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them; and that evidence ought not to be objected to which is partly founded upon facts of this nature.

It must occur to all, that without circumstantial evidence the best medical opinion in these cases will often amount to nothing. It may be, for example, no more than this: the case is either one of homicide or suicide; and why is such an indefinite answer to be returned? Because, in the abstract view of strangulation, it is not easy to determine whether a ligature was suicidally applied round the neck or not. The appearances may be in many cases the same; and where they are different, this difference may be due to accident; so that it is a mistake to suppose that we must look to medical circumstances alone for clearing up this intricate question.

There is, perhaps, one instance which may justify a presumption of homicide. A man, in strangling himself, is not likely to vary the means: it is commonly due to a sudden impulse, if we may judge from the moral proofs afforded in the instances on record. The article which is nearest to the suicide is seized, and made the instrument of destruction. It has already been stated as doubtful whether a person could strangle himself by the mere application of the fingers to the trachea; the discovery of such marks only as would indicate this kind of strangulation, therefore, renders suicide in the highest degree improbable. But if, besides these marks of fingers, we find a circular mark, with the ligature still around the neck, the presumption of murder becomes, indeed, strong. It may be said, that an individual might at first try to strangle himself with his fingers, and, not succeeding, might afterwards employ a cord. But the degree to which the coincidental impressions exist will assuredly in general remove this objection. A murder was committed some years since in this country in the manner here stated. A gentleman of fortune was found strangled on board of a ship in the port of Bristol. Besides the mark of a rope drawn tightly round the neck, there were distinct impressions of nails and fingers in front of the throat. An investigation took place, and the result proved, as, indeed, this state of the neck rendered it almost certain, that the deceased had been murdered. It was afterwards confessed by one of the murderers, that they had first strangled him with their hands, and then drew the rope about his neck, to insure the certainty of his death.

In concluding this account of strangulation, it may be remarked, that attempts are sometimes made to attribute traces of violence on the neck to accidental causes, notwithstanding the almost entire certainty of their being homicidal. Thus, when a man is found dead with a mark on the neck, it will be argued that the deceased might have fallen while in a state of intoxication, and have become strangled by his cravat, his head being at the same time bent forwards. The witness will be asked whether death was not possible under such circumstances. In returning an answer, he should take care to let it be understood, that what is physically possible is not always medically probable.

The marks of strangulation on the throat may be sometimes ascribed to the deceased having fallen with his hand possibly applied to his neck, and the inference will be drawn that they have accidentally resulted from the pressure of his own fingers; but this is a very improbable mode of accounting for the production of ecchymosis or excoriation of the skin.

CAUSES OF SUFFOCATION.

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SUFFOCATION.

CHAPTER LX.

SUFFOCATION FROM MECHANICAL CAUSES-VARIOUS FORMS OF CASES-CAUSE OF DEATHPOST-MORTEM APPEARANCES-EVIDENCE OF DEATH BY SUFFOCATION-ACCIDENTAL, SUICIDAL, AND HOMICIDAL SUFFOCATION-MEDICAL AND PHYSICAL EVIDENCE OF THE CAUSE OF DEATH-CASES-SMOTHERING.

Suffocation from mechanical causes.- -By suffocation we are to understand that condition in which the air is prevented from penetrating into the lungs, not by constriction of the trachea, but by some mechanical cause operating on the mouth externally, or fauces and larynx internally. In this sense, it will be perceived that drowning is nothing more than death by suffocation.

There are many varieties of death by suffocation, all of which are of great medico-legal interest. 1. The continued pressure of the hand over the mouth and nostrils, or the placing of a plaster or cloth over these parts, combined with pressure on the thorax: this was formerly not an unfrequent form of homicidal suffocation. 2. Smothering, or the covering of the head and face with articles of clothing, &c., which effectually prevent respiration. 3. The accidental or forcible introduction of foreign bodies into the mouth and throat. 4. The plunging of the face into mud, snow, dust, feathers, or similar substances. In all of these cases death takes place from asphyxia, and with great rapidity, if the chest sustains at the same time any degree of forcible compression. 5. Swelling or spasm of the glottis produced by the contact of corrosive substances. A case was referred to me in July, 1848, in which death was probably thus caused by the application of a strong solution of pernitrate of mercury to an ulcer in the fauces.

