A State in which Body Lacks O2 or Defective Aeration of Blood Most important cause Mechanical Interference with Respiration

Deficient Oxygenation

ASPHYXIA 1

Reduced Pulmonary Blood Flow

Vicious Circle of Asphyxia

Capillary Dilatation

Reduced Venous Return To Heart

Pooling of Blood

(A)Non- Specific Parenchymal Degeneration of Tissues (B) Specific

1) Cyanosis (Bluish Discoloration)

Due to Decreased O2 tension in bld & Increased reduced Hb Becomes apparent when at least 5 gm of red. Hb is present Blood is Purple / Dark in color.

Bluish color is Marked over: areas of PM Staining, Lips,

organs with abundant capillary & venous bld (Lungs, Liver, spleen, kidneys)

2.

Increased Capillary Permeability Blood transudes into tissue spaces - Gelatinous Moistening of Organs.

Excess Fluid in Serous Cavities (Pleura & Pericardium)

Tissue Edema (Mediastinum & Lungs)

3)

Petechial Hemorrhage / Tardieu Spots

French Police Surgeon described them in 1866 Mechanism: Anoxia Blood Stasis - Increased Capillary Permeability

& Raised Intracapillary Pressure

Dark Red, Well defined, Round, Pin-head sized

3)

Petechial Hemorrhage / Tardieu Spots

Present at sites where capillaries are least supported

[Face, Conjunctiva, Meninges, Serous Surface of Heart & Lungs]

Pronounced in areas where Intracapillary pressure Rises rapidly - Above the Level of Neck Constriction

Better appreciated in

- Fair Skinned Persons &

- Fresh Dead Bodies

Presence of Tardieu spots - Not diagnostic of asphyxia May be found in:

Bleeding Disorders, Coronary Thrombosis, Electrocution, Poisoning,

Anticoagulant Therapy, Thrombocytopenia.

But in these cases - Distribution is Generalized. Absence of Tardieu spots - Does NOT Exclude Asphyxia

If Dead Body is suspended for Long time - Gravitation of blood in dependant body parts Over distension - Rupture of Capillaries. Present on Hands & Legs

Features:
1. 2. 3.

Larger Less Circumscribed Does NOT appear on - Serous Surface of Heart & Lungs

Cessation of Respiration due to Mechanical Force (violence)

1. 2.

Hanging
Strangulation
a. Ligature - Strangulation

b. Manual - Throttling
3. 4.

Suffocation

Drowning

Type of Violent Asphyxial Death in which body is suspended with Ligature around Neck resulting in Constriction of Air passages preventing Exchange of air between Lungs & Atmosphere

Based on Position of Knot 1. Typical Knot - At the Nape 2. Atypical Knot - At any site other than Nape Commonest site Angle of mandible or Mastoid Process

Complete Hanging Body is - Fully Suspended NO Body part touches the ground. Constricting force - Weight of body Incomplete / Partial Hanging Body is - NOT Fully suspended some Body part touches the ground. Some Body weight is transmitted to ground through the part touching the ground

Depends on - Effect of Neck Compression

If Pressure on Larynx is prominent

Symptoms of Asphyxia Predominate.

Respiratory Distress, Cyanosis,

Convulsions, Confusion,

Ringing in the ears.

Pressure on Jugular Vein

Severe Pain on the side opposite the knot Pt. Hemorrhages on Forehead, Eyelids & Conjunctiva

Pressure on Carotid Artery Immediate Unconsciousness Failure of Resp. Center (reduced blood supply to brain)

Asphyxia & Apoplexy - simultaneous pressure on Larynx & Jugular Vein

Asphyxia alone
Apoplexy alone Cerebral ischemia (pressure over carotid & vertebral A Vagal shock: Inhibition of heart due to vagal stimulation. Injury to medulla (Fracture dislocation of C2-C3 Vertebrae)

Force of constriction required to occlude:

Jugular Vein ------------2Kg.

