less than ideal.
You may find, with your dress rehearsal, that they dig into the
skin a bit uncomfortably when you tighten them. Even nylons
(pantyhose) may do this if you are a bit sensitive. If you are
(Image description start)
   A fleece headband could be used for padding the neck when using compression
          (slide over your head and onto your neck before applying the loop)
(Image description end)
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very quick, you might not find this a problem, but it is equally
ok to apply a little padding. Be prepared for any emergency.
(Go back to the original challenge — if you had half an hour to
get the materials now, what would you use?¹ Look around the
room ...) Almost anything will do for padding — a piece of
torn-up clothing for instance. But worth considering if you
have time to plan is a fleece headband, easily purchased from
outdoor adventure shops.

## Recommended materials for the rod
Some actual photographic examples where a large walking
stick or similarly bulky 'rod' has been used in this chapter.
You probably won't need anything quite so big. The ad-
vantage of a longer implement is you can get more leverage
with less pressure, but you may well find a walking stick far
too cumbersome.²

Find what suits you best by gentle experimentation. If you
start to get dizzy in your practice rehearsal, stop. You only
need to experiment to this point, finding convenient materials
and the best way to tighten the tourniquet enough (which will
vary slightly from person to person to person.). At workshops, popular
implements have included a sturdy make-up brush and a
wooden kitchen spoon.

---
¹ Probably the most recent case at the time of going to print involved the use of a
   dressing gown cord. *North hykeham double death,* Lincolnshire Echo 5 Jan 2012.
² One of the first cases in print is reported in the New York Times on 26
   November 1879. An elderly man had tied a red silk handkerchief around his
   neck and then used an eighteen-inch piece of broom-handle to tighten the
   tourniquet. The newspaper describes it as, "one of the most deliberate and
   determined suicides on record."
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## Tourniquet compression: procedure
a) take 2 to 3 feet of fabric strip, 25mm wide;
b) place it around the neck and tie it securely in a reef knot,
leaving a gap of about 3 fingers width between loop and neck;
c) positioning the loop high up on the neck, insert a rod in the
space between the fabric and the neck, to the side of the head;
d) rotate the rod like the hands of a clock until the loop
tightens, and in such a way that the rod catches on the jaw,
collar-bone or (if lying down) the floor or mattress.
e) tighten the tourniquet swiftly until unconsciousness
(Image description start)
   "Ladies' handbag simple compression kit." A large make-up brush and a length of
    rufflette fabric strip make a discreet emergency set that can by taken anywhere..
(Image description end)
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develops.

>>>*Hint (one):* depending on the relative width of your head
and your neck, you may need to cut the loop off after a
rehearsal (when you have removed the rod), so keep a pair of
scissors handy.
>>>*Hint (two):* if you tighten the tourniquet very slowly you
are liable to feel a swelling sensation in your head — this is
mostly due to the veins being compressed before the arteries
and can usually be overcome by simply turning the rod faster
from the start.
(Image description start)
      Dress rehearsal photograph showing a tourniquet made from fabric strip and a
     wooden spoon. The fabric strip is positioned high on the neck, above the Adam's
    apple. Once tightened, the spoon has caught against the collar bone and stays in
             place even when the hands are no longer holding it in place.
(Image description end)
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## *Step by step with tourniquet compression*

The following diagrams provide a ready reference or re-cap.
This method of self-deliverance is the simplest imaginable: but
written explanations can make it look complex. In whorkshops,
some people "get it straight away" whereas others keep
deliberating, often imagining it is more technical than it is.

There are also an almost infinite variety of body shapes, neck
length and muscle tone, so it will be more comfortable for
some people than others, but it is primarily an emergency
method that anyone can use in extremity. Some people will
use a shorter stick (like a pen), some a longer one (such as a
walking stick). There is no need to be prescriptive: just find
what is best for you, or with the materials to hand.

(Image description start)
In *Figure 1,* the person is seated upright in an armchair. The person ties the ligature in a reef knot
that won't slip. The gap between the neck and ligature is about three fingers in width. The ligature
is high on the neck, avoiding pressure on the larynx (in a man, this position is above the Adam's
apple). The person is sitting so he or she will probably slump forward slightly when passing out
(which also slightly increases the circumference of the neck and aids effectiveness).

In *Figure 2,* the person inserts the rod in the space between the ligature and neck.
(Image description end)
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(Image description start)
In *Figure 3, * the person begins to turn the
rod which was inserted in *Figure 2*. it is
turned like the hands of a clock. This can
be done in either direction, and dress
rehearsals will suggest which way is better
for you. Whichever way it is turned, the
effect is the same — it tightens the pressure
on the neck. Not unncomfortably, but
enough to make you feel a bit dizzy.

If you do this very slowly, you may
experience a bloated feeling. This happens
when the veins of neck are com-
pressed before the arteries. Much less
pressure is needed to occlude the veins,
so what happens when you do this too
slowly is that the blood is still trying flow
in to the brain (via the arteries) but is not
managing to flow out (via the veins). Death
can still occur as long as the dizzy point is
passed, but might be less comfortable.


In *Figure 4,* the person has turned the rod
until the ligature is quite tight. At the point
where one starts to feel dizzy, you can
maybe get an extra half turn in. Dizziness
is caused by a decreased blood supply to
the brain, so you are close at this point.
Once the ligature is tight enough to cause
fainting, death will occur shortly afterwards
as the brain is deprived of sufficient oxygen
for a prolonged period.

The whole operation should be done quite
quickly and securely.


In *Figure 5,* the person is able to let go of
the rod as the dizzy point has been
reached and another half turn or more can
achieved before losing consciousness. The
rod catches on the body — depending
which way it was turned and one's
personal body shape, it catches either on
the jaw or the front or back of the collar
bone.

Note: if you do not feel dizzy and pass out
within minutes, the tourniquet has not been
applied correctly or tight enough. Stop,
pause, and start again.
(Image description end)
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## *Choose the least worst option*
The compression method is particularly suited for unforeseen
circumstances, such as hospitalisation. When in such a
desperate 'emergency' situation, detailed fine tuning may seem
superfluous. Additional use of a plastic bag may even be so
difficult in confined environments that any theoretical benefits
seem to outweigh the burdens. In an emergency situation
where you have very few choices left, choose the least worst
option.

Similarly with choosing of materials. Rufflette is a good size,
gentle on the skin, and unlikely to attract attention in a
hospital bag. But if you forget, look out for what is easily
available. You can find some sort of 'cord' in most rooms you
would find yourself in. The belt from a dressing gown, or the
cords from curtains for window blinds, or nylons from a 24-
hour garage or 24/7 store. Test whatever you are going to use,
if necessary, giving it a good yank so you know it is strong
enough. Some men's silk neckties, for instance, have too
much 'give' and the threads can tear, making the ligature
unexpectedly loose, but there is no such problem with
polyester ties. Nylons are stretchy, but the useful quality is that
they only stretch so much and then stop. The elastic nature
may even be a plus point (motorists: think, using nylons to
make a temporary fan-belt).

Different types of ligature vary in how they feel against the
skin. Nylons, or the cords from a window-blind will be less
comfortable as they will dig into the skin a bit when tightened.
The discomfort is only momentary if you do it correctly, and
might not be important if you are in a lot of pain. It is ok to
use some padding (like a piece of torn clothing, for instance)
so the ligature does not cut into the skin.
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No wooden spoon, make-up brush or narrow paintbrush?
What about a pen, a spoon from the hospital dinner tray?
Something long enough not to suddenly come loose. You
might also want to avoid things with a point sharp enough to
scrape the skin accidentally, such as a fork or some biros —
you don't want to stab yourself!

## *Are there any other dangers in dress rehearsals?*
Precautions include having a pair of scissors handy in case you
can't untie the knot: you'd feel pretty silly going to your next
door neighbours and asking for a pair of scissors to cut it off
(even more so if you used the ratchet, as described later in this
chapter!) A more serious concern is something called "valgal
(Image description start)
                                          Vagal inhibition is a rare
                                          phenomenon but one that
                                          causes death almost instantly
                                          — within minutes at most. It will
                                          occur only in a few instances of
                                          ligature compression.

                                          Pressure on receptors in the
                                          carotid sinuses, carotid
                                          sheaths, and the carotid body,
                                          situated about the level of the
                                          jawline, may cause an increase
                                          in blood pressure in these
                                          sinuses and, as a result, a
                                          slowing of the heart rate,
                                          dilatation of blood vessels and
                                          a fall in blood pressure. The
                          carotid sinus   result is instant (or near-
                            & sheath      instant) death,
                        larynx
                                          In normal persons, pressure on
                                          the carotid sinus causes has a
                      carotid artery      minimal effect, decreasing the
                                          heart rate only slightly, and
                                          producing only a slight drop in
                                          blood pressure. Some people
                                          however are extra-sensitive to
                                          stimulation of the carotid
                                          sinuses, with results ranging
                                          from irregular or slow
                                          heartbeats to cardiac arrest
                                          and death.
(Image description end)
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inhibition."¹ Uncommon, but well recognised, this is sudden
cardiac arrest brought about by pressure on the carotid sinus
and sheath.² This is a rare response, not a typical one — and if
it happens, can clearly hasten a good and very quick death —
but is something to be avoided in dress rehearsals! Normal
individuals do not experience this carotid sinus hypersensitivi-
ty, but the risk is there and mostly affects older males and
people in poor health.³

If you are at all worried, do not take your dress rehearsal to
the point where great pressure is applied to the neck: just
make sure you can tie the ligature appropriately, insert the rod,
and wind it until it catches on your collar-bone or jaw. In that
way, you will be familiar with the method if you ever need to
implement it. If and when you sue compression for real, you
will need to tighten the tourniquet rather more so that you
become dizzy and lose consciousness.

