ORIGINAL ARTICLE
Asphyxial Deaths
A Retrospective Study and Review of the Literature
Derya Azmak, MD
Abstract: An increasing death rate as a result of violence constitutes
a large group in medicolegal autopsies. Specially, deaths due to
asphyxia are one of the most important causes in violence deaths.
During the 21-year period from January 1984 to October 2004,
there were 134 asphyxial deaths autopsied by the Department of
Forensic Medicine, Trakya University, Edirne, Turkey. Asphyxial
deaths comprise 15.7% of all forensic autopsies; 20.8% of the cases
are aged between 30 and 39 years, and the average age was 41.9
years. Males constitute 79.8% of all the cases.
The most frequent method of asphyxiation death is hanging (56
cases, 41.8%), followed by drowning (30.5%) and carbon monoxide
poisoning (8.2%). More violent methods, such as ligature or manual
strangulations, constitute 2.9% and 2.3% of all asphyxial deaths,
respectively. Although it was varying according to the methods of
asphyxiation, suicide was found to be the manner of death in the
majority of the cases.
Key Words: method of asphyxiation, manner of death, cause of
death, autopsy
(Am J Forensic Med Pathol 2006;27: 134 –144)
E dirne is one of the biggest cities in Trakya region in the
northwestern part of Turkey. In this region, all medicole-
gal autopsies have been performed by the Department of
Forensic Medicine, Medical Faculty, Trakya University,
Edirne, Turkey.
Asphyxial death is a common incident in forensic
practice, and determination of the manner of death is very
important. The manners of death can be accidental, suicidal,
homicidal, or natural due to main methods of asphyxia. In
such deaths, autopsy plays a major role to solve the case; the
scene investigation and collection of samples are also of
importance.1
Asphyxial deaths are divided into different methods,
such as strangulations (hanging, manual, ligature), suffoca-
tions (environmental, smothering, choking, mechanical, suf-
Manuscript received May 5, 2005; accepted January 26, 2006.
From the Department of Forensic Medicine, Trakya University, Medical
Faculty, Edirne, Turkey.
Reprints: Derya Azmak, MD, Department of Forensic Medicine, Trakya
University, Medical Faculty, Edirne 22030, Turkey.
Copyright © 2006 by Lippincott Williams & Wilkins
ISSN: 0195-7910/06/2702-0134
DOI: 10.1097/01.paf.0000221082.72186.2e
134 The American Journal of Forensic Medicine and Pathology • Volume 27, Number 2, June 2006
focating gases), chemical asphyxia (carbon monoxide !CO",
hydrogen cyanide, hydrogen sulfide), and drownings.1 Addi-
tionally, in some cases, the victim dies as a result of the
combination of different mechanisms of asphyxia. A case
study from Romania2 indicates that a victim was killed by 3
different mechanisms of asphyxia: smothering with the hand,
manual strangulation with the other hand, and traumatic
asphyxia by thoracic compression with the knees.
Autoerotic asphyxial deaths,3– 6 positional asphyxial
deaths,7,8 and neck holds9 are some other reported unusual
forms of asphyxial deaths in forensic practice.
The purpose of this study is to investigate some features
of asphyxial deaths in the Trakya region of Turkey and to
compare them with other worldwide studies on asphyxiation.
MATERIALS AND METHODS
This study is based on a retrospective investigation of
asphyxial deaths that were autopsied by the Trakya Univer-
sity, Medical Faculty, Department of Forensic Medicine,
Edirne, Turkey. In the period between January 1984 and
October 2004, 1206 autopsies were performed; 852 of those
were medicolegal autopsies. From these, a list of 134 cases of
asphyxia was established.
This department performs forensic autopsies, including
Edirne, Tekirdağ, and Kırklareli cities requested by the dis-
trict prosecutors in the Trakya region. Due to the limited
number of forensic experts in Turkey, scene investigations
are sometimes performed by different practitioners. A com-
plete autopsy is performed in each case. Both blood samples
taken from the left chamber of the heart and tissue samples
are collected for systemic toxicologic analysis (STA) accord-
ing to regular procedures. All samples are sent to the Toxi-
cology Section of the Council of Forensic Medicine, Istanbul,
to determine drugs, CO, and ethanol/methanol.
Histopathologic examinations of all cases are done by
the Department of Pathology, Trakya University, Medical
Faculty, Edirne. In addition, the scene investigation files of
the prosecutors were screened to obtain additional data in
all cases.
Sudden natural deaths, deaths due to violence other
than asphyxial causes, all kinds of poisons other than CO and
methane, nonlegal hospital deaths, and negative autopsies
were excluded from this study. The remaining cases were
analyzed in terms of age, gender, the methods of asphyxia-
tion, the manners of death, the places and the time of year, the
The American Journal of Forensic Medicine and Pathology • Volume 27, Number 2, June 2006
locations and the characteristics of wounds on the body, and
the toxicologic-histopathologic findings.
RESULTS
General Findings
