CHAPTER VIII
SUFFOCATION, HANGING, STRANGLING, AND THROTTLING
SUFFOCATION
Death from suffocation is said to result from any impediment to the respiration which does not act by compressing the larynx or trachea.
Suffocation may therefore be caused by pressure on the chest, as in persons crushed in a crowd. It may also be due to the respiration of certain gases, or to the presence of pulverulent substances in the air, which act by choking up the air-passages. Imprisonment in any confined space may cause death from suffocation, and abscesses bursting into the trachea, or vomiting matters in drunken persons lodging in the windpipe, may be attended with a like result. Pressure on the umbilical cord whilst the child is in the maternal passages causes death from suffocation.
=Signs of Death by Suffocation.=--The first effect of arrest to the passage of air into the lungs is the stagnation of blood in the capillaries of the lungs. Non-arterial blood then goes to the brain and consciousness is soon lost. The respiratory sensation is then arrested by the circulation of venous blood. The left side of the heart becomes emptied, and then weak; the right side full and engorged. The great venous trunks are also more or less full, and the abdominal viscera, liver, spleen, and kidneys congested. The arrest of the heart‘s action is a secondary effect; the right side is paralysed by being too full, the left by being empty. These signs may be said to be typical, or, rather, are to be expected in death due to suffocation, but it must be distinctly stated that they are not always present. The right side of the heart is not in all cases engorged with blood; and Christison warns medical men against expecting “strongly marked appearances in every case of death from suffocation.” The heart, moreover, continues to contract after the lungs have ceased to perform their duty. Death is thus due to apnœa--that is, death beginning at the lungs--and not to syncope. Death in some cases is from neuro-paralysis or nervous apoplexy. In death by shock, which in most cases is instantaneous, both sides of the heart are equally filled. Death, the result of disease, may present all the signs of death from suffocation, and no suspicion may be aroused as to the cause of death from the _post-mortem_ appearances, especially if putrefaction have set in.
The following table is given as an aid to diagnosis in this form of death:
Points to be noticed in forming a Diagnosis of Death by Suffocation
1. _The Blood._--There is _unusual fluidity_ of the blood found in death by suffocation, however produced. This condition is sometimes present in deaths due to certain diseases, fevers, &c., and in cases of narcotic poisoning. Even with the blood in this condition, the presence of coagula in the cavities of the heart is not infrequent. The colour of the blood is changed to a dark purple, but in suffocation by carbon monoxide it is red.
2. _Animal Heat._--In persons who have died from suffocation the animal heat is long retained.
3. _Cadaveric Rigidity._--Other things being equal, the _rigor mortis_ is as well marked in this kind as in other forms of death.
4. _The Lungs._--Hyperæmia of the lungs is rarely absent. In most cases both lungs are engorged in about equal proportions. Hypostasis--_post-mortem stains_--must not be mistaken for capillary engorgement.
5. _The Heart._--Engorgement of the right side of the heart, the left being empty, or nearly so. It is advisable always to examine the heart first, and then the lungs. The pulmonary artery is also much congested.
6. _Capillary Ecchymoses._--These appear as purplish-red spots on the pulmonary pleuræ, on the surface of the heart, aorta, in the thymus, and on the diaphragm. They may appear on the above-mentioned parts in a fœtus suffocated _in utero_ by pressure on the cord. These ecchymoses are rarely seen on adults, most frequently on infants, due probably to the thinness of the coats of the capillaries, which are ruptured in the efforts made to breathe. They are not a positive sign of death from suffocation, as they have been seen in death due to cholera, typhus, and other diseases. They are present also where death is due to hanging, drowning, &c.
7. _Condition and Appearance of the Trachea._--The mucous membrane of the trachea is injected, and appears of a cinnabar-red colour. This is present in every case of death by suffocation, and must not be confounded with the dirty cherry-red or brownish-red coloration due to putrefaction. Remember also that the trachea putrefies early. If suffocation be slowly produced, a quantity of frothy mucus may be found in the windpipe, and also in the smaller tubes of the lungs. Always examine, especially in cases of supposed infanticide, the trachea for foreign bodies, the presence of soot, &c. The presence of sand, ashes, &c., in the œsophagus and stomach in persons buried in these materials, is presumptive of the person having been placed in them prior to death.
