-1-

Thanatology
Definitions: - Description or study of death and dying, and the
psychological mechanisms of dealing with them. OR - The scientific study of death. - Death means persistence stoppage of all vital processes in the body. OR - Permanent cessation of both circulation and respiration. OR - Irreversible loss of brain function (brain stem).

Everybody will die that is one thing that we are absolutely certain of. What exactly is death, and what happens in the time after death? From a biological point of view, death is a process, not an event. This is because the different tissues and organs in a living body 10/29/2007die at different rates. Death is classified into somatic death and cellular death. 1-Somatic death: Is when the individual is not longer a unit of society, because he is irreversibly unconscious, and unaware of himself and the world (death of the human body). 2- Cellular (molecular) death: Is when the cells stop respiration and metabolism. When all cells are dead, the body is dead. But all cells do not die

-2simultaneously, except perhaps in a nuclear explosion. Even in a victim of a car bomb, where the body becomes fragmented, individual cells will continue to live for a few minutes or longer. Different cell types can live for different times after cardiac arrest. Nervous cells in the brain are particularly susceptible to oxygen deprivation and will die within 3-7 minutes after complete oxygen deprivation.

Importance of determination of clinical death: 1. To write death certificate 2. To stop life support measures 3. To determine the moment of death (e.g. inheritance) 4. For organ transplantation considering the concept of brain stem death. 5. For rapid burial in cases of epidemics e.g. cholera.

The immediate signs of death:

1-Pallor and loss elasticity of the skin. 2-Ocular signs include: a) Absence of corneal and light reflexes of the eyes. b) Reduction in the intra-ocular tension and may drop to zero. c) Dimness of the cornea. d) Absence of blinking of eyelids

-3e) Trucking of blood in the retinal vessels: the loss of blood pressure allows blood to break up into segments, similar to trucks in a railway train. This phenomenon occurs all over the body, but only the retina that can be viewed by ophthalmoscope (retinal segmentation). 3-Primary flaccidity of the muscles. The limbs become flaccid after death. The body flattens over the areas that are in contact with the surface on which it rests. Contact flattening is usually seen over the shoulders blades, buttocks and calves. Since at this stage death is still somatic, respond of the muscles to electric stimuli can occur and may persist until molecular death occurs.

4-Cessation of circulation: a) No Pulse is an unsafe indication of death b) Absence of heart sound, as determined by repeated auscultation during a period of not less than ''5'' minutes is normally sufficient of death. In doubt E.C.G. should be made (flat ECG.). c) Subsidiary tests that are rarely used include, the ligature test, finger web inspection by transmitted light, the injection of fluorescing, and lastly open of one of the arteries. 1- Cessation of respiration: A- No respiratory movement

-4B- No respiratory sounds. C- A number of subsidiary tests are known for example the mirror, feather, candle tests, but these are unlikely to be done.

Post mortem changes which appear during the first 12 hours after death
1- Cooling of the body: The determination of rectal temperature is often an essential step in the examination of any death, exceptions are usually those where the external appearance indicate that death took place more than 24-36 hour earlier. The normal body temperature is not fixed but varies both with the site of measurement and with physiological change. The rectal temperature is commonly at least 1oC higher than the mouth. The body after death is estimated to loss about 11/2 oC every hour in the first 6 hours after death {i.e. 9 oC}. On the second 6 hours the body looses 1oC every6hours, to reach the environmental temperature from 12-18 hours after death.

Factors affecting the rate of cooling of the body after death

1- The external environmental as wined, draught of air, humidity affecting evaporation and cooling of the dead. 2- The posture of the body:

-5An extended body will cool faster than flexed one with reduced surface area (fetal posture). 3- A dead obese body retains heat longer than thin one, due to subcutaneous fats that is a bad conductor to heat. 4- Clothing: A naked body cools faster than one heavily clothed, also cotton clothed is cooling faster than wool clothed. 5- Infant and children tend to have a larger surface area available for heat loss relative to body weight compared with adults. 6- Edema: bodies who die with edematous tissues such as those with congestive heart failure have been found to cool more slowly. 7- Body temperature at the moment of death. Some types of death are associated with raised body temperature as pontine hemorrhage or other lesions affecting heat regulating center and sever infections such as wounds or abortions may cause the body temperature to be above 40 oC at the moment of death, so these deaths cool slower than normal deaths. 2-Post-mortem hypostasis (PM lividity or PM suggilation): When somatic death occurs, circulation of the blood ceases and subsequent movements of the blood is stopped. In consequence, blood tends to accumulate in the capillaries and small veins in the dependent parts of the body. Filling of subcutaneous capillaries in this manner gives a purple or reddish

