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[Dr. Milton Helpern:] One of the most difficult subjectsfor the forensic pathologist

is the evaluation of deaths

in which asphyxiation has taken place

by some traumatic means.

You all know that peopleare strangled with ligatures.

They're strangled with a hand.

There are other types of violent asphyxia,

and this whole subject is one

in which the forensic pathologisthas considerable difficulty,

and there are timeswhen the condition of the body

may preclude any conclusion

that can be derivedfrom the autopsy itself.

Traumatic asphyxiationoccurs in suicidal cases.

Perhaps the most common typeof suicidal death is that by hanging

in which the strangulationor the compression of the neck

and all the structures in it

is accomplishedby the weight of the deceased body

at the end of the row.

This type of case is usually onethat doesn't offer too much difficulty,

but I would advisethat when hangings occur,

no matter how obviouslysuicidal they appear,

when they occur in placeslike in legal custody

where a prisoner hangs himself,

it's a very good idea,no matter how obvious the case may be,

to include an autopsyin the postmortem examination,

and also to try to getto the scene of death as soon as possible,

because questions do come upabout the post-mortem interval,

when did this happen,when did the individual die,

and all sorts of insinuationsmay evolve during

the investigationand after the investigation.

If you don't have the answers

confirmed by actual autopsy of the body,

someone will bring up the possibility,

"Well, this prisonerwas actually assaulted by a guard,

or this prisoner was assaultedby another prisoner

who was in the cell with him,

and then the hanging occurred afterward.

These are all thingsthat are almost impossible to answer

unless an autopsy is done.

The autopsy is important in these cases,

not that hanging producesvery characteristic findings.

In fact, the findings in hangingare mostly findings that you see

incidents of the post-mortem interval

but the autopsy is important in thatit eliminates other possible

types of violence as a cause of death.

It certainly can eliminatemanual strangulation

which has fairly characteristic findings.

It certainly will eliminate

the possibility of a fractured skullor internal injuries

which may not be evidenton the outside of the body.

My advice would be,

whenever you have the hangingof a young person under circumstances

where the possibility of other types

of violence may be mentioned

to fortify your conclusionwith a complete autopsy.

There are many interesting casesof self-strangulation.

Sometimes, these occurin such a bizarre way that

people who are not familiar with itare apt to be confused by it.

The hangings, for example,

that occur of transvestites

are not really suicidal hangings.

They're hangings incident

to this erotic procedurethat is being carried out usually

for self-stimulationand masturbatory purposes,

and there,the picture may be very confused.

Now, these are all self-accomplished

but self-accomplishmentis not synonymous with a suicide

and there, I think it's rather importantnot to jump to the conclusion

that because the individualdid it to himself, it was a suicide.

It doesn't mean thatit's an accident either

and I think that some of these cases

have to be leftin the undetermined category.

There's nothing wrong with sayingthat you're unable to resolve

what was in the mindof the deceased person.

This hanging incident

to erotic stimulation,

self-stimulation,

is not uncommonly seen

and some of the casesare very bizarre indeed.

Now, I would like to point out to you

a few examples of homicidal strangulation

and smothering types of violence

which have to be studied very carefully.

Unless the examiner,

unless the pathologistis aware of the methods to be used,

he may find himself doingan inadequate examination

and arriving at conclusions

which may not be altogether justified

by the other findings in the autopsy

and even not if they are justified,they haven't been corroborated by findings

which can be determined.

In manual strangulation to take

perhaps the most common typeof homicidal strangulation,

one usually encountersmarks of injury

where the pressure of the assailant'shands and fingers and so on

are applied to the neck

and during the struggle, it may occur.

These are very definitely leftas grouped abrasions

which become quite conspicuouswith the passage of time

and the face assumesa sort of blotchy appearance

and one usually finds petechialhemorrhages in the conjunctivae

and petechial hemorrhagesin the scalp,

and the important thingin a case like this,

this gives you the suspicion

that you're dealingwith the manual strangulation.

Remember that there are cases

where there are no external signsat all on the neck.