8. _Kidneys, Vena Cava, &c._--The quantity of blood in the kidneys is always considerable. The abdominal veins are all more or less congested, and the external surface of the intestines presents numerous traces of venous congestion.
9. _The Brain._--Apoplexy of the brain, as secondary to the pulmonary apoplexy, may be more or less present, attended by its well-known appearances.
10. _Face, Tongue, and Mouth._--The expression of the face is not characteristic of death by suffocation, and differs in no particular from that common to other forms of death, being more frequently pale than turgid; and the starting of the eyes, popularly ascribed to this form of death, is not often seen. The tongue may or may not be protruded beyond the teeth. The presence of _froth_ about the mouth is not constant, and is of common occurrence in those dying from natural causes. The tympanum may be ruptured.
=Was the suffocation homicidal, suicidal, or accidental?=--Suffocation may occur accidentally during the act of swallowing, and by foreign bodies placed carelessly in the mouth and then drawn suddenly into the windpipe, or by blocking the pharynx or œsophagus, also from being smothered by sinking into sand, grain, mud, and such-like, or by the bed-clothes in cases of epilepsy during a fit. Examine the lips for the presence of ecchymosis and other marks of violence. A man, some years ago, was accused of having caused the death of his wife by strangulation, for which he was indicted, and tried before the High Court of Justiciary in Scotland. The _post-mortem_ examination revealed the cause of death as due to suffocation, and the following injuries were found on dividing the windpipe, which contained a quantity of frothy mucus: in the interior of the larynx there was a considerable extravasation of blood lying beneath the investing membrane, and passing up on both sides and behind, as far as the chink of the glottis, and above that opening into the ventricles of the larynx. There was here, also, a fracture of the right wing of the thyroid cartilage, by which its lowest horn was wholly detached, and the cricoid cartilage was broken in two places at opposite sides of its ring. The defence was that she had fallen accidentally while in a state of drunkenness, and had thus produced the fatal injuries.
The man was acquitted, the legal opinion in favour outweighing the medical opinion against the theory of accident. The above case created some discussion at the time, and induced Dr. Keiller to make several experiments as to the possibility of fracturing the cartilages of the larynx. The following are his conclusions:
1. That _ordinary_ falls on the human larynx are apparently not capable of producing fractures of its cartilages, and even _falls from a height with superadded force_ appear to be unlikely to do so.
2. That _severe pressure applied from before backwards_, so as strongly to compress the larynx against the vertebral column, or _violent blows inflicted over the larynx by means of a heavy body_, are sufficient to cause fractures of the larynx. Fractures so produced, however, will be most discernible on the _internal_ surface, and generally _in or near the mesial line_.
3. _Violent compression_ applied to the _sides of the larynx_ (as in ordinary _manual throttling or strangulation by grasping_), is, of all applied forces, the most likely to produce fractures of the alæ of the thyroid cartilage, or even of the cricoid cartilage, and fractures so produced are most perceptible, as well as most extensive, on the _external_ surface of the larynx. By this _lateral_ mode of applying force, the _hyoid bone_ is almost most readily broken.
4. That the condition of the larynx in regard to the absence or presence of ossific deposit materially influences its liability to fracture from external violence. If altogether cartilaginous, partial slits or splittings may be produced. If partly ossified, fractures may be produced by a comparatively moderate degree of applied violence, and if extensively or entirely ossified, extreme violence will generally be required to produce laryngeal fracture (_Edinburgh Medical Journal_, 1855-56).
Homicidal suffocation may be due to forcibly introducing foreign bodies into the air-passages, especially in children; adults suffocated thus are generally under the influence of alcohol or drugs, or enfeebled from disease. Suicidal suffocation by these means is generally limited to lunatics.
