•

• ASPHYXIA
 ASPHYXIA
• Greek : pulselessness

• It is a condition that if oxygen supply to the

blood and tissues is reduced because of
interference with respiration.
• it is also called Anoxia\Anoxaemia\Hypoxia.
• Asphyxia
•
Reduction in o2 tension
Deficient oxygenation in lungs

• Capillary dilatation
• Reduced pulmonary flow
• Capillary stasis
• Diminished venous
return to heart Capillary engorgement

• Stasis of blood in organs

Types or Causes
• Mechanical
• Pathological
• Toxic
• Environmental
• Traumatic
• Postural
• Iatrogenic
 Clinical features
Triad of asphyxial stigmata seen
• Cyanosis of skin, face, nailbeds, mucous
membranes
• Petechial hemorrhages on face, conjunctiva,
pleura (Tardieu spots)
• Congestion and edema of face, visceras
• Other features: dilatation of heart, local injuries
to neck in hanging etc.,
 Types of Mechanical asphyxia or tfiolent
asphyxial deaths
• Hanging
• Strangulation
• Suffocation
• Drowning
• Choking
• Traumatic
 H a n g i n g
Hanging is a form of mechanical asphyxial
death which is caused by the suspension of the
body by ligature which encircles the neck, the
constricting force being the weight of the body.
Types
• Complete hanging.
• Partial hanging.
• Typical hanging.
• Atypical hanging.
 Symptoms
• Loss of power and subjective sensations as
flashes of light and ringing,hissing sound in ears.
• Intense mental confusion ,loss of consciousness
(< 15sec if rope),convulsions
• Face is distorted,eyes prominent and violent
struggling ,heart may beat for 10-15 mins after
stoppage of respiration.
Ligature
• Not particular,like ropes,chains,wire,leather
straps,belts,scarf,dhoti,sarees etc.
• Its important to match the ligature with the
ligature mark and see if its strong enough
to bear the weight and jerk of the body.
• Cut the ligature away from the knot.
 Causes of death
1. Asphyxia
Ligature forces the tongue against posterior wall
of pharynx and folds epiglottis over larynx and
cause airway block. (tension of 15 kg)
2.Cerebral congestion
Obstruction of jugular veins by compression
3.Combined asphyxia and venous congestion
4.Cerebral anemia
5. Reflex Vagal inhibition
6. Fracture & dislocation of cervical vertebra
Fatal period
•3-5 or 5-8 mins
Secondary effects :
• hemiplegia, amnesia, parotitis
 PM Findings in Hanging
External findings
1. Face
• Swollen,cyanosed face
• Prominent eyeballs
• Dilated pupils
• Subconjuctival hemorrhage
• Tongue protruded,bleeding from nose,ears
• Dribbling of saliva
2. Neck
Ligature mark – furrow or groove
• Above thyroid cartilage
• Oblique and V shaped
• Size and shape depends on type of material
• Neck is bent opposite to knot
• Due to suspension neck becomes slender,
increase in length
3. Involuntary discharge of semen.fecal
matter,urine
Cyanosis of finger nails
 PM Internal findings
Neck : tissue under ligature mark is dry white
&glistening.
• Platysma,sternomastoid ruptured
• Hyoid bone may be fractured above 40 yrs.
• Larynx,trachea congested
• Lungs congested subpleural tardieu spots
• Brain congested
• All organs are congested
• Blood is fluid and purplish
 Circumstances of death
• Accidental hanging
• Suicidal hanging
• Homicidal hanging
• Judicial hanging
• Postmortem hanging
• Lynching
 Medico-Legal Aspects
• Was the death due to hanging?
• Whether hanging was suicidal,homicidal or
accidental
 Suicidal
• Usually full suspension.
• Ligature tied to beam,hook,fan,tree etc.
• Suspension without any platform is unusual
in suicide.
• Occasional nail mark-may be self inflicted
while trying to free him\herself.
• Suicidal note.
 Postmortem hanging\Suspension
• Person murdered and the dead body
suspended to simulate suicide.
• Usually the rope is tied first to the neck and
then around the beam\hook where beam
shows evidence of rope being pulled from
below upwards.
• Ligature mark may be produced if the body
is suspended within 2hrs after death.
 Judicial hanging
• Drop of 5-7meters.
• Fracture dislocation at cervical 2-3 or 3-4.
• Transection of spinal cord.
• Tear of intima of carotid artery.
• Injury to pons and medulla
 Strangulation
• It’s a form of mechanical asphyxia caused by
the constriction of neck by ligature or by any
means without suspending the body.
Types :
• By ligature.
• Manual strangulation or Throttling.
• Garroting
• Mugging
• Bansdola
Causes of death
• Asphyxia
• Cerebral Anoxia
• Combined asphyxia and congestion
• Vagal inhibition
 Autopsy finding
Externall findings
Face :
• Congested, swollen, cyanosed,% Tardieu spots
are present more than hanging
• Eyes prominent, wide open,pupils dilated
• Lips ,fingernails and ear lobules are cyanosed.
• Tongue swollen, protrude & bitten
• Bleeding from nose,ears,mouth
Ligature mark
• Well defined,slightly depressed at level of
thyroid cartilage or below.
• Encircles the neck transversely-more
prominently at the front than the sides.
• It may be interrupted by clothing or victims
finger or ornaments.
• May be oblique if the victim is sitting and
assailant is standing.
 Internal
• Superficial hemorrhage under ligature mark and
Laceration of neck muscles.
• Hyoid bone fracture less common..
• Fracture thyroid cartilage is more common.
• Fracture of cricoid is rare,but if pressure is used
may be seen.
• Latynx,trachea,bronchi congested and contain
frothy blood stained mucus
• Lungs are markedly congested
• Brain congested
Si.no. Hanging Strangulation
Difference between ha nging and
Ligature Oblique, does not encircles Transverse, completely
mark strangulation
neck, above thyroid cartilage covers neck, below
thyroid cartilage

