12/2/2016 PostmortemChanges:Overview,Definitions,SceneFindings

PostmortemChanges
Updated:Oct13,2015
Author:SErinPresnell,MDChiefEditor:JScottDenton,MDmore...

OVERVIEW

Overview
Afterdeath,asequenceofchangesnaturallyoccursinthehumanbody.Althoughthesechanges
proceedinarelativelyorderlyfashion,avarietyofexternalfactorsandintrinsiccharacteristicsmay
accelerateorretarddecomposition.Understandingcommonpostmortemchangesandthevariables
thataffectthemallowstheforensicpathologisttomoreaccuratelyestimatethepostmorteminterval
(PMI)andtoprovideatimeframeduringwhichdeathoccurred.Further,anawarenessofcommon
postmortemartifactslimitstheriskofmisdiagnosisatthetimeofautopsy.

History
Deathandthechangesthatfollowhavebeeningrainedinsocietysincethedawnofhistory.Ancient
Egyptianstookextraordinarymeasurestoslowdecomposition,withsomegoodresults.Later
societiesrecognizedtheneedtosequesterthedeadfromthelivingtocontainthespreadofdisease.
Inmoderntimes,bereavedfamiliesmustchoosebetweencremationandembalmmentfortheirdearly
departed.Deathisapartoflife,anddecompositionisapartofdeath.

Epidemiology

Allbodiesundergosomedegreeofpostmortemchangeafterdeath.Changebeginsatthemolecular
levelandsequentiallyprogressestomicroscopicandgrossmorphology.

Overviewoftheentity
Postmortemchangesbeginsoonafterdeathandprogressalongatimeline.Twoprocesses,
putrefactionandautolysis,begintoalterthebodyeitheronemaypredominate,dependingonthe
circumstancessurroundingdeath,aswellastheclimate.Putrefactioninvolvestheactionofbacteria
onthetissuesofthebody.Thisprocess,prevalentinmoistclimates,isassociatedwithgreen
discolorationofthebodygasproductionwithassociatedbloatingskinslippageandafoulodor.

Autolysisisthebreakdownofthebodybyendogenoussubstances.Itproceedsmostrapidlyinorgans
suchasthepancreasandstomach.Itmaypredominateinmorearidconditionsandcaneventually
resultinmummification.

Inmostcircumstances,autolysisandputrefactionoccurintandem.Intemperateclimaticconditions,
theycanresultinrapiddegradationofthetissues.Thesealterationsmayeventuallyproducegreat
distortionofthebodyafterdeath,hamperingtheinterpretationofthepostmortemfindingsbutnot
amelioratingthevalueoftheautopsy.

Someofthemorewellknownpostmortemchanges,suchasrigormortis,livormortis,andalgor
mortis,progressonarelativelysetschedulehowever,manyexternalandintrinsicfactorsmayaffect
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theirdevelopment.Itshouldberememberedthattheestimatedperiodforthearrivalandpassageof
thesemanifestationsofthedecompositionprocessisbasedonstudiesunderverycontrolled
conditions,includingatemperateclimate(ie,75F).[1]

Inreality,manydeathsoccuroutsideoftheseidealsettings,andadditionalconfoundingvariables
maybepresent(eg,layeredclothing,obesity,fever).Further,thelongerthePMI,thelessaccuratethe
PMIestimatebecomes.

Indicationsfortheprocedure
Postmortemchangesmaypartiallyobscureantemortemtraumaanddiseaseormimictheirpresence.
Itisessentialthatthepathologistrecognizethesefindingsforwhattheyare.Despitethedegradation
thebodyundergoesduringthepostmortemperiod,acompleteautopsyofadecomposingbodyoften
yieldsabundantinformation.

Althoughthereisquitealotofvariabilityinthetimescheduleofcommonpostmortemchanges,all
bodieseventuallydecomposetosomedegree.Thephysicalandbiochemicalalterations,when
consideredinconcertwithathoroughmedicolegaldeathinvestigation,mayallowonetoestimatethe
PMI.Estimationofthetimeofdeathisacriticalcomponentofforensicdeathinvestigations,butitisan
imperfectscience.Unlessadeathiswitnessed,itisusuallypossibletoprovideonlyatimewindow
duringwhichdeathcouldhaveoccurred.

Definitions
Rigormortisisthepostmortemstiffeningofthebodysmuscles.Itmayormaynotinvolvesome
degreeofactualshorteningofthemuscles.Inmostcases,rigormortisbeginswithin12hoursafter
deathitbeginstopassafter24hours(seetheimagebelow).

Thedecedentshowspersistentrigormortiswiththerightarmdefyinggravity.Thebodymusthavebeenin
anotherpositionforseveralhoursafterdeathbeforebeingplacedinasupineposition.
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Livormortisisthepurpleredcolorationthatappearsondependentportionsofthebodyotherthan
areasexposedtopressureaftertheheartceasestobeat.Itresultsfromthesettlingoftheblood
undertheforceofgravity(seetheimagebelow).

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Livormortisontheposterioraspectsofthebodyiscausedbysettlingofthebloodbecauseofgravitywhenthe
bodyisinasupineposition.
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Tardieuspotsarepetechiaeandpurpurichemorrhagesthatdevelopinareasofdependency
secondarytotheruptureofdegeneratingvesselsundertheinfluenceofincreasedpressurefrom
gravity(seethefollowing2images).

Asthepostmortemintervallengthens,Tardieuspotsdevelopinareasoflividity,suchasthisindividual'sshoulder
area,asdecomposingcapillariesrupture.
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Tardieuspotsontheabdomen.

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Algormortisistheprocessbywhichthebodycoolsafterdeath.Coolingtakesplaceonlyifthe
ambienttemperatureiscoolerthanthebodytemperatureatthetimeofdeath.

Tachenoireisthedark,redbrownstripethatdevelopshorizontallyacrosstheeyeswhentheeyelids
arenotclosedafterdeath.Itisadryingartifactthatmaymimictrauma(seetheimagebelow).

Tachenoiredevelopswhentheeyelidsarenotcompletelyshutandpostmortemdryingoccurs.
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Purgefluidisdecompositionfluidthatmayexudefromtheoralandnasalpassagesaswellasother
bodycavities(seetheimagebelow).

Postmortempurgefluidexudesfromtheoralandnasalpassagesnotraumaticinjurieswereuncoveredat
autopsy.
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Decompositionisthepostmortemprocessofendogenousautolysisandputrefactionfromexternal
andprimarilyinternalbacterialsources(seetheimagebelow).

