12 - Asphyxia (PPTminimizer)

Asphyxia
By
Dr. Houssien Nofal MD. PhD
Ass. Prof. of Forensic Medicine
College of medicine – KFU – Dammam – SA
Asphyxia
 Asphyxia can literally be translated
from the Greek as meaning 'absence
of pulse', but is usually the term
given to deaths due to 'anoxia' or
'hypoxia'
Asphyxia
 The term 'asphyxia' is thought by some
forensic pathologists to be a vague and
confusing term.
 In its broadest sense it refers to a state in
which the body becomes deprived of
oxygen while in excess of carbon dioxide
(i.e.. hypoxia and hypercapnia).
Asphyxia
 This results in a loss of consciousness
and/or death.
 However, prior to any death the body
usually reaches a low oxygen-high carbon
dioxide state,
 and so an 'asphyxial' death is therefore
one in which the oxygen deprived state
has been achieved unnaturally.
Asphyxia
 human body derived its oxygen supply by the
following ways:
1. pulmonary ventilation (external O2 enter
to reach the heamoglobin)
2. Heamoglobin combined with O2 to form
oxyheamoglobin ( O2-Hb )
3. Circulation system which transfer (O2-Hb)
oxyheamoglobin to the tissues
4. Gasic exchanges in the capillaries
between the blood and tissues
Asphyxia
 therefore, disturbance in any way of four
mentioned ways of supplying oxygen will
result hypoxia or anoxia (asphyxia).
Asphyxia
 According to that we generally can
categorise anoxia into the 4 categories:
1. anoxia by decreasing of respiratory O2

(external O2 )
2. anoxia due to heamoglobin disturbances.
3. anoxia due to hypostatic disturbances.
4. anoxia due to toxic tissue causes.
anoxia by decreasing of
respiratory O2 (external O2 )
 It characterized by decreasing of oxygen (O2) pressure in the arterial
blood.
 It present in several cases like:
 a- Ascending to heights, where O2 pressure less in the air

 b- Occlusion of the respiratory tract or occlusion its entrances,
(traumatic asphyxia like hanging, smothering, strangulation,…), or
due to diseases like tracheal asthma.
 c- Disturbances of Respiratory mechanism as pneumothorax,
dephtherial paralysis, diaphragmal paralysis …..
 d- Pulmonary diseases ( emphysema,…)
 e- Cardiac diseases (congenital in which right and left chambers are
connected,..)
anoxia due to heamoglobin
disturbances
 It characterized by quantitative and/or
qualitative disturbances of Hb to transfer O2,
otherwise, the pressure of O2 in arterial blood
and the saturation rate of Hb with O2 remain
normal.
 It shown in many cases like:
 - anemia,
 - haemorrhage,
 - “carbon monoxide” Co intoxication,
 - all poisons which change Hb into Met-Hb, so it
will be incapable to transfer O2
anoxia of hypostatic disturbances
 O2 pressure and its percentage in the
arterial blood are normal.
 O2 percentage in the venous blood is low,

because of hypostatic .
 It is shown in cardiac failure, shock,…
anoxia of toxic tissue causes
 Tissual oxygenation enzymes (cytochrome
oxidase group) are impaired because of
poisons, as in the case of cyanide
(cyandrique ) intoxication.
 O2 and its pressure are normal in arterial

blood, but the tissues can’t use it.
asphyxia
 our subject in the forensic medicine is the
traumatic asphyxia.
 So we must distinguish between the
traumatic asphyxia and that which is due
to diseases. Both kinds of asphyxia have
the same signs
 to distinguish between them we must
look for the sign of external violent
factors, particularly in the head ,which
may be unobvious
STAGES OF ASPHYXIA
1. - Struggle – (Dyspnea), forceful breathing

2. - Quiescence – unconscious , lifeless, Stop of
breathing
3. - Convulsions – disturbs scene,
incontinence, spasmodic movements
4. - Apnea - lifeless , weak pulse, Terminal
stage.
STAGES OF ASPHYXIA
1 - Struggle – Dyspnea
 forceful breathing (Dyspnea)
 decreasing O2 in blood results -------
 a defensive reaction in the body as a deep &
rapid & strong breathing ---------
 Co2 accumulation in blood (HbCo2 )– cyanosis
(particularly in the face & fingers & …)
STAGES OF ASPHYXIA
1 - Struggle – Dyspnea
 (HbCo2 )------ stimulate respiratory center
 ------ breathing (Tachypnea)
 ------ pulse (Tachyrhthmia)
 ------ BP increased
 ------ tachycardia
 Then vertigo, and sound &visual disturbances
STAGES OF ASPHYXIA
2 - Quiescence
 (HbCo2 ) + HbO2
 – unconscious ,
 - lifeless signs------ ,
 - bradypnea--- Stop of breathing
 - bradycardia
 - bradyrhythmia
STAGES OF ASPHYXIA
3 - Convulsions
 Pulse &
 Systolic BP + diastolic BP
 ------ tearing of capillaries - Petechial
hemorrhages (Tardio spots )
 Co2 - sever cyanosis
 Disturbances of breathing activities
 Tissues lack of O2 - disturbs scene,
STAGES OF ASPHYXIA
3 - Convulsions
 Tissues lack of O2 - disturbs scene,
spasmodic convulsive movements,
 & spasmodic iris -- Mydriasis
 Unconsciousness &
 voluntary functions out of control- 
  Incontinence (urinary, fecal, and
seminal ,..)
 vomiting
STAGES OF ASPHYXIA
4 - Apnea
 lifeless , Terminal stage -
 weak pulse
 Respiratory paralysis
 bradycardia for a while after apnea,
 Then sudden stop of cardiac function
 And death onset
Traumatic asphyxia
 lack of O2 isn’t the unique cause of
death,
 Death may inset because of pressure on
the neck, which stimulate the carotid
sinus
 -- cardiac & respiratory inhibitation
 - sudden death (without 4 stages of
anoxia ).
Asphyxia
 Death by traumatic asphyxia mostly
occurs during 7 -10 minutes.
 Surgery proved that life continues with
the stop of blood circulation for more
than ½ an hour, in condition of
persistence of cerebral blood irrigation
Asphyxia
 Individual rarely survived after traumatic
asphyxia. If he survived he will be in a
coma for several days. He generally had a
pulmonary complications like (pneumonia,
pulmonary edema, laryngeal edema,..)
and after that he died.
Asphyxia general signs
1. cyanosis.
2. petechial haemorrhages
3. congestion & oedema
4. Blood fluidity,
 1 - cyanosis
 - plum colour
 - Due to excess de-oxygenated haemoglobin
(HbCo2) in the venous blood.
 - in the skin & visceral organs
 1 - cyanosis
 - in the face ( lips) & nails is obvious

 - about viscera appears clearly in (lungs,
liver, kidneys, meninges, brain, GI lining)
 - It doesn’t appear in the drowning and
the Co intoxication
 2 - petechial haemorrhages
 - it appears in all types of mechanical
asphyxia.
 - also it appears in some diseases :
(cerebral haemorrhages, skull traumas,
Co intoxication, Arsenic intoxication, death
with convulsions, cardiac failure,..)
 Unfortunately the presence of petechial
haemorrhages does not automatically point to
asphyxia as a cause of death.
 They are fairly non-specific in that they can
be produced whenever
there is a marked or sudden increase in
vascular congestion of the head
that causes rupture of capillaries.
 The areas of the head that are most
characteristically involved are those that have
little surrounding soft tissue support, such as
the conjunctiva, eyelids, lining of the
mouth/ larynx etc.
 Petechiae can therefore be produced not only
during vascular compression of the neck,
 but also where valsalva manouvres operate,
such as during labour,
 straining at stool,
 coughing (e.g. in asthma),
 sneezing,
 Vomiting, … etc.
 Other examples include chest compression,
where the right heart is compressed, but
the left heart is still capable of pumping (and
acute right heart failure due to disease).
 In these circumstances, the level of

congestion would be just above the heart on
the chest wall.
 Where bodies are found lying prone with
the head at a lower level than the rest
of the body,
 there may be coarse petechiae present

in the areas of intense congestion.
 About the post mortem petechial

haemorrhages in livid areas, particularly when
the head is lower than the body for a long
period.
‫تدع ى النزوف بحج م رأ س الدبوس ف ي عين ي هذا الرج ل وعل ى الوج ه الخارج ي لجفني ه‬
‫النزوف النمشية‪ .‬النزوف النمشية ليست نوعية للخنق‪ ,‬فيمكن أن توجد في أشكال االختناق‬
‫األخرى وفي الوفاة المفاجئة‪.‬‬
petechial haemorrhages
‫يمكن مشاهدة النزوف أيضا ً في الرغامى( يسار) في الخنق وأشكال الوفاة االختناقية األخرى‪.‬‬
‫يشير السهم السفلي في الصورة اليمنى إلى الحبال الصوتية بينما يشير السهم العلوي إلى‬
‫النزوف النمشية في لسان المزمار‪.‬‬
Hanging
(cyanosis, petechial hemorrhages)
 3 - congestion & oedema
 it appears in the (face, tongue, larynx)
 - due to increased venous pressure causes
tissue fluid transudation, and it causes venous
congestion (venous return to the heart is
prevented).
 It occurs at the 2nd stage of anoxia,

resulting from direct effect of
 lack O2 + blood stasis ----- increased
venous pressure --- tissue fluid
transudation ----- congestion &
oedema.
 About oedema of lungs the best way to

assess that is weighing them.
 It may be resulted from acute cardiac

failure, or from the treatment of wide
burns by saturation the circulation system
with fluids.
 4 - Blood fluidity
 Blood fluidity in the heart, and the big vessels.

