99. _Biggs and Jenkins: New York Med. Jour., 1890, lii., p. 30._—Case

16; child, 6 months old, sitting on a high chair, fell between the chair guard and seat and was asphyxiated by compression of neck. See also Tidy (_op. cit._), Cases 53 and 54. SUFFOCATION. The term suffocation is applied in a special sense to the act and condition of preventing access of air in other ways than by pressure on the neck, as by pressure on the chest, by obstruction at the mouth or nose, by obstruction in the air-passages or on them from neighboring organs, by irrespirable gases, etc. This article will consider all of these except drowning and irrespirable gases, which are treated of elsewhere by other writers. =Smothering= is generally understood to mean the act and effect of stopping the mouth and nose. CAUSES. =External Causes.=—OVERLAYING is a frequent cause of suffocation in infants, which in such cases have usually occupied the same bed with one or both parents. In some cases the parents have been drunk or otherwise unable to prevent the injury, and the infant may also be partly stupefied with the alcohol derived from its mother’s milk. Infants are also sometimes overlaid by domestic animals. Again, they have been suffocated by being pressed too closely to the mother’s breast, or by covering with bedclothes, shawls, etc. Noble[883] attributes some cases of asphyxia in the new-born to anæmia of the brain from pressure on the skull by forceps, etc., and recommends as treatment for this condition hanging the child head downward, so that the blood may gravitate to the brain (Cases 12 and 30). Infants are sometimes smothered for mercenary purposes. Persons have been suffocated by the pressure of a crowd. Pressure on the chest combined with forcible closure of the mouth and nose was the method of Burke and Williams, in the notorious _burking_ murders (Case 58). The close application of a hand, cloth, or plaster over nose and mouth is of itself sufficient to cause suffocation, especially in children and feeble persons. Pressure on the abdomen crowds up the diaphragm and interferes with breathing. It is very likely that no external mark will be found in cases of pressure on the chest and abdomen, but the lungs will be marbled and emphysematous. Taking plaster casts of the face and neck without inserting tubes in the nostrils has caused death in some cases. Suffocation often follows the falling of walls, houses, banks of earth, piles of coal or corn or wheat. One may fall into and be imbedded in some mobile substance as coal, wheat, corn, quicksand, or nightsoil, and be suffocated. Infants have been destroyed[884] by burying them in manure, ashes, bran, etc. In these cases there is not only the entrance of the foreign body into the air-passages, but the pressure of the mass against the chest and abdomen. =Internal Causes.=—The air-passages may be closed up by foreign bodies within them, or within adjoining organs, especially the œsophagus. A great variety of substances in one of these two ways has caused suffocation: mud, cotton, rags, corn, meat, beans, pepper, potato skins, the fang of a tooth, artificial teeth, buckles, shells, flint, buttons, screws, crusts of bread, bones, fruit, stones, heads of grass, coins, slate pencils, nuts, nut-shells, shot, penholders, worms, fish, etc. (see Cases 6 and 55). Taylor[885] states that there were eighty-one deaths in one year in England and Wales from food in the air-passages. Should an inspiration occur in the act of vomiting, the vomitus may pass into the air-passages; a similar accident may occur in a person who attempts to swallow and speak at the same time. Infants have been suffocated by inspiring vomited milk. Fitz[886] states that food may pass from the digestive tube to the air-passages after death. A case of suffocation in an infant by retraction of the base of the tongue is recorded. It has been stated that negroes have committed suicide by doubling back the tongue into the throat, or, as it is called, swallowing the tongue.[887] In giving anæsthetics, the subject being supine, and the head and neck somewhat flexed, the tongue, epiglottis, and soft palate may fall backward and suffocation may follow. Howard[888] states that pulling the tongue forward under such circumstances may reopen the pharynx, but will not lift the epiglottis. The thorax should be raised and head and neck extended backward. He believes that in giving anæsthetics the head should be lower than the shoulders. In order to avoid vomiting no food should be taken for some hours before the anæsthetic. Cases are recorded of artificial teeth having fallen from the mouth into the air-passages during anæsthesia and sleep, and in epileptic and puerperal convulsions. It would appear