ITRODUCTION OF FORENSIC

MEDICINE AND DEATH

 DR MAHGOUB BABIKER MOHAMED

 Introduction

Indicate use of medical knowledge & skills

to answer a legal question

 historical background:-


imhotep(2980 -2900 bc) is considered as
first medico legal expert.

 medico-legal work slowly spread

throughout the continent of Europe from
Italy in 18th & 19th century.

 the first lecture was given in mid 17th cen in

University of Leipzig (Germany).
 in 1804 the first independent chair was
established at the university of Vienna.

 sir Andrew Duncan(1744 -1828)who

delivered the first medico-legal lecture in
British medical school at University of
Edinburgh at 1791.
 The inquest (Enquiry system)
 The investigation of suspicious & violent deaths form an important aspect of
the administration of justice:-
1. English death inquiry system evolved from Norman modifications of Anglo-Saxon
laws, evolving gradually into coroner system.
2. European continental law; originating from the Roman law strongly influenced by
the code Napoleon.
 The coroner system:-

 The system dated back to the twelfth century. At that time the coroner
played an important role in the financial interest of the crown. Was the
keeper of the pleas of the crown
 Is an independent official who was appointed for life & free from any
influence & answerable only by the Lord Chancellors.

 By 1500 the coroner only function is to conduct inquest into violent deaths.

 In 1887 onwards the only duty was to investigate deaths for the benefit of
community .

 He is a doctor or a lawyer.
 Investigate death in following situations:-
1. Deceased not attended by a doctor or doctor treating the deceased not
having seen the pt with in 14 days of his death.
2. Death was violent unnatural or suspicious.
3. Not known cause of death.
4. Death during surgery or anesthesia.
5. Death cause by industrial disease.
 The Procurator fiscal system (in Scotland):-

 He is always a lawyer

 Charged with duties of conducting the inquest & he aim to exclude any element of
criminality in a particularly deaths.
3. Medical examiner system (USA):-

 First introduce in USA in 1887

 Medical examiner is qualified forensic pathologist.

 Advantage is that deaths are thoroughly examined by a qualified & trained

medico-legal expert.
The Role of Inquest in Modern Society is to:-
 To determine the medical cause of death.

 To draw the attention to the existence of certain circumstances, which

might lead to further deaths.

 To advance medical knowledge.

 To preserve the legal interest of the deceased person’s family, and

other interested parties.
 In Some countries ,the inquest conducted by the magistrate or general
prosecutor . There is no coroner system & the police did not carry the
inquest.
Types of Postmortem Examination (Autopsy):-
 Clinical autopsy (postmortem examination):-
 Here the autopsy is carried to know the extent of the disease, and to
investigate the cause of death for pure medical and academic reasons. This
autopsy should not be carried without the consent of the relatives.
 Medico-legal autopsy:
 Here the autopsy is carried under legal umbrella, the order to conduct the
autopsy is issued by a legal authority. The consent of the relative is not
necessary in this type of postmortem examination.
The patho physiology of
death
The patho physiology of death

 The issue is more complicated by the event of organ

transplantation & tissue donation.
Death occurs in tow stage :-
1/ Somatic death
2/ Cellular death

Somatic death : (Clinical death )

It is the failure o f the body as an integrated system due to complete and
irreversible cessation of vital function of brain ,heart and lungs
Cellular death :
It is death of individual organs and tissue secondary to the cessation of
circulation .
tissue & their constituent cells are dead. It is a process rather than an
event. different tissues die at different rates.
Molecular life
o It is the period between the somatic death and cellular death, the cells and
tissues that response to physical, chemical and thermal stimuli
o It last from minuts to hours depending upon the oxygen requirement of the
tissue ( usually from 3-4 hours of somatic death)
o The most sensitive cells are the nerve cells (die in few minutes after somatic
death ) while the least sensitive are the connective tissue cells(die within
hours)
 Characters of the molecular life
 Muscles contraction on electrical and mechanical
excitation of skeletal muscles
 Ciliary muscles response to atropine by dilatation of
pupils e and physostigmine by constriction
 Motile sperm may be found in the genito-urinary system
at autopsies for few hours
 Some enzymatic processes or activities continue after
death.
MLI of the molecular life :-
Organ transplantation could be carried out only during the
period of molecular life. Liver should be taken within 15
min after death , kidney within 45 min, Heart within 60
min and cornea up to 6 hours.
 Classification of Death
According to the Cause and Mode and Manner of death
 Cause of death:-
 The disease or incident which directly contribute to death.

