Forensic Medicine

with the elements of law

Thanathology
 Thanatology

• The word is derived from the Greek language. In

Greek mythology, Thanatos (θάνατος: "death") is the
personification of death.
• Scientific study of death and the losses brought about
as a result.
• It investigates the mechanisms and forensic aspects
of death, such as bodily changes that accompany
death and the postmortem period, as well as wider
psychological and social aspects related to death.
 Death

• Permanent i.e. an irreversible

cessation of vital body processes
• Respiratory arrest (no breathing)
• Cardiac arrest (no pulse)
• Brain death (no neuronal activity)
 Due to the varying sensitivity of tissues to
hypoxia death is not a single sudden process:

• Agony - the process immediately preceding the

death, is not always fatal.
• Reduced life – 1st stage of agony - reduction of all system
efficiency necessary to keep the a person alive
• Minimal life - 2nd stage of agony - such a low level of
circulatory and respiratory function that can not be
observed or is very difficult to observe with routine
medical methods.
• Apparent death (lethargy) – extending the 2nd stage of
minimum life
 The reasons for lethargy according to
Bahrmann:

• A - anemia, anoxemia
• E – epilepsy
• I - injury (head injury)
• O - opium (intoxication)
• U - uremia (kidney insufficiency)
 After clinical death
full organ function stops:
• Brain 3’
• Heart 15’
• Liver 35’
• Lungs 60’
• Kidneys 120’
 Clinical death

• cessation of blood circulation and breathing, after

invention of cardiopulmonary resuscitation (CPR),
defibrillation, epinephrine injection, and other
treatments became reversible
 Brain death

• (also known as brain stem death)

• Complete and permanent loss of brain function,
including involuntary activity necessary to sustain
life
• Person will not regain consciousness or be able to
breathe without support.
• is legally confirmed as dead.
 Clinical death:

• - no contact with the outside

• - Immobility (akinesia)
• - muscle relaxation
• - loss of reflexes
 Biological death

• Irreversible cessation (ending, termination)

of brain function (mental and regulatory) as
well as the circulatory and respiratory
function
 Interlethal period (indirect life)
The period that occurs between clinical and biological
death

Interlethal reactions
the reactions that are specific for some tissues or
organs, caused by mechanical, chemical
(pharmaceutical), electrical factors during
the interlethal period
 Interlethal reactions

• excitability to mechanical stimuli (eg. hammer – patellar

reflex) 1.5 - 2.5h
• hitting a hard object in muscle transversely to the long axis
causes thickening of the miotonic shaft within 2-3 h
• electrical stimulation of facial muscles causes spasms in the
period 5-8 h and single shaking even longer
• injection of pilocarpine and acetylcholine causes
perspiration for 8 - 16 h after death
• pupillary reactions to medications: single response - about
10 -20 h; double response - shorter reaction
 Brain death

• The diagnosis of brain death is based on the finding

of irreparable loss of its function.
• The three cardinal findings in brain death are:
• coma,
• absence of brain stem reflexes, and
• apnoea (absence of breathing).
Clinical tests should be performed by two experienced
practitioners and carried out by two separate occasions
 Euthanasia

• Deliberate ending of life of a person suffering from

an incurable disease.
• In recent years the concept has been broadened to
include the practice of withholding extraordinary m
eans or “heroic measures,” and thus allowing the
patient to die
• Dysthanasia - keeping the person
(body) ’alive’ with the equipment
(without regard to the person's
quality of life) bad death

• Orthothanasia – the deliberate

stopping of artificial means of
maintaining life, disconnecting
equipment, good death
 Brain death

• In Poland qualification procedure is made by a

Comission (includes: anesthesiologist, neurologist
or neurosurgeon and another doctor. The
commision should be independent from
transplantological teams)
• The qualification procedurę consists of two phases:
• Phase I: Suspicion of brain death
• Phase II: Performance of examinations confirming the
death of the brainstem
 Brain death

• Compliance with all the requirements of Phase I

allows for the transition to Phase II.
• Finally Commission declares brain death and
whether the patient qualifies for deceased organ
donation regulated by the Regulation of the
Minister of Health and Social Welfare
 Phase I: Suspicion of brain death
Includes establishing the following states with the
patient:

• The patient is in a coma

• The patient is artificially ventilated
• The cause of coma is diagnosed
• Structural damage to the brain has been shown
• Structural damage to the brain is irreversible due to
exhaustion of therapeutic options and the passage
of time
 Phase I: Suspicion of brain death
includes establishing the following exclusions:

