Choking – StatPearls – NCBI Bookshelf

Stephanie A. Duckett; Marc Bartman; Ryan A. Roten.

Author Information and Affiliations

Last Update: September 19, 2022.

Continuing Education Activity

Choking or foreign body airway obstruction occurs when an object partially or completely obstructs the passage of air exchange between the upper airway and the trachea. Choking can be seen in individuals of any age, however, it tends to occur with the greatest frequency in either the very young or the elderly population. In the very young, the foreign body is often food, a toy, a coin, or even a battery, whereas in the elderly it is almost always food. This activity describes the causes of choking, reviews the presentation and diagnosis, and highlights the role of the interprofessional team in its management.

Objectives:

• Describes the etiology of choking.

• Describe the presentation of a patient who is choking.

• Describe the evaluation for choking.

• Explain the importance of optimizing care coordination amongst interprofessional team members to improve outcomes for patients affected by choking.

Access free multiple choice questions on this topic.

Introduction

Choking or foreign body airway obstruction occurs when a foreign body such as food, coins, or toys partially or completely obstruct the passage of air from the upper airway into the trachea. Choking affects either in the very young or the elderly[1]. In the young, the foreign body is likely to be food or a toy, while in the elderly it is almost always food.

There is a bimodal distribution in the ages of patients, affecting primarily the young between the ages of 1 to 3 years and the elderly who are greater than 60 years. In 2015, 5,051 people died from choking. Of those, 2,848 (56%) were older than 74. Choking is the fourth leading cause of unintentional death,  the leading cause of infantile death, and the fourth leading cause of death among preschool children[2]. The most common objects on which children choke are food, coins, balloons, and other toys. In a Center for Disease Control review of nonfatal choking episodes in children that were treated in the emergency department, 13% of choking episodes were associated with coins and 19% were caused by candy or gum. Latex balloons are the most likely fatal aspirated foreign body, accounting for 29% of deaths by foreign body aspiration between 1972 and 1992. In the same time period, hot dogs were the most fatal food aspiration, accounting for 17% of food-related aspiration fatalities[3] 

Of the adult fatalities associated with choking, there is a strong association with dementia (including Alzheimer disease) and Parkinson disease[4]. Decreased salivation in the elderly is also implicated as this impairs the ability to transfer food during swallowing.

Anatomy and Physiology

The foreign body lodged in the larynx or trachea is most dangerous as this causes complete airway obstruction. Alternatively, foreign bodies such as small beads or small pieces of food may pass below the vocal cords and become lodged at the carina or within a mainstem bronchus[5]. In adults, due to differences in right versus left pulmonary anatomy, foreign bodies are more commonly retrieved from the right main bronchus. However, children will have equal likelihood in either bronchus, due to equal growth until the age of 16.[6]

Indications

The event may be witness or unwitnessed. A witnessed incident is always diagnostic and facilitates immediate treatment. However, in the cases where the events may be unwitnessed, a high clinical suspicion must be present. Often these patients are unable to verbalize what has happened.

In children, you may appreciate drooling or stridor. The most common presenting symptoms are the classical triad of a paroxysmal cough, wheezing, and dyspnea or decreased air entry/decreased breath sounds in adults. The described “café coronary” refers to cardiac arrest secondary to airway obstruction that occurs while eating rather than a myocardial infarct.

Technique or Treatment

Conscious Children

Infants (children less than 1 year) with foreign body aspiration should be treated with alternating five back blows followed by five chest thrusts. This action is best performed with the infant’s torso on the provider’s nondominant arm or an older child draped across the knees. After five blows delivered between the scapula, turn the child over and perform five chest thrusts (chest compressions).

The Heimlich maneuver should NOT be used on children younger than 1 year. Additionally, while the blind finger sweep is still included in the advanced cardiovascular life support and basic life support protocols for adult airway management, it should be avoided in the infant age group as it may push the object further into the airway.[7]

Older children (those greater than 1 year) may receive the Heimlich maneuver. Best results are produced when the provider performs it while on the knees. A clenched fist should be placed at the level of the umbilicus and an upward thrust delivered posteriorly and superiorly.

Unconscious Children

The loss of consciousness indicates a loss of perfusion. Check for a pulse and move on to advanced airway tactics including direct laryngoscopy and foreign body retrieval with McGill or ringed forceps. If the object can be seen but not retrieved, percutaneous translaryngeal ventilation may be necessary. If the object cannot be seen and the patient may be ventilated, bronchoscopy may be required. Children under the age of 10 should NOT receive a surgical airway as they do not have fully developed posterior tracheal rings. 