Definitive diagnosis of carotid sinus hypersensitivity requires a
precise medical procedure⁴ and not something that can be

---
¹ A great number of supporting technical references are included in the footnotes
   and chapter notes of this volume, for reasons explained. But for readers who
   enjoy a more general, non-technical overview as a companion read, Lyle's
   "Forensics — A Guide for Writers" is an enjoyable paperback, written by a
   doctor, but sublimely free of technical jargon. Writer's Digest Books, 2008.
² Choking as a Cause of Vagal Inhibition (Sudden cardiac arrest) in: Polson C, Gee
   D, Knight B, The Essentials of Forensic Medicine. Pergamon Press 1985:466-
   467 for a general description. There have also been cases of drowning where
   sudden death has been attributed to vagal inhibition.
³ Although commonly referred to, the mechanism is not without controversy. See,
   for instance, http://www.datenschlag.org/howto/atem/english/csr.html
   accessed 1 July 2012.
⁴ Parry S, Richardson D,　O'Shea D, Sen B, Kenny, Diagnosis of carotid sinus
   hypersensitivity in older adults: carotid sinus massage in the upright position is
   essential, Heart 2000;83:22-23.
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guessed, but age and sex seem to increase its likelihood. It is
virtually unknown in persons younger than 50 years old, but
has been observed in up to fourteen per cent of elderly
nursing home patients. If you are wondering how vulnerable
you are to carotid sinus hypersensitivity, as well as age and sex,
it is also associated with hypertension, coronary artery disease,
orthostatic hypotension, vasovagal syncope, Alzheimer
disease, Parkinson disease, dementia, or concurrent medica-
tion with digitalis, beta-blockers, and methyldopa.¹

In summary, vagal inhibition is a danger if you are doing
realistic dress rehearsals, but a very slight one, and considered
non-existent if you are reasonably young and still in good
health.

## *Do I have to be sitting upright?*
No. A number of cases of ligature compression suicide
involve the person lying down. This is particularly suitable for
someone in hospital. The rod can catch against the mattress
or the floor. Doing the procedure lying down may also be
more comfortable for someone who has limited energy.

If you are able-bodied, it is largely a matter of preference. You
do want to make sure that you cannot fall over in a way that
would dislodge the tourniquet. So if you choose a sitting
position, an armchair is better than a straight-backed chair
with no armrests. As a reminder, whichever position you
select, have a thought for those that might find you. If lying

---
¹ A long and detailed examination of carotid sinus hypersensitivity can be found
   online in Medscape reference: Wijetunga M, Carotid Sinus Hypersensitivity,
   http://emedicine.medscape.com/article/153312 accessed 1 July 2012.
 Also: Lacerda G, Pedrosa C, Lacerda R, Santos M, Perez M, Teixeira A, et al.
   Cardioinhibitory carotid sinus hypersensitivity: prevalence and predictors in 502
   outpatients. Arq Bras Cardiol. Mar 2008;90(3):148-55.
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down in hospital, waiting until the early hours when everyone
is asleep is a good idea. Performing the procedure under the
bedclothes (or at least pulling the sheet up over one's head so
as to be shielded from prying eyes) is common sense.

As with all methods of self-deliverance, it will help if you are
able to leave a note for others, as described elsewhere in this
book.

## How much time do you need?
The process only takes a few minutes, and even less than that
time before unconsciousness occurs. To guard against the
possibility of resuscitation attempts, allow a half hour or more
undisturbed.
(Image description start)
      Tourniquet compression can be used lying down — and may be the more desirable
              option to end one's life discreetly in a hospital or nursing home.
(Image description end)
(Page 21 end)
(Page 22 start)
## *Variation 1: addition of a plastic bag*

This has been suggested as a possible double-safety measure.
There is no evidence to suggest it is necessary. However, if
you want to make 'doubly sure,' you can use a large roasting
bag, like the one described in the chapter on helium. There is
no real need to elasticate it, as you did when making the
helium hood: just place the bag over the head before applying
the tourniquet. Experiments have demonstrated that there is
plenty of time to to this. If you get stuck, just take the bag
off, pause, and start again. Putting the bag on *before* tying the
tourniquet loop seems easier in practice than tucking it under
the loop afterwards.

## *What are the arguments about using a plastic bag in*
## *addition to compression?*
Some people will use compression as a last resort when no
other method is available to them. The tightened tourniquet
alone stops oxygen reaching the brain, enough to produce
unconsciousness which is then followed by death of the brain.
As it dies, the brain swells and haemorrhages, also destroying
the brain stem (located at the base of the brain, controlling
automatic functions even in unconsciousness and permanent
vegetative state). Yet the neurology is complex and difficult to
observe directly. It has been argued by some that, in very
exceptional cases of strangulation, the brain stem could
survive as it has a separate blood supply.¹ There are rare² but

---
¹ This idea was put forward by an anaesthiologist on the ERGO right-to-die news
   list. Research by Exit demonstrates that the possibility of it happening is so
   remote as to probably be discounted. As use of the compression method is not
   yet mainstream in the right-to-die movement, a section on using the additional
   plastic bag is nevertheless included in this chapter.

² Becker R, Sure U, Petermeyer M bertalanffy H, Continuous infusion alleviates
   autonomic dysfunction in patients with severe supraspinal spasticity, J Neurol
(Page 22 end)
(Page 23 start)
reported cases of strangulation in healthy people where the
brain stem has survived and the person remained permanently
unconscious in PVS.¹ So it has been argued by some people
that a sensible additional precaution might be to place a small
to medium bag over the head with the ligature over the top.
This will ensure breathing stops and making it impossible for
the brain stem to survive. The roasting bags used in the
helium chapter for making helium hoods are quite sufficient.
Further research is needed to understand why all the available
documented cases of suicidal compression without any bag
have clearly resulted in death rather than PVS. The rare
instances where PVS has occurred that have so far been noted
have all been in cases of *temporary* compression — such as
when one person tries to strangle another person,² other cases
of temporary pressure such as the children's 'choking game'
(used to create a temporary 'high' from depleted oxygen),³ or
neck restraints that used to be used in policing.⁴

---
   Neurosug Psychiatry 1999;66:114, gives one such case of a 33-yr-old woman in
   PVS after hypoxic brain injury originating from non-suicidal strangulation.

¹ For a description of PVS (Persistent Vegetative State), see, for instance:
   Multi-Society Task Force on PVS, Medical Aspects of the Persistent Vegetative
   State, NEJM 1994;330(21):1499-1508. The case involved were not suicides or
   self-deliverances.

² Simpson R, Goodman J, Rouah E, Caraway N, Baskin D, Late neuropathological
   consequences of strangulation, Resuscitation 1987;15(3):171-85. Details the case
   of a young man who was a victim of strangulation. After hospitalisation, he
   survived nearly 5 months in PVS before succumbed to pneumonia.

³ McClave J Russell P, Lyren A, O'Riordan M,Bass N, The Choking Game:
   Physician Perspectives, Pediatrics 2010;125;82-87, p83.

⁴ Hall C, Butler C, TR-03-2007 National Study On Neck Restrains in Policing,
   Canadian Police Research Centre 2007.
   http://www.wildgeesema.com/Neck_Restraints_in_Policing.pdf accessed 2 July
   2012.
(Page 23 end)
(Page 24 start)
Examination of available data and discussions with one of the
world's leading neurologists, persuades the present author that
a plastic bag is almost undoubtedly unnecessary. A key
difference between temporary (attempted homicide) and
prolonged compression (self-deliverance tourniquet) is that,
with the latter, blood cannot flow out of the brain, so the
intercranial pressure is not only maintained but increases. PVS
is exceedingly rare cases of temporary pressure, but in cases
of tourniquet death there is a specific prolongation of the
damage to the brain. The resultant, extensive herniation is
thought to be a main factor in the irreparable damage to the
brain stem.¹ Brainstem damage is a huge concern where there
is swelling or bleeding in the brain, because the brain has
nowhere to expand other than down into the brainstem area.


## *The neurology — brain death and brain stem death*
(nb: although every attempt is made to avoid overly technical
language, what actually happens inside the brain and brain
stem that suggests the plastic bag is unnecessary requires some
familiarity with the terminology. A quick reference guide is
included for non-medics, but general readers can skip the next
four pages (rest of this sub-section) if they wish, as you don't
need to know all the details of how it works in order to use
the compression technique.)