 in serum exist profibrinolytic enzyme, called
plasminogen, which produced by liver.
 Plasminogen ---- plasmin ( fibrinolytic).
 Transformation of Plasminogen into plasmin
need Activator Enzyme secrets by lining of
vessels
 When Activator Enzyme secretion increased,
 plasminogen also increased - more plasmin
 -- fibrinolysis - non coagulation 
 fluidity
 blood fluidity or increasing of Plasminogen
occurs not only in the asphyxial death , but in
all immediate sudden death, like electrical
death
 So blood fluidity related to the speed of death,
whatever the mechanism of death was.
PATHOLOGICAL CHANGES
 General
1. - cyanosis,
2. - congestion,
3. - petechial haemorrhages,
4. - oedema.
5. - fluidity of blood
 Specific
- reflects type of mechanical asphyxia.
MECHANISMS OF DEATH
Mechanical (traumatic) Asphyxia result
 Reduced blood flow to brain (neck pressure)

 Carbon dioxide accumulation
 Oxygen deprivation
 Vagal inhibition ( parasympathic reflex).
 Complex
Mechanisms of Death
1. Mechanical Constriction/Squeezing of
the soft tissues (Carotid sinus, Veins,
Arteries) of the neck
2. Airway Obstruction
3. Cardiac Arrhythmia
4. Complex
1- mechanical constriction
(squeezing of the soft tissues of the neck)
 the most common mechanism is that of
compression of the jugular veins,
 with or without that of the carotid arteries,
 leads to
- reduced oxygen reaching the brain,
- loss of consciousness,
- and if sustained for a sufficient interval
(minutes) death.
 The time interval of compression to loss of
consciousness is approx. 10 seconds if both
carotid arteries are compressed
 and a minute if only the jugulars are
compressed.
 The time interval from loss of consciousness to

death is said to be in the region of minutes
 Compression of jugulars is the main factor of
congestion & oedema & cyanosis &
petechial haemorrhages above
compression.
 The amount of pressure to occlude

 - the jugulars is ~ 2 kg (4.4 lb)
 - the carotid arteries is ~ 4.5 kg (11 lb)
 - the vertebral arteries is ~ 30 kg ( 66 lb)
2 - airway obstruction
 - this is a contributory factor in some hangings,
 where the hyoid bone and tongue are
pushed upwards and backwards against the
laryngo-pharynx.
 This type of obstruction produces 'air hunger',
which is a frightening sensation and which is
not a feature of vascular compression in the
neck.
 The amount of pressure to occlude
 Trachea is ~15 kg ( 33 lb)
3 - cardiac arrhythmia
 - this is a controversial postulated
mechanism whereby pressure over the carotid
artery at the carotid sinus provokes a vagal
reflex
 slowing of the heart (bradycardia),
 which may provoke a fatal arrhythmia, or
Ventricular fibrillation (particularly in the
elderly or those with underlying cardiac
disease).
 The reflex path is going
 “ through baroreceptors on carotid, to 9th CN,
to 10th nucleus of brain stem, and return to
heart by vagus (parasympathic)
 So according to the above reflex, it could be
considered that Stress, Fearness, Alcohol
increased the sensivity of vagus by releasing
Catecholamines.
 This mechanism is unlikely to be
responsible where
there are petichiae or congestion which
would suggest that
the heart had been beating for a more
lengthy period than this mechanism would
support.
4 - Complex
 Complex Of all mechanisms,
 Reduced blood flow to brain (neck pressure)

 Oxygen deprivation -(unconsciousness
+coma)
 Carbon dioxide accumulation -- (cyanosis,
oedema, congestion, petechiae…)
 Airway constriction - (hypoxia +anoxia)
 Vagal inhibition (Reflex) - immediate death
Mechanism of death
of Judicial Hanging
 Because of quick drop of sentenced person
while pulling of the object which is under him,
and he is suspended by a noose person
(hanging cord) -
Luxation (dislocation) of cerebral vertebral


column “ C1- C2, C4 – C3, C4 – C5 ”,
and transection of spinal cord -
immediate death
TYPES OF "MECHANICAL"
ASPHYXIA
1. Exhaustion or Displacement of
Environmental Oxygen (Drowning,
Inhalation Co, CH4, Cyanide, Nitrogen,..)
2. Airway Obstruction (External:
Smothering, Internal: Choking).
3. Neck Compression (Hanging,
Strangulation, throttling)
4. Chest Compression
5. Postural/ Positional Asphyxia
Chest Compression
(Traumatic Asphyxiation)
 This is the term given to the condition most
often seen after mass disasters,
 such as the many football stadium
disasters,
 or as theatre disasters,
 or where people have been crushed by
collapsing trenches,
 or by the weight of grain, crops,.. etc in
silos.
‫وفاة ناجم ة ع ن انس داد الطرق الهوائية‪ .‬س قط الرج ل داخ ل ص ومعة حبوب عندم ا كان‬
‫يجرف الذرة‪.‬‬
Chest Compression
(Traumatic Asphyxiation)
 The thorax is transfixed,
 preventing respiratory movements.
 There are classic signs of
 congestion, cyanosis and petechiae ,
 but there may be no other signs of injury on
the body.
 The florid signs of congestion usually finish
at the level of the clavicles.
‫سقطت السيارة من الحواجز اإلسمنتية على الرجل الذي كان يصلحها‪ ,‬فحدث انضغاط العنق‬
‫احتبس الرجل تحت شاحنته بعد حادث مروري‪ .‬وجهه أرجواني غامق بسبب اندفاع الدم إلى‬
‫رأسه بتأثير الضغط‪ .‬توفي ألنه لم يكن قادراً على التنفس بسبب الضغط على صدره‪.‬‬
‫عثر على جثة شاب منقلبة تحت سيارته بعد تدهور السيارة وانقالبها‬
Postural/ Positional Asphyxia
 is a related condition,
 recently coming to the fore due to interest in
deaths in police custody etc,
 and may involve splinting of the diaphragm
during restraint,
 coupled with the additional requirements
for oxygen during a struggle.
 Research into this aspect is ongoing.
‫الحظ انحناء رأسه بصورة تامة ودوران الرأس ليستقر على صدره‪ .‬لم يكشف تشريح الجثة أية‬
‫أذيات‪ ,‬لم يكن عنقه مكسوراً ولم توجد نزوف نمشية‪ .‬هذا مثال آخر على اختناق الوضعة‪.‬‬
‫تظه ر هذه األذيات ف ي العن ق بشك ل ممي ز ولك ن دون وجود أضرار باطني ة ك بيرة‪ .‬عل ق رأ س‬
‫الرج ل بي ن أرضي ة المص عد والباب الخارج ي لمدخ ل المص عد‪ .‬انحن ى رأس ه بص ورة كافي ة لمن ع‬
‫التنفس‪.‬‬
‫حالة أخرى من اختناق الوضعة‪ .‬سقط هذا الكحولي عن السرير ليستقر في وضعية ال تسمح‬
‫له بالتنفس‪.‬‬
‫انحنى رأسه بصورة كافية للحؤول دون تهوية كافية‪ .‬ال حظ اللون الغامق لرأسه‬
‫سقط هذا الكحولي نائما ً ورأسه على المخدة‬
‫انسد األنف والفم بالمخدة وحدث كتم نفس‪ .‬تشريح الجثة سلبي باستثناء عالمات الكحولية‪ .‬كان‬
‫استقصاء مسرح الوفاة أساسيا ً في تحديد الشكل الطبي الشرعي المناسب للوفاة( حادث )‪.‬‬
Obstruction of the airway
 When oxygen is not able to reach the lungs

