CHAPTER III

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.

##