DEATHIs the termination/end of life.A permanent cessation of all vital functions.It is an irreversible loss of the properties of living matter.It is an event that takes place at a precise time.Ascertainment of death is a clinical and not a legal problem.

Kinds of death1. SOMATIC DEATH (Clinical death) is a complete and persistent cessation of respiration, circulation and almost all brain functions of an organism. It is usually pronounced by a physician or other members of the family.

2. MOLECULAR DEATH (Cellular death) is the cessation of life of the individual cells of the body which occurs one at a time after somatic death.

3. APPARENT DEATH or state of suspended animation is a state of temporary cessation of the vital activities of the body or the vital processes were depressed to the minimum compatible to life.

Kinds of death based on its determination:Brain death - death occurs when there is deep irreversible coma - absence of electrical activity - complete cessation of all the vital functions without possibility of resuscitation

2. Cardio-Respiratory Death - death occurs when there is a continuous and persistent cessation of heart and respiration - is a condition in which a physician and the members of the family pronounced a person dead based on common sense or intuition

SIGNS OF DEATH1. CESSATION OF HEART ACTION AND CIRCULATION Examination by1. Palpation of the pulse2. Auscultation of heart sound3. Use of electrocardiograph

2. Cessation of respirationMethods of Detecting Cessation of Respiration: a. Movement of chest & abdomen b. Auscultation c. Examination with mirror d. Examination w/ feather or cotton fibers e. Examination with glass of water

3. Cooling of the Body (Algor Mortis)The progressive fall of the body temperature is the most prominent sign of death.Factors Influencing the rate of the cooling of the Bodya. Conditions that are connected w/ the body:1) Factors delaying coolinga) acute pyrexial diseaseb) sudden death in good healthc) obesity of persond) death from asphyxiae) death of the middle age

2) Factors AcceleratingLeanness of the bodyExtreme ageLong-standing or lingering illnessChronic pyrexial disease associated with wasting

b. Conditions that are connected to surroundingFactors delaying coolinga) clothingb) absence of airc) small roomd) warm surroundings2) Factors accelerating coolinga) unclothed bodyb) access of airc) large room d) cooling more rapid in water than in air

4. Insensibility of the Body and Loss of Power to MoveNo kind of stimulus is capable of letting the body have voluntary movement.This condition must be observed in conjunction with cessation of heart beat and circulation and cessation of respiration.

5. Changes of the skin a. Observed to be pale and waxy-looking due to the absence of circulation. b. Loss of elasticity of the skin result to post-mortem contact flattening c. Opacity of the skin due to absence of circulation d. Effect of the application of heat will not produce blister or inflammatory reaction

6. Changes in and about the eyeLoss of corneal reflexClouding of the corneaFlaccidity of the eyeball due to lose of tone of orbital muscleDilatation of pupil due to iris muscles loses tone

Changes in the Body Following Death1. Changes in the Muscle The entire muscular tissue passes 3 stages after death:a. Stage of primary flaccidity or muscular irritability-complete relaxation and softening of all muscle of the body-muscles are still irritable due to presence of molecular life after somatic death-usually lasts about 3 to 6 hours after death

b. Stage of post mortem rigidity, cadaveric rigidity, death stiffening, death struggle of muscles or rigor mortis-occurs 3 to 6 hours after death, totally become stiff after 12 hours and may last for 24 to 48 hours during cold weather and 18 to 36 hours during summer -if rigor mortis sets in early it passes off quickly and vice versa -contraction of muscles is due to coagulation of the plasma protein -may be utilized to approximate the length of time the body has been dead -differ from cadaveric spasm or instantaneous rigor which occurs at the moment of death due to extreme nervous tension, only group of muscles are involved and usually not symmetrical e.g. A weapon held in the hand before death and can be removed with difficulty; thus important medico-legal point in determination whether it is a case of suicide, murder, or homicide. -

c. State of secondary flaccidity or commencement of putrefaction-muscles becomes soft and flaccid and does not respond to mechanical or electrical stimulus

2. Changes in the blooda. Coagulation of the blood-soft of consistency-surface of blood vessel smooth and healthy after the clots are remove-clots can be stripped off in layers

b. Post-mortem lividityThis is due to the accumulation of blood in the most dependent portions of the body.-color is dull red o pink or purplish-usually appears 3 to 6 hours after death and fully developed 12 hours after death-Importance of cadaveric or post mortem lividity:-It is one of the sign of death-It may determine whether the position of the body has been changed after its appearance in the body-It may determine how long the person has been dead-It gives an idea as to the time of death

-The color of the lividity may indicate the cause of deathIn asphyxia, the lividity is darkIn carbon monoxide poisoning, the lividity is bright pinkhemorrhage, anemia less markedhydrocyanic acid bright redphosphorous dark brownpotassium chlorate, potassium bichromate chocolate or coffee brownc. If the body is found for considerable time in snow or ice the lividity is bright red

3. Autolytic or autodigestive changes after deathAfter death body enzymes (proteolytic, glycolytic and lipolitic) ferments glandular tissues continue to act which lead to autodigestion of organs.-facilitated by weak acids and higher temperature-delayed by alkaline reaction of the tissues and low temperature

4. Putrifaction of the bodyThis is the breaking down of the complex protiens into simpler components associated with the evolution of foul smelling gasses and accompanied by the change in colour of the body