Adults

All adults can and should receive the Heimlich maneuver while they are conscious. If the Heimlich cannot be performed due to body habitus or pregnancy, the American Heart Association recommends a supine patient with force again applied just above the umbilicus in a cephalad posterior vector. If the adult loses consciousness, it is imperative to check for a pulse and begin cardiopulmonary resuscitation if a pulse is not detected. Advanced airway techniques are now indicated, and you may be able to visualize the foreign body under direct laryngoscopy.

Clinical Significance

Parents should be cautioned about the risks of toys with small movable parts that can break off and use caution with regards to coins, balloons, and cylindrical objects[8]. Food should be cut in such a way that reduces risk (i.e., cutting grapes and hot dogs in half). Until a child has molars and has demonstrated a robust ability to chew. Hard foods such as carrots should be avoided.

Adults who have their food prepared by other family members or by caregivers should be given the most permissive and safe diets, which may mean smaller cut pieces or pureed foods. Aspiration risk may be reduced by altering food consistency. If patients experience coughing or choking while eating, drinking or swallowing medications a formal dysphagia screen may be indicated.

Pearls

• At risk are those between ages 0 and 3 and over age 60.

• Leading cause of death among children 1 to 3 years, and the fourth leading cause of unintentional death overall.

• The most common foreign body objects are coins and balloons.

• The most common foreign body foods are hot dogs, grapes, and steak.

• Do not perform the Heimlich maneuver on children less than 1 year.

• Prevention includes parental diligence regarding risky toys, cutting circular foods in half, and pureeing foods or cutting smaller pieces for elderly persons.

Enhancing Healthcare Team Outcomes

Choking events are fairly common in both adults and children. In minutes, they may lead to a fatal outcome. In a hospital setting, best results will be achieved if nurses and clinicians are familiar with methods to rapidly relieve choking and appropriate assistance is provided. Caregivers should work toward educating the public on methods of responding to a choking event. [Level V]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

References

1.

Committee on Injury, Violence, and Poison Prevention. Prevention of choking among children. Pediatrics. 2010 Mar;125(3):601-7. [PubMed: 20176668]

2.

Salih AM, Alfaki M, Alam-Elhuda DM. Airway foreign bodies: A critical review for a common pediatric emergency. World J Emerg Med. 2016;7(1):5-12. [PMC free article: PMC4786499] [PubMed: 27006731]

3.

Rimell FL, Thome A, Stool S, Reilly JS, Rider G, Stool D, Wilson CL. Characteristics of objects that cause choking in children. JAMA. 1995 Dec 13;274(22):1763-6. [PubMed: 7500505]

4.

Kramarow E, Warner M, Chen LH. Food-related choking deaths among the elderly. Inj Prev. 2014 Jun;20(3):200-3. [PubMed: 24003082]

5.

Debeljak A, Sorli J, Music E, Kecelj P. Bronchoscopic removal of foreign bodies in adults: experience with 62 patients from 1974-1998. Eur Respir J. 1999 Oct;14(4):792-5. [PubMed: 10573222]

6.

Cleveland RH. Symmetry of bronchial angles in children. Radiology. 1979 Oct;133(1):89-93. [PubMed: 472318]

7.

Berg MD, Schexnayder SM, Chameides L, Terry M, Donoghue A, Hickey RW, Berg RA, Sutton RM, Hazinski MF. Part 13: pediatric basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010 Nov 02;122(18 Suppl 3):S862-75. [PMC free article: PMC3717258] [PubMed: 20956229]

8.

Glassy D, Romano J., Committee on Early Childhood, Adoption, and Dependent Care. American Academy of Pediatrics. Selecting appropriate toys for young children: the pediatrician’s role. Pediatrics. 2003 Apr;111(4 Pt 1):911-3. [PubMed: 12671134]

Disclosure: Stephanie Duckett declares no relevant financial relationships with ineligible companies.

Disclosure: Marc Bartman declares no relevant financial relationships with ineligible companies.

Disclosure: Ryan Roten declares no relevant financial relationships with ineligible companies.