Suffocation may also arise from morbid causes, such as a diseased state of the parts about the fauces, a morbid enlargement of the thymus gland, the sudden bursting of a tonsillary abscess, or the effusion of lymph, blood, or pus into the windpipe, or about the rima glottidis. Any of these causes may suddenly arrest the respiratory function; a fact which can only be determined by a proper examination of the body. Two cases of death from suffocation produced by mechanical causes have been reported; the one by Dr. Geoghegan, who has communicated to me the particulars, and the other by Dr. Jackson, of Leith. Dr. Geoghegan's case was that of a boy, who died in half an hour under alarming symptoms somewhat resembling those of poisoning, and it appeared that a simple medicinal powder had been given to him about five minutes before the attack! On inspection, the lower part of the trachea was found blocked up with cheesy scrofulous matter:-it was evident that the child had died from asphyxia. Dr. Jackson's case is perhaps one of the most remarkable on record. A man, aged 31, was put to bed drunk, having previously vomited; and shortly afterwards he was found dead. On inspection, Dr. Jackson discovered the usual appearances of asphyxia, i. e. congestion of the lungs and of the right cavities of the heart. He was thus led to examine the trachea carefully, and he found, lying over the

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rima glottidis, a thin and transparent piece of potato-skin, so closely applied to the fissure as to prevent respiration. The man had died suffocated from this mechanical cause. He had had potatoes for dinner the day before; the piece of skin had probably been thrown up at the time of vomiting, and had been drawn back by inspiration into the singular position in which it was found. Owing to intoxication, the deceased was probably unable to cough it up. I agree with Dr. Jackson in thinking that this case conveys a most important caution. In England, the verdict would most probably have been, "Died by the visitation of God," without a post-mortem inspection! The result clearly shows that in every case of sudden death there should be a strict investigation of all parts of the body. (Ed. Med. and Surg. Journ., April, 1844, 390.) I am indebted to Mr. Richardson, of Mortlake, for an interesting case of death from suffocation, caused by the vomiting of the contents of a full stomach, a portion of the food having blocked up the throat. A similar case is reported by Mr. Matthews, Lancet, Aug. 31, 1850, p. 262. Such facts show the absolute necessity of making a careful post-mortem examination in all cases of sudden death. Children are often suffocated from small portions of food penetrating into the air-passages; and unless an inspection be made, death may be easily referred to some natural cause. (See case by Mr. Synnot, Med. Gaz. xl. 994; and also Lancet, May 16, 1846, 561.) In some instances, a retraction of the base of the tongue may lead to the suffocation of a new-born child. (Seller's Journal, March, 1845, 278.)

Cause of death.-It has been already stated that death takes place by asphyxia; and this occurs with a rapidity proportioned to the degree of impediment existing to the passage of the air. There does not seem to be any reason to attribute death to apoplexy. The congestion of the cerebral vessels may be regarded as a consequence of the disturbance of the functions of the lungs. If the veins of the neck were opened so as to prevent an accumulation of blood in the cerebral vessels, it is pretty certain that the prevention of respiration would destroy life under the same circumstances and within the same period of time. Therefore we may regard death from suffocation as resulting from pure asphyxia. Post-mortem appearances.-There are rarely any considerable marks of violence externally. When the body has become perfectly cold, there may be patches of lividity diffused over the skin; but these are not always present. The lips are livid, but the skin of the face is often pale. The mouth, throat, and parts about the larynx, should be examined for foreign substances. Internally the lungs and right cavities of the heart are distended with blood:-the left cavities either contain but little blood, or are empty. The viscera may here and there present patches of ecchymosis. The cerebral vessels are sometimes congested; but at other times they do not appear more than ordinarily full. All other appearances are of an accidental nature, and are not at all connected with death by suffocation. (See cases by Casper, Med. Gaz. vol. xliv. p. 1084; also a series of papers by Mr. B. W. Richardson, Med. Gaz. xlvii. p. 359, et seq.)

