DEATH & ITS CAUSE

BY:
DR AISHWARYA
Thanatology

 Science which deals with study of death

Thanatos = “death”
Logos = Science
 Thanatology is a subject that deals with scientific study of death, types of death,
the various events, or changes that occur in the cadaver after death and their
medicolegal significance.
 Definition of Death-
• Black’s Law Dictionary defines death as ‘the cessation of life’
• Chamber’s Twentieth Century Dictionary, defines death as ‘the extinction of life’.
• Clinically, Death may be defined as permanent & irreversible cessation of three
interlinked vital systems of body , called tripod of life, namely –the nervous ,
circulatory & respiratory systems.
Types of Death

 Death is a process not an event and, while the cells of some tissues are
still alive and even capable of movement (such as fibroblasts,
leucocytes and muscle fibers, etc.,) others are dying or dead.
 Types of Death-
i. Somatic death: It means complete & irreversible stoppage of vital
functions .
ii. Molecular death: It means death of tissues & cells of body individually
SOMATIC DEATH

 Somatic death is defined as the irreversible cessation of functioning of the

brain, heart and lungs resulting in complete loss of sensibility and ability
to move the body.
 Complete and irreversible stoppage of
1. Circulation
2. Respiration Bishop’s tripod of life
3. Brain functions
 It is the extinction of personality or the death of the body as a whole
(soma means body), also known as clinical or systemic death.
 It is important in resuscitation & organ transplantation.
 Legally a person is dead after somatic death.
 Cessation of heart beating:- Clinical criteria
1. Absence of pulse (central i.e. carotid )
2. Absence of heart sound on repeated prolonged auscultation.
3. A flat electrocardiogram (ECG).
 Cessation of breathing:- Clinical criteria
1. Absence of respiratory movement
2. Absence of breath sound on thorough auscultation of chest. (Central)
 Cessation of brain activity:– Clinical criteria
1. Dilated fixed pupil
2. Absence of motor responses within the cranial nerve distribution on painful stimuli
3. Absence of pupillary and corneal reflexes.
4. A flat Electroencephalogram (EEG) would confirm it.
Brain Death

 Permanent & irreversible cessation of function of brain

irrespective of function of other organs like heart , lungs.
 According to this concept, depending on the structures
involved, the brain death is of three types:
1. Cerebral/cortical death- Loss of function of cerebral
cortex. , heart & lungs may work.
2. Brain stem death- Damage & failure of function of brain
stem , heart & lungs can not work independently.
3. Whole brain death- both cortical & brain stem death.
 Brain death is now considered as legal death . It has great
importance from legal , ethical point of view & in relation to
organ trans plantation .
Cerebral/Cortical Death

Cerebral/Cortical Death
 In this, brainstem is intact, with continuous heart
sounds and respiration, but total loss of sentiment
(sense of perceiving and feeling things) activity.
 Severe brain damage that does not involve the
brainstem, results in a persistent vegetative state
(PVS).
 These patients breathe spontaneously, open and close
their eyes, swallow and make facial grimaces.
 It is in these cases that moral dilemma of allowing
some one to die (euthanasia) arises.
 Causes- Cerebral hypoxia, toxic conditions, widespread
brain injury, etc.
Brainstem Death

Brainstem Death
 In brainstem death the cerebrum is intact, but cut
off functionally.
 Brainstem comprises of small area of tissue in the
floor of aqueduct between the third and fourth
ventricles of brain, containing ascending reticular
activating substance, which extends throughout the
brainstem from spinal cord to sub thalamus and
determines arousal.
 When this small area is dead, person becomes
irreversibly unconscious and irreversibly apneic (i.e.
incapable of breathing).
 Causes- Cerebral edema, increased intracranial
pressure, etc.
 Diagnosis of Brainstem Death
 Brainstem death comprises of establishing following three things:
1. Patient is deeply comatose and unable to breath spontaneously and therefore unconscious and needs to be
maintained on a ventilator.
2. Cause of coma must be known and rule out that it is not due to drugs, hypothermia or profound metabolic
disturbance.
3. All the brainstem reflexes are absent and the apnoeic test is negative.
 Whole Brain Death

