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The detection of petechial haemorrhages of the conjunctivae in dependency on the postmortem interval
Forensic Science International
Science International
Forensic
64 (1994) 61-67
The detection of petechial haemorrhages of the conjunctivae in dependency on the postmortem interval P. Betz*, R. Penning, ofLegal Department
Medicine. (Received
University
W. Keil
ofMunich, Frauenlobsrr. 7a, 80337 Munich. Germany
12 March
1993; accepted
4 June
1993)
Abstract Petechial haemorrhages of the conjunctivae are not specific for lethal throttling or strangulation, but they belong to the important indicators for such mechanisms. In experimental models it is shown that petechial bleedings of the conjunctivae disappear with the
occurrence of advanced signs of putrefaction or in cases of fresh-water logging. Therefore, it must be emphasized that the lack of petechial haemorrhages in putrefied or fresh-water-logged corpses is of very restricted meaning for the examination, whether throttling or strangulation has taken place or not, and the autopsy should always be performed in these cases with special regard to the neck.
Key words: Petechial haemorrhages;
Asphyxiation;
Putrefaction
1. Introduction Petechial haemorrhages, in particular of the conjunctivae, are one of the ‘classic’ signs of asphyxia. Even though they are not specific for death by asphyxiation, their occurrence can be regarded as an indicator for strangulation or throttling. On the other hand, petechial haemorrhages can both appear and enlarge as a postmortem phenomenon and are often present in normal postmortem hypostasis. Since a disappearance with advancing postmortem changes of the corpses has been described [ 11, the present study was performed to analyse the detection of such bleedings in relation to the postmortem interval and also in cases of fresh-water logging in an experimental model. * Corresponding
author.
0379-0738/94/$06.00 0 1994 Elsevier Scientific SSDI 0379-0738(93)01407-I
Publishers
Ireland
Ltd. All rights reserved.
62
P. Be/r (‘I 01. /Forensk
.%i. Inr
64 (1994)
61-67
2. Materials and methods Conjunctivae showing varying numbers of small pin-point bleedings were removed at autopsy from individuals dying of strangulation/throttling, thoracic compression or myocardial infarction. The postmortem interval ranged between a few hours and 2 days, but signs of (beginning) putrefaction could not be observed. Ten conjunctivae were stored at room temperature (1 SC) in a ‘moist’ chamber containing some water to avoid drying out of the tissue, but no contact between the specimens and the water was possible. Ten conjunctivae were stored in fresh-water and further 10 specimens in 0.9% NaCl solution. In addition, 5 specimens were stored in contact with air leading to drying processes of the tissue. The presence of petechial haemorrhages was controlled after 4 h, 8 h and then every day (i.e., 24.48 h and so on) until the bleedings had totally disappeared. Parts of the conjunctivae were removed and fixed in 4’%PBS-formaldehyde solution for light microscopic evaluation. After embedding into paraffin, sections were prepared with a thickness of 2-3 pm and stained with HE. 3. Results 3.1. ‘Moist ’chamber The punctate haemorrhages of the conjunctivae were detectable in all cases up to 2 days after removal, in spite of the original amount of the bleeding. On the third day, in cases with originally numerous petechiae, an unambiguous localization of at least isolated - haemorrhages was still possible in the pale and faded conjunctival tissue, but in conjunctivae showing only moderate amounts of bleeding at autopsy, all haemorrhages had disappeared by then. On the fifth day after removal, however, all petechiae haemorrhages had disappeared in the putrefied conjunctival tissue.
Fig. I. Conjunctiva
showing
numerous
petechial
haemorrhages
shortly
after
removal
at autopsy
P. Bei: et al. /Forensic
Sri. ht.
63
64 (1994) 61-67
-_
pp””
Fig. 2. Same specimen as in Fig. had disappeared,
I after a few hours of fresh-water the conjunctival
logging: all petechial tissue looks pale and edematous.