The left and right common carotid arteries are the major
arteries that supply the head and neck with oxygenated blood;
they divide in the neck to form the external and internal
carotid arteries. The carotids are located near the front of your

---
¹ *See also, for instance:* "Brain herniation is a condition in which a portion of the brain
    is displaced because of increased intercranial pressure, resulting in progressive
    damage to brain tissue that may include life-threatening damage to the brain
    stem." American Academy of Orthopaedic Surgeons, American College of
    Emergency Physicians, Critical Care Transport, Jones and Bartlett 2004, p.407.
(Page 24 end)
(Page 25 start)
neck and are what you feel when you take your pulse just
under your jaw. There are also vertebral arteries, which join to
form the basilar artery, which supplies blood to the brainstem,
and also connect to the Circle of Willis to potentially supply
the rest of the brain if there is compromise to one of the
carotids.

But the Circle of Willis — an arterial circle at the base of the
brain — not only varies anatomically from one individual to
another and is often incomplete¹ — but could at most, and
only that much in some cases, compensate for the occlusion
of just one of the carotid arteries,² and is only there to com-
pensate for minor occlusions. This is because the carotid
arteries each contribute about 40% of the brain's required
blood supply. Only the remaining 20% goes through the
vertebral arteries through the base of skull. So occlusion of
both carotid arteries, as in ligature compression, is more than
can reasonably be compensated for by the Circle of Willis,
which needs to maintain blood pressure at 50 per cent of
normal to prevent death of brain tissue.³

Survival after strangulation attempts is not uncommon;
whereas with ligature compression, the cause of brain damage
is maintained until death occurs.

---
¹ *See, for instance,* Bergman R, Affi A, Miyauchi R, Circle of Willis, in: Illustrated
    Encyclopedia of Human Anatomic Variation, at
    http://www.anatomyatlases.org/AnatomicVariants/Cardiovascular/Text/Arteri
    es/CircleofWillis.shtml accessed on 4 July 2012.

² *See for instance,* Tortori-Donati P, Rossi A, Biancheri R, Pediatric Neuroradiology:
    Head and neck, spine, Springer 2005; p943.

³  McCaffrey P Neuroscience on the Web,
    http://www.csuchico.edu/~/pmccaffrey//syllabi/CMSD%20320/362unit11.html
   accessed 4 July 2012
(Page 25 end)
(Page 26 start)
Brainstem damage is always a high concern with any swelling
or bleeding in the brain, because the brain has nowhere to
expand but down into where the brainstem is. The rapid death
of brain cells deprived of oxygen alone is associated with
swelling, but that is not all. There are a number of other
contributing factors to death with the compression of arterial
flow. When blood pressure is very low, the brain is deprived,
"not only of oxygen but also glucose and all other nutrients as
well as the nutrient/waste exchange process required to
support brain metabolism, resulting in the development of a
hypoxic-ischemic state. This state is characterized by cellular
energy failure, membrance depolarization, brain edema ...".¹

Neither does there need to be total blood stoppage. Several
authors have suggested that watershed infarcts also occur in
cases of carotid occlusion (tissue death caused by insufficient
blood supply at neighbouring areas, much like lack of irriga-
tion at the most distant parts of agricultural fields).² But from
brain death to brain stem death, a number of factors come
into play separately or together. Several of these are a result of
changes in the brain. Direct hypoxic damage affects the cortex
more than the brain stem. But continued compression from
the ligature (not present in strangulation cases where the
compression is only temporary) maintains any increase in
venous pressure, which, together with changes associated with
tissue death in the brain and resultant haemorrhages, can
cause 'coning' — a resulting swelling (oedema). In short,

---
¹ Arciniegas D, Hypoxic-Ischemic Brain Injury, International Brain Injury
   Association 2010; Issue 3, http://www.internationalbrain.org/?=node/131
   accessed 4 July 2012. For a fuller explanation: Haddad G, Ping Yu S. (Eds),
   Brain Hypoxia and Ischemia (Contemporary Clinical Neuroscience), Humana
   Press 2009; pp213-214.

² Hypoxic-Ischemic Brain Damage, In: Rabinstein A, Resnick S, Practical
   Neuroimaging in Stroke, Saunders 2010, p.12.
(Page 26 end)
(Page 27 start)
various physical pressures from the brain itself impact the
brain stem and make its survival unlikely.¹ But how to pin
down the exact sequence of events? A bit like launching a
rocket-propelled grenade into a house and asking what causes
the house to collapse — was it the fire? The air pressure from
the explosion? The initial or subsequent damage to the
structure? Theory, experience and common sense says it
works, but the experimental hurdles to determine the exact
mechanism may be hard to arrange. Similarly, it is difficult to
imagine persons undergoing a brain scan while performing
self-deliverance ligature compression.

Yet although it is a simple process, the precise sequence of
events in the brain, and the rareness of PVS occurrence,
cannot easily be 100 per cent established outside of neurologi-
cal theory and available statistics: it is almost impossible, for
instance, to observe the process of brain herniation as it
occurs, and on sufficient numerous occasions to provide
meaningful data to exclude an as yet unknown exception to
the rule. So even though all the evidence points to the addi-
tion of a plastic bag as being redundant, all that can be said is
that no-one has survived a properly maintained ligature into
PVS, and that there seems no possible likelihood of it.
Whereas the evidence is of a slightly different order when

---
¹ Pallis C, ABC of brain Stem Death: From Brain Death to Brain Stem Death, BMJ
   1982;285:1487-1490. For instance: p.1489 "Direct hypoxic damage affects the
   cortex more than the brain stem." And then (1489-1490), "Intracranial hyperten-
   sion is also a feature of the cerebral oedema that almost invariably complicates
   acute anoxic insults to the brain. The initial effects, in such cases, are often
   complicated by the development of various intracranial 'shifts.' There may be
   downward-spreading oedema and caudal displacement of the diencephalon and
   brain stem with stretching of the perforating pontine branches of the basilar
   artery and secondary haemorrhages in their territory. Or the brain stem may be
   compressed from uncal herniation into the tentorial opening." Several other
   damage routes are listed.
(Page 27 end)
(Page 28 start)
looking at the addition of a plastic bag, inasmuch as it would
be physically impossible to survived into PVS, as the bag forms
a physical barrier against any oxygen entering the system.
(Page 28 end)
(Page 29 start)
***Some key definitions to help understand brain anatomy ...***

**Anoxia** - complete lack of oxygen supply

**Arteries** - blood vessels that carry blood away from the heart (this blood normally
carries oxygen to the tissues). The left and right common carotid arteries are the
major arteries that supply the head and neck with oxygenated blood; they divide in
the neck to form the external and internal carotid arteries. The carotid arteries are
located in the front of your neck and are what you feel when you take your pulse
just under your jaw. There are also vertebral arteries, which join to form the basilar
artery, which supplies blood to the brainstem, and also connects to the Circle of
Willis to potentially supply the rest of the brain if there is compromise to one of the
carotids.

**Brain ischemia / cerebral ischemia** - insufficient blood flow to the brain to meet
metabolic demand leading to poor oxygen supply or cerebral hypoxia.

**Brain herniation** - is when brain tissue, cerebrospinal fluid, and blood vessels are
moved or pressed away from their usual position inside the skull (one of the
causes of this can be haemorrhage).

**Circle of Willis** - an arterial circle at the base of the brain which varies anatomi-
cally from one individual to another and is often incomplete It is there to
compensate for minor occlusions. The carotid arteries each contribute about 40%
of the brain's blood supply. The remaining 20% goes through the vertebral arteries
through the base of skull. So occlusion of both arteries is more than can
reasonably be compensated for by the Circle of Willis.

**Hemorrhage** - escape of blood from a blood vessel. Profused bleeding.

**Hypoxia** - lack of sufficient oxygen supply.

**Infarction** - tissue death caused by an obstruction of the tissue's blood supply,
which leads to a local lack of oxygen.

**Intracranial pressure** - the pressure inside the skull.

**Ischemia** - inadequate blood supply to a local area due to blockage of blood
vessels leading to that area.

**Hypoperfusion** - decreased blood flow through an organ.

**Oedema (edema)** - an abnormal accumulation of fluid that causes swelling.

**Perfusion** - delivery of blood to a capillary bed in the biological tissue.

**Veins** - blood vessels that carry blood towards the heart (most veins carry
deoxygenated blood away from the tissues).
(Page 29 end)
(Page 30 start)
## *How to use a bag with the compression technique*
Experiments by many people and on several occasions in the
workshops have demonstrated that there is plenty of time to
apply the tourniquet after placing the bag over one's head if
you so wish. (Note these were done in the safety of company!)
No feelings of stuffiness or discomfort were experienced.
Practice applying the tourniquet swiftly and safely before
experimenting using the small bag. The whole dress rehearsal
should be done very quickly at this stage. It is highly unlikely
that a person would get 'stuck' or pass out accidentally, but we
strongly recommend that you do such a dress rehearsal in the
company of a trusted friend or partner for safety's sake. Place
the knotted loop over the head. Some people, especially if
they have a very wide head and a very narrow neck, may find
it easier to tie the loop once it is around the neck instead of
beforehand. Learn how to make a secure knot blindfold when
tying the ends of your strip of material together to form your
loop. Even without the bag, you probably need to do this at
some point as the angle means you can't judge the distance
and appropriate place for the knot without a mirror. Have a
pair of scissors to hand for safety — the loop is quite loose, but
it might not be loose enough to pull over your head again.
Once the loop is tied loosely around your neck, practice
inserting the stick and tightening it quickly like the hands of a
clock — to the point where it catches on your jaw or shoulder,
not necessarily to the point where it makes yhou dizzy. Then
take the stick out and place it nearby. Then do it again but put
the roasting bag over the head first and apply the tourniquet
over the top. The whole procedure takes less than half a
minute.

