ASPHYXIA

 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.
Causes of asphyxia
 Obstruction to the air passages due to
hanging,strangulation or throttling.
 Causes of external respiratory orifices,as in
smothering.
 Occlusion of the air passages within as in
drowning or laryngeal spasm.
 Pressure on the chest,as in traumatic asphyxia
 Inhalation of irrespirable gases like carbon
monoxide.
 Spasm of the respiratory muscles,as in
strychnine poisoning.
 Paralysis of the respiratory center,as by
narcotics and anesthetics.
 Obstruction to the upper respiratory
passage in cases of angioneurotic oedema.
 Features of asphyxia

 Cyanosis,capillary dilatation,capillary
stasis,rise of capillary pressure.

 Increased capillary permeability,Tardieu’s

spots and relaxation of sphincters.
 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

 Mechanical asphyxial deaths
or Violent
asphyxial deaths

 Hanging
 Strangulation
 Suffocation
 drowning
 Hanging

 Hanging is a form of asphyxial death which

is caused by the suspension of the body by
ligature around the neck, The constricting
force being the weight of the body.
 Types

 Complete hanging.
 Partial hanging.
 or
 Typical hanging.
 Atypical hanging.
 Complete hanging
 When feet do not touch the ground and
the weight of the body acts as a
constricting force.
Partial hanging
 When the weight of the head as a
constricting force, not the whole body ,is
known as partial hanging.
 Typical hanging
 The ligature is situated in the midline above
the thyroid cartilage and runs symmetrically
upwards on both sides of the neck to the
occipital region.

Atypical hanging
 Any variation of this standard position.
 Ligature

 Any material , like ropes, chains, wire,

leather straps, belts, scarf, dopatta 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, so the
knot remains intact.
Cutting the ligature
 Symptoms
 So rapid that they are rarely observed.
 Flashes of lights before the eyes,ringing in
the ears.
 Unconsciousness and death.
 The individual can do nothing to help
himself even if it were possible.
 Respiration stops before the heart which
may continue for 10-15min.
 Causes of death
1-Asphyxia
Ligature forces the tongue up and
occludes air,15kg tension occludes the
trachea.

2-Cerebral congestion
Obstruction of jugular veins by
compression and this with 2kg wt tension.
 3-Cerebral anoxia
 Carotid artery occludes with 3.5kgs
tension and vertebral artery with 20kgs
tension, trachea 15kg, jugulars 2kg.

4- Reflex vagal inhibition.

5-Fracture and/or dislocation of cervical spine at
the level of C2 & C3,,sometimes C3 & C4
vertebra, rarely C2.

6-Combination of any of the above.

 Postmortem appearance
External appearance.
Internal appearance.
Ligature mark.

External appearance
-Above the ligature.
-Beneath the ligature.
-Below the ligature.
 Above the ligature mark
 Along with general features of asphyxia.
 Face is pale and placid.
 If vessels constriction is incomplete , face is livid &
swollen with profound petechiae.
 Tilt of the head.
 Stretched neck.
 Protrusion of tongue.
 Dribbling of saliva. (vital sign)
 Le Facia Sympathique. (vital sign)
 Congestion of the face.
 Petechial haemorrhages.
 Beneath the ligature
 Fixed or running noose.
 Position of the knot.
 Course of the ligature.
 Width and multiplicity.
 Point of suspension.
 Slipping of ligature.
 Weight of the body.
Ligature mark
 Pressure mark on the neck at the site of
ligature, appears as depression or groove.
 Looks pale initially but later yellowish
brown ,dry , hard and parchment like.
 Abrasions and bruises seen occasionally in
bed of groove.
 Along the edges there may be areas of
hyperemia and occasionally a few
ecchymoses
 Below the ligature

 Postmortem lividity (Glove and Stocking)

 Relaxation of sphincters.