advisable that these teeth should be worn only while eating (Case 13). Hemorrhage from the lungs, from rupture of an aneurism or from injury of the mouth or throat, may make its way into the air-passages and cause suffocation. So also the bursting of an abscess of the tonsils or other part near the air-passages (Case 7). Œdema of the glottis from scalding or other irritation of the fauces or glottis, or from disease of the kidneys; tumors pressing on some portion of the air-passages; rapid, profuse bronchial secretion in infants; acute double pleuritic effusion; cheesy glands ulcerating into trachea; simultaneous œdema of both lungs—all of these may cause suffocation (Cases 18 and 49). [For cases of enlarged thymus gland, see Hofmann, _op. cit._, pp. 587, 588.] Paralysis of the muscles of swallowing, from diphtheria or other cause, predisposes to suffocation. Progressive asthenia in which the muscles are exhausted; injury of spinal cord or pneumogastrics; paralysis of muscles of respiration from the use of curare; the spasms of tetanus and strychnia poisoning; the entrance of air into the pleural cavities with collapse of the lungs—all tend to cause mechanical suffocation either by pressure or by paralysis (for deaths in epileptics, see Cases 1, 10, 11, 33, and 40). It is not necessary that the air-passages should be _absolutely_ closed to cause suffocation. The _cause of death_ is more likely to be pure asphyxia, because of the absence of the complicating pressure of the hand or ligature on the vessels and nerves of the neck, and of fracture of larynx or vertebræ. =Symptoms.=—Foreign bodies[889] entering the trachea naturally fall toward the right bronchial tube instead of the left because of the size and position of the entrance of the right tube. If then but one tube is involved, the signs will usually be on the right side; whereas if the foreign body stop in the larynx or trachea, both sides will be affected. The latter condition is much more dangerous. The symptoms would be resonance over the lung with the respiratory murmur partly or wholly absent; less mobility; puerile breathing on the unaffected side. In either case there may at first be little disturbance, especially if the shape of the foreign body is such as not to greatly interfere with the access of air; otherwise there may be at once, and almost always will be after a time, more or less urgent dyspnœa. Diminution of the necessary oxygen may cause convulsions, apoplexy, and other brain symptoms. Acute emphysema of the portion of lung not obstructed may follow its forcible distention. The local effect of the foreign body is an irritation which causes spasm and cough. It may be carried upward by the expirations and downward again by each inspiration. Inflammation is likely to appear eventually and may involve the lung. If the obstruction is not complete there may follow periods of alternation of good and bad health, ending perhaps in recovery. The foreign body may be expelled after a greater or lesser interval. On the other hand death may result from secondary causes. In the absence of correct history the symptoms may lead to a wrong diagnosis and inappropriate treatment; as where a patient whose symptoms resulted from the presence of a piece of bone in the larynx, was treated for syphilis. A foreign body may be coughed up from the lung into the trachea and fall backward into the opposite lung. Partial closure of the larynx, most likely caused by a flat or irregular substance, rather than globular, may cause gradual asphyxia with symptoms of apoplexy, making the diagnosis difficult. When a foreign body remains a long time in the larynx, spasmodic cough and croupy breathing usually ensue, expectoration tinged with blood, hoarseness, or complete aphonia, pain, dyspnœa, possibly crepitation and dulness over the lungs. The case may end suddenly in death from closure of the glottis, or the foreign body may pass into the trachea and set up a new train of symptoms, or it may be expelled. The frequency with which foreign bodies in the pharynx or œsophagus obstruct respiration, and the facility with which they may usually be removed, suggest a careful examination. Otherwise the patient may be treated indefinitely for supposed obstruction in the air-passages. Foreign bodies in the œsophagus have perforated into the trachea, and even the lungs, heart, and aorta. In complete suffocation death will occur in from two to five minutes (see remarks under Strangulation). Death may also occur instantaneously. The experiments of the Committee on Suspended Animation[890] showed that when the trachea of a dog was exposed, incised, and a tube tied in, the average time covered by the respiratory efforts after stopping up the tube with a cork