CHAPTER XII.

THE CHANGES IN THE BODY AFTER DEATH.

=Cooling of the Body.=—The internal temperature of the healthy living being is about 37 degrees centigrade. But it may be increased several degrees in consequence of disease. After death the chemical changes upon which the maintenance of this temperature depends rapidly diminishes, and the body gradually cools to the temperature of the surrounding atmosphere. This usually occurs in from about fifteen to twenty hours, but the time required depends upon a variety of conditions. Immediately after death there is, in nearly all cases, a slight elevation of internal temperature, owing to the fact that the metabolic changes in the tissues still continue for a time, while the blood ceases to be cooled by passing through the lungs and peripheral capillaries. After death from certain diseases yellow fever, cholera, rheumatic fever, and tetanus, a considerable elevation of internal temperature has been repeatedly observed.

The time occupied by the cooling of the body may be prolonged after sudden death from accidents, acute diseases, apoplexy, and asphyxia. A number of cases is reported in which the body retained its heat for several days without known cause.

After death from wasting chronic diseases, and in some cases after severe hemorrhage, the cooling of the body is very rapid, the internal temperature being reduced to that of the surrounding air within four or five hours.

Fat bodies cool less quickly than lean ones, the bodies of well nourished adults less quickly than those of children or old persons. The temperature of the surrounding atmosphere, the degree of protection of the body from currents of air, of course, modify the progress of cooling; and the internal organs naturally retain their heat longer than the surface of the body. The rate at which cooling occurs is most rapid as a rule, during the hours immediately following death, notwithstanding the postmortem rise which may ensue.

=Cadaveric Lividity.=—This means the black and blue discoloration from the effects of the congestion or contusion of the blood.

After life becomes extinct, and before the blood coagulates, it changes its position chiefly in two ways: First, it is driven by their contraction out of the arteries and into the veins; second, it settles in the veins and the capillaries of the more dependent parts of the body, inducing, usually within a few hours after death, a mottling of the surface with irregular livid patches. These patches may coalesce, forming a uniform dusky red color over the back of the trunk, head and extremities, and sometimes over the ears, face and neck. The same effect is noticed on the anterior aspect of the body if it has lain on the face. At points of pressure, from the folds in the clothing, and from the weight of the body on the bed or the cooling board, the red color is absent or less marked. This to the undertaker and the embalmer is known as postmortem discoloration. These changes occur before putrefaction sets in. This cadaveric lividity should not be mistaken for the antemortem ecchymoses from which it may usually be distinguished by its position and extent by the fact that the surface of the skin is not elevated, and by the fact that on incision no blood is found free in the interstices of the tissues. Not infrequently the subcutaneous tissue in the neighborhood of these postmortem discolorations become infiltrated with a reddish serum. Very soon after death, particularly in warm weather, the tissues immediately around the subcutaneous veins of the neck and the thorax and in other situations, may become stained a bluish red color from the decomposition and escape from the vessels of the coloring matter of the blood. This to the undertaker and the embalmer is known as postmortem discoloration.

=Putrefactive Changes.=—As soon as the body dies, it becomes as any other inanimate object, subject to putrefaction and decay.

The tissues of the body undergo various changes as to consistency of the solids, semi-solids, fluids, and as to color.

Putrefactive changes are caused by the presence of putrefactive germs normally present in the tissues or gaining access to them, which in their effort to satisfy their own nutrition, break down those complex molecules of which the tissues are composed into simpler compounds.

Putrefaction then is organic decomposition or decay the result of putrefactive bacteria. Putrefaction may also be defined as the separating of the constituent elements of the body due to the presence and growth of bacteria.

Although septic changes may take place before the death of a body, yet the term putrefaction is not applied until after the death of a body, and denotes those changes in color, consistence, and smell so clearly perceptible.