because of external occlusion of the mouth
and/ or nose,
 or the airway at the level of the larynx is
obstructed (e.g. by a bolus of food),
 the cause of the asphyxial death is
'obstruction of the airways'.
 There are no specific autopsy findings
 that would support the main types of airway
obstruction deaths,
 and circumstantial evidence,
 physical evidence (e.g. plastic bags used by
the deceased)
 and the scene of death
 would be relied on to support the diagnosis.
smothering
 - the covering of the mouth or nose
(or external occlusion) e.g. by a plastic
bag or in overlay deaths
 (may see abrasions etc in a homicidal
smothering if the victim could put up a
struggle)
 It is mostly accidental,
 may be homicidal,
 rarely suicidal ( plastic bag, …)
‫اختناق بس د الطري ق الهوائ ي بواس طة كيس ‪ .‬تشاه د هذه الطريق ة ف ي االنتحار بشك ل أكث ر‬
‫شيوعا عند المسنين‪.‬‬
smothering
 Homicidal, in infants, and elderly
(particularly women)
 Homicidal need a high different of strength
between the victim & assailant
 So the victim (infant, elderly, with fearness,
unconsciousness, under alcohol, under
narcosis,….)
 Bruises in the lining of lips, cheeks because
of pressure the soft tissues on teeth & jaws.
 Difficult diagnosis; history and scene.
smothering
 accidental in the infants when he overlaying
on his face, so his mouth & nose are occluded
- by pillow or mattress,
- or by breast of his mother (deep sleeping,
alcohol, ..),
- or by her arm if he was sleeping on her arm
 in the epileptic when he falls on his face
smothering
smothering
smothering
smothering
gagging
 - the tongue is pushed backwards and

upwards,
 and the gag becomes saturated with saliva
and mucus causing further obstruction.
Choking
 Obstruction of upper airway or glottis
 Gag, homicide,
 rarely suicide
 Accidental generally in
elderly,
mental defectives,
children
Choking
 foreign body obstruction (those at risk being
children/ infants,
- the intoxicated
- and those with neurological difficulties
with swallowing etc)
 swelling of the airway lining
- (anaphylactic hypersensitivity reactions,
- or thermal/ heat injury.
Choking
Death can be natural in individuals with acute
fulminating epiglottitis, diphtheria
where there is obstruction of the airway by the
inflamed epiglottis and adjacent soft tissue.
 such individuals develops a sore throat,
hoarseness,
respiratory difficulty,
inability to speak, nausea, sweating
and then suddenly collapses as the airway is
completely obstructed.
Choking
 Inhalation of steam can cause the same
picture of inflamed epiglottis.
 Inhalation of hot gases
 Inhalation of corrosive gases (Hcl, NH4,..)
 inhalation gases ( cyanide: combined with
Ferrous of enzyme cytochrome oxidase, so
cellular oxygenation stops)
 inhalation gases ( H2 S )
Choking
 accidental, due to inhalation of food ( meat,..)
teeth,
abscess (pus)
tumors (hemorrhages), (clots),
 about( Children) they aspired foreign bodies:
small objects, small balls, (drugs) tablets, pins,
needles, small coins, screws, seeds,..

Choking
 may occurred by insect bites 
anaphylactic reaction in larynx & vocal
cords  oedema -- constriction airway
- increased oedema - obstruction
airway
Choking
 “Cafe Coronary” is the case of individual
who is eating and talking,
suddenly stops talking,
stands up,
and collapses.
- People thought that he had heart attack, so
cardiopulmonary resuscitation is ineffective
Choking
 Occasionally, choking death occurs when
individual falls into finely ground material,
such as cornmeal, or sawdust.
 There is involuntary inhalation and the
airway is completely occluded by this
material.
Choking
 Criminal choking is rare.
 Victim mostly are children.
 Occlusion the inside of mouth by piece of
clothes or textile, and pushed deeply inside
mouth.
 Or the victim is woman also occluded her

mouth by a piece of textile and push it deeply
inside the mouth,
 - or occluded her mouth by silt,
Choking
 At autopsy
 the finding of airway occluded by the
object .
 Oedema in pharynx & larynx
 General signs of asphyxia

Choking
‫كرة من اللحم الديك الرومي محشوة في الطريق الهوائي‬
‫تقيس قطعة اللحم المنحشرة ‪ 1.52‬إنش بالقطر األعظمي‬
Exhaustion or Displacement of
Environmental Oxygen (Suffocation)
 This may occur in tight or confined
spaces,
 where toxic fumes are released from
bedding etc in cots,
 or in drowning (the inhaled water displaces
the oxygen).
 It is Low or no atmospheric oxygen
(underground chamber, high Co2)
 Normal percentage by volume of O2 in the

atmosphere is 20,946 %
 At O2 concentration of 10 to 15 % there is
impairment in judgment and coordination.
 At 8 to 10 % of O2, there is loss of
consciousness.
 at 8 % and less of O2, death occurs.
 At 4 to 6 % there is loss of consciousness

in 40 sec, and death within a few min
 Ships' holds ( nitrogen ),
 Scuba – diving ( less O2),
 Surgical anaesthesia,
 Disused refrigerators (children)
 fungi plants inside rooms (Co2)
 silos of wheat.
 This is 'pure' asphyxia and results in a fairly
rapid, painless loss of consciousness,
followed by death if not discovered.
 Toxicological studies showed no value

 Circumstances of death is valuable for
diagnosis.
 There are no diagnostic autopsy findings.
Strangulation
 Strangulation implies pressure to the
neck, and deaths due to strangulation are
therefore of immense forensic
importance.
Strangulation
 It can be defined as a circumferential
squeezing of the neck that is
independent of the gravitational weight
or suspension of the head.
 It is Airway obstruction at larynx from

hand pressure or hand held ligature
INJURIES TO THE LARYNX
 Hyoid bone
- horseshoe shaped, curve to the front
- greater horns fractured by squeezing or
downward traction.
 Thyroid cartilage
- Adam's apple
- two plates, midline ridge, notch
- superior horns fractured by squeezing
INJURIES TO THE LARYNX
 Cricoid cartilage
- signet ring shaped
- fracture uncommon, direct blow
 Carotid artery
- main blood supply to brain
- divides adjacent to superior horn of thyroid
cartilage
- sudden loss of consciousness
 Vagus nerve
- alongside carotid artery
- innervates heart
- sudden death from reflex vagal inhibition
Categories of Strangulation
 manual strangulation
 ligature strangulation
 choke holds
MANUAL STRANGULATION
(THROTTLING)
 Different grips, different patterns
 Finger pad bruises, crescent abrasions
 Neck muscle haemorrhages,
 hyoid and thyroid fractures
 Mugging, sleeper hold
 Grip for half a minute.
Manual Strangulation
 Otherwise known in the UK as 'throttling' and
in the USA as 'choking',
 this mode of death is usually caused by men
against women,
 and rarely against another man due to the
requirement for there to be a large disparity
in physical strength between the
assailant and victim.
Signs of manual strangulation
 1. disc-like finger-tip bruises
 (although it is unwise to over-interpret such

bruises, as hands may be changed over during
the course of the attack, making it difficult to
distinguish between single handed or double
handed attacks, and between left or right
handed assaults etc)
 2. Abrasions
 3. linear finger-nail scratches (from the
assailant, or the victim when trying to remove
the assailants hands from the neck)
 4. often limited signs of suffocation as
fingers are more likely to probe deeper neck
structures and cause reflex cardiac arrest
 5. damage to the larynx - particularly the
superior horns of the thyroid cartilage, and the
greater horns of the hyoid bone.
 6. sustained pressure may cause congestion