 Injury to legs.(partial hanging)

 Internal appearance
 Ligature mark is a pressure mark.
 Dry, white and glistening appearance and
Petechial haemorrhages beneath ligature
mark
 Rupture of platysma and sternomastoid.
 Transverse tear in the intima of carotid
artery.
 Fracture of hyoid is rare
 Congestion of organs.
 Petechial haemorrhages.
 Diagnosis
 Ligature mark around the neck.
 Presence of abrasions , Echymosis and redness
around the ligature mark.
 Trickling saliva from the mouth.
 Echymosis of larynx and trachea.
 Rupture of intimae of carotids. Extravasation of
Blood in to its wall
 Signs of asphyxia. But if death is sudden e.g spinal
injury or vagal inhibition then these are absent
 Haemorrhages in local lymph nodes.
 Medico-Legal Aspects
 Was the death due to hanging?
 Whether hanging was suicidal ,homicidal or
accidental?
 In death due to hanging there will be.
 Typical oblique, non-continuous , high up
ligature mark.
 Abrasions and Ecchymoses above and
below the ligature mark.
 Extravasation of blood and tear of the
intima of the carotid artery
 Saliva and signs of asphyxia.
 Suicidal
 Usually full suspension. But partial is
possible,
 Isolated place
 Readily available material as ligature
 Ligature tied to beam hook, fan, tree etc.
 Position of body must be compatible with
self hanging
Occasional nail mark-may be self inflicted
while trying to free him\herself.
 Suicidal note may be present .
 Homicidal

 Extremely rare , except in case of lynching.

 Difficult , unless the victim is unconscious

by injury or by drugs.
 Very weak physically

 Marks of violence may be seen on the body.

 Suspect if
 1- knot is on back of neck.
 2- mouth is gagged.
 3-limbs are tied very tightly specially
upper limbs.
 4-injuries found on body
 5-signs of struggle are present.
 Postmortem hanging\Suspension
 Person murdered and the dead body
suspended to simulate suicide.

 Ligature mark may be produced if the body

is suspended within 2hrs after death.
 Judicial hanging
 Drop of 5-7 feet
 Fracture dislocation at cervical 2-3 or 3-4.
 Transaction of spinal cord.
 Tear of intima of carotid artery.
 Injury to pons and medulla due to pull .
Death is usually instantaneous though heart
continues to beat for few minutes.
 Strangulation
It’s a form of asphyxia caused by the
constriction of neck by some means,, the
constricting force being other than weight
of the body. The means may be a ligature,
hand .elbow or any hard object.
 1- ligature strangulation
 2- Manual strangulation or Throttling.
 3-Mugging (elbow)
 4-Garroting . (From behind)
 Causes of death

 Asphyxia, common in ligature

strangulation
 Anoxia,
 Congestion
 Vagal inhibition
 Combination of any of the above
 Autopsy finding
 Externally-usually those of asphyxia.
Ligature mark
 Well defined, slightly depressed usually at
the level of thyroid cartilage or below, but
maybe at any level on the neck-
 Encircles the neck horizontally , 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.
 Appears pale initially, yellowish brown
later on
 Dry, white and glistening appearance and
Petechial haemorrhages beneath ligature
mark
 Injuries to muscles, laryngeal cartilages,
tracheal rings and carotids extensively.
 Fracture of hyoid is not common, broken
ends displaced outwards.
 Congestion of organs.
 Petechial haemorrhages.
 Fold marks on neck
 Seen in infants and children with short
neck.
 Tight collar , ornaments etc may produce a
similar mark during putrefaction swelling of
neck
 Examination of ligature for blood, fragments
of epidermis, hair or other substances.
 Sign of struggle.
 Internal
 Laceration of muscles.
 Hyoid bone fracture usually not seen.
 Fracture thyroid cartilage is more common.
 Fracture of cricoid is rare , but if pressure is
used may be seen.
 Organs are congested.
 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, surprise attack, under
intoxication, weak person.
 Common methods of Homicidal
strangulation
Throttling
 Compression of neck by hands.
 Bruises produced by tips of fingers.
 More force is used than is necessary.
 Marks of thumb on one side and fingers on other
side.
 Pressure of nails produce crescentic marks with or
without incision , concavities follow anatomical
shape of the nail margin and nails with straight
border give unpredictable results.
 Hyoid bone fracture and bruising can be seen with
careful neck dissection.
 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.
 Suffocation
 It’s a form of asphyxia caused by mechanical
obstruction to air passage due to causes other
than constriction of the neck.