Usually in from one to three days, depending upon circumstances, a greenish discoloration of the skin occurs at first upon the middle of the abdomen, over which it gradually spreads, assuming a deeper hue, and often changing to greenish purple or brown. Greenish patches may now appear on the different parts of the body, earliest upon those overlying the internal cavities; this discoloration is probably produced by the action on the haemoglobin of gases developed by decomposition.

The eyeballs now become placid and if the eyelids are not closed the conjunctiva and cornea become brown and dry. The pressure of gases developed by decomposition in the internal cavities not infrequently forces a greater or less quantity of frothy, reddish fluid or mucous from the mouth and nostrils, distends the abdomen, and, if excessive, may lead to changes in the position of the blood in the vessels and even a moderate amount of displacement of the internal organs.

After five or six days, under ordinary circumstances, the entire surface is discolored to a green or a brown. After this the epidermis becomes loosened through the formation of gases and separating of fluids beneath, and the tissues become flaccid.

The abdomen and the thorax may be greatly distended, and the features distorted and scarcely recognizable from swelling, and the hair and nails loosened.

On the interior of the body, those soft and less compact tissues, or those tissues in which there is a great amount of fluid, are the first to decompose. This may be noticed by examining the walls of the trachea, esophagus and the intestines and noting the change in color.

Decomposition of the soft and liquid portions of the body take place almost immediately after the death of the body, and then follow in rapid succession the decomposition of the semi-solids and finally the solids. Beyond this stage of putrefaction, the consecutive changes can scarcely be followed with accuracy.

The putrefactive changes can not be said to begin at the same place in all bodies, as the conditions under which death occurred will regulate that. The rapidity with which these changes follow one another depends upon a variety of conditions such as temperature, moisture, access of air and the diseases which have preceded or caused death.

Various temperature relations will effect greatly the more or less rapid decomposition of the body. Bodies dying in mid-summer are decomposed much more quickly than those dying in mid-winter.

Moisture added to the temperature relation will hasten the rapidity of the decomposition as can be noticed in those localities with a high temperature but moist climate that the decomposition takes place very quickly. In those climates with high temperature, but dry or absence of moisture, the tendency is to dry up the tissues, and instead of putrefaction we have mummification as the result. This last statement then serves to explain the reason for the high state of preservation in the forms of mummification as exists in those countries like Egypt with their extremely hot and dry climates.

Exposure added to the temperature and the moisture relations adds greatly to the rapidity of the decomposition. A moist climate with a hot temperature and free exposure favors rapid decomposition. We notice that putrefaction progresses much more rapidly in the air than in the water and in the earth its progress is slower than in the water. The more exposed a body is then, to the elements, especially the air, the more rapid will be the decomposition.

An elevated temperature and the presence of air and moisture hasten the advent and progress of putrefactive changes.

Bodies dying in high fever and edematous subjects are much more quickly decomposed than those dying with the ordinary wasting away disease.

The bodies of infants usually decompose more rapidly than those of adults, fat bodies more rapidly than lean ones.

The infectious diseases, intemperance, and the puerperal condition promote rapid decomposition as also does death from suffocation.

Poisoning from arsenic, alcohol, antimony, sulphuric acid, strychnine and chloroform may retard the progress of decay.

It is impossible, then, to say how long a body will keep without the use of preservatives, as it depends partly upon temperature, partly upon moisture, partly upon the amount of exposure and partly upon the conditions existing in the body before death.

We can easily understand the reason for all this if we understand the bacteriology relating to the subject.

In the first place, bacteria require for their best and most rapid growth the proper temperature, moisture and media relations. By this we mean that the temperature should be moderately warm, ranging from about forty to one hundred degrees Fahrenheit, the optimum being about the body temperature 98.6 degrees Fahrenheit or 37 degrees on the centigrade scale. With this optimum temperature, the element of moisture should always be present, as we find that nothing in nature will germinate without the necessary moisture. Then the bacteria must have the proper media, meaning that they must have the right substance on which to grow. Inasmuch as the cause of putrefaction is the host of putrefactive bacteria which abound trying to satisfy their own nutrition, and since these bacteria require a moderately warm and moist media on which to grow, it is only natural that putrefaction and decomposition should occur much more rapidly in warm moist climates than in dry cold climates.