[Illustration:
Fig. 16.--The pulse in this case became slower than normal. Five minutes after the drop the type reached that of bradycardia, then recovered itself, and even 14½ minutes after the drop was beating with normal frequency, but in the meantime had become very feeble.
1. The day before execution, 102 per minute. 2. 5 minutes after the drop, 54 per minute. 3. 7 minutes, 102 per minute. 4. 10 minutes, 96 per minute. 5. 13 minutes, 66 per minute. 6. 14½ minutes, 72 per minute.]
[Illustration:
Fig. 17.--The pulse in this case became accelerated and then fell again, but was feeble throughout.
1. The day before execution, 84 per minute. 2. 3½ minutes after the drop, 162 per minute. 3. 4 minutes, 156 per minute. 4. 5½ minutes, 132 per minute. 5. 6½ minutes, 102 per minute. 6. 9 minutes, 84 per minute. 7. 11½ minutes, 78 per minute. 8. 12½ minutes, 78 per minute.]
[Illustration:
Fig. 18.--In this case the pulse rate increased, and then fell to 72 per minute towards the end.
1. 1 week before execution, 60 per minute. 2. 2½ minutes after the drop, 162 per minute. 3. 3 minutes, 138 per minute. 4. 3½ minutes, 132 per minute. 5. 4½ minutes. 6. 5¼ minutes, 168? per minute. 7. 5¾ minutes, 108 per minute. 8. 7 minutes. 9. 8½ minutes. 10. 10 minutes, 72 per minute. 11. 12 minutes.]
Homicidal suffocation by compression of the chest has been effected in infants; in adults it is combined with the covering of the nose and mouth. The victims are generally old or enfeebled. Suffocation of infants may be homicidal, or accidental, due to “overlaying”; in the latter the greatest mortality is amongst the youngest infants. A child ten months old may struggle and free itself or awaken the mother.
In France a favourite mode of committing suicide by suffocation is the use of irrespirable gases--carbonic acid, carbon monoxide, and the like. Collateral circumstances must be taken into consideration, and will more or less help to point to the true cause of death.
The cause and nature of the death in all of its forms just mentioned are in general the same. Pressure on the trachea--thus arresting respiration--and also on the important vessels and nerves of the neck, results in death, which may be brought about in four different ways:
1. Cerebral congestion, or apoplexy. 2. Congestion of the lungs and heart--apnœa or asphyxia. 3. Combination of above--apoplexy and asphyxia or apnœa. 4. Neuro-paralysis--nervous apoplexy, or syncope.
The following table will show the relative frequency of each form of death:
Remer. Casper. Apoplexy 9 9 Asphyxia 6 14 Mixed 68 62 -- -- 83 85 -- --
=Traumatic asphyxia= occurs when a heavy weight such as a fall of earth or masonry compresses the chest, and thoracic respiration is impossible. The head and neck appear ecchymosed, the purplish-blue lividity generally ending abruptly at the lower part of the neck or upper part of the thorax, about the level of the clavicles. The conjunctivæ are ecchymosed, and there may be epistaxis. This discoloration does not disappear on pressure by the finger, indicating its petechial character. If the person survive long enough, the discoloration gradually disappears, passing through the colour changes of an ordinary ecchymosis.
The effects on the eyes may be such as to be followed by changes in the retina, and optic atrophy leading to loss of vision.
Parts of the neck pressed upon by clothing may escape ecchymosis, and present a white mark of almost normal skin.
HANGING
Death by hanging is caused by the more or less perfect suspension of the body by a cord applied around the neck, the weight of the body
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The body need not hang completely, partial suspension is sufficient to cause death. The ligature surrounds the neck above the thyroid cartilage, the epiglottis is pushed against the back of the pharynx, the base of the tongue and the soft parts are pressed into the cavity of the pharynx, so that the obliteration of the naso-pharyngeal and the laryngeal passages is complete. Death is due to asphyxia and pressure on the cervical blood-vessels, even if the air-passages be not completely occluded; stoppage of the cerebral circulation being sufficient to cause death; in such a case the signs of asphyxia are absent.