Smothering
 It’s a form of asphyxia caused by closure of
external respiratory passage either by hand or
other means,or introduction of foreign materials
like cloth or paper etc.
 Medico-Legal importance
Suicide
 Not possible by hands.
 Possible by means of tying polythene bag over
the head/burring the face in mattress.
 Creating suffocation in the closed and non-
ventilated rooms.
Homicidal
 Possible when victim is incapacitated by
drugs/alcohol,can be smothered.
 Accidental
 Infants/children by weight of clothes etc.
 While playing with plastic bags.
 In adults-plastic bags for auto erotic exercise as
partial anoxia enhances sexual sensation.
 Mothers-during breast feeding.

Postmortem findings.
 Asphyxial signs.
 Abrasions & bruises around the lips and cheeks.
 Injuries on inner side of lips.
 Gagging
 It results from closure of mouth by a cloth
or similar material causing obstruction to
the larynx or force the base of the tongue
against the fauces.
Overlying
 Compression of chest to prevent breathing.
 Mother infants.
 Forceful pressure over the chest.
 Burking
 Method of homicidal smothering.
 Practiced by “Burk” and “Hare”

Chocking
 Caused by obstruction within air passage.
 Usually accidental.
 From diseases-Diphtheria,laryngeal
spasm,infection etc.
 Hyoid bone fracture

 Inward fracture.
 Antero-posterior fracture.
 Avulsion fracture.
 Inward fracture

 Seen in throttling-main force is an inward

compression on the hyoid bone.

 Fingers squeeze the greater horns towards

each other,due to which the bone may be
fractured and post fragments displaced
inwards.
Antero-posterior compression
fracture

 In case of hanging,the hyoid bone is forced

directly backwards due to which,the
divergence of greater horns is increased
which may fracture with outward
displacement of the posterior small
fragments.

 Ligature strangulation,run over accidents.

 Avulsion fracture

 Very rare and is due to over activity of

neck muscles without direct action or
injury to hyoid bone.

Incidence-
 Hanging 15-20% above 40yrs age.
 Very common in throttling.
 Diagnosis of throttling
 Cutaneous bruising and abrasions.
 Extensive bruising with/without rupture of
neck muscles.
 Engorgement at/above the constriction.
 Fracture of larynx,thyroid cartilage and
hyoid bone.
 Cricoid I almost exclusively fractured in
case of throttling.
 Asphyxial signs.
 Chocking
 Obstruction within the air passages.
 Accidental inhalation of food when the victim is
laughing or crying.
 Vomited material may be inhaled by a person
under the influence of drink or anesthetic drug.
 Large food bolus,piece of meet seeds or
fish,teeth(loose),marbles in children.
 From diseases-diphtheria,laryngeal
edema,bronchial growths.Hemorrhages.
 Causes of death

 Asphyxia,vagal inhibition,laryngeal
spasm,infection.
 Café coronary
 Impaction of food in the sensitive larynx causes
sudden death due to cardiac arrest.
 Healthy intoxicated person in hotel while eating
suddenly turns blue,coughs violently-collapses and
dies.
 At autopsy a large food bolus seen in the
respiratory tract-larynx obstructing air passage.
 Signs of chocking are absent because of high
blood alcohol which inhibits the gag reflex.
 Post-mortem appearance-the foreign body is
embedded in a thick mucus in the trachea.
 Traumatic asphyxia
 Its due to respiratory arrest due to mechanical
fixation of chest so that the respiratory
movements are prevented.
 E.g.:Stampede in a theatre or in places where
crowded gatherings are there.Fall of earth-coal
mines,tunneling accidents etc.
Post-mortem appearances
 An intense deep purple red colour of the
head,neck and upper part of chest above the level
of constriction.
 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 in
which access of air into the air passages
is prevented by submersion of the body in
water or other fluid medium.

