Morphological Characteristics of Different Rates of Dying

Цель исследования: научное обоснование и разработка доступных морфологических критериев, позволяющих устанавливать длительность умирания и темп наступления смерти. Материалы и методы. Материал основного исследования — 206 выявленных случаев смерти у лиц с различным заранее известным процессом умирания, что и являлось критерием отбора из 1500 случаев смерти (n=206, 14%). Из них в рамках судебно-медицинской экспертизы — 110 случаев наблюдений, судебно-медицинского исследования трупа — 79 случаев и в рамках патологоанатомического вскрытия — 17 случаев. Объем выработки исходного материала составил от 30 до 57 случаев наблюдения в 5 группах. Для первого временного интервала было отобрано — 53 случая наблюдений, для второго — 30 наблюдений, для третьего — 32 наблюдения, для четвертого — 34 наблюдения и для пятого — 57 наблюдений. При исследовании материала применяли следующие методы: анализ сведений об обстоятельствах наступления смерти (по материалам дела), ретроспективный клинико-анатомический анализ, основной (классический) метод вскрытия трупов людей при секционных исследованиях и гистологическое исследование. Дополнительно применяли ИГХисследование, а также морфометрический, макроскопический и фотографический методы. Для точности и надежности полученных результатов исследования использовали морфолого-статистический анализ, который включал в себя как статистический анализ морфологических признаков, так и танатогенетический анализ случаев отобранного материала. Результаты исследования. Разработали и научно обосновали методику установления 5-и темпов умирания по морфологическим признакам, систематизированным в морфологические комплексы: молниеносный темп 15—30 мин; быстрый темп >30 мин — 2 ч; средний темп >2 — 6 ч; медленный темп >6 — 12 ч; длительный темп >12 ч. Апробация предложенного метода на валовом экспериментальном материале позволила для каждого морфологического комплекса установить диагностический предел суммарной значимости и, таким образом, усовершенствовать методику установления темпа умирания по морфологическим признакам для судебно-медицинской практики. Заключение. Установленные в данной работе морфологические комплексы темпа наступления смерти послужат дальнейшему развитию не только судебно-медицинской танатологии, но и совершенствованию лечебно-профилактической помощи.

phometric, macroscopic and photographic methods were used. For the accuracy and reliability of the findings, morphological and statistical analysis was used, which included both statistical analysis of morphological characteristics and tanatogenetic analysis of the cases of the sampled material.
Study results. We developed and scientifically proved a methodology for determining 5 rates of dying according to the morphological characteristics systematized in morphological complexes: fulminant rate 15-30 min; fast rate >30 min -2 h; moderate rate >2 -6 h; slow rate >6 -12 h; lingering rate >12 h. Approbation of the proposed method on the gross experimental material allowed to set the diagnostic limit of the total significance for each morphological complex, and thereby, to improve the methodology of establishing the rate of dying in accordance to the morphological characteristics for the use in forensic practice.
Conclusion. The morphological complexes of the rate of dying established in this work would serve as a base for further development of not only forensic thanatology, but also for the aim of improving the medical and preventive care.

Introduction
The determination of the life expectancy in different types of violent and non-violent death provides substantial assistance to the judicial and investigative authorities in establishing the truth in the investigation of crimes.
The determination of the duration of dying, as well as the associated rate of dying based on morphological characteristics is one of the oldest and most complex problems of forensic thanatology, which has not yet received a satisfactory solution. The rate of dying depends on a number of subjective and objective reasons that can accelerate or slow it down and thus affect not only the duration of the dying process, but also the thanatogenesis as a whole. The understanding of processes occurring in the dying organism is associated with the timeliness, intensity and purposefulness of measures aimed at resuscitation [1]. First of all, it is important to objectify the process of dying in relation to timing to assess the timeliness and completeness of the treatment adequately. In this regard, the study of the duration of dying and the rate of dying according to the morphological characteristics during thanatogenetic analysis at various causes of violent and nonviolent death, taking into account the influence of external and internal factors, might contribute to further development of not only forensic thanatology, but also to improving preventive and medical care [2][3][4][5].
It should also be noted that the determination of the duration and rate of dying is an important part of thanatogenetic analysis while assessing lethal cases at clinical-anatomical conferences in the process of differential diagnosis, for example: between acute massive blood loss and acute anemia, sudden and unexpected death (SD and UD, respectively), etc. The duration of the interval between the heart attack and the moment of death makes it possible to distinguish rapid death in the UD group (SD within 60 minutes) and UD with the duration of the disease manifestation for up to 1 day [7,8]. And it is no accident that the formula of the specialty, i.e. forensic medicine (code of specialty: 14.03.05), contains the study of the causes and thanatogenesis of sudden death, improvement of methods of its diagnosis and prevention as one of the items of its principle areas of research [9]. All this objectively indicates the relevance of such a study and necessitated further study of the morphological changes in the process of dying with time in different types of violent and non-violent death, in order to improve methods of diagnosis of the rate of dying in forensic practice, as well as in addressing public health issues. In this connection, the team of authors of the Russian Center of Forensic Medicine under the Ministry of Health of the Russian Federation has been studying the problem of establishing the rate of dying and the duration of dying according to morphological data for several years [10,11]. The introduction of molecular biology methods in the study of the terminal state morphology is urgent [12,13], especially in view of the efforts of clinicians to predict the outcome of resuscitation [14,15].
The purpose of the study was to accumulate scientific evidence and develop accessible morphological criteria that allow to determine the duration of dying and the rate of dying.
The following methods were used to study the material: analysis of information about the circumstances of death (based on the case records), retrospective clinical and anatomical analysis, the main (classical) method of autopsy of human corpses in sectional studies, histological study, as well as immunohistochemical study, according to our data on the expression of fibrinogen in the lungs (table 2), contributing to the resolution of the problem of establishing the rate and duration of dying. In addition, morphometric, macroscopic and photographic methods were used. In one case of death from fulminant sepsis, the method of PCR (polymerase chain reaction) was applied for the first time to study the autopsy material.
For the accuracy and reliability of the findings, morphological and statistical analysis was used, which included both statistical analysis of morphological characteristics and thanatogenetic analysis of the cases of the sampled material [16,17]. The thanatogenetic (semi-quantitative) analysis [16] allowed to make a judgment about the immediate cause of death and the rate of dying, as well as to formulate clinical and anatomical epicrisis as a necessary component for morphological and statistical analysis (table. 1). During the statistical analysis, we calculated the average scores and their errors, the mean square deviations, confidence intervals, and conducted a correlation analysis of these morphological characteristics. The significance was assessed according to the t-test. Differences were considered significant, if p was 95% or more (p<0.05-0.01). Data processing was carried out using the licensed version of the SAS (Statistical Analysis System) application package and standard mathematical tables «Microsoft Excel».