Abrasions About edges of ligature mark More common

not common

Bruising Of neck muscles less common More common

Neck Stretched and elongated not

Signs of External signs less marked Well marked

asphyxia
 Hanging Strangulation

Face Usualy pale, and Congested,bluish

petechiae not common
Tongue Swelling less marked More marked
protrusion

saliva common absent

bleeding Not common More common
Larynx trachea Fracture rare More common
Caroted arteries Damage may be seen rare

Thyroid cartilage Fracture less common More common

Hyoid bone Fracture more common Less common
 Medico-Legal aspects
Suicide
• Its rare but possible.cord may be used and
twisted with a stick.
• Congestion is very prominent because of
slow obstruction.
 Homicide
• Common form of murder-associated with
sexual offences.
• Infanticide-by strangulation with umbilical
cord.
• Evidence of struggle
 Bansdola
• Practiced in north India.
• Bamboo or sticks are used.

Garrotting
• Victim is attacked from behind without
warning,ligature thrown round the neck and
tightened.

Mugging
• Strangulation by holding the neck in the bend of the
elbow/knee.
 Accidental strangulation
• Children may get entangled during play.
• Infants are strangled in their cots,when the
neck is caught in sidebars.
• Alcoholics,epileptics and insane persons are
susceptible for accidental strangulation.

.long scarf syndrome

 Throttling
Asphyxia produced by Compression of neck by hands
Cause of death:
• Asphyxia
• Cerebral anoxia
• Vagal inhibition
In throttling pressure must be applied for minimum 2 min to
cause death.
PM Findings
External findings ;
• Bruises on front and sides of neck produced by finger tips
and nail scratch abrasions
• Cyanosis, congestion, edema ,Tardieu spots and bleeding
from nose, ears are seen
Internal findings :
• Hemorrhage under bruises and abrasions is
significant
• Tear or platysma,sternomastoid
• Hemorrhage,ecchymoses in
larynx,pharynx,epiglottis
• Fracture of byoid bone is diagnostic finding
• Fracture of supr horns of thyroid cartilage more
common.
 Suffocation
• It is a general term which is caused by deprivation
of oxygen either due to lack of O2 in the
environment or from obstruction of air passages
at the level of nose and mouth.
OR
• It’s a form of asphyxia caused by mechanical
obstruction to passage of air into RT by any means
other than constriction of the neck or drowning.
 Classification
• Smothering
• Choking
• Gagging
• Overlaying
• Burking
• Traumatic asphyxia
 Smothering