Carotid Artery -----------3.5 Kg. Trachea -------------------15 Kg. Vertebral Artery ---------16.5 Kg. Fatal Period About 3-5 minutes Instantaneous - Fracture dislocation C.Vertebrae medulla injured

Occlusion of Carotid & Vertebral A - Fatal Period is shorter

Death due to Asphyxia - Fatal Period is longer

Post Mortem Changes

External Findings
Face - Pale, Congested, Swollen, Pt. hm. Eyeballs - Prominent due to congestion. Tongue - Protrude due to Pressure at its base Exposed part of Tongue - Dark Brown / Black

Salivary stains at Angle of Mouth opposite to the Side of Knot

(due to Dribbling of Saliva) Neck Stretched, Head - Inclined opposite to the side of knot

PM staining
Circumferentially on dependant parts of Arms & Legs, Face & Neck above the ligature. Bluish discoloration of Hands, Nail Beds & Lips. Tardieu Spots on Forehead, Eyelids & Conjunctiva.

Involuntary Discharge of Semen & Fecal matter.

Pressure Mark around the Neck. Abraded Contusion

Immediately after Death - Appears as Pale Groove.

Later - Yellowish Brown, Dry, Hard, Parchment like. Edges of Groove - Hyperemia & Pt. hm.

Situated - Above the level of thyroid cartilage & directed obliquely upwards along the line of mandible & Reaches Mastoid Process behind the ears. Non-continuous (Incomplete)

May be absent at - Back of Neck or Below the Knot.

1.

Ligature Material Tough & Narrow Prominent Mark

Soft & Broad Faint Mark

2.

Period of Suspension: Longer Period - Deep & prominent mark

3.

Degree of Suspension: Complete Hanging Mark is Prominent

4.

Body Weight :
Heavy Body: Mark is Prominent.

5.

If something intervenes between L. material & Neck -

LM is Less Prominent.
4.

LM also depends on Number of turns around the Neck

Larynx & Trachea - Congested.

Larynx, Trachea, Pleura - Petechial Hm

Internal Organs - Congested. S/C tissue underneath L. Mark - Dry, Pale, Firm & Glistening Platysma & Sternomastoid Ms - Injured

HANGING

Ligature Strangulation

Fracture Hyoid Bone Less common in Hanging than Throttling

Hyoid bone m/b fractured in persons > 40 yrs # Greater Cornua at Junction of Inner 2/3rd & outer 1/3rd

Fractured Ends - Displaced Outwards.

Carotid Arteries - Transverse Tear in Tunica Intima. Lymph Nodes Above & Below LM - Congested. Judicial Hanging - # Dislocation of C2-C3 / C3-C4

Ante-mortem or Post-Mortem ?

Ante-mortem Hanging
1. Dribbling of Saliva (Angle of Mouth) 2. Pt. Hm. & Ecchymosis underneath LM

3. Carotid A. - Tear in Tunica Intima,

- Extravasation of bld. within the vessel wall 4. Congestion & Hm of Lymph Nodes - Above & below LM

Suicidal, Homicidal or Accidental Hanging - Most commonly Suicidal Partial hanging - Almost always Suicidal

Signs of Struggle Absent, However self Inflicted injury/due to

convulsions may be present Homicidal Rare Lynching - Mob kills a person by hanging him publicly. Accidental Hanging Rare Fall from Height Victim get hanged on a Rope / Neck-tie Children - while playing (imitate Judicial Hanging)

Sexual Asphyxia / Auto-Erotic Hanging

Sexual perverts get Sexual gratification by Partial Asphyxiation Place a Noose around his Neck & Pulls other end of rope across a pulley (create Partial Asphyxia).

After gratification - releases the pull.

May become semi conscious and unable to release the pull - Dies due to Asphyxia.

Victim - Naked / Dressed in Female dress pornographic literature lying along.

Violent Asphyxial death caused by constriction of Neck by means other than body weight
Strangulation Throttling / Manual Strangulation Mugging Bansdola Ligature Hand

Elbow / Knee bent Stick

Cause of Death - Same as Hanging. Postmortem Appearance Asphyxia, Face - Congested & Cyanosed. Eye balls - Prominent. Tongue Protrudes, may be Bruised & Bitten. Tardieu Spots Abundant Sub Cunjunctival Hemorrhage.

PM staining - Dark & Prominent.

Injuries on other Body Parts - Due to Struggle

Neck injuries L Mark - At or Below Thyroid level Horizontal, Encircles the Neck Completely.