 Mode of death:-
 Mechanism of death… abnormal physiological state that pertained at time of
death ( ex.. coma).

 Manner of death:-
 Circumstantial event such homicide, suicide, accident or natural
 According to the Mod of death
a. CNS Failure
causes :-
1. Disease of the brain : inflammation or tumor.
2. Injuries of the brain : heamorrage or vascular lesions
3. Intoxication within certain poison : opiates and alchols
4. Metabolic errors : uremic or hepatic encephalopathy

b. CVS Failure
1. Cardiac causes : Valvular diseases , Infarction , coronary
diseases ,penetrating wound of the heart and cardio toxic
drugs e.g. digitalis or aconitine.
2. Circulatory causes : Excessive hemorrhage (Internal and
External )
3. Nervous causes : Reflex cardiac inhibition(RCI)
C. Respiratory failure

1. Pathologic : Pneumonia , pulmonary edema and

embolism , obstruction of the airways e.g.
Diphtheria ,Foreign bodies, tumors
2. Violent causes : Strangulation, Smothering or Drowning
3. Poisining : Opiates (depress the respiratory center ),
Strychnine (spasm of the respiratory muscles ).
 According to the manner of death
a) Natural death
Death occurring in non-suspicious circumstances refers to pathological etiology as in life-
threatening diseases e.g. Epilepsy , cerebrovascular stroke or terminal diseases e.g. Advance
malignancy .
b) Unnatural death
Death due to any other causes rather than diseases , this is could be :

1. Accidental death
Death due to accidents and unintentional incidents causes e.g. RTA

2. Suicidal
Person deliberated to kill him self e.g. Drowning ,Firearm injuries

3. Homicidal
Willful killing of the human being by another one e.g. firearm injuries

4. Undetermined
Suspicious death with negative autopsy finding .
 According to the cause of death
The cause of death is the physical condition that directly contributed to the persons death e.g.
traumatic or toxic which end fatal .
 signs of arrested vital functions
1. Signs of arrested circulation
 Absence of pulsation in the big arteries
 No perceived blood pressure
 In ability to auscultation heart sound for continues five
 ECG is flat in all leads for least five mints continuously
 Other observation :
-Arrest bleeding from wound- no hyperemia on putting a hot object on skin
2. Signs of arrested respiration
 No respiratory movement (chest and abdominal wall)
 No respiratory sound detected
 ABG analysis reveals severe hypoxia not consistent
with allive
3. Signs of arrested brain function
irreversible cessation of all functions of the entire
brain including cortex and brain stem, according to
accepted medical standards .
a. Signs indication cortical death
 Deep irreversible comma
 Total absent of any movement ,tremors or fasciculation
b. Signs indication brain stem death
 Loss of spontaneous breathing
 Loss of cranial reflex es
c. Investigation suggested brain
death
 EEG is flat
 CBF by contrast cerebral angiography or
Doppler technique (confirm)
 Diagnosis of death in difficult cases

_Soon after death

_Comma following excessive doses sedatives/hypnotics
e.g. barbiturates
_Hypothermia especially in elderly
_ Suspended animation (apparent death)
minimum vital signs compatible with alive , the condition
maybe either :-
 Involuntary as in Drowning, Electrical shock, after
anesthesia and Cerebral concussion
 Voluntary as in Yoga practitioners
Postmortem changes
 Primary flaccidity :
 Occurs immediately after death.. Loss of muscle tone due to loss of
neuronal supply.
 it is complete relaxation and loss of both tone and reflexes of voluntary and
involuntary muscles
 The face acquires the peaceful lock the lower jaw drops , the eyes ball lose
their tension and the pupils dilated, the sphincters relax resulting in
incontinence of urine and feces.
 The duration of primary flaccidity is about 3 hours after death , during this
period the muscles still react to external stimuli (period of molecular life)
 Contact flattening
_ it is flattening of the convex part of the muscles at sites of compression
against flat surface
 Skin changes
. After death the skin become pale, loses its elasticity leading to
absence of post mortem gaping of wound
. It loses its translucency due to absence of circulation
 Post mortem cooling (Algor Mortis):
during life there is balance between heat production(mainly by the
oxidative processes) and heat loss
after death the heat production stops and body continued loosing heat at
an average rate 1-1.5 °C till reach the temperature of the surroundings
inviroment
Medico-legal important of cooling:
1. Denotes time passed since death
2. Differentiation between the primary and secondary flaccidity
3. Denotes the cause of death from rate of cooling
Eye changes after death:

Loss of corneal reflex, not reliable sign it Found in cases of deep coma.

Opacity of the cornea, brown and black coloration ( tache noir) -2 to.3 hours

Flaccidity of the eye ball, decrease in the intraocular tension from 14 –

25 to less than 3 within ½ an hour.

Dilatation of the pupils.

Retinal vessels, trucking or segmentation of blood columns in retinal vessels

as seen by ophthalmoscope.

.
Opacity of the
cornea

tache noir
 Hypostasis (post mortem lividity):

 Due to stagnation of blood on the dependant part

 Usually bluish red color

 Pink in hypothermia & refrigeration
 Cherry- pink in CO poisoning
 Brown blue in cyanide poisoning
 Pale bronze in septic abortion

Difference between
hypostasis & bruise
 In dependant area  Any where
 No abrasions  There is abrasions
 Intravascular  Infiltrate the tissues
 Extravascular
 Rigor mortis: (post mortem rigidity)
It is a P.M condition characterized by progressive rigidity of voluntary and
involuntary muscles following primary flaccidity
 Stiffing of the muscles.
 Start 3-6 hrs after death.
 First affect jaws, facial muscles & neck before affecting wrist, ankles, knee,
elbows & hip.
 Maximum with in 6-12 hrs . Full duration 18-30 hrs & Fade in same manner
 ATP is responsible for elasticity of the muscles. Release of
actomyocin need energy .

 Rigor start with ATP concentration falls to 85%, maximum rigidity

when level decline to 15%.
 Affected by ..

1\ Temperature .
the lower the temperature the slower the
process.
2\ Physical activity shortly before death.
muscular exercise fastens the onset of rigor.
3\ muscle bulk and age :
Rabid onset and rabid offset in infant and female
and old people and in muscular athletics is delayed
onset and offset
the rigidity of rigor mortis turns the
body into board like as seen in this
.photo
Conditions simulating rigor
mortis:
1. Heat stiffening: exposure to temperature above 65 degree .
Muscles contracted and even carbonized. With flexion of
the limbs due to muscle contraction.
2. Cold stiffening: freezing of tissues, warming of the body
lead to disappearance and rigor starts after that. Harding of
subcutaneous fat especially in infants makes the skin folds
rigid and may be mistaken for ligature mark.
3. Cadaveric spasm :
Rare form develop at time of death ocur in one group of
muscle(small voluntary on hand and feet only )
No period of postmortem flaccidity .
Confined to deaths that occur in intense physical or
emotional activity.
 The Secondary flaccidity:-
The muscles become soft and flaccid once again, but don not respond to
external stimulation
The stage is synchronous with the onset of putrefaction
DD between the primary and secondary flaccidity ---------------
Onset
Cause
Body temperature
Response to external stimulation
 Putrefaction :(autolysis, putrefaction and decomposition)
It is process of decomposition of soft tissues resulting in resolution of the
body from organic to inorganic state
Mechanism ( by 2 processes):
1. Autolysis certain enzymes released from cell tissue causing liquefaction of
the body tissues
2. Bacterial action: bacteria produce a large variety of enzymes that breaks
down body tissues and produce gases ( saprophytic bacteria responsible of
putrefaction are both anaerobic- Cl Welchii- and aerobic – streptococci, B.coli &
proteus) – the most offender is Cl Wellchii that produce lecithinase which
hydrolyze the lecithin present in all cell membrane.
 Tissue in Putrefaction and become greenish-blue, or greenish-black color.
 The earliest change is greenish color of the skin seen at the region of the right
iliac fossa and it gradually spreads over the whole abdominal wall. Blood later into
the cavities of the body.
 — It is the prominence of the superficial veins with reddish discoloration during the
process of decomposition which develops on flanks of the abdomen, root of the
neck and shoulder and which makes the area look like a
reticule of branching veins. This is observed easily among dead person
One of the products of putrefaction is the evolution of gases.
Carbon dioxide, ammonia, hydrogen, sulphurated hydrogen, hydrogen, and
methane gases are formed. The offensive odor is due to these gases
The formation of gases causes the distention of the abdomen and bloating of the
whole body. Gases formed in the subcutaneous tissues and in the neck cause
swelling of the whole body. Small gas bubbles are found in solid visceral organs and
give rise to the "foamy" appearance of the organs.
Effects of the Pressure of Gases of Putrefaction:
1. Of the Blood:
post-mortem bleeding in open wounds on account of the increased pressure inside
the body brought about by the accumulation of gases. The post-mortem lividity be
shifted to other parts of the body. The heart may empty itself
2. Bloating of the Body:
The eyes may be protruding from its the tongue may come out of the mouth, and the
face is black
3. Fluid Coming Out of Both Nostrils and Mouth:
4. Expulsion of the Fetus from the uterus
5. Floating of the Body
 1 – 2 weeks, marbling of skin (arborization), distention of vessels with
green coloration.

