MODES OF DYING, SUDDEN DEATH, SIGNS OF DEATH
MODES OF DYING
Syncope--death beginning at the heart.
Asphyxia--death beginning at the lungs.
Coma--death beginning at the brain.
=Syncope.=--From δνγκοπτω, _I strike down_. Sudden arrest of the action
of the heart.
This condition may be brought about by
1. Deficiency of blood due to hæmorrhage--_death by anæmia_.
2. Effect of certain diseases and poisons, &c.--_death by asthenia_.
Causes--_Heart Disease._--Aortic regurgitation, fatty degeneration, &c.
_Hæmorrhages_ from wounds of blood-vessels or the heart, profuse
hæmoptysis or hæmatemesis, uterine hæmorrhage, bursting of varicose
veins, bursting of aneurysms.
_Shock._--Emotion; blows on the head or epigastrium; sudden evacuation
of fluids from the body, as in emptying an over-distended bladder,
tapping a hydrocele, ascites, or a pleural effusion. Extensive
injuries to the body (railway and machinery accidents). Drinking large
quantities of cold water when heated.
_Exhaustive diseases_, chronic or infective.
Symptoms.--Pallor of the face and mucous membranes, dimness of vision,
cold perspirations, sense of impending death, restlessness, air hunger
and gasping for breath, nausea, and, maybe, vomiting, noises in the
ears, passing delirium, quick, feeble, and fluttering pulse, or the
latter may be imperceptible at the wrist, insensibility, convulsions.
In ordinary fainting attacks many of the above symptoms are absent;
such as are present are temporary. In collapse, consciousness is
retained.
Post-mortem Signs.--The cavities of the heart contain a normal quantity
of blood in death by asthenia, but may be almost empty when death
is due to anæmia. The blood in asthenic death is simply arrested in
its course; blood is, therefore, found in the large veins and in the
arteries. The brain and the lungs are not engorged with blood.
=Asphyxia.=--From ἀ priv. et δφνξιϛ, pulse. Apnœa is the better
term--ἀ priv. et πνεω, I _respire_; but this word is now used by
physiologists to denote a cessation of the respiratory movements due
to artificially oxygenated blood. Blood in this condition fails to
excite the respiratory centre in the medulla, and respiration ceases.
To avoid confusion the term asphyxia had better be retained, especially
as it is most commonly used and generally understood. Asphyxia, or
death from defect in the quality of the blood, is brought about when
any impediment is placed on the healthy action of the lungs. Experiment
has shown that for a short time after respiration has ceased, the
heart still continues to act, and that if the impediment to the proper
aeration of the air by the lungs be removed, life may be prolonged.
Taking therefore the primary meaning of the terms asphyxia and apnœa
into consideration, it may be remarked that the latter precedes the
former in point of time--asphyxia marking the period at which the
action of the heart ceases, apnœa the cessation of the respiratory
functions.
_Causes of Asphyxia._--1. Mechanical obstruction to the air passages:
foreign bodies, exudations, tumours, suffocation, strangulation,
drowning, hanging, spasm of glottis from mechanical irritation, or
irritant gases.
2. Interference with the action of the respiratory muscles: exhaustion
of the muscles from cold; paralysis of muscles from injury to or
disease of respiratory centre; poisons acting on the centre; continued
pressure on walls of the chest; fixation of muscles from tetanus or
strychnine poisoning.
3. Diseases of and injuries to the lungs: pleurisy with effusion, acute
pneumonia, empyema, pneumothorax, pyopneumothorax, pulmonary apoplexy,
embolism of pulmonary artery.
4. Inhalation of air deficient in oxygen.
_Symptoms of Asphyxia._--Divided into three stages. _First stage_:
deep, frequent, and laboured respiration; the extraordinary muscles
of respiration are called into play. _Second stage_: the inspiratory
muscles are less active than expiratory, convulsions of nearly all the
muscles of the body occur. _Third stage_: paralysis of respiratory
centres, dilated pupils, loss of consciousness, absence of reflexes.
Gasping inspirations with prolonged intervals precede dissolution.
_Post-mortem Signs._--Engorgement of the pulmonary artery, the right
cavities of the heart, and vent cavæ; but on the left side of the heart
the cavities, together with the aorta and pulmonary veins, are either
empty or contain but little blood. It must be remembered, however, that
cases of asphyxia do sometimes occur where the cavities on each side of
the heart are _empty, or nearly so_. This is the case in the syncopal
asphyxia of some writers. If also the obstruction to respiration be
imperfect, the circulation may be continued for some time, congestion
of one or more of the internal organs being the result. The blood
is dark-coloured, contains much CO₂, and the hæmoglobin is almost
completely reduced. The blood coagulates slowly.
=Coma.=--Insensibility ending in death. _Causes._--Concussion of the
brain, cerebral hæmorrhage, embolism, thrombosis, tumour, depressed
fracture of skull, meningitis, and serous effusions; effects of
poisons such as opium, alcohol, ptomaines, arsenic, barium, oxalic
and carbolic acids; in certain diseases of kidneys and liver, uræmia,
cholæmia, acetonæmia, profound anæmia, _e.g._ pernicious, and as a
terminal stage to acute or chronic diseases.
_Symptoms of Coma._--Coma is generally preceded by stupor, from which
the patient may be roused to a certain extent, but only temporarily.
The reflexes in this stage may be exaggerated, and the power of
swallowing fluids may be retained. When coma is present there is
complete abolition of consciousness, sweating, the patient is
powerless, the breathing stertorous. The temperature may vary according
to the cause; normal or subnormal generally, it may rise in lesions
of the pons Varolii. The pulse is generally full and bounding, the
pupils dilated or contracted and insensitive to light, the conjunctival
reflex absent. Mucus collects in the air-passages and causes “the
death rattle,” and the breathing becomes more and more embarrassed and
irregular. The reflexes are lost, and the sphincters relaxed.
