The pathophysiology of

death
* Outline :
• Types of death.
• Hypostasis .
• Rigor mortis .
• Post- mortem decomposition.
• Putrefaction .
• Formation of adipocere.
Types of death :
A- somatic death :
the person irreversibly loses his/her ability t sense , being :
- un-conscious
- un-able to be aware of the environment .
- un- able to appreciate any sensory stimuli .
- un- able to initiate any voluntary movement .
• Cellular death :
- In which the tissues and their constituent cells are dead >>> no
longer function or metabolic activity.
- It follows ischemia and anoxia as a consequence of cardiorespiratory
failure >>> so it’s a process rather than an event EXCEPT in some cases :
falling in to molten metal , nuclear explosion .

Note : different tissues die at a different rates

Brain death
• Persistent vegetative state (PVS) :
- Extensive cortical damage with preserved brainstem >>> this will
ensure spontaneous breathing and uncompromised cardiac activity>>>
deep coma with debilitating complications
• Brain stem death :
- Cortical damage + brain stem damage >>> not only irreversible coma
but also loss of the cardiorespiratory centers >>> so incapable of
spontaneous breathing
* Note: In brain stem death >> the person is dead in the somatic
sense , however , not in the cellular sense , it’s through this ‘
physiological window “ that the cadaver transplant surgeries occur .
Medico legal aspects
The indications of death :
1- Un-consciousness and loss of all reflexes with no reaction to painful
stimuli .

2- Muscular flaccidity immediately after cerebral and cerebellar

functions failure ( though they are physically capable to contract many
hours after the event ) .

3- Cessation of heart beat and respiratory movement .

- heart beat >>> prolonged auscultation , echocardiogram.
- respiration >>> prolonged auscultation over the trachea and lung
fields
• 4- Eyes signs
- loss of the corneal and light reflexes and the pupil is in the
mid – dilated position >> relaxed neutral position of the pupillary
muscles .
- loss of pupils circular shape and regular size
loss of globe tension due to decrease in the arterial pressure
- the eye ball progressively becomes softer
- cornea >> loses its normal glistening reflectivity due to laxity anf
failure of lacrimal moistening
- eye led >> incomplete closure >> due to muscle flaccidity >> two
triangles appear on the exposed sclera ( yellow > brown > black )
“ TACHE NOIRE “
- Retina >>> “trucking” of blood in the retinal vessels due to
breaking up of blood into segments due to loss of BP ( one of the
earliest positive signs of death . page 57
The mode of death and its cause :
• The mode of death :
the abnormal physiological state that pertained at the time of death.
EX: congestive heart failure , coma , cardiac arrest … these give no
information to the underlying pathological and should not be used as
the definitive cause of death
The manner of death :
• The circumstantial events such as “ homicide , suicide , accidental or
natural cause “ .
Post – mortem changes :
• Number of post – mortem changes are of interest and potential
usefulness :
- Relation to the estimation of the post mortem interval (PMI) .
- Possible interference with the body .
- Indication of the cause of death .
 Hypostasis
• Older names :
- lucidity , staining , or cogitation , but the current is the most suitable as it
indicates the ause .
• Cause :
- Ceasing of circulation >>> no arterial propulsion or venous return >>> no blood
movement through the capillary bed >>> gravity pulls down the stagnant blood to
the lowest possible points .
- The RBCs are most affected , and plasma also drifts downwards to a lesser
extent , causing post – mortem “dependent edema “ , which contributes to skin
blistering .
• Color :
- Bluish red discoloration .
• Locations :
- On the lateral and dependent surfaces , upper surfaces of the legs especially
thighs , the coalesces and slide down the lowest areas
Hypostasis
The distribution of hypostasis :
- It depends on the posture of the body after death .
1- It’s most common when the body on the back with the
shoulders , buttocks and calves pressed against the supporting
surface>> this compresses the vascular channels in those areas >>>
hypostasis is prevented from forming there >>> skin remains white.
2- If the body remains vertical after death ( as n hanging ) >>
hypostasis most marked in the feet , legs , and to lesser extent in the
hands and distal part of the arm.
- Local pressure can exclude hypostasis and produce a distinct pattern
in contrast in contrast to the discolored areas .
The color of hypostasis :
• The usual color is bluish red , but there is wide variation that depends
on the state of oxygenation at the time of death .
- congested , hypoxic state >> darker color due to reduced
hemoglobin in the skin vessels.
- natural deaths from coronary or other diseases have dark
hypostasis .
• Color of hypostasis varies from area to area on the same body .
- lighter color rim along the margin of a darker area >>> this
depend on PMI length .
The mechanism of formation :
• it’s not fully understood , but it’s obviously a result of oxyhemoglobin
forming at the expense of the reduced hemoglobin .
• Sometimes the originally bluish hypostasis >> pink along the upper
part or the horizontal margin , and the lower parts remaining darker
>>> the hemoglobin being more easily re-oxygenated where RBCs are
backed less densely
• “ Cherry – pink “of carboxyhemoglobin :
- very unique , the first indication to carbon monoxide poisoning .
• Cyanide poisoning >>> dark blue – pink .