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Decompositionisaprocessofautolysisandputrefaction.
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Macerationisanautolyticpostmortemprocessthatoccursinintrauterinedeaths.Itiscausedby
endogenousenzymesputrefactivebacteriaarenotafactor(seetheimagebelow).

Macerationafterretentionofanintrauterinefetaldeath.
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Postmortemintervalisthetimesincedeath.

SceneFindings
Findingsatasceneareextraordinarilyhelpfulintheassessmentofpostmortemchanges.The
environment,inparticularthetemperature,influencestherateofdecompositionhighertemperatures
hastentheprocess.Itshouldberememberedthattheremaybeavarietyofmicroclimateswithinthe
samelocalethatcaninfluencepostmortemchanges(eg,thebodymayhavelainbelowanair
conditioningvent).Whenestimatingthetimeofdeath,thegrossfindingsmustbecorrelatedwiththe
prevailingenvironmentalfactors.Theinfluenceoflocalfaunamustalsobeconsidered.Thepresence
ofinsectsorsignsofanimalactivitynearthebodymaybecorrelatedwithtissuedefectsresultingfrom
postmortemcarnivorousfeeding.

Rigormortismaydevelopveryrapidlyifthebodyisacidoticatthetimeofdeath.Signsofastruggle
mayexplainacceleratedrigormortis,becauserigormortisisrelatedtoadropinpHwithinmyocytes.

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Insomecases,rigormortisorlivormortismayappearinpatternsinconsistentwiththeeffectofgravity
atthescene.Thisindicatesthatthebodywasmoved(eitherbyearlyrespondersorsomeoneelse)
beforetheinvestigatorassessedthebody.Itmayindicatethatthebodyhasbeentransportedfrom
anothercrimescene.

Circumstantialtimemarkersmayassistinnarrowingthepostmorteminterval.Forexample,thedate
oftheoldestnewspaperonthefrontdoorstepmayindicatethatthedecedentdiedbeforethedelivery
ofthatnewspaper(providedthepersonregularlypickedupthenewspaper).Apersonfounddead
wearingpajamasinthekitchenwithabowlofcerealonthetablesuggeststhatdeathoccurredinthe
morning.Anautomatedtellermachine(ATM)receiptfoundintheclothingofadecomposingbody
suggeststoinvestigatorsthatthedecedentwasaliveatthetimeanddatethatappearsonthereceipt.
Similarly,thetimeanddatethatafinalemailortextmessagewassentmaybehelpfulinassistingin
theestimationofthePMI.

TraceEvidence
Advancedpostmortemchangesmayobscureordestroysometraceevidence.Hairsandfibersmay
belostastheupperlayersofskinslough.Thepresenceofsootorstipplingaroundagunshotwound
mayalsobedifficulttoassessonsloughed,discoloredskin.DuringtheearlyPMI,however,valuable
traceevidencemaypersist,includingthepresenceofspermandprostaticacidphosphataseinsexual
assaultcases,althoughsuchevidencedoesdegradewithtime.[2]

GrossExaminationandFindings
Rigormortisdevelopsasthebodysenergysource(adenosinetriphosphate[ATP])isdepleted.
MusclefibersrequireATPforrelaxationoncedepleted,actinandmyosinproteinsremaincomplexed,
resultinginstiffeningofthemuscles.Rigormortisisthoughttodevelopinallmusclessimultaneously
however,itismostevidentfirstinthesmallermusclegroups,suchasthejaw,afterwhichrigormortis
typicallyoccursintheupperextremitiesandthenthelowerextremities,asinthefollowingimage.

Thedecedentshowspersistentrigormortiswiththerightarmdefyinggravity.Thebodymusthavebeenin
anotherpositionforseveralhoursafterdeathbeforebeingplacedinasupineposition.
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Rigoraffectsbothsmoothandskeletalmuscles,includingthemyocardium(simulatinghypertrophy),
hairfollicles(resultingincutaneous"goosebumps")(seetheimagebelow),andseminalvesicles
(resultinginpostmortemsemenreleasefromthepenilemeatus).

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Rigormortisoftheerectorpilaecanresultinpostmortem"gooseflesh."
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Rigormortisfirstappearsapproximately12hoursafterdeath.Progressivestiffeningoccursfor
approximately12hours,persistsforapproximately12hours,thendiminishesoverthenext12hours
astissuesbreakdownasaresultofautolysisandputrefaction.

Rigormortismaybeusedtodeducethepositionofthedecedentifthebodyhasbeenmovedafterthe
developmentofrigormortis.Ifrigormortisisbrokenbymanipulationbeforebecomingfullyfixed,it
mayreforminthenewposition.

Theestimationofthestrengthofrigormortisisoftenratedonascaleof04andishighlysubjective.

Cadavericspasmisanuncommonanddisputedformofrigorthatdevelopsimmediatelyupondeath,
usuallyafterstrenuousactivity.Onetheoreticalexamplewouldbeadrowningvictimshandclutched
aroundaswatchofgrassgrowingonthewatersedge.Insuchcases,itispresumedthatthe
decedentwasinprofoundlacticacidosisatthetimeofdeathasaresultofviolentstruggleandwent
intorigormortisimmediately.

Livormortisusuallyappears30minutesto2hoursafterdeath,thoughitmayappearsoonerin
casesofsevereheartfailureinwhichtheantemortemcirculationwassluggish.AfteraPMIof812
hours,redcellsextravasatefromthevesselsintothesurroundingsofttissue.Untilthattime,the
applicationofpressuretoanareaoflivorwillresultinblanchingoftheskin(asdepictedintheimage
below).

Pressureonunfixedlivorresultsinblanchingofthecoloration.

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Afterthatperiod,livormayblanchwithforcefulpressurebutwilleventuallynotblanch,atwhichtimeit
isconsideredfixed.Movementofabodybeforethecompletefixationoflivorwillresultinthe
redistributionoflividityintothenewlydependentareasofthebody.Ifthereispartialfixationofthelivor
atthetimethebodyismoved,itistobeexpectedthattheoriginalpatternofdistributionofresidual
livorwouldremain,asshowninthefollowingimage.

