CHAPTER 4MEDICO-LEGAL ASPECTS OF DEATH

Death

* is the termination of life/complete cessation of all the vital functions (heart and lungs) w/o possibility of resuscitation.

Kinds of death:1. Somatic or clinical death persistence of vital functions2 .Molecular or cellular death 3 to six hours after cessation of life, death of indiv. cells3. Apparent death or ''State of suspended animation'' transient loss of consciousness/temporary cessation of the vital fxns of the body, as in hysteria,uremia, electric shock,catalepsy

Importance of Death determination:1.The civil personality of a natural person is extinguished by death.

2. The property of a person is transmitted to his heirs at the time of death.

3. The death of a partner is one of the causes of dissolution of partnership agreement.

4. The death of either the principal or agent is a mode of extinguishment of agency.

5. The criminal liability is extinguish by death.

6. The civil case for claims which does not survive is dismissed upon death of the defendant.

Based on the criterion used in its det'n, death may be: 1) Brain death -Harvard report of 1968,chars of'' irreversible coma'' a) unreceptivity / unresponsibility b) no mov'.ts/breathing c) no reflexes d) flat ECG-great confirmatory value e) falling arterial pressure w/o support by drugs/other means

BRAIN DEAD

2) CR death-(CARDIO- RESPIRATORY) >MD pronouncement based on intuition/ordinary standards of med practice. > death occurs when there is a continuous & persistent cessation of heart action & respiration.

CARDIORESPIRATORY DEATH

Signs of death:1. Cessation of heart action and circulation. -entire and continuous cessation of heart axn and flow of blood in the whole vascular system -as a gen rule, (-) heart axn for a period of 5 mins, death is regarded as certain -in judicial hanging, heart continues to beat for 25mins or half an hour after he has been executed although its beating is irreg and feeble

Methods of detecting the cessation of heart action and circulation:

a) Examination of the heart- pulse palpation, auscultation for heart sound, flouroscopy, ECG b) Examination of peripheral circulation

b) Examination of peripheral circulation 1) Magnus test application of ligature around the base of the finger w/ mod. lightness bloodless area at site of application dead man no change in color 2) Icards test injection of flourescein subcutaneously - greenish yellow discoloration in the whole skin dead man sol'n will remain at the site of injection

3) Diaphanous test fingers are spread wide & the finger webs are viewed through a strong light* if person is dead,the color is yellow * if alive, the color is red

4) Pressure on fingernails

5) Application of heat on the skin blister

6) Palpation of Radial pulse

7) Dropping of melted wax

2. Cessation of respiration breath holding not more than 3 minutesMethods of detecting cessation of respiration:a) Observance of movement of chest and abdomenb) With the aid of stet.c) Examination with a mirrord) Examination with a feather or cotton fiberse) Examination with a glass of water

Winslows test no movement in the image formed by reflecting artificial light on the water in a saucer and placed.

3. Cooling of the body ( ALGOR MORTIS) - After death the metabolic process inside the body ceases. - The progressive fall of the body temp. is one of the most prominent signs. - First two hours after death the cooling is rapid. - Fall of temp. of 15 to 20 degrees Fahrenheit is considered as a certain sign of death.

*POSTMORTEM CALORICITY is the rise of temp. of the body after death due to rapid and early putrefactive changes. Usually in the first 2 hours. >seen in cholera, liver abscess, tetanus, RF, Strychnine poisoning, Peritonitis

A. Conditions connected with the body:Factors delaying the rate of cooling of the body:1) Acute pyrexial disease2) Sudden death in good health3) Obesity of person4) Death from asphyxia5) Death of the middle age

Factors accelerating cooling:1) Leanness of the body2) Extreme age3) Long-standing illness4) Chronic pyrexial disease with wasting

B. Conditions that are connected with the surroundings

Factors delaying cooling:1) Clothings2) Want of access of air to the body3) Small room4) Warm surroundings

Factors accelerating cooling:1) Unclothed body2) Conditions allowing the access of air3) Large room permitting the dissipation of heat4) Cooling more rapid in water than in air

*Methods of estimating how long a person has been dead from the cooling of the body:1. If body temp. is normal at the time of death: = the average rate of fall of the temp. during the first 2 hours is of the difference of the body temperature and that of the air. =as a gen rule, the body attains the temp. of the surrounding air from 12 to 15 hours after death in tropical countries.

2. Chemical Method ( Schourups formula) for the determination of the time of death of any cadaver whose CSF is examined for the concentrations of Lactic.A., NonProteinNitrogen, AminoA. = L.A> 15 mg to 200 mg/100cc rapid in 1st 5 hours. = NPN inc. from 15 to 40 mg/100 cc in 1st 15 hours = A.A. inc. from 1 mg to 12 mg% 1st 15 hours.

