Forensic Thanatology

[Link] .[Link] yesmin

Forensic medicine
 Introduction
• The term Thanatology is of Greek origin
• Thanatos means death, logus meaning the
science
Or,
• It means a subject which the scientific study of
death, types of death, the various changes or
events that occurs in the dead body & their
medico legal significance.
 Definition of Death
• In law there is on clear-cut definition about
death in most of the countries of the world.
• However as per Black’s Law dictionary death
means cessation of life
• The Oxford dictionary gives the meaning in
simple form as The end of life
 Contd.

• Forensic thanatology is defined as the branch

of forensic medicine which deals with various
aspects of death of medico legal importance.
 Medico-legal definition of death:
Definition:
Death is defined as the irreversible & permanent
cessation of all the functions of the three interlinked
vital systems of the body ( Bishop’s tripod of life) such
as nervous, circulatory & respiratory system.

In short it means cessation of life.

• With the advent of human organ transplantation,

1960s lead to the necessity of scrutinizing the
phenomenon of death.
 Contd.
• Essentially the need of a donor heart which
must be removed at the earliest after death is
declared thus difficult to decide when
connected to the modern medical artificial
means
• This generated the newer concepts of
moments of death.
 Modes of Death
1. Coma
2. Syncope
3. Asphyxia
 Manner of Death
1. Natural.
2. Unnatural.
Natural death: Death occurs completely by
disease process or due to old age , trauma or
poisoning did not play any part in bringing it
about.
Unnatural death: It occurs due to trauma or
poisoning.
 Types of Death
❑According to death of cells & tissues: two
types-
1. Somatic death /Systemic death/Clinical death.
2. Molecular death/ Cellular death.
❑Medicolegal classification
1. Suicidal
2. Homicidal
3. Accidental
 Cont..
❑Others type-
1) Natural death
2) Unnatural death
3) Sudden death
4) Apparent death
Somatic Death/Systemic or Clinical Death

• Somatic death is defined as the cessation of

the functions of nervous, circulatory &
respiratory systems. where individual cells
remain alive.
• Such as, certain parts of the body such as
muscles can still respond by an electrical,
thermal or chemical stimulus suggesting the
reality that death is not complete.
 Explanation
In somatic death, though life has ceased from
the body as a whole, it still persists in certain
parts, namely tissues & cells
• Somatic death is diagnosed by the facts of
1. Cessation of beating of heart
2. Cessation of breathing
3. Cessation of brain activity
 Diagnosis of Cessation of heart beating

• By careful auscultation of cardiac area with

the stethoscope continuously, for 5 minutes &
repeat three times at 5 minutes interval.
• A flat ECG may confirm stoppage of heart
beating.
 Diagnosis of Cessation of breathing
• By thorough auscultation of the chest for
breath sound by the stethoscope.
• Respiratory tracing may confirm it.
 Diagnosis of cessation of brain activity &
declaration of death
• By a flat EEG
• By examining the jerks, tests for sensory
activity
• Death is declared clinically when the three
vital systems fail to do their function called the
tripod of life & confirmed by flat ECG & flat
EEG (often known as Harvard’s criteria of
assessing death).
 Differential Diagnosis (D/D) of Somatic
death
• Suspended animation.
• Coma.
• Excess dose of sedatives or hypnotics.
• Hypothermia in old age.
Medico legal importance of somatic death

• For issuing death certificate

• For organ transplantation, e.g-Cornea, Bones ,
Skin , Blood vessels.
• To take decision for resuscitation.

** somatic death sometimes confused with

apparent death.
 Molecular death & Explanation
Definition:
Molecular death is defined as the death of all
individual cells or tissues. Its takes place
usually one to two hours after the stoppage of
vital function.
• After somatic death, various tissues survive
due to still oxygen supply adequately present .
When oxygen in the cell depleted, cellular or
molecular death occurs.
 Contd.
• Generally molecular death is completed
within 3-4 hours of somatic death & there is
absence of response to electrical, thermal,
chemical or mechanical stimulus.
 Contd.
• In molecular death, death of brain cells stands
first . Nervous tissue / brain cells dies within
5 minutes.
• Muscle tissue live up to 3-4 hours.
• Blood cells & cornea may remain alive for 5
hours.
• Liver, kidney, Heart die early.
• Fibrous tissue die lately.
 Contd..
• As a general rule , organ which receive more
blood supply during life , die early in absence
of circulation.