• It’s a form of asphyxia caused by closure of

external respiratory orifices by hand or other
means, or blocking the nose and mouth by
introduction of foreign materials.
like mud,cloth or paper etc.
 Postmortem findings
External
• Asphyxial signs.
• Abrasions & bruises around the mouth and
nostrils
• Injuries on inner side of lips and gums .
• Blood may ooze out from mouth and nose.
• Tongue may be protruded may be bitten
Internal
• Blood stained frothy fluid is present in air
passages
• Internal organs are deeply congested.
 Medico-Legal importance
Suicidal smothering
• Not possible by hands.
• Possible by means of tying polythene bag over
the head/burring the face in mattress. It is usualy
seen in mental pts.
• Creating suffocation in the closed and non-
ventilated rooms.
Homicidal
• Possible when victim is incapacitated by
drugs/alcohol,can be smothered.
 Accidental smothering
• Epileptic or intoxicated persons may
smother himself buy burying
• A person accidentaly may fall into heap of
ash,sand etc
• children while playing with plastic bags.
• Also occurs if membranes remain around
head of baby after delivery
 Choking
• It is a form of asphyxia caused by an
obstruction within the air passages by
foreign objects like coin, groundnut, fish,
toffies etc
Mechanism :
• initially stridor, respiratory distress ,cough
and inability to speak
• Later deep inhalation, object move down
further, laryngo spasm, vagal inhibition and
death.
Cause of death :
• Asphyxia
• Cardiac inhibition
• Laryngeal spasm
• Delayed death from pneumonia, lung abscess
Medico-legal aspects
• Accidental
• Suicidal
• Homicidal
PM Findings
• Signs of asphyxia, subconjuctival hemorrhages
• Presence of food items or any foreign objects in RT
 Café coronary
• It is a condition of accidental choking where food
bolus completely blocks airway .
• It looks like Heart attack and commonly seen in
intoxicated persons.
• A grossly intoxicated person enters restaurant and
starts meal.suddenly he turns blue,coughs violently
,collapses and dies.
• death appears to be due to heart attack.
• At autopsy a large piece of meat is found obstructing
larynx.
• Clinical signs of choking are absent because high blood
alcohol abolishes gag reflex.
 Gagging
• It is form of asphyxia results from pushing a
rolled cloth or paper (gag) into the mouth
sufficiently deep to block pharynx
• Combines features of smothering and choking
PM Findings :
• Signs of asphyxia
• Injuries to nose and mouth
ML Aspects :
• Always homicidal
 Overlaying
• Overlaying or compression suffocation results
from compression of chest ,nose, mouth so as to
prevent breathing.
PM Findings :
• Usual findings of asphyxia
• Face,nose,chest of infant appear compressed
and pale.
MLI :
• Accidental
• Can be infanticide
• SIDS
 Traumatic asphyxia
• It results from respiratory arrest due to
mechanical fixation of chest so that the normal
respiratory movements are prevented.
Examples :
• Stampede in a theatre or in places where
crowded gatherings are there.
• Crushing by Falls of earth or stone -coal
mines,tunneling accidents etc.
• Sometimes victim pressed to ground by heavy
objects like vehicle.
 Post-mortem appearances
• An intense deep purple red colour of the
head,neck and upper part of chest above the
level of compression.
• Below this skin is pale or cyanosed.
• Fracture of ribs,other bones may occur.
 Burking
• It is combination of homicidal smothering and
traumatic asphyxia
• Willium burke and willium hare killed 16
persons during 1927-28 in scotland and sold
dead bodies to dr robert knox for anatomy
classes.
 Sexual asphyxias
• Partial asphyxia causes cerebral disturbances
with feeling of sexual gratification.
• Pressure on carotids/trachea leads to
hallucinations of an erotic nature.
• Associated with masochism and transvestitism.
• Usually can be seen in young males.
• Place-victims own house-bed/bath room.
• Padding of neck.
• Ligature,a running noose,the free end of
which is tied to limb,weight of the body is
used to control the ligature.
• Naked,pornographic literature etc.
• Its due to retrograde displacement of blood
from superior venacava into subclavian
veins of the head and neck due to sudden
compression of the chest blood does not
enter the upper limbs due to the valves.
• Blood goes into the valve less veins of the
head & neck causing stasis and
engorgement of the vessels and rupture of
the distal venules and capillaries causing
petecheal hemorrhages.
• If patient survives-purple colour gradually
disappears within 14-15 days.
 Drowning
• Drowning is a form of asphyxial death due to
aspiration of fluid into the air passages by
submersion of the body in water or fluid
medium.

