Violent Asphyxial

Death
Dr. Rakibul Hasan Khan
MBBS, DFM (BSMMU), BCS (HEALTH)
LECTURER,
FORENSIC MEDICINE
SHEIKH HASINA MEDICAL COLLEGE,
TANGAIL
 Asphyxia
When Supply of oxygen to the blood and tissues has been
reduced markedly below the normal working level by any
interference with respiration is termed as asphyxia.

There are different types of asphyxia:

1.Mechanical
2.Pathological
3.Toxic
4.Environmental
5.Traumatic
6.Postural
 Violent asphyxia
Prevention of exchange of air between the atmosphere &
the lungs by violent mechanical means is called violent
asphyxia.

There are different types of violent asphyxia:

Constriction of the neck:
 Hanging.
 Strangulation.
By closure of mouth and nose/Obstruction asphyxia:
 Suffocation
 Smothering
 Violent asphyxia
By occlusion of the lumen of the air passage by solid, or liquid
substance
 Choking
 Drowning.

By restricting the movement of the chest:

 Traumatic asphyxia.
 Postural/positional asphyxia.
 Violent asphyxia
Cardinal features of violent asphyxial death
a) Cyanosis.
b) Petechial haemorrhage/ Tardieu’s spot
c) Congestion
 Petechial hemorrhage (Tardieu's spot)
• Tardieu , French police surgeon described it in 1866.

• These are occur due to anoxia, stasis and increased capillary

permeability and rise of intracapillary pressure.

• The spots are round, dark-red, well-defined & pin-head in size

but occasionally may be larger. Found where capillaries are
less supported as in face, conjunctiva, epiglottis & serous
surface of heart & lungs
 Petechial hemorrhage (Tardieu's spot)
• Petechial hemorrhage are classical features of asphyxial
death, but they are not pathognomic as they are found in
other forms of death also e.g.
 Scurvy
 Leukamia
 Coronary thrombosis
 Electrocution
 Poisoning
 Blood dyscariasis
Hanging
 Hanging
Hanging is a form of violent asphyxial death which is
caused by suspension of the body by a ligature which
encircles the neck, the constricting force being the weight
of the body or part of the body.
 Types of Hanging
According to the position of the knot used
• Typical hanging
• Atypical hanging
According to the degree of suspension
• Complete hanging
• Partial hanging
Medico-legal classification
• Suicidal hanging
• Homicidal hanging (Ex- Lynching)
• Accidental hanging
• Judicial hanging
• Post mortem hanging(suspension)
 According to the position of the knot
used
Typical hanging Atypical hanging
The knot of the ligature The knot of the ligature may
is at the nape of the be at any site other than
neck on the back. the nape of the neck.
According to the degree of suspension

Complete hanging:- When

the body is suspended from
a high point of suspension
and feet are not touching
the ground, it is called as
complete hanging.
According to the degree of suspension
Incomplete or partial
hanging:-
When some parts of the
body touches the
ground like knees, feet,
etc. it is called
Incomplete or partial
hanging. Constricting
force being the weight
of head alone.
Accidental hanging
 Homicidal Hanging
Rare
Not possible in adult
Possible only in intoxicated, unconscious state, weakness,
senility or under the influence drinks or drugs, children
It cannot be perpetrated by single assailant
Rope is first fastened around the neck and then pulled.
Homicidal hanging can be suspected in a victim when-
 The knot is tied at the back of the neck
 The mouth is gagged
 The limbs are tied
 Injuries are found on the body which could not have been
self-inflicted
 Signs of struggle with some other individual are present
 Lynching
It is a form of homicidal
hanging in where persons
enraged by an offence
committed by another
person. They kill him
publicly to demonstrate the
punishment given to him.
Common in South America,
where a black rapist was
used to be lynched by
angry white mob.
 Sexual Asphyxia (Autoerotic Hanging)

It means those deaths in which fatal conditions are self-induced

during course of solitary erotic behaviour.
Males are only involved
Naked or wearing female dress.
Pornographic pictures surrounding the victim
VCR, Video, TV, CD, Dummy of female or female wearing
articles in bed may be found
Signs of ejaculation.
Sexual asphyxia is a partial hanging but accidental in nature.
 Cause of death in case of hanging