-
haemorrhages
In evaluation using a light microscope, relevant changes in the tissue structure could not be observed during the first and second day, even though some erythrocytes had ‘paled’ and were only detectable in the form of ‘ghosts’. In specimens obtained on the third day after removal, the nuclear staining was significantly reduced, but, in particular in conjunctival glands, rather well preserved. In specimens with naked eye detection of haemorrhages, the erythrocyte extravasates were clearly detectable by light microscopy even though an advanced number of erythrocytes were only present in the form of silhouettes. In all cases of advanced postmortem interval (5 days or more) no identification of erythrocyte extravasates was possible in the putrefied conjunctival tissue. 3.2. Fresh-water logging In all specimens investigated the haemorrhages were absent on the first check after 4 h and the conjunctivae seemed to be edematous and looked pale. Using light microscopy, no erythrocytes could be detected neither in blood vessels, nor in the form of extravasates. Only fragments of erythrocytes were observed in the blood vessels of the conjunctival tissue which showed a considerable relaxation of the structure in the form of an interstitial edema while the nuclei of some leukocytes could still be detected. 3.3. 0.9’S NaCl solution On the first day after
removal,
no reduction
in the amount
of the petechial
64
P. Bet: et al. /Forensic
Fig. 3. Punctate
bleeding
in the conjunctival
Sci. hi. 64 (1994) 61-67
tissue (see Fig. I) (paraffin.
HE. x95)
Fig. 4. Blood vessel showing only fragments of ruptured erythrocytes while the nuclei of leukocytic cells are still detectable, edematous swelling of the connective tissue (fresh-water-logged conjunctiva. see Fig. 2) (paraffin. HE. x 190).
P. Be12 et al. /Forensic
Sri. ht. 64 (1994) 61-67
65
haemorrhages could be observed. In some cases the number of pin-point bleedings seemed to have decreased after the second day and therefore somewhat earlier than in the specimens stored in the ‘moist’ chamber. After 3 days or more, haemorrhages could not be detected in the putrefied conjunctivae. The microscopical examination revealed similar results as described for the specimens stored in the ‘moist’ chamber. 3.4. Contact with air The drying process of the conjunctivae was linished at least approximately 12-24 h after removal and some of the haemorrhages were rather well preserved in the yellow-brown leather like tissue leading to an unambiguous detection of the pinpoint bleedings. The petechiae were still detectable after 4 weeks; a longer observation was not performed. A microscopical examination was impossible due to the consistency of the dried conjunctival tissue. 4. Discussion Petechial haemorrhages in the conjunctivae are one of the ‘classic’ signs of asphyxia [2] and can be observed in almost all cases of lethal throttling or strangulation, indicating their importance for such a diagnosis [3-51. Punctate pin-point bleedings of the conjunctival tissue, however, can also be observed in other natural and nonnatural causes of death [3,6] and occur occasionally following coughing fits, vomiting or during delivery [4]. Furthermore, petechial haemorrhages can develop can or enhance in hypostasis [ 1,7]. On the other hand, petechiae of the conjunctivae occasionally be absent in cases of lethal throttling due to a considerable discrepancy between the size of the throttling hand and the neck of the victim; also, in cases of non-typical throttling, the carotides can be compressed immediately leading to the absence of the conjunctival bleedings [6,8,9]. In addition, in cases of severe anemia, petechial haemorrhages can be absent [IO]. The small pin-point collections of blood extravasates are predominantly localized in regions with delicate loose connective tissue like the conjunctivae not significantly [ 111. They develop during asphyxia by throttling or resistant to blood extravasation strangulation due to the increased venous pressure in the head following compression of the veins while the arterial vessels are not totally obstructed, leading to ruptures of small blood vessels. Hypoxia is not assumed to be a relevant cause of development, but a possible contribution during longer intervals of oxygen reduction is controversal [2,6]. Since pin-point bleedings of the conjunctivae are an important indicator for lethal throttling/strangulation, their occurrence as a function of the postmortem interval is of interest to the forensic pathologist. Autolysis and putrefaction are assumed to lead to the disappearance of the petechiae [6,12] and Gordon and Mansfield [l] report on the postmortem disappearance of spontaneously developed bleedings in the visceral pericardium. In our experimental model, petechial haemorrhages could be found in all cases with a postmortem interval up to 2 days, but after 5 days the signs of putrefaction were so advanced that it lead to the disappearance of these bleedings in all specimens investigated. It is clear that these time-intervals cannot be applied to human condi-