May be Absent at Back (due to hair / cloth)

May be Oblique If victim is Dragged with Ligature or Strangulated in Recumbent Position. S/C Tissues under LM Ecchymosis Neck Ms, Laryngeal Cartilages, Trachea, Carotid A. - Injured

(injury more extensive than Hanging)

Superior Horn of Thyroid Cartilage Commonly Fractured Hyoid Bone Fracture: Rare (Level of constriction is Below Hyoid) Hyoid Bone Fracture may be present if 1. Excessive force is used

2. Age more than 40 yrs

Broken Fragments are displaced outwards.

Homicidal - Most Common Knot At Back of Neck.

Mouth Gagged; Limbs Tied Signs of Struggle Present In Females Signs of Sexual Assault Infanticide - by passing Umbilical Cord around the Neck.
Suicidal Rare Knot usually at Front

Using such a Method - that ligature remains Tight without

any victims effort.

Accidental Rare
Neck tie / Scarf - Caught in moving machinery

Strap placed on Head may slip and compress the Neck

During Birth Umbilical Cord gets twisted around the Neck

PM Findings Signs of Asphyxia - Petechial Hemorrhages Asphyxial Signs are minimal in Cardiac inhibition due to Pressure on Carotid Sinus / Vagus N.

Tongue Protrude; may be Bitten

Eye Balls Prominent. Signs of Struggle Neck- Bruises - Oval & Larger (thumb) - Multiple & Smaller (Fingers)

Neck - Scratch marks (Multiple, Crescent shaped) Internal Findings S/C Tissues underneath Bruises & Nail Marks Hemorrhage Superior Horns of Thyroid Cartilage Fracture - More common

than Hyoid Bone Fracture.

Hyoid Bone Fracture common in persons > 40 yrs. Internal Organs Congested.

Homicidal - Almost Always Accidental - Rare - Sudden holding of neck - Vagal Inhibition

Suicidal - Extremely rare

- Self Throttling is Impossible - as victims becomes Unconscious - Hands Relax and Grip is released

Ante-mortem Throttling
1.

Bruises on the Neck

2.
3. 4.

Swelling of Tissues at and above the level of Compression

Bruises of Larynx, Trachea, Surrounding Muscles of Neck Fracture - Thyroid cartilage & Hyoid Bone - Hemorrhage at the Fractured ends.

5.

General Signs of Asphyxia

Mugging / Choke Hold Strangulation by Compressing Neck with Elbow / Knee Bent

Garroting

Victim is Strangled by throwing a

Ligature over the Neck from back and Tightening it quickly.

Loss of consciousness Rapid. It can kill a Strong man without any Sign of Struggle

Bansdola Neck is Compressed between 2 bamboo sticks (one placed in front & other behind the neck).

Sticks are tied at one end & a rope is passed at the other
end to bring the sticks together

Neck can also be compressed with one stick against the ground.

Exchange of Air between Atm. & Lungs is prevented by means other than Neck Constriction & Drowning Types:

1. Smothering
3. Gagging

2. Choking
4. Burking

5. Traumatic asphyxia

Smothering

Air exchange is prevented by - closure of Mouth & Nostrils PM Findings

homicide - Nail Marks & Contusions around mouth & nose

(Absent if a cloth is used)

Inner side of Lips & Gums- Abrasion, Contusion, Laceration

Fracture Nasal Cartilage. Bleeding from nose. Fracture dislocation of teeth. Signs of Struggle on other body parts

Accidental Smothering Abrasion, Contusion, Laceration around mouth & nose and Injury on inner side of Lips & Gums - May be present

Fracture Dislocation of Teeth.

Signs of Struggle - ABSENT In epilepsy - Tongue bitten & injury to other body parts Fall on Dust / Flour Traces of these materials present in Mouth & Nose

Smothering due to masochistic activity circumstances :-

Pornographic Literature, Exposed Private Parts, Wearing Dress of opposite sex Method used for Self Smothering

Suicidal Smothering
Pillow tied around Mouth & Nose Plastic Bag around Head Local effect of pressure but NO remarkable injuries.

Medicolegal Aspects of Smothering

Accidental (Most Common) Alcoholics / Epileptics Fall on Bed - Burry their Face in Bed - Fail to revert to favorable posture (Postural / Positional Asphyxia)

Accidental Smothering Child Birth - Placental Memb. adhere Mouth & Nose Overlaying - Mother rolls over the baby during sleep. Children - while playing with Plastic Bags.