_Post-mortem Appearances._--Causal lesions are found in the brain or
other organs; there is usually hyperæmia of the brain and spinal cord
and their membranes, unless there be profound anæmia preceding death.
The condition of the heart and lungs is not constant; the general
appearances resemble those in death from asphyxia.
Table giving the Diagnosis of Several Forms of Insensibility
Injury to the Head--_Concussion of the Brain._--The symptoms are very
similar to those of shock, with unconsciousness, but it may be possible
to rouse the person. The pupils are equal and dilated or contracted,
and react sluggishly to light. The breathing is shallow and slow with
sighing, the pulse feeble. The muscles are relaxed but not paralysed.
Vomiting and involuntary micturition and defæcation may occur. The
temperature is usually subnormal.
Cerebral Compression.--This, when due to injury, is usually associated
with fracture of the skull and hæmorrhage. Insensibility is complete,
the person cannot be roused. The pupils may be unequal, contracted or
dilated, and may not react to light. The breathing is slow, stertorous,
and may be irregular, or Cheyne-Stokes in type. The pulse is full
and bounding, the cheeks are blown out during expiration. Paralysis,
rigidity, or convulsions may be present on one side of the body. There
may be retention of urine, with overflow incontinence.
In cases associated with severe fracture or hæmorrhage within the
skull, the conjunctivæ may be chemosed, or there may be hæmorrhage from
the nose or ear; and a flow of cerebro-spinal fluid may take place from
the nose.
Alcohol.--In coma due to alcohol, there will be an alcoholic odour of
the breath, alcohol in the stomach contents, and it can be detected
in the urine. The odour of alcohol in the breath may be due to the
administration of alcohol by an outsider at the onset of the symptoms
which have ended in the coma. The pupils are equal, contracted, the
conjunctival reflex present, and the pupil dilates on pinching the
skin of the neck. The pulse is rapid, at first strong it becomes
feeble, the respirations snoring. If the coma be not complete, muscular
inco-ordination may be noticed. The person can usually be aroused by
stimulation.
In pure alcoholic coma the presence of the special features of coma
from other causes will be absent. It must be remembered, however, that
alcoholic coma may be combined with other kinds, and the more serious
form should be kept in mind. Where there is the slightest doubt in the
diagnosis, one‘s procedure should be ruled by the possibility of the
graver cause.
Opium or Narcotic Poisoning.--The skin is usually perspiring freely,
moist and cold; the countenance placid, pale and ghastly, the lips
livid. The eyes are heavy, and the pupils contracted to a pin-head and
equal, the conjunctival reflex usually present. There is the odour of
opium in the breath. The pulse is slow, and the respiration stertorous
and slow. There is no paralysis, and the person can be momentarily
roused by a sharp question or blow.
Apoplexy.--The person is with difficulty, if ever, temporarily aroused.
The face is red and bloated. Respiration suspirious and stertorous,
and there is often Cheyne-Stokes breathing. The pupils are dilated or
irregular; in pontine hæmorrhage, contracted. The temperature may at
first be subnormal but gradually rises.
There may be rigidity of the limbs, or hemiplegia. The pulse is full
and bounding, often of high tension with hardened arteries.
Albuminuria may be present.
Uræmia.--This is less profound than in cerebral hæmorrhage; the
patient may be temporarily aroused; the onset is usually gradual.
There is albuminuria with casts; albuminuric retinitis may be present.
The pupils may be contracted or dilated. The breath has a peculiar
so-called “uræmic odour.” The pulse is generally slow, the tension
high, and the heart enlarged. The respirations are slow and sighing,
and may be Cheyne-Stokes in type. There is no paralysis. There may
have been preceding convulsions, and the coma may alternate with these
attacks.
Anasarca may be present.
Diabetic Coma.--This may come on suddenly, and may occur unexpectedly
in a person in whom diabetes has not been discovered up to the time of
coma. There is sighing respiration, “air hunger.” The odour of acetone
in the breath is present, and sugar in the urine.
Epilepsy.--Unconsciousness is profound, and comes on immediately with
rigidity, followed by convulsions, unilateral, limited to the side of
the face, jaws, head and neck or arm, or generalised. Bloody froth
exudes from the mouth, the tongue being bitten. The eyes are wide open,
the pupils dilated and insensible to light. Micturition may occur.
After the convulsive attack has passed off, post-epileptic coma may
remain, though usually for a short time only.
Syncope.--This has been described under modes of dying (p. 38).
In all cases of coma when first seen examine the head for signs of
injury, note the odour of the breath, observe the state of the pupils
and their reactions, examine the limbs for paralysis, count the pulse
and note its character, and the state of the arteries, note the size of
the heart and auscultate it at each area. Count and note the character
of the respirations, take the temperature, examine the urine, take note
of the person‘s age, and inquire into the previous history.
SUDDEN DEATH
Sudden death may proceed from natural or violent causes. From the
former, death may occur unexpectedly and very rapidly, but as a rule
the period of time occupied by the phenomena of “dying” is measurable,
though inconstant. Should such period of time be immeasurable, death
may be considered as instantaneous.
Apart from sudden death resulting from violence or poisoning, the
common causes are as follows:--
1. Diseases of the heart: angina pectoris, valvular diseases with
failure of compensation, especially aortic regurgitation, degeneration
of the heart muscle, rupture of the heart, heart failure from
diphtheria or toxic diseases.
