Written by Dr. D. Rao

This is a form of asphyxia which results from forcing a cloth into the mouth, or the closure of mouth and nose by a cloth or similar material, which is tied around the head. A gag (such as rolled up cloth ) pushed into the mouth sufficiently deep to block the pharynx will cause asphyxia. Initially, the airway may be patent through the nose; collections of saliva, excessive mucus with oedema of the pharynx and nasal mucosa, progressively causes complete obstruction. In adults, false dentures may impact in the throat and sometimes during anaesthesia. In injuries to the nose and mouth, blood may seep into the back of the throat and clot. It is almost always homicidal and the victim is usually an infant. It is not possible for one person to gag and bind another. Sudden death due to reflex vagal inhibition may occur.

Gagging is usually resorted to prevent the victim’s shouting for help, and death is usually not intended. The victim’s hands are tied behind to prevent their removing the gag, and the legs are tied together to prevent walking or running for help. It should be noted, as to how the cloth piece is wrapped round the nose and mouth, how it is tied, and how far the mouth gag is stuffed inside the mouth.


Overlaying or compression suffocation results due to compression of the chest, so as to prevent breathing. It occurs when the mother or other person shares a bed with an infant. During sleep, the older person rolls on to or crushes the infant. The thoracic movements are limited and respiratory exchange is either reduced or completely prevented. In many such cases, the mother or older person goes to the bed under the influence of alcohol. It is very rare. Flattening of the nose and face may or may not be seen. These parts are pale. The nostrils are often filled with froth, which may be blood-stained and this may stain the pillow or garment. The usual findings are those of asphyxia.


Burking is a method of homicidal smothering and traumatic asphyxia. William Burke and William Hare, killed 16 persons in Edinburgh during the years 1927 and 1928, and sold their bodies to Dr. Robert Knox for use as specimens in his anatomy classes. A victim was invited to their house and given alcohol. Then the victim was thrown to the round and Burke used to kneel or sit on the chest and close the nose and mouth with his hands, and Hare used to pull him round the room by the feet.


Choking is a form of asphyxia caused by an obstruction within the air-passages.

Accidental Choking: Choking is almost always accidental. Choking from objects being lodged in the throat is commonly seen in the very young, elderly, psychiatric patients or in the infirm, particularly where the ability to swallow or masticate is severely impaired. Choking commonly occurs during a meal when food is accidentally inhaled, especially when the victim is laughing or crying. Vomited matter may be inhaled by a person under the influence of drink or of an anaesthetic, during a fit of epilepsy, or while in a state of insensibility from other causes. Infants usually regurgitate clotted milk after a meal, and this may fall into the larynx. Choking may occur due to inhalation of blood from facial injuries, such as a broken nose, or dislodged teeth, and laceration of the lips and gums inflicted during fight, if the victim becomes unconscious and lies on his back. Impaction of solid bodies, such as a large bolus of fold, piece of meat, fruistone, corn, button, coin, rag, rubber teat, seeds, live fish, mud, leaves, cotton, or a set off false teeth amy cause asphyxia. Gauze packs inserted during an operation can be inhaled and cause death. children often place objects like marbles or coins in their mouths, which may pass into larynx or trachea during a sudden deep inspiration. Objects like rubber balloons may be inhaled by children during play. Choking due to regurgitation of food may occur during rape or violent sexual intercourse. In head injury, irritation of the brain causes vomiting, which may be inhaled. The foreign body becomes arrested at, or just below the vocal cords and may produce an inflammatory reaction with oedema. Food aspiration following suppression of the gag reflex by tranquilizing drugs is sometimes seen in lunatic asylums. Microscopically, lungs show intense interalveolar oedema and collection of desquamated respiratory type epithelium. If there is struggle to breathe and attempts to remove the occluding object are unsuccessful, asphyxial changes are well marked. When a foreign body is inhaled, there is immediate acute respiratory distress, but once this has passed, the victim has little subsequent distress. Complications may develop after a latent interval.