Livormortisinananteriorposition.Theareaofblanchingacrossthechestandabdomenresultedfromthe
decedentlyingontopofhisleftarmandrighthand.
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Livormortisalsoaffectstheorgansitisoftenmostappreciatedinthelungs,whichappearcongested
independentareas(seethefollowingimage).Inappearance,livormaydiffermarkedlyfromcaseto
case.Itmaybedifficulttodiscernlividityindarklypigmentedindividualsandincasesinwhichnear
exsanguinationhasoccurred.

Thelungisdarkpurpleintheposteriordependentareasasaresultoflivormortis.Thismaysimulatecongestion.
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Livorhasbecomeparticularlyimportantindeterminingthepostmortempositionofinfants(eg,prone
sleepingposition)whenfirstrespondershavemovedthedecedentbeforethearrivalofagency
investigators.Asbreakdownoftissues,includingthevasculature,progresses,redcellextravasation

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intothesofttissuesmayactuallysimulateantemortemhemorrhage,asdemonstratedintheimage
below.Differentiationismadeinthecontextofthelocationandpatternofthediscolorationandthe
eventssurroundingthedeath.Insomecases,itmaynotbepossibletodifferentiateantemortem
traumafrompostmortemartifactualeffects.

Decompositionhasprogressedinthisindividualwithbreakdownofbloodvesselsandextravasationofredblood
cellsintothesubcutaneousandadiposetissuesoftheabdomen,simulatingantemortemhemorrhage.Therewere
noassociatedcutaneousorbonyinjuries,andthescenewasinnocuous.
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Tardieuspotsdevelopinareasofdependency,hence,inareasoflivor.Theyoccursecondarytothe
ruptureofvesselsundertheinfluenceofincreasedpressurefromgravityinconjunctionwithvascular
breakdown(seethefollowing2images).Classically,theyareseenincasesinvolvinghangingsthey
appearonthelowerlegsofindividualswhohavebeenfullysuspended,althoughtheymaybeseenin
anyareaofdependency.

Asthepostmortemintervallengthens,Tardieuspotsdevelopinareasoflividity,suchasthisindividual'sshoulder
area,asdecomposingcapillariesrupture.
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Tardieuspotsontheabdomen.
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Tardieuspotsmaybeconfusedwithpremortempetechiaeorpurpurichemorrhages.Ananalogous
processmayoccurintheconjunctivaandsclera,asissometimesseenincasesinwhichaperson
diesinapositioninwhichtheheadhangsdownwardoffofabed.Inthesecases,theconjunctivaand
scleraareinjected,andhemorrhagemaybecomeconfluentnevertheless,attentionshouldstillbe
paidtoantemortemcausesofocularhemorrhages.

Algormortisistheprocessbywhichthebodycoolsasheatproductionceasesandbodyheatislost
totheenvironment.Bodiesinwhichtheratioofthesurfaceareatobodymassislargecoolmore
quickly(eg,bodiesofthinpeopleandinfantscoolmorequicklythanbodiesofobesepersons).

Thereareseveralformulasforestimatingtherateofpostmortemcoolinghowever,withallthese
formulas,itisassumedthatdeathoccursintemperateconditionsandthatthedecedenthadnormal
antemortembodytemperature(ie,theantecedentbodytemperatureactuallyvariesfrom93.74
100.04F,asdeterminedrectally).[3]

Theseformulastendtogiveasenseofscientificaccuracytotheexaminationandcanbemisleading.
Ageneralruleofthumbisthatthebodylosesheatatanaverageof1.52Fduringthefirst12hours
afterdeath.[4]However,therateofcoolingisdramaticallyaffectedbythecircumstancesofdeath,
mostsignificantly,bytheenvironmentalandbodytemperatures.Abodywillonlycooltothe
environmentaltemperatureabodylyingin105Fduringthesummerwouldnotbeexpectedtocool
atallinfact,insuchcircumstances,thebodystemperaturewouldincrease.

Othersignificantfactorsaffectingalgormortisincludethebodylocation(eg,shadeversussun),
clothing,andthehabitusofthedecedent.Acoldtilefloorwouldpromotebodycoolingasaresultof
conduction.Obeseindividualsandheavilyclothedindividualswouldbeexpectedtoloseheatmore
slowly.

Purgefluidisfoulsmelling,redbrownfluidthatmayexudefromtheoralandnasalpassagesas
decompositionprogresses,asdepictedintheimagebelow.Itoftenflowsafterpressureisexertedon
thebody,eitherfromthepresenceofgasesthatresultfrominternaldecompositionorfollowing
manipulationofthebody.Purgefluidmaysimulateantemortemhemorrhage,butnotraumaticinjuries
willbedetectedatautopsy.

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Postmortempurgefluidexudesfromtheoralandnasalpassagesnotraumaticinjurieswereuncoveredat
autopsy.
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Tachenoireishorizontaldarkeningoftheexposedsclerathatoccurssecondarytodryingwhenthe
eyelidsareleftpartiallyopenedafterdeath.Thecharacteristiclocationalongthepartedeyelidsis
instrumentalininterpretingthisfinding(seetheimagebelow).

Tachenoiredevelopswhentheeyelidsarenotcompletelyshutandpostmortemdryingoccurs.
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Othermucusmembranes,suchasthelipsandtongue,mayalsodarkenandappearhemorrhagic
whendried.Incisionsintotheunderlyingtissuewillrevealnohemorrhage(seethefollowingimage).

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Postmortemdryingofthetongueandmucosalmembranesdarkensthetissues,impartingapseudohemorrhagic
appearance.
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Gastricemptyingreferstotheprocessofdigestionafterconsumptionofameal.Dependingonthe
sizeandcompositionofthemeal,emptyingofthestomachmayoccuroveraperiodofto6hours
or,insomecases,muchlonger.Stressmaydelaynormaldigestion.Thepresenceofstomach
contentsmaybemosthelpfulifthecontentsarerecognizableandifitisknownwhenthedecedent
consumedthatparticularmeal.ItisnotareliableindicatorofthePMI.

Decompositionisaprocessofendogenousautolysisandputrefaction,primarilyfromintestinal
microorganisms.Thebacterialfloradisseminates,owingtothefactthatthebodynolongerhasa
functionalimmunesystem.Theabdomendevelopsagreendiscolorationafter2436hours,usuallyin
therightlowerquadrantfirst(thelocationofthemicrobeladencecum).Anexampleofthisisbelow.

Earlydecompositionalchangesaremanifestedbygreendiscolorationovertheabdomen.