-6purple color to the adjacent skin, a change to which the term postmortem hypostasis, lividity or suggilation is applied. Pressure of mild degree is sufficient to prevent gravitation of blood into the compressed areas of contact flattening. When laid on the back, the body has pale area over the shoulder blades, buttocks and calves corresponding areas are present when the body lies on face down. Hypostasis may acquire a pink (or red) color. This color of hypostasis might suggest a death from carbon monoxide, cyanide or nitrite poisoning. Refrigeration (or death from cold) may also produce pink (or red) hypostasis. Hypostasis occurs in the skin and also in viscera. Its ordinary appearance is attained within 2 hours after death and complete development is attained from 6 to 8 hours. It is reported sometimes to occur shortly before death e.g. cholera, typhus, uremia and congestive heart failure, and delayed in death due to anemia. It is present in all bodies, although it may be unremarkable in some cases (e.g. dark skin). The initial appearance of hypostasis is a patchy mottling of skin; then enlarged and coalesces to produce extensive discoloration. Practical importance of hypostasis (ML importance of hypostasis): A- It is a sure sign of death.

-7B-Its extension helps in estimation the time pass science death. C-It indicates the position of the body at the time of death, and any movements of the body after death. D-May gives an idea about the cause of death: 1) In co, cyanide, and nitrites poisoning hypostasis in bright red in color (red death or red asphyxia). 2) In nitrates, potassium chlorate and aniline dyes, hypostasis is deep brown or brown in color. 3) In asphyxia hypostasis is dark violet in color. 4) In hemorrhage hypostasis is faint and ill defined in color, depending on the amount of hemorrhage. 5) In drowning hypostasis is in the head and shoulders. E- Hypostasis indicates the position of the body after death whether, laid on back, face, suspended from neck or if the body moved after death at any time. F- May be mistaken with bruises (Contusions). 3- Rigor mortis : The initial flaccidity of the body after death is soon followed by stiffening or rigor mortis. The time of its onset is varied by several factors: Violent exertions shortly before death, convulsion or violent death fasten the onset. Also septicemia or wasting diseases accelerate and

-8passing fast rigor mortis. It is delayed when the body exposed to cold after death. Fatigued muscles pass more rapidly than resting muscles into rigor mortis. Rigor mortis is reported first to appear in the eyelids, face, lower jaw and neck. Then, it involves the trunk and limbs. It disappeared in the same order and the body again becomes flaccid. It is usually established in 8 to 12 hours and lasts about 36 hours from the moment of death. The order of onset and passing of rigor mortis may be determined by the size and kind of muscles involved, the smaller the muscle the earlier the onset and passing of rigor mortis. Rigor mortis is due to the disappearance of adenosine triphosphate (ATP) from the muscle. ATP is the basic source of energy for the muscle contraction. Muscle needs a continuous supply of ATP to contract because the amount present is sufficient to sustain muscle contraction for only a few seconds. After death generation of ATP stops, though consumption continues. In the absence of ATP, actin and myosin filaments become permanently complexed and rigor mortis sets in. this complex remains until decomposition occurs. Any violent muscular exertion prior to death will produce a decrease in ATP and speed up the onset of rigor mortis, since no ATP is produced after death.