The marks of violencemay be entirely absent,

but it's rather important

that in any such autopsy

that the throat organsbe very carefully exposed and dissected.

This dissection of the throat organsmust be done in a very painstaking way.

It's not enough to incise over the larynxand poke around a little bit

and put your finger inor something like that

because that will determine nothing.

You have to examine all of the layersof the soft tissues,

the muscles of the neck

looking for localized evidences of injuryin the form of hemorrhage,

and then the larynx has to be taken out

with the tongueand very carefully dissected

with regard to the intrinsic muscles

over the thyroidand the cricoid cartilage.

Before the larynx is actually opened,

the cartilages should all be dissectedand very carefully examined

to determinewhether there are any fractures.

If you open the larynx and pry it open,

and then start looking for fractures,

you get to the pointwhere you are not sure

whether the fracture was there.

You know what was there

but somebody may say,"Well, how do you know you didn't do it

when you pried the larynx open?"

In all casesof suspected manual strangulation,

it's rather importantthat you take the larynx out

and very carefully dissect itand then save it for future reference.

The injuries are, in some cases,of course, of young people,

the larynx doesn't necessarily fracturebut you will see the localized injuries

in the form of small hemorrhagesaround the muscles

and the asphyxial hemorrhagesin the mucosa of the larynx.

Sometimes, you don't have the opportunityof making all these observations

if the postmortem intervalhas been very long

before the body is discovered.

In the fresh case,

there should be no difficultyin making this dissection.

What I notice is

that these structures are not dissectedas careful as they should be.

The hyoid bone is not sometimesincluded in the specimen.

It always should be included

because fractures of the hyoid boneare apt to be found,

fractures of the cornuaof the thyroid cartilage,

and fractures of the cricoid

with associated hemorrhagesin the soft tissues

as well and the general signs of asphyxiawhich vary quite a lot.

In ligature strangulation,

strangely,where a ligature is used,

the ligature can compress

but it doesn't usually fracture the larynx

and it doesn't producethese localized scattered hemorrhages.

The ligature can compress

and effectively cut off the blood supplyand the air supply and cause death.

In most pure ligature strangulations,it's not common to find injuries

to the structures of the larynxand the surrounding tissues.

This is a pointthat one should keep in mind

because occasionally,

both types of violence occur,

a manual strangulationand ligature strangulation.

When one finds fractures of the larynx,one should suspect the possibility of

the fingers or the hand having been usedduring a manual strangulation.

Now, next case is one that I'm showing

because it's very confusing

and it was reported in a wayto make it even more confusing.

If the medical examiner

who had gone out on the casehad been off his guard,

it might have been certified

at the scene as a deathfrom natural causes

merely because a cousin said

that the deceased had been sufferingfrom bronchial asthma.

Watch out for the diagnosisof bronchial asthma as a cause of death.

It turns up in cases of criminal abortion.

It turns up in cases of strangulationand other types of homicidal death.

If a person does diefrom bronchial asthma from time to time,

this should be verifiedand confirmed by a very careful autopsy.

Now, this woman that I'm showing

in this picture is that of a person

who workedfor some very important families

in New York as a domestic,and her employers liked her very much.

When she died,they heard that she had died.

They all came to the apartment

and by the timethe medical examiner got there,

there were a good many people in the room.

The death was reported to usas apparently not suspicious,

history of bronchial asthma.

The story was this.

This woman was foundin bed in her night clothes,

in her bed jacket by her cousin,

a woman who was in constant touch with herand who would call her up on the phone.

The woman called up on the phone that dayand to her surprise,

a man answered the phone.

This was all the more of surprise to her

because the deceased husbandhad been committed

to a mental hospitalin the New York City area

on the petition of the wife.

They had also heard that he had escapedfrom the mental hospital

and had gone down to Florida by bus.

Now, this brought upa series of possibilities

and nothing very definite.

The cousin then went to the houseand got no answer,

had the superintendententer the apartment again.

When she found the deceased lying in bed,

she didn't realize thatthe deceased was already dead

but thought that she had fainted

and took the bodyand placed it on the floor

and immediately begangiving artificial respiration.