was four minutes five seconds; the heart-beat stopping at seven minutes eleven seconds on the average. After four minutes ten seconds it seemed to be impossible for the dog, unaided, to recover. Faure[891] made the following experiment upon a large dog: He fixed a cork in the trachea. At first the dog was quiet; it then extended its neck, parted its jaws, and made efforts as if to vomit; then tried to walk, but its gait was uncertain; fell down and rose up. Its eyes became dull, and finally it fell down on its side, and became convulsed; then after several seconds stretched itself out. The thoracic movements were at first tumultuous, then became rapidly feeble; the heart beating very slowly. At the necroscopy the lungs filled the thorax, were full of thick dark blood and emphysematous. The blood was black and fluid in the left ventricle and arteries, and in the right cavities and veins resembled molasses. Liver darkly congested. There was no mucus in the trachea and no ecchymosis in the lungs. He also (p. 306) tried the experiment upon a large dog of fastening boards against its thorax and tightening them by means of cords. For some minutes it was quiet, but suddenly it became much agitated, stood upon its hind legs, threw itself against the wall, rolled on the ground, and uttered frightful cries; finally fell on its side. There was no movement of the thorax, but the muscles of the neck and belly were in full and rapid action, dry and sonorous râles were heard, and a large quantity of mucus appeared at the nose and mouth. The movements grew feebler, the respirations infrequent, and at the end of thirty-four minutes it was dead. The necroscopy showed the blood black and thick; heart relaxed; lungs red, a little emphysematous, containing but little blood, and on their surface were blackish points and small red spots. The death of Desdemona (Shakespeare’s “Othello”) has been much criticised. The declaration that she was strangled (or suffocated) does not consist with the symptoms described (see _Med. News_, Philadelphia, May 1st, 1886, p. 489). TREATMENT. The obvious indication is to search for and remove the obstruction. The means and methods of treatment are fully treated of in surgical works, but may be briefly mentioned here. Laryngoscopical examination may be necessary. A curved forceps is usually the best instrument for removing the foreign body. A tallow candle may serve to push it into the stomach if there is no bougie at hand. Suction may be used. Sneezing may be brought on by tickling the nostrils; coughing by tickling the glottis; vomiting by irritating the fauces, or by emetic; the body of the subject may be inverted and in this position the fauces may be tickled, or fingers may be passed back into the pharynx. Johnson[892] says that at the moment of inversion the patient should try to take a deep inspiration; this opens the glottis and facilitates the expulsion of the foreign body. The inspiratory current has no appreciable effect in retarding the movement of the foreign body in the direction of gravity. Noble recommends inversion of the body in new-born infants in which asphyxia may be supposed to be due to anæmia of the brain. Tracheotomy or laryngotomy may be necessary. It may be necessary to administer oxygen. Foreign bodies like beards of grass and fish-heads can be withdrawn only with difficulty because of their sharp projections. Intense suffering and dyspnœa in a robust subject may necessitate venesection. Generally speaking it is better to bring up the foreign body than to push it down into the stomach. Beveridge suggests to blow into the ear, to induce a reflex action and cause expulsion of the foreign body. Cold affusions, artificial respiration, galvanism, frictions of the limbs, artificial heat, stimulants by mouth and rectum, may one or all be needed. Hamilton[893] says that it is useless to expect good results from electricity if five minutes have elapsed since life appeared to be extinct; Althaus,[894] that three hours after death the muscles will cease to respond to faradization; and Richardson,[895] that a low temperature prolongs the sensitiveness of the muscle. With regard to insufflation, Le Bon[896] objects to it in asphyxia as being hurtful and not useful. Colin[897] tamponed the trachea of a horse; in four minutes fifty seconds it was apparently dead; the tampon was removed and insufflation practised for fifteen to twenty minutes without effect. He claims that artificial respiration is useless after the circulation ceases. Fell[898] and O’Dwyer[899] recommend forced inspiration. McEwen[900] uses a tracheal tube by the mouth. Dew[901] offers a new method of artificial respiration in asphyxia of the new-born; Lusk[902] considers the subject of