· 11 മിനിറ്റ് വായന

Living with dead bodies

Forensic Medicineഅനുഭവങ്ങൾ

I have performed over one thousand and two hundred autopsies, and seen over three thousand, in a career spanning seven years in Forensic Medicine and twenty in health care. Over these years I have forgotten more deaths (homicides, suicides, accidents) than most people will ever see in a lifetime. But of all these numerous post-mortem cases one image still remains in my mind, the distressing image of a dead girl lying pale on an autopsy slab, as fresh now as when I first saw her.

Both her palms are tinted green with some kind of herbal paste. We remove it and see the skin blistered underneath, obviously infected. Her skin is covered with similar blisters, many of them leak pus. We examine her internal organs and find them devastated, damaged beyond recognition. Both her kidneys are wrecked, so are both her lungs from infection. These are not usual findings at her age.

She had been diagnosed with a disease which affected her kidneys and was referred to our Medical College from the District Hospital. Her parents took her instead to a relative who specialized in ritual healing and one shot medicines. What we see in our post-mortem is the end result of his treatment which mostly consisted of prayers and poojas every alternate week. It was a treatable disease and even when it worsened she could have lived with a kidney transplant and led a normal life.

I’m a Forensic surgeon, one of a specialized group of medical doctors who find out how people die. We listen to the tales our patients say, but unlike in other specialties our patients cannot talk to us, so we learn their tales from clues in their bodies. We do this routinely and have no qualms when we ascertain cause of death, nor when we give evidence in court. But this case, this child, is unusual. She comes to me now and then as a pain inside, the memory of useless suffering which arrives and stays with me for a while. A curable disease treated with magic and prayers, with flaming camphor placed over a child’s sick body, a raging infection left untreated.

My child, I tell her as she lies on her autopsy table, your death was a crime, you were killed by superstitions, by ignorance, that these beliefs persist today is a crime. That I live in this society which tolerate them makes me an accessory to the crime, impotent or otherwise, like everyone else here.

Since that day I have heard of ten more deaths in our State from these belief, superstitions claiming ten more people who otherwise would have lived.

The other day I read another story in the papers and I suddenly remembered again this little girl because it was a story as strange as hers. A man had died of some sudden illness and his wife and children had held vigil over his corpse for three months hoping he would spring back to life. It was unbelievable because dead bodies start to decompose a few hours after death, a process which is difficult to keep secret.

It may be easy to avoid these beliefs if one knows what happens to the body after death. You know that breathing stops after death. Blood circulation stops. You may also know that the pupil of the eye dilates and becomes fixed in death. These signs taken together make a diagnosis of death.

There are some conditions, however, where a diagnosis of death may be difficult to make. In a condition called suspended animation or apparent death the heart slows down, and breathing slows to a point where it is difficult to distinguish life from death. Drowning , electrocution and sunstroke are some of the conditions which may cause suspended animation. This may occur in newly born children too for reasons difficult to understand.

Certain well defined changes happen to the body after death. We all know that the normal body temperature is 98.6 degrees F. This temperature is maintained by normal bodily process which come to a halt immediately after death. The dead body loses heat and soon attains the temperature of its surroundings.

In some special circumstances body temperature may be maintained for several hours after death. This is called post-mortem caloricity. Death due to sunstroke, tetanus, septicemia and some kinds of poisoning can cause post-mortem caloricity. Here certain biological processes in the dead body results in body temperature being maintained after death.

Since the heart stops after death and circulation ceases the only force which acts on blood inside the body is gravity. Gravity causes blood to settle in dependent areas. The skin over these areas will exhibit color change due to pooling of blood. This effect is called post mortem staining and is seen in small patchy areas about a couple of hours after death. These small areas coalesce together over several hours, and become fixed by 12 hours. Post mortem staining is useful to calculate time of death. For example the body of a person who has died from suicide by hanging will exhibit staining in his hands and feet after a predictable interval.

Soon after death muscles become flaccid, a process called primary flaccidity. The lower jaw falls open. Joints become lax. Primary flaccidity continues until ATP in muscles lose energy. Flaccid paralysis is well depicted in Michelangelo’s famous sculpture Pieta.

The next stage is rigor mortis. After ATP in muscles lose energy the body become contracted and stiff. This first happens in smaller muscles. The heart is the first muscle to undergo rigor. The first external muscles to undergo rigor are the muscles of the eyelid. The process affects all muscles in the body from the head first to the feet. Rigor mortis will set in about two hours in the head and neck, four in the arms and six in the legs. One can apply a strong force and overcome rigor mortis. Once overcome it will not occur again.

Rigor mortis naturally loosens up over time. In warmer climates rigor begins to pass off by about 18 hours after death. Rigor passes off completely in 36 to 48 hours and this happens in the same way as it develops: from head to foot. It is used to accurately fix the time since death.

In certain cases the normal process of flaccidity may be absent in some group of muscles. This is usually seen in violent deaths and is called cadaveric spasm. Cadaveric spasm may be seen in suicides using a gun where the hand clutches the weapon in a death grip or in drowning deaths.

Immediately after death the decaying process begins. This happens due to the action of microorganisms, chiefly bacteria. Tissues and organs, proteins, carbohydrates and fats liquefy. Methane, Hydrogen sulphide and Ammonia are released by the actions of bacteria. This happens mainly in the intestines. The abdomen distends and the scrotum enlarges. The face becomes puffy and the tongue protrudes. These changes begin about 12 hours after death in tropical climates.