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Marblingmaydevelopwiththedelineationofthevasculatureasaresultofthereactionofhydrogen
sulfideproducedbybacteriawithhemoglobinfromthelysisoferythrocytes,asshownbelow.Bloating
ofthebodyoccursasaresultofbacterialgasproductioninintemperateconditions,bloatingoccurs
overaperiodof23days.Bloatingcausesdistortionofboththebodyandface.

Marblingoutlinesthevasculatureinthisdecedentasthepostmortemintervallengthens.
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Gas(eg,hydrogensulfide,methane)formsintheorgansandsubcutaneoustissuesaswellasthe
bodycavities.Epidermalvesicleformationandskinslippageoccurastheepidermisseparatesfrom
theunderlyingdermis.Thebodybecomesdiffuselydiscoloredgreenblack,oftenobscuringtherace
ofthedecedent(seethefollowingimage).

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Decompositionadvanceswithgreendiscolorationoftheskin,generalizedbloating(beginningintheabdomen),
andvesicleformationwithsubsequentskinslippage.
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Deglovingoftheskinofthepalmsandsolestypicallyoccursduringdecomposition,aswellasin
casesinvolvingthermalexposure(ie,fires)andimmersions(seethefollowingexample).

Postmortemdeglovingofthehand.
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Theepidermiscommonlyretainsenoughridgedetailtoallowfingerprintstobeobtained,which
assistsintheidentificationofthedecedent,asdemonstratedbelow.

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Alawenforcementofficialutilizesthedeglovedfingerstoobtainfingerprints.
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Internally,organsdisintegrateatdifferentrates.Thepancreas,adrenalglands,andgastrointestinal
mucosashowmarkedautolysisearlyinthePMI(seethefollowingimages).Indeed,withitsdigestive
enzymes,thepancreasmayshowearlybreakdownofitsvasculaturetotheinexperiencedexaminer,
seepageofredbloodcellsmaymimichemorrhagicpancreatitis.

Viewofcollapsed,decomposingorgansinthechestcavitywithmaggotspresentandgaseousdistentionofthe
intestines.
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Theuterusandprostateresistdecompositionthelongest,owingtotheamountoffibromusculartissue
intheseorgans.

Thebrainturnsapinkgraycolorandundergoesliquefactionoveraperiodofweeks.Fatmayalso
liquefy,asseeninthefollowingimage.Small,whitecalciumsoapgranulesmaydeveloponthe
epicardialandendocardialsurfacesoftheheart,andtheintimaofthevasculatureturnsadusky
purpleasaresultofredcellhemolysis.

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Liquefiedfatdrainingintothechestcavity.
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Otherpotentialartifactsofdecompositionsimulatingantemortemillnessortraumaincluderuptureof
thestomachoresophagus,"hemorrhage"intheposteriorneckanteriortothevertebrae,and
extravasationofbloodintothesofttissuesinareasofdependentlividity.

Factorsacceleratingdecompositionincludesepsis,heat(ie,environmentalheatandbody
temperature),andprocessesthatpromoteheatretention.Ofnote,bodiessubmergedinwater
decomposeataslowerratethanthoseonlandthatareexposedtoair.Bodiesburiedintheground
havetheslowestrateofdecomposition,owingtothetypicallycoolertemperaturesundergroundand
therelativeinaccessibilityofthebodytoenvironmentalpredators.

Twolesscommonvariantsofdecompositionaremummificationandadipocereformation.The
formerprocessoccursinwarm,dryenvironmentswherethetissuesrapidlydesiccateandresistthe
typical"wet"decomposition.Withmummificationofthebody,externalinjuriesmaybepreserved,
thoughthesizeofwoundsmaybedistorted,asdemonstratedbelow.

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MummificationofthishomicidevictimoccurredaftersheremainedinasecurebedroominAugustinthe
southeasternUnitedStatesforalmost2weekswithnoairconditioner.Mummificationpreservedthenumerous
stabwoundsandincisedwounds,allowingaccuratepostmortemassessmentofherinjuries.
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Adipocereformationtypicallyoccursinbodiessubmergedinwaterorinwarm,humidenvironments.
Thetissuesareconvertedintoawaxy,pastymaterialasaresultofthereactionofclostridialenzymes
withtissuefattyacids,asseeninthefollowingimage.

Adipocerehasdevelopedinthispersonwhowassealedinabarrelcontainingwaterandburiedforover5years.
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Organsconvertedintoadipocereresistdegradationandarefrequentlypresentforpostmortem
examination(seetheimagebelow)however,thetissuesareextremelyfriableandwilloftencrumble
uponmanipulation.

Althoughwaxy,theinternalorgansresistputrefactionwhenconvertedtoadipocere.
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Itisnotuncommonformummificationandadipocereformationtoaffectlocalizedareasofthebody
thatwouldotherwiseundergotheusualdecompositionalchanges(eg,mummificationofthefingers
andtoesiscommonplace).Anexampleofthisisbelow.

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Isolatedmummificationmaybeevidentinareasofthebodywithlesstissuemass,suchasthenose,ears,hands,
andfeet.
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Adramaticcomponentofthespectrumofpostmortemchangeresultsfromexposureofthebodyto
insectactivity.InNorthAmerica,thedepositionofflyeggsonhumanremainsandtheensuingmaggot
activitycanbetracedtotheblowfly,asseenbelow.

Thedecedentdemonstratesalmostcompleteskeletonizationoftheheadasaresultofmaggotactivity.
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Thedefectscausedinhumantissuesbyinsectlarvae(eg,maggots)maymimictrueinjury.
Additionally,thebloodandexposedtissuesinantemortemwoundsattractinsects,whoseactivities
distortantemortemlesionsand,insomecases,obscuretheircharacteristicsorpresence.Blowflies
usuallylayeggsintemperatureshigherthan50Findaylighthourswithinhoursofdeathwhenthey
haveaccesstobodies(seethefollowingimage).

Flyeggs,whichresembleParmesancheese,accumulateonmoistareasandaccessibleorificesofthebody.
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Theeggshatchin12days.Thelarvae(ie,maggots)consumetissueandgrowthrough3larval
stages,knownasinstars,asdemonstratedintheimagebelow.

Youngmaggotsresembleflyeggsbutaremobile.Inthiscase,flyeggswerelaidinthemoistenvironmentsofthe
partiallyopeneyes,nares,andmouth.Theeggshatchedandmigratedacrosstheface.