Most people will choose the largest size of roasting bag
available. Try it on for size when you get home just to make
sure. It needs to be long enough so the lower edge will be
(Page 30 end)
(Page 31 start)
under the tourniquet when applied, but apart from that, it is
not really critical.

When it comes to do the procudre for real, the only differ-
ence isan extra turn or two to ensure you go dizzy and pass
out. This will occur before you run out of oxygen if you are
using a plastic bag as well.
(Page 31 end)
(Page 32 start)
## *Variation 2: Continuous looping*
One of the best documented cases of compression in a
hospital setting in the medical journals involved no tourniquet
and nothing to tighten the loop. Many types of ligature can be
made simply by looping material around the neck repeatedly.

Continuous looping simply means passing a cord or textile
strip around the neck again and again, with many turns, using
a material that doesn't slip. Nylon coated cords, for instance,
tend to slip, whereas many cords (such as traditional string)
create a certain amount of friction. Simple knots with some of
the turns may help. Once the cord has been wrapped tightly
around the upper part of the neck it tends not to slip and, if
there is sufficient pressure to occlude the arteries, death
results. This variation is only recommended in an emergency
(for instance if no other materials were available). For com-
fort, some padding is desirable, especially if using thin cord or
string. A number of deaths have been recorded where a
person has simply had time to wrap stockings around the neck
(Image description start)
Continuous looping takes longer than using a tourniquet, but may be used in emergency,
especially if one is very weak or does not have suitable items to make a tourniquet.
(Image description end)
(Page 32 end)
(Page 33 start)
and tie them at the nape of the neck.

Friction of the material keeps it in place and prevents it from
loosening.¹ Cardiologist DP Lyle explains it simply:

     "Suicide by ligature strangulation is rare, but not un-
     heard of. Since it takes approximately fifteen seconds
     or so to lose consciousness, the victim has time to
     secure the ligature in place by either tying a knot or
     wrapping the cord several times. In the latter situa-
     tion, the overlapping loops secure the ligature in
     place. Once the victim loses consciousness, he cannot
     loosen the ligature and death from asphyxiation
     follows."²
This is something that can be practiced on your leg first of all
— keep wrapping the material, cord or whatever else you have
to hand around your thigh again and again fairly tightly. You
need quite a long length.³ But eventually you will find (unless
it is very slippery material that the wrapping stays in place
without coming undone. It can even be tight enough to cut
off much of the circulation in your leg (of course, we recom-
mend you take it off quickly once you feel that happening!).
But it is simple enough. It does away with wondering if it is

---
¹ Frazer M, Rosenberg S, A Case of suicidal ligature strangulation, American Journal
of Forensic Medicine and Pathology 1983;4(4);351-354. "... successive layers of
twine provided gradually applied tension." （53-year-old male, looping twine around
his neck 35 times then pulling it tight with a single knot.)

² Lyle DP, Forensics, Writers Digest Books 2008, p.163.

³ Demirci S, Dogan KH, Erkol Z, Gunaydin G, Suicide by Ligature Strangulation:
Three Case Reports, Am J Forensic Med Pathol 2009;30(4),369-372, 371. The
authors note that cases with up to 20 turns have been recorded in the medical
literature.
(Page 33 end)
(Page 34 start)
tight enough as the pressure can gradually be increased with
each successive turn.

But bear in mind two very important points. Firstly, as the
pressure is increasing only gradually. it will also decrease
gradually as you ***unwind*** it, so be *very* careful in any dress
rehearsal that you can unwind it again before passing out.
Another good reason to do the main dress rehearsal on your
leg!

Secondly, we only recommend continuous looping if you are
too weak or for some other reason unable to form a satisfac-
tory tourniquet. Although there have been many cases of
suicide with a continuous loop, you must be very sure that it is
not going to unwind.

## *Variation 3: Knotted cord or ligature alone*

In some cases, sufficient pressure can be arranged just by
knotting the ligature after tightening it. See the example of the
66-yr-old woman pictured in this chapter.¹ The simple facts
are that everyone's neck is different. Some will find sufficient
pressure using knotted tights. There are cases of people using
a textile belt, a scarf, or even cable ties, a clothesline or a
sphygmomanometer.² But a textile strip, of the sort recom-
mend in this chapter, is a common choice and a comfortable
one.

---
¹ And detailed in Case 1 from: Di Nunno N, Costantinides F, Conticchio G *et al,*
   Self-Strangulation, Am J Forensic Med Pathol 2002;23(3): 260-263.

² Maxeiner H, Bockholdt B, Homicidal and suicidal ligature strangulation—a
   comparison of the post-mortem findings, Forensic Sci Int 2003;137(1):60-66.
(Page 34 end)
(Page 35 start)
Belts and cable-ties can sometimes be tightened sufficiently to
cause death. The present author, who also practices yoga, has
been experimenting with meditation belts.¹ An artist might use
an artist's paint-brush, A Scotsman a sturrock.² In this way,
death can be personalised to say something about one's own
lifestyle. One of the photographs in this chapter shows a man
who has used a walking stick to tighten his tourniquet.
Looking at his deceased body, one can conjure a fine picture
of him walking over the hills. But many people might find
such a large implement unwieldy.

Practically anything will do, but experiment to see what suits
you as well as what may go unnoticed (important if discretion
is an important factor for you). A make-up brush would
probably go unnoticed in a woman's hospital purse, but the
same could not be said of a man's overnight bag. Everyone's
body has slightly different proportions. It is only necessary
that the rod, stick, brush (or whatever you use) is sufficient for
you to turn the tourniquet and then catch on your shoulder,
jaw, or the floor/mattress so it does not unwind. If you use
some other method of compression, not involving a rod to
tighten the ligature, make sure you can achieve sufficient
tightness and that it will not slip.

Individual responses will clearly vary, but the examples are
very varied. For instance, one woman committed suicide by

---
¹ These are sturdy belts (see illustration in this chapter), mostly used in Iyengar
   Yoga, for maintaining a posture by looping the belt around the body. They are
   designed for easy adjustment. The author, using one in a seated posture for over
   an hour, has noticed some movement in a cheaper belt that had a small buckle
   (which might make it unsuitable) though a sturdier one didn't slip, even with
   body pressure.
² The traditional Scottish kitchen implement for stirring porridge.
(Page 35 end)
(Page 36 start)
tying a purple sweater tightly around her neck while in
hospital.¹

## *Variation 4: Ratchet Tie-Down*

The ratchet tie-down is a main variation on this method. What
Marjorie achieved with a handmade tourniquet is here
achieved with a easy-to-obtain, inexpensive piece of equip-
ment. Some people find the ratchet off-putting. You can skip
this section if you wish.

You might want to purchase one and familiarise yourself with
it before deciding if it is to be one of your methods of choice.
You will find them at various retail stores such as those that
stock materials for home improvements or car accessories.
The usual purpose is for such things as securing luggage on a
car roof rack or holding items securely on garage walls; the
(Image description start)
              An example of a suitable 'hookless' ratchet tie-down
(Image description end)

---
¹ Coroner's Inquest Number 23/2009 (1173/2007) into the death of Sofija
   Dobrijevic, 2007, Neck Compression by ligature.
   http://www.courts.sa.gov.au/courts/coroner/findings/findings_2010/Dobrijev
   ic_Sofija.pdf accessed 2 July 2012.
(Page 36 end)
(Page 37 start)
load stays secure because the webbing tightens and stays
locked in place with every push, until you release it by pushing
         Image A    the thumb lever(s).

                    The advantage of the ratchet is that once
                    you are comfortable working it, the
                    procedure is very straightforward. You
                    don't have to worry about whether to give
                    it an extra turn — just keep working the
                    lever back and forth an inch or so until it
                    is very tight and you pass out. It takes very
                    little effort (but beware - it takes quite a
B Image             bit more effort to take it off!) Another
                    advantage is that it is very comfortable.
                    There is no fabric strip knot digging into
                    your neck, just a smooth metal plate
                    where the fabric loop meets.

                    Only practice with the ratchet on your
                    neck if you are extremely confident that
                    you can operate the mechanism easily and
         Image C    release it when required. If possible, do
                    your dress rehearsal with a trusted friend,
                    and keep a pair of scissors handy just in
                    case it gets stuck or you can't operate the
                    release mechanism once the ratchet is in
                    place.

                    Some people find working the ratchet tie-
                    down comes quite naturally and also like
the aesthetic appeal (it looks nice and neat once in place) —
others find it quite the opposite and even distasteful. In the
workshops, persons who have already used them for ordinary
purposes, were naturally inclined to physical work involving
(Page 37 end)
(Page 38 start)
ratchets, and more men than women, preferred them. Those
who had difficulty working them initially also seemed less
inclined to favour them. Although it comes with full instruc-
tions, some may find it awkward to use or worry about
operating the release mechanism once the tie-down is in place.

If you buy the ratchet and find you are not attracted to the
mechanism, you can cut the fabric strip off it and use that as a
band for the tourniquet variation.