4. INSENSIBILITY OF THE BODY AND LOSS OF POWER TO MOVE may be seen in the living with- apoplexy, epilepsy , trance, catalepsy, hysteria ,cerebral concussion.

5. CHANGES IN THE SKIN opacity on transillumination, flattening, loss of elasticity of skin, pale, waxy looking, no blister formation on application of heat.

6. CHANGES IN AND ABOUT THE EYE a) Loss of corneal reflex may be seen In live pts: Gen./local anesthesia., uremia, narcotic poisoning b) Clouding of cornea c) Flaccidity of the eyeball d) Pupil in the position of rest. e)'' TACHE NOIR DE LA SCLEROTIQUE'' spot found in the sclera after death.

7. ACTION OF HEAT ON THE SKIN >Heat applied while alive produced blister with serum and redness around the area. >Following combinations of signs show death has occurred:a) Loss of animal heat to a point not compatible with lifeb) Absence of response of muscle to stimulusc) Onset of rigor mortis.

CHANGES IN THE BODY FOLLOWING DEATH

1. CHANGES IN THE MUSCLE complete relaxation of the whole muscular system. *Three Stages After Death: a) Stage of primary flaccidity (POSTMORTEM IRRITABILITY) = muscle relax, may contract, dilated pupil, sphincters are relaxed, incontinence of urination and defecation = presence of molecular life = warm place: 1 hour and 51 minutes = chemical reaction of muscle is alkaline b) Stage of postmortem rigidity

(CADAVERIC RIGIDITY/ DEATH STRUGGLE OF MUSCLES OR RIGOR MORTIS) = whole body is rigid due to contraction of the muscles = starts at muscle of neck, lower jaw = Reaction is acidic due to inc. of lactic acid = develops 3 to 6 hours after death in temperate, earlier in warm = last from 2 to 3 days in temperate, warm: 24-48H cold weather 18-36H summer

c) Stage of Secondary flaccidity or Commencement of putrefaction ( DECAY OF MUSCLES) > muscle are flaccid, not respond to stimuli, reaction is alkaline.

> due to dissolution of muscle proteins.

*FACTORS INFLUENCING THE TIME OF ONSET OF RIGOR MORTIS(1) Internal Factors a) State of the muscles > healthy appears late > Onset is hastened in: a.1 hunted animal a.2 prolonged convulsion/lingering illness a.3 death from- TY, Cholera, Phthisis, typhus

b) Age * early onset aged and newborn * delayed good health, good muscular development

c) Integrity of nerves > section of the nerve will delay onset, paralyzed muscle

(2) External factors a) Temperature > Hastened by high temperature > 75 degrees will produce heat stiffening b) Moisture > rapidly but with short duration in moist air

Conditions simulating RIGOR MORTIS:1. Heat stiffening > 75 degrees coagulates muscle proteins resulting to rigidity. * Pugilistic attitude flexed upper and lower limb, hands clenched, flexor stronger than extensors, burned to death 2. Cold stiffening = due to solidification of fats when exposed to cold temp.

3. Cadaveric spasm or Instantaneous Rigor > instantaneous rigidity due to extreme nervous tension, exhaustion, injury to the nervous system. > findings of weapon in hand, weeds-alive before disposal.

RIGOR MORTIS CADAVERIC SPASM1.) Time of appearance 3-6H after death Immediately after death 2.) Muscles involved All muscles Certain group3.)Occurrence Natural phenomena after death - May or may not appear 4.)Medico-legal signif. Approximates time of death - Determine nature of crime

RIGOR MORTIS- MUSCLE CONTRACTION1. Contracted muscle Losses transparency More or less transparent2. Elasticity Loss elasticity Very elastic3. Litmus reaction Acidic Neutral or sl. alkaline4. Contraction Absolute flaccidity Possess inherent contraction

2. CHANGES IN THE BLOOD a) Coagulation of blood * blood may remain fluid inside the blood vessels 6-8H after death.

ANTEMORTEM CLOT POSTMORTEM CLOT1. Consistency Firm Soft2. Surface of blood vessels Raw after clots are removed Smooth, health after 3. Clots Homogenous in construction so it: cannot be stripped into layers can be stripped off in layers

b) Postmortem Lividity or Cadaveric Lividity , or Postmortem Suggilation or Post-mortem Hypostasis or Livor Mortis * Stopp. age of heart action and loss of tone of blood vessel accumulates in dependent areas except in bony areas. * capillaries coalesce > purplish in color called ''Postmortem lividity'' = Hasten by death due to cholera, uremia, Typhus fever = appears 3 6 H after death and fully developed 12 H after death.