Everybody nowadays is trainedto give artificial respiration.

When the patrolman came

and saw this woman givingartificial respiration,

she asked the patrolmanto get an ambulance.

While the ambulance wasin the process of getting to this scene,

the patrolman took overand he was giving artificial respiration.

When the ambulance got there,

the woman's body was on the floorin its nightgown and in a bed jacket.

The ambulance attendant indicatedthat the deceased was dead

and much to the reliefof the police officer

who was rather tired by that time.

They notifiedthe medical examiner's office,

and then our doctor went there

and got this story about the husband.

Now, when he examined that body,

these marks that you see on the neckmust have been very inconspicuous

because he said he lookedthe body over very carefully.

As often happens,

the abrasions and so onbecome more conspicuous

with the passage of time.

Sometimes, if you get there a little soon,

you're at a little bit of a disadvantage

and it's a more difficult thingto evaluate marks

such as you see here,

but they were evident

when I photographedthe body the next morning.

Now, we did an autopsy on this case

and the autopsy very clearly revealedthat this woman had been strangled.

Her larynx was fractured in several placesand she had the usual hemorrhages

and other signs of asphyxiationin the scalp and in the eyelids and so on.

We also noticed that

there was a large amountof semen in the vagina

and there was a dried seminal depositon the pubic hair

and another thin stain,dried seminal stain on the thigh.

It was very easy to corroborate the factthat this was semen.

There were large numbers of spermatozoa,

and the acid phosphatase test

was strongly positivein all three samples.

I asked Dr. Wiener, our serologist,

to see whether he could group this semenbecause it was there in such large amount.

Dr. Wiener then using methods,which the serologist knows,

he was able to group the serum,

all three specimens,the pubic hair specimen,

the thigh specimen,and the vaginal specimen,

and got a very strong reactionfor a Group A person.

That is a Group A substancethat was in that semen.

The blood group of the deceased,which is also routinely grouped

in every case of homicideor suspicious death,

the blood groupof the deceased was Group O.

We had this information aboutthe semen being in Group A,

and we notified the police

and the policewere very impressed with us.

Then, we also toldthe district attorney about that.

He was rather impressed with the progressthat science was making,

the laboratory was makingto help the pathologist out.

They immediately began to lookfor the husband of the deceased.

About a day later,

I got a callfrom the district attorney saying,

"You know,we sent someone down to Florida

and picked up the husband

who was formally a memberof the Chilean Navy."

This woman herself was from Chile.

He said, "You know,this fellow admitted doing

what you say happened."

He said he escaped from the hospital.

He came back to the house.

He rang the bell.His wife wouldn't let him in.

Then he went around by wayof the fire escape window

and obtained access to the apartment.

Then he said he strangled his wifeand had intercourse with her.

Which came first is notparticularly important in our case,

but he admitted the whole thing.

The district attorney said,"We have a very good case,

but you're making it difficult for us

because on the discharge cardfrom the Chilean Navy

which this man carried in his pocket,

his blood group is includedand his blood group is listed as Group O."

All I could say was, "Oh,"

and then I took it up with Dr. Wiener

and Dr. Wiener wasa little bit upset about it.

I cheered him up and said, "Well,you know, during the war,

about 10% of the groupingsof the military were incorrectly done."

He said, "Yes,but 90% were correctly done."

I said, "Well, let's wait anyway."

The perpetrator was brought backand then placed in Bellevue Hospital.

The blood was regroupedand it was Group A.

In that case, knowing the group,while at first,

it created a little confusionand at the end, it was very helpful.

During the course of the investigation,

there were two other menwho were considered suspect

and they consented to havingtheir blood grouped,

and both of them were eliminated,because one was a Group O

and the other was a Group B.

This added informationthat you can obtain.

It means something extra.

You don't have to do,

that is determining the cause of deathis so easy in a case like this.

Determining that they were semen present,

but that extra little somethingreally goes a great deal

to wrap the case up,as one might say.

Now, another type of situation.