M/L importance’s of molecular death:

1)It is the confirmatory sign of death.
2) Organ transplantation is not possible in this
stage.
Concept of death or Moment of death

• The concept is cessation of spontaneous heart

& lung functions.

• However bypass machine, mechanical

respirators, etc. have helped to maintain
circulation & supply of oxygenated blood to
the vital centers of brain when organ
transplantation is an important issues.
 Contd.
• Thereby prolong existence of life only
terminates after withdrawal of these devices/
artificial supply.
• For organ transplantation, kidneys, heart, etc.
removed from the body soon after the
cessation of respiration.
 Difference between somatic & molecular Death
Traits Somatic Death Molecular Death

Definition Death of body as a whole but Death of cells and tissues

the individual cells still individually.
remain alive.

Precedence It precedes molecular death. It follows somatic death.

Confusion May confused with apparent No chance of confusion.

death.

Organ transplantation Possible. Impossible.

Respond to electrical stimuli Respond. Not respond.

 Types & Time of Transplantation of different
organs
Types:
A) Homologous: Also called [Link] grafting
in the same person, ex- Skin grafting
B) Heterologous: Two types
➢ Live donation: Transplantation from one living person
to another living person. E.g-Blood, Kidney , Bone
marrow, Liver, cornea
➢ Cadaveric donation: Transplantation of organ from
dead person to living person. Ex- cornea, kidney, liver
 ORGANS & TIME OF TRANSPLANTATION
Brain can not be transplanted because it is damaged
within 3 minutes of death
Organ Time of transplantation

Lungs, heart, kidney, liver Soon after death

Cornea Within 6 hours of death

Skin Within 24 hours of death

Bones Within 48 hours of death

Arterial grafts Within 72 hours of death

 Brain death & its types
Definition:
Permanent & Irreversible cessation of brain
function.
Brain death is classified as:
[Link] or Cerebral Death
2. Brain Stem Death
3. Whole Brain Death (combination of both
cortical & brain stem death)
 Cortical Death
• The function of cortex alone is stoppage but
Brain stem is intact.
• So, Continue heart beat & respiration,
• Total loss of power of sense perception.
• This is termed as persistent vegetative state or
PVS.
• This may occurs due to drugs, poisoning, head
injury, hypoxia etc.
 Cont…
➢Permanent & irreversible cessation of the
function of the cerebrum but the brain stem
remain intact. But in this condition patient
breaths spontaneously , spontaneous cardiac
rhythm and patient shows a cycle of eye
opening & closing which simulate with
sleeping and awaking but the patient is
unaware of himself and environment. It is
known as persistent vegetative state.
 Brain Stem Death
• Permanent & irreversible cessation of the
function of the brain stem. Cerebrum is
remain intact but its function is cut off due to
stem lesion.
• Caused by cerebral edema, increased
intracranial pressure , intracranial hemorrhage
etc.
 Whole Brain Death

Combination of both cortical & brain stem

death.
 Diagnostic criteria of brain stem death/
Brain death

[Link] must be in deep coma , but not due to

the effect of depressional drugs , hypothermia
or metabolic disturbances , do not responds to
electrical stimuli.
2. No active movement.
3. No spontaneous breathing.
 Cont..
[Link] spontaneous cardiac rhythm.
5. No sensory or motor response.
6. Absence of reflexes:
▪ Corneal reflex.
▪ Vestibulo ocular or gyro ocular reflex.
▪ Gag reflex.
▪ Pupilary reflex: fixed dilated pupil , not
reacting to light.
7. Flat & iso-electric EEG.
 Modes of Death

• Stoppage of function of circulatory

system is known as syncope.
• Stoppage of function of nervous system
is known as coma.
• Stoppage of function of respiratory
system is known as asphyxia.
 Syncope
Syncope is sudden stoppage of the function of
heart and failure of circulation causes death.
• This leads to decreased O2 supply to the
brain, results in ischemia to the vital centers of
the brain and finally death occurs.
 Contd.
Causes of Syncope:
• Pathology of the heart e,g-diseases in the
myocardium, heart valves.
• Excessive Hemorrhage .
• Pathological conditions of blood like sever
anemia.
• Exhausting diseases
• Cardiac poisons
 Contd.

• Reflex vagal inhibition or Vaso vagal shock.

