Deceased Male with a Cigarette In Situ: Is This a Cadaveric Spasm?
Article information
Abstract
When death occurs, the supply of adenosine triphosphate through respiration ceases, and rigor mortis begins approximately 20 minutes after death. The underlying mechanisms of rigor mortis and cadaveric spasm are assumed to be similar. However, unlike rigor mortis, cadaveric spasm is a very rare phenomenon in which muscle stiffness develops almost immediately after death. Herein we describe a 27-year-old male with suspected cadaveric spasm. A forensic pathologist concluded that the cause of death was a head injury due to a fall. When the body was discovered, a cigarette remained in the mouth, suggesting a cadaveric spasm. Some opinions deny the existence of cadaveric spasm because there is no precise pathophysiological mechanism to support it. Cadaveric spasm could not be confirmed in the present case; however, while the complete mechanism is unclear, as in this case, it is sometimes difficult to rule out the presence of cadaveric spasm in forensic investigations. Therefore, a comprehensive forensic examination is necessary, and forensic examiners should be cautious.
Case Report and Discussion
The deceased was a 27-year-old male, who after consuming alcohol and breaking up with colleagues the previous day, was found by one of his colleagues in the garden next to his residence at approximately 8 am on the next day. His residence was in a rural area with no streetlights and the height from the rooftop of the residence where the deceased was believed to have fallen to the ground was approximately 4 meters (Fig. 1A). A 45 cm height hump was installed on the edge of the rooftop to prevent falls (Fig. 1B). When discovered, the body was facing the sky, and a postmortem examination revealed rigor mortis throughout the body, from the small joints, such as the jaw and hands, to the large joints. Blood stains were observed around the nose and mouth in an upward direction. A cigarette was held in the mouth between the upper and lower teeth (Fig. 2). Based on information from the police investigation and the presence of rigor mortis, the postmortem interval was estimated to be 7 to 8 hours.
The height from the rooftop to the ground is approximately 4 meters (A). There is a 45 cm high hump on the edge of the rooftop to prevent falls (B).
The direction of the blood stains is upward from the face to the head, and there is a cigarette in the mouth.
A forensic autopsy was performed to investigate the death under a court-issued warrant at the request of the public prosecutor. The autopsy revealed multiple circular and linear fractures in the skull around the forehead and vertex, cerebral hemorrhage and brain contusion, and excessive damage to the head (Fig. 3). There were skin-peeling lacerations and contusions on both shins. The autopsy did not reveal any injuries, such as a dislocated temporomandibular joint or fractured mandible, which could have caused the cigarette to become lodged in the mouth. No damage that could be the cause of death was observed in other body parts. Autopsy and postmortem examinations revealed no lethal disease. The ethyl alcohol concentration in postmortem blood sampled from the external iliac vein during autopsy was 0.200%. No signs of poisoning were identified during autopsy or postmortem laboratory tests. Through a comprehensive forensic examination, including death scene investigation, autopsy, and postmortem laboratory tests, the cause of death was confirmed to be multiple head injuries caused by a fall. The death was considered to be an accident by a fall from a dark rooftop while smoking after consuming alcohol.
Circular and linear compound fractures are identified in the calvarium.