66
P. Brrr
et ul. /Forensic
Sci. Inr. 64 (IYY4)
61-67
tions on methodological reasons (air moisture, temperature, differences in contact with air, etc.) but indicate that in cases of advanced putrefaction (for example haemoglobin-imbibition of the conjunctivae) the lack of pin-point bleedings is not necessarily connected with their absence at the time of death. On the other hand, our experiments provided evidence that these bleedings can be well-preserved in dried tissues. However, these results are only of rather restricted importance for forensic medicine, since in corpses the conjunctivae do not normally have such direct contact with the air as in our experimental model due to covering by the eyelid skin. Another important aspect of this study, however, seems to be the rapid disappearance of petechial haemorrhages in cases of fresh-water logging. In our series, even in specimens showing numerous bleedings at the time of removal, these were absent after the 4-h check, and by light microscopic evaluation, only fragments of erythrocytes as a sign of the (hypo-osmolaric) fresh-water-induced haemolysis could be observed in blood vessels. A (relevant) wash-out effect by the fluid responsible for that rapid disappearance could be excluded since, in all cases stored in 0.9% NaCl solution, the bleedings were clearly detectable at this point in time and could still be observed up to l-2 days after removal. A minor wash-out effect of the fluid, however, cannot totally be excluded in our experiments and may explain the somewhat earlier disappearance of the bleedings in comparison with the specimens stored in the ‘moist’ chamber. In summary, our results indicate that in every case of advanced putrefaction and in particular in cases of fresh-water-logged corpses the absence of petechial haemorrhages must not be interpreted as a lack of these changes at time of death. Therefore, very special interest should be given to the preparation of the neck to detect other signs of throttling or strangulation. 5. References I. Gordon and R.A. Mansfield, Subpleural, subepicardial and subendocardial haemorrhages - a study of their incidence at necropsy and of the spontaneous development, after death, of subpericardial petechiae. J. Forensic Med., 2 (1955) 31-50. 1991. B. Knight, Forensic Medicine, Edward Arnold, London. Melbourne, Auckland, F. Bschor, Beurteilung van Stauungsblutaustritten im Kopfbereich bei Strangulation und anderen Todesursachen. Beifr. Gerichtl. Med., 25 (1968) 146-152. 0. Prokop and R. Wabnitz, Frequency of punctate conjunctival haemorrhages [Vorkommen van Bindehautblutungen bei Lebenden und Toten, dargestellt in 10 Tabellen]. Z. Rwh/smrd.. 67 (1970) 249-251.
F. Wolff, Zum Begriff der “lebensgefihrlichen Gesundheitsschiidigung” gem20 # 116 StGB als Folge van Wiirgen und Drosseln. Krim. Forensische Wiss.. 55156 (1984) 126- 129. G. Geserick and U. KImpfe, Zur Bedeutung van Stauungsblutungen bei der gewaltsamen Asphyxie. In B. Brinkmann and K. Piischel (eds.), Erstickm ~ Forrsc~hrittc in der Brwkfihrung. Springer. Berlin, Heidelberg, 1990, pp. 73-85. H. Reh and K. Haarhoff, The significance of the settling of blood into dependent and soft tissues as evidence for death by throttling and choking [Zum Beweiswert der Stauungs- und Weichteilblutungen beim Erdrosseln und Erwiirgen]. Z. Rrch~smc~tl.. 77 (1975) 47-60. B. Brinkmann. E. Koops, F. Wischhusen and M. Kleiber, Compression of the neck and arterial obstruction [Halskompression und arterielle Obstruktion]. Z Rrc~hrsmrd.. X7 (1981) 59-73. E. Koops, K. Piischel. F. Wischhusen, G. Fechner and B. Brinkmann, Zur Obstruktion der Halsarterien und der oberen Luftwege beim Wiirgen. Bci/r. Gerichtl. Med. 41 (1983) 315-321.
P. Berz et al. /Forensic
10
I1 12
Sci. Int. 64 (1994) 61-67
67
G. Adebahr, Value of cyanosis and petechiae in strangulation and concurrent severe anemia [iiber die Wertigkeit von Zyanose und Petechien bei Gewalteinwirkung auf den Hals bei gleichzeitig vorhandener erheblicher Anamie]. Z Rechtsmed., 86 (1981) 123-128. K. Walcher, ijber Erstickung. In W. Hueck and W. Frei teds.), Ergebnisse der aIIgemeinen Pathologic, Vol. 36, Bergmann, Munich, 1943, pp. 63-95. E. Koops, M. Kleiber and B. Brinkmann, iiber Befundmuster und besondere Befunde bei homicidalem und suicidalem Erdrosseln. Be&. Gerichtl. Med., 40 (1982) 129- 133.