and blueness of the tongue, pharynx and
larynx
‫يوجد نزف في قاعدة اللسان( السهم ) نجم عن الخنق اليدوي‬
 7. haemorrhage under the skin of the
neck and bruising of the strap muscles
(where suffocation is suspected, the neck
is dissected after the great vessels of the
thorax have been emptied, to enable the
dissection to be carried out in a relatively
bloodless field, so that post-mortem
artefacts are not mis-interpreted)
‫توح ي وضعي ة يدي المعتدي ف ي هذا النموذج بإحدى طرق خن ق البشر‪ .‬يموت الناس‬
‫من الضغط على األوعية الدموية وليس من انخماص الحنجرة أو الرغامى‪.‬‬
‫يمكن للضحية أن تقبض على يدي المعتدي تاركة عالمات ظفرية على العنق‬
‫خنق هذا الرجل يدوياً‪ .‬توج د الكدمات على الجزء السفلي من العنق ويوجد أعالها العالمات‬
‫الظفرية( السهم )‪ .‬وجدت نزوف عديدة في النسيج الرخو وكذلك نزوف نمشية في العنين‪.‬‬
(Mugging) manual strangulation
manual strangulation
Hyoid bone, Thyroid cartilage,
Cricoid cartilage
Hyoid fracture
STRANGULATION BY
LIGATURE
 Tied, held, removed;
 sexual assault
 Horizontal groove, uniform depth,
imprint abrasion
 Bruises, abrasions
 Neck muscle haemorrhages,
 thyroid fractures
 Homicidal , Suicide uncommon,
 accident occasional
Ligature Strangulation
 Where a constricting band is tightened
around the neck,
 there is usually gross congestion,
cyanosis and petechiae in the face if
the pressure is maintained for more than
about 20 seconds.
 The ligature mark is a vital part of the
evidence, as it often reproduces the pattern
and dimensions of the ligature itself.
 If the assailant has removed the ligature
from the scene, and is subsequently arrested,
possible ligatures found on the assailant or in
his home etc can be compared with the mark
on the victim's neck.
.
 Some modern techniques involving
computer imaging are being developed to
assist in this comparison process,
- in much the same way as pioneers in the field
superimposed photographs of suspected
victims over skulls of unidentified persons
 Ligatures that have been left on the neck after
death, or which have caused sliding friction
over the skin result in a brown-coloured dry
leathery band,
 and there may be a red 'flare' of vital tissue

reaction on either side of the ligature.
 The mark is usually horizontal, just above
the laryngeal prominence ('Adam's apple').
 It usually continues around the

circumference of the neck, sometimes with
a cross-over or knot.
 There will not be a rising peak indicating a
suspension point, unlike in cases of hanging or
suspension.
 Ligature marks represent the nature of the
ligature, i.e..
 soft, fabric based ligatures may leave a diffuse

mark,
 whilst wires or cords leave a deeper more

defined mark.
 External skin markings may include
scratches from the struggling victim,
 and the internal injuries may include those

seen in manual strangulation, but are often
less obvious or developed.
 Homicidal commonly.
 Suicidal strangulation by ligature is less

common,
 but there may be a ligature wound around the
neck several times, involving complicated
knots.
Choke Holds
These include the so-called 'carotid
sleeper' and 'bar arm' choke holds that are
sometimes used in law-enforcement
situations,
 although they are increasingly being
outlawed in many jurisdictions.
Choke Holds
 There is often little or no external neck
injury visible,
 whilst haemorrhages in the strap muscles
can be more extensive and broader in
nature.
 If the bar arm hold has been of sufficient
strength, the airway may have been
obstructed, leading to 'air-hunger', and lead to
violent struggling on the part of the restrained
person.
Arm-lock
Hanging
 Body partly/completely suspended by ligature
around neck
 Brown leathery ligature furrow,
 imprint abrasion
 Fixed noose - inverted V-shape, knot mark
 Running noose - horizontal
 Low suspension point - groove less marked,
lower, horizontal
 Typically no classic asphyxial features
 Scene shows preparation and precautions.
Hanging
 This is defined as 'external compression of
the neck by the weight of the suspension
of an individual's head'.
 Hangings are overwhelmingly suicidal,

 but can be accidental (e.g. in autoerotic
asphyxiation).
Hanging
 Hanging may occur with the body in the fully
erect posture, with the feet clear of the
floor,
 but this is not necessary - some individually
hang themselves in the sitting or slumped
position, where the suspension point is a
door knob, or something at a similarly low
level, rather than a tree branch or exposed
beam etc.
Hanging
 Hangings that involve free swinging result in an
almost instantaneous death due to sudden
pressure on the neck arteries.
 If a long drop is involved, the cervical spine
may be broken.
 (Judicial hanging resulted in death due to a
broken cervical spine caused by a combination
of the knot above the noose, the drop and the
weight of the criminal).
Hanging posture
(complete, incomplete)
Hanging
Hanging
vital signs
 in men observed existence of urinary & fecal
incontinence & seminal ejaculation & erection
(sexual asphyxia)
 In women there is also urinary & fecal incontinence,

but it accompanied with vaginal congestion and
serosanguineous secretion.
 That is observed in all kinds of asphyxia, and

head trauma.
‫ق د توج د دماء عل ى الثياب واس ترخاء ف ي المثان ة واألمعاء عن د األفراد الذي ن يشنقون‬
‫أنفسهم‪ .‬من الشائع أيضا ً أن تكون قدما المتوفى تلمسان األرض‪.‬‬
Hanging
vital signs
 saliva flowing out of mouth on the chin
and the anterior of neck due to pressure
on saliva glands by hanging ligature.
 saliva flowing is a vital sign.
 Transversal tears in lining of carotids

Autopsy findings in hangings
 1- ligature furrow on the neck coursing
upwards towards the point of suspension.
 However this furrow may be absent
- if the ligature material is soft (e.g. a bed
sheet),
- or where the deceased was cut down
shortly after hanging him/herself,
- or where the body is decomposed.
 2- The furrow is usually above the
level of the Adam's apple
 and becomes dried and parchmented
after death.
 3- congestion and petechiae of the head
depend on the extent of body suspension
 - if the feet are off the ground the carotid
arteries are likely to have been compressed,
and the face is pale
 - if the body was fully supported on the
ground, it is more likely that the jugular veins
have been compressed but not the carotid
arteries,
 and so the face would be intensely congested
with many petechiae being present.
 4 - 'stocking and glove' Livor mortis
distribution
- if the body has been fully suspended/
hanging
 5 - bruising to the neck 'strap' muscles

- immediately underlying the furrow (less
likely with a 'soft' ligature)
 6 - fracture of the hyoid bone (this
bone, you will recall from pre-clinical
anatomy lectures, is that bone in the neck
which acts as a sling supporting the
tongue, and is the highest structure in the
larynx)
 - this is only really a possibility in those
with osteoporotic bones, and is more
commonly a feature of manual
strangulation where there is more of a
'pincer-type' action involved.
 General sign of anoxia,
 the External.
 and Internal
- Oedema of lungs, with petechiae on it.
- Fluid blood in the heart,
- Congestion of trachea, meninges,)
Hanging
 The usual suicidal hanging leaves an
interrupted mark, rising to a peak
- the point of suspension.
 However, if a slip knot is used, this peak

may be absent, and the mark difficult to
interpret in isolation of the features of the
scene of death.
‫من الصعب أحيانا ً تحديد الشكل الطبي الشرعي للموت‪ .‬هذا حادث عرضي على األغلب‪ ,‬ولكن‬
‫ال يمكن تأكيد ذلك‪ .‬ربما كان الصبي يجرب شعور االختناق‪.‬‬
Ligature mark in hanging
Knot (hanging)
Knot (hanging)
Knot (hanging)
Hanging
‫عالمات الرباط واضحة بشكل حرف( ( ‪V‬مقلوب‪ .‬يمكن أن تمتلك عالمة الرباط نموذج‬
‫الشيء( حبل في هذه الحالة) أو قد تكون غير مميزة أبداً‪.‬‬
‫عالمات شاحبة مع نزف مجاور نجمت عن شريط حذاء لف مرتين حول العنق‬
‫لدى هذا الط بيب المتقاع د مشاك ل ف ي العن ق يس تخدم م ن أجله ا التمدي د لتخفي ف األلم‪ .‬أظه ر‬
‫تشريح الجثة قلبا ً مريضا ً لديه‪ .‬ال يوجد سبب لالعتقاد بأنه أقدم على االنتحار‬
‫الزرقة الرمية على أسفل الوجه كما هو متوقع‪ .‬جفت الشفتان واللسان‪ .‬ال توجد نزوف في‬
‫النسج الرخوة للعنق وال توجد نزوف نمشية في العينين‪.‬‬
‫تبدو الزرقة الرمية كما هو متوقع‪ ,‬فهي تتركز في األطراف المعتمدة‬
‫يظهر المنظر الخلفي الزرقة الرمية المعتمدة أيضا ً‬
‫يوجد في الساق اليسرى أوعية شعرية عديدة متمزقة تدعى( بقع تارديو)‪ .‬ال حظ غياب البقع‬
‫في الساق اليمنى ألنها كانت مستقرة على الكرسي‪ .‬تشاهد هذه البقع أيضا ً في أجزاء أخرى‬
‫من الجثة إذا حدث الموت لفترة متطاولة من الزمن‪.‬‬
‫يكش ف أخم ص القدمي ن أ ي منهم ا كان مس تقراً عل ى الكرس ي وأ ي منهم ا كان يالم س‬
‫األرض‪ .‬الكرة الشاحبة( السهم ) على القدم اليسرى ألنها كانت تالمس األرض بشدة‪.‬‬
Hanging
 Hanging is usually suicidal,
 but some cases may be accidental, particularly