2. Diseases of the blood-vessels: rupture of aneurysms or varicose
veins, thrombosis, embolism.
3. Cerebral hæmorrhage, especially when in the region of the pons
Varolii or cerebellum.
4. Lesions of the respiratory system: œdema or spasm of the glottis,
membranous deposit or foreign bodies in the larynx or trachea, foreign
bodies in the pharynx, tumours, whooping-cough, asthma, embolism
of the pulmonary artery, air embolism, fat embolism, rupture of a
vessel or aneurysm into the air-passages, as in phthisical cavities,
pneumothorax, hæmothorax, pleuritic effusion, and in acute pneumonia.
5. Rupture of a gastric ulcer or ulcer of some other part of the
alimentary tract.
6. Sudden hæmorrhage into the peritoneal cavity from ruptured uterus,
ectopic gestation, &c.
7. Rupture of internal organs: distended bladder, spleen, pregnant
uterus, or other abdominal viscus.
8. Hæmorrhage into the pancreas.
9. Conditions associated with the nervous system: mental emotions,
epilepsy, uræmia, laryngismus stridulus in children.
10. Sudden death has occurred in Addison‘s disease, in diabetes, in
cases of lymphatism or status lymphaticus in young people, during the
early stage of chloroform anæsthesia, during simple vaginal examination
in women, during the injection of fluids into the vagina or uterus.
Bouvalat (_Annales d‘Hygiène_, 1892) relates a case in which, as the
cannula of a syringe was being introduced into the os uteri of a woman
with the object of criminal abortion, she fell back before any fluid
was injected, and died in a few minutes.
A similar case came under my notice, in which death took place while
the husband of the woman was attempting to introduce a solution of 20
minims of tincture of iodine, mixed with water to measure two drachms,
into her uterus through a No. 3 catheter.
SIGNS OF DEATH
Real or Apparent Death
It will be unnecessary here to discuss any of the theories put forward
with regard to cases of apparent death or prolonged trance, but simply
to note in the order of their occurrence the phenomena which attend
real death.
Real Death
Under this heading it is important to draw a distinction between
“Somatic death” and “Molecular death.” “Somatic death” is defined as
“the cessation of the vital functions and of the general renewal of
tissue consequent on that cessation”; “Molecular death” is the death of
the tissues themselves.
The signs of death occur as follows:--
1. _Entire and continuous cessation of the respiration and circulation;
no sounds heard on auscultation._ The absence of the heart sounds is
the most important sign of death, for even in the severest forms of
syncope the cardiac pulsations, as shown by M. Bouchet, can with care
be heard.
=Tests for cessation of respiration:--=
(_a_) Auscultation. (_b_) Placing a cold hand-mirror or empty
drinking-glass over the mouth or nostrils, or a light feather, and
noting the presence or absence of bedewing or movement. (_c_) Placing
a shallow vessel, such as a saucer, full of water on the chest or
abdomen, and observing the presence or absence of rippling of the fluid
(Winslow‘s test).
=Tests for cessation of the circulation:--=
(_a_) Auscultation.
(_b_) Manual exploration of the principal arteries for pulsation or
thrill.
(_c_) Magnus‘s test, applying a ligature tightly round a finger,
sufficient to stop the venous but not the arterial circulation, and
noticing whether or not a bloodless ring forms at the seat of ligature,
and a zone of livid redness on the distal side of the ligature, the
part becoming first red, then purple.
(_d_) Applying pressure to the finger-nail, and noticing whether the
colour disappears on pressure, and a pink tinge appears after relaxing
the pressure.
(_e_) Applying heat, such as dropping melted sealing-wax on the skin,
and noting whether or not redness or vesication ensues.
(_f_) Holding the hand, with the fingers abducted, against a strong
fight, and observing whether or not the web of the fingers is
translucent.
(_g_) Inserting a brightly polished needle into a fleshy part of the
body, allowing it to remain for ten seconds or so _in situ_, and
noticing whether it is tarnished or not on withdrawing it.
(_h_) Injecting hypodermically a solution of fluorescin
(resorcin-phthalein and sodium bicarbonate, a gramme of each dissolved
in 8 c.c. of water). No local discoloration of the skin takes place if
the circulation has ceased, but if not, a yellowish-green coloration
of the skin occurs round the seat of injection, and the substance may
be detected in the blood at a part some distance from the seat of
injection. By immersing some white silk threads in the blood drawn
at a distance from the prick, then boiling them in distilled water,
the latter will have a greenish colour if the fluorescin has been
circulated (Icard‘s test).
These tests will detect whether the circulation has ceased or not, and
so differentiate suspended animation from real death.
2. The _lustre of the eye_ is lost immediately after death. It has,
however, been stated that the iris will respond to the action of
atropine and eserine for some hours after death, and that the action of
the latter is always more marked than that of the former. The fundus
as seen by ophthalmoscopic examination is altered, the normal redness
changes to a yellowish-white, the vessels in the disc and just around
it become empty, and the veins appear to contain bubbles of gas and the
column of blood is broken up (Bouchet). A blackish round or oval stain
has been described by M. Larcher on the sclerotic coat on the outer
side, which he calls _l‘imbibition cadavérique du fond de l‘œil_. It is
probably due to thinning of the sclerotic from evaporation, enabling
the choroid to be seen through it. The spot precedes rigidity and is a
forerunner of putrefaction.
3. The _most powerful stimulus applied to the body does not cause any
reaction_. The muscles _may_, however, be made to contract shortly
after death by the stimulus of a slight blow, or by galvanism.
4. _The surface of the body becomes of an ashy-white colour._
Exceptions.
(1) Persons of florid complexion retain this on the malar
prominence for some time after death.
(2) The red or livid edges of ulcers.