Accidental Smothering Sexual perverts - Cover their head with plastic bags. Glue Sniffing (Solvent Abuse)

Victim re-breathes plastic bag contents (glue)

Glue solvents (Xylene) induce drowsiness Moisture accumulates in plastic bag Bag adheres to mouth & nose Breathing is blocked. Cause of Death Asphyxia or

Arrhythmias (Halogenated hydrocarbons in solvent)

Trauma to Chest, Abdomen / Back - Prevent Resp. movement E.g House Collapse, Stampede, Run over by Vehicle, Fall of Earth on Trench workers

PM Findings
Signs of Asphyxia. Deep Cyanosis of face, Numerous petechiae

Demarcation Line b/w discolored Upper Body and Normal Lower Body. Chest CompressionBack pressure-Displace blood in opp. Direction (From SVC to Head & Neck Veins - No valves in SVC) Valves in Subclavian Veins Prevents blood to enter Veins of Upper Limbs.

Pressure on ChestBlood Flows in Opposite Direction

Blood unable to cross the Valve

Blood cannot cross the Valves

Gets pooled in Head & Neck, Upper part of Chest

Face & Neck deeply Cyanosed Eyes Blood Shot Petechiae Scalp, Face, Neck & Shoulders Heart & Lung Injured

Ribs Fractured (Bilaterally at the angles)

Other Body parts - Injuried (depending on cause of Trauma)

Most Commonly Accidental Mothers Roll over a baby - Traumatic Asphyxia Can be Homicidal (Burking Phenomenon)

Lumen of Air Passage occluded by :Foreign Material / Pathology in Resp. Tract or Esophagus. Size of Object NOT Important Object smaller than lumen may cause spasm of Air passage

Cause of Death
Asphyxia, Vagal Inhibition, Laryngeal Spasm / Bronchospasm

PM Findings: Asphyxial signs. On Autopsy - Cause of Choking may be found. Chocking is most commonly Accidental May occur due to Foreign material in Air Passages

Inhalation of Vomitus due to Drunkenness, Anesthetic agent, Epilepsy or Coma. Regurgitation of Milk (Infants) Bleeding into Resp. Passages

(Cut Throat Injuries, Tonsillectomy / Tooth Extraction)

GAGGING
Cloth is pressed inside the mouth Gag blocks the mouth Blocks passage of Air coming from Nostrils to pass through Back of Throat.

Gag become moist due to Saliva - Obstruct cloth Pores Leads to complete Obstruction of Air Passage. Autopsy findings: Lips, Soft palate & Pharynx - Abrasion, bruise & lacerations.

Medicolegal aspects:
Mostly Homicidal (in Infants / children) Adult - Gagged to prevent shouting (Death is Accidental)

Choking - Obstruction of larynx due to Food Bolus Occurs in Cafe / Restaurant Sudden Collapse mimics Coronary Heart Attack. common in suppressed Gag Reflex- (Intoxication, Sedation)

Cause of Death
Asphyxia or Reflex Cardiac Arrest (Stimulation of Laryngeal N.)

Food bolus impacted in Larynx. Death is Accidental (Relatives can claim Insurance benefits) Timely treatment can save the person. Blow on Back / Sternum or pressure on Abdomen

(Heimlich Maneuver) Violent Coughing - Expels foreign body

Combination of Smothering & Traumatic Asphyxia. Burke & Hare used to kill the Victims and sell their body to Edinburgh Medical School for dissection. Burke used to Sit on Chest of inebriated Victim and

Cover Mouth & Nose with one Hand &

Push the Jaw Upwards with other hand, Hare pulled the Victim by holding the feet.

Passage of Air between Atmosphere & Lungs is prevented by Submersion of Body in Water / Fluid. Types : - 1) Typical 2) Atypical.

Typical drowning (Wet Drowning)

Typical Signs of drowning are present

Exchange of Air is blocked by :- Inhalation of Fluid It may be Fresh Water or Salt Water Drowning.