In regard to exposure we learn that certain putrefactive bacteria are aerobic in character, i. e., that they need a great quantity of oxygen for their growth, and for this reason a body in water or buried in the earth does not decompose as rapidly as one exposed to the air. But although they do not decompose as rapidly yet we find that they do decompose in time. This is due to the fact that there is another class of bacteria, called anaerobic, i. e., which do not need oxygen for their growth. In the case of the body in water these anaerobic bacteria exist and develope slowly in the alimentary tract, and eliminate gases sufficient to bring the body to the surface, where the aerobic bacteria enter, and putrefaction progresses much more rapidly.

The starting point of decomposition is usually at the seat of the disease the subject had before death, but it soon spreads to all the various tissues of the body.

Putrefaction is always accompanied by a great amount of odor, which is caused by the generation of gases the result of bacterial action. The obnoxious gases, offensive to the smell are sulphureted hydrogen, nitrogen, carbonic acid and ammonia.

The material actually present when the body is actually decomposed has been determined as being water, nitrogen, methane, carbon dioxide, etc.

_Treatment by the Embalmer._—Putrefaction always means that there is present a great amount of putrefactive bacteria and if you are to arrest this condition you must resort to the most thorough embalming. By placing some preservative fluid in the arteries and having a thorough circulation all the tissues of the body can be reached and hence the complete destruction of those bacteria causing the putrefaction.

If all the tissues are properly bathed with embalming fluid there need be no further danger of putrefaction; but what seems sometimes at first a thorough circulation, proves afterward to be only a partial one. If after several days the body still shows signs of decomposition it is best to reinject or if the decomposition only occurs in spots a simple hypodermic injection will prove adequate.

=Skin Slip.=—To properly understand the causes of skin slip a thorough knowledge of the structure of the skin is necessary. It would be best then to turn to the chapter on the tissues of the body and study the minute structure of the skin.

Skin slip is caused by a putrefactive softening of the epidermis. There is a watery infiltration from the minute capillaries and the surrounding tissues between the dermis and the epidermis, causing the latter to loosen and if touched to slip and tear away from the dermis or true skin.

Many embalmers have been led to believe that the slipping of the skin is due to the use of certain fluids used in injecting the arterial system. This error should be corrected, as it is most generally the absence of the fluid from the part which results in the slipping of the skin.

Diseases of the heart, liver, kidney and dropsical conditions predispose to the early skin slip. The immense amount of water occurring in the minute capillaries of the skin prohibits the embalming fluid from reaching the tissues.

Skin slip then is due to putrefactive changes occurring in the skin, and if it should occur after embalming, it is positive proof that the part or parts have not received a sufficient quantity of a preservative fluid.

_Treatment by the Embalmer._—In the average case you will never see skin slip, because you will be called comparatively soon after death has occurred and the body will be embalmed and buried before this later form of putrefaction will manifest itself. But in some few cases you will have to keep the body for a greater length of time, say to await the arrival of some friend living abroad, or it may be a coroner's case. In cases like this the body being kept for a period of weeks, will if it is not perfectly embalmed show signs of skin slip. As has been stated above, cases that die from diseases causing dropsical infiltration in the subcutaneous tissues should also be handled carefully. If you are aware before hand that you are to keep the body for a great length of time or that you have a dropsical subject, a little formaldehyde should be added to the fluid that is injected, about two or three ounces to each quart of fluid. Zinc compounds might be added, but formaldehyde is better because of its great affinity for water.

If skin slip occurs after the body is embalmed it is best to place a layer of cotton over the part where the skin slip occurs and saturate the cotton with equal parts of alcohol, formaldehyde and glycerine.

In drowned cases where all the skin is slipping it is best to envelope the whole body with a layer of cotton saturated with formaldehyde.