During the period of 21 years, between January 1984
and October 2004, 1206 autopsies were performed; 852
(70.6%) of those 1206 cases were forensic cases. For the
study group, 134 (15.7%) cases of asphyxial deaths were
separated from all forensic autopsy records.
In this group, there were 107 males (79.8%) and 27
females (20.2%). The ratio of male to female was found to be
3.9:1. The races of the victims were from Turkey (97.7%,
n # 131), from Middle East (1.4%, n # 2), and from Europe
(0.9%, n # 1).
The ages of the cases in this study include children
from day 6 after birth to adults aged 97 years. The mean age
of the cases is 41.9 years. The age group of 30 –39 years
accounts for 20.8% of the cases, followed by those 20 –29
years (19.4%) and 40 – 49 years (14.1%); 53.2% of the cases
constitute the age group of 20 – 49 years (Fig. 1).
Most of the deaths (35.8%, n # 48) occurred in sum-
mer, 35 deaths (26.1%) in spring, 33 deaths (24.6%) in
autumn, and 18 deaths (13.5%) in winter.
When seasonal variations according to the methods of
asphyxiation are examined, it is observed that hanging deaths
mostly occur in summer and spring, drowning deaths in
summer, and CO poisoning deaths in winter. But there are no
significant seasonal differences between the other methods of
asphyxiation.
Table 1 shows the detailed distribution of the cases
according to the methods of asphyxiation, the manners of
deaths, and gender. In the study period between 1984 and
2004, there were no natural asphyxial deaths, autoerotic
asphyxial deaths, or positional asphyxial deaths.
Methods of Asphyxiation in Detail
Hanging Deaths
In this study, the most common method of asphyxiation
was hanging (56 cases, 41.8%); 83.9% of those cases were
male. The age ranged from 14 to 97 years, with a mean of
41.6 years. Most of the cases were in the age group of 25–30
years. Most of the deaths occurred in summer. According to
STA, ethanol was detected in 5 cases (8.9%), plasma con-
centration being between 29 mg/dL and 93 mg/dL. There was
FIGURE 1. Age distribution of asphyxia-related deaths.
© 2006 Lippincott Williams & Wilkins
Asphyxial Deaths
no evidence of violence occurring before the cases hanged
themselves. Only 2 cases had small bruises. Seventy-six percent
of the cases hanged themselves indoors, mostly at home.
In the records, a ligature mark on the neck was well
described for all cases, and the knot of the loops was found to
be tightly placed under the chin in 85.7% (n # 48) of the
cases. In 37 of 56 cases (66%), the suspension point was
occipitally, 14 of 56 cases were laterally (right, left), and 5 of
56 cases were frontally localized. In these series, 26 of 56
victims (46.4%) had hyoid bone fractures, 10 of 56 victims
(17.8%) had thyroid cartilage fractures, and 7 of 56 cases
(12.5%) had both hyoid bone and thyroid cartilage fractures.
Gross bleeding in the neck muscles and other soft tissues was
seen in 51.7% of the cases (n # 29). Fifty-four victims were
found to be suspended freely, and the remaining 2 were
incompletely suspended. All of the cases accepted suicide,
according to the knowledge of the scene investigation files
and autopsies.
Drowning Deaths
The second largest method of asphyxiation was drowning
(41 cases, 30.5%); 90.2% of the cases were male. The age
ranged from 6 to 94 years, with a mean of 42.7 years. Most of
the deaths occurred in the summer months. STA was performed
on only 8 cases, and ethanol was detected in 2 cases, plasma
concentration being 196 mg/dL and 242 mg/dL.
Of 41 cases, 30 cases (73.1%) were found in the river,
5 cases (12.1%) in the sea, 3 cases (7.3%) in a well, 2 cases
in a dam, and 1 case in a small ditch.
A mushroom of foam was observed around the nose
and mouth in 14 cases (34.1%). In drowning deaths, the
average weight of both lungs with the amount of pleural
transudate was 1.136 g, which ranged between 380 g and
2050 g.
The distributions according to the manner of death
show that accidents accounted for 78.1% (n # 32) of all
cases, suicides such as jumping from a bridge to the river
accounted for 17.1% (n # 7), and homicidal cases accounted
for 4.8%. Of the 32 accidental drowning cases, 2 victims
drowned in a motor vehicle accident fall from a bridge to the
river. Of 2 homicidal drowning cases, all had severe blunt-
force injuries all over their bodies. Autopsy and prosecution
findings indicate that the perpetrators applied severe blunt
force to the decedents, who then inhaled water in one case
from a river and from the sea in another. In these 2 cases, the
death was attributed to the combined effects of drowning and
severe blunt-force injuries.
CO Poisoning Deaths
The third method of asphyxiation was due to CO (11
cases, 8.2%); 54.5% of the cases were male. The age ranged
from 15 to 82 years, with a mean of 50 years. STA was
performed on all cases, and blood carboxyhemoglobin
(COHb) saturations were found in the range of 49%– 61%.
There was only 1 case (COHb was 52%) in this category,
with 279 mg/dL blood ethanol level.
135
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TABLE 1. Methods of Asphyxiation, Gender, and the Manners of Death