There are two main types of ratchet tie-down — ones with a
hook and ones without. The only type that you are interested
in is the one without (see illustration). It is possible to place
the loop from the ratchet tie-down around the upper part of
the neck, tightening with the ratchet until the carotid arteries
are compressed sufficiently for the blood supply to the brain
to be interrupted (without interrupting the breathing). This
results in loss of consciousness followed by death.

It is very important to familiarise yourself with the way the
ratchet tie-down works before placing it around your neck.
**The thumb release mechanism generally needs a bit of**
**practice. Read the instructions on the box and experi-**
**ment with strapping down luggage or using it on your**
**thigh (where you can see what you are doing and remove**
**it easily).**

Some people will find that, once fitted, the ratchet tie-down is
more aesthetically pleasing than many other methods. The
webbing material is also comfortable against the neck and
generally will not necessitate additional padding.
(Page 38 end)
(Page 39 start)
## Using the ratchet tie-down
The ratchet tie-down is simply a mechanical refinement of the
tourniquet method that appeals to a small number of people.
Trim off excess strapping — only about a metre is needed.
Then thread the strapping: it is a bit like threading the film in
an old-fashioned camera. Practice on your thigh for dress
rehearsals, and especially practice undoing the ratchet, which
is much harder to undo than tighten.

*Step by step:*
*     Work the handles until the slot is exposed on the centre
      spindle.
*     With the handles in a 'V'-shape, feed a few inches of the
      free end of the strap through the centre of the spindle (A).
      This part is like threading a bobbin or camera sprocket.
      Hold it with 'V' pointing upwards, insert the strap from
      the top of the 'V' shape.
*     Crank the handle to secure the strap (two or more layers
      of strap must be wound around ratchet reel for a secure
      hold.) See diagram (B).
*     Place the loop around your neck (or your thigh if you are
      in a dress-rehearsal practice-run). Tighten swiftly, as need-
      ed, by cranking the handles a few turns.

*To release the ratchet:*
*     Compress the spring release bars and open the handle
      180° until it clicks. (You can still release the strapping if it
      won't open to 180° but it may require more effort.)
*     Firmly pull apart each side of the secured strap (C).
*     Compress the spring release bar again and return to the
      start position.
(Page 39 end)
(Page 40 start)
*Other variations on the compression method*
Successful suicides have been recorded in the medical litera-
ture with two other methods — continuous looping and
suspension.

    ***Suspension*** is a gentle method that has been recorded
       frequently in the medical literature. It does not require
       suspension of the whole body (as in hanging) but
       simply uses the weight of the upper body to apply
       pressure via a large loop or strap to the carotid arter-
       ies.¹ For instance, *Bhardwaj and Rautji* cite a case of a
       male, "... suspended ... with his feet touching the
       ground." The loop can be attached to any fixed object
       such as a door handle, hook, ceiling fan, stair rail or
       kitchen bar. The loop is placed around the neck in
(Image description start)
              Ratchet tie down in place (dress rehearsal photograph)
(Image description end)

---
¹ Some confusion from reading the literature can arise as words are sometimes used
   differently according to context. "Around 50% of hanging suicides are not fully
   suspended — ligature points below head level are commonly used." Gunnell D,
   Bennewith O, Hawton K, Simkin S, Kapur N, The epidemiology and prevention
   of suicide by hanging: a systematic review, International Journal of Epidemiology
   2005;34:433–442.
(Page 40 end)
(Page 41 start)
such a way that, by slumping forward (facing the
floor), pressure is placed on the carotid arteries. The
carotid arteries are compressed with as little as seven
pounds of pressure (the jugular veins with even less —
about four and a half pounds). This varies greatly be-
tween individuals, but is quite small, which is why a
sitting or semi-reclining position is sufficient.¹ A mas-
sive 33 pounds of pressure, in contrast, is needed to
compress the airway. Suspension does not require
much knowledge and can be accomplished even by
invalids.² The optimum position for the ligature is
with the person facing downwards. If a knot is tied, it
is best at the back of the neck. This maximises occlu-
sion of the arteries leading to unconsciousness and
death.³

***Pressure gadgets*** have been discussed on and off by
the NuTech group.⁴ You find something that you can

---
¹ Percentage of body weight involved stretching the ligature: Standing with toes
   touching the floor: 98%. Standing with feet flat: >65%. Kneeling with buttocks
   down: 74%. Kneeling with buttocks up: 64%. Sitting with back inclined
   down32%. Sitting with back upright: 17.5%. Recumbent (lying down), prone
   (face down): 18.3%. Recumbent, supine: 9.7%. Khokhlov V, Calculation of
   tension exerted on a ligature in incomplete hanging, Forensic Sci. Int. 123:172–
   177, 2001.

² It has sometimes been objected that only persons in prisons and institutions,
   driven to suicide by desperation, use such methods. According to the review by
   Gunnell and Bennewith *(ut supra)* this is not the case. They found that: "Only a
   small proportion (around 10%) ... occur in the controlled environments of
   hospitals, prisons, and police custody; the remainder occur in the community."

³ Iserson K, Strangulation: A review of ligature, manual and postural neck
   compression injuries, Ann Emerg Med 1984;13:179-185, pp.179-180.

⁴ World right-to-die news list, Vol.18, Issue 96, Sat, 16 Jun 2012; "Neal Nicol (long
   time colleague of Jack Kevorkian's) developed a prototype of a carotid artery
   compression device. Theoretically the blood supply to the brain would be
(Page 41 end)
(Page 42 start)
put inside the ligature that exerts more pressure on
the carotids area than the rest of the neck. In one
suggestion, a ligature with pressure items is tightened
around the neck and then a second ligature — one
suggestion being sphygmomanometers¹ (blood pres-
sure cuffs) to increase the pressure on the arteries.
The type of blood pressure cuffs designed for chil-
dren are a preferable width but often not long
enough.²

The use of a second ligature is not unknown in the
medical literature. In one case, a man attempted to
use cable ties, tightening them by means of a cable-tie
tensioner³ and then resorting to an ordinary leather
belt when there was no loss of consciousness.⁴

---
   quickly cut off and a painless, quick death would occur. This apparatus has not
   been tested. This is a variation of what Ruth Van [sic] Fuchs suggested many
   years ago at a NuTech meeting in a more primitive version, the Killer Potato,
   where compression was caused by two potato halves" In both the Nicol version
   and the von Fuchs version, solids — pieces of potatoes or pieces of pipe — are
   attached to the ligature to exert additional pressure to the carotids. The idea
   seems sound enough in theory, although the present author can find no known
   cases at the time of writing.
¹ "velcro added inside, 4 inch pvc connector 001, adjustable strap added to outside
   velcro, cut in half velcro neck strap 2 holes, hand pump connected to both
   bladders, two pediatric cuff bladders velcro on inside" (private communication).

² Thank you to a researcher in India who contributed this idea and who wishes to
   remain anonymous.

³ Readily available by mail order on the Internet.

⁴ Sorokin V, Persechino F, DeRoux SJ, Greenberg M, Suicidal ligature strangulation
   utilizing cable ties: a report of three cases, Forensic Sci Med Pathol. 2012;8(1):52-
   5
(Page 42 end)
(Page 43 start)
## How to find the carotid arteries
This is usually quite easy (but don't worry if you can't find
them!) The instructions from St John's Ambulance suggest:
"With the head tilted back, feel for the Adam's apple with two
fingers. Slide your fingers back towards you into the gap
between the Adam's apple and the strap muscle [the easily
identifiable muscle running up the side of the neck from the
shoulder blade to the hinge of the jaw] and feel for the carotid
pulse." You are feeling under the jaw bone at the front/side
of the neck. Use the pads of the fingers rather than fingertips
or thumbs. Some people have a stronger (or more apparent)
pulse here than others. In workshops, most, but not all,
participants were able to identify the carotid artery successful-
ly. (It may help if you close your eyes.)Knowing where it is
will make it easier to understand what you are going to
accomplish when you compress it with the ligature, but don't
worry if you can't feel the pulse.

*How common is compression suicide?*

One study cites 19 suicides by ligature strangulation in Berlin,
Germany, alone.¹ Meta-analyses of cases are fairly recent.²
One of the difficulties with researching some statistics is that
they frequently fail to distinguish between homicide and
suicide and, of the latter, between ligature compression alone
(for instance, using a tourniquet) and ligature compression

---
¹ Maxeiner H, Bockholdt B, Homicidal and suicidal ligature strangulation—a
   comparison of the post-mortem findings, Forensic Sci Int 2003;137(1):60-66.

² See for instance, McMaster A, Ward E, Dykeman A, Warman M, Suicidal ligature
   strangulation: case report and review of the literature. J Forensic Sci
   2001;46(2):386–388. Meta-analyses of self-strangulation by ligature have also
   been mentioned by Palmiere C, Risso E, van Hecke O, La Harpe R, Unplanned
   complex suicide by self-strangulation associated with multiple sharp force
   injuries, Med Sci Law. 2007;47(3):269-73. At least one is in German, so not cited.
(Page 43 end)
(Page 44 start)
where the compression force is provided by suspension or
partial hanging.¹ The method has not been widely promoted
by self-deliverance societies until recently, so there have been
relatively few occasions where it has been used in rational
suicide by members of 'right-to-die' societies. There are many
cases involving persons who have been mentally unstable,
some suffering from severe illness, and a good number of
simply elderly persons. (Similarly, there were hardly any cases
of helium suicide until that method was widely publicised.)
Although the statistics are convincing, and more numerous
than when the first edition of *Five Last Acts* was published, it
places even greater responsibility on the science itself, so we
have looked into it in considerable detail.