 Whole brain death comprises combination of both cortical and brain stem death.
With this newer concept, clinical definition of death has been now modified as
irreversible state of coma consisting of:
- Deep state of unconsciousness with no response to external stimuli/internal need
- No movements, no spontaneous breathing.
- Cessation of spontaneous cardiac activity without assistance.
- No reflexes.
- Bilateral dilated fixed pupils.
- A flat isoelectric EEG.
- No profound abnormalities of serum electrolytes, acid-base balance or blood glucose.
 Personnel who should perform tests
a) Two medical practitioners.
b) Expert in the field (not transplant surgeons).
c) One should be consultant status (No JRs).
d) Each should perform tests separately, twice.
 Various criteria for Determining Brain death:

i. Philadelphia Protocol (1969)

ii. Minnesota Criteria (1971)
iii. Harvard Criteria
MOLECULAR DEATH

 Molecular death is defined as ultimate death of all cellular elements.

 In absence of circulation and respiration different cells die at different times.
 Generally molecular death is takes place after 2 to 4 hours of somatic death.
 Molecular death can be confirmed by absence of any response to an
electrical, thermal or chemical stimulus in the tissues.
 It is reported that
- nervous tissue dies rapidly (i.e. the vital centers of brain die in about 5
minutes),
- the muscle tissue lives up to 3 to 4 hours, after the cessation of the
circulation.
Survival of Organs

 Cornea – 6 hours
 Skin – 24 hours
 Bone – 48 hours
 Blood vessels – 72 hours
 Kidney, heart, lungs, pancreas and liver must be obtained soon after
circulation has stopped
 Cornea transplanted is not rejected
Different Aspects of Death

 3 main aspects to be considered:

1. Mode of death
- Depending on the system most obviously affected, irrespective of the remote
causes of death
2. Cause of death
- Cause of death is defined as the disease or injury that produces a
physiological derangement in the body that results in death of the individual.
3. Manner of death
- It explains how the cause of death came about. Manner of death is generally
considered to be natural, homicide, suicide, accident and undetermined.
MODE OF DEATH

 The term mode of death usually refers to the system that initiates the
process of death.
 Stoppage of which system initiated the process of death.
 Modes of death are classified by Bichat, Those modes are:
1. Coma. (failure of nervous system).
2. Syncope (failure of circulatory system).
3. Asphyxia (failure of respiratory system).
 Syncope

 Syncope is a result of sudden stoppage of functioning of the heart, which may prove fatal.
 Syncope or fainting is due to vasovagal attacks resulting from reflex parasympathetic
stimulation, reflex bradycardia or asystole, or by reflex splanchnic vasodilatation.
 Causes- Anemia due to sudden and excessive hemorrhage, myocardial infarction, exhausting
diseases, poisoning with cardiac poisons, reflex cardiac inhibition (vagal inhibition of heart) due
to sudden fright or emotion or trigger area injuries (e.g. blow on epigastrium), etc.
 Due to acute reflex circulatory changes, blood pressure falls suddenly causing cerebral anemia
and rapid unconsciousness.
 Death resulting so, is called instantaneous physiologic death, vasovagal shock, vagal inhibition
or neurogenic shock.
 Clinical Features- pallor, perspiration, gasping, slow pulse, weakness, fall of BP, dilated
pupils, nausea, vomiting, delirium
 Autopsy Findings- heart is contracted and the chambers are empty or show little blood, all
the viscera (lungs, brain, abdominal organs) appear pale.
Asphyxia