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Theproteolyticenzymessecretedbylargenumbersofmaggotsworktoincreasetherateoftissue
breakdown.Thelarvaepupateinapproximately12weeksadultfliesemergeinanother2weeks,as
seeninthefollowing2images.Thesetimelines,however,varygreatlywiththespeciesand
environmentalfactorsinsomecases,aforensicentomologistmayneedtobeconsultedtoassistin
estimatingthePMI.

Flypupaesuchastheseareoftenrecoveredawayfromthebody,becausemaggotsmigratebeforepupation
theseshouldberecoveredfromthedeathsceneifthetimeofdeathisinquestion.
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Flypupaeonadecedentnotethepresenceofotherinsects.
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InsectpredationbyroachesandantsmayoccuratanystageduringthePMI.Theytypicallyproduce
yellowred,irregularabrasions,whichusuallymayberecognizedbytheirgroupedpatternonthebody
(seetheimagebelow).Antsthemselvesmayconsumeflylarvaeandslowtherateofdecomposition.
[5]

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Postmortemantandroachactivityleavesatypicalgroupedpatternofpostmortem"abrasions."
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Carnivoressuchasrodents,cats,dogs,andvulturesmayfeastonabody.Rodentactivityistypified
byayellowbaseddefect,oftenwithscallopededges(seetheimagesbelow).

Thisindividualwasrecoveredinahomewithrats.Postmortembitemarksareyellow,bloodlessdefectswith
scallopededges.Top:Thirdmetacarpalandproximalphalanx.Bottom:Fifthmetacarpalandproximalphalanx.
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Canineactivityalsoresultsinyellowdefectsgnawmarksmaybeapparentontheunderlyingbones,
asshownbelow.

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Postmortemgnawmarksonalongbone.
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Vulturescreatecutaneousdefectsandmayconsumeinternalorgansthroughsurprisinglysmall
openingsintheskin.Beakmarksmaybeevidentaroundthecutaneousdefects,asdemonstrated
below).

Postmortemvultureactivityonthelegofawomanrecoveredinawoodedareatheunderlyingtendonisexposed,
andmuchofthemusculatureisabsent.Irregular,yellowdefectsaroundthedeeperwoundareconsistentwith
beakmarks.
ViewMediaGallery

Bodiesrecoveredfromopenwatercommonlydemonstratethefeedingactivityofmarinelife(eg,fish,
crabs,shrimp)onthefleshypartsofthebodysuchasthelips,eyelids,andears(seetheexample
below).

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Postmortemtissueconsumptioncausedbysmallmarineanimalssuchasfishandcrabsonthedorsalhand.The
edgesofthedefectsaretypicallyscalloped.
ViewMediaGallery

Largermarinelifesuchasalligatorsandsharksmayproducedefectsthatmimicantemortemsharp
andbluntforceinjuries,asdemonstratedinthefollowingimage.Althoughthesepostmortemdefects
aretypicallyyellow,bloodseepageintotheseareasmaycausethesedefectstoresemble
antemortemtrauma.Conversely,watermaywashcleanantemortemsofttissuehemorrhage,causing
atrueinjurytoresembleanartifact.

Largermarinelifesuchassharksandalligatorsmayconsumelargeamountsoftissueandleavesharpinjuriesin
thesofttissueand/orbone.Insuchcases,itmaybedifficulttodeterminewhethertheinjuriesrepresent
antemortemtraumaorpostmortemartifacts.
ViewMediaGallery

Skeletonizationusuallyrequiresmonthstooccurintemperateconditions,butitmaydevelopinless
timeiflargerpredatorshaveaccesstothebody(seethefollowingimage).Largerpredatorsmay
removebodypartsandcreatepostmortemartifacts,suchasgnawmarksonbones.Theapplicationof
anthropologicstudiesishelpfulinassessingthedecedentsgender,race,size,andage.Unless
antemorteminjuriesaffectthebonystructures,evidenceofthecauseofdeathinsomecasesmaybe
completelylostasaresultofskeletonizationandthelossofsofttissue.

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Thisskeletonisthatofanadultmanwhohadbeenmissingfor1.5monthsduringthelatefallinthesoutheastern
UnitedStates.Hewasfoundinawoodedarea.Althoughtheskeletonwasmostlyintact,gnawmarkswereevident
onseveralribs.
ViewMediaGallery

Macerationisaprocessthatoccursincasesofintrauterinedemise,asshowninthefollowingimage.
Itisanautolyticprocessnoticeableseveraldaysafteranintrauterinedeathcausedbyendogenous
fetalenzymesbecausethefetusistypicallysterile,putrefactivebacteriausuallydonotplayarole.
Exceptionsincludecasesinwhichthefetushadaninfection,suchaschorioamnionitisorcongenital
pneumoniainsuchcases,thefetusmayshowmorecharacteristicsignsofdecomposition.

Macerationafterretentionofanintrauterinefetaldeath.
ViewMediaGallery

Typically,themaceratedfetusshowsdarkpinktobrowndiscolorationoftheskin,followedbyskin
slippagewithoutgaseousbloating.Asmacerationprogressesinutero,jointsloosenandtheskull
platesseparatecharacteristically,theskullplatesoverridetheirsutures,whichtotheinexperienced
examinermaymimicheadtrauma.Onceexpelledfromtheuterus,thefetusorinfantmaybecome
colonizedbyenvironmentalbacteria,addingaputrefactivecomponenttosubsequentpostmortem
changes.

Thepresenceofmacerationmaybeusedasproofofanintrauterinefetaldeath.Theabsenceof
maceration,however,doesnotexcludeanintrauterinedeath,becauseittakessometimetodevelop.
[6] Anotherprocessthatcommonlyoccursincasesofinfantmortalityisthepostmortemsubcutaneous
congealingoffatafterthebodyisrefrigeratedtheresultantdoughyconsistencyofthetissuemay
simulatealigaturemarkaroundtheneck,asshownbelow).

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Congealingofsubcutaneousadiposetissueontheneckofaninfantmaymimictrauma.
ViewMediaGallery

Embalming,whichinvolvestheadministrationoffixativefluidsand/orpowdersintothebody,slows
theprocessofdecompositiondramatically.However,embalmingintroducesitsownartifacts,including
cutaneousincisionstogainvascularaccess,typicallyonthelateralneckand/orgroin,andtrochar
defectsontheabdomenwithassociatedinternalorgandisruption.Anexampleisshownbelow.The
visceraldefectsarecharacterizedbytheabsenceofhemorrhageandtheabsenceofhistologic
reactivechanges.