*Is compression of the arteries uncomfortable?*

As long as the loop is applied correctly, there should be little
or no discomfort. For a visual demonstration of passing out
from compression, one only needs to look at any of the many
instances of the 'sleeper hold' demonstrated.² This hold,
readily applied by a martial arts expert, is simply being dupli-
cated mechanically. In martial arts, the hold is released after
the person loses consciousness; in suicide, it is maintained
after loss of unconsciousness until death ensues. Martial arts
experts interviewed by the author have described it as 'quite

---
¹ Some make at least an attempt. For instance, the Annual Report of the Office of
   the State Coroner 2004-2005 (Perth, Australia) reported 160 prison deaths,
   listing 63 suicides, which included 29 by ligature compression of the neck, 23 by
   hanging, 5 by using a plastic bag, 2 from self-stabbing, 1 by gunshot, 1 by
   cyanide, 1 by multiple injuries and 1 by electrocution. Some caution may be
   needed due to different ways of reporting.

² eg http://www.dailymotion.com/video/x6x1hf_gene-lebell-how-to-sleeper-
  hold_spo accessed 21 May 2012. Gene LeBell, the legendary judo master, applies
  the hold to a volunteer, who is interviewed afterwards. The volunteer clearly
  feels nothing as he is seen being 'put to sleep.'
(Page 44 end)
(Page 45 start)
pleasant' or 'just like fainting.' The method, perversely, is used
for *pleasure* by persons in the dangerous cult practice of erotic
asphyxiation.

If the compression is applied too slowly, a feeling of fullness
(by blood being backed up in the head) can occur. If a poor
choice of looop is made, it may press uncomfortably into the
skin. Dozens of people have tried the compression dress-
rehearsal in Exit workshops without incident. Visual evidence
of persons who have died using compression suicide (such as
the example illustrations in this chapter) show no strong sign
of discomfort, such as one might expect in a painful death.
Indeed, there is no practical or theoretical reason why the
method should entail any more than momentary discomfort,
and this seems borne out by the evidence.

Compression is a peaceful and quick method of dying by
suicide. It should not be confused with homicidal strangula-
tion or hanging, both of which can exert uncomfortable and
even painful pressure on the neck that causes struggling and
gasping for breath, as well as other injuries.¹

*Bodily appearance after death*

As you can see from the photographs, there are no obvious
signs of pain or discomfort in these cases. But there may be
both tell-tale evidence (such as petechiae) as well as a congest-
ed, bluish appearance to the face.²

---
¹ Stapczynski J, Strangulation Injuries, Emergency Medicine Reports
  2010;31(17):193-203.

² McMaster A, Ward E et al, ibid, p.61: "Half of the suicidal cases had a prominent
  congested and dark blue (livid, 'cyanotic') face."
(Page 45 end)
(Page 46 start)
The eminent pathologist Cyril Polson performed experiments
to confirm that the carotid artery is appreciably obstructed by
a ligature under low tension. His tests showed that "7lbs
(3.2kg) was sufficient to reduce free flow through the artery to
a mere trickle."¹ Adding that this will "rapidly induce cerebral
anoxia and unconsciousness." Polson goes on to detail
examples of self-strangulation (as he calls it) using nylon
stockings.² Oehmichen and Auer also detail both internal
signs (apparent on autopsy) and external ones.³

## What you need
*For the tourniquet method:*

*    Only household equipment is needed although any of the
     following may come in useful:
*    Rufflette is ideal. Stockings, bowtie, rope, flex, window
     sash-cord or webbing. The type of material used in a
     ratchet tie-down is quite adaptable and can be purchased
     easily (you can use almost anything from which you can
     make a tourniquet loop — be inventive!) Note that some
     neckties tend to be 'stretchy' and are less than suitable;
     stockings, on the other hand will only stretch so far. For
     the workshops, we used many materials, but especially
     rufflette. This can be purchased from John Lewis' or hab-
     erdashers (it's used for trimming curtains). You need a
     width of about 25mm. A very narrow width can be un-

---
¹ Polson C, Gee D, Knight B, The Essentials of Forensic Medicine. Pergamon
   Press 1985:369.
² Ibid 396-402.

³ Ligature Strangulation, in: Oehmichen M, Auer R, König H, Forensic Neuropa-
   thology and Associated Neurology, Springer 2005; 14.2.2 (p.298).
(Page 46 end)
(Page 47 start)
     comfortable and a very wide strip will be difficult to twist
     effectively when you insert the stick.¹
*    Padding. If you want to obtain one, a foam cervical collar
     or a section cut from one (buy on the Internet from med-
     ical suppliers) is excellent, but almost any padding will do.
     A fleece headband (see earlier illustration) also works.
*    A plastic bag if desired. Large roasting bags (the very large
     size) are a good choice.
*    A broom handle, walking stick, mixing spoon, large pen,
     sturdy artist's brush, or similar (anything which you can
     use as a rod, your 'stick' to turn the tourniquet).

Although favourite materials can be obtained in advance (and
especially for practice purposes), suitable implements can be
found in most situations and environments with a minimum
of fuss or trouble. You might even want to make an occasion-
al habit of looking round a new room or environment and
thinking, "What would I use?"

*For the ratchet tie-down method:*
*    A ratchet tie down, the sort without hooks
*    A bag for extra safety if desired, as above.

## General description of what happens
Pressure is applied by one of a number of means such that the
arteries and veins in the neck that supply blood to and from
the brain are compressed, though without enough pressure to
compress the windpipe (In the classic judo 'choke' for
instance, which uses the same principle, pressure is often
achieved by pulling cross-wise on the lapels). Without a fresh
supply of oxygenated blood, the brain then dies within a few

---
¹ Too wide a ligature can mean the pressure is widely distributed and less effective.
   Khokhlov V, Pressure on the neck calculated for any point along the ligature,
   Forensic Sci Int 123(2001) 178-181
(Page 47 end)
(Page 48 start)
minutes.¹ (Allow 20 - 30 minutes however to ensure you will
not be disturbed.) As with other methods of starving the brain
of oxygen, interruption early on could lead to brain damage.

In experiments during workshops (the present author demon-
strating on himself), a sensation of light-headedness is preced-
ed by the voice getting fainter and a sound in the ears. No
discomfort is experienced.
(Image description start)
                              Child sized
                              BP cuff - chosen for
                              narrowness
           attached
           ligature
  A novel compression device (suggested by an Exit member) using a child's blood
 pressure cuff (sphygmomanometer) which is a good width. To make it long enough
       for an adult's neck, the length has been extended with a Velcro strap.
(Image description end)
*What is the evidence for compression?*

The evidence for compression comes from three main
sources. Firstly, in the medical literature, many cases have
been reported although it is far less common than other

---
¹ For a precise anatomical description, please see Iserson K, Strangulation: A review
   of ligature, manual, and postural neck compression injuries, Ann Emerg Med
   1984;13:179-185, p.181. Iserson also postulates (p.182) that loss of conscious-
   ness due to initial venous compression causes the body to go limp, and muscle
   tone in the neck to be decreased, thus increasing pressure on the arteries.
(Page 48 end)
(Page 49 start)
methods of asphyxia. For instance, one study found that
suicides by means of ligature compression in Berlin occurred
about once a year. Nineteen cases over a period of 20 years
were reported by Maxeiner & Bockholdt.¹ Similarly in a study
of asphyxial deaths in Turkey, ligature deaths appear although
accounting for less than three per cent of the total.² A large
number of cases are described and illustrated in the literature.³

Secondly, in the academic literature concerning sextual devi-
ance, many cases of auto-erotic asphyxiation are known. This
seems strange at first, but they are relevant inasmuch as the
same technique is employed, compressing arteries to stop
oxygen to the brain, although with entirely different inten-
tions. One partner applies pressure to the other's neck to
obtain a 'high' by partial stopping of oxygen to the brain, or
self-induced compressions for the same purpose. Fatalities
occur when the pressure is continued for too long. The
quantity of documented cases enables greater study of the
physical process by which anoxia is achieved painlessly.

Thirdly, the technique used by martial arts experts (and for
some time the police) of applying pressure to an opponent is
well understood. The 'lateral vascular neck restraint' (or
'sleeper hold') was once a widely taught choke in law en-
forcement, performed from behind by putting an arm around

---
¹ Maxeiner H, Bockholdt B, Homicidal and suicidal ligature stran-gulation—a
   comparison of the post-mortem findings, Forensic Science International
   2003;137(1):60-66.

² Azmak D, Asphyxial deaths: a retrospective study and review of the literature, Am
   J Forensic Med Pathol. 2006 Jun;27(2):134-44.