(3) Blue, black, or red tattoo marks, if not effaced during
life, do not disappear.--Ecchymoses retain the hue they
had at the time of death.
(4) An “icteric” coloration existing at death, as in
jaundice, never becomes white.
(5) A rosy tint of the skin on those poisoned by carbon
monoxide.
(6) Dusky-red patches in those frozen to death.
(7) In certain cases of drowning, a rosy colour may be
observed on the lips and malar prominences.
5. The _temperature of the body_ at the time of death is retained
for some time. As a sign of death the fall of temperature must be
progressively continuous. Cooling will depend on the medium in which
the body is placed, and mere coldness of the body is not a sign of
death.
(1) Fat persons retain the heat longer than lean ones;
adults longer than children or old persons. Bodies are
cooled by--1. Radiation. 2. Conduction. 3. Convection.
(2) Bodies immersed in water cool more rapidly than in air.
This fact may be of importance in determining survivorship
in a case of drowning.
(3) Bodies in bed and covered by the clothes, or in
cesspools and in dung-heaps, cool less rapidly than when
exposed.
(4) Persons killed by lightning may keep warm longer than
others.
(5) Death by suffocation retards the process of cooling.
(6) The body may be cold externally, but possesses a
considerable amount of heat when the internal organs are
exposed. Persons who have died of cholera, yellow fever,
or suddenly of some acute disease--rheumatism--may retain
for some hours a considerable amount of heat. It has
even been asserted that in some diseases--cholera--there
is an increase of temperature soon after death
(Laycock), also after death due to some diseases
of the nervous system as in pontine hæmorrhage and
cerebro-spinal meningitis, and following prolonged muscular
spasm as in tetanus.
(7) Most bodies, under ordinary circumstances, are, as a
rule, quite cold in from eight to twelve hours after death.
The rate of loss of temperature depends upon the difference
between that of the body and its surroundings; it lessens
as the body cools. It takes at least twenty-four hours for
it to fall to the heat of the surrounding atmosphere.
6. _Relaxation, primary flaccidity, more or less general, of the
muscular system takes place._
_“If the above signs are alone present, death must have taken place
in from ten to twelve hours at the longest”_ (Casper). _Exception:
cadaveric spasm._
7. _Want of elasticity in the eyeball: flaccidity of the iris._ This
condition invariably occurs in from twelve to eighteen hours after
death.
8. _Flattening of the muscles_ of those parts on which the body rests,
due probably to loss of vital turgidity.
9. _Hypostasis._--Suggillation, or _post-mortem_ staining, is due to
the gravitation of the blood to the most dependent parts of the body
not subject to direct pressure. The hypostatic marks begin to form
in from eight to twelve hours after death, and increase in size till
putrefaction sets in. They alter their position with changes in the
position of the body so long as the blood remains fluid, but when it
has coagulated they remain permanent. Hypostasis may be mistaken for an
ecchymosis or a bruise, and in the lungs for congestion, inflammation,
&c. Errors may also occur with regard to the brain, stomach, kidneys,
and intestines: in the last, the redness of inflammation is seen all
over the parts, whereas the coloration of hypostasis is interrupted,
and this is best shown by drawing out the convolutions. The heart is
an exception to the rule, but it may contain clots varying in size
and colour. These are _post-mortem_ formations. The use of the word
suggillation is objectionable, as it has been used in opposite senses
by Continental and British authors--some writers restricting the term
to ecchymosis proper, others using it as synonymous with cadaveric
lividity or external hypostasis.
Cutaneous Hypostasis
(1) _Meaning of the expression._--The gravitation of
the blood in the capillaries after death, in obedience
to the laws of inert matter.
(2) _On what parts of the body usually seen?_--On the
most dependent parts of the body; on the whole of the
back of the body, if the body be supine. The patches are
irregular and slashed, terminate abruptly, and do not
fade gradually into the surrounding colourless skin.
(3) _At what period after death first observed?_--In
from eight to twelve hours, gradually extending in size
till putrefaction sets in.
(4) _Whether or not affected by death from
hæmorrhage?_--Formed after every kind of death, even
after death due to hæmorrhage, although the coloration
may not be quite so marked.
(5) _Hypostasis is liable to be mistaken for
ecchymosis--the result of injury._--Hypostasis must
also not be confounded with the livid patches seen on
the legs and feet of aged persons and on those who have
died from typhus, chronic renal and cardiac disease, &c.
The rose patches--“frost erythems”--seen on those who
have died from exposure to cold, must not be mistaken
for ecchymosis. The above patches are as frequently on
the upper surfaces of the body as on the lower, and are
not so extended as cadaveric lividities; the blood,
moreover, which gives rise to them is diffused through
the areolar tissue, and not incorporated with the true
skin.
(6) _How distinguished from ecchymosis?_--Effused or
coagulated blood is found when an incision is made
in a _true_ ecchymosis, however small, whereas
a few bloody points are alone seen on a slight or
deep incision into a _post-mortem_ stain or true
hypostasis. The seat of hypostasis is the superficial
layer of the true skin. Hypostases are never raised
above the surface, as ecchymoses sometimes are. In
describing these two conditions, “ecchymosis” and
“hypostasis,” it is preferable to describe the former as
“discoloration from extravasated blood,” and the latter
as “lividity after death.”
10. _Cadaveric rigidity._--From the moment of death till the time when
putrefaction sets in, the muscular structures of the body may be said
to pass through three stages:--
(1) _Muscular Irritability._--The muscles flaccid,
but still possessing the power of contractility on the
application of certain stimuli. Parts contracted during
the act of dying--cadaveric spasm--as the muscles of the
hand grasping a knife or other weapon, may continue so
for some time after death.