1) Asphyxia- by compression or constriction of laryngeal or

tracheal Lumina.
2) Venous congestion- by compression of jugular veins.
3) Both asphyxia & venous congestion (Most Common)
4) Cerebral anoxia- by blocking of carotid vessels
5) Reflex vagal inhibition- by pressure on the vagal sheath
or carotid bodies. (Immediate death)
6) Fracture or dislocation of cervical vertebra (Occurs in
judicial hanging).
Force required for death in hanging

• Jugular vein-2 Kg
• Carotid artery-5kg
• Trachea-15Kg
• Vertebra-20Kg.
 Complications of hanging
Delayed complication
 1) Aspiration pneumonia
 2) Edema of the larynges
 3)Oedema of the lungs
 4)Hypoxic
encephalopathy
 5) Infraction of the brain
 6) Brain abscess
 7) Bronchitis.
Secondary complication-
 Hemiplegia
 Epileptic convulsion
 Dementia
 Amnesia
 Cervical cellulites
 Parotitis
 Retro-pharyngeal abscess.
 Post mortem findings in case of hanging
External findings
 Ligature mark- Oblique, non continuous
& high up in the neck above the thyroid
cartilage.
 Gap near the site of the knot due to the
pull on the knot from the point of
suspension above
 When the knot is in contact with the skin
-it looks `V' shaped
 Dribbling of saliva: From the angle of
mouth opposite the site of knot.
Salivation occur due to irritation of the
sub mandibular gland.
 Post mortem findings in case of hanging
 Tardieu’s spot may present just above the ligature
especially on face, conjunctiva etc., pericardium.
 Bending of neck: The neck is stretched and elongated
and gets flexed to the side opposite to the site of knot .
 Bleeding per nose or mouth may present.
 Protrusion of tongue may present
 Cyanosed.
 Purple
colored postmortem hypostasis in the lower limbs
and lower regions of upper limbs
 Post mortem findings in case of hanging
Internal findings
 Subcutaneous tissue underneath the ligature mark
shows Parchmentization. That means it becomes
dry, white, firm and glistening.
 The hyoid bone may be fractured In 5-10% of
cases.
 The carotid arteries may be found lacerated
 Larynx, trachea, lungs, brain and all other organs
are congested.
 The fracture of the 2nd & 3rd cervical vertebrae
along with rupture of spinal cord may be seen in
judicial hanging.
 Ligature mark may be absent in

 Bearded person.
 If portion of clothing intervenes.
 If soft & broad materials e.g. towels, scarf is used
 Decomposition.
 Post mortem suspension

 Victim is killed by other means and then hanged to simulate a

suicidal death
 Evidence of dragging of the body on ground.
 Friction at the point of suspension as ligature is first tied.
 Inapproachability of the point of suspension by the victim.
 Evidence of actual cause of death present on the dead body.
 Medicolegal Importance of hanging

 Hanging is always suicidal unless otherwise proved

 Partial hanging is more suicidal than complete hanging.
 Hanging may be homicidal in case of judicial hanging and
lynching
 Hanging may be accidental in case of autoerotic
hanging/Sexual asphyxia
 Hanging of a young lady even with torture mark (ante mortem
injury) throughout the body may indicate suicidal hanging.
 Opinion as we give in case of Hanging

Death, in my opinion, was due to asphyxia as a result of hanging

which was ante mortem & suicidal in nature
Strangulation
 Strangulation
Strangulation is a form of violent asphyxial death caused
by constricting the neck by some means without
suspending the body, and the constricting force being
other than body weight or head of the victim.
Types of Strangulation:
a) Strangulation proper:
-Ligature strangulation.
b) Manual strangulation:
-Throttling.
c) Mechanical:
-Bansdola
-Mugging
-Garroting
 Types of strangulation
Throttling is defined when Mugging : When constriction
constriction of neck is of neck is done by a foot,
produced by fingers or knee, or bend of elbow it is
palms. called mugging.
 Types of strangulation
Garroting: In this a rope
is suddenly thrown from
behind around victim’s
neck and
unconsciousness
develops suddenly due
to pressure and
ultimately dies.
 Types of strangulation
Bansdola: In this method
one bamboo is put in
front of neck and one
on the back. These are
tied by rope. The
constriction is caused
by squeezing.
 Cause of death in case of strangulation