 Skin-slippage with hair detachment easily picked off. Distension of the face
with protrusion of the tongue making visual identification impossible.
 Tissue destruction accelerated by maggots infestation

 Internally, decomposition proceeds more slowly than at the surface.

 After several months only the most resistant organs are still attached to
skeleton like prostate, uterus and heart.
 After 1 year the body turns into skeleton
( skeletalization.).

 Maggots are larvae of flies as blue and yellow flies

 Figure 2.
protrusion of
the tongue and
pulging of the
eyes. This is
seen due to
putrefaction
and gas
production.
Should not be
interpreted as
sign of
strangulation.
Condition replacing putrefaction

1. Adipocere: submersion in water

2. Mummification: death in desert
3. Maceration: death in uterus
 Adipocere:-

 A common postmortem change

 is a waxy substance derived from the body fat.
 caused by hydrolysis and hydrogenation of adipose tissue
 Occurs in humid and wet condition
 it takes about 3 months to develop

 Usually occurs in immersed bodies and those in wet graves.

 Adipocere formation inhibits putrefaction due to increased acidity which

slows down the growth of the putrefactive bacteria.
 Mummification:

 Drying of tissues in place of liquefying putrefaction occurs in dry

environment in hot desert zones.

 It assists identification
 Estimation of Time since Death:-
 very crucial in most of criminal investigations.
 methods:
 body cooling
 Rigor Mortis and hypostasis (not reliable).
 Electrical excitability of muscle.
 Gastric emptying.
 Vitreous humour chemistry ( rise in K* concentration).
 Cytological changes in the bone marrow
 Body Cooling and Estimation of Time since Death:-
 Except where the environmental (ambient) temperature remains at or even above
37ºC, the human body will cool after death.
 Factors Affecting the Cooling curve:-
 Initial body temperature.
 The body dimensions.
 Posture; (fetal positions).
 Clothing and coverings.
 The ambient temperature.
 Air movement and humidity
 The medium around the body (in air, in water).
 Haemorrhage.
 Calculation of Time since Death:-
 Taking the rectal temperature using thermometer.
 A fall in ºC from 37ºC plus three was equal to the time since death in
hours.
 Equation
 ( 37 – X) + 3 = time since death in hours. Where X is the rectal temperature.
Maceration

 Definition it is post mortem condition replaced

putrefaction. It is refers to a septic autolysis of the dead
fetus in side the uterus(sterile environmental with no
bacteria)
 Characters of maceration
- Started immediately after IUFD
- Within three days the fetal may present fairly normal
apperance, but the skin is usually softened
- After 5-7 days is characterized by :-
1\ softening of the fetus flattened when placed on the table
2\ over mobility of the joint
3\ over-riding of skull bones by X RAY (Spaulding sign)
4\ rancid smell
MLI
Indicated IUFD
Fals allegation of the live birth baby
Time of death