Suffocation may occur from diseases, such as diphtheria, infectious mononucleosis, H. influenzae infection in children, rupture of aortic aneurysm in air-passages, haemoptysis in pulmonary tuberculosis, a tuberculous gland eroding into a bronchus and prolapsing into its lumen, acute oedema of the larynx due to inhalation of steam or ingestion of irritant substances, pharyngeal abscess, laryngeal and bronchial growths, haemorrhage into the trachea, etc., and from the effects of certain poisons. Insect bites especially those of bees, wasps and hornets, and drug reaction from penicillin, etc., can cause swelling of the lining membranes of the larynx and death within a few minutes due to an allergic reaction. A blow to the front of the neck may cause sever swelling of the mucosa of the airway due to oedema and haemorrhage. Death may occur due to reflex vagal inhibition.

Choking from external causes may occur from impaction of a relatively large foreign body, a bolus of food, or a denture in the oesophagus, compressing the trachea.

Suicidal Choking: It is rare. The victims are usually mental patients or prisoners. For this a foreign body is thrust into the throat.

Homicidal Choking: Choking as a mode of infanticide may be caused by stuffing a wad of paper or cloth into the pharynx or larynx. It is very rare and is practicable only when the victim is suffering from disability or disease.

Cause of Death: (1) Asphyxia, (2) Cardiac inhibition is the common cause, (3) Laryngeal spasm. (4) Delayed death may result from pneumonia, lung abscess or bronchiectasis.

Mechanism of Death: Large foreign bodies may be impacted in the pharynx and cover the opening of the larynx. By completely obstructing the airway, such impacted bodies may cause death from hypoxic hypoxia or anoxic anoxia. A small cause death by laryngeal spasm. Usually laryngeal spasm passes off before the hypoxia becomes fatal. Sudden reflex neurogenic cardiovascular failure is probably produced by reflex parasympathetic cardiac inhibition. Impaction of a foreign body at the bifurcation of the trachea may cause death by asphyxia, but irritation in this region usually causes parasympathetic cardiac inhibition. A foreign body impacted in a bronchus may produce reflex cardiac inhibition.

CAFÉ  CORONARY: This is a condition in which a healthy but grossly intoxicated person (restaurant patron), who begins a meal, suddenly turns blue, coughs violently, then collapses and dies, without much fuss. Death appears to be due to sudden heart attack. At autopsy, a large piece of poorly chewed food (bolus or a piece of meat) may be found obstructing the larynx. The clinical signs of choking are absent, because of the high blood alchohol content which anaesthetizes the gag reflex.

Treatment: A blow on the back or on the sternum may cause coughing and expel the foreign body. If this is not successful, the foreign body should be removed from the hypopharynx with the middle and index fingers or with forceps.

Autopsy: The foreign body which caused the occlusion of air-passages will be found in the mouth, larynx or trachea. When food or vomited matter has been inhaled, particles of food material may be observed embedded in thick mucus in the trachea and bronchi, and particles may be drawn into the bronchioles which distinguishes the condition from those cases in which food is forced up the oesophagus and falls into the larynx after death. Other signs of asphyxia will be seen.


Traumatic asphyxia results from respiratory arrest due to mechanical fixation of the chest, so that the normal movements of the chest wall are prevented. Fatal cases are only due to accident. Usually, there is a gross compression of the chest by powerful force. Multiple deaths are likely to occur when there is an outbreak of fire in  a theater or whenever large crowds gather in an enclosed place. Some are crushed by the weight of the crowd, the chest being pressed violently, or may even get trampled on and crushed under feet (riot crush or human pile deaths). Another common cause is crushing by falls of earth or stone usually in  a coal mine or during tunneling or in a building collapse. Sometimes, the victim is pressed to the ground by some heavy weight as by a motor vehicle or other machinery. A person repairing a car may be crushed when the jack slips and the vehicle falls on top of him. It may occur in assault cases, where the victim is jumped or stamped upon and crushed by one or more assailants. Occasionally, it results from indirect compression, when the body is subjected to force in such a manner that his thighs and the knees are driven against his chest, the so-called “jack-knife” position