2. CONTENTS:
1. Introduction
2. Suffocation:
a) Definition
b) Types
c) Explanation
d) Recent Updates
e) Medico legal importance
3. Drowning:
a) Definition
b) Types
c) Explanation
d) Recent Updates
e) Medico legal importance
4. Discussion
5. Summary
6. References
3. 1. Introduction:
Suffocation and Drowning are a type of mechanical asphyxia.
Mechanical asphyxia is a broad term in which enough external
pressure is applied to the neck, chest or other areas of the body, or
the body is positioned in such a way that respiration is difficult or impossible.
In 2015, about 9.8 million cases of unintentional suffocation occurred which resulted in 35,600
deaths.
SUFFOCATION
DROWNING
The word ‘Asphyxia’ is from Ancient Greek means “without” and
‘sphyxis’ means “squeeze” (throb of heart).
Asphyxia can cause coma or death.
According to WHO drowning is the major public health problem worldwide.
It is the 3rd leading cause of unintentional injury related to death.
About 1,50,000 person die from drowning every year around the world.
4. 2. SUFFOCATION
a) Definition:
It is a general term to indicate that form of asphyxia, where the entry of air to the lungs is
prevented by any means other than pressure on the neck or drowning.
Environmental suffocation: Death from hypoxic may usually result from breathing in a vitiated
atmosphere.
The death occurs due to lack of oxygen in the atmosphere.
The most commonly found suffocating gases in the atmosphere are CO2 and methane gas.
b) Types:
1. Smothering
2. Gagging
3. Choking
4. Overlaying
5. Traumatic asphyxia
6. Burking
5. c) Explanation:
1. Smothering: This is a form of asphyxia which is caused by closing the external respiratory
orifices either by the hand or by the other means, or blocking up the cavities of the nose and
mouth by the introduction of foreign substances, such as mud, paper, cloth, etc..
Autopsy Findings:
• External: Obstruction applied with skill may not leave any external sign of violence
especially in young and old age.
When pressed into pillow, the skin around the nose and mouth may appear pale or white
due to pressure.
When orifices are obstructed by hand, there may be scratches, nail marks on the soft parts
(lips, tongue, gums) of the victim’s face.
Often, death caused due to obstruction from face enclosed in a plastic bag are pale, with
few petechial haemorrhage in the eyelid and pricardium or there may be no asphyxia sign.
6. • Internal: Slight acute emphysema and oedema of the lungs with scattered areas of atelectasis,
petechiae and congestion are seen.
Mucus may be found at the back of the mouth.
Blood stained frothy fluid is present in the airpassage.
If the person is buried alive, earth and sand will be found in the respiratory tract.
Smothering done by (A) pillow ; (B) hand
7. 2. Gagging: This is a form of asphyxia which results from forcing a cloth (gag) into the mouth,
sufficiently deep to block the pharynx or closue of mouth and nose by a cloth or similar material, which
is tied around the head.
Initially, the airway may be clear through the nose, collection of saliva, mucus with oedema of
pharynx and nasal mucosa, which then causes complete obstruction.
Congestion of the face and fine petechiae of face, sclerae and conjuctivae may be present.
In injuries to the nose and mouth, blood may seep into the back of the throaat and clot.
Gag obstructed in the airway deep in the pharynx.
8. 3. Choking: This is a form of asphyxia caused by an obstruction within the airpassages,
usually between the pharynx and bifurcation of trachea.
Mechanism of Choking: Intially, there is a stridor, respiratory distress, coughing and inability of
the victim to speak. This is followed by a rapid, deep inhalation which causes the foreign body to
pass further down the airway. Laryngospasm occurs, followed by vagal stimulation, leading to
arrhythmia, apnea ad death.
Causes of death:
Autopsy findings: Thickening of epiglottis and jelly like oedema and inflammed tissue will be
found obstructing the entrance to larynx.
Mucus may be found at the back of mouth and throat.
Lugs shw intense inter-alveolar oedema and congstion, haemorrhage of different sizes.