Trocharholeinanembalmeddecedent(buttonremoved).
ViewMediaGallery

Wiringofthejawsmayhamperoralexamination.Capsovertheeyeglobesmustberemovedto
assessocularfindings.Cosmeticcreamsusedontheskinmayobscureantemorteminjuries.
Embalmedbodiesthathavebeenburiedandsubsequentlyexhumedcommonlyshowcutaneous
fungalgrowth,especiallyinwetenvironments,asdepictedinthefollowingimage.Withthepassageof
time,adipoceremaydevelop.

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Fungalgrowthonapreviouslyembalmedandsubsequentlyexhumedbody.
ViewMediaGallery

Specialdissections
Decompositiondoesnotprecludethepossibilityofperformingacompleteautopsy.Tissuessuchas
liver,spleen,skeletalmuscle,kidney,andbrainmaybeusedfortoxicologicanalysisifbloodisnot
available.Longbonesegments,includingthemarrowspace,teeth,andskeletalmuscle,areusefulfor
DNAanalysis.

Specialautopsyprocedures

Imagingstudies

Itisadvisabletoobtainradiographsofbodyregionsinadecomposingbodywhenpotentialtrauma
cannotbeassessed.Theseusuallyincludeareasinwhichtissuewaslostasaresultofinsector
animalactivity.Imagingstudiesallowthepathologisttofindprojectilesorradiopaquefragmentsinthe
bodyincasesinwhichthedecedentsustainedagunshotwoundorwasassaultedwithametallic
object(eg,aknife).However,theabsenceofradiopaquefragmentsdoesnotexcludethepossibilityof
anassault.

Radiographsarealsousefulintheidentificationofdecomposedremains(eg,facialsinus
configuration,orthopedichardware).PostmortemCTscanscanbeusefulindocumentinginjuriesand
diseaseindecomposedbodies.Theyareparticularlyusefulinidentifyingintracranialpathologybefore
removalofthecranium.

Insectcollection

Itisextremelyhelpfultoinvolveanentomologistincasesinvolvinginsectactivityentomologistscan
provideinformationastothetypeofinsect(s)andthestageoftheinsectlifecycleatthetimeof
discovery.Theselection,handling,andstorageoftheinsectspresentonandaroundthebodymust
beproperlycarriedoutfordatatobeuseful.Insectsatallstagesofdevelopmentpresentatthetime
ofdiscoveryofthebodyshouldbekilledandpreservedsomeshouldalsoberetainedalivewitha
foodsourceforsubsequentevaluation.Also,thecharacteristicsoftheenvironmentinwhichthe
decedentwasfoundmustbedocumentedandtheambienttemperaturerecordedtoassistin
predictingtheinsectsmaturationrateinthoseparticularcircumstances.

Specialhandling
Standardprecautionsshouldbeutilizedwhenperforminganautopsyofanyindividual,regardlessof
theextentofdecomposition.Inallcases,itiswisetoensureproperautopsyroomventilation.The
pathologistshouldproceedwithsomedegreeofcareduringtheautopsyofadecomposingindividual,
becausetissuesbecomemoredelicateasthePMIprogresses.Indeed,itisnotunusualforthebrain
tobeintactatthetimethecalvariumisremovedandtothendisintegratecompletelyasaresultof

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disruptionofthearachnoidmembranesupportingtheliquefyingparenchymawhenanattemptis
madetoremovethebrain.

HistologyandMicroscopicExaminationandFindings
Histologymayassistindiscriminatingapostmortemartifactfromanantemorteminjuryby
documentingthepresenceorabsenceofaninflammatoryresponse.[7]However,insignificantly
decomposingtissues,histologyrevealsextensiveautolysisandbacterialovergrowth,whichhampers
histopathologicinterpretationofbothdiseaseandtrauma.Insomecases,atrichromestainmaybe
usefulinconfirmingmyocardialfibrosisorcirrhosis.

PhotographyandDocumentation
Asinallforensiccases,photographsofthedecedenttakenatthescenedocumentingthepositionof
thebodywhendiscovered(whenpossible)arevaluableadjuvantstotheinterpretationofthe
postmortemfindingsandchanges.Photographsofallpertinentpositiveandnegativefindingsmay
addressquestionsthatariseasthecaseunfolds.Photographyanddiagramssupplementthewritten
descriptionscontainedinthefinalautopsyreport.

AncillaryandAdjunctiveStudies
Vitreousfluid,ifavailable,maybeevaluatedforthepresenceofseveralanalytes,includingsodium,
potassium,chloride,ureanitrogen,creatinine,glucose,andketones/acetone.Immediatelyafterdeath,
vitreousanalytelevelsreflectterminalantemortemserumconcentrationsbetterthanpostmortem
bloodsamplesdo,owingtothefactthatvitreousfluidiscontainedwithintheeyeandispartially
protectedfromthebyproductsofcellularautolysis.Ureanitrogenandcreatininelevelsshowthemost
postmortemstabilitysodiumandchloridelevelsarerelativelystableovertheearlyPMIbutdeclineas
decompositionprogresses.Typically,markedlydecreasedlevelsofsodiumandchlorideanda
markedlyincreasedpotassiumlevelarereflectiveofdecomposition.

TheglucoseleveldeclinesrapidlyduringthePMIaconcentrationofzeroisnotunusualinahealthy
individualwhosuccumbedtotraumaticinjuries.However,highlevelsmayreflectadiabeticstate.The
presenceofacetoneand/orketonesintheocularfluidsubstantiatesadiagnosisofdiabetic
ketoacidosisincasesinwhichtheglucoseleveliselevated.Intheabsenceofahighglucose
concentration,theirpresencemayindicatestarvation.[8]

Vitreousfluidpotassiumlevelshavebeenshowntosteadilyincreaseafterdeaththevitreousfluid
potassiumlevelmaybeusedtohelpestimateaPMIintemperateconditions.However,theexisting
formulasarerestrictedbyconfidencelimitsofalmost+/1dayallarebestutilizedinthefirst100
hoursfromthetimeofdeath.Numerousothervariablesaffectthevitreouspotassiumlevel,including
antemortemserumlevelsandtheaforementionedconditionspromotingaccelerateddecomposition.In
temperateconditions,vitreousfluidistypicallynotretrievableafterapproximately4days.