-9-

Medico legal importance of rigor mortis:

1- It is sure sign of death. 2- Estimation the time pass since death 3- It fixes the body's position at the time of death. 4- It may suggested to the cause of death, which is rapid in onset in death following exhaust (tetanus, strychnine poisoning). 5- It may be mistaken with other conditions of stiffness after death as: a) Cadaveric spasm: This condition occurs at the moment of death in a group of voluntary muscles which were already in a state of state of strong contraction, while the hole body in a state of primary flaccidity except this group of voluntary muscles, and this continuous until rigor mortis sets in. it occurs in cases of death with extreme nervous tension such as: 1- Suicidal cases, when the weapon used is firmly clenched in the victim's hands. 2- In drowning, the victim grasping weeds or gravel. 3- Homicidal cases, the victim may firmly grasping hair or portion of clothes belong the assailant. Medico legal importance of cadaveric spasm: 1- The victim may hold the weapon; pointed to suicide. 2-The victim may hold piece of cloth or hair of the assailant, pointed to homicide.

- 10 b) Heat stiffness: these cases are due to shortening of the muscles fibers due to the effect of heat. This shortening result in flexion of the limbs (pugilistic attitude) and will remain stiff until putrefaction sets in. This stiffness due to coagulation of the muscles proteins in cases of burning leading to stiffening of the body and rigor mortis does not develop in the muscles that have undergone heat stiffening. c) Cold stiffness: This cases are due to frozen of the body, resulting in freezing of inter and intra cellular fluids of the tissues and also freezing the synovial fluids in the joints. If the temperature rises gradually, cold stiffening disappears and followed by appearance of rigor mortis with rapid spread and remains short per

- 11 -

Mechanism Type of death Type of muscle Extension 4 Onset Primary flaccidity P u Putrefaction:

Rigor mortis Phiso -chemical reaction. Occurs in all types deaths. All types of muscles. All over the body Occur usually after death. Proceeded by primary flaccidity

Cadaveric spasm Sever stimulation of the nervous system Death with nervous tension Voluntary muscle only Group of muscles Occur at the moment of death. Not proceeded by anything

It is the last stage that takes place in the dead body. Putrefaction is mainly due to fermentation and proteolysis enzymes of aerobic and anaerobic bacteria. Autolysis occurs before the action of microorganisms due to proteolyses, glycolytic, and lipolytic ferments of the body, act on body tissues leading to auto digestion of organs. Autolysis occurs early in the brain. Organisms of putrefaction are two groups. The first groups are aerobic pathogenic organisms present prior to death in relation to diseases caused by them. The second group are anaerobic

- 12 (more common) e.g. B Coli , Cl. Welchi and B. Proteus. These are present normally in intestinal tract. The liberated gases from putrefaction are a mixture of bad odorous gases like hydrogen sulphid, ammonia, methane, and other gases, with a bad odor froth coming from mouth and nose. When putrefaction advances, there is complete digestion of the soft tissues of the dead body with liberation of bad smell gases, liquids and salt leaving the body skeleton (skeletonization). Occurrence of putrefaction: 1- After 24 hours in summer of 36 hours in winter, there is a greenish discoloration of skin of the anterior abdominal wall starts opposite to the right iliac fossa, due to the presence of caecum in this place. 2- Marbling phenomenon. This is due to formation of gases inside the blood vessels causing their distention (arborization) under the skin and mucous membranes. It is more evident after 48 hours. 3- After 1-3 days after death, the green discoloration is all over, the face is swollen, the feature is difficult to recognize with distention of the abdomen and scrotum. 4- After one week after death. There is putrefactive bulla under the skin, protrusion of the tongue and a foul coarse bloody froth at the mouth and nostrils.

- 13 5- Two weeks after death there is peeling of the skin and abdominal wall become burst due to putrefactive gases. The viscera are liquefied to a dark doughy mass. Eggs of flies will become larvae (Entomology of the dead). This body color is black and the hair and nails fall. 6- At 6 months after death, nothing is left except bones attached with ligaments. 7- At one year after death, these ligaments will also dissolve leaving nothing but loose bones. 8- Putrefaction of internal organs takes place gradually depending on the blood supply of the organ, till the entire abdominal organ liquefied to a dark greenish doughy, and the abdominal wall burst. This doughy material percolates into the ground. This take place 2 weeks after death. 9- After one year from death, the time is estimated by weight of bones. Factors affecting the rate of putrefaction: 1- Age: Newly born breast -fed (due to scanty organisms) and old age (due to dryness of tissues decrease humidity), putrefied very slowly. 2-Causes of death. Bodies dying from infectious diseases undergo putrefaction much more rapidly than bodies dying of acute arsenical poisoning or hemorrhage (fluids or blood loss). In arsenical poisoning putrefaction is delayed due to dehydration and the poison hindering the growth of putrefactive organisms, this is also occurs with poisoning with heavy metals.