Vagal inhibition is the common cause.
Asphyxia.
Laryngeal spasm.
Delayed death may result from pneumonia, lung abscess or bronchiectasis.
9. CAFE CORONARY: This is a condition of accidental choking where a bolus of food
produces complete obstruction of the larynx. it is so called because it mimics heart attack, and is
usually seen in intoxicated person havig food.
Clinical features: Victim who was apparently healthy, suddenly, turns blue, coughs violently,
collapses and dies while eating at the dining table.
Treatment for Choking: A blow on the sternum may cause coughing which may expel the
obstructed food.
If there is difficulty in breathing and cyanosis give first aid by applying
pressure on the abdomen tillthe patient recovers or loses consciousness.
The foreign body should be removed from the hypopharynx with middle
or index finger or forceps.
Treatment for choking
Autopsy findings:- The foreign body will be found in the mouth, larynx or
trachea and other signs of asphyxia will be found.
10. 4. Overlaying (Compression Suffocation): This is a type of asphyxia which is caused due to
compression of the chest, nose, mouth, so as to prevent breathing.
Common example is when the mother or any older person (usually under the influence of
alcohol) sleeping next to the infant rolls over or crushes the infant which occludes the airway.
Autopsy Findings: Face, nose, and chest of the victim may appear compressed and pale, and the usual signs of
asphyxia will be seen.
The nostrils are filled with froth, which may be blood stained which may stain the pillow/garment.
Death may occur from neurogenic cardiac arrest.
Overlaying where an elderly rolls over an infant
11. 5. Traumatic asphyxia (Crush asphyxia/ Perthes Syndrome): This is a type of asphyx
respiratory arrest due to mechanical fixation of the chst by an unyielding substance or object, so that the normal
movements of the chest wall are prevented.
Causes:
Due to house collapse accidentally or in wars or earthquakes.
Run over by a vehicle or overturned vehicle.
Collapse of wall inside a mine or cave in bunkers of sand/grain.
Stamped by crowd, running in pans, due to outbreak of fire in public gathering.
When held between the buffers of 2 bogies of a train.
Burying the person in sandy soil upto the neck.
Occasionally, from indirect compression, when th body is subjected to force in such a
manner that
his thighs and knees are drivn against his chest, the so called “jack-knife” position.
12. Autopsy findings:- An intense congestion, petechial and confluent
haemorrhages and cyanosis of deep purple or purple-red colour of the head,
neck, and upper chest above the level of compression.
Pallor is seen at the level of the collar of the shirt,
into the folds or creases in the garments, buttons,
braces,etc.
The face, lips and scalp may be swollen, congested
and dotted with petechiae and ecchymoses.
Fractures of the ribs, and other bones may be found.
The bleeding in the eyes may form blood blisters
which bulge through the eyelids and may occupy the
whole of the sclera.
Petechial haemorrhages may be seen over the
surface of the cerebral hemispheres.
The lungs are usually dark, heavy and have
subpleural petechial haemorrhages.
Internal organs are congested.
Traumatic
asphyxia
findings
13. Burking:- Burking is a method of homicidal smothering and traumatic
asphyxia.
William Burke and William Hare, made their living by digging up
bodies from graveyards and supplying them to the medical schools
for dissection.
Later they killed 16 persons during 1927-28 in Scotland and sold
their bodies to Dr. Robert Knox for use as specimens in his
anatomy classes in Edinburgh Medical School .
This came to be known as the case of the Body snatchers (West
Port murders).
Method: A victim was invited to their house and
given alcohol. When drunk. he was thrown on the
ground. Burke would kneel or sit on the chest and
close the nose and mouth with his hands and Hare
used to pull him around the room by the feet till he
is dead.
Burking done by William burke and William hare
14. [d]. Recent updates:-
Due to prolonged use of mask people face problems in breathing like
suffocation, easy fatigability, etc. The study concludes that most of the
population of North Gujarat that wears their mask for more than 4
hours/day are facing some problems due to prolonged wearing of mask.