• Anoxia / Hypoxia.
 Clinical Features of Syncope
• Pallor of lips, face, finger nails etc.
• Dimness of vision & dilated pupils.
• Skin -cold & clammy
• Gasping respiration
• Nausea- vomiting
• Pulse- Weak, slow .
• Blood pressure- fall.
• Delirium, convulsions & death
 Autopsy Findings

• Heart contain little or no blood

• The viscera are pale
• The capillaries are congested
 Asphyxia
Definition:
It may be define as prevention of exchange of
air between the atmosphere and to the lung
alveoli and there is lack of oxygen supply to
the tissue, called asphyxia.
 Cont..
• Death due to asphyxia occurred ,when respiratory
function stoppage first.
Which can lead to impaired blood oxygenation
leading to--Tissue anoxia.
• The brain tissue is highly sensitive to oxygen
deprivation which results in Failure of vital centers &
ultimately death .
 Anoxia / Hypoxia (Gordon’s
hypothesis, 1944)
• Anoxia or hypoxia: Anoxia means ‘lack of O2’ to the
tissue & hypoxia means ‘less amount of O2’ to the
tissues from any cause ,so that anoxia & hypoxia are
the conditions or state & asphyxia is the one of the
process or cause of these condition.
• Stoppage of vital function depend upon tissue
anoxia/ hypoxia.
 Contd.
• According to this hypothesis anoxia is classified into
four types:
1. Anoxic anoxia
2. Anemic anoxia
3. Histotoxic anoxia &
4. Stagnant anoxia
 Cont..
1) Anoxic anoxia:
O2 cannot reach the blood due to lack of O2 into the
lungs. Which occurs due to mechanical interference
with the air passages or decreased atmospheric O2
level. E.g-
exposure to the fumes, tanks or sewer gas.
Hanging, Drowning etc.
2) Anemic anoxia:
Reduced O2 carrying capacity of blood ,e.g-
excessive Hemorrhage, Poisoning by CO.
 Cont..
3) Stagnant anoxia:
Here Impaired circulation, so O2 delivery to
the tissue is reduced. E.g-
Heart failure, Hypovolumic shock
4) Histotoxic anoxia:
Enzymatic process in the tissue are blocked,
that’s mean Utilization of O2 into the tissue
are reduced. E.g-
Acute Cyanide (CN) poisoning.
 Cont..
NB:
• Normal level of O2 in arterial blood ( PO2) is 90 to
100 mm of Hg at 30 yrs of age.
• 65 to 80 mm of Hg at 60 yrs of age or above.
• Reduce 60 mm of Hg causes Hypoxia.
• Reduce 40 mm of Hg causes severe hypoxia & at 20
mm of Hg causes anoxia and death.
 Causes of asphyxia
1. Mechanical:
a) Closure of external respiratory orifices, e.g
smothering.
b) External pressure on the neck. E.g- Hanging,
strangulation
c) Blockage of air passages by impaction of foreign
bodies . e.g- Choking.
d) Prevention of entry of air due to air passage filled
with fluid. E.g-Drowning
e) External Compression on the chest. E.g-Traumatic
asphyxia.
 Cont..
2) Pathological:
Entry of oxygen to the lungs is prevented due to
disease of the URT & lungs. E.g- Bronchitis,
Pulmonary edema, Laryngeal spasm, Tumors,
Paralysis of respiratory muscle ( Poliomyelitis) .
3) Toxic:
a) ↓O2 binding capacity with the Hb (CO, CO2)
b) Enzymatic process in the tissue are blocked, that’s
mean Utilization of O2 into the tissue are reduced.
E.g-
Acute Cyanide (CN) poisoning.
 Cont..
c)Paralysis of the respiratory center due drug ( Opium,
Barbiturates).
4) Environmental:
a)Exposure to high altitude.
b)Exposure to irrespirable gases like sewer gas,
Co, Co2.
c) Insufficiency of O2 in the inspired air.e.g-
closed place, trapping in trank.
5)Traumatic:
Pulmonary thrombo -embolism, Fat embolism, air
embolism, Pneumothorax.
6) Postural:
Seen in unconscious person either from alcohol or
drugs or disease
7) Iatrogenic:
Associated with anesthesia.
 Clinical Features of Asphyxia
Clinical features are described under three stages:
1. Stage of dyspnoea :
Increased CO2 level in blood causes respiratory
stimulation. So, increased respiratory rate , Pulse
rate , BP, there is present breathlessness, chest
tightness, Headache , mild cyanosis present.
 Contd.
2. Stage of convulsions:
CO2 level increased more. Pulse rate, BP still high, Neck
vein engorged . marked cyanosis & convulsion
occurs.
3. Stage of exhaustion & respiratory failure:
Respiratory & other nervous centers are depressed
&completely paralyzed, muscles flaccid, reflexes are
lost & lasts for 2-3 minutes, RR decreased and
gasping, deep cyanosis.
 Autopsy Findings
findings are:-
• Cyanosis present at the fingertips, nail bed,
ear lobules, lips.
• Deep postmortem lividity
• Petechial hemorrhage (Tardieu’s spots) over
forehead, eyelids , conjunctiva, under surface
of the pleura, pericardium, meninges.
• Visceral congestion
 Contd.