those related to autoerotic asphyxiation.
 Homicidal is very rare, (in children, under

narcosis, alcoholic intoxication, incapable..) …
SEXUAL ASPHYXIAS
 Accidental hangings, failure of safety
mechanisms
 Male,
 trasvestism or nudity,
 masochism,
 pornographic material
 Scene is diagnostic.
‫االختناق بالتهيج الجنسي الذاتي‪ .‬توفي هذا الشاب من انضغاط العنق بعد أن فقد وعيه خالل‬
‫االستمناء‪ .‬وجدت مجالت جنسية مصورة على األرض ومرآة بالطول الكامل قبالة السرير‪.‬‬
‫وجدت منشفة تلتف حول العنق لمنع حدوث السحجات ووجد الحبل مربوطا ً بشكل معقد يشبه‬
‫األرجوحة‬
‫صمم الضحية عقدة انزالقية تساعده عند الحاجة للتخلص من الوضع بسرعة‬
‫توف ي هذا الجندي أيضا ً أثناء االس تمناء‪ .‬كان يض ع كيس ا حول رأس ه خالل االس تمناء فتوف ي‬
‫من عوز األكسجين‪.‬‬
Ligature Mark Comparison
of hanging & strangulation
Complete, 1 – Incomplete,
Circumferential Uncircumferential
(except slip knot)
Horizontal 2 – Upwards
Beneath Larynx, or 3 – Above Larynx

at Same Level of
larynx,
Less depth. 4 – Deep, Obvious,
Less clearance (bigger compressing
force, it last more time)
Immersion & Drowning
 Immersion artefacts occur in any corpse
immersed in water, irrespective of whether
death was from drowning or the person
was dead on entering the water.
Immersion & Drowning
 Therefore, immersion artefacts do not
contribute to proof of death by drowning.
 However, such artefacts are typically the

most striking findings in a body recovered
from water.
EFFECTS OF IMMERSION
 1. Hypothermia
 2. Pink, light–red Lividity
 3. Anserina cutis (goose-skin)
 4. Maceration of the Skin
 5. Adipocer
 6. Existence of water or liquids in airway
 7. Moss and Algae
 8. Post Mortem Injuries
 9. decreasing of Body Temperature
 10. Sinking, putrefaction and refloating
 11. Alcohol
 12. Fleas and Lice
Immersion signs
 These immersion artefacts include:
1. Hypothermia occurs quickly ( T of water)

2. Pink, light –red Lividity (anterior part of
body, face, )
3. goose-skin, or anserina cutis, which is
roughening, or pimpling of the skin,
‫‪goose-skin, or anserina cutis‬‬
‫تجع د الجل د نتيج ة الغرق‪ .‬ال ح ظ غياب هذا التغي ر عل ى بقي ة الجثة‪ .‬كان الجل د متس لخا ً ف ي‬
4. Maceration of the Skin
(washer-woman's skin)
skin
 Immersion in water produces progressive
maceration of the skin (washer-woman's skin)
which becomes blanched, swollen and wrinkled.
 It is first apparent in
the skin of the finger pads
and then appears on the palms,
backs of the fingers
and back of the hand in that order.
 When fully developed it is most striking on the palms
and soles.
skin
 Generally there are obvious changes within
24-48 hours.
 With developing putrefaction the epidermis

including the nails peels off like a glove or
stocking.
 Fingerprints may be easily prepared from

the glove.
skin
 The wrinkling and blanching of water-soaked
skin in reflected histologically in water uptake
with swelling of the epidermis progressing
to  epidermal detachment from the
dermis.
 Tattoos and scars are readily identified in

the dermis following autopsy removal of the
peeling epidermis
Immersion signs
 5. Adipocer, ( transformation of the fatty
layer beneath the skin into a soap-like
material - a process requiring many weeks or
months).
 6. Existence of water or liquids in airway
even in bronchioles, and in stomach.
 7. Moss and Algae are covering the surface
of immersed body.
‫‪Algae, Moss‬‬
‫تغطي جثة هذا الشاب أشنيات غزيرة بعد ثالثة أسابيع فقط في بركة ماء‬
‫‪Algae, Moss‬‬
‫كانت طبقة االشنيات ثخينة بشكل خاص على الجذع‪ .‬يجب كشط االشنيات للبحث عن األذيات‬
8. Post Mortem Injuries
 The body may be attacked by sharks,
small fish, sea lice and other fauna. .
 Injuries may be inadvertently inflicted

during the recovery of the body using
grappling irons, hooks and ropes.
 post-mortem head injuries are

commonly produced by Buffeting in the
water.
- it may be difficult to distinguish from injuries
sustained during life.
 The presence of bleeding and inflammatory
response usually distinguish ante-mortem
from post-mortem injuries.
 The presence of pulmonary fat or bone

marrow embolism indicates that bony
trauma is ante-mortem but the absence of fat
embolism is not proof that the trauma was post
mortem.
‫توجد س حجات وكدمات وجروح رضي ة عديدة ف ي وجه وفم هذا الصبي‪ .‬غرق وعمه ف ي نه ر‬
‫ضحل خالل نزهة عائلية بعد الظهر‪.‬‬
‫هذه ص ورة تح ت الماء تظه ر عدم وجود أ ي م ن األذيات المشاهدة ف ي وج ه الشاب ف ي‬
‫تشريح الجثة‪ .‬لم تحدث تلك األذيات خالل شجار أو عراك للبقاء على قيد الحياة‪.‬‬
‫غرق هذا الرجل ولم تكتشف الجثة إال بعد مرور ثالثة أسابيع وقت الشتاء‪ .‬حدثت األذيات بعد‬
‫الوفاة‪.‬‬
‫عثر عل ى هذه المرأة في حوض ماء بعد أن ذهبت الشرطة إلى بيتها إلبالغها بوفاة صديقها‬
‫الذي انتحر باستنشاق عادم السيارة‪.‬‬
‫وجد مذياع في الماء مما يوحي بصعق كهربائي‬
‫سبب الماء انسالخ جلد كبير‬
‫وجدت سحجات على اليد والمعصم األيسر‬
‫وجدت س حجات تح ت الذق ن و نزوف نمشي ة ف ي العيني ن و نزوف نس يج رخ و ف ي العنق‪ .‬لق د‬
‫خنقت ووضعت في حوض الماء مع الراديو لتبدو وكأنها توفيت نتيجة صعق كهربائي‪ .‬خنقها‬
‫صديقها ثم انتحر‪.‬‬
9. Decreasing of Body
Temperature
 The body cools in water about twice as fast
as in air
 (i.e. about 5°F per hour)
 and reaches the temperature of the water

usually within 5 to 6 hours,
and nearly always within 12 hours.

10. Sinking, putrefaction and
refloating
 The normal changes of decomposition of a
body are delayed in cold, deep water.
After that cadaver refloats
 Corpses in water always lie with the face

down and with the head hanging.
 These conditions also favour the formation of

adipocer, which protects against
decomposition.
refloating
 Having sunk to the bottom the body will remain there until
putrefactive gas formation decreases the specific gravity of
the body and creates sufficient buoyancy to allow it to rise to
the surface and float.
 Heavy clothing and weights attached to the body may delay

but will not usually prevent the body rising.
 Putrefaction proceeds at a slower rate in water than in air,

in sea water than in fresh water and in running water than in
stagnant water.
 The principal determinant is the temperature of the water so

that in deep very cold water e.g. the North American Great
Lakes or the ocean the body may never resurface
refloating
 For the Thames, Simpson offers the following
guidelines for resurfacing times:
 June to August: 2 days;
 April, May, September and October: 3-5 days;
 November, December: 10-14 days;
 January, February; possibly no resurfacing.
 At water temperatures persistently below 45°F
there may be no appreciable decomposition
after several weeks.
refloating
 In the water the body floats face down with the head
lower than the rest of the body so that lividity is
most prominent on the head, neck and anterior
chest.
 Lividity is often blotchy and irregularly distributed
reflecting movement of the body in water.
 It is not intensive and appears a pink or light red
colour.
 In cold water it can be dusky and cyanotic.
 It may be difficult to recognize due to swelling with
water of the upper layers of the skin with resultant
loss of translucency.
refloating
 Putrefaction begins first within the areas
of lividity i.e. the head, neck and anterior
chest.
 It assumes a greenish bronze or dark brown
colour; if exceptionally dark there is a tete de
negre appearance.
 Putrefaction destroys any foam present in the
airways and produces instead a reddish brown
malodorous fluid containing bubbles of gas
 A similar appearing fluid appears in the pleural
cavities
‫غرق هذا الشاب األبيض في نهر‪ ,‬وعثر عليه بعد ‪ 5 -4‬أيام من موته في أوائل فصل الخريف‪.‬‬
‫لم توجد عالمات غرق‪.‬‬
refloating
 Once removed from water putrefactive changes
advance with remarkable rapidity.
 Adipocer which is a soap-like transformation

of subcutaneous fat is common in bodies
immersed in water usually appearing after
some months; it may be present in as little as
six weeks.
11. Alcohol
 Approximately two thirds of adult males
found drowning have consumed alcohol..
 Corroborative measurements on
vitreous humour, urine or bile should
be performed where possible.
12. Fleas and Lice
 Fleas associated with a body can survive

for up to 24 hours submerged.
 Lice survive for 12-48 hours.