Science International
Forensic
64 (1994) 61-67
The detection of petechial haemorrhages of the conjunctivae in dependency on the postmortem interval P. Betz*, R. Penning, ofLegal Department
Medicine. (Received
University
W. Keil
ofMunich, Frauenlobsrr. 7a, 80337 Munich. Germany
12 March
1993; accepted
4 June
1993)
Abstract Petechial haemorrhages of the conjunctivae are not specific for lethal throttling or strangulation, but they belong to the important indicators for such mechanisms. In experimental models it is shown that petechial bleedings of the conjunctivae disappear with the
occurrence of advanced signs of putrefaction or in cases of fresh-water logging. Therefore, it must be emphasized that the lack of petechial haemorrhages in putrefied or fresh-water-logged corpses is of very restricted meaning for the examination, whether throttling or strangulation has taken place or not, and the autopsy should always be performed in these cases with special regard to the neck.
Key words: Petechial haemorrhages;
Asphyxiation;
Putrefaction
1. Introduction Petechial haemorrhages, in particular of the conjunctivae, are one of the ‘classic’ signs of asphyxia. Even though they are not specific for death by asphyxiation, their occurrence can be regarded as an indicator for strangulation or throttling. On the other hand, petechial haemorrhages can both appear and enlarge as a postmortem phenomenon and are often present in normal postmortem hypostasis. Since a disappearance with advancing postmortem changes of the corpses has been described [ 11, the present study was performed to analyse the detection of such bleedings in relation to the postmortem interval and also in cases of fresh-water logging in an experimental model. * Corresponding
author.
0379-0738/94/$06.00 0 1994 Elsevier Scientific SSDI 0379-0738(93)01407-I
Publishers
Ireland
Ltd. All rights reserved.
62
P. Be/r (‘I 01. /Forensk
.%i. Inr
64 (1994)
61-67
2. Materials and methods Conjunctivae showing varying numbers of small pin-point bleedings were removed at autopsy from individuals dying of strangulation/throttling, thoracic compression or myocardial infarction. The postmortem interval ranged between a few hours and 2 days, but signs of (beginning) putrefaction could not be observed. Ten conjunctivae were stored at room temperature (1 SC) in a ‘moist’ chamber containing some water to avoid drying out of the tissue, but no contact between the specimens and the water was possible. Ten conjunctivae were stored in fresh-water and further 10 specimens in 0.9% NaCl solution. In addition, 5 specimens were stored in contact with air leading to drying processes of the tissue. The presence of petechial haemorrhages was controlled after 4 h, 8 h and then every day (i.e., 24.48 h and so on) until the bleedings had totally disappeared. Parts of the conjunctivae were removed and fixed in 4’%PBS-formaldehyde solution for light microscopic evaluation. After embedding into paraffin, sections were prepared with a thickness of 2-3 pm and stained with HE. 3. Results 3.1. ‘Moist ’chamber The punctate haemorrhages of the conjunctivae were detectable in all cases up to 2 days after removal, in spite of the original amount of the bleeding. On the third day, in cases with originally numerous petechiae, an unambiguous localization of at least isolated - haemorrhages was still possible in the pale and faded conjunctival tissue, but in conjunctivae showing only moderate amounts of bleeding at autopsy, all haemorrhages had disappeared by then. On the fifth day after removal, however, all petechiae haemorrhages had disappeared in the putrefied conjunctival tissue.
Fig. I. Conjunctiva
showing
numerous
petechial
haemorrhages
shortly
after
removal
at autopsy
P. Bei: et al. /Forensic
Sri. ht.
63
64 (1994) 61-67
-_
pp””
Fig. 2. Same specimen as in Fig. had disappeared,
I after a few hours of fresh-water the conjunctival
logging: all petechial tissue looks pale and edematous.