 Complete submersion not necessary,

submersion of nose and mouth is enough.
 Classification
 Typical
 Atypical
Typical drowning
 Obstruction of air passages and lungs by
inhalation of fluid and is known as “Wet
drowning”.
 Typical signs are found at autopsy.
 Atypical drowning
 Conditions in which there is very little or
no inhalation of water or fluid in the air
passages.
 Dry drowning.
 Immersion syndrome(vagal inhibition).
 Submersion of the unconscious.
 Secondary drowning syndrome/near-
drowning.
 Typical drowning
 Fresh water drowning.
 Salt water drowning.

Fresh water drowning

 Water cross the alveolar membrane into the circulation.
 Produces marked hypervolaemia.
 Red cells swell or burst-hemolysis-liberation of
potassium.
 Circulation will suffer 50% dilution within 2-3 min.
 The heart is submitted to the insult of
anoxia,hypervolaemia,potassium excess and
sodium deficit.
 Ventricular fibrillation due to anoxia and
potassium excess within 4-5 min.

Salt water drowning

 Marked hypertonicity of the inhaled water cause
loss of fluid from circulation into the lungs-
fulminating pulmonary edema and progressive
hypovolaemia.
 Circulatory shock and cardiac arrest.
 Atypical drowning
Dry drowning
 Intense laryngeal spasm due to entry of water
into nasopharynx and larynx.
 Very little water enters into lungs.
 Best case for resuscitation.
Immersion syndrome
 Due to sudden impact with very cold water and
causes death from cardiac arrest.
 Victims are young people with excess of alcohol.
 It also result from falling or diving with feet or
duck diving by the inexperienced swimmers.
 Loss of consciousness instantaneous and death
occurs in few minutes.
 Autopsy disclose non of the usual signs of
drowning.

Submersion of the unconscious

 Commonly seen if the victim is suffering from
disease like epilepsy,heart diseases and is drunk
or head injury during fall.
 Ballooning of the lungs may be absent.
 Formation of the foam my be negligible.
 Complete picture of death by drowning is not
found.

Secondary drowning/near-drowning
 Its mainly due to infection from inhalation of
contaminated water.
 Lung complications,oxygen lack,tired heart
muscle and cerebral edema.
 A victim look alert and breathing,may respond to
initial resuscitation.
 Late stage-respiratory distress,hypotension and
cardiac arrhythmia may cause death.
 Vicious cycle of drowning

 Deep inspiration

 Need for air

 Water enters
resp.passage

 Air driven out of lungs

Cough reflex
 Medico legal aspects
 Whether the death was due to drowning or
other cause?
 Length of time the body was in water.
 Whether it was accidental/suicidal/homicide?
 “Brides of the bath case”
 Postmortem findings
External findings
 Fine froth at the nose and mouth. It is white or
rarely blood stained leather-like, abundant and
increases in amount with compression of the
chest.
 Rarely the presence of weeds, mud etc in the
tightly clinched hand.
 Cutis anserina(Goose skin)

 Due to spasm of the erector pilae muscles and

due to exposure to cold water at the time of
death.
 Rarely seen in India.
 Skin appears granular and puckered with hair
standing on the end.
 Extremities are mainly affected.
 The skin of the fingers, palms and later the
soles of the feet may be wrinkled, bleached and
sodden.
 Due to osmotic action of water on thickened
epidermis.
 This immersion changes known as Hands and
Feet of a Washer-Woman.
 Internal findings
 Lungs & respiratory tract:-

 Airways filled with froth, sand, weeds etc found in

the water.
 Lungs are voluminous, edematous, with rib
markings.
 Paltauf’ hemorrhages seen.
 C/s:- Oozing out of blood stained frothy fluid and
ballooning of the lungs is known as
“Emphysema Aquosum”.
 Wt up to 2 kgs.
 Watery fluid transudates into pleural cavities
during putrefaction.
 Hydrostatic lung:- 2 meters depth-20min.
 Hemorrhages in the middle ear & mastoid air
cells.
 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.
 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.
 Cause of death
 Asphyxia
 Ventricular fibrillation
 Laryngeal spasm.
 Vagal inhibition.
 Exhaustion.
 Injuries.
 Fatal period 4-8min.
 Diagnosis of drowning

 Froth (abundant)
 Weeds & gravel/soil in hand.
 Voluminous lungs.
 Diatoms in tissues.