A Brief Anatomy of Strangling, Choke, and Triangle Techniques

Home >> Articles >> A Brief Anatomy of Strangling, Choke, and Triangle Techniques

• Self-Defense

by
Steve Scott

July 11, 2022

Using strangles and chokes is serious business and is not for the immature. It’s better to tap out than pass out.

The action of strangling may often (but not always) cause pain, especially when using the legs, and could have lethal consequences if applied long enough. That’s why they used to hang bad guys in the Old West: it hurt, and it was effective. Aside from that obvious point, cutting off the blood supply to the brain deprives the brain of oxygen and causes unconsciousness. The fact is, when you strangle or choke someone you are depriving him of his breath, and no matter how tough a guy is he still has to breathe. Apart from the physical effects, depriving someone of his ability to breathe has a big psychological impact on him.

You usually want to focus your choke on, or directly below, the Adam’s Apple (thyroid cartilage). The thyroid cartilage is located right under the hyoid bone, a small bone that supports the thyroid cartilage and has many functions in swallowing. The trachea (windpipe) is located below the thyroid cartilage and is a flexible tube made up of cartilage. All these things are tough but not really made for having somebody else squeeze them with great intensity! The sides of the neck contain the carotid arteries, which are large arteries and the brain’s major source of blood. When they are constricted, most of the blood going to the brain doesn’t get there anymore. Deprived of oxygen for even four or five seconds, the brain starts to shut down and unconsciousness occurs. If the brain is deprived of oxygen for four to six minutes, clinical death can occur. Whether you make an opponent pass out from constricting his carotid arteries or constricting his windpipe and connected organs, you still deprive him of oxygen.

Using strangles and chokes is serious business and is not for the immature. I have coached for many years specializing in submission techniques and sincerely believe strangles and chokes are more dangerous than armlocks. A broken arm or leg can mend, but the effects of the brain cells lost from being choked cold always stay with you. The lack of oxygen to the brain kills brain cells and these brain cells don’t grow back. Lose enough of them and neurological damage can take place.

It’s better to tap out than pass out, especially in training. Don’t be macho and risk serious injury and possible problems later in life. By the same token, if you’re strangling an opponent or training partner and he taps out, he means it. Release the pressure and stop choking him for his safety. An old saying goes, “When in doubt, tap out.” You’re not any less brave, less tough, or less of anything. You’re using your survival instinct to let your opponent know it’s time to stop choking you. Don’t risk your health or be a risk to the health of others. Practice safe and practice smart. It’s better to tap out than pass out.

The Difference Between a Strangle and a Choke

It’s common to interchange the words “strangle” and “choke.” Specifically, “strangle” describes all the techniques we associate with any technique or move that attacks the neck or throat. “Choke” is more specific and refers to an action that obstructs or blocks the windpipe. Often, we refer to any strangle aimed against the side of the neck and the carotid arteries as just that, a strangle. Any strangle that close, blocks, or obstructs the front of the neck at the throat is often referred to as a choke. A choke makes an opponent gag and sputter and is often more painful than when you cut off the blood supply to his brain pressing against his carotid arteries. But we all use the words “choke” and ‘strangle” to mean either action, so it really doesn’t matter if you call it a “strangle” or a “choke.” We all know what is meant.

Triangles Chokes from the Bottom Guard Position

The oldest and most basic way of performing a triangle choke is when the attacker is on the bottom fighting from his buttocks, back, or backside. As a result, this position produces a large number of opportunities (and as a result a large number of applications) for a triangle choke.

Historically, fighting from the bottom in what is now commonly called the guard position has been known in Japanese judo (both Kodokan judo and its offshoot Kosen judo) as newaza (grappling techniques from a supine or reclining position). Japanese judo athletes, especially those who followed the Kosen form of judo where the emphasis was (and continues to be) on groundfighting, favored strangling techniques, and triangle chokes from the bottom were developed to a high standard. Likewise, Brazilian jiu-jitsu exponents have traditionally favored fighting from the newaza or guard position and have developed highly refined triangle chokes from this position. The triangle chokes applied from the bottom guard position have proved to be a mainstay in many modern forms of sport combat including MMA (mixed martial arts).

From a coaching perspective, initially presenting the fundamental skills of the triangle choke from the bottom guard position seems to be the most effective way to develop the technical skills necessary for effective triangle chokes from any starting position. This is what I do as a coach, and it has been my experience that athletes who initially learn triangle chokes from the bottom guard position gain a better fundamental understanding of what the triangle choke is about and ultimately progress in skill acquisition more quickly and develop a more disciplined approach to applying triangles from any position. Literally, the best way to learn triangle chokes is from the ground up.

