He was committed to a mental hospital because of withdrawn behavior. He had arteriosclerotic heart disease; his electrocardiogram (EKG) showed premature ventricular contractures which was partially controlled by quinidine.
When an order was granted, two police officers were dispatched to his home to bring him to the hospital. Coaxing by the police officers proved futile. In an attempt to overpower and handcuff him, one officer stepped behind the victim and grabbed him about the neck. The hold intended by the officer was the carotid sleeper with the neck of the victim in the crook of the arm and forearm of the officer. After a brief but violent struggle, during which both the officer and victim fell to the floor, the victim became lifeless. He did not respond to CPR. An EKG taken during resuscitation showed cardiac arrest. Witnesses, including family members, stated that the entire struggle lasted only a "short time," with the neck hold in place several seconds.
The reported cause of death was cardiac arrest, arteriosclerotic hypertensive heart disease, and neck compression, contributory, classified as homicide.

Case 14
A 35-year-old manual laborer was taken into custody for threatening his wife with a shotgun. He had been treated on many occasions for manic depressive psychosis and had been on maintenance dose of lithium. On the third day in jail, although on lithium, he became combative, disruptive, and threatened the life of another prisoner. He resisted the restraining attempt of six guards, but was finally overpowered and handcuffed and moved to a solitary confinement cell where he remained violent and combative.
He was forced face down on the bunk while the handcuffs were removed and replaced by nylon flex cuffs. During this time, a guard put the victim's head in a neck hold which the guard described as the carotid sleeper. The prisoner ceased to struggle and the guards left him to recover. A few minutes later when a guard returned to check on the prisoner, the prisoner was found apneic. CPR was immediately begun, and in a matter of minutes medical personnel arrived at the scene. EKG showed fine ventricular fibrillation which progressed to cardiac standstill.
The reported cause of death was neck hold.




Choke Holds Used by the Police
The Carotid Takedown Modified and Control
A right-handed officer maneuvers behind the suspect, wraps his right arm around the suspect's neck between the throat and the carotid. At this point, pressure is applied to the suspect's neck between the throat and the carotid artery with the lower forearm. The suspect is then pulled backwards so that the suspect's back is in contact with the officer's chest. The technique is the same as hadakajime used in judo in the standing position. The suspect is then pulled down to a sitting position. If the suspect continues to resist, the move is made to go into the "locked carotid control." The officer can do this by driving the right thumb into the left armpit, then griping the upper left arm with the right hand. The right arm is flexed and the left hand is extended beyond the right shoulder. This maneuver will draw the officer's right arm tighter around the neck.

The Bar Arm Takedown and Control
In the event that the suspect is uncontrollable and the officer is unable to apply the modified carotid hold, the officer may have to resort to the bar arm to take the suspect down. The locked bar arm control is performed by gripping the left biceps with the right hand. At the same time, the officer bears down with the left and against the back of down to a sitting position with the same maneuver as the carotid takedown and control. This technique is the same as the one method of hadakajime (naked choke-lock) used in judo.
It is important to point out that the police training manuals emphasize that the application of pressure must be stopped as soon as the suspect ceases resisting or goes limp. When a situation escalates to the point that a control hold is necessary to restrain and control a suspect, both the officer and the suspect are prone to injury. It is preferable to use persuasion and command presence to control a situation. When it does become necessary to apply a control hold, proficiency with the control holds described will help to restrain a combative suspect.

Discussion
The 14 fatalities presented were allegedly caused by "choke holds", 13 by law enforcement officers, 1 by a student learning Vo et Vat, a Vietnamese version of judo. In the sport of judo, which started in 1882, no fatalities have been reported. Judoists are taught to apply shime-waza using the principle "maximum efficiency with minimum effort." The maximum pressure is applied directly on the "carotid triangle" without applying the pressure on other parts of e neck, causing unnecessary damage. In all 14 cases, this author has noted evidence of injuries to the structures of the neck from bruises, ecchymosis, hemorrhages to fractures of the cartilage of the neck (Cases 1, 5, 10, 13, and 14), and intervertebral discs (Case 7). Submucosal or mucosal injuries are noted in the larynx in Cases 1, 2, 6, 11, and 13, All these findings indicate that tremendous force was exerted on the necks of the suspects.
If the carotid artery hold is properly applied, unconsciousness occurs in approximately 10 seconds (8-14 seconds). After release, the subject regains consciousness spontaneously in 10-20 seconds. Neck pressure of 250 mm of Hg or 5 kg of rope tension is required to occlude carotid arteries. The amount of pressure to collapse the airway is six times greater.


Contents of anterior triangle of the neck. Structure in a deeper dissection of the neck exposing the carotid artery and its branches and the vagus nerve in the superior carotid triangle where pressure is applied for maximum effect. (From W. H. Hollingshead. Textbook of Anatomy, 3rd ed. Harper & Row, Philadelphia p. 756).
Anatomically, the anterior cervical triangle of the neck contains the superior carotid triangle. The pressure can be applied to either side. The anterior cervical triangleis a triangle bordered by the sternocleidomastoid muscle (large neck strap muscle) laterally, the mandible jaw bone above, and medially by the cervical midline, a line drawn from the tip of the jaw to the sternal notch. Within the anterior cervical triangle, there are three smaller triangles:
• submandibular (submaxillary or digastric)
• superior carotid
• inferior carotid (muscular).
In