• patient intoxicated and under the influence of some

pharmacological agents (drugs, neuroleptics,
hypnotics, sedatives, muscle relaxants)
• hypothermia induced external causes
• the metabolic and endocrine disorders
• with convulsions and spasms
• children under 7 days old
Compliance with the conditions contained in the
"states" and "exclusions" allow for the suspicion
of brain death and the transition to Phase II.
 Phase II includes a 2-fold performance by the Head
of the Department of anesthesiology and intensive
care and another doctor 3-hours following tests
confirming:
• 1. Apnea
• 2. The absence of brain stem reflexes
• a. lack of corneal reflex
• b. lack of spontaneous eye movements
• c. lack of eye movements to the caloric test
• d. lack of any motor response to a pain stimulus
• e. lack of vomitory and cough reaction (reflex)
• f. lack of ocular-brain reflex
 Brain death
brain stem reflexes
 lack of corneal reflex corneal reflex

(V and VII cranial nerves).

lightly touch the cornea with a cotton wool,
bringing the wool from the side of the eye.
reflex blinking of both eyes - normal
 lack of vomitory and cough reaction
„gag reflex”:

(cranial nerve IX and cranial nerve X).

Touching the soft palate evokes a strong
contraction of the back of the throat
 lack of ocular-brain reflex
eye movement in the direction opposite to head movement
aiming to preserve the image on the centre of the visual field.
when the head moves to the left, the eyes move to the right,
and vice versa.

lack of eye movements to the caloric test

With cold water (30C) the eyes turn toward the ipsilateral ear
(same side). With warm water (44C) the eyes turn toward the
contralateral ear (oposite).
 Apnea examination shows lack of reactivity
of the respiratory center

Commission declares brain death and whether

the patient qualifies for deceased organ
donation regulated by the Regulation of the
Minister of Health and Social Welfare
• Natural death - due to illness : sudden or
expected???
• Violent death - due to external factor : sudden or
expected???

• Caused by:
• 1. crime
• 2. suicide
• 3. misadventure, accident
• Features of sudden death:
• - liquid blood
• - abundant livor mortis (lividity)
• - congestion of organs
• Post-mortem blood clots - feature of slow death
• flaccid, smooth, juicy, flexible, cherry-yellow,
slippery
• Intravital blood clots intravital are:
• brittle, dry, dense layered
 Symptoms that occur
immediately after death:
• 1. muscle relaxation - passive body posture, due to
inertion: jaw drops and eyelids drop etc.
• 2. sphincter relaxation
 Early signs of death :
• Livor mortis (lividity, postmortem hypostasis) - blood drops to the
lower-lying vessels because of the force of gravity
• - In slow death lividity may already occur during prolonged agony
"cemetery roses”
• - In sudden death:
• the earliest (not very clear) after 20-30 min. p.m.
• clear, at the earliest after 60 minutes. p.m.
• beginning confluence of livor mortis - 2 hours p.m.
• total shifting – up to 12 hours p.m.
• partial shifting to 20 hours p.m.
• disappearing under the pressure of the finger up to 36 hours. p.m.
 What is the most important
during LM description?:
• Localisation of lividity,
• Colour
• Intensity
• Shifting
 Early signs of death :

• Rigor mortis (rigidity, stiffening of the body)

• Due to the depletion of the body's energy reserves
(from muscles), mainly ATP - lack of ATP
resynthesis
• Lack of ATP - causes strong binding actin and
myosin to form the complex which is sticky and
indivisible and causes stiffness
 Rigor Mortis

• Strength of rigor mortis depends on the concentration of

muscle mass
• The earliest in 30-60 minutes. p.m.
• beginning a clear rigor mortis (eg. the muscles of the jaw) 2-3
hours. p.m
• fully developed (covering the whole body) 6-8 pm. p.m.
• reappearance after "the breaking" – when the breaking happens
whitn 6-8 hours - total return
• beginning regression - 3-4 days p.m.
• complete termination (the end) of 3-4 days p.m
 Early signs of death :