Evidences of death from suffocation.-In medical jurisprudence, there is not, perhaps, an instance in which we have fewer medical data upon which to base an opinion, than in the case of alleged death from suffocation. The inspection of the body of a person suffocated presents so little that is peculiar, that a medical man, unless his suspicions were roused by circumstantial evidence, or by the discovery of foreign substances, would probably pass it over as a case of death without any assignable cause; in other words, from natural causes. In examining the body of the woman Campbell, who was murdered by Burke, in Edinburgh, Dr. Christison was unable to come to a conclusion respecting the cause of death until some light had been thrown on the case by collateral evidence. On this occasion a violent death was suspected because there were marks of violence externally, and the face of the deceased exhibited the characters of strangulation; but these conditions are by no means essential to death from suffocation, and when they exist, they can only be regarded as purely accidental accompaniments.

ACCIDENTAL DEATH FROM SUFFOCATION.

521

Appearances similar to those found in the bodies of suffocated persons are very frequently met with in post-mortem inspections when death has taken place as a consequence of disease or accident. They can, therefore, furnish no positive evidence of the kind of death; they do not even permit us to establish a presumption on the subject until, by a careful examination of the body, we have ascertained that there is no other cause of death depending on organic disease or on violence. Medical evidence may, however, be highly serviceable in some instances. Thus, let the general evidence establish that a deceased person has probably been suffocated,-the witness may have it in his power to state that the appearances in the body are not opposed to the supposition of this kind of death; that the body is in all respects healthy and sound; and that the death was probably sudden, as where, for instance, undigested food is discovered in the stomach. In all cases of this description, we must bear in mind that our opinion relative to the supposed cause of death is to be formed from the medical circumstances only, unless it be otherwise ordered by the Court. From this want of clear evidence, great difference of opinion on the cause of death will exist among medical witnesses. In the case of Reg. v. Heywood (Liverpool Summer Ass. 1839,) some of the witnesses referred death to suffocation, others to apoplexy. (Lancet, Sept. 14, 1839, 896.)

Accidental, suicidal, and homicidal suffocation. Suffocation is by no means uncommon as an accident; and there are several varieties of accidents under which a person may die suffocated. 1. Disease about the tongue, larynx, or fauces, may advance to such an extent as effectually to impede respiration. 2. The deceased may have fallen, so that the mouth became covered with dust, or other substances; and if the subject be helpless, as an infant or an aged person, or one who is intoxicated, death may thus easily take place. A child was found dead in a room, with its face in the ashes under the grate. It had fallen during the absence of the mother, and, from its helpless condition, had speedily become suffocated. Some of the ashes were found in the windpipe. (Med. Gaz. xvii. p. 642. For a case in which suffocation was caused by a pea, see the same journal, xxix. 146.) In trials for murder or manslaughter, a medical opinion respecting the possibility of the accidental suffocation of a drunken person, under similar circumstances, is very often required. These subjects, it must be remembered, are generally to be considered as helpless as children:-if they fall in a position so that the mouth be covered, it is possible that they may have been so intoxicated as not to be able to escape. 3. A portion of food may have remained fixed in the larynx or fauces. Children are often accidentally suffocated from drinking boiling water from a tea-kettle. The parts about the larynx then become swollen from the action of the hot water, and respiration is arrested. 4. Accidental suffocation is not uncommon among infants, when they sleep with adult persons. A child may be in this way very speedily destroyed. Even the close wrapping up of a child's head may effectually kill it, without any convulsive struggles to indicate the danger to which it is exposed. These convulsions by no means necessarily attend on death from suffocation.