1)Asphyxia
2) Cerebral venous congestion or apoplexy
3) Both asphyxia & venous congestion
4) Cerebral anoxia
5) Reflex vagal inhibition
6) Fracture or dislocation of cervical vertebra (Rare)
 Post mortem findings in case of strangulation
External findings
 The ligature mark may be circular, continuous, at or
below the thyroid cartilage, completely encircle the
neck.
 Along the edges of the ligature mark abrasions and
ecchymosis is found.
 There is always some damage to the skin underneath the
ligature.
 Tardieu’s spot may seen in conjunctiva & eyelids.
 Bleeding per nose or mouth may present.
 Protrusion of tongue may present
 Protrusion of eyeball may present
 Cyanosed
 Post mortem findings in case of strangulation
Internal findings
 In neck-subcutaneous tissue is ecchymosed.
 Neck muscles, laryngeal cartilages, tracheal rings injured.
 There
is severe congestion & hemorrhage into the tissue in
& about the area of compression.
 Fracture of the thyroid cartilage is commonly seen
 The carotid arteries may be found lacerated
 Larynx,
trachea, lungs, brain and all other organs are
congested.
 Medicolegal importance of strangulation

a) Suicidal -not common

b) Accidental-rare
• Newborn by umbilical cord, if at the time of birth is
twisted round the neck
• Children restrained in their cots by harness
c) Homicidal-common
In fact strangulation should be assumed to be homicidal,
until the contrary is proven to be more likely under the
circumstances.
 Suspicion of Strangulation

• Knot is tied on the back of the neck

• Mouth is gagged
• Limbs are tied
• Injuries on body
• Signs of struggle
• Sexually assaulted-if female
 THROTTLING

It is a form of manual strangulation in which the constriction

of the neck is produced by the pressure of the human
fingers or palms on the victim’s throat. Usually the carotid
arteries are occluded, airway occlusion plays minor role.
 When one hand is used
• One single bruise on one side is due to pressure of the
thumb and obliquely directed
• multiple bruises one below the other on the opposite side
due to pressure of other finger pads or finger tips
• There may be more extensive cresentric abrasion marks
in the neck.
When Right hand is used
• If numerous scratches are found on the left side of the
neck
• The inference will be that the throttling was by the right
hand of the assailant and vice versa
 When both hands are used

a) Bruising pattern depends upon the relative position of

the thumbs and fingers & degree of pressure applied.
b) VICTIM'S own nail mark due to free himself from assailant
c) Finger nail abrasions are often produced due to the
victim trying to free himself from the throttling grip
d) Examination of nails of the victim and assailant may
indicate their origin
 Post mortem findings in case of Throttling

 The marks of thumb and fingers may be seen around the

trachea.
 These small bruises are disc-shaped,1-2 cm in diameter
and red initially and may look brown later.
 Small linear or crescentic marks may be seen on the neck
due to pressure of finger nails.
 There are scratches & bruise caused by nail & fingertips is
found.
 Post mortem findings in case of Throttling

 Hemorrhage in the subcutaneous tissues and the muscles

underlying nail mark is usually scanty when compared
with external injuries
 Superiorhorn of the thyroid cartilage are more commonly
fractured than the hyoid bone
 Deeper tissue may show extensive bruise.
Differences Between Hanging & Strangulation
Differences Between Hanging & Strangulation