-
haemorrhages
In evaluation using a light microscope, relevant changes in the tissue structure could not be observed during the first and second day, even though some erythrocytes had ‘paled’ and were only detectable in the form of ‘ghosts’. In specimens obtained on the third day after removal, the nuclear staining was significantly reduced, but, in particular in conjunctival glands, rather well preserved. In specimens with naked eye detection of haemorrhages, the erythrocyte extravasates were clearly detectable by light microscopy even though an advanced number of erythrocytes were only present in the form of silhouettes. In all cases of advanced postmortem interval (5 days or more) no identification of erythrocyte extravasates was possible in the putrefied conjunctival tissue. 3.2. Fresh-water logging In all specimens investigated the haemorrhages were absent on the first check after 4 h and the conjunctivae seemed to be edematous and looked pale. Using light microscopy, no erythrocytes could be detected neither in blood vessels, nor in the form of extravasates. Only fragments of erythrocytes were observed in the blood vessels of the conjunctival tissue which showed a considerable relaxation of the structure in the form of an interstitial edema while the nuclei of some leukocytes could still be detected. 3.3. 0.9’S NaCl solution On the first day after
removal,
no reduction
in the amount
of the petechial
64
P. Bet: et al. /Forensic
Fig. 3. Punctate
bleeding
in the conjunctival
Sci. hi. 64 (1994) 61-67
tissue (see Fig. I) (paraffin.
HE. x95)
Fig. 4. Blood vessel showing only fragments of ruptured erythrocytes while the nuclei of leukocytic cells are still detectable, edematous swelling of the connective tissue (fresh-water-logged conjunctiva. see Fig. 2) (paraffin. HE. x 190).
P. Be12 et al. /Forensic
Sri. ht. 64 (1994) 61-67
65
haemorrhages could be observed. In some cases the number of pin-point bleedings seemed to have decreased after the second day and therefore somewhat earlier than in the specimens stored in the ‘moist’ chamber. After 3 days or more, haemorrhages could not be detected in the putrefied conjunctivae. The microscopical examination revealed similar results as described for the specimens stored in the ‘moist’ chamber. 3.4. Contact with air The drying process of the conjunctivae was linished at least approximately 12-24 h after removal and some of the haemorrhages were rather well preserved in the yellow-brown leather like tissue leading to an unambiguous detection of the pinpoint bleedings. The petechiae were still detectable after 4 weeks; a longer observation was not performed. A microscopical examination was impossible due to the consistency of the dried conjunctival tissue. 4. Discussion Petechial haemorrhages in the conjunctivae are one of the ‘classic’ signs of asphyxia [2] and can be observed in almost all cases of lethal throttling or strangulation, indicating their importance for such a diagnosis [3-51. Punctate pin-point bleedings of the conjunctival tissue, however, can also be observed in other natural and nonnatural causes of death [3,6] and occur occasionally following coughing fits, vomiting or during delivery [4]. Furthermore, petechial haemorrhages can develop can or enhance in hypostasis [ 1,7]. On the other hand, petechiae of the conjunctivae occasionally be absent in cases of lethal throttling due to a considerable discrepancy between the size of the throttling hand and the neck of the victim; also, in cases of non-typical throttling, the carotides can be compressed immediately leading to the absence of the conjunctival bleedings [6,8,9]. In addition, in cases of severe anemia, petechial haemorrhages can be absent [IO]. The small pin-point collections of blood extravasates are predominantly localized in regions with delicate loose connective tissue like the conjunctivae not significantly [ 111. They develop during asphyxia by throttling or resistant to blood extravasation strangulation due to the increased venous pressure in the head following compression of the veins while the arterial vessels are not totally obstructed, leading to ruptures of small blood vessels. Hypoxia is not assumed to be a relevant cause of development, but a possible contribution during longer intervals of oxygen reduction is controversal [2,6]. Since pin-point bleedings of the conjunctivae are an important indicator for lethal throttling/strangulation, their occurrence as a function of the postmortem interval is of interest to the forensic pathologist. Autolysis and putrefaction are assumed to lead to the disappearance of the petechiae [6,12] and Gordon and Mansfield [l] report on the postmortem disappearance of spontaneously developed bleedings in the visceral pericardium. In our experimental model, petechial haemorrhages could be found in all cases with a postmortem interval up to 2 days, but after 5 days the signs of putrefaction were so advanced that it lead to the disappearance of these bleedings in all specimens investigated. It is clear that these time-intervals cannot be applied to human condi-