• Pallor mortis – paleness - in consequence of the

formation of livor mortis (blood displacement)
• Post-mortem drying
• remember that due to post-mortem drying even
very superficial (intravital or post-mortem)
abrasions eg. ligature marks are more visible
The behavior of the blood in the
cadaver :
• The slow death:
• decreased fibrinolysis - intravascular coagulation
• increase of trombokinasis because of disintegrating
thrombocytes,
• clots appear
• The sudden death:
• as in the shock reaction
• increase of fibrinolysis – blood is liquid, lack of tissue
trombokinasis
 Early signs of death :
• Algor mortis (decrease of body temperature)
• Is the result of the cessation of circulation and respiration, metabolism
expiration and the simultaneous loss of heat by evaporation,
conduction.
• The cooling rate of about 1 ° C / hr.
• depends on the
• humidity
• ambient temperature
• abundance of subcautaneous tissue
• clothing
• rise of temperature after the death of example: sepsis
 Late signs of death
putrefaction

• Autolysis: the destruction of cells by their own enzymes

• Different enzyme systems are differently sensitive to
lack of oxygen.
• Autolysis Features :
• 1. hemolysis
• 2. exfoliation of epithelium serosal and mucous membrane
epithelium
• 3. solid organ lysis, blood and bile pigment on surrounding
tissues
• The earliest autolysis begins in the brain, liver, kidney,
pancreas
• Quickly disappearing enzymes: oxidoreductases,
aminotransferases
• Long active: hydrolase, cathepsin (proteolytic enzymes)

• enzymes own lysis effect is caused by the lack of central

regulation:
• reductase and phosphotransferase are inactive (decrease)
- hydrolase - increased activity
- lack of oxygen - anaerobic growth - tissue acidification -
increased activity autholytic enzymes
 Putrefaction

• caused by saprolytic bacteria predominantly from

gastrointestinal and respiratory tract
• development, the rate of putrefaction depends on
the season, the environment, temperature,
humidity, health status and possible treatment with
antibiotics
 Symptoms of putrefaction:
• 1. green-gray discoloration of the skin caused by sulpfhemoglobin and
choleglobin (blood pigment derivatives)
• 2. Marbling (diffuse streaks)- hemolyzed blood moved by gas and
pushing on the walls of veins and appears as network of dark red, dark
pink, greenish streaks (post-mortem blood circulation
• 3. fluid released from the tissue - softens and blurs the structure of
organs
• 4. epidermis (scarfskin) peels off
• 5. distension (bloating) of the skin and subcutaneous tissue of the
gases (Casper putrefactive gigantism)
• 6. tyramine, hydrogen sulfide, ammonia - give odor
 1.Adipocere
• Also known as "grave wax," adipocere (from the Latin, adipo for
fat and cera for wax) is a grayish-white postmortem (after death)
matter caused by fat decomposition , which results from
hydrolysis and hydrogenation of the lipids (fatty cells) that
compose subcutaneous (under the skin) fat tissues.

• Although decomposition of fatty tissues starts almost

immediately after death, adipocere formation time may vary
from two weeks to one or two months, on average, due to
several factors, such as temperature, embalming and burial
conditions, and materials surrounding the corpse.
 2. Mummification

• dead human whose soft tissues and organs have

been preserved by either intentional or accidental
exposure to chemicals, dry heat, extreme cold, very
low humidity, or lack of air, so that the recovered
body does not decay further if kept in cool and dry
conditions.
• hot, dry climates, the body dries rapidly; skin will
have a brown to black leathery appearance, internal
organs are small and dry
 Bog chemistry

• The preservation of bog bodies in peat bogs is a

natural phenomenon, and not the result of human
mummification processes. It is caused by the unique
physical and biochemical composition of the bogs.
• Different types of bogs can affect the
mummification process differently: raised bogs best
preserve the corpses, whereas fens and transitional
bogs tend to preserve harder tissues such as the
skeleton rather than the soft tissue.
Tollund Man, Denmark
Bog body
Year found: 1950
Age at death: about 30–40
Dated to: about 280 BCE—early Iron Age
Where found: Bjældskovdal bog
(Denmark), relatively near the bog body
known as Elling Woman
Manner of death: hanging, but death
caused by suffocation only, not by the
combination of suffocation and broken neck
Noteworthy: He has the most well-
preserved body of all bog bodies to date.
Only his arms and hands are like those of a
skeleton. Either his clothing disintegrated or
he was buried wearing only a pointed cap
made of sheepskin and an oxhide belt.
 Skeletonization

• the state of a dead organism after undergoing

decomposition. Skeletonization refers to the final
stage of decomposition, during which the last soft
tissues of a corpse have decayed or dried to the
point that the skeleton is exposed.
• 3-5 years - loss of soft tissue
• 5-10 years - complete skeletonization
Thank
you