Virtual Cause of Death

-Dilemma Unabated

Dr. Shrabana Kumar Naik

Professor, Forensic Medicine,
Lady Hardinge Medical College,
New Delhi-110001
Email: naikshrabana@yahoo.co.in
Ph: 9891224143 (M)
 Abstract
Determination of cause of death is one of the most important aims and objectives
of medico-legal autopsy. However, even barring obscure autopsy and negative
autopsy, concluding the cause of death is not an easy task at all. There are certain
situations where the forensic pathologist cannot observe or demonstrate the
pathology behind the cause of death but only have to rely upon the virtual cause
of death based upon strong circumstantial history, improvable but undeniable
physiology, and exclusion of other causes of death in the absence or presence of
minimal pathological findings supporting the circumstantial history. However,
neither other forensic pathologists well versed with medical patho-physiology nor
the lay presiding officers in the court of law, especially in criminal cases show any
sympathy or restraint towards the hapless and helpless doctor in such situation.
On the other hand, it will be unethical on the part of forensic pathologist to
attribute the cause of death to non-existent but explainable one only to avoid
criticism in future. Thus the dilemma continues. This paper is an attempt to
highlight such problems faced by the doctors.

Keywords:Medico-legal autopsy; Cause of death; Obscure autopsy; Negative

autopsy; Virtual cause of death; Dilemma
 Introduction
Determination of cause of death is one of the
prime aims and objectives of medico-legal
autopsy.
Determination of cause of death is essential
for:
Legal reasons- Trial in case of homicidal cases
Ethical reasons- Medical negligence
Social reasons- Relatives of the deceased have
every right to know the cause of death/
Inheritance of property
Statistical reasons- To maintain death/ crime
record
Compensation- Insurance
 Introduction.....
However, determination of cause of death is not
an easy task at all.
Even, after thorough and meticulous necropsy
supported by chemical analysis of preserved
viscera, histo-pathological examination of
different tissues, microbial and biochemical
examination of body fluids may not indicate the
cause of death.
Thus negative autopsy and obscure autopsies are
not uncommon at all.
 Introduction.....

Barring negative and obscure autopsies, there

is another group where minimal or nil autopsy
findings against strong circumstantial findings
shake the thought of forensic pathologists.
With minimal or nil autopsy findings, neither
the circumstance of death can be denied nor it
can be proved to the satisfaction of court of
law or own colleague.
 Real or Virtual cause of death !
A.
Vaso-vagal shock (Reflex Cardiac Arrest)
Neurogenic shock/ Spinal shock
Anaphylactic shock
Diffuse Axonal Injury/ Concussion
Epilepsy
Bronchial Asthma
Cardiac arrhythmia/ fibrillation/ SA node block
SIDS
 Real Virtual cause of death !
B.
Adrenal haemorrhage
Suffocation from inert gases
Delayed recovery of drowning death
Snake bite- Cobra
Myocardial infarction
Agonal Regurgitation
Post-mortem discharge
Vaso-vagal shock (Reflex Cardiac Arrest)
Also known as vasovagal attack, vagal inhibition
nervous apoplexy, instantaneous physiological
death, primary neurogenic shock etc.
Situations:
Entry of cold water into ear or larynx as in hydrocution
or immersion syndrome.
Stimulation of carotid sheath, carotid sinus or carotid
body near carotid bifurcation at neck described in
hanging, ligature strangulation and throttling cases.
Strike over epigastrium, scrotum, larynx or genitals.
Surgical procedures like laryngoscopy, cathetrization,
tapping, introduction of instrument into vagina etc.
 Perception about Vaso-vagal shock

Many of famous authors/ forensic pathologists

agreed to death following Vagal inhibition
especially under:
Entry of cold water into ear or larynx, strike over
epigastrium as in hydrocution or immersion
syndrome or laryngeal spasm as in dry drowning.
Stimulation of carotid sheath, carotid sinus or
carotid body near carotid bifurcation at neck
described as in hanging, ligature strangulation and
throttling cases.
Even Caf coronary has been attributed to vagal
inhibition rather than choking.
 Perception about Vaso-vagal shock..

Thus perception about Death following Vagal

inhibition/vagal shock varies among forensic
pathologists, depending upon knowledge and
personal medico-legal work experiences.
 Perception about Vaso-vagal shock..

The present author came across one large review

article where death following Vagal inhibition due
to stimulation of carotid sheath/ carotid sinus/
carotid body at neck described as in hanging,
ligature strangulation and accidental throttling
cases across almost all the famous foreign text
books since the beginning of forensic medicine till
date has been ridiculed with detailed case
histories and discarded as nothing but pure
imagination, even to make their textbooks more
interesting and more sailable.
Vasovagal shock - My personal experience
Case No.1
Case history:
A 35 years male deceased was brought with strong
circumstantial allegation of death following homicidal
assault (a kick to epigastric region).
Autopsy findings:
Nothing in particular except contusion of size 4cm X
3cm in internal muscle over epigastric region.
OPINION:
Death was assigned to Reflex Cardiac Arrest following
homicidal blunt trauma to the epigastric region.
Vasovagal shock - My personal experience..

Case No.2
During routine fighting at my Karate school, I
kicked my opponent over xiphisternum, my
opponent just fell down unconscious for few
minutes.

