THANATOLOGY-

Study Of Death
 DEFINATION
• CLINICALLY :- “Irreversible cessation of life”
cessation of all vital functions such as nervous,
circulatory and respiratory systems.
• Death is a process not an event, while the cells
of some tissues are still alive and even capable
of movement, others are dying or dead.
 TYPES:-
1. SOMATIC DEATH
2. MOLECULAR DEATH
1. SOMATIC DEATH (SYNONYMS: SYSTEMIC
DEATH, CLINICAL 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.
• In somatic death, though life has ceased in the
body as a whole ,it still persists in its
component parts, namely the tissues and
cells.
DIAGNOSED BY :-
1. Cessations of heart beating
2. Cessation of breathing
3. Cessation of brain activity
 2. MOLECULAR DEATH
(SYNONYM: CELLULAR DEATH)
• Molecular death is defined as ultimate death
of all cellular elements.
• After somatic death, various tissues survive till
the oxygen supply to them is adequate. When
the oxygen reserve in the cells gets depleted,
cellular death or molecular death sets in.
Generally molecular death is not complete
before 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.
• Thus, it is a fact that death is a process rather
than an event and body dies by bits and
fragments. It is reported that nervous tissue
dies rapidly (i.e. the vital centers of brain die
in about 5 minutes), while the muscle tissue
lives up to 3 to 4 hours, after the cessation of
the circulation.
 MODES OF DEATH
1. Syncope (Fainting)
2. Asphyxia
3. Coma
 1. Syncope (Fainting)
• It is result of sudden stoppage of functioning
of the heart, which may prove fatal.
• Mechanism:-
– Syncope or fainting is due to vasovagal attacks
resulting from reflex parasympathetic stimulation,
reflex bradycardia or asystole, or by reflex
splanchnic vasodilatation. Due to acute reflex
circulatory changes, blood pressure falls suddenly
causing cerebral anemia and rapid
unconsciousness.
 2. Asphyxia
• It is a condition resulting from interference with
respiration or sudden stoppage of functioning
of lung causing unconsciousness or death.
• Mechanism:-
– Sudden stoppage of or failure 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.
Gordon’s Hypothesis (1944)
• It emphasises 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 four
types:-
1. Anoxic anoxia
2. Anemic anoxia
3. Histotoxic anoxia
4. Stagnant anoxia.
1. Anoxic anoxia:
– This means defective oxygenation of blood in the
lung and due to:
i. Absence of oxygen .
ii. Obstruction to respiratory passage
iii. Obstruction to respiratory movements
iv. Depression of respiratory centre
 II) Anemic anoxia
2. Anemic anoxia:
– ↓ O2 carrying capacity of the blood: hemorrhage and CO
poisoning
3. Stagnant anoxia:
– Inefficient circulation through the tissues, as in: Shock and
heart failure

4. Histotoxic anoxia:
– Inability of the tissues to utilize oxygen delivered to them,
cyanide poison
 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:-
1. Stage of dyspnoea
2. Stage of convulsions
3. Stage of exhaustion and respiratory failure.
1. Stage of dyspnea:
– The excess of carbon dioxide in the blood stimulates the
respiratory centre.
– Cyanosis, rapid deep breathing with acting extraordinary
muscles of respiration.
– Rapid pulse and high blood pressure.
2. Stage of convulsions:
– Cyanosis becomes deeper.
– Breathing becomes difficult and spasmodic.
– Congestion and edema of lungs and other organs.
Petechial hemorrhages in skin, lungs, heart and brain.
– Frequent Convulsions occur.
3. Stage of exhaustion:
– Respiratory centre is paralysed.
– Muscles become flaccid.
– Complete insensibility.
– Reflexes are lost and the pupils are widely dilated.
– Breathing is gasping, mostly inspiratory with long
intervals between the gasps.
– Blood pressure falls, muscles relax, respiration
ceases, and death takes place.
– Pulse is imperceptible, but the heart may continue to
beat for some minutes after respirations have ceased.
• The three stages last for 3 to 5 minutes
before death takes place.
 3. 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.
• Mechanism:- In coma there is a combination
of both syncope and asphyxia leading to
death. It is due to paralysis or insensibility of
central portion or vital centres of the
brainstem.
• Causes:-
1. Compression of brain
2. Acute poisonings
3. Metabolic disorders and infections
4. Other causes – embolism and thrombosis in
cerebral vessels, epilepsy, hysteria etc.
 MANNER OF DEATH
• Manner of death is generally considered to be
natural, homicide, suicide, accident and
undetermined.
• Manner of death, in India, is determined by
the court after examining all facts about the
case including the evidence and interpretation
by the doctor.
• Agonal period: It is the time between a lethal
occurrence and death.
 MECHANISM OF DEATH
• It is the physiological or biochemical
derangement produced by the cause of death,
which is incompatible with life and results in
death. For example, mechanism of death
could be, haemorrhage, septicemia, cardiac
arrhythmias, etc.
 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.
TYPES:-
1. Immediate cause
2. Antecedent cause
3. Contributory cause.
1. Immediate Cause:- It is the actual cause at the
time of terminal event, e.g.
bronchopneumonia, peritonitis, trauma, etc.