The attacker on bottom lies at an angle and sideways to his opponent (the two bodies forming somewhat of an “L” shape) as shown in this photo. The advantage of this side angle position is that it allows the bottom grappler to “have longer legs.” In other words, the side angle of the bottom grappler’s body in relation to the top grappler’s position closes the distance between the two grapplers and allows the bottom man to extend his legs further, trapping and forming a triangle easier. This side angle also allows the bottom grappler a good opportunity to roll his opponent over onto his side to complete the strangle or apply an armlock.

The Primary Parts of the Triangle: Anchor Leg and Tie-Up Leg

Each leg has a specific function when forming a triangle. Fundamentally, the triangle with the legs is formed with (1) an “anchor” leg and (2) a “tie up” leg. The anchor leg is the leg that the attacker slides over his opponent’s shoulder and initially uses to trap the defender’s head. The tie-up leg is used to form the triangle by hooking onto the anchor leg.

Think of it this way: both legs trap an opponent’s head, shoulder, and arm, and the leg that the attacker initially slides over his opponent’s shoulder to wrap around his neck is the anchor keeping the opponent’s head in place. The other leg is the leg that is used to tie up, secure, and form the triangle trapping the opponent’s head, shoulder, and arm to create the strangling action.

The above is an excerpt from The Triangle Hold Encyclopedia, by Steve Scott, Pub Date May 1, 2022, YMAA Publication Center, ISBN 9781594396496.

About the Author

Steve Scott

Steve Scott is a professional judo, sambo and jujitsu coach residing in Kansas City, Missouri.  He was born in 1952 and is a graduate of the University of Missouri-Kansas City. He holds 8th dan (Hachidan) rank in judo and 7th dan rank in shingitai jujitsu. Steve is the author of over a dozen published books on the subject of judo, sambo and other Martial Arts. Starting his judo career in 1965 and his sambo career in 1976, Steve has been active at all levels of competition, coaching and … More »

Related Articles

• by , Jun. 13, 2022
  The term “ground fighting” is actually a generic one and for the sake of clarity, needs to be parsed out and examined.

• by , May. 16, 2022
  “If you don’t know how you got somewhere, you don’t know where you are.”—James Burke

• by , Dec. 30, 2019
  The purpose of a successful throwing technique in sambo is to get an opponent to the mat or ground as effectively as possible…

Site map

Site map

About clinic

Contact information

Psychiatrist in Yekaterinburg

Psychotherapist and psychologist in Yekaterinburg

Online consultations

Quick start program

News

9 0003 Our Services

Alcoholism

Drugs

Mental disorders in childhood and adolescence. Treatment of “difficult” adolescents

House calls

Treatment of gambling addiction

Treatment of insomnia

Treatment of neurosis in children, adolescents and adults

Treatment of OCD

Treatment of mental disorders, including psychosis

Treatment of schizophrenia and schizotypal disorder

Treatment of phobias , anxiety in children, adolescents and adults

Overweight and weight loss

Eating disorders

Treatment of panic attacks in children, adolescents and adults

Treatment of depression in children, adolescents and adults

Attempted suicide

Psychological and psychotherapeutic assistance

Psychosomatics, head and back pain

Irritable bowel syndrome

Family problems

Autonomic neuroses

Combating smoking, vaping and vaping

Memory disorders and dementia

Nursing homes for the elderly

Relaxation training for corporate employees

Preventive training for schoolchildren and youth

Depersonalization and derealization

Mental health care

Photo gallery

Certificates, licenses, letters of thanks

Reviews

90 003 Music for mental relaxation

Creativity dedicated to the psychological state

Questions for a specialist

Teaching materials

“Dirty Science” History of pathological anatomy: Books: Culture: Lenta.

ru

Can fingerprinting be trusted? How do insects help determine the time of a kill? How are political and war criminals found in portraits made with aging in mind? The famous Scottish writer, author of detective stories Val McDermid in the book “Anatomy of a Crime: What Insects, Fingerprints and DNA Can Tell” tells the story of forensic science – from ancient Chinese forensic science to DNA profiling. The book will be released on the 20th of August by the Alpina non-fiction publishing house. “Lenta.ru” publishes a fragment of a chapter on pathological anatomy.