People face problems like inability to do heavy work while wearing mask,
suffocation, change in breathing rate, etc [1].
It is difficult task for forensic experts and scientific community to find out
the exact cause of increasing number of unnatural violent asphyxial death.
Suffocation deaths cannot be attributed to a single entity but to a spectrum
of smothering, choking, traumatic/positional asphyxia, entrapment/
environmental types of deaths, study proved that alcohol has played a key
role as circumstantial evidence on suffocation deaths; alcohol played a
significant role in mainly in deaths due to choking [2].
15. Safe sleep environments can reduce infant suffocation deaths. Increased
knowledge about the characteristics of suffocation deaths can help inform
prevention strategies by targeting highest- risk groups [3].
Fibreoptic bronchoscopy should be done in all patients with suspected
foreign body inhalation who either are asymptomatic clinically or lack
radiological support.Fibreoptic bronchoscopy not only helps in visualizing
inhaled foreign bodies in suspected inhalation cases but also helps in ruling
out inhalation in patients were parents are suspicious of foreign body
inhalation but patient are either asymptomatic or lack clinical and
radiological support [4].
16. [e] Medico-legal importance:-
Accidental smothering is the most fatal smothering.
Accidental smothering is common in alcoholics or epileptics, who may fall or roll over in a
heap of mud or such other material.
Children may get smothered while playing with plastic bags over face or head.
After birth, infant may die from smothering if he is born with membranes covering the
nose and mouth (cul-de-sac).
Suicide by smothering is impossible.
Homicidal smothering is possible if the victim is intoxicated from drink or drugs.
Gagging is almost always homicidal and the victim is usually infant or elderly person.
Gagging is usually done to prevent the victim from shouting for help, death is usually
unintentional.
The gag should be examined for buccal epithelial cells.
Most choking deaths are accidental Suicidal, homicidal choking are rare.
Accidental choking deaths are more common in children below 5yrs of age.
Overlaying is purely accidental in nature.
These case are likely to be the victims of sudden infant death syndrome (SIDS).
It may be also a case of infanticide.
17. 3. DROWNING
[a] Definition:-
DROWNING is the form of asphyxial death where, obstruction of
respiratory passages with fluid caused by complete or partial submersion in
water or other fluids.
[b] Types:-
18. [c] Explanations:-
CAUSES OF DEATH ASSOCIATED WITH DROWNING
• Asphyxia – wet drowning
• Laryngeal spasm – dry drowning
• Vagal inhibition - immersion syndrome
• Injuries
• Ventricular fibrillation
• Post hypoxic encephalopathy- secondary drowning
• Complications of drowning- secondary drowning
20. 1. Fresh water drowning:-
• Water is hypotonic to blood
• The blood get hemodiluted with water
entering into the circulation from lungs
• RBCs swell and rupture
• This causes hyperkalemia leading to cardiac
arrhythmia
• Lungs appear big and voluminous
2. Salt water drowning:-
• Water is hypertonic to blood
• The circulation is hemoconcentrated as
water leaves vascular circulation
towards lungs
• Lungs develop massive pulmonary
edema.
• Such lungs are termed heavy and boggy.
21. GENERAL FINDINGS
• Clothing: wet
• Skin : wet, cold, pale, cutis ansernia
(goose flashing of skin)
Washer woman’s hand and feet:-
• 2 to 4 hours : wrinkling and soddening
• 4 to 8 hours : bleaching of epidermis
• 48 hours : peeling of cutical from palm
and sole
• 3 to 4 days : skin can be peeled off like
a glove
22. SPECIFIC FINDINGS SUGGESTIVE OF ANTEMORTEM DROWNING
1. Macroscopic findings :
2. Microscopic findings: Diatoms test :
Diatoms are the unicellular algae having cell wall made of
silica . Finding of diatoms from distant body tissue, brain,
bone marrow, liver, spleen, kidney etc . The presence of
similar type of diatoms from water of drowning is the
surest sign of antemortem drowning.
• Cadaveric spasm of drowning.