Case Gender Manners of Death
Methods of Asphyxiation No. % Male Female Accident Suicide Homicide
Hanging 56 41.8 47 9 0 56 0
Drowning 41 30.5 37 4 32 7 2
CO poisoning 11 8.2 6 5 11 0 0
Compressive asphyxia 7 5.3 4 3 5 0 2
Environmental suffocation 5 3.8 5 0 5 0 0
Choking and aspiration 4 2.9 3 1 4 0 0
Ligature strangulation 4 2.9 3 1 2 0 2
Manual strangulation 3 2.3 1 2 0 0 3
Smothering 3 2.3 1 2 0 0 3
Total 134 100 107 27 59 (44%) 63 (47%) 12 (9%)

Ten of 11 deaths occurred in the winter months. Nine of
those 11 cases were found dead in the bathroom, using a
shower connected with the gas water heater or charcoal-
heating devices (in one event, both an 82-year-old male, with
279 mg/dL ethanol, and a 73-year-old female; in the other
event, both a 63-year-old male and a 62-year-old female were
found dead). One of 11 cases was found dead at a bakery
shop, and 1 case was found in the kitchen due to kitchen fire
fumes.
In 9 of 11 cases, gross findings such as cherry-red livor
of the skin, blood, and viscera were significant and supported
the CO poisonings. The manners of death were accident in all
cases.
Compressive Asphyxial (Chest-Abdomen
Compression) Deaths
In this category, there were 7 cases (5.3%), 4 of which
were males. The age ranged from 5 to 77 years. The manners
of death showed that accidents accounted for 71.5% (n # 5)
and homicides for 28.5% (n # 2) of all compressive asphyx-
ial deaths. Table 2 shows the descriptions of compressive
asphyxial deaths cases in detail.
Environmental Suffocation Deaths
In this category, there were 5 cases (3.8%), all being
males. The age ranged from 17 to 39 years. The manner of
death was accident in all cases. In 1999, 1 worker and in
2003, 3 workers died in an underground coal mine accident
by staying behind a cave-in. All of the 4 had slight abrasions,
and STA was negative for drugs, ethanol, and COHb. Table
3 shows the descriptions of these deaths in detail.
Ligature Strangulation Deaths
In this category, there were 4 cases (2.9%), 3 of which
were females. The age ranged from 1.5 to 58 years. Fifty
percent of the cases were homicide, and 1 of the female case
had vaginal sexual assault. Intravaginal swab samples were
positive for the presence of spermatozoa by microscopic
examination, and there were acute injuries involving hymenal
tears and bruises. Table 5 shows the descriptions of these
ligature strangulation deaths in detail.
Manual Strangulation Deaths
During a 21-year period, there were only 3 manual
strangulation deaths, 2 of which were females. One male case
had severe body trauma that was antemortem. The manner of
death was homicide in all cases. Table 6 shows the descrip-
tions of manual strangulation deaths in detail.
Smothering Deaths
In this category, there were only 3 smothering deaths, 2 of
which were females. One female victim was 3 years and 1 male
victim was 11 years old. One female case had sexual assault
with vaginal penetrating findings, including lacerations of the
labia minor and major, hymenal tears, and bruises. But anogeni-
tal swab samples were not positive for the presence of sperma-
tozoa by microscopic examination. Another smothering case had
severe child abuse findings before his death. There were multiple
and large fresh bruises on the entire body, blunt-force head
injury findings involving lacerations, bruises, and abrasions of
the scalp and cerebral edema. Table 7 shows the descriptions of
smothering deaths in detail.