This is a microphotograph of the semen

from the vagina of this woman.

You can seethe large numbers of spermatozoa

which are quite well-preservedand show up very well.

Now, this is another typeof case of smothering.

The reason I show it to youis because it's wonderful

to show the importance of a prompt visitto the scene by the medical examiner.

This death was originally reported

as not suspicious.

While this was being placed on our book,

I got a call from a detectivein the homicide squad,

this was about 6:30 in the evening,and he apologized for calling.

He said, "We have a deathin this hotel rather

which doesn't look terribly exciting,

but I'd like you to come overand look at the body

because the first patrolman on the casewas a little bit concerned

in that he found froth in the mouth."

I might say that this womanhad registered with a man as man and wife

two days before the bodywas discovered dead.

The following day, that is 24 hoursbefore it was found,

the man left and said,"Don't disturb my wife

as she's sleeping."

The next morning, that is the morningin which the body was found,

the maid came in and saw the bodyin an apparently undisturbed--

It's lying on the bedwith a blanket tucked up and the coats on.

The shoes are off.

There is this froth oozing from the mouth.

You will notice that the body alsohas a slightly blotchy appearance

and the rigor mortisis just beginning to disappear.

I point these things out to showthat we were able to examine this body

at a critical time

and really evaluate the signs

which one would not have been ableto evaluate the following day

for the reason that the decompositionhad advanced very rapidly

by the timethe body got to the mortuary.

Once you take a body like this decomposingin the undisturbed state

and transport the bodylike that to the mortuary

and disseminate or move the gasesin the tissues,

the decomposition productwill continue at a much more rapid rate.

It's accelerated.

When you see certain thingsin the undecomposed state

as compared to seeing themin the decomposed state,

you have a much better chanceto make a valid observation.

Anyway, in this particular case,

I got there and there was a pillowcasewith some lipstick smudges on it

on the undersurface of it.

The cop thoughtthat was rather unusual too and so did I.

We looked this woman overand in the whites of her eyes,

way up in the periphery of the sclera,

there was some very clear-cutpunctate hemorrhages

of an asphyxial type

and with the pillowcasebearing her imprint,

one got the impression thatthis might be a homicidal smothering

with the few manifestationsthat we saw.

We suggested thatas a possibility to the police.

I find out who the woman is.

This was doneand they got hold of the deceased sister,

and the sister's first remarkto the police was,

"What did he do to her this time?"

Apparently,this man with whom she had registered

was her estranged husband,

with whom she would meetfrom time to time.

He would promise her all sorts of thingsand never keep his promise

and leave her in a frustratedand angry state.

This time, apparently,when they caught up with him,

he says, "I didn't do anything to her.I left her there sleeping."

They showed him the pillowcase

and told him thatshe probably wasn't asleep

in view of the fact thatshe had these signs in her eyes and so on.

Then he finally admittedthat he had smothered her.

She had asked him for a giftand he didn't have it for her.

She had a tantrum, and he said,"I just put the pillow over her face

to keep her quiet,

and I kept the pillow thereevidently too long."

He confessed to this thing.

We don't know exactly how long it took

because his storywasn't altogether complete.

The point about this case thatI want to make outside of the fact

that the findingsof a smothering are very subtle.

If you don't examinethe body at the scene,

the undisturbed body,the same findings the next day,

in the presence of more decomposition,with a body in a now changed position,

it isn't possible to interpretthose hemorrhages

nearly as welland to be assured of yourself

as when you examine the bodyat the time it is found

and in the undisturbed state.

This case is oneI think that shows the importance

of a visit to the scene

by the medical examineror the forensic pathologist

who is in a positionto determine the subtle signs.

I might say that, in smothering,

you don't find very muchand with decomposition,

the physical signs of smothering,

the anatomical signsmay disappear entirely,

but sometimes, you're fortunateto get there early enough

before the decomposition sets in

and from the appearance of the bodyand from the surroundings and so on.

You can make a valid determination

based mainly on the paucityof the findings

rather than on the excess of the findings.

I think I'll conclude at this point.

Thank you.

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