³ Polson C, Gee D, Knight B, The Essentials of Forensic Medicine. Pergamon
   Press 1985, pp395-405.
(Page 49 end)
(Page 50 start)
the neck with the crook of the elbow over the midline of the
neck. By pinching the arm together while assisting with the
free hand, the carotid arteries and jugular veins would be
compressed on both sides of the neck. Correctly applied, this
caused unconsciousness without putting any pressure on the
airway. In 1981, a class action suit was brought against the
City of Los Angeles over fatalities connected with carotid
artery control holds. Whereas judo practitioners are expert at
not continuing the choke long enough to cause death, police
were generally less skilled.

Inexpert application of a choke hold is also believed to have
caused cardiac arrest, particularly in someone with underlying
heart disease (there is some evidence showing that a reflex
action alone from pressure to the vagus nerve can cause death
in this manner). *Prahlow,* for instance, makes mention of the
'carotid body,' a specialised group of cells within the wall of
the carotid artery that, when stimulated, can result in signifi-
cant changes in heart rhythm and rate, as well as blood
pressure.

A 'blood choke,' or carotid restraint, specifically refers to a
chokehold that compresses one or both carotid arteries
and/or the jugular veins without compressing the airway,
causing a hypoxic condition in the brain. Regardless of who
the opponent is, a well applied blood choke leads to uncon-
sciousness in 4–10 seconds, and if released, the subject usually
regains consciousness in double the time the choke was
applied after he had blacked out (e.g. a choke applied for
fifteen seconds after the person passed out results in the
person regaining consciousness 30 seconds later). Applied for
longer, they are lethal. In ordinary language, a person passes
out when the brain doesn't receive oxygen. If the deprivation
is continued, death results. Compressing the arteries requires a
(Page 50 end)
(Page 51 start)
fraction of the pressure to compress the airway in the throat.
This is also seen in the difference between traditional manual
strangulation and properly applied blood chokes. The latter
require little physical strength, and can be applied successfully
by a comparatively weak person. There are many cinematic
depictions if you want to visualise the difference. Old James
Bond movies will have the secret agent or the villain simply
applying fingertip pressure to points on the neck until the
victim faints and slides to the floor. Similarly the Japanese film
*In the Realm of the senses* depicts erotic asphyxiation between
lovers – the pressure applied to the neck generally stopping
short of unpleasant. It is not more pressure that is needed to
cause death – simply a longer time period. (For those consid-
ering these films, the Japanese movie is a tasteful, critically
acclaimed and award winning film — but it is also very sexually
explicit.)

Finally there are well-documented cases of 'choking game'
deaths. These involve youths seeking a brief euphoric state
caused by cerebral hypoxia.¹.

The method of applying a tourniquet and positioning it on the
neck to cause minimum discomfort was known as early as the
first part of the nineteenth century. "Fleischmann placed
cords round his own neck between hyoid bone and chin, tied
them tightly, sometimes at the side, sometimes at the back,
without respiration being interfered with, because there was
no pressure on the air passages."² His experiment lasted two

---
¹ see for instance, Toblin R, Paulozzi L, Gilchrist J et al, Unintentional strangulation
   deaths from the 'choking game' among youths aged 6-19 years — United States,
   1995-2007, J Safety Res 2008;39(4):445-8.

² Tweedie a (ed) A System of Practical Medicine Vol III, Whittaker and Co 1840,
   p.233. The chapter on Asphyxia gives extensive descriptions of different types of
   compression both from experiment and pathology.
(Page 51 end)
(Page 52 start)
minutes, whereas when he tied the cord over the larynx he
could only manage it for half a minute.

It was first brought to the author's attention by judo practi-
tioners writing in saying how it was 'the simplest form of
suicide' and explaining the technique of judo holds that can be
readily adapted for self-inflicted, painless asphyxiation. But it
was only during work for his Masters degree at Glasgow
University that a pathologist alerted him to the high incidence
in the pathology literature, conveniently disguised. As one
police surgeon writes (Henry, 1966), "The confusion and
embarrassment felt by a person discovering a body who has
died through sextual asphyxia is likely to be considerable.
Attempts may be made to disguise the nature of the death to
medical attendants and to investigating police officers." A
review of published studies soon confirmed both the preva-
lence and method used. The number of reported and well-
documented cases is now very considerable.

*Typical medical literature cases examined*

    1.   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 bed clothing 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
(Page 52 end)
(Page 53 start)
         was directly below her nose. Her face and neck, above
         the ligature, were congested and of purple colour.
         Bleeding had occurred beneath the conjunctivae [eye-
         lids], but petechial haemorrhages [pinpoint haemor-
         rhages often found in asphyxia]¹ 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.

    2.   In one case, however, a 53-year-old man succeeded..
         .. 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,² 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 suspi-
         cious. However, there was no internal damage to the
         fairly delicate anatomical structures in the neck, a fact
         consistent with suicide, but not murder.

    3.   A 70-year-old-man was found dead in his room, a
         piece of belt-like cloth wrapped around the neck,
         knotted, and tightened by a walking stick. He was
         found lying on the bed, with his feet touching the
         floor. His hand was still on the walking stick which
         was seemingly used by him for a tourniquet effect.
         This case study included photographs of the diseased

---
¹ "A petechia is a pinpoint, nonraised, round, purple or red spot (<2 mm or 0.125
   in.) that results from capillary rupture." Shkrum M, Ramsay D, Forensic Pathol-
   ogy of Trauma, Humana Press 2007: 67

² Compare: "the action of bending forward caused further constriction which
   would only increase as the decedent lapsed into unconsciousness and continued
   to fall forward" Frazer M, Rosenberg S, A case of suicidal ligature strangulation,
   Am J Forensic Med Pathol 1983;4(4):351-354.
(Page 53 end)
(Page 54 start)
         with the tourniquet still in place, reported in the
         American Journal of Forensic Medical Pathology
         (Atilgan, 2010).

    4.   There are three reported cases of compression suicide
         using cable ties. One used a tool to tighten the cables.
         Compression can be an emergency method if the
         method of first choice is unavailable, and the three
         cases quoted used no padding (with a tightening tool,
         the cable ties could be applied very quickly). For more
         considered self-deliverance however, a degree of pad-
         ding would be comfortable. In one case, the man was
         not able to tighten the cable ties sufficiently by hand
         and finished the act using a leather belt.¹

    5.   Two recent cases (Tzimas 2014) used that
         instinctively appear to be a comfortable method:
         gymnastic bands. The authors of the report point out
         that the ligature must be relatively broad and soft,
         rough enough to avoid slipping, and/or elastic in
         order to maintain further compression after the
         person has lost consciousness. The use of talcum
         powder is recommended to prevent sticking together.

         Gymnastic bands are a commonplace means of
         exercise. These long, wide elastic strips are usually
         made from natural rubber latex or synthetic rubber
         and are available in different 'strengths' (degrees of
         elasticity), usually colour-coded. They are very strong,
         suitable for a wide variety of stretching exercises, and
         promoted as products for sports, rehabilitation and

---
¹ Sorokin V, Persechino F, deRoux S, Greenberg M, Suicidal ligature strangulation
   utilizing cable ties: a report of three cases, Forensic Sci Med Pathol 2012;8(1).
(Page 54 end)
(Page 55 start)
         fitness. They are also convenient for exercise when
         travelling. There are many brands available. In the
         cases studied, one had used a *Thera-Band*® and the
         second had use a *Deuserband.*® The main difference
         between a Thera-Band® and a Deuserband® is that
         the latter forms a loop.

         In the first case, the woman had taken a mild sedative.
         The bands had not caused disfigurement about the
         neck although a band of pale skin was evident in one
         case.
(Image description start)
Gymnastic bands are a commonplace item for exercise
 and sports fitness and arouse no suspiction. They are
 colour-coded for their degrees of elasticity and widely
         available from sports shops or online.
(Image description end)
(Page 55 end)
(Page 56 start)
The use of gymnast bands for compression is not one that has
been tested and experimented with in Exit workshops yet; but
suggests a potentially promising method with a high comfort
factor. It lacks the one-size-fits-all associated with some self-
deliverance methods. Even the selection of a band requires an
estimation of one's own strength when stretching and tying it.
Some very ill people will not have sufficient strength to use a
gymnast band. Ligature compression seems to depend very
much on working out what is right *for you* and understanding
how it will work.

There are many more case histories, often with ingenious
variations. Additionally, the case histories in autoerotic
asphyxiation show examples of unintentional death.¹ Most
involved males, although one study¹ looked at differences
where women were involved, particularly noting how neck
padding had been used to avoid chafing. There is no need to
go into too much graphic detail (the sample of literature
quoted at the end of the chapter will provide the necessary
documentation for the serious researcher). All the cases
involve a degree of neck compression, a few with the addition
of a plastic bag. One particular amusing case (amusing of
course except for the deceased and those who knew him) is
perhaps worthy of mention to give the gentle reader an idea.
The man in question had rigged a complex system of pulleys
to apply pressure to the neck, compressing the arteries and
producing a 'high' whilst indulging in solitary sextual activity.
To tighten the ligature, but not to a deadly degree, he had
attached the pulley to a garden lawnmower. A stake in the

---
¹ Berman A, Maris R, Silverman M, Comprehensive Text Book of Suicidology,
Guilford Press 2000, p165, suggest up to 1,000 deaths annually in the U.S. alone.
(Page 56 end)
(Page 57 start)
lawn prevented the power lawnmower from going too far.
Except it rained, and the stake came loose...