Choking and Aspiration Deaths DISCUSSION

There were 4 cases (2.9%) in this category. The age
ranged from 5 days after birth to the age of 36 years. Three
of them were male. One case, known as an epilepsy patient,
died of aspiration of gastric contents during an epilepsy
attack. The other case, a baby 5 days old, died of aspiration
of milk while suckling. The manner of death is accident in all
cases. Table 4 shows the descriptions of choking deaths in
detail and aspirated materials.
Asphyxial deaths are caused by the failure of cells to
receive and/or use oxygen.1 Brain is most sensitive to oxygen
deprivation, and it is the organ mostly affected in all types of
asphyxial death. However, cardiac function usually continues
for several minutes after respiratory arrest.9
Autopsy plays an important role for the investigation,
and the collection of samples is of value in the reconstruction
of the cases.

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TABLE 2. Detailed Descriptions of Compressive Asphyxial Deaths (n # 7)

Case No., Sex, Method of Cause of Manner of Place of Nature of Autopsy
Year Age Asphyxiation Death Death Death Case Findings Other
1, 1988 Male, 35 y Compressive Chest compression Accident Field Under Minor head injury; 2 rib
overturned fractures; Marked
tractor congestion of face, neck
and upper part of chest;
Wheel imprint mark on the
chest
2, 1997 Female, 60 y Compressive Chest and abdomen Homicide Field Compression Blunt force injury to the Sexual assault
compression by the head; Fresh contusions on with anal
perpetrator the face; Severe congestion penetration
on the face and neck; findings
Multiple rib fractures;
Cervico-facial cyanosis;
Local subarachnoidal
hemorrhage
3, 2001 Female, 5 y Compressive Chest compression Accident Stable Underneath a 4- $ % 5-cm Fresh contusion
fallen on the chest; Three rib
hanging fractures; Marked
farm congestion on the face and
machine neck; Subconjunctival
hemorrhages
4, 2002 Male, 41 y Compressive Chest compression Accident Near a Under Multiple bruises on the body; Neck
road overturned Marked congestion of face compression
motorcycle and neck; Petechial
hemorrhages of the face;
Hemorrhages in the soft
neck tissues
5, 2003 Female, 77 y Compressive Chest and abdomen Homicide Victim’s Compression Blunt force injury to the Findings of
compression house by the head; Fresh contusions on manual
perpetrator the face; Marked smothering
congestion on the face and
neck; Fingernail marks
around the nose
6, 2003 Male, 42 y Compressive Chest compression Accident Coal Under cave-in Congestion of face, neck, and
mine in coal upper part of chest;
mine Multiple minor bruises all
body; Petechial
hemorrhages of the face
7, 2003 Male, 40 y Compressive Chest compression Accident A farm Under fallen Petechial hemorrhages of the Aspiration of
hayloft straw bales face; Congestion of face, the straw
neck, and upper part of
chest; Multiple rib
fractures

Asphyxial deaths constitute 15.7% of all forensic au-
topsies in the Edirne, Trakya, region of Turkey. It has been
the third or sometimes the fourth leading cause of death,
changing over the years. Asphyxial death rates in forensic
autopsy series from other cities in Turkey were between 6.7%
and 14.7%.10 –14
In this study, gender distribution shows a higher pro-
portion of males (79.8%), and the male:female ratio was
3.9:1. Some Turkish studies11,12,14 show a similar male pre-
ponderance in asphyxial deaths, the proportions being
64.2%,70.3%, and 78.4%.
In Table 1, the methods of asphyxiation and the man-
ners of death are shown in detail. In this region, hanging is the
most common method of asphyxiation (41.8%), followed by
drowning (30.5%), CO poisoning (8.2%), and compressive
asphyxia (5.3%). The other rare methods are environmental
suffocation (forced depletion of oxygen), choking and aspi-
ration of gastric contents, ligature and manual strangulations,
and smothering, which constitute 2.3%–3.8% of asphyxial
deaths.
The distribution according to manners of death showed
that suicides accounted for 47% of asphyxial deaths and
accidents 44%, while homicides were 9% of all cases. Ege et
al13 reported that 36.1% of asphyxial deaths were suicidal,
35.1% were accidental, and 22.5 were homicidal.
Most hangings are suicidal,1,15,16 being 100% of cases
in this study. There is only 1 case defined as an adolescent
suicide at the age of 14 years, who hanged himself at home.
Accidental hangings are uncommon and constitute nearly 5%
of all hangings.15,17,18 Deaths due to accidental hanging
among youth and adults are a well-known phenomenon,
which commonly occurs during autoerotic activity.3– 6,19,20

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TABLE 3. Detailed Descriptions of Environmental Suffocation Deaths (n # 5)