(2) _Cadaveric rigidity._--A state of rigidity, the
power of contractility absent.
(3) _Commencement of Putrefaction and Chemical
Change._--Relaxation again present; all power of
contraction lost, not to be regained.
Cadaveric rigidity, or _rigor mortis_, is a purely muscular phenomenon,
and is not dependent on the nervous system, as it is not prevented,
though it may be delayed, by division of the nerves, and is as well
marked in paralysed as in non-paralysed limbs. Cadaveric rigidity,
which occurs early in the heart, must not be mistaken for hypertrophy,
or its absence for dilatation. In every case the _rigor mortis_
precedes putrefaction, and consists in a shortening and thickening
of certain muscles, chiefly the flexor and adductor muscles of the
extremities, and also the elevators of the lower jaw.
This condition commences in the involuntary muscles, and in the heart
may simulate hypertrophy of that organ, then passes into the voluntary
muscles of the back of the neck and lower jaw, and then into the
muscles of the face, front of the neck, chest, and upper extremities,
and then into the trunk muscles, and last of all, into those of the
lower extremities. In most cases it passes off in the same order, the
body becoming quite flaccid, the _rigor mortis_ never returning. These
phenomena occur whilst the body is cooling. The muscle becoming rigid
is dying, the rigid muscle is dead. The cause of the _rigor mortis_ is
held to be due to the coagulation of the myosin. The reaction is acid
from the presence of sarcolactic acid, but becomes alkaline during
putrefaction.
If fresh difibrinated blood be passed through the rigid muscle, it will
become flaccid, and respond by contraction to electric stimulation.
Cadaveric rigidity generally supervenes from _eight_ to _twenty_ hours
after death, and may continue from a few hours to four or nine days.
The sooner rigidity comes on after death the sooner will it pass away,
and the later the onset the longer it will last. It is a general rule
that whatever exhausts the muscular irritability before death causes
the early appearance and the more rapid disappearance of _rigor mortis_.
Conditions which modify the onset and duration of _rigor mortis_:--
(1) _Age._--Transitory _rigor mortis_ may appear
in the immature fœtus according to the state of its
muscular development.
It is feeble and disappears quickly in infants and young
children.
It is usually well marked in adolescents and healthy
adults, but feeble in old people.
(2) _The Degree of Muscular Development of the
Body._--Other things being equal, the greater the
muscular development and muscular strength at the
time of death, the slower is the onset of _rigor
mortis_, and the longer its duration; the more feeble
or exhausted the muscular condition, the more rapid the
onset and the shorter its duration.
(3) _The Temperature of the Environment of the
Body._--In temperate and colder climates _rigor
mortis_ follows the usual course. A low temperature,
below freezing-point, will retard the onset and favour
the duration of _rigor mortis_, but if the body be
suddenly thawed before _rigor mortis_ has set in,
it will appear rapidly and disappear more quickly than
if it had not been subjected to the process of thawing.
If a body already in a condition of early rigidity be
exposed to a temperature of 75° C., the rigidity becomes
more marked, since albuminates in the muscles, other
than the myosin, become coagulated in addition. This
phenomenon has been called _heat stiffening_.
(4) _Mode of Death._--After all exhausting diseases
of long or short duration, rigor mortis appears early
and passes off quickly, as in death from phthisis,
cholera, typhus fever, typhoid, hydrophobia, scurvy, and
occasionally in chronic Bright‘s disease.
Death during alcoholic intoxication favours the duration of _rigor
mortis_. After violent muscular exercise death is quickly followed by
rigidity. Animals that have been hunted for some time before death
stiffen very rapidly. When convulsions precede death, _rigor mortis_
sets in early as a rule, but in certain cases, where death has been
preceded by strong convulsions, rigidity may appear quickly, but last
for some days, as in some cases of poisoning by strychnine.
Conditions which simulate _rigor mortis_:--
(1) _Stiffening by Catalepsy._--In this condition
the temperature of the body will remain at a degree
compatible with life over a period incompatible
with real death. If a limb be extended and rigid in
catalepsy, after passive flexion of it, it will return
to its former state.
(2) _Rigidity from the Body being Frozen._--In this
condition passive movement of the joints is accompanied
by crackling due to fracture of their frozen contents.
(3) _Heat Stiffening._--Is seen in the bodies of
persons who have been suddenly immersed in boiling
fluids; also to a certain degree in bodies of persons
who have met their death by burning from paraffin lamp
accidents.
_Cadaveric Spasm or Instantaneous Rigor._--“When this phenomenon occurs
the last act of life is crystallised in death.” It is a prolongation of
the last vital contraction of the muscles into the rigidity of death.
Cadaveric rigidity of the muscles must be distinguished from _muscular
spasm_ occurring at the moment of death.
They may thus he distinguished: In cadaveric rigidity any object
placed in the hand prior to the onset of _rigor mortis_ can be readily
removed, even if the precaution be taken of binding it in the hand
prior to the accession of _rigor mortis_.
In the case of _muscular spasm_ the object is found grasped in the
hand, and can only be with difficulty removed.
The difficulty experienced in removing a pistol or other weapon from
the hand may point to suicide; its easy removal to homicide, the weapon
having been placed there after death.
No adequate explanation of this phenomenon has yet been made. It is not
an unusually early onset of _rigor mortis_ in the muscles affected,
because they do not share in the initial relaxation that precedes
it, or the weapon would fall from the hand, and the bodies would not
retain the peculiar attitudes which have been described in different
instances. Nothing can simulate cadaveric spasm and it cannot be
produced in any way after death. Instantaneous rigor only occurs in
cases in which there has been great mental tension and nerve excitation
before death. It is a continuation of probably the very last voluntary
act of life.