Traits Hanging Strangulation

Manner of death Usually suicidal Usually homicidal

Signs of struggle Absent Present

Injury to muscles of Rare Common

neck
Bleeding from nose & Rare Common
mouth
Protrusion of tongue Less Marked More Marked
Suffocation
 Suffocation
Suffocation is a form of violent asphyxia caused by
mechanical obstruction to the passage of air into the
respiratory tract by means other than constriction of the
neck and drowning.
Types of suffocation:
 Smothering
 Choking
 Gagging
 Overlying
 Traumatic Asphyxia
 Burking
 Types of Suffocation
Smothering: It is form of suffocation caused by mechanical
obstruction of air passage at the level of mouth & nostrils
by hand or other means (Plastic bag, Cloth, pillow etc.)
 Types of Suffocation
Gagging:- A form of asphyxia in which entry of air into the
lungs is prevented either by forcing a piece of cloth or alike
material into the mouth or by closing the mouth and nose
by similar material
 Types of Suffocation
Choking:
It is a form of smothering caused by mechanical obstruction
within the air passage by a foreign substance.
• Usually any object within the air passage excites violent
coughing to expel the object but if this fails, chocking
results
• The size of the object is not much importance, even an
object smaller in size than the lumen of air passages may
bring about reflex spasm of air passage with fatal outcome.
 Medico Legal importance of Chocking
 It is always ACCIDENTAL.
• Impaction of food, fish-bone, denture & other foreign body in the air
passage
• Inhalation of vomitus of persons under influence of alcohol, drugs or
during epileptic fit or coma
• Gauze during operation
• Regurgitation of food in infants, impaction of objects like marble,
coins, rubbery balloons may occur in children while playing.
• Tongue of the person who is in epileptic attack may fall back on to
the posterior pharyngeal wall.
 Homicidal- In case of infant
Café coronary: Is a condition of accidental
choking in which a healthy but grossly
intoxicated person, who begins a meal,
turns blue, coughs violently, then collapse
& dies; where a bolus of food completely
obstruct the larynx. It is so called because it
occurs in a café & its suddenness &
associated collapse mimics heart attack
• At autopsy, a large piece of poorly
chewed food may be found obstructing
the larynx.
• A blow on the back or on the sternum
may cause coughing and expel the
foreign body.
 Traumatic Asphyxia
It is a form of violent asphyxia resulting from trauma to the
chest or external pressure on the chest, back & abdomen
which prevents respiratory movements by mechanical fixation
of chest and abdomen.
Causes:-
• Traumatic injury to chest [stab injury] resulting in
pneumothorax leading to collapse of the lungs
• Non penetrating due to run over car accident or steering
wheel impact injury on chest or collapse of a building fixing
the victim under a collapsed beam or any masonry
• Due to house collapse.
• Multiple deaths are likely to occur when there is an outbreak
of fire in a theatre or whenever large crowds gather in an
enclosed place. Some are crushed by the weight of the
crowd, the chest being pressed violently.
• By being run over by a vehicle.
• Due to collapse of a wall inside a mine.
• When held between the buffers of two bogies of a train.
 Types of Suffocation
Overlying: It is a form of violent asphyxia in
which entry of air into the lungs is prevented
due to compression of the chest & usually
occurs when mother or other persons share a
bed with infant. During sleep the older person
rolls on to or crushes the infant & respiration is
reduced or prevented

M/l importance- The victims are cases of

Sudden Infant Death Syndrome (SIDS), it may
be also a case of Infanticide.
 Burking
It is a form of violent asphyxia where there are combination of
smothering, palmar strangulation & traumatic asphyxia.
 It derives its name from the fact that it was
employed by William Burke & William Hare
to obtain human bodies for selling those to
Dr. Robert Knox at anatomy school of
Edinburgh in 1927-1928.
 The victim was invited & given alcohol &
thrown to the ground. Burke used to kneel
or sit on the chest & close the nose &
mouth with hands & Hare used to pull him
round the room by feet. Hare introduce the
terminology after the name of Burk who
planned the method.
Drowning
 Drowning

It is a form of violent asphyxia in which the entry of air into the

lung is prevented due to aspiration of water or fluid into the air
passage caused by submersion of mouth & nostrils under water
or any other fluid media.
 Types of Drowning

TYPICAL (Wet/Primary drowning)

-Fresh water drowning
-Salt water drowning
ATYPICAL
-Dry drowning
-Immersion syndrome
-Submersion of the unconscious
-Secondary drowning (Post immersion syndrome,
Near drowning)
 Types of Drowning
Wet drowning-
In this water is inhaled into lungs and the victim gets severe
chest pain. This is also called primary drowning
 Types of Drowning
Dry drowning-
In this type water does not enter the lungs but death result
from immediate sustained laryngeal spasm due to inrush of
water into the naso-pharynx or larynx.
 Types of Drowning
Secondary drowning (post immersion syndrome or near
drowning)- In this type of drowning death occurs after some
times when the person is rescued from being drowned. Death
may occur due to pulmonary oedema, electrolyte imbalance,
metabolic acidosis etc.
 Secondary drowning
 Not drowning in truest sense
 Complication or sequelae of drowning
 Resuscitated victim develop hypoxic encephalopathy
& secondary changes in the lungs as a result of
infection from contaminated inhaled water
 Death occurs after some hrs. to several days after
resuscitation from combined effect of cerebral
hypoxia, pulmonary edema, aspiration pneumonia,
electrolyte imbalance & metabolic acidosis.
 Types of Drowning
Immersion syndrome-
Death result from cardiac arrest due to vagal inhibition as a
result of-
a) cold water stimulating the nerve endings of the surface
of the body.
b) water striking the epigastrium.
c) cold water entering ear drums, nasal passage, and the
pharynx and larynx which cause stimulation of nerve
endings of the mucosa.
 Types of Drowning
Submersion of the unconscious
This is possible in alcoholics, epileptics, hypertensive
with heart disease & who sustains head injury during fall
into water.
 Pathophysiology of Drowning
Fresh water drowning:
Water enters into the lungs
Crosses alveolar membrane & enters into
circulation
Enters into RBC
Swelling & bursting of RBC
(Hemolysis)