Case No., Sex, Method of Cause of Manner of Place of Nature of Autopsy
Year Age Asphyxiation Death Death Death Case Findings Histopathology
1, 1999 Male, 28 y Environmental Hypoxia by Accident Coal mine Staying behind No external trauma; Lung congestion
suffocation oxygen cave-in in Marked cyanosis; and edema;
depletion coal mine STA was negative Hypoxia in all
organs
2, 2003 Male, 17 y Environmental Hypoxia by Accident Coal mine Staying behind Slight abrasions; Hypoxia in all
suffocation oxygen cave-in in Peripheral organs
depletion coal mine cyanosis; Coal dust
in the trachea;
STA was negative
3, 2003 Male, 29 y Environmental Hypoxia by Accident Coal mine Staying behind Slight abrasions; Hypoxia in all
suffocation oxygen cave-in in Peripheral organs
depletion coal mine cyanosis; STA was
negative
4, 2003 Male, 39 y Environmental Hypoxia by Accident Coal mine Staying behind Slight abrasions; Hypoxia in all
suffocation oxygen cave-in in Peripheral organs
depletion coal mine cyanosis; Coal dust
in the trachea;
STA was negative
5, 2004 Male, 35 y Environmental Asphyxia by Accident Natural gas Found dead No external trauma; Edema in all
suffocation methane pipeline with 2 Marked peripheral organs
excavating unconscious cyanosis
site friends in
the pipeline
excavating
site

TABLE 4. Detailed Descriptions of Choking Deaths (n # 4)

Case No., Sex, Method of Cause of Manner of Place of Nature of Aspirated Autopsy
Year Age Asphyxiation Death Death Death Case Material Findings
1, 1999 Male, 5 d Choking Asphyxia Accident Home Choked while Massive milk Milk in trachea,
suckling main bronchi,
peripheral
bronchi;
Marked
congestion
2, 2001 Female, 17 y Choking Asphyxia Accident Home Choked while Undigested boiled A lot of grains
eating dinner wheat grains in trachea,
main bronchi;
Emphysema
3, 2003 Male, 36 y Aspiration of Asphyxia Accident Home Choked during Gastric contents Gastric contents
vomit epilepsy in the mouth,
attack and trachea,
vomiting bronchi;
Known
epilepsy
patient
4, 2004 Male, 6 y Choking Asphyxia Accident Home Choked while A green olive A green olive in
eating lunch the trachea,
Emphysema;
Petechiae of
conjunctivae

Moreover, accidental hangings can be seen in rare cases such
as rounding the collar of a sweater,21 hanging with a lanyard
key chain,22 hanging with a cloth belt,23 hanging with the
hand strap of a garage door,24 and playing with a rope.25
Hangings may also take place in murder-suicide cases for
perpetrators26 or both perpetrator and victim.27 In addition,
hangings may be accompanied by other suicide methods like
gunshot wounds.28 Accidental hanging is another major pub-
lic health problem in infancy due to loose restrainers, cloth-
ing, or curtain cord29 and in childhood due to experimental

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TABLE 5. Detailed Descriptions of Ligature Strangulation Deaths (n # 4)

Case No., Sex, Method of Cause of Manner of Place of Nature of Autopsy
Year Age Asphyxiation Death Death Death Case Findings Other
1, 1988 Male, 1.5 y Ligature Asphyxia Accident Cot Strangled with Petechiae of conjunctivae;
strangulation gauge while Partially ligature imprint
sleeping on the neck; Congestion
of the face
2, 1994 Female, 32 y Ligature Asphyxia Homicide Behind a Strangled with Petechiae of conjunctivae; Sexual assault
strangulation mosque plastic rope Petechiae of the face with vaginal
skin; Fully encircled penetration
ligature imprint on the findings
neck; Hemorrhages at
the neck muscles
3, 2000 Male, 58 y Ligature Asphyxia Homicide Nightclub Strangled with Petechiae of the face skin; Findings of
strangulation nylon Fully encircled ligature manual
woman’s imprint on the neck; smothering
sock Hemorrhages at the
neck muscles; Bruises
around the mouth, chin
and lips; Tearing of the
upper frenulum
4, 2004 Male, 24 y Ligature Asphyxia Accident “Troll”; Strangled with Fracture of the chin;
strangulation fishing ship troll-net cord Twice fully encircled
while casting large ligature imprint of
the troll net “troll” on the neck;
Hyoid bone and thyroid
cartilage fractures;
Massive hematoma in
the neck muscles and
the soft tissues