Immersion
 When a body is recovered from water,
 two critical questions require resolution:
 1 - Was the victim alive or dead when he

entered the water?
 2 - Is the cause of death drowning? (and if

not, what is the cause of death?).
Immersion
 To resolve the above questions, the following
information must be correlated:
1. the circumstances preceding the death,
2. the circumstances of recovery of the body, and
3. the autopsy findings.
 The approach should be to consider the

circumstances revealed by the investigation and to
then determine if the autopsy findings are
consistent with those circumstances.
Drowning
 Drowning is "suffocation due to
immersion of the nostrils and mouth in a
liquid".
 The mechanism of death is complex and is

not simply asphyxiation due to suffocation.
Drowning
 Submersion is followed by
 struggle which
 subsides with exhaustion
 and drowning begins.
 When the breath can be held no longer,
 water is inhaled,
 with associated coughing and vomiting,
 and is rapidly followed by loss of
consciousness with death some minutes
later.
Drowning
 Instantaneous death may occur following
sudden, unexpected immersion in cold water.
 This is "atypical drowning" due to vagal

inhibition
DROWNING
 Qualifications:
 the mechanism of death is complex and varies
somewhat with circumstances.
- It is not simply asphyxiation due to suffocation in
a liquid.
 immersion of the nostrils and mouth is the
minimal requirement; typically the entire body is
submerged in the liquid.
 the liquid is most commonly water but drowning can
occur in any liquid e.g. beer, wine, gasoline,
bitumen, dye, paint or some other chemical
solution.
DROWNING
 Mechanism of Death
 Drowning was originally conceived as suffocation due
to the mechanical obstruction of the airways by
liquid.
 The animal experiments of Swann and his

colleagues during 1947-51 highlighted the
pathophysiological importance of disturbances of
blood electrolytes and fluid balance.
 In the experiments dogs were completely
submerged in salt water and fresh water.
DROWNING
 In fresh water
 Within three minutes of submersion
haemodilution was up to 72%.
 Circulatory overload,
 hyponatraemia
 and sodium/potassium imbalance together
with myocardial hypoxia resulted in a
dramatic collapse of systolic pressure quickly
followed in the majority of cases by
ventricular fibrillation.
DROWNING
 In salt water (3-4% salinity) drowning the
aspiration of water results in withdrawal of water
from the pulmonary circulation into the alveolar
spaces as a result of the osmotic differential while at
the same time electrolytes (sodium, chloride,
magnesium) pass into the blood.
 There is haemo-concentration but not haemolysis
and little change in the sodium/potassium balance.
 The pulse pressure decreases slowly and is
followed by A-V dissociation but not ventricular
fibrillation.
 Up to 42% of the water content of the circulating
blood was absorbed into the alveoli,  death by
(Asphyxia=full of liquid)
DROWNING
 In both fresh water and salt water drowning
there is terminal pulmonary oedema.
 In both drowning media there is concurrent
transfer of water in both directions between
the alveolar spaces and the blood
 i.e. pulmonary oedema develops
simultaneously with the diffusion
process.
DROWNING
 These experiments have been extrapolated to
man but have been criticised because
 (a) the animals were always completely
submerged
 and
 (b) the main intracellular action in the
dog erythrocyte is not potassium but
sodium.
 The biochemical findings in humans surviving
drowning are less distinct.
Phases of Drowning
1 - Submersion is followed by struggle which
subsides with exhaustion and drowning
begins.
2 - Breath holding lasts until carbon dioxide

accumulation stimulates respiration
resulting in inhalation of water.
3 - Gulping of water coughing and vomiting

is rapidly followed by loss of consciousness.
Phases of Drowning
4 - Profound unconsciousness and
convulsions are associated with involuntary
respiratory movements and the aspiration of
water.
- Respiratory failure precedes heart failure
in one- third of cases, it is coincident in one-
third, and follows it in the other third.
5 - Death occurs within 2 to 3 minutes (see
below for "Instantaneous Deaths").
Phases of Drowning
- Death is almost invariable when the
period of submersion exceeds 10 minutes.
- The survival rate from potentially

fatal salt water submersion is about 80%
whereas in fresh water it is less than 50%.
Drowning
 Hypothermia (death from loss of body heat) may
occur following immersion in water with a temperature
less than 68oF = 68 – 32 = 36 C
 A healthy person in ordinary clothes and wearing a

lifejacket would have an expected survival time of
 less than 3/4 an hour at Tmp. less than 35 F= 3 C,
 less than 1.5 hours at 35-40oF = 3 – 8 C ,
 and less than 3 hours at 40- 60 F = 8 -28 C.
Drowning
 There are no autopsy findings
pathognomonic of drowning .
 Consequently,
 obtaining proof that the victim was alive on
entering the water,
 and excluding the presence of natural,
traumatic and toxicological causes of death,
are critically important
Drowning
 Some pathological changes are characteristic
of drowning,
 but the diagnosis is largely one of exclusion.

Signs of drowning
 1 – Froth or foam
 2 – Oedema of lungs (Emphysema aqueous)
 3 – sand , silt, weed, and other foreign matter, in the
airways, and large quantities of water and debris in the
stomach
 4 – Haemorrhages in the boney middle ears
 5 – petechial haemorrhages on Conjunctiva , pleura, and
lungs
 6 – Venous congestion and fluid blood
 7 - cadaveric Spasm in one hand or in the both. (in hands
sand, grass, silt,…)
 8 – Shoulder-girdle bruises
 9 – congestion and oedema of viscera and brain
 10 – diatom in bone medulla, and brain
1. Foam in the airways
 Externally a fine white froth or foam is seen
exuding from the mouth and nostrils.
 The froth is sometimes tinged with blood producing a

pinkish colour.
 If the foam is wiped away then pressure on the chest
wall will cause more to exude from the nostrils and
mouth.
 It is persistent and resists submersion for several days
(up to a week in winter). The foam is also found in the
trachea and main bronchi.
1. Foam in the airways
 The foam is a mixture of water, air, mucus
and possibly surfactant whipped up by
respiratory efforts.
 Thus it is a vital phenomenon and indicates
that the victim was alive at the time of
submersion.
 Similar foam is found with severe pulmonary
oedema from any cause such as drug
overdose, congestive cardiac failure and
head injuries.
‫‪A fine, white, froth‬‬
‫الغرق‪ .‬الزبد في األنف عالمة تقليدية للغرق‪ ,‬وقد تكون العالمة الوحيدة للفرق في الجثة‪ .‬توجد‬
‫سحجات في الوجه والجبهة واليدين والقدمين والركبتين عند بعض ضحايا الغرق‪.‬‬
2. Emphysema aqueous
 The lungs are voluminous/ bulky/ ballooned.
 The pleural surface has a marbled appearance with
grey-blue to dark red areas interspersed with pink and
yellow-grey zones of more aerated tissue.
- They feel doughy and pit on pressure.
 On sectioning there is a flow of watery
material.
 The appearances reflect active inspiration of air
and water and cannot be reproduced by the passive
flooding of the lungs with water.
 However the appearances are not generally
distinguishable from pulmonary oedema.
 Contrary to expectations (see Mechanisms
of Drowning) lung weights in fresh water
drowning are not statistically different from
lung weights in salt water drowning.
 The average lung weight is approximately