_A body showing the signs of death before mentioned_ (Nos. 1 to 10)
_may be held to be that of a person who has been dead from two to three
days at the longest_ (Casper).
Muscular states of the body between the period of somatic and molecular
death:--
(1) _Primary Flaccidity._--The muscles respond to
electrical stimuli; the chemical reaction of the muscles
is either neutral or faintly alkaline.
(2) _Cadaveric Rigidity_ or _Rigor
Mortis_.--During this condition molecular death takes
place; the muscles do not respond to stimuli, but fresh
defibrinated blood passed through the muscles will
restore the response to stimulation, and their reaction
is markedly acid.
(3) _Secondary Flaccidity._--Disintegration of the
muscular elements takes place, no stimuli will provoke
response, and the reaction again becomes alkaline.
Table showing the principal points to be noted in the period of
accession of Cadaveric Rigidity and the causes which retard or hasten
its appearance, or modify its duration:--
_In what does it consist?_--In a shortening and
thickening of the muscles, particularly the flexors and
adductors of the extremities, and elevators of the lower
jaw.
_Period of Invasion._--Generally in from eight to
twenty hours after death. It has been known, however, to
supervene within three minutes of death, but it may be
delayed for sixteen or seventeen hours.
_Period of Duration._--From one to nine days. Three
weeks (Taylor).
_Order in which the Muscles are affected._--Involuntary
muscles, back of neck and lower jaw, muscles of the
face, front of the neck, chest, upper extremities and
then the lower extremities.
_Order in which it disappears._--Back of neck, lower
jaw, &c., following the course of its accession.
_Effects of Exposure to Cold._--Prolonged by dry cold
air, and by cold water.
_Effects of Enfeebling Disease prior to Death._--Rapid
in its invasion, and passing off rapidly.
_Effect of a Robust Frame at Period of Death._--The
accession may be prolonged; but, other things being
equal, it is more strongly manifested, and continues
longer.
_Effects of Violent Exercise prior to Death._--Rapidly
supervenes and rapidly disappears, as in soldiers killed
at the end of a battle.
_Effects of Poison._--Poisons which cause violent
contractions for some time prior to death--strychnine,
&c.--influence the rapid invasion of the _rigor
mortis_, its short duration, rapidly followed by
putrefaction. Where death in poisoning by strychnine is
almost instantaneous, with a short convulsive stage,
_rigor mortis_ comes on _rapidly_ and remains
a _long_ time.
11. _Putrefaction_.--the last of the phenomena which follow death--is
the resolution of the organised tissues of the body to the inorganic
state. It is a gradual process, and is the result of the action of
_micro-organisms, aided by moisture, air, and warmth_.
Putrefaction is the only absolute sign of death having taken place.
The _conditions which modify putrefaction_ are as follows:--
_External Conditions._--1. Micro-organisms; 2. Air; 3. Moisture; 4.
Warmth.
_Internal Conditions._--1. Age; 2. Sex; 3. Condition of the body--(_a_)
_Constitutional peculiarity_; (_b_) State of the body. 4. Kind of
death--(_a_) _The result of disease_; (_b_) _The result of poisons_.
External Conditions Which Modify Putrefaction
1. _Micro-organisms._--A fauna and flora of decomposition has been
described in a paper by Hough on “The Fauna of Dead Bodies,” _B. M.
J._, vol. ii. 1897, p. 1853, to which the reader is referred.
Many different forms of micro-organisms combine in the production of
putrefaction, and the result of their action is inevitable, unless the
body be guarded against their invasion by special means, or the tissues
be rendered unfit for their use.
2. _Air._--Exposure in the open air has a marked effect in promoting
putrefaction; but garments fitting close to the body, and thus
excluding air, have a contrary effect. Dry air, or air in motion,
by assisting evaporation from the corpse, acts as a preservative.
The composition of the soil in which the body is placed has also a
more or less modifying effect. In light, porous soil, allowing of
the free ingress of air, decomposition is more rapid than in close,
compact soil, as clay; but in this we have to contend with another
agent--moisture--which more or less counteracts the protective virtue
of the closer earth.
3. _Moisture._--Putrefaction cannot proceed without moisture. The body,
however, contains sufficient water to enable this process to commence
spontaneously. Organic substances artificially deprived of water do not
putrefy. Cold and heat possess marked antiseptic properties--the former
by freezing the fluids in the body, the latter by drying them up.
4. _Warmth._--A temperature between 70° and 100° F. is found most
favourable to decomposition. The effect of cold is shown by the fact
that a body immersed in water during winter, at a temperature between
36° and 45° F., may be so well preserved as to present, ten or twelve
days after death, well-marked signs of violence, which would in summer
have been utterly obliterated in five or seven days. The preservative
influence of cold water will, however, depend greatly on the depth
at which the body has been submerged. Bodies so submerged, and then
exposed to the air, putrefy with such rapidity that exposure for one
day is said to work a greater change than three or four days longer
retention of the body in the water. As an instance of the preservative
power of cold, may be mentioned the mammoth found in Siberia embedded
in a block of ice.
Internal Conditions Which Modify Putrefaction
1. _Age._--The bodies of young children, other things being equal,
are said to putrefy rapidly. It should be remembered, however, that
clothing possesses considerable power in retarding putrefaction, and
that, in the hurry and anxiety to get rid of the infants, they are
oftener exposed naked than clothed, which may, in some measure, account
for their more rapid decomposition.
2. _Sex._--Sex, it would appear, has little or no influence either to
retard or hasten putrefaction; but it has been remarked that females
dying during or soon after child-birth, irrespectively of the cause of
death, putrefy rapidly.