The eyes protrude, so does the tongue in 24 to 36 hours. A red fluid leaks out of the nose and mouth. The characteristic bad smell of putrefaction now begins. The skin blisters all over the body after 24 hours and peels away. 72 hours after death hair falls from the scalp.

The body changes color. This happens first in the lower abdomen about 18 hours after death. It becomes pale green in the area next to the cecum of the intestine which is rich in bacteria. Over time the body turns green and greenish black.

Hydrogen sulphide released by bacteria combines with met-hemoglobin and forms sulph-hemoglobin. This fills the small blood vessels of the body and resembles a marble slab with a green tinge. It takes about 36 hours for marbling to happen. It occurs first in the thighs, shoulders and the backs of the hands and feet.

Changes happen in internal organs too. Twelve hours after death the larynx and trachea in the throat turn pink inside. So does the inner lining of the aorta. The spleen liquefies into a gel. The liver becomes soft and flabby in 36 hours after death and later becomes honey combed in appearance. The lungs decay and turn into a blackish mass. The heart softens, so do the kidneys. So does the urinary bladder but this is often very late.

The last organs to decay are the prostate gland in men and the uterus in women.

You may have seen worm filled dead bodies of animals. This is also part of the process of putrefaction. Ants colonize the dead body in a few hours. Soon houseflies set up house and lay eggs in the body. 24 hours later the eggs hatch. Larvae roam the body. By the tenth day the dead body is abode to many species of insects.

It will take a year for the body to skeletonize completely, depending on the circumstances.

There are two important exceptions where normal putrefaction process does not occur. One such condition is called adipocere and the other mummification.

Adipocere: In adipocere skin over the body is lost appears as a layer of soap. In this process, hydrolysis and hydrogenation of fat occurs and the body fat is converted into palmitic, oleic, stearic and hydroxy-stearic acids, and mixture of these forms adepocere. The common sites are the face, the abdomen, the breasts, the buttocks and the thighs. Adipocere can occur as early as five days in the tropics. In temperate climates this may take up to three weeks. Adipocere formation may protect the body from putrefaction for several months.

Mummification: Mummification is rare. You may have heard of the Egyptian Pharaohs who were preserved as mummies for several centuries. This is a similar process. The body loses its water content and becomes dried and dehydrated. Its structure is preserved and recognizing features may be preserved for centuries. A combination of hot environment and dry atmosphere is necessary for mummification.

We have discussed the general process of decay. Several factors may affect these changes. Atmospheric temperature, humidity, clothes worn, fat content, cause of death- all these may affect normal decay processes. Putrefaction happens faster in open air and more slowly in water. In a body buried deep it takes upto eight times as much time. If the surrounding temperature is below 4 degree C normal decay processes may be completely halted.

What certainly does not affect decay processes are religion or caste. One religious group may choose to bury its dead and another may choose some other form of disposal. These may change the decay process. But magic does not change it, nor witchcraft, nor prayer. Death is a reality which must happen after birth. Illness, however, can be modified with medicines. Modern medicine has managed to prevent and cure many disease and has contributed to increasing the average lifespan of the human race. To let go of all this knowledge in the name of culture or religion and embrace ignorance is a step backwards to a dangerous darkness.

The loss of loved ones is painful. There will be difficulty in accepting reality. Grief is a normal reaction to loss and has been described in certain well defined stages. This may be different for different individuals.

The first stage of grief is denial where the griever refuses to accept his or her loss. This is manifested as lack of emotional response (numbness), often with a feeling of unreality, and incomplete acceptance that death has taken place. This may last from a few hours to a few days.

The next stage may last from several days to even several months. An extreme sadness, weeping, anxiety, loneliness, crying bouts and obsessive thoughts about the dead person may occur. Sleeplessness, loss of appetite an irritability are also seen. There is also guilt here, a feeling of not having done the right thing and anger arising from this guilt. Relatives or health caretakers may be thought to be involved in the death. Minor hallucinations may occur where the dead person is seen or heard.

The third stage lasts from a few weeks to a few months. Sadness slowly decreases and the person returns to normal life. Happier memories of good times with the departed person surfaces. There may be temporary lapses, for example on death anniversaries, but usually these periods do not last long.

If such a normal grieving process lasts abnormally long, longer than six months, a psychiatric evaluation may be necessary to rule out depressive illness. Unscientific practices in the form of rituals and magic which try to harness normal grief due to death still exist, even in educated society. We must analyze why this continues to happen.

It is certainly not the fault of the individual or the family. It is a problem of the society at large, a lack of scientific thinking in every day life, a separation of science from daily living. This attitude is exemplified by such instances as conducting a religious ritual before a space launching. Science is compartmentalized and held separate from daily life. These customs and practices gain currency when practiced by educated scientists and intellectuals in society. Change is necessary, and this change must come from the society, from the individual, from you and from me.

Dr. Jinesh P.S. Completed MBBS and MD in Forensic Medicine from Govt Medical College, Kottayam. He has worked in Dept. of Forensic at Govt Medical College, Kottayam as Lecturer and at Community Health Center Kumarakom and Edayazham as Medical Officer. He is interested in spreading of scientific temper, health awareness.
Dr Viswanathan K. Trained at trivandrum Medical College. Finished MS Ortho in 2000 and have been working in private hospitals.Presently at Trivandrum Medical Centre. Area of interest is sports medicine surgery and Arthroplasty surgery. Interests are fitness and reading.
Design Co-ordinator, Infoclinic.

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