*Physical characteristics of Postmortem Cadaveric Lividity1) Occurs in the most dependent areas2) Involves the superficial layer of the skin3) Does not appear elevated from the rest of the skin4) Color is uniform5) No injury of the skin

*Kinds of Postmortem Cadaveric Lividity

1) Hypostatic lividity

2) Diffusion lividity

*Importance of Cadaveric lividity:1) One of the signs of death.

2)Determines the position of the body has been changed after its appearance in the body.

3) Color of lividity may indicate the cause of death example:* asphyxia lividity is dark* CO poisoning pink* Hemorrhage less marked* Hydrocyanic acid bright red* Phosphorus dark brown* Potassium chlorate coffee brown

4)Determines how long the person has been dead.

5) Gives us an idea as to the time of death.

*Points to be considered which may infer the position of the body at the time of death:1) Posture of the body when found.

2) Post-mortem hypostasis or lividity

3) Cadaveric spasm

CONTUSSION (BRUISE) POSTMORTEM HYPOSTASIS1.Small bruises Below epidermis in true skin In the epidermis or cutis larger ones below this 2. Cuticle Abraded by the same violence - Unabraded that produce the bruise.3. Bruise Appears at the seat or surrounding -Always dependent may or may not be dependent 4.Elevated, inflammatory condition - Not elevated, blood in b.v.

CONTUSSION (BRUISE) POSTMORTEM HYPOSTASIS5. Incision shows blood outside the b.v. - Blood inside the vessels = most certain test of difference6. Color variegated Uniform color

*Internal hypostasis in Visceral organs::Organs affected are:1) Lungs

2) Loops of intestine

3) Brain

POST-MORTEM LIVIDITY OF ORGANS vs SIMPLE CONGESTION1. Postmortem staining in organs Irregular, most dependent parts = Uniform,all organs 2. Mucous membrane Dull,lusterless = Not in congestion3. Inflammatory exudate Not seen = Not seen

*Other changes in the blood1). Hydrogen ion concentration acid pH CO2, L.A., After 24H alkaline ammonia. 2). Breakdown of liver glycogen leads to accumulation of dextrose in the IVC and the right side of the heart.3). Rise in NPN and Free A.A.

4. Chemical: * Chloride in the plasma/RBC decrease due to extravascular diffusion, in 72 H only of its content. * Mg increases due to diffusion from without. * K increases due to diffusion from the vascular endothelium.

3. AUTOLYTIC OR AUTODIGESTIVE CHANGES AFTER DEATHAfter death, proteolytic, glycolytic and lipolytic ferments of the glandular tissues continue to act which lead to the autodigestion of organs.

4. PUTREFACTION OF THE BODY Is the breaking down of complex proteins into simpler components associated with the evolution of foul smelling gasses and accompanied by the change of color of the body.

*Tissue changes in putrefaction:1. Changes in the color of the tissue * Hemolysis of blood within blood vessels > Hgb diffuses through the walls of BV imparting a Reddish-brown color * In the tissues > Hgb undergo chemical change imparting Greenish-yellow 1st seen at R Iliac fossa then spreads over whole abd'l wall

MARBOLIZATION prominence of the superficial veins with reddish discoloration which develops on both flanks of the abdomen, neck, and shoulder . * look like marbled reticule of branching vein ( esp. observed among fair complexion )

2. Evolution of gases in the tissues * CO2, ammonia, H2, Sulfurated hydrogen, methane = offensive odor * Effects of pressure of gases of putrefaction: a) displacement of the blood bleeding in open woundsb) bloating of the bodyc) fluid coming out from nostrils, mouthd) extrusion of the fetus in a gravid uterus e) floating of the body

3. Liquefaction of the soft tissues * Putrefy rapidly : Eyeball, lining of trachea, larynx , brain, stomach, intestine, liver, spleen * Putrefy late : Highly muscular organs and tissues, Esophagus, diaphragm, heart, lungs, kidneys, U.B., uterus, P.G.