3. _Condition of the Body._
(_a_) _Constitutional Peculiarity._--It is generally admitted that
persons of the same age and sex, dying similar deaths, and subjected
to like conditions as to exposure to the air and interment in the same
soil, exhibit marked differences as regards the accession and rapidity
of putrefaction. The explanation may be difficult, but the fact still
remains.
(_b_) _State of the Body._--Fat and flabby corpses putrefy more rapidly
than the lean and emaciated. Hence old people, who are generally thin,
keep fresh for a comparatively long time. Bodies, also, which are
much mutilated rapidly decompose--decomposition setting in first at
the parts injured. In examining wounds and bruises said to have been
inflicted during life, it is well to remember that the tendency of
putrefaction is to make them appear more severe.
4. _Kind of Death._
(_a_) _Effect of Disease._--Healthy persons dying suddenly, other
things being equal, are said to decompose more slowly than those
who have died from exhausting diseases, as in the case of typhoid,
phthisis, and dropsy, following organic disease, or of those diseases
attended with more or less putridity of the fluids.
(_b_) _Effects of Poisons._--Putrefaction rapidly supervenes in
those who have died suffocated by smoke, by carbonic oxide, and by
sulphuretted hydrogen. Narcotic poisoning is stated to accelerate this
condition; but in poisoning by phosphorus or alcohol, and in cases
of death from sulphuric acid, the putrefactive changes are greatly
retarded. Arsenic, chloride of zinc, and antimony are reputed to
possess antiseptic properties. The manner in which death takes place
from the action of the poison greatly hastens or retards putrefaction.
Thus, in the case of poisoning by strychnine, it is found that
when death has occurred rapidly, without much muscular exhaustion,
putrefaction sets in slowly; but that, when the muscular irritability
has been greatly exhausted by successive fits, the contrary is the
result.
THE PHENOMENA OF PUTRESCENCE IN THEIR CHRONOLOGICAL ORDER
1. =External=
_One to Three Days._--Greenish coloration of the abdominal walls. Odour
of putrescence is gradually developed, and, concurrently with this, the
eyeball becomes soft and yielding to pressure.
_Three to Five Days._--The green colour, of a deeper shade, has
now passed over the abdomen, extending also to the genital organs.
Patches of this green coloration also make their appearance somewhat
irregularly on other parts of the body, such as the neck, back, chest,
and lower extremities. A dark reddish frothy fluid about this time
wells up from the mouth.
_Eight to Ten Days._--The patches of green colour have now coalesced,
so that the whole body is discoloured. On some parts of the body the
colour is of a reddish-green, due to the presence of decomposed blood
in the cellular tissue. The abdomen is now distended with gases, the
products of decomposition. In India this distension has been known to
occur in less than six hours, the average period being a little over
eighteen hours. Much depends upon the season of the year. The colour of
the eyes has not disappeared, but the cornea have fallen in. Relaxation
of the sphincter ani takes place, and the superficial veins appear like
reddish-brown cords. The nails still remain firm.
_Fourteen to Twenty Days._--The colour of the surface is now bright
green, with here and there patches of a blood and brown colour. The
epidermal layer of the skin is raised in bullæ of varying size, in
some places the skin being more or less stripped off. The nails are
detached, and can be easily removed. The hair can be pulled from the
scalp with ease. The body is now greatly distended with gases, and
the features cannot be recognised, owing to the swollen condition of
the face. The body is generally covered with vermin. In determining
the time at which death occurred, it will be necessary to take into
consideration the season of the year, as it is found that an advanced
stage of decomposition may be present in from eight to ten days, with
the thermometer ranging between 68° and 77° F., which in winter, with a
temperature of from 32° to 50° F., would require twenty to thirty days.
“_Bodies green from putridity, blown up and excoriated, at the expiry
of one month, or from three to five months after death (cæt. par.),
cannot with any certainty be distinguished from one another_” (Casper).
_Three to Six Months._--During the above period the stage of
colliquative putrefaction has set in. The thoracic and abdominal
cavities, due to the increased formation of gas, have burst. The bones
of the cranium have more or less separated, allowing the brain to
escape. The soft parts are more or less absorbed, and no recognition
of the features is possible. The sex can only be positively made out
by the presence of a uterus, or by the peculiar growth of hair on the
pubes, which in woman only covers the pubes, but in man extends upwards
to the navel.
_Saponification._--Bodies exposed to the action of water, or buried in
damp, moist soil, are apt to undergo certain changes, in the course of
which they become saponified, and the formation of a substance known
as _adipocere_ is the result. Adipocere--_adeps_, lard, and _cera_,
wax--is chiefly composed of margarate of ammonia, together with lime,
oxide of iron, potash, certain fatty acids, and a yellow-coloured
odorous matter. The melting-point is 126.5° F. Adipocere has a fatty,
unctuous feel, is either pure white or of a pale yellowish colour,
and with the odour of decayed cheese. It is highly resistant to
putrefactive organisms, and is generally free from them. The formation
of this substance “to any considerable extent is not likely to occur
in less than three to four months in water, or six months in moist
earth, though its commencement may take place at a much earlier
period” (Casper). The above-quoted authority mentions a case in “which
the remains of a fœtus were found imbedded in adipocere, and which
fœtus was proved to have been buried in a garden exactly six months
and three-quarters.” Taylor also records the case of a bankrupt who
committed suicide by drowning, in which the muscles of the buttocks
were found converted into adipocere in five weeks and four days at the
longest.