The poet John Donne reminds us: “The death of every man diminishes me, for I am one with all mankind.” These are noble words. And yet we will not deny: we are more affected by someone’s sudden and violent death, if it has some relation, albeit remotely, to ourselves. This was the case for me with Rachel McLean, who attended the same small college for women at Oxford University that I did. We have never met, but I can’t help feeling a certain sense of belonging to her and her fate.

Nineteen-year-old Rachel McLean was studying at St. Hilda’s College when she was courted by John Tanner. After 10 months of relationship, on April 13, 1991, he proposed to her. Any girl would tell all her friends such important news. But for the next few days, no one in college, or in the whole university, saw Rachel. Diligent, friendly, open – no one could believe that she took it and left without telling anyone. Tanner called her home and asked to call her to the phone, but the housemate replied that she did not know where Rachel was.

The college became increasingly worried and notified the police five days later. The police contacted Tanner – he lived in Nottingham, where he studied at the university – and he said that he last saw his girlfriend on April 14, 1991 in Oxford, when he was leaving on a train to Nottingham, and she waved to him from the platform. A long-haired young man they had met at the station canteen offered to give her a ride back to Argyle Street.

Tanner cooperated with the police, assisted in the search, and even took part in a televised reenactment of her departure from the Oxford station to refresh the memory of those who may have seen Rachel. Apparently, this was the first killer who participated in such a reconstruction. At the press conference, he excitedly told friends and reporters that he and Rachel loved each other and were going to get married.

However, the police suspected that Tanner was hiding something. They persuaded reporters to ask him provocative questions, such as “Did you kill Rachel?” The way he responded, with a goofy smirk, without much emotion, convinced the police that he knew more about the disappearance than he was letting on.

Shot: TV series Sherlock

The house on Argyle Street, where Rachel lived with her friends, was searched. However, everything seemed to be in order. Nobody touched the floorboards, and nothing looked suspicious. The detectives were almost desperate to find evidence that would allow Tanner to be arrested or even pressured. Divers searched the Cherwell River while other employees combed the nearby bush.

Then the police asked the city council to find out if the house on Argyle Street had a basement. The answer came: there is no basement, but some houses on this street are built on pile foundations. So, under the floor there is space.

Armed with this information, on May 2, the police searched the house again. And this time they found Rachel’s body, partially mummified, under the stairs. Tanner slipped it into the 20-centimeter space at the bottom of the closet under the stairs and pushed it into the cellar. Although 18 days have passed since the death, the body has hardly decomposed. The cold, dry air blowing through the hollow brick dried out the skin.

However, the discovery of the body ends only the first part of the investigation. After that, the pathologist begins to collect the facts that will form the basis of the accusation. In the case of the murder of Rachel McLean, this task was entrusted to Ian West, head of the forensic department at London’s Guy’s Hospital. During the autopsy, he found a bruise measuring 1 cm to the left of Rachel’s larynx and four spots to the right of the larynx. He photographed them, as well as petechiae – pinpoint hemorrhages on the face and eyes. Internal examination showed a fracture of the cartilage of the larynx. All of these injuries indicated death by strangulation. The tuft of hair on the head was also missing. According to West, he broke free when Rachel tried to loosen the grip on her throat.

When the police presented John Tanner with forensic evidence, he broke down and confessed to the murder. At the trial, he said: “In my rage, I attacked her and grabbed her by the throat. I think I have lost control of myself, because I remember what followed only vaguely. According to him, he killed Rachel after she confessed to cheating on him. And then spent the night near her lifeless body. In the morning, he began to look for where to hide him. Stuffed the corpse into the gap at the bottom of the closet under the stairs and took the train to Nottingham. Tanner was sentenced to life in prison. In 2003, he was released and returned to his homeland, New Zealand.

Forensic science is like a puzzle. The pathologist must record all the unusual details found on the body and inside the body, and on the basis of these scraps of information, try to reconstruct the past. Man has always wanted to understand why his loved ones died. It is no coincidence that the very word “autopsy” goes back to ancient Greek words meaning “seeing with one’s own eyes.” An autopsy is an attempt to satisfy curiosity with the help of medicine.