=Rigor Mortis.=—Rigor mortis is the stiffening condition which occurs on the body after death.

When the muscle substance dies it becomes rigid, or goes into a condition of rigor; it passes from a fluid to a solid state. The rigor that appears in the muscles after somatic death is designated usually as rigor mortis, since its occurrence explains the death stiffening in the cadaver. It is characterized by several features: the muscles become rigid, they shorten, they develope an acid reaction, and they lose their irritability to stimuli.

After the death of an individual the muscles enter into rigor mortis at different times. Usually there is a certain sequence, the order given being the jaws, neck, trunk, upper limbs, lower limbs, the rigor, therefore, taking a downward course. The actual time of the appearance of the rigidity varies greatly, however; it may come on within a few minutes or a number of hours may elapse before it can be detected.

Death after great muscular exertion, as in the case of hunted animals, or soldiers killed in battle, is usually followed quickly by muscle rigor. Death after wasting diseases is also followed by an early rigor, which in this case is of a more feeble character and shorter duration.

Certain drugs such as veratrum, hydrocyanic acid, caffeine and chloroform, will hasten the development of rigor.

People who die in full habit, meaning that there has been no muscular exertion or wasting processes before death, usually have the rigor developing more slowly and of a longer duration.

After a certain interval, which also varies greatly, from one to six days, the rigidity passes off, the muscles become soft and flexible; this phenomenon is known as the release of the rigor.

The usual explanation that is given of rigor is that it is due to a coagulation of the fluid substance, the muscle plasma, of which the fibers are constituted. During life the fluids exist in a liquid or viscous condition; after death they coagulate into a solid form.

Rigor mortis is not a sign of death, as there is rigidity of the muscles following apparent death, as in cases of asphyxia and trance. If the body is rigid, in a case in which there is a doubt that death is present the rigidity may be broken up. If it is a case of trance or that of the contraction of the muscles following drowning, it is likely to return, especially in case of trance; but if death is actually present it will not return.

The chemical changes occurring, the result of rigor mortis can be briefly stated:

(a) There is a coagulation of the proteid material of the muscle plasma.

(b) There is an increased acidity, which is doubtless due to the production of lactic acid.

(c) There is a production of carbon dioxide.

(d) There is a consumption of glycogen.

_Treatment by the Embalmer._—Many times when called to embalm a subject you will find the body in a state of rigor. In cases of this kind the rigor mortis should be broken up. This can be done by taking each of the joints and gradually bend them a little at a time until they become perfectly lax. Once a joint is bent the stiffening disappears and the embalmer can proceed.

=Fermentation and the Production of Gas.=—A molecule is the smallest portion of a compound which can exist by itself.

An atom is one of the ultimate particles composing a molecule. A complex molecule is one in which two or more elements have been combined. Example: water molecules are formed by two atoms of hydrogen and one atom of oxygen.

A ferment is a substance causing fermentation in other matter with which it comes in contact. There are two kinds of ferment expressed by the names organized and unorganized.

Unorganized ferments are chemical substances having the power to produce or assist in the production of fermentation.

Organized ferments are bacteria having the power to produce fermentation.

Fermentation means the process through which complex molecules are decomposed and their ingredients disassociated by the action of ferments. As an example of fermentation, we can take proteid food substances, the molecules of which are always of complex form, and by subjecting them to the action of organized ferments (bacteria), decompose them, and separate each gas ingredient, obtaining therefrom a variety of gases from what was formerly a substance of perfect chemical union. Fermentation is present in most of the natural processes whereby chemical changes are produced in animal and vegetable matter. Fermentation is taking place all the time in all the climes excepting possibly the frigid zones. The organized ferments (bacteria) are subject to the same temperature limits that govern the reproduction and the growth of all bacteria.

Fermentation is divided into spirituous fermentation, digestive fermentation, metabolic fermentation, and putrefactive fermentation.