Results and Discussion
Based on the analysis of the findings, 34 non-specific morphological features (criteria) with a high frequency of occurrence were determined (table 2). In group 1 (n=53), the analysis of violent and non-violent deaths identified 12 morphological features. In groups 2 and 3 (n=30 and n=32, respectively) 6 morphological features were identified. In groups 4 and 5 (n=34 and n=57, respectively), 5 morphological features were identified.
На основании морфолого-статистического анализа морфологических признаков в случаях смерти лиц с заранее известным процессом умирания подтвердили ранее установленные и выделили новые (всего 34) информативные неспецифические perience, which adversely affects the probative value of the conclusions or judgments. To improve this method of forensic practice, a table was developed that allows establishing five variants of the rate of dying in 5 morphological complexes with a description of morphological features and the diagnostic limit of their total significance (table 2). The diagnostic limit of total significance for each morphological complex was established during the approbation of the proposed method on the gross expert material. For the first complex, the diagnostic limit of the total significance of morphological features is -1.21; for the second complex it is -0.82; for the third one it is -0.66; for the fourth one -0.39 and the fifth one it is -2.1. This table is a reference material for the evaluation of the total diagnostic significance of the identified features of the duration and rate of dying in forensic practice.
Therefore, morphological complexes of the rate of dying were established in our work. The data obtained can be estimated from several points of view. First, they have practical forensic value, because they allow answering the questions of investigative authorities more accurately and reasonably about the experience of trauma, the ability of mortally wounded to active targeted actions, etc. Secondly, the morphological equivalent of thanatogenesis in a temporary relation is important for understanding of general pathological processes. While its clinical parallels have been described long ago [18,19], the morphological characteristics has not been studied enough so far. Third, the significance of this work lies in the possibility of analyzing the general biological pattern of destruction of such a complex homeostatic system as the human body in the time scale. In particular, the brilliant generalization of academician Sarkisov D. S. on the time gradation of the destruction of functional system sublevels of the body in the process of thanatogenesis was confirmed [19]. Finally, our work has some philosophical significance in terms of demonstrating the laws of destruction of hierarchically arranged functional systems. The concept of such systems has been used in medicine since the time of academician Anokhin P. K., but their destruction has not drawn close attention of pathologists and forensic doctors [20]. In particular, it is shown that the earliest changes occur in the homeostatically ancient systems of hemocirculation, however, their decay occurs, on the contrary, last of all, while the substrate of higher nervous activity is irreversibly destroyed first.

Conclusion
The results of the study of morphological changes in the basic homeostatic systems of the human body in different categories and types of death allow diagnosing the rate of dying with agonal period up to 12 hours in the form of five time intervals.
On the basis of morphological and statistical analysis of morphological features in cases of deaths w w w . r e a n i m a Мониторинг и исход критических состояний морфологические признаки (критерии) с высокой частотой встречаемости.
with a pre-known process of dying, we confirmed previously established informative nonspecific morphological features (criteria) and identified new ones (in total, 34) with a high frequency of occurrence.
Using morphological and mathematical modeling of pathological processes of dying, abstracting from the main cause of death on a relatively intact background of observation, we developed and scientifically justified the procedure [21] for identification of 5 rates of dying based on morphological features systematized in the complexes: 1) fulminant rate with the agonal period of 15-30 min; 2) fast rate with the agonal period of >30 min -2 h; 3) moderate rate with the agonal period of >2 -6 h; 4) slow rate with the agonal period of >6 -12 h; 5) lingering rate with the agonal period of >12 h.