Frame: Knickerbocker Hospital series

The first case of forensic autopsy known to us dates back to 44 BC, when the doctor of Julius Caesar reported that of the 23 stab wounds inflicted on the consul, only one was fatal: between the first and second ribs . In the second half of the 2nd century AD, the Greek physician Galen produced highly authoritative treatises on anatomy based primarily on dissections of monkeys and pigs. Despite the insufficient solidity of the base, his anatomical theories dominated until the 16th century, when Andreas Vesalius described the normal structure of the body and deviations, becoming the forerunner of modern pathological anatomy – the science of disease.

The epochal textbook by Vesalius “On the structure of the human body” (1543) is dedicated to Charles V, the emperor of the Holy Roman Empire, during whose reign a breakthrough in forensic medicine took place. For the first time in the history of this state, the rules of criminal procedure were introduced. They established what crimes were considered serious (for example, witches were burned), gave the courts the power to order the investigation of serious crimes. These rules, collectively referred to as the “Caroline Code,” required judges to consult surgeons in cases where someone was suspected of murder, which was an important step in the development of forensic science.

The Caroline Code was adopted in much of continental Europe, and physicians played an increasingly prominent role in courtrooms. Among these physicians was Ambroise Pare, “the founder of forensic medicine.” In his writings, he wrote about the impact of violent death on internal organs, explained how to detect death from a lightning strike, drowning, suffocation, poisoning and apoplexy; showed how to recognize the violent nature of the death of infants and how to distinguish wounds received by a person during life from wounds inflicted after death.

Illustration: Title page of Ambroise Pare’s book The Works of the Famous Surgeon Ambroise Pare

As knowledge about the human body expanded, science developed. In the 19th century, much for the development of forensic science in Britain and in other countries was done by Alfred Swain Taylor. His main “Textbook of Medical Jurisprudence” (A Manual of Medical Jurisprudence, 1831) went through 10 editions during Taylor’s lifetime. By the mid-1850s, Taylor had acted as a consultant in 500 court cases, but he learned from experience that medical examiners can make mistakes.

In 1859 the Central Criminal Court in London heard the case of Dr. Thomas Smethurst, accused of poisoning his mistress Isabella Banks. At the trial, Swain Taylor stated that there was evidence: traces of arsenic in a bottle that belonged to Smethurst. A death sentence followed, but later Taylor’s examination was rejected: apparently, there was no arsenic in the bottle. Isabella Banks had been ill for a long time and died, probably a natural death. Smethurst was pardoned: he only had to serve a year for bigamy. In the Lancet and the Times, both Taylor himself and the death sentence were smashed to smithereens, and forensic science began to be called “dirty science.” For many years her reputation was ruined.

The adversarial system of English justice, with its theatricality, assumed that a bright, charismatic person had to stand up for the good name of forensic medicine. Such a figure was the irresistible Bernard Spilsbury. Handsome and a brilliant orator, he never appeared in public except in tailcoat, top hat and spats. His skill was beyond doubt. He was equally dexterous with both hands and worked with the corpse very quickly and accurately, and he spoke about his findings clearly and without abusing terms.

Spilsbury was loved by both the jury and the public. For newspapermen, he was a stronghold of the law, against which the machinations of scoundrels and murderers are broken. After the death of the forensic scientist in 1947, the Lancet magazine called him “a unique and unrivaled forensic scientist.” Spilsbury represented the prosecution in more than 200 murder cases.

The public first drew attention to him in 1910, when he acted as an expert in the sensational trial of Dr. Hawley Harvey Crippen. The American homeopath and drug salesman Crippen lived in Camdentown with his wife, Cora, a music hall singer known as Belle Elmore. The marriage did not work out, and after some time, friends noticed that Cora had completely ceased to appear in public. Dr. Crippen told them one thing, then another: then she died, then she left to perform in America. This aroused suspicion and they contacted the police. The police questioned Crippen, searched his house, but found nothing. However, the investigation caused Crippen to panic, and he fled with his young mistress Ethel Le Neuve on the steamer Montrose to Canada. At the same time, Le Neuve dressed in men’s clothes and pretended to be Crippen’s son.

Their escape rekindled the suspicions of the police. However, a second search of Crippen’s house turned up nothing. But doubts remained, and the police conducted a third search. Under the brick floor of the basement, human remains were found: a torso wrapped in a piece of men’s pajamas.

Meanwhile, the captain of the Montrose noticed two strange passengers on board and, before the ship left the communication zone, sent a wireless telegram to the British authorities: “I have a strong suspicion that the London murderer Crippen is among the passengers along with an accomplice. He shaved his mustache, grew a beard. The accomplice is disguised as a boy.