=Spirituous Fermentation.=—Spirituous fermentation is that process of fermentation by which forms of yeast cells, by their growth and reproduction in such complex substances as grapes, fruit, apple juice, grains, etc., extract alcohol from these substances and by this process produce wine, cider, spirits, etc. Many times in the dead body, spirituous fermentation occurs. Spirituous fermentation is caused by a vegetable parasite called yeast.

=Digestive Fermentation.=—Digestive fermentation is that process by which digestion and nutrition in the living body is assisted through the action of ferments called enzymes, acting on the food substance. This process is mainly one where each food particle is split up by a particular ferment or enzyme. After death this process may continue for a certain length of time and result in the formation of gas. Digestive fermentation is mostly chemical.

Enzymes are unorganized ferments and are cast off the living body within the living body.

=Metabolic Fermentation.=—Metabolic fermentation is that process by which enzymes in the tissues of the living body destroy the dead cells, and reduce them to the following gases: nitrogen (N), carbon-dioxide (CO₂), ammonia (NH₃), uric acid, and other materials. In the living body these gases and other products are eliminated from the tissues, by the sudoriferous glands and ducts through perspiration, by the lungs with the expired air, by the intestines with the feces and by the kidneys with the urine. In the dead body the enzymes become active agents in tissue gas production, unless they are kept in restraint by being brought in contact with germicidal embalming fluids.

=Putrefactive Fermentation.=—Putrefactive fermentation is the process by which undigested food substances (principally proteids), under the influence of ferment bacteria, yield gases. This change rarely takes place in the small intestines of the living body as the germs are held in restraint by lactic acid and acetic acid bacteria in those parts. There is little restraint to their activity in the large intestines, however, and the intestinal gases along with putrefactive changes in fecal material are a natural consequence.

Intestinal fermentation is hastened in the dead body by the presence of much undigested food and the absence of any restraining organisms. The gases produced in the intestines of either the living or dead body by the action of putrefactive ferment bacteria are: carbon-dioxide (CO₂), hydrogen (H), nitrogen (N) hydrogen sulphide (H₂S), methane (CH₄). The continued fermentation in the stomach and the intestines causes a coffee colored material of a frothy character to purge from the mouth.

When the hollow needle or trocar is used to reach the scene of ferment activity, the gases mentioned are released from the effected organs. As these gases are extremely odorous, they should be passed through a pledget of cotton saturated with formaldehyde, before being allowed to pass into the open air. Germicidal fluids when directed against the bacteria in an intelligent manner should destroy them and prevent their becoming active again.

Putrefactive fermentation is divided as follows: abdominal fermentation, gastric fermentation, and intestinal fermentation.

=Abdominal Fermentation.=—Abdominal fermentation is putrefactive fermentation as it effects the tissues and necrotic substances of the abdominal cavity itself (excepting the digestive organs), caused by the action of zymogenic bacteria. Perforations of the intestines or appendix, inflammation of the mesentery or peritoneum, may allow putrid material to escape into the cavity proper, where bacterial action will produce noxious gases. You will recognize a condition of this kind by the following illustration: As soon as the point of the trocar has penetrated the peritoneum and the rod has been withdrawn, there will be an escape of gas. This escape is due to the internal pressure being greater than the atmosphere pressure. This explains the swollen condition of the abdominal wall and its subsequent relaxation as the gas is allowed to escape.

Certain diseases predispose to abdominal fermentation as inflammatory diseases which effect the peritoneal covering of the organs, and cause a swollen abdominal wall after death.