behavior involving ligatures around their necks.30 In this
study, there was no accidental hanging either in children or in
adult age groups.
Homicidal hanging deaths are extremely rare. There
was no homicidal hanging in this study group, whereas some
studies reported homicide both in children15,31 and in
adults32–35 who had mental disease, physical weakness, or a
state of drunkenness.
In this series, most of the victims (76%) were found to
be hanged indoors, specially at home15,16; only 1 case was
found dead inside a bus.36,37
STA revealed ethanol in 8.9% of the hanging deaths,
whereas ethanol was found in 34% of the cases in a previ-
ously reported study.16
Most of the cases (96.4%) show complete suspension.
Inanıcı et al38 reported complete suspension in 78% of all
cases. In this study, in 66% of the cases the location of the
ligature knot was posterior (occipital). There are also papers
which report posterior location as the most common knot site
of hanging, 66% by Inanıcı et al,38 61.7% by Nikolic et al.39
This study reveals that 76.7% of the cases (n # 43) had
fractures of solid neck structures. Frequency of fractures of
solid neck structures is reported between 9.5% and 68%.39 – 43
The hyoid bone fractures in cases of hanging are reported to
be 30%, 18.8%, 3.2%, and 10%38 – 40,44; this ratio is 46.4% in
this study, being higher than other reported ones. The ratio for
the thyroid cartilage fractures is 42.8%, 6.8%, and 22.5%,39,40,44
being 17.8% in this study. Of the cases, 12.5% had both hyoid
bone and thyroid cartilage fractures, similarly to the results
reported by Green et al.44 In contrast, Elfawal and Awad45 stated
that in their series there were no fractures of the hyoid bone,
thyroid cartilage, and cervical vertebrae in any of the victims.
Previous studies state that there were no association
between fractures of solid neck structures and types of liga-
ture and/or suspension39 – 41,43,44 but a slight relation between
frequency of fractures and the length of suspension time,42
fractures, and increased age.39 – 41,44
Injuries of soft neck structures (muscles and other
tissues) were found to be 51.7% of all cases; previous studies’
reports were between 29% and 98%.38,39,41
Drownings constituted the second major method of
asphyxiation in this study, with a ratio of 30.5%. Çoltu and
Durak14 reported that 27.8% of the asphyxial deaths were
related to drowning in Bursa, 91.2% of which were male and
died in summer; these results are in line with this study.
In this study, most of the cases (73.1%) were found in the
river, and deaths were due to freshwater drownings46; in con-
trast, other studies reported that saltwater drownings were seen
in most of the cases to die.47– 49 Locations of drownings varied
due to the region of the study whether it was coastal or not.
In 78.1% of the cases in this study, the manner of death
was accident due mostly to fishing activities and illegal
passage of fugitives from the Meriç River, which is the
natural border between Turkey and Greece. This percentage
is higher than that reported (47.9%) by Kringsholm et al,48
(57%) by Gamero et al,50 and (58%) by Lunetta et al.51 Lucas
et al52 reported that suicidal drowning cases constituted 41%
of the cases, whereas 17.1% of all cases were suicidal in this

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TABLE 6. Detailed Descriptions of Manual Strangulation Deaths (n # 3)

Case No., Sex, Method of Cause of Manner of Place of Nature of Autopsy
Year Age Asphyxiation Death Death Death Case Findings Other
1, 1999 Male, 57 y Manual Asphyxia Homicide Empty well Strangled with Multiple bruises on the
strangulation hand; then body; Fingernail
thrown in a scratch marks on the
well neck; Bruises on the
neck skin; Hematoma
under the scalp;
Hyoid bone and
thyroid cartilage
fractures;
Hemorrhages on the
neck muscles
2, 2000 Female, 75 y Manual Asphyxia Homicide Own home Strangled with Petechial hemorrhages No sexual
strangulation hand on the face; Bruises assault;
on the neck skin; Findings of
Fingernail scratch manual
marks on the neck; smothering
Bruises around the
mouth and nose;
Hyoid bone and
thyroid cartilage
fractures;
Hemorrhages on the
neck muscles;
Hemorrhages in the
back of the tongue
3, 2001 Female, 19 y Manual Asphyxia Homicide Own home Strangled with Petechial hemorrhages No sexual
strangulation hand on the face; assault
Fingernail scratch
marks on the neck;
Hyoid bone fractures;
Hemorrhages on the
neck muscles and the
soft tissues

TABLE 7. Detailed Descriptions of Smothering Deaths (n # 3)

Case No., Sex, Method of Cause of Manner of Place of Nature of Autopsy
Year Age Asphyxiation Death Death Death Case Findings
1, 1997 Female, 11 y Smothering Asphyxia Homicide Victim’s Smothering by Abrasions and bruises around
home hand the nose and the mouth;
garden Hematoma of the lips;
Tearing of the upper
frenulum; Multiple bruises
at the nape and back;
Abrasions and bruises
around the external
genitalia
2, 1998 Female, 25 y Smothering Asphyxia Homicide Field Smothering by Postmortem wild animal
plastic bag feeding findings; Plastic
bag covering the head and
the neck; Petechial
hemorrhages of the facial
skin
3, 2002 Male, 3 y Smothering Asphyxia and Homicide Victim’s Smothering by Multiple and large bruises on Severe child
head injury home hand all body; Blunt-force head abuse
injury findings; Fingernail findings
marks on the cheeks;
Abrasions and bruises
around the nose and the
mouth