*Factors modifying the RATE of putrefaction:1. INTERNAL FACTORSa) age : healthy adults, NB not yet fed, later than infantsb) condition of body : full grown/obese rapid, Stillborn- latec) cause of death : infection - rapid

2. EXTERNAL FACTORSa) Free air a.1 air : free air hasten decomposition

a.2 moderate moisture - accelerates

a.3 loaded with septic bacteria early aerobes, later anaerobic

* Clostridium welchii= decomposition

b) Earth b.1 dry absorbent soil - retards b.2 moist fertile soil - accelerates c) Running water- more rapid than still water d) Clothings early it hastens but delays in the later stage. * tight clothings - delay

*Factors influencing the changes in the body after burial:1) state of the body before death thin slower, mummify2) time elapsed between death and burial and environment of the body3) effect of coffin later

4) clothings and other coverings on the body when buried pressure, insects

5) depth at which the body was buried - greater the later

6) condition and type of soil7) inclusion of something in the grave which will hasten decomposition-food8) access of air to the body after burial9) mass grave rapid10) trauma to the body 11) violent death - slow

*CHRONOLOGICAL SEQUENCE OF PUTREFACTIVE CHANGES OCCURING IN TEMPERATE REGIONS1-3 DAYS AFTER DEATH (greenish discoloration over iliac fossa, soft eyeballs ) 3-5 DAYS ( frothy blood from mouth, nostrils)

8-10 DAYS (abdominal distention, nails firm )

14-20 DAYS( blisters all over the body, maggots)

2-5 MONTHS (skull exposed, orbits empty)

*IN TROPICAL REGION12 HOURS ( Rigor mortis all over, hypostasis, greenish-discoloration caecum ) 24 HOURS ( Rigor mortis absent all over, abdominal distention )48 H ( Ova of flies, trunk bloated,face discolored)

72 H (Whole body grossly swollen, hairs and nails loose ) ONE WEEK ( Soft viscera putrefied)TWO WEEKS ( Soft tissues largely gone)ONE MONTH (Body skeletonized)

*BEEN SUBMERGED IN WATER

FIRST 4 OR 5 DAYS (Cold water little change, in rigor mortis)FROM 5 7 DAYS ( Skin on hands, feet is bleached, face faded white ) 1 2 WEEKS (Face swollen and red, skin of hands and feet wrinkled ) 4 WEEKS (Skin wrinkled, nail intact )6 8 WEEKS (Abdomen distended, skin of hands/ feet come off with nails)

*Factors influencing the floating of the body in water:1) age fully developed, well nourished - rapid2) sex females floats sooner3) conditions of the body obese float quicker4) season of the year moist hot air putrefaction floats due to gas

5) water- shallow and stagnant water of creeks, higher specific gravity seawater floats sooner than fresh water, higher specific gravity 6) external influence heavy-wearing apparel - slower *Only teeth, bones and hair remain for an indefinite time. Flat bones disintegrates faster than round bones.

*SPECIAL MODIFICATION OF PUTREFACTION1. Mummification *is the dehydration of the whole body which results in the shivering and preservation of the body. * usually occurs when buries in a hot, dry with free access of hot air.

2) Saponification or Adipocere formation

* a condition where the fatty tissues of the body are transformed to soft brownish-white substance known as ADIPOCERE at SQ level.

3. Maceration > softening of the tissues when in fluid medium in the absence of putrefactive micro-org, seen in death in utero . > reddish or greenish color, skin peeling off and arms flaccid and frail.

HOW LONG A PERSON HAS BEEN DEAD? DURATION OF DEATH1. Presence of rigor mortis: 2-3 hours after death 12 H fully developed 18-36 H disappears concomitant with putrefaction

2. Presence of Post-mortem lividity 3-6 H after death appears as small petechia-like red spots

3. Onset of decomposition 24-48 H after manifested watery. foul smelling froth, mouth, nostrils4. Stage of decomposition5. Entomology of the cadaver 24 H before eggs are hatched, maggots

6. Stage of digestion - 3-4 H gastric empty 6-8 distal ileum, cecum

7. Presence of live flies in the clothing in the drowning victim less than 24H8. State of clothings - pajama = night

9. Changes in CSF

10. Blood clots inside the b.v. in 68 H after death.

11. Soft tissues of the body may disappear 1 to 2 years after burial.

Postmortem conditions simulating disease, poisoning or injury:1) post mortem hypostasis contusion, inflammation , poisoning2) blisters of the cuticle scald and burns3) swelling, detachment or splitting - injury

PRESUMPTION OF DEATHDisputable presumption = not heard in 7 yearsPresumption of death =Absence of 7 years except succession 10 years ~ Vessel for 4 years ~ Armed forces 4 years ~ In danger of death 4 years

PRESUMPTION OF SURVIVORSHIP1. under 15 y.o. older survives2. above 60 y.o.- younger3. under 15, above 60 - former4. over 15 and under 60 y.o. male, older5. under 15, or over 60 y.o. and the other in between - latter

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