Vitreousfluidconcentrationsofsomecompounds,includingalcoholsandsomemedications,are
reflectiveofserumlevels12hoursbeforedeath.Comparisonsofvitreousfluidconcentrationswith
serumlevelsmaybeofvalueinassistingthedeterminationofthemannerofdeathinoverdosecases.
[1] Forexample,significantlyhigherdrugconcentrationsinthepostmortemblood,ascomparedwith
thedrugconcentrationsinvitreousfluid,suggestanacuteoverdose(possiblysuicide)ratherthan
chronicoverconsumptionofthemedication(whichwouldlikelybeaccidental).Itshouldalsobe
rememberedthatputrefactionmayresultinethanolformationinthetissuesandbloodasthePMI

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lengthens.Levelsashighas0.1g/dLarereadilyencountered.Somesourcesstatethatlevelsmaybe
ashighas0.2g/dL.

CommonMisconceptions
Oneofthemostcommonmisconceptionsinforensicpathologyconcernstheabilitytospecifyan
exacttimeofdeath.Therehavebeennumerouscasesinwhichpostmortemchangestakenoutof
contextconfoundedPMIestimates.Morethananything,environmentalconditionsalterthe
decompositionprocess.Onedecedentwhowaspreservedinachestfreezerfor1yearshowed
minimalsignsofdecomposition.AnotherindividualfoundinafieldinthesoutheasternUnitedStates
duringsummershowedadvanceddecomposition,yetallinvestigativeinformation,includingareceipt
onhispossession,indicatedthathediedwithin24hoursoflastbeingseenalive.Interpretationof
physical,microscopic,andbiochemicalpostmortemchangeswithoutcorrelationwiththe
circumstancesofdeathmayresultinsignificantlyerroneousPMIestimates.

Othermisconceptionsrevolvearoundthepresumedabilityoftheforensicpathologisttodefinitively
differentiatebetweenantemorteminjuriesandpostmortemchangesinabodyshowingsignificant
decomposition.Dependingonthedegreeofdecompositionandcharacterofthepostmortemartifacts,
suchdifferentiationmaynotbepossible.Woundsinflictedimmediatelybeforeorimmediatelyafter
death(the"perimortem"interval)areparticularlyproblematic.

Anothercommonmythinvolveslossofbowelandbladdercontrolatthetimeofdeath.Althoughthis
mayoccur,itisinnowayauniversalphenomenon.Inmostcases,urinecanberecoveredfromthe
bladderatthetimeofautopsyandtherectumoftencontainsfecalmaterial.

Perhapsthegreatestmisconceptionrevolvesaroundtheutilityandusefulnessofperformingan
autopsyonadecomposedbody.Asageneralrule,informationcanbeobtainedfromeveryautopsy,
thoughputrefaction,skeletonization,orpredationmaylimittheabilityofthepathologisttodraw
definitiveconclusions.

IssuesArisinginCourt
Issuesarisingincourtconcerningpostmortemchangesmaycenteraroundpostmortemartifactsbeing
interpretedasresultingfromantemortemdiseaseortrauma.Indeed,onestudyrevealedthata
numberofcaseswerereferredforforensicautopsyfromlaycoronersonthebasisofmisinterpretation
ofcommonpostmortemartifactsasantemorteminjuries.Thesechangesincludedpurgingoffluid,
deepbluishlividity,dryingoftheskin,bloating,andskinslippage.[9]

PMIestimatesareoftenscrutinizedinthecourtroomandmayaffecttheveracityofadefendantsalibi.
Integrationofallgross,biochemical,environmental,circumstantial,andadjunctiveinformationis
requiredbeforedeterminingatimeframethatincludesthePMI.

References

1.DiMaioVJM,DiMaioD,eds.ForensicPathology(PracticalAspectsofCriminalandForensic
Investigations).2nded.BocaRaton,La:CRCPress,LLC2001.

2.CollinsKA,BennettAT.Persistenceofspermatozoaandprostaticacidphosphatasein
specimensfromdeceasedindividualsduringvariedpostmortemintervals.AmJForensicMed
Pathol.2001Sep.22(3):22832.[Medline].

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12/2/2016 PostmortemChanges:Overview,Definitions,SceneFindings

3.SundLevanderM,ForsbergC,WahrenLK.Normaloral,rectal,tympanicandaxillarybody
temperatureinadultmenandwomen:asystematicliteraturereview.ScandJCaringSci.2002
Jun.16(2):1228.[Medline].

4.SpitzWU,SpitzDJ,FisherRS,eds.SpitzandFisher'sMedicolegalInvestigationofDeath:
GuidelinesfortheApplicationofPathologytoCrimeInvestigation.4thed.SpringfieldIll:Charles
CThomasPublisher,Ltd2006.

5.CampobassoCP,MarchettiD,IntronaF,ColonnaMF.Postmortemartifactsmadebyantsand
theeffectofantactivityondecompositionalrates.AmJForensicMedPathol.2009Mar.
30(1):847.[Medline].

6.SaukkoP,KnightB.KnightsForensicPathology.3rded.London,UnitedKingdom:Oxford
UniversityPress,Inc2004.

7.DettmeyerRB.Theroleofhistopathologyinforensicpractice:anoverview.ForensicSciMed
Pathol.2014Sep.10(3):40112.[Medline].

8.CoeJI.Postmortemchemistryupdate.Emphasisonforensicapplication.AmJForensicMed
Pathol.1993Jun.14(2):91117.[Medline].

9.SauvageauA,RacetteS.Postmortemchangesmistakenfortraumaticlesions:ahighly
prevalentreasonforcoroner'sautopsyrequest.AmJForensicMedPathol.2008Jun.
29(2):1457.[Medline].

10.ZilgB,AlkassK,BergS,DruidH.Postmortemidentificationofhyperglycemia.ForensicSciInt.
2009Mar10.185(13):8995.[Medline].

MediaGallery

Thedecedentshowspersistentrigormortiswiththerightarmdefyinggravity.Thebodymust
havebeeninanotherpositionforseveralhoursafterdeathbeforebeingplacedinasupine
position.

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Livormortisontheposterioraspectsofthebodyiscausedbysettlingofthebloodbecauseof
gravitywhenthebodyisinasupineposition.

Asthepostmortemintervallengthens,Tardieuspotsdevelopinareasoflividity,suchasthis
individual'sshoulderarea,asdecomposingcapillariesrupture.