140 © 2006 Lippincott Williams & Wilkins

The American Journal of Forensic Medicine and Pathology • Volume 27, Number 2, June 2006
study. The ratio of suicidal drowning cases is reported be-
tween 4% and 42.6% in forensic studies.47,48,50,51,53,54
In this study, there were 2 cases (4.8%) whose deaths
were attributed to the combined effects of blunt-force injuries
and drowning; these were accepted as homicidal drowning.
Homicidal drowning is a rare but an important case in
forensic practice. Such deaths can occur either as a pure case
of homicidal drowning55 or with other traumatic injuries such
as strangulation,56 gunshots, stab wounds, and blunt-force
injuries as in this study.
Mushroom foam was observed around the nose and
mouth in 34.1% of all cases, which is similar to the Lunetta
et al51 report (29%) from Helsinki.
CO poisoning is another major public health problem in
Turkey. It is reported that CO poisoning deaths constituted
3% of all forensic autopsies in Istanbul between the years
1985 and 1992.57 The other Turkish study between 1995 and
1998 reported that 2.5% of all forensic autopsies were related
to CO poisonings in Istanbul.58 In this region, our study
showed that CO poisoning deaths constituted 1.3% of all
forensic autopsies and 8.2% of asphyxial deaths. Also, 90.9%
of all CO poisoning deaths occurred in winter.57– 62
In this study, all CO poisoning cases were accidental
(unintentional) in manner. There were no suicidal cases with
CO poisoning. Most of the cases (81.8%) were found dead in
bathrooms while using a shower connected to gas water
heaters59,63 or charcoal-wood heating devices.61 There was
only 1 case found dead in the bread bakery shop due to
accidental occupational CO poisoning from the big wood
oven.64 Another case was found dead due to inhalation of fire
fumes in the kitchen.59,65 As stated previously by Abu Al-
Ragheb and Battah,61 most CO poisoning deaths in this study
could also have been prevented.
Compression asphyxia is another form of suffocation,
where deaths results from mechanical compression of the
chest and/or upper abdomen, which makes respiration impos-
sible.1,9 Although the manner of deaths in compressive as-
phyxia is usually accidental,1,66,67 homicidal traumatic as-
phyxial cases are reported in forensic studies.68,69 In this
study, most of the compressive asphyxiations (71.4%, n #
5/7) were naturally accidental, specially work-related vehicle
accidents. Two of 7 cases who were female and aged over 60
were homicidal compression asphyxia. One of them had
sexual assault with anal penetration findings, and the other
one was killed with a combination of manual smothering and
compressive asphyxia. The combination of traumatic as-
phyxia and different methods of mechanical asphyxia was
reported in previous forensic studies.2,67– 69 Belviso et al8 also
noticed the difficulty of differential diagnosis between posi-
tional asphyxia and traumatic asphyxia.
In this study, there were 5 cases whose deaths were due
to environmental suffocation due to forced depletion of ox-
ygen. Four of 5 cases were dead because of staying behind a
cave-in in a coal mine. There was no toxicologic evidence for
these deaths because atmospheric sampling of scene was not
performed by investigators. And the other was found dead
with 2 unconscious friends in a natural gas pipeline excava-
© 2006 Lippincott Williams & Wilkins
Asphyxial Deaths
tion. In all cases, STA was negative for ethanol and COHb,
and all of them had no major external injuries causing death.
Marked external cyanosis and, histopathologically, edema
and hypoxia in all organs were the only external and internal
findings. In environmental suffocation deaths, the autopsy
findings were not specific, and death resulted from the dis-
placement of atmospheric oxygen by suffocating gases.1,70,71
All cases were work-related accidental in manner. In this
study, an atmospheric sampling for the gases at the scene and
transthoracic aspiration of the bodies were not performed that
were essential.1,70
Choking and aspiration deaths constituted 2.9% of all
asphyxial deaths in this study. All of the cases were acciden-
tal in manner and caused with food items. Çetin et al72
reported that most choking cases (59%) in Istanbul are in
children aged between 8 months and 15 years and caused
with food items such as dry beans, cherry seeds, chickpeas,
sunflower seeds, a piece of carrot, and grapes. Accidental
choking with nonfood items in children were reported previ-
ously, such as by a balloon, a screw, a plastic pistol bullet,72
a marble, a small toy, a stone,73 by a rubber balloon,74 and by
a pacifier.75
An example for accidental choking in adults, caused
with foods so that the victim died from asphyxia due to
airway obstruction, took place in this study (in Table 4, case
2). Accidental and suicidal choking in adults with different
items was also reported.76 – 80 In one case, death was due to
