Week 5

Week 5
Deaths due to Natural Causes
Death is usually considered “natural” if it wasn't caused by an external factor. Simply put,
a “natural” death is one that occurs due to an internal factor that causes the body to shut down,
such as cancer, heart disease or diabetes. It means there was no external reason for the death,
such as a traumatic injury (Alexander Fitzthum, MD., Pathologist, Assistant Professor, The Ohio
State Wexner Medical Center).
Course Learning Outcomes

CLO1: Determination of the time, cause, mechanism and manner of death.
CLO2: Basic knowledge of ballistics and gunshot wounds.
CLO3: Proficiency in the methods by which a detailed external examination of the deceased
should be carried out, to include methods of assessing the “postmortem interval”.
CLO4: Medical examination and detailed description and assessment of injuries and their
sequelae on both the living and deceased persons throughout the age spectrum, including
cases of abuse that would enable a full evaluation of such aspects of direct legal interest as
their method of infliction, possible causation, consequences and complications.
CLO5: Compilation of authoritative medico-legal reports to the relevant authorities, describing in
detail the findings and results of any examinations carried out and including a full and pertinent
commentary which provides balanced scientific opinion and conclusions.

According to the Philippine Statistic Authority,the top three causes of death in the
country from January to june 2021 were ischemic heart disease, cerebrovascular diseases and
neoplasms commonly known as cancer. Deaths due to diabetes mellitus ranked fourth. Despite
the deaths, from Covid 19 occupies the fifth rank followed by hypertensive diseases,
pneumonia, other heart diseases, chronic lower respiratory tract infection, genito-urinary tract
infection
Cardiovascular diseases, the five most common:
1. Heart attack or myocardial infarction - occurs when the heart muscle is cut off from the
oxygen it needs to function. The blood flow delivering the oxygen is significantly reduced
or stops entirely. This is due to atherosclerosis or the slow build up of plaque, which
includes fats, cholesterol and other substances in the coronary arteries. Blot clots can
form around the plaque, which can slow or block the blood flow.
2. Stroke is due to the problem of blood flow in the brain. Ischemic strokes account for 87%
of all strokes and occur because of blockage in the blood vessel that delivers blood and
oxygen to the brain. Without blood and oxygen, parts of the brain can suffer damage or
die off if not treated quickly. Hemorrhagic strokes may have various causes besides
blockages, such as vascular malformation or abnormal growth of brain blood vessels.
3. Congestive heart failure, the heart continues to pump blood but not high enough rate for
the body to continue to function. FAtigue and shortness of breath that can result from
untreated heart failure can interfere greatly with everyday activities like walking or
climbing stairs.
4. Arrhythmia is any abnormal rhythm of the heart: too fast, too slow, abnormal irregular
beat causing the heart to work ineffectively and not able to pump enough blood to deliver
oxygen and nutrients to the organs.
5. Heart valve compilations: stenosis mean the valves in the heart don’t open enough to
allow blood flow normally. Regurgitation when the valves don’t close correctly allowing
blood to leak.
Cerebrovascular diseases: A group of conditions that affect the blood flow and blood vessels
in the brain. Problems with blood flow may occur from blood vessel narrowing (stenosis), clot
formation (thrombosis), artery blockage (embolism) or blood vessel rupture (hemorrhage).
Cerebrovascular conditions include:
1. Aneurysm
2. Arteriovenous malformation (AVM)
3. Cerebral cavernous malformation (CVM)
4. Arteriovenous fistula (AVF)
5. Carotid-cavernous fistula
6. Carotid stenosis
7. TIA and Stroke
Malignant Neoplasms
Malignant tumors are cancerous, meaning their cells has sustained several abnormal changes
to their DNA. They begin invading neighboring cells, multiplying and dividing at a very fast and
out of control rate. Each time they copy themselves, they pass along their defects and cells
become more and more abnormal as time passes and they spread further.
The invasive nature of the malignant cells cause them to spread to nearby tissues and can also
spread by travelling through the bloodstream allowing them to form new malignant tumor in
completely different location, called secondary or metastatic cancer.
The most common cancers are:
1. breast
2. lung
3. colon and rectum
4. prostate
5. skin (non melanoma)
6. stomach
While many individuals have pre existing medical conditions that lead to their deaths,
there are still individuals who die unexpectedly from an undiagnosed medical condition or
disorder. To determine if death was to be the result of natural causes by inspecting the death
scene and examining the body during autopsy. If the forensic pathologist comes to the
conclusion that a death was the result of natural causes, his involvement in the autopsy typical
ceases as the medical examiner and the coroner can complete the autopsy on their own.
Sudden Natural Death
The term covers the following deaths from an internal (pathological) cause:
Sudden death - without any previous symptoms (“in complete well-being”), Unexpected death
after a short period of complains not regarded as threatening. Some authors suggest a third