66
P. Brrr
et ul. /Forensic
Sci. Inr. 64 (IYY4)
61-67
tions on methodological reasons (air moisture, temperature, differences in contact with air, etc.) but indicate that in cases of advanced putrefaction (for example haemoglobin-imbibition of the conjunctivae) the lack of pin-point bleedings is not necessarily connected with their absence at the time of death. On the other hand, our experiments provided evidence that these bleedings can be well-preserved in dried tissues. However, these results are only of rather restricted importance for forensic medicine, since in corpses the conjunctivae do not normally have such direct contact with the air as in our experimental model due to covering by the eyelid skin. Another important aspect of this study, however, seems to be the rapid disappearance of petechial haemorrhages in cases of fresh-water logging. In our series, even in specimens showing numerous bleedings at the time of removal, these were absent after the 4-h check, and by light microscopic evaluation, only fragments of erythrocytes as a sign of the (hypo-osmolaric) fresh-water-induced haemolysis could be observed in blood vessels. A (relevant) wash-out effect by the fluid responsible for that rapid disappearance could be excluded since, in all cases stored in 0.9% NaCl solution, the bleedings were clearly detectable at this point in time and could still be observed up to l-2 days after removal. A minor wash-out effect of the fluid, however, cannot totally be excluded in our experiments and may explain the somewhat earlier disappearance of the bleedings in comparison with the specimens stored in the ‘moist’ chamber. In summary, our results indicate that in every case of advanced putrefaction and in particular in cases of fresh-water-logged corpses the absence of petechial haemorrhages must not be interpreted as a lack of these changes at time of death. Therefore, very special interest should be given to the preparation of the neck to detect other signs of throttling or strangulation. 5. References I. Gordon and R.A. Mansfield, Subpleural, subepicardial and subendocardial haemorrhages - a study of their incidence at necropsy and of the spontaneous development, after death, of subpericardial petechiae. J. Forensic Med., 2 (1955) 31-50. 1991. B. Knight, Forensic Medicine, Edward Arnold, London. Melbourne, Auckland, F. Bschor, Beurteilung van Stauungsblutaustritten im Kopfbereich bei Strangulation und anderen Todesursachen. Beifr. Gerichtl. Med., 25 (1968) 146-152. 0. Prokop and R. Wabnitz, Frequency of punctate conjunctival haemorrhages [Vorkommen van Bindehautblutungen bei Lebenden und Toten, dargestellt in 10 Tabellen]. Z. Rwh/smrd.. 67 (1970) 249-251.
F. Wolff, Zum Begriff der “lebensgefihrlichen Gesundheitsschiidigung” gem20 # 116 StGB als Folge van Wiirgen und Drosseln. Krim. Forensische Wiss.. 55156 (1984) 126- 129. G. Geserick and U. KImpfe, Zur Bedeutung van Stauungsblutungen bei der gewaltsamen Asphyxie. In B. Brinkmann and K. Piischel (eds.), Erstickm ~ Forrsc~hrittc in der Brwkfihrung. Springer. Berlin, Heidelberg, 1990, pp. 73-85. H. Reh and K. Haarhoff, The significance of the settling of blood into dependent and soft tissues as evidence for death by throttling and choking [Zum Beweiswert der Stauungs- und Weichteilblutungen beim Erdrosseln und Erwiirgen]. Z. Rrch~smc~tl.. 77 (1975) 47-60. B. Brinkmann. E. Koops, F. Wischhusen and M. Kleiber, Compression of the neck and arterial obstruction [Halskompression und arterielle Obstruktion]. Z Rrc~hrsmrd.. X7 (1981) 59-73. E. Koops, K. Piischel. F. Wischhusen, G. Fechner and B. Brinkmann, Zur Obstruktion der Halsarterien und der oberen Luftwege beim Wiirgen. Bci/r. Gerichtl. Med. 41 (1983) 315-321.
P. Berz et al. /Forensic
10
I1 12
Sci. Int. 64 (1994) 61-67
67
G. Adebahr, Value of cyanosis and petechiae in strangulation and concurrent severe anemia [iiber die Wertigkeit von Zyanose und Petechien bei Gewalteinwirkung auf den Hals bei gleichzeitig vorhandener erheblicher Anamie]. Z Rechtsmed., 86 (1981) 123-128. K. Walcher, ijber Erstickung. In W. Hueck and W. Frei teds.), Ergebnisse der aIIgemeinen Pathologic, Vol. 36, Bergmann, Munich, 1943, pp. 63-95. E. Koops, M. Kleiber and B. Brinkmann, iiber Befundmuster und besondere Befunde bei homicidalem und suicidalem Erdrosseln. Be&. Gerichtl. Med., 40 (1982) 129- 133.