aspiration of gastric contents during an epilepsy attack. In
such cases, the differentiation between agonal overspill from
true vital aspiration is necessary.73 The tracheobronchial tree
must be filled with the aspirated material.81 Homicidal chok-
ing is rarely reported in forensic practice.82
Another method of asphyxiation is ligature strangulation
(2.9% in this study), which is mainly homicidal in manner1,14,83–86;
female victims constitute most of the cases,83,84,86 and generally
have sexual assaults.83,84 In this study, there were 2 homicidal
ligature strangulations. One of them was a young female who
had vaginal sexual assault findings that intravaginal swab
samples were positive for the presence of spermatozoa by
microscopic examination, and there were acute injuries in-
volved hymenal tears and bruises. Fatal sexual assaults on
women due to ligature strangulation had been reported pre-
viously.87
Although it was reported in previous studies,88 –91 there
was no suicidal ligature strangulation in the present study. In
contrast, in this study accidental ligature strangulation cases
were seen in 2 (Table 5, cases 1, 4), similar to the reports
published previously.92–95
According to Table 5, one ligature strangulation case
had manual smothering findings83; there were also reported
cases who died as a result of a combination of other methods
of asphyxiation and ligature strangulation.83– 86
Both external and internal injuries due to ligature stran-
gulation are described in detail in Table 5. Ligature mark,
petechiae of conjunctivae and the face skin, and hemorrhages
at the neck muscles were the most common findings in these
141
Azmak The American Journal of Forensic Medicine and Pathology • Volume 27, Number 2, June 2006
cases. These findings in mechanical asphyxiation are well
documented.96 –106
In the present study, during the 21-year period, another
rare method of asphyxiation is manual strangulation deaths
that constitute 2.3% of all asphyxial deaths. Çoltu and Du-
rak14 reported that manual strangulation deaths were found to
be 5.85% of all asphyxiation deaths in Bursa. The method
distribution among the asphyxial deaths was varied between
regions as manual strangulation is the most common method of
asphyxial homicide.83,85 On the other hand, some reports state
that ligature strangulation is the common method.84,86,107 In this
study, 2 female victims and 1 male victim were strangled with
the hand, and one of the female victims also had findings of
smothering. Fingernail scratch marks, bruises on the neck, and
hyoid bone fracture were found in all cases. Thyroid cartilage
fracture was found only in 2 cases.83,86 None of the female
victims showed sexual assault findings.
Smothering is a kind of suffocation due to mechanical
obstruction or occlusion of the nose and mouth with the
hands, a plastic bag, or a smooth cover.1,9 Smothering deaths
in this study were found in 3 victims, which constituted 2.3%
of all asphyxial cases. Most smothering deaths are homicidal
in manner,84 – 86 most of them are children,108,109 and many of
them are associated with sexual assault.86,108 In this study, 2
of 3 cases who were smothered with the hand were children
(Table 7, cases 1, 3), one of them also had sexual assault with
vaginal penetration findings, and the other one showed severe
child abuse findings. Another young female adult was smoth-
ered with a plastic bag and found in an empty field. Homi-
cidal smothering in young adults and adults was reported
previously.110 Homicidal smothering is a killing method
often used by a physically stronger assailant against a weaker
victim.
Plastic bags are most commonly used items for suicidal
smothering.111–116 Accidental smothering cases were re-
ported with a pillow,117 undersurface of a truck,67 and pack-
ing tape.118 Accidental smothering as a cause of death was
also reported in sexual asphyxia cases114 and in crib deaths in
infants.1,73 In this study, there were no suicidal and accidental
smothering cases.
In the study period between 1984 and 2004, there were
no autoerotic asphyxial deaths and positional asphyxial
deaths. In addition, there was no natural asphyxial deaths in
this retrospective study, whereas natural diseases causing
sudden asphyxial deaths were reported by Byard et al,78 with
2 case of mucosal cavernous hemangioma and an enlarged
tonsil; by Carrick et al,119 with 2 cases of esophageal fibro-
vascular polyp; by Taff et al,120 with 1 case of esophageal
fibrolipoma; by Fyfe and Mittleman,121 with 1 case of hypo-
pharyngeal lipoma; and by Cochet et al,122 with 1 case of
esophageal polyp.
In conclusion, this retrospective study shows that as-
phyxial deaths, most of which can be prevented by education
and rehabilitation of individuals, are common in males and
young-middle-aged people. The importance of scene investi-
gation and so proper postmortem external and internal exam-
inations is obvious.
142
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