Rigor mortis is the process by which muscles stiffen after death. Adenosine triphosphate (ATP), a bioenergy source used in muscle movement is required to break actin and myosin cross-links when muscles relax. When death occurs, the ATP supply through respiration ceases, actin-myosin cross-links cannot be broken, muscles cannot relax, and rigor mortis occurs [1]. Previous studies have reported that the time of onset and peak of rigor mortis vary widely. It is generally known to begin in the small muscles of the face, such as the mouth, eyes, temporomandibular joints, and hands, starting approximately 20 minutes to 2 hours after death, gradually progressing to the arms and legs, reaching completion approximately 6-12 hours after death, lasting for approximately 12 hours, and then starting to disappear [2,3]. The speed of onset varies depending on factors, such as ambient temperature, body temperature, physical activity, and age. Cadaveric spasms are a phenomenon in which the body stiffens immediately after death and they are mainly associated with firearm suicide and various types of deaths involving objects held in the hand, such as drowning, electrocution, or drug poisoning [2]. As ATP is not produced after death, a rapid decline in the ATP level before death accelerates rigor mortis. Factors that cause the ATP level to decrease before death include strenuous muscle exercise, high body temperature, and severe convulsions. These factors cause rigor mortis to develop rapidly, starting within minutes or, in rare cases, immediately [3]. Although the mechanism of cadaveric spasm is unknown, it has been suggested that cadaveric spasms may be a form of decerebration rigidity [4]. In cases where guns were found in the hands of soldiers, extensive cerebral damage has resulted in an inability to release the weapon, which has been suggested as a mechanism of cadaveric spasm [2]. In a previous report [5], the following criteria were proposed to differentiate between rigor mortis and cadaveric spasm: (a) The position the body was in at death must be maintained after death; (b) The position does not change due to gravity; (c) The body should be examined before rigor mortis is expected to occur.
Bedford and Tsokos [2] presented an example of what is believed to be cadaveric spasm, noting that there are several cases where a gun is held in the hand after a gun suicide, such as a finger straddling the trigger or holding it loosely. In addition, in the case of cadaveric spasm where the bodies of soldiers were fixed in unusual positions during wartime, it was suggested that the abnormal positions were likely to be caused by blast waves or the removal the other bodies. An additional 15 cases of presumed cadaveric spasms were presented, but there was insufficient evidence to suggest that any were true cadaveric spasms. Madea also cited Jacques Louis David's painting “Death of Marat” as an example, arguing that the quill and paper in the hands of the corpse are simply the effects of gravity, and that the presence of objects in the hand has no significance, thus it does not prove the occurrence of cadaveric spasm [4]. Similar to these reports, others deny the existence of cadaveric spasms because the mechanism cannot be completely explained [2]. To date, there is no precise pathophysiological basis supporting the concept of cadaveric spasm.
However, citing three cases he encountered, Fierro stated that unexplained cadaveric spasms occur very rarely but there are difficult cases in forensic practice where it should be considered [6]. Esnault et al. [7] reported a case where bronchial intubation could not be performed due to trismus caused by cadaveric spasm, and Lee and Jung [8] reported two cases requiring emergency cricothyrotomy due to trismus caused by momentary rigor mortis. Cadaveric spasms appear to occur primarily in small joints, such as in the jaw and hands.
The present case does not meet criterion (c) for distinguishing rigor mortis from cadaveric spasm because rigor mortis was already present throughout the body during the postmortem examination. It is also possible that the cigarette was stuck to the lips. However, it is assumed that the deceased was smoking a cigarette before falling, and if so, it would have been difficult for the cigarette to not be displaced after the impact of the fall. In addition, it is difficult to rule out the possibility that the cigarette was lodged between the upper and lower teeth due to trauma at the time of the fall and that rigor mortis began after the fall in this position. However, as no temporomandibular joint dislocation or mandibular fracture was observed during the autopsy, it was considered unlikely that there was a significant impact causing the mandible to fix the cigarette in the mouth. Therefore, we concluded that cadaveric spasm could not be ruled out.
In conclusion, although the complete mechanism is not clear, there are cases in forensic practice in which the occurrence of cadaveric spasms can be considered, as in this case. Previous studies have also noted that the presence of cadaveric spasm in drowning or deaths from falls may be of some value in estimating whether the person was alive at the time of the fall [9]. Therefore, we suggest that a comprehensive forensic examination, including an appropriate on-site investigation is necessary and forensic examiners should be cautious [10].
Notes
Conflicts of Interest
Joo-Young Na, Jin-Haeng Heo, and Young San Ko, editors of the Korean Journal of Legal Medicine, were not involved in the editorial evaluation or decision to publish this article. The authors declare no conflicts of interest.