Water moves from Lungs to Bld Vessels Hyper-volemia & Hemodilution. RBCs Burst & Hemolysis occurs - Liberation of K++ Decrease in Na++ & Cl -

Vent. Fibrillation due to:

Anoxia, Hypervolemia, Hyperkalemia & Na ++ deficit

Fatal Period:

4 - 5 mts (Five)

Due to Hypertonicity of water -

Water moves from Bld Vessels to Lungs (Pulmonary Edema)

HypoVolemia, HemoConcentration, Crenated RBCs, Hypoxia Circulatory Shock - Cardiac Standstill Fatal Period - 8-12 mts.

Very little or NO inhalation of water into Air passages. 1. Dry Drowning 20% cases of drowning are due to Dry Drowning. Water enters Larynx - Sustained Laryngeal Spasm.

Very less Water enter Lungs

Cause of Death - Asphyxia.

2. Immersion Syndrome (Vagal Inhibition)

It may occur in:

Sudden Impact with very Cold Water.

Falling or diving in Water with Feet first.

Horizontal Entry into Water (Impact on Epigastrium)

Cause of Death: Vagal Inhibition

3. Submersion of Unconscious Victim is Semiconscious / Unconscious during fall in water (Epilepsy, Drunk, Head Injury or Dizzy due to HT,) Typical findings drowning Absent

4. Near Drowning / Sec. Drowning Syndrome

Complications or Sequelae of Drowning in victims who survive. Hypoxic encephalopathy & Secondary changes in lungs (fibrosing alveolitis) due to infection from inhaled water

Lungs - Rigid, Stiff & heavy but are NOT edematous. Microscopically lungs show ARDS Death occurs after some hours or days.

Cause of Death: Combination of Cerebral Hypoxia, Pulmonary Edema, Aspiration Pneumonitis,

Electrolyte Imbalance & Metabolic Acidosis.

Mechanism of Drowning
Non-Swimmer Falls in Water

Sinks due to

(1) Body Weight (2) Force of Fall

Rises to the Surface due to (1) Buoyancy of Body (2) Struggling Movements. Shouts for Help & Tries to Breath -

Water is Swallowed & Aspirated - cause Violent Coughing Air expels & its space is filled by water - Sp. Gravity of Body Increases Victim Sinks - Struggling Movements - Comes to Surface Again Sinks (due to inhalation of more water) This continues several times till he finally sinks

Sign / Symptoms
Auditory & Visual Hallucinations Return of Memory of Past Events.

Confusion
CAUSE OF DEATH: Asphyxia Vent. Fibrillation In Fresh water drowning.

Cardiac Standstill In Salt water drowning

Other causes of death:

1. 2. 3. 4. 5. 6.

Vagal inhibition Hypothermia, Sec. Drowning Syndrome, Injury to Head / other Vital organs during fall,

Cardiac failure,
Rupture of Cerebral Aneurysm.

Cause of Death can be (1) Drowning alone or (2) Combination of Drowning + Disease / Trauma

POSTMORTEM CHANGES:

External Changes Body & Clothes: Wet (if body is recently recovered from water) Skin - Wet, Cold & Pale (contraction of blood vessels)

Face - Cyanotic
Conjunctiva - Congested. PM Staining may be Absent (body constantly moving) When present it is confined to - Head & Neck, Front of Chest Rigor Mortis

Appears Early (muscular exhaustion)

Passes off Late (cold water)

Fine Froth from Mouth & Nostrils

White, rarely Blood Tinged, Lather like Abundant & Increases with Compression of Chest, Reappears on applying Pressure. Mechanism of Froth Formation

Water in Resp. passage acts as irritant Stimulates secretion

of mucus Air & Mucus Churned up (due to Violent Respiratory efforts) Fine Froth is produced

Froth is also Present in Poisoning

Opium, Cocaine, OPC & Barbiturates. In poisoning, froth is Neither so Fine, Nor so Copious & Persistent and Typical signs of Drowning are Absent.

Froth may be Absent in death due to Laryngeal Spasm.

Cadaveric Spasm may be present in localized group of Muscles (Hands) Weeds / Mud may be found tightly clenched in the Hands.

Cuties Anserina / Goose skin Skin appears Granular & Puckered with

Hair standing on the end.