life-saving in still-births; Forest,[903] artificial respiration in the same; Read[904] discusses Schultze’s method with approval; Duke[905] plunges the infant into hot water; Richardson[906] recommends artificial circulation by injection of vessels, or electric excitation; Jennings[907] recommends the same; Richardson[908] also considers fully the subject of artificial respiration and electrical excitation; Woillez[909] has described and recommended what he calls a spirophore. After the removal of a foreign body the irritation remaining may cause a sensation as if the body was still lodged. Death may occur from hemorrhage after its removal. POST-MORTEM APPEARANCES. These are mainly those of asphyxia. There may also be evidences of external violence, homicidal or accidental, as of pressure on the chest. Persistent deformity, flattening of the nose and lips, and excoriation of these parts may result from forcible closure of mouth and nose. The SKIN AND CONJUNCTIVA usually show patches of lividity and punctiform ecchymoses; especially lividity on the lips and limbs. The face may be pale or violet; it is often placid, especially if the suffocation is accidental. Tardieu[910] admits that infiltration of the conjunctiva and punctiform ecchymoses of the face, neck, and chest may also be found sometimes in women after severe labor, and in epileptics. He records the result of the examination of those who died from suffocation at the Pont de la Concorde, 1866. The face and upper parts of the trunk were generally light red to a deep violet or black color, with punctated blackish ecchymoses on the face, neck, and upper part of chest. The EYES are usually congested. Mucus and sometimes bloody froth are found about the NOSE and MOUTH. The TONGUE may or may not protrude. The BLOOD is usually dark and very fluid. Wounds after death may bleed. According to Tardieu[911] fluidity of the blood is most constant in compression of the chest and abdomen, as also its accumulation in the vessels and right side of heart. Its color varies from red to black. The BRAIN and pia mater are generally congested. This is said to be invariable if the eyes are congested. Mackenzie in thirteen cases found the brain congested in all. The HEART varies much in appearance and condition. The right side is often full of blood; occasionally empty. Sometimes subpericardial ecchymoses are found, usually along the coronary vessels. The blood in the heart may be partly coagulated if the agony has been prolonged and there has been a partial access of air, which is gradually diminished. Mackenzie[912] found the right cavities full and the left empty in nine out of thirteen cases. Johnson[913] as a result of experiment on animals claims that when access of air is prevented there is a rise in pressure in the arteries, the right side of the heart fills, the pulmonary capillaries become empty, and therefore the left side of the heart becomes empty. As a result of further experiments[914] he verified his former conclusion, and added that in the last stage of asphyxia there is increased pressure on the pulmonary artery and lessened pressure in the systemic vessels. He thinks[915] that when both sides of the heart contain blood, there is paralysis of vaso-motor nerves and the arteries. The TRACHEA is usually bright red and often contains bloody froth. The LARYNX or trachea as well as PHARYNX or ŒSOPHAGUS may contain a foreign body. If the latter has been removed the resulting irritation may be seen. The LUNGS are sometimes congested, at others normal; color red or pale. Sometimes one lung only is affected. They may be emphysematous. Mackenzie found them congested in all of thirteen cases examined by him. The lungs of young persons may be found comparatively small, almost bloodless, and emphysematous. Tardieu, Albi, and others believed that the _punctiform subpleural ecchymoses_ indicated suffocation, and were due to small hemorrhages from engorged vessels which ruptured in the efforts at expiration. These spots are usually round, dark, from the size of a pin-head to a small lentil, and well defined. They are not like the petechiæ in the lungs and heart after purpura, cholera, eruptive fevers, etc., nor like the hemorrhages under the scalp after tedious labor, all of which are variable in size. These punctiform spots are usually seen at the root, base, and lower margin of the lungs. Hofmann states (“Lehrbuch”) that they are found in the posterior part of the lungs and in the fissures between the lobes. They are indisputably frequent after death from suffocation, and if well marked either in adults or infants that have breathed, they indicate suffocation, unless some other cause of death is clear. Simon, Ogston, and Tidy, however, have shown