Consciousness is quickly lost, due to pressure on the vessels, and, for this reason, in accidental or suicidal hanging the person is prevented from making any effort to save himself.
=Post-mortem Appearances.=--The _external appearances_ are more or less those described under “Death from suffocation.” In the greater number of cases the face bears a quiet, placid expression, no turgidity or lividity being noticeable. The eyes are usually half open, but not protruded, and the condition of the pupils variable. The tongue may be protruded, but just as often not. The face may be pale or livid, and a bluish colour present on the free border of the lips. Cyanosis and swelling of the face are only present when the death agony has been long; they soon disappear.
Ecchymosis of the conjunctiva, and on the outer surfaces of the lids may be present. The escape of urine, fæces, and semen may take place, but are not characteristic, and are extremely rare.
Casper states that in not one of the many cases he had examined of persons hanged has he ever “found an erection of the male organ,” and he also asserts that the emission of semen is extremely rare. Seminal emissions take place more frequently in persons who have been shot, and also in those who have been poisoned by irrespirable gases or by hydrocyanic acid. As a test of strangulation, it is therefore worthless. Tardieu, however, only noticed the escape of urine and fæces in two out of forty-one cases; it is by no means a test of hanging, as it may occur after death if the body is shaken in a cart, or roughly used when first found. A fat person dying of apoplexy may have a mark round the neck as if strangled. Injury to the spinal cord due to fracture or dislocation of the cervical vertebræ is rare in suicidal hanging. Fracture of the spinal ligaments and of the hyoid bone is also rare. Rupture of the internal and middle coats of the carotid arteries sometimes occurs. But it appears that considerable damage is done to the soft parts of the neck by the present judicial mode of hanging with the “long drop.”
Dr. Dyer has recorded (_New York Medical Journal_, vol. iii., 1866) some experiments he made on the eyes of a man and some dogs killed by hanging. He found certain transverse fissures across the lens, which he is inclined to think are characteristic of this mode of death. Dr. R. F. Hutchinson states that an invariable sign of death from hanging is _the flow of saliva out of the mouth, down the chin, and straight down the chest_. The appearance is unmistakable and invariable, and _could not occur in a body hung up after death_, the secretion of saliva being a living act (Chevers). Death from hanging may take place although the toes or other parts of the body rest on the ground. Death is complete in four or five minutes.
=Marks of the Cord, &c.=--The mark of the cord is nearly always present. It varies with the breadth and hardness of the ligature, but is often interrupted. Its irregularities are reproduced on the skin. It is sometimes only seen on one side. In strangling, the mark is low down, most frequently encircling the neck; in hanging, the mark is generally above or on the thyroid cartilage, and carried obliquely upwards. The mark of the cord may be of a dirty yellowish-brown colour, and, when cut into, feels more or less hard and leathery. In general appearance it is not unlike the mark left by mustard-plasters or blisters applied within a short time of death. This effect is probably produced by the rubbing off of the epidermis, and subsequent drying up of the cutis on exposure to the air. At other times the mark may be of a dirty reddish or bright blue colour; or, lastly, there may be little or no mark present, or the edges may assume a livid red coloration, being nothing more or less than a _post-mortem_ stain.
=May the mark of the cord be produced after death?=--On this point Casper says: “That any ligature with which any body may be suspended or strangled, not only within a few hours, but even days after death, especially if the body be forcibly pulled downwards, may produce a mark precisely similar to that which is observed in most of those hanged while alive.” And the same authority also adds that “the mark of the cord is a purely cadaveric phenomenon.”
=Accidental= hanging is rare, and generally happens with children while playing at hanging, or by accidentally becoming entangled in a window-blind cord or swing rope, or by the neck-band of an article of clothing by which they may become accidentally suspended from the spike of a railing.
=Homicidal= hanging is rare, but the body may be suspended after death from violence, to simulate suicide; and it may have to be decided whether the hanging took place during life or after death.