700gm with a standard deviation of
approximately 200gm so that in a minority of
cases the lungs are "dry".
 Subpleural petechiae are rare but larger
ecchymoses are sometimes seen most often in the
interlobar surfaces of the lower lobes.
 Subpleural bullae which may be haemorrhagic are

occasionally found.
 Haemorrhages are the result of tears in the

alveolar walls and this is the explanation for the
occasional blood tingeing of foam in the airways.
 For detailed histological studies one
central and one peripheral section from
each lobe is recommended.
 The tissue should be cut with a sharp
knife avoiding squeezing out of the
fluid content.
 The microscopic appearance varies from being
suggestive of drowning to entirely normal.
 Aspiration of large quantities of water results in
(emphysema aqueous) the alveolar septae
are thinned and stretched with narrowing and
compression of the capillaries.
 The appearances resemble pulmonary
emphysema.
 The lungs are characteristically over-inflated and
heavy with fluid (ribs imprints on lungs surface,
dissecting them will result flow out of haematic
liquid with aero bubbles)
However, this is not invariable and, when

present, is not distinguishable from "fluid on
the lungs“
 (pulmonary oedema seen in heart failure,
drug overdose and head injury).
3. Foreign material in airways,
lungs and stomach
 (water and contaminating debris) Sand,
silt, weed or other foreign matter may be
found in the airways, lungs, stomach and
duodenum of bodies recovered from water.
 Disputed is whether the presence of such

material consistitutes proof of immersion
during life.
lungs and stomach
 However water will not reach the terminal
bronchioles and alveoli to any significant
extent so that the finding of abundant foreign
material generally distributed within the alveoli
provides strong evidence of immersion
during life so long as the body is recovered
early (within 24 hours) from shallow water (less
than 3 meters deep).
 The same in stomach
lungs and stomach
 Debris and chemical contaminants present
in liquid recovered from the lungs and
stomach can be compared with samples of
water from the place of submersion to
provide corroboration that drowning occurred
at that locale.
lungs and stomach
 Microscopy as well as chemical analysis of the
gastric contents may be useful in this regard.
 Vomitus may be found in the oesophagus and

airways as a result of agonal inhalation or attempted
resuscitation.
 The presence of large quantities of sand in the upper

airways raises the possibility of inhalation of a
thick suspension of sand in sea water produced by
heavy surf; death is very rapid in such cases.
4. Middle ear and mastoid air
cell haemorrhage.
 Their pathogenesis is unknown and their presence
does not contribute to proof of death by drowning.
 They may be the result of baro-trauma or the

irritant/pressure effects of aspiration of fluid into
the Eustachian tubes or extreme congestion.
 Such haemorrhages also occur in cases of head

trauma, electrocution and mechanical
asphyxiation
5. Petechial Haemorrhages
on Conjunctiva
 Occasional small Conjunctival
haemorrhages may be seen but the multiple
petechial haemorrhages found in other
asphyxial deaths are not seen in drowning
(except in rare instances of rapid death
associated with glottic spasm - see below).
 The conjunctivae are often congested.

6. Venous congestion and
fluid blood
 Heart failure combined with blood volume
expansion from the absorption of fresh water
is reflected in
engorgement of the right side of the heart
and large veins.
 As a result of haemodilution the blood is

fluid and thin lacking its normal sticky
consistency.
7. Foreign material in the
hands (cadaveric Spasm)
 Victims struggling in water may clutch at objects
which are then found grasped in the hand after death.
 Weeds, branches and other objects fixed in the
hand by cadaveric spasm (instantaneous rigor)
provide good evidence that the victim was alive and
conscious at the time of submersion.
 Similar materials may be recovered from beneath
the fingernails.
 Injuries to the hands or fingertips and tearing of the
fingernails may be produced during attempts to grasp
at objects.
8. Shoulder-girdle bruises
 Victims struggling violently to survive in water
bruise or rupture muscles particularly those of the
shoulder girdle, neck and chest (most often the
scaleni and pectoralis major).
 Haemorrhages may be bilateral and tend to follow

the lines of the muscle bundles. They may be present
in up to 10% of cases and are strong indicators that
the victim was alive in the water.
 In decomposing bodies these haemorrhages should be

examined histologically.
 Extravascular erythrocytes provide histological
proof of the existence of true haemorrhage.
9. Congestion of internal
organs
 Congestion of internal organs.
 oedema of viscera and brain.

10. Diatom in bone medulla,
and brain
 There are no universally accepted

diagnostic laboratory tests for drowning
 the demonstration of Diatoms in internal

organs such as bone marrow is strong
corroborative evidence of death by
drowning
Diatoms
INVESTIGATION
 These cases represent a challenge because:
 1 - The mechanism of death in drowning is

neither simple nor uniform.
 2 - The circumstances of drowning introduce

further variables.
Drowning
 The questions to be resolved by the
investigation are:
1. Did death occur prior to or after entry into the

water? (i.e. was the victim alive or dead at the time
of entry into the water?)
2. Is the cause of death drowning? If not what is
the cause of death?
3. Why did the victim enter the water?
4. Why was the victim unable to survive in the
water?
Drowning
 To resolve these issues
 the following information must be correlated?
 1. Circumstances preceding the death.

(identification of the victim becomes a priority.)
 2. Circumstances of recovery of the body
from water.
 3. Autopsy and laboratory analyses.
 4. environmental factors
 5. and human factors (inexperience, poor
judgment, intoxication
Investigative Considerations -
Case Example
 An 80 year old male swimming in warm ocean
water in mid-summer.
 He was found dead in the water and the body

recovered.
 Autopsy disclosed minor degrees of pulmonary
congestion and oedema.
 There was severe coronary artery atherosclerosis
with posterior wall myocardial fibrosis but no evidence
of recent infarction or coronary thrombosis.
Consider the environmental and
human factors.
 Some alternatives are:
 1. A fatal cardiac dysrhythmia with a
collapse "dead" into the water.
 2. A fatal cardiac dysrhythmia with
collapse into the water and agonal aspiration
of some water.
 3. A non-fatal cardiac dysrhythmia with
syncope and collapse into the water and
drowning.
Consider the environmental and
human factors.
 Some alternatives are:
 4. Stepping into or being swept into deep
water and an inability to escape due to a
lack of cardiac reserve or lack of cardiac
rhythm stability.
 5. Stepping into or being swept into deep
water, panicking and drowning while the
heart continued to function normally until
overcome by the terminal anoxia of drowning.
Given these alternatives the death
certificate might read:
 1. Atherosclerotic coronary artery disease
 2. . Atherosclerotic coronary artery disease
with a contributory effect of "agonal
aspiration of water".
 3. Atherosclerotic coronary artery disease
with a contributory effect of drowning.
 4. Drowning with a contributory effect of
atherosclerotic coronary artery disease
 5. Drowning..
CIRCUMSTANCE AND MANNER
OF DEATH
 the majority of victims are young adults
and children
 two-third is accidental
 and one-third are suicidal;
 homicide by drowning is rare
OF DEATH
 Accidental drowning of toddlers (uncovered
fish ponds, the bath and swimming pools)
 Accidental drowning in adults is commonly
associated with alcohol consumption and
males predominate.
OF DEATH
 In suicidal drowning some clothing may be
left in a neat pile close to the water
 The pockets may be filled with stones or
weights may be tied to the body.
 The hands or the feet are sometimes tied
together and an examination of the ligatures
will show whether they could have been tied by
the deceased.
 Previous suicidal trials ( slashing a wrist,
drugs ..)
‫غرق هذا الرجل بعد تقييد يديه وضربه على الرأس ودفعه داخل النهر‬
OF DEATH
 Homicidal drowning is uncommon and requires
either physical disparity between the assailant and the
victim or a victim incapacitated by disease, drink or
drugs, or taken by surprise.
 Disposal in water may be attempted where the victim
has already been killed by other means.
 A victim of infanticide is sometimes disposed of in this
way.
 Autopsy is directed towards establishing injuries
inconsistent with accident in the absence of signs of
drowning.
OF DEATH
 The investigation of a death in a domestic
bath may be made more difficult by the
lack of accurate information concerning the
position of the body as found and the level of
the water.
 First it must be established whether the nose

and mouth were truly under the water?.
OF DEATH
 Such drowning will only occur if
unconsciousness is produced by disease
(epilepsy, coronary artery atherosclerosis ) or
the consumption of alcohol and/or drugs or a
head injury from a fall.
 Suicide in the bath is rare but well documented.
 Homicide in the bath is described