• Complete submersion not

necessary,submersion of nose and mouth is
enough.
 Classification
1. Typical or Wet
drowning Fresh water
drowning Salt water
drowning
2. Atypical
• Dry
• Secondary or near drowning
• Immersion syndrome or hydrocution
• Wet drowning:
Water is inhaled into lungs and victim has severe
chest pain (80-90%)
• Dry drowning :
Water does not enter lungs bcz of laryngeal spasm
induced by inrush of water into nasopharynx or
larynx.(10-20%)
• Secondary drowning (near drowning)
it refers to survival beyond 24hr after submersion
episode.
• Immersion syndrome (hydrocution) : death results
from cardiac arrest due to vagal inhibition as result of
 Fresh water drowning (0.5-0.6%NaCl)
• Water cross the alveolar membrane into the
circulation.
• Hemodilution, Produces marked hypervolaemia.
• Red cells swell or burst-hemolysis-liberation of
potassium-hyperkalemia,hyponatremia
• Circulatory overload,myocardial hypoxia results in
fall of SBP –ventricular fibrillation-death
Fatal period: 4-5 min
 Salt water drowning (3-4% salinity)
• Marked hypertonicity of the inhaled water
cause loss of fluid from circulation into the
lungs-
• Hemoconcentration with crenation of RBC
fulminating pulmonary edema and
progressive hypovolaemia.
•Circulatory shock and cardiac arrest.
Fatal period: 8-12 min
 Cause of death
• Asphyxia
• Ventricular fibrilation
• Laryngial spasm
• Vagal inhibition
• Exhaustion
• Injuries
Fatal period;
Fresh water; 4-5 mins
Salt water; 8-12 mins
 tficious cycle of drowning

• Deep inspiration

• Need for air

• Water enters resp.passage

• Air driven out of lungs

Cough reflex
 Postmortem findings
External findings
• Face is pale,discolored,cyanosed
• pupils dilated,subconjuctival hemorrhage may be
present
• Tongue may be swollen,protruded
• PM hypostasis is light pink
• Fine white leathery froth at the nose and mouth
• Weeds, grass,sticks etc floating in water may be firmly
grasped in hand due to cadaveric spasm.
• Rigor mortis appears early
• Cutis anserina(Goose skin); Skin appears granular
and puckered,with hair standing on the end due to spasm
of the erector pilae muscles and due to exposure to cold
water at the time of death, Rarely seen in India.

• The skin of the finger,palms and later the soles of the feet
may be wrinkled,bleached and soddened due to osmotic
action of water is Washer-Woman hands.
 Internal findings
• Airways filled with froth,sand,weeds etc found in the
water.
• Lungs are voluminous,and bulge out of chest when
sternum removed known as balloning .
• On Lungs impressions of ribs.
• In fresh water drowning lungs are balloned bt light in wt
and pale pink and on section crepitus heard
• In salt water drowning lung baloons and heavy wt and
bluish colour
• On section edematous, Oozing out of blood stained
frothy fluid is “Emphysema Aquosum”.
• Paltauf’ s hemorrhages seen.
• Water in the stomach & intestine.
Biochemical changes
 “Getlers test”
 Chloride content in chambers of the heart
normally 600mg/100ml.
 Chloride decreases by 50% in fresh water &
increases of 40% in salt water.
 Test is of doubtful value in
-Septal defects
-Putrefaction
-Death due to vagal inhibition
-Chloride in water
 Diatoms
• Microscopic unicellular algae present in water.
• Silicaceous cell wall which resists acid digestion,
heat and putrefaction.
• Size 10-80 microns to 1mm
• Only a live body with a circulation can transport
diatoms from lungs to the brain or bone marrow.
• Isolation- acid digestion of tissue commonly bone
marrow ,lung, blood and kidney-centrifugation and
washing, residue is examined under phase contrast
microscopy.
 Diagnosis of drowning
• Fine white Froth at the mouth and nose
• Presence of fine froath in lungs and
respiratory passages
• Weeds & gravel/soil firmly held in hand.
• Voluminous ,waterlogged lungs.
• Presence water in stomach and intestine
• Diatoms in tissues.
Features Antemortem PM immersion
Difference i b antemortem drowning and post
drowning
mortem immersion
Froath over Appears absent
mouth ,nostrils spontaneously

Cadaveric spasm Sand etc in hands Not observed

in hands

Trachea and Presence of absent

bronchioles algae,mud etc

lungs ballooned Collapsed,decomposed

stomach Mud,algae may be absent
present
Other suggestive Water in middle Water never present in
signs ear,washer womans middle ear,
hands