The Autopsy Posts: Manual Strangulation & Petechial Hemorrhaging in the Face/Eyes

Today, Rabia Chaudry released the autopsy report for Hae Min Lee, whose death was the subject of the Serial Podcast. Obviously, this is pretty gruesome/disturbing material, so read it at your own risk.

So, what does the autopsy tell us about Lee's death? What does any autopsy tell us about anyone's death? What is the history of the autopsy? This will be a first in a series of posts about autopsies in general and this specific autopsy. Let's start with one particular entry on Lee's autopsy report:

I. Strangulation....

E. Petechial hemorrhage of the lower left palpebral conjunctiva

So, what is a "[p]etechial hemorrhage of the lower left palpebral conjunctiva," and how did it tend to support a finding that Lee was strangled?

Petechiae 

are pinpoint, round spots that appear on the skin as a result of bleeding under the skin. The bleeding causes the petechiae to appear red, brown or purple. Petechiae commonly appear in clusters and may look like a rash. Usually flat to the touch, petechiae don't lose color when you press on them. 

Petechiae are tiny, usually measuring less than an eighth of an inch (about 3 millimeters). Larger varieties of these types of spots are called purpura. Petechiae may indicate a number of conditions, ranging from minor blood vessel injuries to life-threatening medical conditions.

The initial important point to note is that

Petechiae do not prove strangulation and their absence does not disprove it; they are simply a marker of increased cephalic venous pressure (Ely & Hirsch, 2000; Hawley, McClane & Strack, 2001; Hawley, 2002). Ther presentations may include voice changes, hyperventilation, difficulty breathing, vomiting, aspiration, difficulty swallowing and adult respiratory distress syndrome.

Nonetheless, you are very likely to find petechiae in cases of strangulation. Here are some relevant excerpts:

From Moulton v. State, 395 S.W.3d 804, 806 (Tex.Crin.App. 2013):

The medical examiner explained that in eighty-five percent of manual strangulation cases, petechiae—small red or purple spots caused by a hemorrhage—are present in the eye.

From the transcript of testimony by Dr. Charles V. Wetli in Harrington v. United States, 2000 WL 35501294 (S.D. Iowa 2000):

Q. Dr. Wetli, I think you told us at your deposition that petechial hemorrhaging was found in 85 percent of the people that suffered traumatic asphyxia; is that correct?

A. No. In a study that we had done sometime earlier looking at 5,000 consecutive cases we found that 85 percent of the people who died, I believe it's from manual strangulation, had petechiae; but we did Q. Okay. Are there necessarily going to be petechial hemorrhages?

A. No. In probably 95 percent of the cases you get congestion of - you know, usually of the head and neck, and you get petechiae. But I've seen occasional cases where there have not been petechia.

From the deposition of Charles V. Wetli, M.D., in Glowczenski v. Taser International, Inc., 2010 WL 9929281 (E.D.N.Y. 2010):

Q. Under other circumstances, putting this case aside, what does it mean?

A. Basically it means there is an increased pressure that occurred in the head and neck region. The most common cause of this is sudden cardiac death, but that occurs in a relatively small percentage of people who die from sudden cardiac death. That's where you most frequently see it. You tend to see it in 85 to 91 percent of cases of manual strangulation. So when you see petechiae, you have to explain why they're there.

From the deposition of Werner U. Spitz in Williams v. Taser International, Inc., 2008 WL 5596663 (N.D.Ga. 2008):

Q. Is it still the case, as you said in your chapter, that 70 percent of strangulation victims have such hemorrhages, petechiae?

A. Yes, that's right.

(An interesting side note is that these latter three lawsuits all involved plaintiffs claiming that decedents died as the result of asphyxiation due to being shot by taser guns).

As you can see, it seems like somewhere in the neighborhood of 70-91% of strangulation victims exhibit petechiae/petechial hemorrhaging. Why? Check out this excerpt from State v. Maynard, 151 Wash.App. 1014 (Wash.App. 2009):

Expert testimony also established that the severity of petechiae—an injury resulting from sustained pressure causing blood vessels in the face and eyes to burst—indicated the level and type of force used in strangulation. The expert testified it takes about 30 seconds of sustained pressure to produce petechiae.

Thus, it is the sustained pressure from manual strangulation that likely causes petechial hemorrhaging. As some of the excerpts above noted, this petechiae is especially likely in the eyes and face. As noted, the autopsy report for Lee uncovered "[p]etechial hemorrhage of the lower left palpebral conjunctiva." The palpebral conjunctiva is "the part of the conjunctiva lining the posterior surface of the eyelids and continuous with the bulbar conjunctiva at the conjunctival fornices." 

As noted above, the presence of such hemorrhaging doesn't prove that Lee died from strangulation, and the absence of such hemorrhaging wouldn't disprove strangulation. That said, the finding is certainly consistent with a determination that Lee's death was due to strangulation.

-CM