A few years since, a coroner's inquest was held on the body of a child, which was found dead in a bed; and I assisted a friend in the post-mortem inspection. It was lying in a composed attitude on the bed, with the face nearly covered. There were faint traces of cadaverous lividity about the neck and back; but the body did not present the least mark of violence. The face was pale, but the lips were livid. On examining the chest, the great vessels connected with the heart and lungs were found congested with blood. The vessels of the brain were empty. There were no morbid appearances whatever in any of the other organs. The account given by the girl who attended the child was, that she had laid it to sleep about nine o'clock in the morning, covering over the greater part of its face. She remained in the room; but in the course of an hour, not hearing the child breathe, she looked and found it dead. The only opinion which we were

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HOMICIDAL SUFFOCATION.

asked to give, was,-whether, from the circumstances, suffocation was probable? We answered in the affirmative; and a verdict of accidental death was returned. This case shows the ease with which an infant may be destroyed, even when its respiration is only partially impeded. The weight of the clothes may have combined to cause death, by preventing the free expansion of the chest.

Those instances of accidental suffocation which depend on disease or the impaction of food, are easily known by a post-mortem examination:-generally speaking, they present no difficulty. (See case, Med. Gaz. vol. xlii. p. 970; also Lancet, Sept. 2, 1848, p. 259.) But in other cases, e. g. when a child or a drunken person is presumed to have been suffocated owing to the position in which he has fallen, evidence as to the position of the body, or even actual sight of the body, is necessary before forming an opinion. The following questions may here arise:-Was the position such as to be explicable on the supposition of accident? Was it not such a position as might have been given to it by a murderer? Could not the deceased have had strength or presence of mind to escape? Could he have been actually suffocated in the position in which his body was discovered? A little reflection upon the circumstances, for here something more than medical circumstances will be required,-may enable us to give satisfactory answers to these questions.

It

Suicidal suffocation. As an act of suicide, suffocation is extremely rare. would require a peculiar adaptation of means, and considerable resolution, in order that a person should thus destroy himself. The following case occurred in France some years since. A woman locked herself in her room with her young child-she placed herself under the bed clothes, and desired the child to pile the several articles of furniture in the room upon her. When the apartment was entered some hours afterwards, the woman was found dead. She had evidently been suffocated. Had not the child clearly detailed the circumstances, a strong and even justifiable suspicion of murder might have arisen. In the case of a body found with a plaster covering the mouth and nostrils, or the traces of such having been applied, the witness might be asked whether this could have been so placed by the individual himself? No such case has ever occurred as an act of suicide; but we are not, therefore, to say it is impossible; all that we are justified in stating is, that it is a highly improbable mode of self-destruction.

Some singular cases are on record, in which individuals have wilfully destroyed themselves by blocking up the fauces mechanically. A remarkable instance of this form of suicide is reported in the Ed. Med. and Surg. Jour. April, 1842. A woman, confined in prison, forced a hard cotton plug into the back of the fauces. The cavities of the chest and abdomen had been already examined, and a medical certificate given that the deceased had died of apoplexy! The body was sent to one of the anatomical schools, and, on re-inspection, it was then accidentally found that the fauces were firmly blocked up with a plug of spindlecotton. A similar case was the subject of an inquest in London, in September, 1843. The deceased here had thrust into her throat a large piece of rag, which had been used in applying a lotion. She speedily died suffocated, and after death the rag was found lodged at the back part of the larynx. The internal organs in these cases present no particular appearances indicative of the kind of death. Such cases are very likely to be mistaken for apoplexy, and they certainly show the absolute necessity for a careful post-mortem examination in every instance of sudden death. (See Ed. Med. and Surg. Jour. liv. 149; also, Med. Chir. Rev. xxviii. 410.) The case of Reg. v. Heywood, Lancaster Sum. Ass. 1839, proves how easily a defence of apoplexy may be sustained in a case of alleged murder by suffocation.

Homicidal suffocation. Homicide by suffocation is not very common, although it is a very ready means of perpetrating murder. Hitherto, the cases which have come before our courts of law have been those of infants or of aged and infirm persons. In regard to the latter subjects, the rigorous administration of the law