that they are sometimes absent in fatal suffocation, and are sometimes present in the absence of suffocation, as after hanging and drowning; in fœtuses before labor has begun; often in still-births, although some of these are probably due to suffocation from inhaling fluid or from pressure. Also in death from scarlet fever, heart disease, apoplexy, pneumonia, and pulmonary œdema. Grosclaude[916] quotes from Pinard, who declares that these ecchymoses are found in fœtuses which die from arrest of circulation. Grosclaude himself made a large number of experiments on animals by drowning, hanging, and strangling, and fracturing the skull. The ecchymoses were found in nearly all the cases. The ecchymoses are partly the result of venous stasis, which overcomes the resistance of some capillaries; and the latter rupture, partly from the aspirating action of the thoracic wall, the lung being unable to fill itself with air, but mainly[917] from vaso-motor contraction and lateral pressure at the maximum of the asphyxia, the time of tetanic expiration. If the asphyxia is interrupted before this stage, the spots do not appear. Similar ecchymoses may be found under the scalp, in the tympanum, retina, nose, epiglottis, larynx, trachea, thymus, pericardium, in the parietal pleura, along the intercostal vessels, rarely the peritoneum, in the stomach, and sometimes the intestines; and in other parts of the body, especially the face, base of neck, and front of chest; in convulsive affections, as eclampsia and epilepsy, and in the convulsions of strychnia and prussic acid poisoning there may be suffusion and congestion of the lungs though not the punctated spots. Mackenzie, in thirteen cases of suffocation from various causes, failed to find the Tardieu spots either externally or internally. Briand and Chaudé[918] state that they are less constant and characteristic in those who have been buried in pulverulent substances. Ogston[919] holds that in infants that are smothered the ecchymoses are found in greater number in the thymus gland; while in adults dying from other forms of asphyxia they were found only once in that gland. The spots are found in clusters in infants that are smothered, but only single and scattered in adults who die from drowning, hanging or disease. They were wanting in the lungs of but one infant. They may be recognized as long as the lung tissue is unchanged. The apoplectic spots in the lungs seen in strangulation are not found in suffocation. Tardieu[920] from experiments on animals and examination of twenty-three new-born infants who showed traces of violence around the mouth, found the lungs rather pale and anæmic, subpleural ecchymoses well marked. All the deaths were rapid. In cases of compression of chest and abdomen[921] the congestion of the lungs was extensive, and pulmonary apoplexy frequent; more so than in other forms of suffocation. He gave strychnia to animals which died in convulsions, and found very irregular and partial congestions, generally not marked because death was so prompt; blood always fluid; no subpleural ecchymoses. The LIVER, SPLEEN, and KIDNEYS are generally congested; the kidney more than the other organs named. The spleen is said to be often anæmic. Semen has sometimes been found, unexpelled, in the urethra. Page[922] experimented on three kittens, suffocating them in cinders. The post-mortem examinations showed the veins engorged, left side of heart empty, right side full of dark, half-clotted blood. Lungs distended, much congested, color violet; many small fluid hemorrhages in substance; no subpleural ecchymoses. Frothy mucus tinged with blood in trachea and bronchi; bronchi congested. Brain and abdominal organs normal. PROOF OF DEATH BY SUFFOCATION. It is sometimes difficult in a given case to state WHETHER DEATH IS DUE TO SUFFOCATION. There is no lesion which of itself could be accepted as proof. But a collation of the lesions found taken in connection with the surroundings of the body will in many if not in most cases lead to a definite conclusion. Infants have been found alive four and five hours after having been buried in the earth.