 Asphyxia is a condition resulting from interference with

respiration or sudden stoppage of functioning of lung
causing unconsciousness or death
 Sudden stoppage of functioning of the lungs can lead to
impaired blood oxygenation leading to tissue anoxia.
 Nervous tissue is affected first by deficiency of oxygen,
disturbing their functions. Subnormal blood supply to
brain causes rapid unconsciousness.
 As per the ‘rule of thumb’, breathing stops within 20
seconds of cardiac arrest, and heart stops within 20
minutes of stoppage of breathing.
 The brain is highly sensitive to oxygen deprivation, which
results in failure of vital centers and ultimately death.
Gordon’s Hypothesis (1944)
 It emphasizes the fact, that tissue anoxia, irrespective of its origin can invariably lead to
cessation of vital functions, especially the circulatory failure resulting in death.
 According to this hypothesis, anoxia is classified into 4 types, namely anoxic anoxia, anemic
anoxia, histotoxic anoxia and stagnant anoxia.
1. Anoxic anoxia: This is mainly due to mechanical asphyxia leading to defective oxygenation in
lungs. E.g. Hanging, strangulation, suffocation, choking, drowning, high altitudes, etc.
2. Anemic anoxia: This is mainly due to the reduced oxygen carrying capacity of blood. E.g. CO
poisoning
3. Histotoxic anoxia: This is mainly due to the depression of tissue oxidation- due to impairment of
cytochrome oxidase enzyme the tissues are unable to utilize oxygen. E.g. Cyanide poisoning
4. Stagnant anoxia: This is mainly due to the inefficient circulation of blood. E.g. Congestive cardiac
failure, traumatic shock, heat stroke
Clinical Features of Asphyxia
 Clinical features of asphyxia can be described under three stages, which may
last for 3 to 5 minutes and they are:
 Stage of dyspnoea
 Stage of convulsions
 Stage of exhaustion and respiratory failure.
Postmortem Appearances of Asphyxia
 Characteristic findings are-
- cyanosis, deep
- postmortem hypostasis/ lividity,
- petechial hemorrhages (Tardieu’s spots),
- visceral congestion
- cardiac dilatation.
 Coma

 Coma results from sudden stoppage of functioning of the brain.

 It is a state of unarousable unconsciousness determined by absence of any
psychologically understandable response to external stimuli or inner need.
 Coma is a combination of both syncope and asphyxia leading to death. It is due to
paralysis or insensibility of central portion or vital centers of the brainstem.
 Causes- Compression of Brain: Hemorrhage, inflammation, abscess of brain
- Acute Poisonings- opium, alcohol, cocaine
- Metabolic Disorders- diabetes, heat stroke
- Others: thrombus, embolism
 Autopsy Findings- Postmortem findings could reveal all specific pathological findings
depending on the actual cause. The brain and meninges are congested. The right side of
the heart is usually full, while the left empty. Lungs are congested.
CAUSE OF DEATH

 Cause of death is defined as the disease or injury that produces a

physiological derangement in the body that results in death of the
individual.
 Cause of death could be any one of three types
i. Immediate cause: actual cause at the time of terminal event, e.g.
bronchopneumonia, peritonitis, trauma, etc.
ii. Antecedent cause: actual pathological process responsible for the death at
the time of the terminal event or prior to or leading to the event, e.g.
gunshot wound of abdomen complicated by generalized peritonitis.
iii. Contributory cause: the pathological process involved in or complicating,
but not causing the terminal event, e.g. Carcinoma stomach.
MANNER OF DEATH

The way in which cause of death was produced

1. Natural
2. Unnatural
[Link] death: Means that the death was caused entirely by the disease,
and the trauma or poison did not play any part in bringing it about.
[Link] death: If death occurs exclusively by injury or is hastened due
to injury in a person suffering from natural disease, the manner of death is
unnatural or violent.
a. Accidental injuries e.g. RTA
b. Homicidal injuries e.g. stab, lacerated, incised, firearm
c. Suicidal injuries e.g. firearm injury
 Agonal period: It is the time between a lethal occurrence and death.
Example