Duration of deathIn the determination as to how long a person has been dead the following points must be given consideration:

Presence of rigor mortis, sets in from 2 to 3 hours after death, fully after 12 hours, may last for 18 hours to 36 hoursPresence of post mortem lividity, usually develops 3 to 6 hours after death

Cont...3. Onset of decomposition, 24 to 48 hours after death4. Stage of decomposition:12 hoursRigor mortis complete, hypostasis well-developed and fixed. Greenish discoloration showing over the rectum.24 hoursRigor mortis absent all over. Greenish discoloration over whole abdomen and spreading to chest. Abdomen distended with gasses.48 hoursOva of flies seen. Trunk bloated. Face discoloured and swollen. Blisters present. Moving maggots seen.

Cont...72 hoursWhole body grossly swollen and disfigured. Hair and nails loose. Tissue soft and discolored.

One weekSoft viscera putrified.

Two weeksOnly more resistant viscera distinguished. Soft tissues largely gone.

One monthBody skeletonized.

5. Entomology of the cadaverThe common flies undergo as egg, larval, pupal and adult stage.Usual time for the egg to be hatched into larva is 24 hours so that by the presence of maggots in the cadaver death has occurred more than 24 hours.

6. Stage of digestion of stomachIt takes normally 3 to 4 hours for stomach to evacuate its contents after meals; however this is influenced by the following factors:a. Size of last mealstomach starts to empty w/in 10 minutes after the first food entered, light meal leaves stomach w/in 1-1/2 to 2 hours after being eaten, medium size after 3 to 4 hours, and heavy meal after 4 to 6 hours.b. Kind of mealliquid move more rapidly than semi-solid and the latter more rapidly than solids.

Cont...c. Personal variationpsychogenic pylorospasm can prevent departure of the meal from the stomach for several hours, while a hypermotile stomach may enhance entry of food into duodenum.

d. Other factorsvegetables needs time for gastric digestion, less fragmented food needs more time to stay in the stomach, absence or insufficiency of gastric enzymes (e.g. Pepsin) and hydrochloric acid and lesser amount of liquid consumed with solid food will delay gastric evacuation.

7. Presence of Live Flea in the clothing in drowning cases:Flea can survive 24 hours submerged in water and can no longer be revived more than 24 hours.

8. State of clothing 9. Chemical changes in the cerebro-spinal fluid (15 hours following death) a. Lactic acid increases from 15 mg to 200 mg per 100 ccb. Non-protein nitrogen increases from 15 to 40 mgc. Amino-acid concentration rises from 1 to 12 % following death10. Post mortem clotting and decoagulation of blood- blood clots inside the blood vessels in 6 to 8 hours after death-decoagulation of blood occurs at the early stage of decomposition.

11. Presence of absence of soft tissues in skeletal remainsUnder ordinary condition the soft tissues of the body may disappear 1 to 2 years after burial. 12. Condition of the bones

Causes of DeathThe primary purpose of medico-legal autopsy is the determination of the cause of death. It must also be shown that the death is the direct and proximate consequence of the criminal or negligent act of someone.

1. Immediate (primary) cause of deathThis applies to cases when trauma or disease kill quickly that there is no opportunity for sequelae or complication develop.

2. Proximate (secondary) cause of deathThe injury or disease was survived for a sufficiently prolonged interval w/c permitted the development of serious sequelae which actually caused death. E.g. Stab wound in the abdomen later caused generalized peritonitis, the peritonitis is the proximate cause of death.

The mechanism of death is the physiologic derangement or biochemical disturbance incompatible with life which is initiated by the cause of death. E.g. Hemorrhagic shock, metabolic disturbance, respiratory depression, toxemic condition, cardiac arrest, tamponade, etc.

The manner of death is the explanation as to how the cause of death came into being or how the cause of death arose. It is either natural or violent.

1. Natural death

It is natural when the fatality is caused solely by disease.

2. Violent deathDeath due to injury of any sort (gunshot, stab, fracture, traumatic shock, etc.)1) accidental death2) negligent death3) infanticide death4) parricide death5) murder6) homicidal death

Degree of certainty to the cause of death1. When the structural abnormalities established beyond doubt the identity of the cause of death e.g. Stab wound w/ profuse hemorrhage, crushing head injury in v.a.2. When there is degree of probability amounting to almost certainty the cause of death e.g. Electrical shock, lobar pneumonia.3. When the cause of death is established primarily by historical facts which are confirmed or supported by positive or negative anatomic or chemical findings e.g. Tetanus, rabies, drug reaction.4. When history, laboratory and anatomic findings, taken individually or in combination is sufficient to determine the cause of death; but merely speculate as to the cause of death e.g. Crib death among infants.

Steps in the Intellectual Process in the determination of the cause of deathRecognition of the structural organic changes or chemical abnormalities responsible for the cessation of vital function.Understanding and exposition of the mechanism by which the anatomic and other deviations from the normal actually caused the death, or how the deviation created or initiated the train of sufficiently potent functional disturbance which led ultimately either to cardiac standstill or to respiratory arrest.

Hanging/Garroting/Poisoning

From: Legal Medicine by Solis

presented by:Rey J. Millena, MD, MCHM, DPCAM