Rethinking asphyxia in forensic medicine: From an umbrella term to mechanism-based reporting

The term asphyxia is deeply embedded in forensic medicine, although its etymological meaning and contemporary use are not equivalent and the conditions grouped under it do not share a single pathophysiological pathway. Hanging, strangulation, choking, drowning, and thoracoabdominal compression may involve different and often overlapping contributions from impaired ventilation, hypoxia, hypercapnia, obstruction of cerebral venous drainage, reduced cerebral arterial inflow, hemodynamic compromise, and possible reflex cardiac effects. Neither these processes nor their relative contributions can always be established from post-mortem findings alone. We therefore do not propose a new diagnostic entity or a replacement for established cause-of-death terminology. Instead, we suggest a layered, evidence-sensitive reporting approach that distinguishes: (1) the precipitating event or etiological context; (2) the pathophysiological processes supported in the individual case; and (3) the downstream physiological consequences and limits of mechanistic certainty. This approach retains established terms such as hanging, drowning, and strangulation while discouraging the use of asphyxia as a self-explanatory mechanistic label. More explicit acknowledgment of interacting mechanisms and evidentiary limitations may improve scientific precision and medicolegal transparency.