1. Manner of death- Homicide

2. Cause of death- Stabbing
3. Mode/Mechanism of death- Loss of blood/Syncope
Medicolegal Importance of Death

 Death and the Indian Penal Code (IPC)- Section 46, IPC, states the fact that the word ‘death’
denotes death of a human being unless the contrary appears from this context.
 Disposal of the Body- Rarely, during cremation of a dead body immediately after somatic death,
spontaneous movements of hand or feet may be observed in the cadaver on the funeral pyre,
creating an impression that the person is not actually dead and the disposal is premature.
 Tissue and Organ Transplantation- Viability of transplantable tissues and organs falls sharply
after somatic death; a liver must be removed within 15 minutes, kidney within 45 minutes and
heart within an hour.
 Legal Presumption of Death- In India the Law is:
a. that if a person is proved to have been alive within 30 years the legal presumption is that he is still
alive, unless
b. b. it is proved that the person has not been heard of for 7 years by those who would naturally have
heard of him if he had been alive, in which case the law presumes that he is dead.
DEATH CERTIFICATE

 A doctor is the person who is legally authorized to declare a death &

issue a death certificate.
 To issue a death certificate/Condition of certifying death:
1. Inspection of the dead body by the doctor himself.
2. Full satisfaction about the death
3. The doctor must sure of the cause of death
4. The doctor should free from least suspicion of foul play
5. The doctor registered as a qualified medical practitioner.
Negative Autopsy

“when gross and microscopical, toxicological analysis and laboratory

investigations fail to reveal a cause of death, the autopsy is consider to
be negative”

• 2-5% of all autopsies are negative.

• Causes:

1. Inadequate history. Ex. Death from vagal inhibition, status epilepticus,

hypersensitivity reaction or laryngeal spasm etc.
2. Inadequate external examination. Ex – Needle mark, insect
3. Inadequate or improper internal examination
4. Insufficient laboratory examination
5. Lack of toxological analysis
6. Lack of training of doctor
Obscure Autopsy

 In about 20% of all postmortem examination cases, the cause of death

may not be clear at the time of dissection of the body and there are
minimal or indeterminate findings or even no positive findings at all.
 The cause of death can be made out after detailed clinical & laboratory
I/v & interview with persons
Causes are:

i. Natural disease. Ex – little microscopic finding, fibrillation etc

ii. Biochemical disturbances. Ex- Uremia, diabetics, K deficiency etc

iii. Endocrine dysfunction. Ex- Adrenal insufficiency, Thyrotoxicosis.

iv. Concealed trauma (v) Poisoning (vi) Miscellaneous

SUDDEN DEATH

 Sudden death may be defined as a death which occur suddenly or

unexpectedly when a person not known to have been suffering from any
dangerous disease, injury or poisoning is found dead or dies within 24hours
after the onset of terminal illness.
 The incidence is approximately 10 percent of all deaths.
 Natural death means that the death was caused entirely by the disease,
and the trauma or poison did not play any part in bringing it about.
 Currently the accepted definition (SCD) is natural death due to cardiac
causes, heralded by abrupt loss of consciousness within 1 hour of the onset
of acute symptoms.
 Causes of sudden death

 Causes:
(1) CVS MI, CAD, Valvular, Atherosclerosis

(2) RS  Bronchopneumonia, embolism,

pneumothorax, impaction of foreign bodies

(3) CNS Hemorrhage, abscess, tumor,

meningitis

(4) GIT Varices, perforated ulcer, Intestinal

obstruction

(5) GUT Nephritis, tumors

(6) Misc. DM, Reflex vagal inhibition,

anaphylaxis
Medicolegal Significance

 In cases of sudden death, it is usually not possible to certify the cause

of death from an external examination of the body.
 In all such cases, an autopsy is necessary to obviate the possibility of
unnatural death.
 A doctor who issues a death certificate in such a case runs the risk of
being accused as an accessory to a crime and obstructing the course of
justice, should the death be found eventually due to foul play.