• Deaths from septic abortion where Clostridium perfringens is the

infecting agent >> pale bronze mottling may sometimes be seen on
the skin .

• Skin hemorrhage may develop in areas of hypostasis >> common

areas : back of shoulders and neck
The timing and permanence of hypostasis :
• Once hypostasis is established , there is controversy about its ability
to undergo subsequent gravitational shift >> if the body is moved into
a different posture , the primary hypostasis may either :
- remain fixed .
- move completely to the newly dependent zones .
- partly fixed and partly relocated .
Hypostasis in other organs :
• It’s important to differentiate organ hypostasis from ante- mortem
lesions .
- Intestine >>> jejunum and ileum
- The lungs >>> there is a marked difference in color from front to
back .
- myocardium >> dark patches in the posterior wall of the left ventricle
- retro – esophageal hemorrhage at the level of the larynx
Hypostasis vs. bruising :
• Hypostasis : regular , diffuse engorgement of the surface vessels , the
color varying between purple red and bright pink , density vary from
place to place , without sudden change in color nor any sharply
circumscribed areas as in bruising .
• Hypostasis on dependent areas , bruises can be any where with dicoid
and irregular margin
• If there is difficulty in differentiation between them >> the classic
test is to : incise the suspected area to see if to under laying blood is
intravascular ( hypostasis ) or infiltrating the tissues outside the
vessels (contusions ) .
• If a post-mortem pressure mark ( belt or tight clothing) crosses an
area of :
- hypostasis : there will be a pale bloodless zone
- bruise : it won’t be affected .
• Hypostasis >> blood is in the most superficial layer of the dermis
Bruise >> blood is in deeper skin layers or underlying tissues .
• Histology .
Rigor mortis
• It’s stiffening of muscles after death .
• Range of times where rigor appears can be summarized as follow :
- The flaccid period immediately after death ( 3- 6 hours ) >> rigors
first appears in the smaller muscle groups( jaw , facial muscle …) >>
wrists and ankles >> knees , elbows and hips . The usual method of
testing is by flexing and extending the joint .
-Rigor mortis >> spread to involve the whole muscle mass within a
variable period but in average ( 6 – 12 hours ) >> this remains constant
until the muscle mass begins to undergo autolysis .
- full rigor >> ( 18- 36 hours )
Factors affecting timing of rigor mortis
• The temperature in the surrounding environment .
( the colder the environment the slower the process )
• The availability of glycogen and ATP in the muscle is crucial element in
rigor formation .
• The following is reasonable ‘ spot check ‘ for temperature conditions :
- if the body is warm and flaccid >>> less than 3 hours
- if the body is warm and stiff >>> 3 – 8 hours
-if the body is cold and stiff >>> 8 – 36 hours
- if the body is cold and flaccid >>> more than 36 hours
Gross effects of rigor mortis :
• There has been controversy over whether rigor mortis only stiffens
the muscles or actually shortens them .
-” Sommer’s movement “
- Smith >>> decrease in glycogen >> shortening in muscle.
- “ Breaking “ Rigor
• It can never be assumed that the posture of rigor in which the body
is found was that which obtained at the time of death .
Cadaver spasm
• It’s a rare form of instantaneous rigor that develops at the time of
death with no period of post – mortem flaccidity .
• It’s confined to those deaths that occur in the midst of intense
physical and / or emotional activity
• it’s initiated by motor nerve action, with failure of normal relaxation.
• It usually affects one group of muscle rather than the whole body .
• Ex : solder in the battlefield , person fall into water ,gripping a gun as
evidence of “true suicide “ rather than a “planted weapon “ in a
homicide
Heat and cold stiffening :
• At extremes of temperature the muscles may undergo a false rigor .
- Cold (>>> causes stiff below zero ) once intrinsic body heat is lost ,
the muscles may harden because body fluids may freeze .