Although the above statements may be accepted with regard to the
formation of adipocere as far as European countries are concerned,
they do not seem to be applicable to India, where the change appears
to be more rapid. Dr. S. Coull Mackenzie, in his valuable book on
_Medico-Legal Experiences in Calcutta_, records a case of a young
man whose body, recovered after seven days‘ immersion in the river
Hooghly, “was found to be in an advanced state of saponification,” and
the fleshy portions of undigested food in the stomach were converted
entirely into adipocere. “Lastly,” he writes, “in the hot, steamy,
rainy months of September and October, in three of the cases above
mentioned, saponification was found in bodies immersed in water, both
externally and internally, in from two days to eight days ten hours. In
the soft and porous soil of Lower Bengal during the rainy seasons, even
in a wooden coffin, the change is very rapid--three or four days.”
To explain the formation of adipocere, it has been supposed to be due
to the decomposition of the muscular structures of the body, by which
hydrogen and nitrogen are evolved, these combining to form ammonia, and
this, coming in contact with the fatty acids of the fat, forms a soap.
The process of saponification takes place most rapidly in young fat
persons; next, in those adults who abound in fat, and in those whose
bodies have been exposed to the soil of water-closets; more rapidly
in running than in stagnant water; and lastly, in those who have been
buried in moist, damp soil, especially if the bodies have been piled
one on the top of the other, the lowest being first saponified. The
muscular tissue appears to be the first to undergo this change. In
water the process is said to be completed in about five months, but in
soil a period of two or three years appears necessary.
_Mummification_ is of no medico-legal interest, as the causes which
produce it are unknown, and no reliable data can be obtained as to the
period of its accession, or the time required for its production.
2. =Internal=
Table showing the order in which the Internal Organs undergo
Putrefaction:
1. The Trachea.
2. The Brain of Infants.
3. The Stomach.
4. The Intestines.
5. The Spleen.
6. The Omentum and Mesentery.
7. The Liver.
8. The Adult Brain.
9. The Heart.
10. The Lungs.
11. The Kidneys.
12. The Bladder.
13. The Gullet.
14. The Pancreas.
15. The Diaphragm.
16. The Blood-vessels.
17. The Uterus.
Organs which Putrefy Early
1. _The Trachea, including the Larynx._--The rapid change in the
trachea must be borne in mind, in order to avoid the error of
attributing death to suffocation or drowning. An examination of the
trachea should never be omitted.
2. _The Brain of Infants up to the First Year._
3. _The Stomach._--The first traces of putrefaction are seen in
from four to six days after death. All the coats of the stomach are
softened, but there is no excoriation, as is the case when corrosive
poisons are taken. Emphysematous separation of the mucous coat may be
present, but must not be confounded with the excoriation just mentioned.
4. _The Intestines._--Casper declares that he does not remember any
case in the course of his experience where the intestines were “found
earlier putrefied than the stomach.” In the course of putrefaction
they become of a dark brown colour, bursting, and allowing an escape
of their contents; and they ultimately become changed into a dark
pultaceous mass.
5. _The Spleen._--This organ in some cases putrefies before the stomach
and intestines; but, as a rule, it resists decomposition longer.
6. _The Omentum and Mesentery._
7. _The Liver._--This organ is not unfrequently found firm and dense
some weeks after death. It putrefies earlier in new-born children than
in adults. The convex surface first shows signs of putrefaction. The
gall-bladder also remains for some time recognisable.
8. _The Adult Brain._--The brain of newly-born children, as mentioned
before, soon putrefies. This is not the case in the adult brain.
Putrefaction sets in not on the surface, but at the base of the brain.
A wound of the brain causes it to putrefy more rapidly than if no
injury be present.
Organs which Putrefy Late
9. _The Heart._
10. _The Lungs._--Contemporaneously with the appearance of
decomposition in the heart, the lungs also begin to show signs of
putrefaction, though this condition may take place earlier.
11. _The Kidneys._--These organs are long in yielding to the
putrefactive process.
12. _The Bladder._--Nearly all the other organs of the body are in a
state of decomposition before this viscus becomes materially affected.
13. _The Gullet._--This long remains firm, even after the stomach and
intestines fail to be recognised.
14. _The Pancreas._--The body must be far advanced in putrefaction
before this gland becomes affected.
15. _The Diaphragm._--This may be distinguished after the lapse of four
to six months.
16. _The Blood-vessels._--The aorta may be recognised after the body
has been interred for fourteen months.
17. _The Uterus._--Of all the organs of the body, the uterus resists
the putrefactive changes longer than any other organ.
Table showing some important Facts to be noticed with regard To
Putrefaction:
1. Earliest external indication of it.
(1) _In a Body exposed to Air._--Greenish coloration of the
abdominal coverings.
(2) _In a Body immersed in Water._--Face, head, and ears,
gradually extending from above downwards.
2. Earliest internal indication.--Found in the trachea, including
the larynx.
3. Advanced putrefactive appearances to be expected in a body
exposed to air, say from fourteen to twenty days at mean
temperature, as regards--
(1) _Epidermis._--Raised here and there in blisters about
the size of a walnut, in some places the size of a dinner
plate, and quite stripped off.
(2) _True Skin._--Maggots cover the body, chiefly in the
folds of the skin.
(3) _Cellular Tissue._--Blown up with gas.
4. Comparative time required to produce equal extent of putrefaction
in a body--
(1) _In Air._--One week. One month.
(2) _In Water._--Two weeks. Two months.
(3) _In Earth._--Eight weeks. Eight months.
_Does Lime hasten Putrefaction?_--It is a very general opinion that it
does. Careful experiment has, however, proved that lime neither retards
nor hastens putrefaction, but that it prevents the escape of the gases
produced during the process by absorbing them; it is, therefore, a good
and safe deodoriser, and in this property its true value lies.