[923] If the pulverulent material has penetrated into the œsophagus and stomach, the burial has occurred during life. Exceptionally when burial has occurred after death and traces of the material are found in the air-passages, they are _not_ found in the œsophagus or stomach. The committee on “Suffocation,” of the New York Med. Leg. Soc., reported[924] the following group of appearances as evidences of death by suffocation: The general venous character of the blood, the turgidity of the larger veins, the congestion of the parenchymatous organs, especially at the base of the brain, the lungs congested in a variable degree and œdematous, frothy mucus in the bronchi, the right side of the heart always fuller than the left. Fitz[925] holds that suffocation is a condition composed of a group of symptoms and appearances due most probably to accumulation of carbon dioxide in the blood and a deficiency of oxygen. The appearances are: The blood dark and fluid (though in gradual suffocation there may be clots in the right side of the heart), the right side of the heart full, venous congestion of the lungs (not constant), interstitial emphysema of the lungs, and venous congestion of the liver, kidneys, and brain. He prefers the word _engorgement_ to congestion in this connection. Tardieu[926] holds that when in infants buried in pulverulent substances we find emphysema of the lungs in high degree, bloody froth in the air-passages, abundant subpleural and subpericardial ecchymoses and the blood fluid, the burial has occurred during life. The same lesions are found in small animals similarly treated. It must not be forgotten that an intoxicated person or one in an epileptic spasm is practically helpless, and can, therefore, be suffocated, accidentally or otherwise, under circumstances in which one in possession of his senses would be able to escape. ACCIDENTAL, HOMICIDAL, AND SUICIDAL SUFFOCATION. =Accidental suffocation= is frequent, as has already appeared. =Suicidal suffocation= is very rare. =Homicidal suffocation= occurs. Foreign bodies have been forced into the air-passages. Smothering has been done by holding the face in various materials to prevent access of air; by pressure on the chest; by forcible closure of the mouth and nose as in burking; by laying compresses over the face, as in the case of King Benhadad,[927] whom Hazael killed. “And it came to pass on the morrow that he took a thick cloth and dipped it in water, and spread it over his face so that he died; and Hazael reigned in his stead.” Benhadad was already quite ill and not expected to live. Death by suffocation[928] may be considered as presumptive of homicide unless the facts are already referable to accident. In infants, suffocation is, of course, either accidental or homicidal; in adults usually accidental. The absence of signs of a struggle in adults suggests accident; unless there is cause of suspicion of previous stupefying with narcotics. Taylor[929] calls attention to a dangerous practice among some attendants upon infants, of putting into the mouth of the child to quiet it a bag containing sugar; and instances a case in which the child would have died of suffocation but for the fortunate discovery of a part of the bag protruding from the mouth. In ten years, 3,612 deaths were reported in the city of London, of infants smothered by being overlaid.[930] Infants may be born into a mass of blood and fæces, from which the unattended mother in her weakness may be unable to remove them. Page[931] shows by experiment that the inspiratory effort when violently exerted is sufficient to convey small objects into the air-passages. Cinders passed thus into the trachea and œsophagus of kittens and rabbits. Berenguier[932] experimented on new-born pups, placing them in ashes, plaster, and starch. In ashes they lived fifteen hours; these found their way into the middle of the œsophagus, but were stopped at the glottis. Plaster and starch formed a paste with the oral mucus and the movement of the mass was not so great as the ashes. In no case did either of the materials pass beyond the glottis. Tardieu[933] examined three infants which had been buried during life. One was in ashes: the nose was obstructed, mouth full: ashes also in the œsophagus and stomach, but none in larynx or bronchi. The second infant was in manure; a greenish stuff was found in the mouth and stomach. The third in bran (confessed to by the mother); the nose and mouth were full, but there was none in the throat; a few grains in the trachea. Tardieu experimented on rabbits and Guinea pigs by burying them in bran, sand, and gravel, some of them being alive and the others dead. In those buried alive he found the substance filling the mouth and nose to the base of the tongue; in most of the cases the œsophagus and trachea were not penetrated. In the animals first killed and then buried, the substance had not passed into the mouth or nose. In one case only he found ashes in the larynx and trachea of a rabbit which had been buried many hours after death in a box of ashes. Matthyssen[934] held a Guinea pig, head downward, with its nose under mercury; the lungs were full of globules of mercury (which has a specific gravity of 13.5). A dog was plunged head first into liquid plaster-of-Paris; the plaster was found in the bronchial tubes. ILLUSTRATIVE CASES. ACCIDENTAL.