Case No.3
During my class IV, one of close friend slapped
another classmate near his left ear. The victim fell
unconscious for few minutes.
 Neurogenic shock
Also regarded as synonymous with spinal shock by some
authors
Situations:
Described to be caused by trauma or injury to spinal cord
commonly noticed in RTA, blunt force to back of chest
Autopsy Findings:
Minimal spinal lesions detected in CT or MRI if available
before autopsy are rarely visible to naked eye examination
of the spinal cord during autopsy.
In the absence of prior investigations or fracture/
dislocation of vertebral column, spinal cord is very rarely
opened during autopsy.
 Neurogenic shock..
Some forensic pathologists perceived
Neurogenic shock to be caused by severe
pain resulting out of burn injury, fracture
of bone, multiple injuries.

However, it is known that pain causes

sympathetic stimulation (contrary to
vagal inhibition) raising pulse, BP and
respiration, therefore reactive cardio-
respiratory failure and death.
 Neurogenic shock..
Thus they conclude cause of death as:
Shock means any kind or mixture of any kinds
of shock

Shock & haemorrhage means Neurogenic

shock + Hypovolumic shock

Whereas, Haemorrhage & shock means

Hypovolumic shock due to loss of blood or
body fluid
 Anaphylactic shock
Situations:
Type I (anaphylactic, atopic reaction):
administration of antisera, drugs, stings
Type II (cytotoxic):
Transfusion reaction, drug induced reactions
Type III (immune-complex):
Injection of anti-tetanic serum
Type IV (delayed type):
tuberculin reaction, transplant rejection
 Anaphylactic shock
Autopsy findings:
Clinical history of laryngeal edema and
hypotension may be found in the inquest.
However, laryngeal edema-the typical autopsy
finding is rarely noticeable after long post-mortem
interval.
Estimation of serum tryptase from post-mortem
blood may not truly indicate anaphylactic
reaction.
 Anaphylactic shock- My personal experience

I had conducted 3 autopsies where there were

histories of death following soon after
administration of penicillin and chloroquine
injections. During autopsies, laryngeal odema
was not found in two cases. However, injection
marks were evident in all those cases.

As a member of National AEFI committee, I have

noticed many deaths due to anaphylactic shock
during causality assessment of immunization
deaths.
 Death due to Diffuse Axonal Injury/Epilepsy/
Bronchial Asthma/Cardiac arrhythmia/ SIDS

History of these disease may be found from

the relatives.
Even, previous medical prescriptions about
these diseases may be found on some
occasions.
However, all will agree that autopsy findings
suggesting the cause of death are almost nil in
those cases.
 Problems associated with Virtual
Causes of Death
A. Problems with forensic Pathologist:
Autopsy findings are not conclusive.
There is absence or minimal autopsy findings/ No
apparent pathology or trauma/ Negative visceral
chemical analysis report/ Negative histopathological
and microbial findings
There may be strong circumstantial history suggesting
cause/ manner/ mode of death or events prior to
death
In the absence of any circumstantial history, cause of
death may be put under negative or obscure autopsy.
 Problems....
However, strong circumstantial history
supported by eye witness may not be ignored
The physiological mechanisms behind such
death in the absence of any evidentiary
pathological changes cannot be denied.
Cause of death ( virtual cause of death) is
opined on the basis of exclusion rather than
inclusion of any substantial autopsy findings
 Problems......
Dilemma to opine the cause of death based upon
circumstantial history (rather than based upon
autopsy findings) or put under obscure or
negative autopsy
Fear of criticism of incompetence from own
colleague and court of law
Fear of degradation of reputation
Conflicting documentations about such deaths in
Forensic Medicine texts- No clarity among
Forensic Medicine fraternity
 Problems......
Such deaths are not so common. Thus proper
knowledge, skill and experience can only give
confidence to assign virtual cause of death
In natural deaths or when no foul play is
forthcoming, it is relatively easy to assign virtual
cause of death. However, in alleged homicidal
deaths, the dilemma crosses all boundaries.
Public hue and cry in certain such deaths can put
additional pressure in the mind of forensic
pathologist
 Problems........
It is unethical to opine the cause of death to a
real one that is not existed in dead body , only
just to avoid criticisms
Visceral chemical analysis is usually conducted
too late, hence cannot be relied completely
for exclusion of poisoning
Other essential ancillary investigations like
histo-pathological, microbial and biochemical
examinations are rarely conducted due to:
 Problems........
Forensic medicine experts are not trained in this
aspects.
Infrastructures and facilities are rarely available
nearby except for few govt. medical institutions in
India.
Even if facilities are available in few govt. medical
institutions, their faculty are too reluctant to take-
up medico-legal cases due to fear psychosis for
court appearance
 Problems........
In the absence of all the essential ancillary
investigations for complete autopsy, it is
almost an impossible task to rule out any
undiagnosed pathology, poisoning or disease
with conviction to opine virtual cause of death
 Problems associated with Virtual
Causes of Death
B. Problems with Investigating Police agency:

Further investigation regarding circumstance/ crime

may be hampered either due to lack of interest or
due to total reliance upon the preliminary
circumstantial history.

In alleged murder case, it is very difficult to link the

chain of events, witnesses, weapon of offence and
trace evidences at scene of death.
 Problems associated with Virtual
Causes of Death
C. Problem with court of Law:
Appreciation of virtual cause of death can vary
among different courts of law, depending upon
degrees of medical knowledge and experience
among presiding officers
As there is always an possibility of doubt about
virtual cause of death, the judgement can vary
among courts of law as evident in many cases-
ranging from acquittal to conviction
 Problems.......
It is very difficult to convince all the three-
public prosecutor, defence lawyer and
presiding officer regarding virtual cause of
death in the absence of any supporting
autopsy findings
Again it is very difficult to prove the intention
of the alleged accused in all such cases.
 Conclusion

Thus the dilemma regarding virtual

cause of death remains unabated !