• Cardiac dilatation
• Interstitial edema & each specific findings in
individual cases.
 Coma
• Loss of consciousness which may be partial or
complete , depending on the degree of
involvement of CNS.
It causes due to sudden stoppage of brain
function.
• There is combination of both syncope &
asphyxia leading to death.
• It is due to insensibility or paralysis of vital
centers in the brain stem.
 Causes of Coma
• Cerebral Compression due to Head injury or
injuries to the brain matter or tumor.
• Acute poisonings with opium, barbiturates,
carbolic acid, alcohol,CO2,CO etc. having
specific depression action on brain
• Metabolic disorders like- uremia, Diabetes etc.
• Infection like encephalitis, meningitis, abscess.
 Autopsy Findings

• Could reveal the specific cause of death

• The brain & meninges are congested
• Right side of the heart is usually full, while the
left empty
• Lungs are congested
 Medico legal Importance of Death

• Disposal of the body

• Organ transplantation
• Presumption of death
• Presumption of survivorship &
• Issuing death certificate
 Disposal of the Body

• Though rarely at the time of cremation in

early during somatic death, there may be
movements of hand or feet.
This indicate that death was not actually taken
place but prematurely disposed off.
 Presumption of Death
• This is an legal issue. This is connection with
inheritance or succession of property of a
person, missing for long period.
• A person unheard of for 7 years
• An application by the nearest relatives, the
court presume death to have taken place.
 Presumption of Survivorship
• If two or more persons of one family died in a
common accident who are related
# It may be necessary, to decide the question
of succession .
# It may be necessary, to determine which of
them died first .
• It is generally accepted that the stronger &
more vigorous on will survive longest.
 What are the investigations of diagnosis of death?/ How
can you diagnose a death?/ How can you declare a death?

Investigations for CVS:

1. Pulse: Not palpable.
2. Heart sound: Not audible.
3. Blood pressure: Not recordable.
4. ECG: Flat & iso-electric.
5. Heat test: application of heat over the skin
producing blister indicating presence of
circulation.
6. Cut test: Sectioning of radial artery
shows jerky bleeding indicating
presence of circulation.
7.I card test: Subcutaneous injection
of fluorescine with NaHCO3,
producing greenish yellow
discoloration at the injection site
indicating presence of circulation.
Investigations for respiratory system:

1. Inspection: No visible respiratory

movement.
2. Palpation: No respiratory movement
appreciated.
3. Auscultation: No audible breath sound.
4. Mirror test: Holding a mirror in front of
the mouth and nostrils producing
movement, indicating presence of
respiration.
5. Feather test: Holding a feather in
front of the mouth and nostrils
producing movement indicating
presence of respiration.
6. Winslow test: Holding a water
containing vessel over the chest
producing reflection spot from the
surface of the water to the wall of
the vessel indicating presence of
respiration.
Investigations for CNS:
1. All superficial and deep reflexes are lost.
2. Pupil: dilated & fixed, non reacting to
light.
3. Loss of sensory function.
4. loss of motor function.
5. Flat & iso-electric EEG.
Surest signs:
1. Decomposition.
2. Saponification.
3. Mummification.
 Criteria fulfilled for issuing death
certificate
1. The doctor must be qualified registered medical
practitioners.
2. The doctor should examine the patient at least
once within 14 days prior to his death.
3. Doctor must be fully satisfied about the cause
of death.
4. Doctor have to wait at least 30-45 minutes
before issuing death certificate.
He must be examine repeatedly in five minutes
interval at least three times.
 Cont..
5. Without doing investigations of diagnosis of
death a doctor should not issue death
certificate.
6. In suspicious cases a doctor should not issue a
death certificate.
 Tardieu's spot
Petechial hemorrhage are seen under the serous
membrane of various organ due to rupture of small
capillaries by increased pressure.
Condition of occurrence:
1. Death due to asphyxia
2. Death due to scurvy , Purpura, Hemophilia,
Endocarditis, coronary thrombosis.
 Cont..
• Sites: visceral pleura, Endocardium ,
pericardium , Meninges, Conjunctiva, Skin of
face, neck, eyelids.
 Suspended animation/Apparent
death/Death trance/catalepsy
• Definition:
It is a condition in which all signs of life are seemed to
be absent, though the individual is still remain alive
& it is confirmed or detected by ECG or EEG.