• Frothing from nostrils and mouth – fine lathery and
tenacious
23. LUNG APPEARANCE IN DROWNING
• Emphysema aquosum : paltauff hemorrhage- present on
surface of lung, due to ruptured alveoli. Seen in antemortem wet
drowning.
• Edema aquosum : seen in post mortem drowning.
• Fresh water drowning : lungs are big and voluminous.
Salt water drowning : lungs are heavy and boggy with deep rib
impression Mark‟s
➢FATAL PERIOD
• Fresh water drowning : 4 to 5 minutes
• Salt water drowning : 8 to 12 minutes
➢Getlers test:- It is done to distinguish between fresh water and salt water
drowning.
• It is a biochemical test based on blood changes in the heart.
• Fresh water : left sided chloride concentration is 25% lesser than right side.
• Salt water : left sided chloride concentration is 25% elevated than right side.
24. Differences between ante-mortem and post-mortem drowning
Characteristics features Ante-mortem drowning Post-mortem drowning
1. Defination Drowning had occurred during life,
usually accidental or suicidal.
Dead body thrown into water after
killing, homicidal mode of death.
2. Incidence 80% 20% of all drowning cases.
3. Evidence of struggle/ injury on
the body
Absent Present
4. Fine, white, leathery persistent
froth around the mouth and nostrils
Present Absent
5. Cadaveric spasm Presnt Absent
6. Fine white froth in the air
passage
Present Absent
7. Lungs Bulky & oedematous which exude
copious, frothy blood-stained fluid
on section.
May be bulky & oedematous but
no escape of blood-stained fluid on
section.
8. Stomach and intestine Shows presence of water, mud or
weeds including diatoms.
No such foreign objects ever
present
25. Characteristics features Ante-mortem drowning Post-mortem drowning
9. Haemorrhage in the middle
ear cavity
May be present Never found
10. Diatom test Positive ( diatoms <20um enters
the circulation to reach other body
organ).
Negative (except if a dead body is
deposited in water or when the
death in water is not due to
drowning, then though the diatoms
may be able to reach the lungs by
passive percolation but not reach
to the distant organs because of
absence of circulation.
26. [d] RECENT UPDATES
• The latest WHO Global health estimates indicates that almost 236000 people lost
their lives to drowning in 2019.
• Over 50% of these death occur among those aged under 30 years.
• Drowning is the 6th leading cause of death worldwide for children aged 5 to 14 years.
• Over 90% of drowning death occur in low and middle income countries.
• World Drowning Prevention Day, declared through the April
• 2021 UN General Assembly Resolution “Global Drowning Prevention Day” held
annually on 25th July.
• This global advocacy event serves as an opportunity to highlight the tragic and
profound impact of drowning on families and community and offer life saving
solution to prevent it.
27. [e] MEDICO LEGAL IMPORTANCE OF DROWNING
It is a quit common to encounter cases of drowning in India.
Middle ear findings :
In case of antemortem drowning there will be water in the middle ear.
Features Suicidal Homicidal Accidental
1. Incidence Highest, being attempted
by non- swimmers
Rare, except in infants
and kids.
Common, mostly in non-
swimmers, at bathing
places, common in
alcoholics/ drug addicts
in the bath tub.
2. Marks of violence on
the body
Not found Present Absent
3. Clothing on the body Complete, the lower end
of clothes folded flat not
to expose nakedness
after death (specially in
female)
Present, body attached
with heavy weight
Usually only a single
piece of cloth or
swimming costume
present.
28. 4. DISCUSSION
• Asphyxia refers to the condition of oxygen deprivation, while asphyxiated
means a person has died due to oxygen deprivation.
• Asphyxiated is used to describe how someone has died.
• The concentration of oxygen in air is about 21%, nitrogen 79% and carbon-
dioxide is 0.033%.
• An oxygen concentration of 16% or less is dangerous.
• With 5% concentration, consciousness is lost rapidly and death occurs within a
few minutes.
• According to WHO 7% of all death each year are due to unintentional drowning
worldwide.
• Large number of drowning death are also associated with floods on world wide.