_Treatment._—In the treatment of these cases it is always advisable that the operator be familiar with the location of the disease, so that direct trocar application can be made to the affected part. The location of the affected part is not always the same, as it varies with the location of the particular tissue or organ affected. In appendicitis, where death has occurred without surgical attempts to remove the appendix, the operator should spray the right inguinal space with enough fluid to neutralize the cause of the gas. Where the cause of death has been typhoid, the umbilical, hypogastric and epigastric spaces should be sprayed. Where the cause of death is puerperal fever, the right and left inguinal and hypogastric spaces should be sprayed. The gas itself, will be eliminated from the cavity of the body by simply inserting the trocar and allowing the gas to escape until the internal pressure approximates that of the atmospheric pressure. This though does not prevent the reformation of gas, as the origin of the gas is the living and growing fermentative and putrefactive bacteria. To prevent a recurrence the bacteria must be killed, and this is done by spraying a germicidal fluid around the affected part. Abdominal fermentation and gas is much easier to treat than gastric or intestinal fermentation.

=Gastric Fermentation.=—This is recognized by a frothy coffee colored purge from the mouth or nose caused by pressure in the stomach, due to putrefactive bacteria, and their action on proteid food substances which are present in the stomach. Where the cause of death has been principally from inflammatory processes, or where the deceased has died shortly after eating a full meal, this condition must be looked forward to. The swollen condition directly over the stomach is another visible sign of value in diagnosing the condition.

_Treatment._—When the body is placed in your care, the embalmer should make a careful and thoughtful survey of the condition of the body and the cause of death. Any inflammatory disease of the abdominal tissues or a full meal eaten shortly before death will almost always predispose to the formation of gas. The treatment would be to take proper care of the stomach contents.

(a) Insert the trocar at a point two inches to the left of the median line, half the distance from the ensiform cartilage and the umbilicus. Direct the trocar downward and diagonally to the left to a depth of three to four inches. Remove the trocar rod and allow the gas to escape into a fluid bottle, containing a small amount of fluid, so that the gas may be deodorized. Before removing the trocar, inject not less than one pint of normal fluid into the stomach, so that the fermentable materials and the bacteria may be destroyed.

(b) Make an incision in the median line of the body, three inches long, from the tip of the ensiform cartilage downward toward the umbilicus, and proceed as directed for the direct incision described on page 257.

The treatment for gastric fermentation demands the specific treatment as directed above. No short treatments can be depended upon for certain results. Cotton placed in the mouth only delays the time for the purging to begin from the mouth. Gastric fermentation can be prevented in all cases by the use of the specific treatments as described in (a) and (b).

If in your practice, you receive a body from a shipping undertaker, which unfortunately was not treated in the correct manner, and which is purging from the mouth, arrange to puncture the stomach in the manner described in treatment (a). This can be done without disturbing the position of the body in the casket, by opening the clothes above the stomach. After puncturing the stomach and allowing the gas to escape, inject not less than one pint of fluid therein, cleanse the mouth with absorbent cotton by the use of the lock forceps and a recurrence of the purge will not be possible.

If in your practice you have overlooked the possibility of gastric fermentation, and find, either by advice from the family or from your own observation, that purging is going on, use either the treatment (a) or (b), neutralize the fermentable material, cleanse the mouth and no recurrence will be possible.

=Intestinal Fermentation.=—Here we have the fermenting gases in the intestines and the colons. The pressure of the gases will bear upon the stomach and there may or may not be purging from the mouth depending upon the fact of presence or non presence of material in the stomach. The abdomen though will be greatly distended, and when palpated will give a drummy note.

_Treatment._—(a) Insert the trocar through the umbilicus, and direct the point downward into the right inguinal region so as to relieve the gases from the caecum, then inject a small quantity of fluid; then direct the point of the trocar upward into the left inguinal region so as to relieve gases from the sigmoid flexure, and inject a small quantity of fluid; then direct the point of the trocar upward into the right hypogastric region so as to relieve gases from the hepatic flexure, and inject a small quantity of fluid; then direct the point of the trocar upward into the left hypogastric region so as to remove gases from the splenic flexure, and inject a small quantity of fluid; and if at this time it is thought that the stomach contains gas, relieve it, and inject therein a small quantity of fluid; now place some fluid directly into the abdomen around the small intestine and with this treatment you are assured that your intestinal fermentation is taken care of.

(b) Intestinal fermentation may also be treated by the direct incision, as described on page 257.