category, namely, death following rapid deterioration of a known disorder not regarded as
serious.
When an individual dies without having presented any previous symptoms ( sudden death), the
medical examiner can determine neither the manner (natural/unnatural) nor the cause of death,
these cases has to be categorized as “manner of death undetermined” and can only be clarified
by performing an autopsy and further examination.
The following includes sudden natural death:
1. Cardiovascular Diseases - account for about 70-80% of sudden natural death. The
incidence in males continuous to be significantly higher than in females and common in
the fourth to sixth decades.
2. Coronary heart disease- Arteriosclerotic vascular changes may lead to acute coronary
occlusion either due to edematous swelling of an atheromatous plaque or by bleeding in
the intima or most import ant - by thrombotic material adhering to the inner surface of the
vascular wall. Sites of predilection are the great subepicardial vascular trunks (left
coronary artery with its anterior interventricular and circumflex branch, right coronary
artery), whereas embolic coronary occlusion is rare.
Stenosing coronary atherosclerosis can cause relative coronary insufficiency either alone or in
combination with cardiac hypertrophy and is able to trigger a fatal arrhythmia.
3. Non ischemic heart disease
Severe hypertrophy of the myocardium always involves the risk of acute cardiac death,
especially if the critical heart weight (500 g) has been surpassed, usually limited to the right
ventricle (cor pulmonale), unexpected and sudden death may occur.
The large group of cardiomyopathies (CMs) comprises non inflammatory myocardial diseases
not associated with any organic defect or hypertension in the systemic and pulmonary
circulation. They are of forensic significance because an acute arrhythmia may trigger sudden
cardiac death.
4. Aortic rupture
At autopsy, aortic ruptures often present as spontaneous laceration or dissection of the vascular
wall. Major risk factors are systemic hypertension, or a congenital weakness of the aortic wall as
seen in Marfan’s syndrome (cystic degeneration of the middle layer).
5. Pulmonary embolism
In clinical pathology, post operative pulmonary artery embolism and embolism associated with
clinically manifest leg and/or pelvic deep vein thrombosis are predominant. Forensic
pathologists see acute fatalities from pulmonary embolism also without any previous symptoms
of thrombosis in seemingly healthy persons who die during routine activities such as climbing
stairs.
This type of “spontaneous” thromboembolism is observed especially in older women; in pre
menopausal women, a potential relation with hormonal contraception has to be kept in mind.
Usually the deep veins of one or both legs still contain the residual thrombi.
Post traumatic pulmonary embolism is a sequel of the preceding injury, thus not classified as
natural death.
6. Disease of the Respiratory Tract
A considerable part of untreated pneumonia ending in sudden death concerns persons from
marginal social groups (homeless people and alcoholics). In persons living alone and found
dead in their flat.
Focal pneumonia (bronchopneumonia) diagnosed only at autopsy may occur as a consequence
of a preceding intoxication (alcohol, psychotropic drugs, narcotics and carbon monoxide);
toxicological analyses should therefore be mandatory especially in aspiration pneumonia.
Among the non infectious pulmonary diseases, bronchial asthma can cause unexpected death.
At autopsy, obstructive pulmonary emphysema and copious, viscous mucus in the deep
respiratory tract are found. Histologically, characteristic signs are mucous obstruction of the
bronchi, Curschmann’s spirals snd Charcot-leyden crystals.
Patients with central bronchial carcinoma may die unexpectedly due to erosion of a pulmonary
vessel with subsequent hemoptysis and blood aspiration.
7. Gastrointestinal diseases
Most esophageal varices develop due to portal hypertension, with liver cirrhosis. The
subepithelial veins at the lower end of the esophagus are most prone to rupture.
8. Diseases of the Central Nervous System
Massive cerebral hemorrhage is a dreaded complication of arterial hypertension. apart from
high blood pressure, regarded as the most important etiological factor, the following are causes
of bleeding: aneurysm, leukosis, hemorrhagic diathesis, angiomas and tumors.
9. Other causes of sudden death
Among the metabolic diseases, diabetes mellitus is of special forensic relevance (death in hypo-
or hyperglycemic coma).
In the presence of an (isthmic) tubal pregnancy, rupture of the fallopian tube may lead to
internal exsanguination within a very short time.
Eclampsia and amniotic fluid embolism are also associated with high maternal mortality.
10. Sudden Infant Death syndrome
Sudden infant deaths that occur within the first year of life during sleep or in association with
sleep.
According to the San Diego definition of SIDS, this diagnosis can only be made onlu of
“an infant under one year of age has died suddenly and unexpectedly, the onset of the fatal
episode was apparently associated with sleep, and thorough investigation of the case, including
performance of a complete autopsy and review of the circumstances of death and the clinical
history does not provide an explanation for the death.”

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Week 5

Deaths due to Natural Causes

Course Learning Outcomes

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