- Heat >> causes stiffness , as the protein becomes denatured and

coagulated >>> this depends on the intensity of heat and the time for
which it was applied
Post-mortem decomposition
• Hypostasis and decomposition occur relatively soon after death when
somatic death has occurred , but cellular death is incomplete .
• Death is a process rather than an event >> while the call of some
tissues are still alive , others are dying or dead >>> decomposition.
• Decomposition is a mixed process >> ranging from :
- autolysis due to internal chemicals
- external process introduced by bacteria and fungi from the
environment .
• Decomposition varies from environment to environment , from body
to body , and even from one part of the same corpse to another .
Post-mortem decomposition
Putrefaction
• The process of corruption of the dead body , which usually begins at a
variable time after death but in an average climate it begins in about
3 days in unrefrigerated corpse.
Sequence of putrefactive changes
• What ever the time scale , the general order of corruption is similar .
1- Discoloration of the lower abdominal wall , most often in the right iliac
fossa where the bacteria – laden cecum lies superficially . ( first external
naked – eye sign ) >>> this discoloration spreads over the abdomen >>
eventually the abdomen becomes distended with gas .
2- The generalized spread of bacteria >>> discoloration of moist tissues .
3- “ Skin – slippage “ sacs due to upper epidermis loosening >> breaking of
this sacs makes identification of fingerprints more difficult
4- The face and neck become reddish and begin to swell
5- Bacteria from intestine and lungs travel to the venous system >>
haemolysing the blood that stains the vessel wall and adjacent tissues >>
“ marbling “
6- Bloody fluid , which is liquefaction stained by hemolysis , may leak
from mouth , nostrils , rectum , and vagina . ( by this stage , some 2-3
weeks may have elapsed since death **
7- After several weeks , the reddish – green color of the skin may
deepen to a dark green or almost black .
8- Heavy maggot infestation will have supervened except in winter
conditions , and the destruction of skin by these maggot holes and
sinuses gives access to other bacteria from the environment .
9- The maggots secrete proteolytic enzymes that speeds up the
destruction of the tissues .
10 – Internally , decomposition proceeds more slowly than at the surface . (
the lining of the intestine , the pancrease and the adrenal medulla
autolyse within hours of death , yet prostate and uterus may still be
recognized a year later .
11- Brain >>> quickly become discolored , and liquefy within a month .
>>> meningeal hemorrhage and hematoma persist well , but
apart from some tumors , non- hemorrhagic lesions in the brain substance
vanish early .
12-Heart >> it’s moderately resistant
>>coronary arteries examination may be well worthwhile for
many months
>> complete occlusion by firm ant-mortem thrombus persists well
>> “ military plaques “ white granularity on the epicardium and
endocardium surfaces
13- Body fat in obese people (especially perirenal , omental and
mesenteric ) may liquefy into translucent , yellow fluid that fills the
body cavities between organs .
14- later putrefactive changes lead to breakdown of the thoracic and
abdominal walls .
15- later on >> softer tissues and the viscera progressively disintegrate ,
leaving the more solid organs such as the uterus , prostate , and heart .
16- eventually , the body will be reduced to a skeleton , with ligament ,
cartilage and periosteal tags .

Note : the season of the year and the location will make a great
difference to the time scale of skeletalization .
Decomposition in immersed bodies
• The old rule :the bodies decay twice as fast in air as in water is grossly
inaccurate , but emphasized the slower rate of decomposition.
• Water slows up decomposition mainly because of the lower
temperature , and protection from insect and small predators .
• The gas formation is the reason for the inevitable flotation of an
un weighted body >>> the usual posture of a freely floating body is
face down , as the head is relatively dense , and doesn’t develop the
early gas formation as thorax and abdomen .
• As stated before , temperature is the major detemainant or the rate
of decomposition .
Decomposition in buried bodies
• The rate of decay of bodies buried in earth is much slower than of
those in either air or water .
• The process of putrefaction may be arrested to a remarkable degree
in a certain conditions , allowing exhumation several years later to be
of a value .
• The speed and extent of decay in interred corpses depend on a
number of factors :
- If the body is buried soon after death.
- low temperature, exclusion of animal and insect predators , and
lack of oxygen are all important factors .
• Deep graves preserve the corpse better than the shallow ones seen in
some concealed homicides . ( colder , exclude air better , not directly
affected by rain .
• The nature of the soil in it’s drainage and aeration properties .
• The coffin .
Formation of adepocere
• Adepocere : a waxy substance derived from the body fat .
• The change of adipocere is partial and irregular and almost the whole
body may be affected .
• It’s caused by hydrolysis an hydrogenation of adipose tissue >>
formation of greasy and waxy material if of recent origin >> after
years it becomes brittle and chalky .
• Color >>> vary from white to grey or greenish green .
• Smell >>> earthy , cheesy ammoniacal .
• The formation of adepocere , as an alternative to total putrefaction ,
requires certain environmental conditions .
• it’s usually taught that moisture is necessary for the process , and it’s
undoubtedly a fact that most adipocere formation occurred in
immersed bodies , however numerous cases have formed adipocere
while being in dry ,concealed environment >>> in this case original
internal body water was sufficient for hydrolysis to proceed .
• The activity of anaerobes such as Clostridium prefringens assist in the
reaction which needs some warmth in the initial stages .
Thank you