Due to spasm of Erector Pillae muscles (due to Cold). Not diagnostic of Drowning. (also occurs due to Rigor Mortis)

Skin of Hand & Feet - Wrinkled, Bleached & Sodden. Due to Immersion in Water. Not Diagnostic of Drowning Indicates that Body remained in Water for some time.

Emphysema Aquosum (Ballooning of Lungs) Lungs - Voluminous, Water Logged, Bulge out on Opening Chest Cavity. Impression of Ribs on its surface &

Surface: Pale, Pitting Edema.

On Cut Section - Blood stained Fluid Oozes out. Tardieu Spots - Scanty - Bld Vessels get Compressed by Water filled Alveoli

Microscopic, Unicellular Algae, Present in Natural water (single or in colonies). Size varies from 10-80

Sillicacious Cell Wall - Resist Acid, Heat & Putrefaction

Drowning - Victim inhales water

Alveoli distend - Alveolar wall rupture

Water along with diatoms moves from Alveoli into Circulation and carried to Distant Organs (Brain, bones etc) - Detected Microscopically - Indicate Antemortem Drowning

1. Deceased did NOT drink this water just before drowning 2. All the species present in Test sample are also present in Control sample. 3. Different Species of diatoms in Test sample & Control

sample are in similar proportion.

Diatom test:
5-10 gm of Bone marrow kept in 10 ml conc. HNO3 + 0.5 ml conc. H2SO4 for 12 hrs Fluid is washed with DW and Centrifuged Repeatedly Final residue - Examined under Phase contrast Microscope

Diatoms resist Putrefaction - Test is valid in decomposed bodies

Diatom Test is Negative in

Postmortem Drowning & Dry Drowning.

Signs of Ante mortem Drowning 1. Persistent, Copious, Fine Froth - from Mouth & Nose. 2. Fine froth in Air passages. 3. Diatom Test - Positive.

4. Edematous Lungs.
5. Cadaveric spasm - Hands Tightly Clenched containing material present under water

Suicidal Drowning Signs of Struggle Absent. common in Indian females (Dowry death).

Victim may tie her hands / legs & attach weight before jumping
She may take Poison, Cut her throat before drowning

Dead body may be injured by sea animals Injuries will be postmortem NO Vital Reaction.

Homicidal drowning Common

- Body remains concealed for some time
-

It is carried to distant place.

PM Findings of drowning - Almost similar in Suicidal,

homicidal or accidental death

Circumstances of the Case helps to find the manner of death

Anoxic - Prevention of O2 from reaching Lungs Stagnant - Impaired Blood Flow resulting in Lack of oxygenated Bld transport to Tissues Anemic - Low Hb - Inability of Blood to carry O2 Histo-toxic Tissues Destruction Tissues cannot use O2

Cause of Death Vagal Inhibition

Signs No Asphyxial signs Death instantaneous

Slight Vagal Effect Slight Asphyxial Signs & Cyanosed face; Suffused Eyes Some Venous Constriction

Occasional Petechial Hm.

Few petechiae Pronounced Venous & Well marked Asphyxial Signs Resp. obstruction Deeply Cyanosed face, Blood Shot Eyes, Bitten Tongue, many petechiae in Scalp, Slight Arterial Constriction Conjunctivae & Face.

Moderate Venous Moderate Asphyxial Signs Constriction Cyanosed Face, Bulging Eyes, & Conjunctival Ecchymosis & Some Resp. Obstruction

Rope & knot may form Fixed Noose

Two Limbs of Rope near Knot are Pulled upwards Inverted V shaped Mark At apex of V - Mark is Absent (Head tilts away from the knot)

Running noose:
End of Rope is passed through the loop (slip knot) Noose tightens in Horizontal plane LM - Horizontal. - additional Vertical mark (due to suspending ligature)

Gettler Test
In a living person Cl level of Bld. In Left & Right chambers of Heart - Equal According to Gettler In Fresh Water Drowning

Hemo-Dilution of Right side Chambers - occur Early

Cl level of blood in Right side is 50% of Normal value (Normal Value = 600mg/100ml)

In Salt Water Drowning Hemo-Concentration occurs on Left side First 30-40% increase in Cl level in Left Chambers of Heart

Gettler Test is NOT Significant if:

1. Victim had Patent Foramen Ovale, or VSD or 2. Drowning in Water with Saline Conc = Blood 3. Advanced Stage of Decomposition