The mark of the cord is of no assistance, rents in the carotids with extravasation into the coats of the vessels indicate _ante-mortem_ suspension. The flow of saliva down the chin to the body indicates suspension before death. It is important to examine the body for injuries which could not be self-inflicted, and to remember the possibility of poison having been administered with suspension after death.
=Suicidal= hanging is the most common, as it is a favourite mode of death with suicides. The absence of marks of injury on the body found suspended, and the want of evidence as to a previous struggle having taken place, all point to suicide. The fact that the feet are found in contact with the ground does not militate against the probability of suicidal hanging; and it appears that in India the natives seldom hang themselves from any height, and are most frequently found with their feet on the ground. A person may take poison first, and hang himself before the poison has had time to prove fatal.
STRANGLING
Death is due to pressure made on the neck by any form of ligature carried circularly round the neck, without suspension. The cord in hanging is, as a rule, placed more obliquely than in strangling.
The mode of death is the same as in hanging. The _post-mortem_ appearances are similar to those of hanging, practically those of asphyxia. The mark on the neck is the principal feature. In position it is generally horizontal and situated below or on a level with the thyroid cartilage. It more completely encircles the neck. It may be interrupted in places if an irregular ligature has been used, causing irregular pressure. Its character depends largely upon the nature of the ligature. If the constriction has been uniform a continuous depression is produced which may be marked by ecchymosis. If the skin has been abraded, the line dries, and has a brownish, parchment-like appearance and feeling. If the ligature has been removed before life is quite extinct, the depressed line may disappear or be but slightly evident.
A soft, broad ligature may leave no mark on the neck, if not applied too tightly, or for too long a time. Should the victim have been strangled in the recumbent posture, and dragged upwards and backwards by the ligature, the mark will be on a slant as in hanging. According to the amount of violence used injuries may be caused to the deeper structures of the neck, such as effusion of blood into muscles, fractures of the thyroid or cricoid cartilage; rupture of the tympanum and epistaxis may take place.
=Accidental= strangulation may occur when a cord suspending a weight on the back and passing across the chest slips and encircles or compresses the neck.
Falling out of bed, with entanglement in the clothes or nightdress, may cause strangling by tightening of the neck-band round the neck.
=Homicidal= strangling is as common as homicidal hanging is rare. It is difficult to hang a man, but easy to strangle him, because consciousness is rapidly lost, and the victim is unable to offer any resistance once the cord is tightened round the neck. In homicidal strangling the murderer generally uses a great deal more violence than is necessary, and so there is found after death much more local injury in such cases.
Severe local injuries, such as fracture of the laryngeal cartilages or hyoid bone, denote homicide, as they are rarely noticed in suicidal strangulation.
There may also be signs of general violence about the face, neck, chest, or other parts of the body. The position of the knot affords no material help, as the murderer may tie it in any position, but more than one knot, especially if in different positions, points to homicide. It must be remembered that finger-nails or other marks in the vicinity of the ligature may be present in cases of suicides, from the slipping of the cord or the determined attempts of the suicide to carry out the act, or plucking at the cord involuntarily. When a person is first strangled, then hung, there would be two marks--one probably horizontal, the other slanting.
=Suicidal= strangulation is rare. The knot is generally adjusted at the front or side of the neck, the cord may encircle the neck several times. Injuries to the deep structures of the neck are absent. Signs of general violence are not necessarily present.
If there be two marks upon the neck, one due to an attempt at strangulation, the other to suspension, in a suicide, the first would be the less marked, the latter more pronounced, whereas in homicide the strangulation mark would be most distinct.
THROTTLING
Throttling is strangling by means of the hand or hands alone, and is due to constant pressure of the fingers upon the throat. Very little pressure is required to occlude the glottis; it can be done with slight pressure of the thumb and forefinger on the side of the thyroid cartilage.