Excess K+ in the plasma & K+ goes to heart

Cardiac arrhythmias leading
to ventricular fibrillation
Death occurs within 2-3 minutes

Death
Pathophysiology of Fresh water Drowning
Water enters into the lungs
Crosses alveolar membrane &
enters into circulation
Enters into RBC (Hemodilution)

Increase Volume of Swelling & bursting of

Blood (Almost 50%) RBC (Hemolysis)

Excess K+ in the plasma & K+

Overloads of Heart goes to heart

Ventricular fibrillation Heart failure &

Death
 Pathophysiology of Drowning
Salt water drowning:

Shifting of water
Water enters High osmolarity from
into the lungs of inhaled water bloodstream
into the lungs

Causes
A marked bradycardia hemoconcentration,
occurs, probably due pulmonary oedema,
to the raised plasma Increase level of Na, Cl,
Na level Mg
Death occurs
within 5-12
minutes
Hypoxia Death
 Cause of death in case of Drowning

1) Asphyxia
2) Ventricular fibrillation
3) Laryngeal spasm (Dry drowning)
4) Reflex vagal inhibition
5) Exhaustion
6) Injuries
 Post mortem findings in case of Drowning
External findings
 A fine, white, lathery, tenacious and copious (profuse, persistent)
froth or foam is seen at the mouth and nostrils.
 Presence of mud, sand and weeds in the firmly clenched hands as
well as under the finger nail.
 Wet clothing, sand and mud on the body.
 Cutis anserina (goose skin) in which skin has granular and
puckered appearance may be seen(surest sigs)
 Washer-woman’s hand- The skin of hands and feet shows a
bleached and sodden appearance when the body has remained
in water for more than 10 to 12 hrs.
 Rigor mortis appears early.
 Post mortem findings in case of Drowning
Internal findings
 The respiratory passage usually contains blood-stained fine
froth & also some foreign materials as algae, weeds, mud,
sand.
 Lungs- Voluminous, overlapping the heart and bulge out
the of chest when the sternum is removed.
 The presence of fine froth in the lungs and air- passage.
 The stomach, upper small intestine may show presence of
water, sand, mud & weeds. If in small intestine, it is
diagnostic sign of death from drowning.
 Hemorrhage in the middle ear.
 Findings of diatoms (Algae) in the tissue.
 DIATOMS

 These are microscopic unicellular

algae with silicaceous cell wall
which resist acid digestion, heat &
putrefaction.
 About 25000 species, size- 2
microns- 1mm.,mostly,10-80 microns
in length & 10 microns in width
 Only live body with circulation can
transport diatom from lungs to
remote organs, from where they
may be detected microscopically
after suitable treatment.
 Medico-legal Importance of Drowning
 ACCIDENTAL- Mostly
 Accidental fall in water of non-swimmer
 In case of swimmer- exhaustion due to prolonged bathing,
during high tide, being caught by under current in a river,
boat capsize, ship wreck, fall of bus or train from a river bridge
 Natural calamity like-flood, cyclone
 Suicidal- Common in rural women
 Non-swimmer jumping into deep water
 Swimmers-before jumping some heavy wt. may be tied to
body or hands & legs are tied
 Electrocution in bath tub
 H/O previous suicidal attempts.
 Medico-legal Importance of Drowning
 Homicidal
 Victim is made unconscious by injury or by drinks or drugs
 Hands & feet are tied before pushing into water or may
be pushed all on a sudden
 Head is forcefully dipped into water
 Victim may be packed in a gunny bag with mouth tied &
unwanted newborn thrown into water
 Electrical heating system of the bath tub may be used.
Thank You