## How quickly does it work?
Like helium, compression works by starving the brain of
oxygen and takes no more than a few minutes.² Occasionally
fatal cardiac arrest can be triggered at the same time. This is
due to 'reflex vagal inhibition' — a mechanism that may
sometimes leap into action as the vagus nerve in the neck is
depressed, particularly in the elderly or if there is some
underlying heart disease. Studies using an apparatus causing
rapid carotid occlusion and quoted by *oehmichen et all* demon-
strated loss of consciousness in seven seconds. Ten seconds is
generally quoted.³ One should ensure a minimum of twenty
minutes without possibility of being disturbed.

## Are there any unpleasant side effects?
There may be slight discomfort from the pressure on the
neck, though this is not enough to interfere with breathing. As
the blood supply to the brain is interrupted, there is a sense of

---
¹ Byard RW, Hucker SJ, Hazelwood RR, Fatal and near-fatal autoerotic asphyxial
   episodes in women. Characteristic features based on a review of nine cases, Am J
   Forensic Med Pathol. 1993 Mar;14(1):70-3.

² "Death may be rapid and is probably faster than manual strangulation" Strangula-
   tion by ligature, in: Cowan S, Hunt A, Mason's Forensic Medicine for Lawyers,
   Tottel Publishing 2008; p.201.

³ "hypoxia or ischaemia and unconsciousness occurs within 10 seconds of
  interruption of the cerebral blood supply": Walallawita L, Brainstem Death and
  Organ Donation, Sri Lankan Journal of Anaesthesiology (CME Lectures)
  2009;17(2):95-98, p.95. The brain normally dies within a few minutes without
  oxygen. The figure of 20 minutes is based on the longest known time that it has
  ever been possible to revive someone after the flow of oxygenated blood has
  been stopped, which is 9-14 minutes (Saukko P, Knight B, Fatal pressure on the
  neck, Chapter 15, In: Knight's Forensic Pathology 3rd Ed, Hodder Arnold
  2004, p.369.)
(Page 57 end)
(Page 58 start)
dizziness or fainting, followed by unconsciousness and death.
Judo practitioners have described their experience of losing
consciousness from compression-technique judo holds as
'quite pleasant', like controlled fainting. This tallies with the
reports of brief euphoric state caused by cerebral hypoxia in
studies of youths playing the 'choking game.' Photographs of
persons who have ended their life by compression, such as
those reproduced in this chapter and in other studies¹ show
the deceased peacefully at rest with the ligature in place. The
difference in length between the tightened ligature and the
uncompressed neck is quite small — for instance a tightened
ligature of 30cm on a neck of 35cm.

If the tourniquet is tightened too slowly there may be a
swelling sensation in the head. This is a result of applying
enough pressure to compress the veins but not enough to
compress the arteries, and generally happens when people
turn the tourniquet very slowly. It means the blood supply
*from* the brain is blocked but not the blood supply *entering* the
brain. It will be just as lethal, but slightly less comfortable — at
least until consciousness is lost. To avoid this, simply turn it a
little faster until the 'dizzy point' or required pressure is
reached.

## A note on psychological elements
While Helium and compression are equally quick, compression
has the advantage of easy-to-find materials and could be put
into practice while confined to hospital. Yet there is a differ-
ent feeling between turning a tap at arm's length and doing
the final action close to one's head. One is like flicking a

---
¹ eg Di Nunno N, Costantinides F, Conticchio G, et al, Self-Strangulation: An
   Uncommon but Not Unprecedented Suicide Method, Am J Forensic Med
   Pathol 2002;23(3):260-263.
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switch — like diving into water as opposed to wading out into
the ocean. The other relies on repeated turns until the loss-of-
consciousness point is reached. Additionally, we tend to
associate our sense of self somewhere in the head, where four
out of five sense organs are located. One workshop partici-
pant contrasted "doing something with a helium tank" with
the act of compression which *feels* more like, "You are doing it
to *yourself."* The result is that it might take more courage to
use compression — but such things are relative if one is
suffering from an unbearable and unrelievable condition.

##　Checklist:

* 　　 You need two or three items: something you can make a
　　   strong loop with, and something you can use to tighten
　 　  the tourniquet. Make a list of suitable household items.
　　   Get into the habit of looking around or imagining your-
　　   self in other situations such as hotels, nursing homes, or
　　   on holiday — what would you be able to use in an emer-
　　   gency? You will find there are types of material that are
　　   more comfortable, but stockings are fairly easy to obtain
　　   at any hour of the day or night (for instance, from 24-
　　   hour petrol stations). People have used belts, suspenders,
　　   shoelaces, scarves, handkerchiefs, neckties, shirtsleeves,
　　   pantlegs, and undershirts, among many other things. Shop
　　   around for a suitable roasting bag or similar.
*　 　 If using an elasticized material (such as stockings or
　　   tights), make the loop the size you want when the material
　　   is at its maximum stretch.
*　 　 A fraction of the pressure that would compress the
　　   windpipe is needed to compress the carotid arteries (these
　　   supply oxygenated blood to the brain). Avoid placing
　　   pressure on the windpipe though by keeping the loop
　　   higher around the neck rather than lower down. Padding
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　　   may be used for extra comfort — find out by experiment-
　　   ing with different loops and see which ones are comforta-
　　   ble without padding (don't cut into the skin) or which
　　   ones need padding.
*　 　 Practice making the tourniquet on your thigh first, rather
　　   than your neck. This allows you to see what you are do-
　　   ing. Make sure you can do the knot easily.
*　 　 When you come to practice the tourniquet around your
　　   neck, maybe have a pair of scissors handy to cut the prac-
　　   tice stocking (or cord) should you need to.
*　 　 A wooden kitchen spoon is excellent for practice. Try
　　   turning it until you can feel the pressure (but not causing
　　   you to feel dizzy or faint). See how it catches on the collar
　　   bone or jaw. Decide if turning it in one direction or the
　　   other feels to work better for you.
*　 　 The tourniquet 'lever' can be placed at any point, but at
　　   the side and towards the front of the neck is perhaps easi-
　　   est and most comfortable — and also positioned well to
　　   catch on chin or collar bone. (Do experiment — it is the
　　   quickest way to understand it!)
*　 　 The pressure needed for self-deliverance is the same
　　   puressure that is needed to cause you to become dizzy and
　　   faint, so exercise due caution during your dress rehearsals.
*　 　 If you experience a swollen feeling in the head while
　　   practicing, start again but tighten the tourniquet more
　　   quickly.
*　 　 Remember, keep the tourniquet high up on the neck to
　　   minimize uncomfortable pressure on the windpipe and
　　   maximise pressure on the carotids.
*　 　 Make sure the knot is secure and does not slip.
*　 　 Ensure the fitted loop is sufficiently distant from the neck
　　   (about two or three inches) to allow the 'stick' (pen,
　　   spoon, etc) to be inserted and turned. You need to be able
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　　   to turn the stick like the hands of a clock to tighten the
　　   tourniquet.
*　 　 Ensure the loop isn't *too* big. Otherwise you will end up
　　   turning it for a long time to make it tight enough. By the
　　   time you feel the pressure on your neck, the twists in the
　　   loop will have become very unwieldy.
*　 　 Practice until you can do it comfortably, effectively and
　　   safely. Practice very carefully at first, especially if practic-
  　 　ing on one's own. You can go almost to the 'dizzy point'
 　 　 and no further.
* 　 　You do not have to tighten the tourniquet to a dangerous
 　 　 degree in dress rehearsals. The loop will acquire a natural
 　 　 tension so you can experience the stick catching against
  　 　the jaw or shoulder-blade.
* 　 　Everyone's physical dimensions are individual, so experi-
 　 　 ment. For some people turning it clockwise will be best,
  　 　for others anti-clockwise. If you have a very pronounced
  　 　jaw, it will catch differently. But it works for everyone and
  　 　there is nothing very complicated about it. This whole
  　 　chapter is describing a process that can be demonstrated
  　 　in a matter of seconds.
* 　 　If you want to experience the 'dizzy point' when you are
  　 　practicing alone, simply apply pressure at the pulse points,
  　 　as explained (in the event of fainting, your hands fall away
  　 　so you are not in danger). This is *not* recommended as a
  　 　regular practice though. If you are in poor health, excep-
  　 　tional care is needed so as not to trigger the vagal reflex
  　 　and you should *not* go as far as making yourself dizzy in a
  　 　dress rehearsal.
* 　 　It is not necessary to be able to find a pulse for the
  　 　technique to work. Some people's pulse is more pro-
  　 　nounced than in others.
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## 'Amazon' possible shopping list

* **Webbing tape** — 25mm wide cotton webbing tape
    (similar to rufflette)
* **Make-up brush** — or anything else that is your desired
    length for comfort and convenience
* **Ratchet tie down quick release** — (check the picture to
    make sure it is not the sort with hooks!)
* **Gymnast band**
(Image description start)
    Personalising your exit? The photograph shows one of the sturdier adjustable
    meditation belts used in some forms of yoga. This particular belt might be too
  Wide for some people with shorter necks. The buckle on this one doesn't seem to
                            slip — other belts may vary.
(Image description end)
(Page 62 end)