The impression of the fingers and thumb upon the throat have characteristic marks. They are usually to be seen on both sides of the throat. The thumb mark is on one side, and the marks of the fingers, separated from one another or clustered together, are on the other, the thumb mark being the highest. When grasped from the front by the right hand, the thumb mark will be on the right side of the throat. If the victim be throttled by the two hands at the same time, as when on the ground, the thumb marks are on the same side. If the assailant be left-handed, and has used this hand to grip the throat, the thumb mark will be on the left side of the victim. The finger marks are one above the other. The marks may appear as ecchymoses if the examination be made soon after death; if later, they may appear and feel like parchment, and of a brownish colour. Crescentic marks of finger-nails may be present, also other scratches in the vicinity. Other marks of general violence may be present, and should the victim have fallen to the ground, the head may be injured. Much blood is effused in the tissues of the neck and the laryngeal cartilages, and the hyoid may be found fractured; the carotids may escape injury, but not always.
The mucous membrane of the cheeks may be found lacerated. Where the victim is thrown to the ground and knelt upon, fracture of the ribs and ecchymosis of the chest wall may occur.
In a case examined by me of combined strangling and throttling, marks of the ligature and fingers were both present, and on the clavicles separate marks produced by the knuckles while tying the cord. These knuckle marks did not show up till some time after death. Effusions of blood were present in the tissues of the neck on each side of the larynx, and amongst the muscles on both sides, and in the sheath of the left carotid artery.
The hyoid bone was fractured in two places in its left half. The thyroid cartilage was fractured vertically on each side of the middle line into three pieces, the central portion having fallen behind the other two into the cavity of the larynx. The right wing of the thyroid was comminuted. The cornua were fractured. The cricoid cartilage was also fractured posteriorly, and into three pieces in front. Effusions of blood in the fractured areas had formed beneath the mucous membrane. Effusion of blood was present on the front wall of the pharynx and the upper part of the œsophagus. The right carotid artery was atheromatous, and linear and star-shaped fissures were present, the latter surrounded by a ring of sub-intimal effusion of blood.
On the right side of the thorax the fifth rib was fractured at the junction with its cartilage, and on the left side the second, third, fourth, fifth, and sixth ribs were fractured close to their cartilages, and again from three to five inches further back. Blood effusions in the tissues of the chest wall and under the pleuræ were present in the region of the fractures.
A handkerchief was found tight on the neck and tied with two knots both fastened securely. It was probable that the handkerchief had been tied on after the throttling, as the knot ends were too short to allow a sufficient pull on them to cause the injuries. Throttling may be regarded as a homicidal act; although one or two instances of suicidal throttling have been recorded in the insane.
=Judicial Hanging.=--In judicial hanging the prisoner is suspended by a rope with a running noose around the neck, after a sudden drop of from six to eight feet according to the weight of the body. The noose may be arranged with the knot or slip-ring fixed at the side below the ear, or in front so as to jerk the head backwards. The sudden and severe strain upon the neck produces fracture or dislocation of the spinal column at the second or third cervical vertebra, with rupture of the spinal cord. Other local injuries occur, such as rupture of cervical muscles, fracture of the larynx, and even lacerated wounds of the neck. The head has even been severed completely from the body, and the deep structures of the neck have even been so lacerated that the body has hung by skin only, stretched to the thickness of two or three fingers. Death is said to take place from shock, pressure on the vagi, and asphyxia, probably also cerebral apoplexy. When death is instantaneous, the body hangs motionless, the head fallen over the side opposite the knot, and the neck stretched.
The heart may, however, continue to beat for a varying period after apparent death--in some cases even as long as 14½ minutes. The following interesting series of pulse tracings were taken by Dr. Llewellyn Morgan, of Liverpool, and kindly placed at my disposal. In No. 1 the heart beats could be recorded at the wrist for 14½ minutes after the drop; in No. 2 for 12½ minutes; and in No. 3 for 12 minutes. The frequency and character of the beat is variable, but in each case shows a practically normal rate towards the end. (See Figs. 16, 17, 18.)
Apart from the local injuries to the neck, the external appearances in judicial hanging are similar to those in other forms.
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