2. Antecedent Cause:-It is the 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.
3. Contributory Cause:-Contributory cause is the
pathological process involved in or
complications, but not causing the terminal
event, e.g. Carcinoma stomach.
 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- 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-
– If a person is proved to have been alive within 30 years the
legal presumption is that he is still alive, unless
– 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.
• If a person is unheard of for seven years, the court may on
application by the nearest relatives, presume death to have
taken place.
• Section 108, Indian Evidence Act (IEA) 1872, deals with burden
of proving that the person is alive who has not been heard of
for seven years.
• Section 107, Indian Evidence Act (IEA) 1872, deals with burden
of proving death of a person known to have been alive within
thirty years
• Issuing of Death Certificate- Before issuing this, doctor must
confirm that the person is dead. Death certificate or Certificate
of cause of death has a standard format.
 SUDDEN DEATH (RAPID DEATH,
SUDDEN NATURAL DEATH)
• The WHO definition of a sudden death is that
it is someone who dies within 24 hours of
appearance of symptoms.
• Medicolegal importance of this type of sudden
unexpected natural death is that it usually
raises a suspicion of foul play and death
certificate must not be issued in such cases till
an autopsy is conducted and cause of death is
confirmed.
 Causes :-
• Where a natural death is very rapid, perhaps virtually
instantaneous, the cause is invariably cardiovascular.
• TYPES :-
1. Cardiovascular System
2. Respiratory System
3. Intracranial Vascular Lesions
4. Psychiatric Patients
5. Gastrointestinal System
6. Gynaecological Conditions
7. Endocrinal Causes
8. Iatrogenic Causes
Fig: Common causes of sudden death
 1. Cardiovascular System
• Coronary artery diseases (atherosclerosis,
thrombosis, syphilis, etc.)
• Congenital heart diseases
• Valvular heart diseases (rheumatic, syphilitic, etc.)
• Hypertensive diseases
• Infections (myocarditis, postinfectious myocardial
degeneration)
• Cardiac tamponade
• Obscure conditions such as cardiomyopathies,
Fiedler’s myocarditis, etc.
• Aortic aneurysms of atherosclerotic or dissecting
 2. Respiratory System
• Pulmonary embolisms
• Massive hemoptysis (from pulmonary
tuberculosis)
• Severe infections such as fulminating viral
pneumonia(usually influenza)
• Chronic asthma/status asthmatics
• Anaphylaxis
• Obstruction of respiratory tract.
 3. Intracranial Vascular Lesions
• Intracranial bleeding due to cerebral
atheroma and stroke or hypertension
• Subarachnoid hemorrhage from ruptured
aneurysm
• Cerebral thrombosis
• Embolisms
• Infections of meninges (meningitis)
• Brain tumors
• Idiopathic epilepsy
• Functional inhibition of the vagus nerve.
 4. Psychiatric Patients
• Use of psychotropics, especially
antipsychotics, may be associated with an
increased risk for sudden death.
 5. Gastrointestinal System
• Severe gastrointestinal bleeding due to gastric
or duodenal ulcers.
• Ulcerative colitis, malignancies
• Mesenteric thrombosis and embolism leading
to infarction of the gut
• Perforation of peptic ulcer
• Intestinal gangrene
• Aortic aneurysmal rupture
• Diseased viscera undergoing rupture
• Fulminant hepatic failure
 6. Gynaecological Conditions
• Complication of pregnancy
• Haemorrhage in female genital organs could
be due to abortion or ruptured ectopic
pregnancy
 7. Endocrinal Causes
• Adrenal insufficiency
• Diabetic coma
• Myxoedemic crisis
• Parathyroid crisis
 8. Iatrogenic Causes
• Abuse of drugs
• Sudden withdrawal of steroids
• Anesthesia
• Mismatched blood transfusion.
 9. Miscellaneous Causes
• Anaphylaxis,
• Bacteremic shock
• Shock from fright or emotions
• Malaria
• Sickle cell crisis
• Alcoholism, etc.
 BRAIN DEATH AND
ORGAN TRANSPLANTATION
Depending on the structures involved, the brain
death is of three types:-
1. CEREBRAL/CORTICAL DEATH
2. BRAIN STEM DEATH
3. WHOLE BRAIN DEATH
 1. CEREBRAL/CORTICAL DEATH
• Brainstem is intact, with continuous heart sounds
and respiration, but total loss of sentient (sense of
perceiving and feeling things) activity. Thus, severe
brain damage, which does not involve the
brainstem, may result 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.
 2. BRAIN STEM DEATH
• Cerebrum is intact, but cut off functionally.
• person becomes irreversibly unconscious and irreversibly
apnoeic (i.e. incapable of breathing).
• The dilemma of euthanasia does not apply to those who
are brainstem dead. These patients are dead irreversibly
and unequivocally. Switching off the ventilator under such
circumstances would not kill the patient, but would
certainly discontinue ‘ventilating a corpse’.
• Causes: Cerebral edema, increased intracranial pressure
• After brainstem death is established, retention of the
patient on ventilator, undoubtedly facilitates a fully
oxygenated cadaver transplants’, the so called ‘beating-
heart donor’.
• 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.
 3. WHOLE BRAIN DEATH
• Whole brain death comprises combination of both
cortical and brain stem death.
• 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.