OF DEATH
 The domestic bathroom presents other
hazards than drowning such as
electrocution and carbon monoxide
poisoning from faulty heaters.
 Persons unconscious by reason of natural

disease and injury can drown in quite
shallow water so long as it is sufficiently
deep to cover the nose and mouth.
OF DEATH
 Diving into shallow water may result in impact
of the forehead against the bottom with
resultant hyperextension of the head and
loss of consciousness.
 Individuals engaged in underwater swimming

competions may hyperventilate prior to entering
the water
 This can result in sudden loss of consciousness
and drowning
OF DEATH
 In skin diving a mask and fins are used and it is
essentially an extension of swimming with similar
hazards.
 SCUBA is an acronym for self contained underwater
breathing apparatus.
 This apparatus allows the diver to reach depths not
usually attained by skin divers.
 The hazards are those of drowning and baro-
trauma.
 The commonest problems include "the bends"
(caisson disease, decompression sickness), acute
pulmonary emphysema, pneumothorax and systemic
air embolism
OF DEATH
 Prolonged immersion in water less than
36C= 68F carries the threat of hypothermia
 For a person in good health ordinarily clothed
and wearing a life jacket, the expected
survival time for given water temperatures
are:
1. less than 3/4 hour at less than 3 C= 35°F ;
2. less than 1.5 hours at 3 – 8 C= 35-40°F;
3. less than 3 hours at 8 – 18 C= 40-50°F;
4. less than 6 hours at 18 – 28 C= 50-60°F.
ATYPICAL DROWNING
 1. Vagal inhibition (cardiac arrest,
laryngeal shock)
 2. Laryngeal spasm
 3. "Dry drowning“
 4. Delayed death ("secondary
drowning", post-immersion syndrome)
1. Vagal inhibition (cardiac
arrest, laryngeal shock)
 This is uncommon but well recognized.
 Loss of consciousness is usually
instantaneous and death ensues soon
afterwards, at most within a few minutes.
 Autopsy discloses none of the usual signs
of drowning.
 The mechanism is believed to be cardiac
arrest induced by impact of cold water on
the back of the pharynx and larynx.
1. Vagal inhibition (cardiac
arrest, laryngeal shock)
 The three circumstances common to these
deaths are
 (a) entering the water feet first,
 (b) surprise or unpreparedness and
 (c) a "state of hypersensitivity" e.g. alcohol
intoxication.
 There may be instantaneous rigor (cadaveric

spasm).
2. Laryngeal spasm
 There is likely some element of laryngeal
spasm in all drowning deaths.
 However in these cases there is no evidence
of aspiration of liquid and there are the
typical signs of an asphyxial death including
facial cyanosis and petechial haemorrhages.
 The possibility of an asphyxial death prior to
entry into the water must be excluded (e.g.
homicidal strangulation).
2. Laryngeal spasm
 The mechanism is thought to be sudden
chilling of the neck and chest
 followed by immediate inhalation of water
 resulting in
- reflex spasm of the larynx,
- early unconsciousness
- and a rapid asphyxia.
3. "Dry drowning"
 It is possible that water was inhaled, absorbed
into the circulation and then death occurred
prior to the onset of active pulmonary
oedema.
 The confusing concept of dry drowning has
been used to widen the spectrum of cases of
vagal inhibition and laryngeal spasm
bringing these valid concepts into some
disrepute.
4. Delayed death ("secondary
drowning", post-immersion syndrome)
 Autopsy discloses acute pulmonary
oedema.
 This phenomenon has been reproduced in
animal experiments.
 Later complications include
1. pneumonitis,
2. broncho-pneumonia and hyaline
membrane disease together with
3. renal failure secondary to
4. haemoglobinuria.
DROWNING TESTS
 There are no universally accepted diagnostic
laboratory tests for drowning.
 1. Specific gravity of blood

 2. Plasma Chloride
 3. Plasma Magnesium
 4. Diatoms
1. Specific gravity of blood
 It is suggested that a lower plasma
specific gravity in blood from the left
side of the heart reflects
haemodilution produced during the
drowning process.
2. Plasma Chloride
 Haemodilution in fresh water drowning is
considered to produce a lower chloride level in
left heart blood.
 Conversely haemo-concentration and

chloride ion absorption in salt water drowning
is considered to produce the reverse result
(high in left heart blood)
3. Plasma Magnesium
 A high level of plasma magnesium in left
heart blood is considered to reflect absorption
on that ion from the drowning medium
particularly salt water.
 None of the above tests are considered

definitive
4. Diatoms
 Diatoms or Bacillariophyceae are a class of
microscopic unicellular algae of which about
15,000 species are known (approximately half
live in fresh water and the other half in sea or
brackish water).
 The cell structure is unique in that it secretes a
hard siliceous outer box-like skeleton called a
frustule which is chemically inert and almost
indestructible being resistant to strong
acids.
4. Diatoms
 during drowning, diatoms could enter
the systemic circulation via the lungs.
 Their presence can be demonstrated in such
tissues as liver, brain and bone marrow
following acid digestion of the tissue.
4. Diatoms
 The use of diatoms as a diagnostic test for
drowning is based upon the hypothesis
that diatoms will not enter the systemic
circulation and be deposited in such
organs as the bone marrow unless the
circulation is still functioning
 thus implying that the decedent was

alive in the water.
4. Diatoms
 The test is limited by the difficulty of excluding the
possibility of contamination.
 Diatoms are ubiquitous in the environment e.g.
in the building industry and as dusting powder for
rubber gloves.
 Additionally diatoms have been found in the organs of
decedents not recovered from water, raising the
possibility that diatoms may enter the circulation via
the gastro-intestinal tract (as contaminants of
foods such as salads, watercress and shellfish) or via
the respiratory tract (diatoms are normally present
in small numbers in the air).
4. Diatoms
 The present consensus is that, given adequate
precautions to prevent contamination,
 the demonstration of diatoms in organs such as
bone marrow is strong corroborative evidence of
death by drowning.
 This is true for decomposed bodies provided there

is no gross mutilation.
 It should be confirmed that the species of diatoms
found are the same as those present in the water
from which the body was recovered).
4. Diatoms
 Examination of lung fluid for diatoms is
of more limited value but their presence in
large numbers provides corroboration of
death by drowning.
Thanks for attention

12 - Asphyxia (PPTminimizer)

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12 - Asphyxia (PPTminimizer)

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Asphyxia

1. anoxia by decreasing of respiratory O2

 a- Ascending to heights, where O2 pressure less in the air

 O2 percentage in the venous blood is low,

 O2 and its pressure are normal in arterial

1. - Struggle – (Dyspnea), forceful breathing

 - in the face ( lips) & nails is obvious

 In these circumstances, the level of

 there may be coarse petechiae present

 About the post mortem petechial

 It occurs at the 2nd stage of anoxia,

 About oedema of lungs the best way to

 It may be resulted from acute cardiac

 Blood fluidity in the heart, and the big vessels.

 Reduced blood flow to brain (neck pressure)

 The time interval from loss of consciousness to

 The amount of pressure to occlude

 Reduced blood flow to brain (neck pressure)

Luxation (dislocation) of cerebral vertebral

 When oxygen is not able to reach the lungs

 - the tongue is pushed backwards and

 Or the victim is woman also occluded her

 Oedema in pharynx & larynx

 General signs of asphyxia

 Normal percentage by volume of O2 in the

 at 8 % and less of O2, death occurs.

 At 4 to 6 % there is loss of consciousness

 Toxicological studies showed no value

 It is Airway obstruction at larynx from

 (although it is unwise to over-interpret such

 6. sustained pressure may cause congestion

 and there may be a red 'flare' of vital tissue

 It usually continues around the

 soft, fabric based ligatures may leave a diffuse

 whilst wires or cords leave a deeper more

 and the internal injuries may include those

 Suicidal strangulation by ligature is less

 Hangings are overwhelmingly suicidal,

 In women there is also urinary & fecal incontinence,

 That is observed in all kinds of asphyxia, and

 Transversal tears in lining of carotids

 5 - bruising to the neck 'strap' muscles

 However, if a slip knot is used, this peak

 but some cases may be accidental, particularly

 Homicidal is very rare, (in children, under

Beneath Larynx, or 3 – Above Larynx

 However, such artefacts are typically the

1. Hypothermia occurs quickly ( T of water)

 With developing putrefaction the epidermis

 Fingerprints may be easily prepared from

 Tattoos and scars are readily identified in

 Injuries may be inadvertently inflicted

 post-mortem head injuries are

 The presence of pulmonary fat or bone

 and reaches the temperature of the water

and nearly always within 12 hours.

 Corpses in water always lie with the face

 These conditions also favour the formation of

 Heavy clothing and weights attached to the body may delay

 Putrefaction proceeds at a slower rate in water than in air,

 The principal determinant is the temperature of the water so

 Adipocer which is a soap-like transformation

 Fleas associated with a body can survive

 Lice survive for 12-48 hours.