Types :
A) Voluntary: e.g- Yoga practitioner.
B. Involuntary :
▪ Drowning.
▪ New born.
▪ Electrocution.
▪ Poisoning.
▪ Snake bite.
▪ After anaesthesia.
▪ Hit stroke.
▪ Hypothermia.
▪ Diseases like cholera , typhoid fever etc.
M/I:
1. It may confused with clinical death.
2. Death certificate may be issued
whether the person is not really dead.
3. A living person may be send to the
morgue for autopsy or may be
prepared for disposal.
 Sudden Death
Death is said to be sudden or
unexpected , when a person not
known to have been suffering from
any dangerous disease, trauma or
poisoning did not play any part in
bringing it about. Death occurs
within 24 hours of onset of terminal
illness.
 Causes of sudden death
A. Causes of CVS:
▪ Coronary artery disease: atherosclerosis ,
thrombosis.
▪ Hypertensive heart disease.
▪ Ischemic heart disease: MI.
▪ Congenital heart diseases: ASD , VSD , PDA.
▪ Cardiac temponade.
▪ Rupture aortic aneurism.
▪ Infections: pericarditis , myocarditis ,
endocarditis.
B. Causes of respiratory system:
▪ Pulmonary thrombo embolism.
▪ Haemoptysis from TB or carcinoma
lung.
▪ Fulminant viral pneumonia.
▪ Any pathology causing obstruction of
the airways.
C. Causes of CNS:
▪ Intra cerebral haemorrhage.
▪ Sub arachnoid haemorrhage due to ruptured
Berry aneurism.
▪ Cerebral thrombosis.
▪ Cerebral embolism.
▪ Meningitis.
▪ Epilepsy.
▪ Neurogenic shock .
▪ Trauma or other lesion producing sudden
pressure within the cranium.
D. Causes of GIT:
▪ Haemorrhage from ruptured hollow
viscus.
▪ Haemorrhage from bleeding peptic
ulcer disease , colonic bleeding due to
ulcerative colitis , diverticulitis.
▪ Acute haemorrhagic pancreatitis.
▪ Fulminant hepatic failure.
▪ Acute intestinal obstruction.
▪ Ruptures abdominal aneurysm.
D. Causes of genito-urinary tract:
▪ Nephritis.
▪ Nephrolithiasis.
▪ Obstructive nephropathies.
▪ Pyelo-nephritis.
▪ Tumor , tuberculosis of kidney & bladder.
For female only:
▪ Toxaemia in pregnancy.
▪ Ruptured ectopic pregnancy.
▪ Twisted ovarian cyst.
▪ Bleeding from uterus for large fibroid.
▪ Vulvo vaginal carcinoma causing eroding femoral
vessel.
E. Endocrine causes:
▪ Adrenal insufficiency.
▪ Diabetic coma.
▪ Myxoedemic crisis.
▪ Para thyroid crisis.
▪ Pituitary insufficiency (Sheehan’s syndrome).
F. Iatrogenic cause:
▪ Abuse of drugs.
▪ Mismatched blood transfusion.
▪ Anaesthetic mishap.
▪ Sudden withdrawal of steroid & beta blocker.
G. Miscellaneous cause:
▪ Anaphylactic shock.
▪ Bacteriaemic shock.
▪ Malaria.
▪ Sickle cell crisis.
▪ Malaria.
H. Special causes in children:
▪ SIDS.
▪ Congenital cardiac & cerebral abnormalities.
I. Indeterminate:
▪ Decomposed body.
 That’s it.
• Thanks………