• Alcohol is a risk factor for drowning among adults and adolescents.
29. 5. SUMMARY
• Suffocation is a type of asphyxia death where the entry of air to the lungs is
prevented by any means other than pressure on the neck or drowning.
• Suffocation is of 6 types- smothering, gagging, choking, overlaying, traumatic
asphyxia and burking.
• Lack of oxygen causes suffocation.
• The most commonly found suffocating gases in the atmosphere are CO2 and
methane gas.
• Drowning is a form of asphyxial death where air entry into lung is prevented due to
submersion of mouth and nostrils into water or any fluid medium.
• Complete submersion is not necessary because the process will be completed even
if the nose and mouth are submerged.
• Hence knowledge about medico legal importance of suffocation and drowning
death is needed to make a proper and accurate determination of the cause of death.
30. 6. REFERENCES
Suffocation:-
1. Ankush Patel, Dr. Jayesh Thakrar, "Effects of Wearing Mask on Breathing in Population of North
Gujarat during COVID 19: A Survey", International Journal of Science and Research (IJSR),
https://www.ijsr.net/get_abstract.php?paper_id=SR21413193532, Volume 10 Issue 4, April 2021, page
709 – 712, (12 december 2021).
2. B. Lakshmi Prasanna, Bharath Kumar Reddy, D. Sridhar, Nishat Ahmed Sheikh, “Deaths due to
Suffocation: A Comprehensive Study”, Indian Journal of Forensic Medicine and Pathology,
https://www.researchgate.net/publication/314452782_Deaths_due_to_Suffocation_A_
Comprehensive_Study, Volume 9 Number 2, April-June 2016, page 41-46, (12 december 2021).
3. Alexa B Erck Lambert, Sharyn E Parks, Carri Cottengim, Meghan Faulkner, Fern R Hauck, Carrie K
Shapiro-Mendoza, „Sleep-Related Infant Suffocation Deaths Attributable to Soft Bedding, Overlay, and
Wedging‟, pediatrics, https://pubmed.ncbi.nlm.nih.gov/31010907/ , may 2019: page 1, (12 december
2021).
4. Baba Aijaz Khaliq, Owais Makdoomi, Zubair Ah Lone, Javed Iqbal, Showkat Ahmad Showkat, "Role
of Fibre Optic Bronchoscopy in Foreign Body Inhalation in Children", International Journal of Science
and Research (IJSR), https://www.ijsr.net/get_abstract.php?paper_id=ART20181411, Volume 7 Issue 4,
April 2018, page 352 – 354, (12 december 2021).
31. 5. Dr.K.S.Narayana Reddy and Dr.O.P.Murty, Essentials of Forensic
Medicine and Toxicology,Mechanical asphyxia, 34th edition-
2017,Jaypee medicine publishers, page-336,337,338,339,340,341
6. Nagesh Kumar G Rao, Textbook of Forensic Medicine and Toxicology, Asphyxial death, 1st edition, 2003,
Jaypee Brothers medical publishers, page-166,167,168,169 .
7. Wikipedia, Asphyxia, 23 october 2021, URL- https://en.wikipedia.org/wiki/Asphyxia
8. Kirsten Nunez, What is asphyxiation?, 1 june 2021, URLhttps://www.healthline.com/health/asphyxiation
Drowning:-
1. Dr.K.S.Narayana Reddy and Dr.O.P.Murty, Essentials of Forensic Medicine and Toxicology,Mechanical
asphyxia, 34th edition- 2017,Jaypee medicine publishers, page-300,341,350
2. Nagesh Kumar G Rao, Textbook of Forensic Medicine and Toxicology, Asphyxial death, 1st edition, 2003,
Jaypee Brothers medical publishers, page-169-176
3. International ayurvedic medical journal, volume 7, issue 7,July 2019.
Research updates:-
1. The new England journal of medicine, may 2012,David szpilmen,host berens,Anthony handley.
2. The world health organization, global report on drowning prevention a leading killer. Geneva,world health
organization 2014.