- 14 3-Temperature: The optimum temperature for putrefactive bacteria is 37 oC. So, putrefaction is more rapid in summer and delayed in winter. Bodies kept in temperature less than 4oC and more than 50 oC may not show putrefaction even after long periods. 4- Moisture. In dehydrated bodies putrefaction is delayed, while in cases of congestive heart failure (CHF) or general anasarca or bodies recovered from water putrefaction is rapid. 5- Air. Most of putrefactive organisms are aerobic. Thus bodies buried under compact soil putrefy later than bodies buried in spongy soil or sandy soil. Bodies submerged under water putrefy more slowly than those kept in the air, and putrefaction is more rapid under stagnant water than running water. Putrefaction is more rapid when the body is taken out of water. 6- Manner of burial. Putrefaction is delayed in bodies buried in sealed coffins and deep in the soil as Christians do. 7- Blood .The blood content of the organ is a good medium for putrefactive bacteria. So the liver is putrefied rapidly than the nongravid uterus, the putrefaction is delayed in case of death due to blood loss. 8- Mutilated bodies. Bodies sustaining multiple stab wounds putrefy early due to many opening for entrance of bacteria.

Conditions that may replace putrefaction: 1- Adipocere formation (Saponification): In cases of bodies kept under water (submerged) for long time (from 3 weeks to six months), hydrogenation of the nonsaturated body fats (palmitic and oleic) into saturated (steraric) hard fat. It is occurs in bodies submerged under water after death for a period of 3 weeks and become completely after six months. Adipocere is a yellow greasy rancid material. The

- 15 process is called wrongly saponification (old theory) as it was though that soap is formed due to exchange of Na and K ions by magnesium and calcium forming Ca and Mg soaps. Medicolegal importance of adipocere formation: 1- It denotes long submersion under water. 2- Estimation of the time passes since death (from 3 weeks to 6 months). 3- Identify the person as adipocere can preserve the features. 4- May share to the case of death as it preserve the pre-existing injuries or trauma if present.

2- Mummification: This is another postmortem change replacing putrefaction. It is natural process for preservation of the body by natural cause (high temp and sandy soil). This is observed in upper Egypt, where dryness of the body by the high temperature and absence of the humidity prevent growth of organism and preserve the body. It starts to occur after 3 weeks from death and completed in one year after death.

Medicolegal importance of mummification: 1- Estimation of the time passes since death by extension of dryness and shrinkage of the tissues. 2- Identify the person as it preserve the body features. 3- It may share to the cause of death as it preserves the preexisting injuries or trauma.

- 16 3- Embalming: This is artificial chemical preservation of the tissues, and it is done by injecting formaldehyde and methyl alcohol into one of the body cavities. 4- Maceration : It is a term applied to the aseptic autolytic changes which occur in the body of a fetus which had died in uterus and remains in the membranes in a sterile condition, characterized by brown red discoloration of the skin , flaccidity of the body and undue mobility of the skull bones, with rancid smell. It is another condition replacing putrefaction.

Estimation of post-mortem interval: 1- From biological and histological changes. The lactic acid and potassium content in cerebero-spinal fluid are rise in the first 15 hours after death and in the muscles and liver involving their phosphate, chloride and nitrogen contents. 2- From the rate of body cooling. 3- From the extent of hypostasis. 4- From the distribution of rigor mortis. 5- From the extent of putrefaction. 6- From adipocere formation, and its extent. 7- From mummification and its extent of dryness and shrinkage of the tissues.

- 17 8- Entomology of the dead. Flies lay their eggs on the dead body and from the life cycle of such fauna of the cadaver, we can have an idea about the time passed since death. 9- From gastric content, as the normal stomach empties in about 2-3 hours depending on the motility of stomach and the consistency and osmotic pressure of the content (fat inhibits gastric motility). So empty stomach suggests that nothing had been eating within 3 hours before death.