Tardieuspotsontheabdomen.

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Tachenoiredevelopswhentheeyelidsarenotcompletelyshutandpostmortemdryingoccurs.

Postmortempurgefluidexudesfromtheoralandnasalpassagesnotraumaticinjurieswere
uncoveredatautopsy.

Decompositionisaprocessofautolysisandputrefaction.

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Macerationafterretentionofanintrauterinefetaldeath.

Rigormortisoftheerectorpilaecanresultinpostmortem"gooseflesh."

Pressureonunfixedlivorresultsinblanchingofthecoloration.

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Livormortisinananteriorposition.Theareaofblanchingacrossthechestandabdomen
resultedfromthedecedentlyingontopofhisleftarmandrighthand.

Thelungisdarkpurpleintheposteriordependentareasasaresultoflivormortis.Thismay
simulatecongestion.

Decompositionhasprogressedinthisindividualwithbreakdownofbloodvesselsand
extravasationofredbloodcellsintothesubcutaneousandadiposetissuesoftheabdomen,
simulatingantemortemhemorrhage.Therewerenoassociatedcutaneousorbonyinjuries,and
thescenewasinnocuous.

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Postmortemdryingofthetongueandmucosalmembranesdarkensthetissues,impartinga
pseudohemorrhagicappearance.

Earlydecompositionalchangesaremanifestedbygreendiscolorationovertheabdomen.

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Marblingoutlinesthevasculatureinthisdecedentasthepostmortemintervallengthens.

Decompositionadvanceswithgreendiscolorationoftheskin,generalizedbloating(beginningin
theabdomen),andvesicleformationwithsubsequentskinslippage.

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Postmortemdeglovingofthehand.

Alawenforcementofficialutilizesthedeglovedfingerstoobtainfingerprints.

Viewofcollapsed,decomposingorgansinthechestcavitywithmaggotspresentandgaseous
distentionoftheintestines.

Liquefiedfatdrainingintothechestcavity.

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Mummificationofthishomicidevictimoccurredaftersheremainedinasecurebedroomin
AugustinthesoutheasternUnitedStatesforalmost2weekswithnoairconditioner.
Mummificationpreservedthenumerousstabwoundsandincisedwounds,allowingaccurate
postmortemassessmentofherinjuries.

Adipocerehasdevelopedinthispersonwhowassealedinabarrelcontainingwaterandburied
forover5years.

Althoughwaxy,theinternalorgansresistputrefactionwhenconvertedtoadipocere.

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Isolatedmummificationmaybeevidentinareasofthebodywithlesstissuemass,suchasthe
nose,ears,hands,andfeet.

Thedecedentdemonstratesalmostcompleteskeletonizationoftheheadasaresultofmaggot
activity.

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Flyeggs,whichresembleParmesancheese,accumulateonmoistareasandaccessibleorifices
ofthebody.

Youngmaggotsresembleflyeggsbutaremobile.Inthiscase,flyeggswerelaidinthemoist
environmentsofthepartiallyopeneyes,nares,andmouth.Theeggshatchedandmigrated
acrosstheface.

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Flypupaesuchastheseareoftenrecoveredawayfromthebody,becausemaggotsmigrate
beforepupationtheseshouldberecoveredfromthedeathsceneifthetimeofdeathisin
question.

Flypupaeonadecedentnotethepresenceofotherinsects.

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Postmortemantandroachactivityleavesatypicalgroupedpatternofpostmortem"abrasions."

Thisindividualwasrecoveredinahomewithrats.Postmortembitemarksareyellow,bloodless
defectswithscallopededges.Top:Thirdmetacarpalandproximalphalanx.Bottom:Fifth
metacarpalandproximalphalanx.

Postmortemgnawmarksonalongbone.

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Postmortemvultureactivityonthelegofawomanrecoveredinawoodedareatheunderlying
tendonisexposed,andmuchofthemusculatureisabsent.Irregular,yellowdefectsaroundthe
deeperwoundareconsistentwithbeakmarks.

Postmortemtissueconsumptioncausedbysmallmarineanimalssuchasfishandcrabsonthe
dorsalhand.Theedgesofthedefectsaretypicallyscalloped.

Largermarinelifesuchassharksandalligatorsmayconsumelargeamountsoftissueandleave
sharpinjuriesinthesofttissueand/orbone.Insuchcases,itmaybedifficulttodetermine
whethertheinjuriesrepresentantemortemtraumaorpostmortemartifacts.

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Thisskeletonisthatofanadultmanwhohadbeenmissingfor1.5monthsduringthelatefallin
thesoutheasternUnitedStates.Hewasfoundinawoodedarea.Althoughtheskeletonwas
mostlyintact,gnawmarkswereevidentonseveralribs.

Congealingofsubcutaneousadiposetissueontheneckofaninfantmaymimictrauma.

Trocharholeinanembalmeddecedent(buttonremoved).

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Fungalgrowthonapreviouslyembalmedandsubsequentlyexhumedbody.

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Tables

BacktoList

ContributorInformationandDisclosures

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12/2/2016 PostmortemChanges:Overview,Definitions,SceneFindings

Author

SErinPresnell,MDProfessor,CoDirectorofMedicalandForensicAutopsySection,Departmentof
Pathology,MedicalUniversityofSouthCarolinaCollegeofMedicine

SErinPresnell,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
SocietyforClinicalPathology,CollegeofAmericanPathologists,NationalAssociationofMedical
Examiners,AmericanAcademyofForensicSciences,InternationalAssociationofMedicalScience
Educators

Disclosure:Nothingtodisclose.

ChiefEditor

JScottDenton,MDClinicalAssistantProfessorofPathology,UniversityofIllinoisCollegeof
MedicineatPeoriaForensicPathologistandIllinoisCoronersPhysician

JScottDenton,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
MedicalAssociation,AmericanMedicalAssociation,AmericanSocietyforClinicalPathology,College
ofAmericanPathologists,IllinoisStateMedicalSociety,NationalAssociationofMedicalExaminers,
AmericanAcademyofForensicSciences,IllinoisSocietyofPathology,PeoriaMedicalSociety

Disclosure:Nothingtodisclose.

Acknowledgements

StephenJCina,MD,FCAPChiefMedicalExaminer,CookCountyClinicalProfessorofPathology,
RushMedicalCollegeofRushUniversityMedicalCenterClinicalProfessorofPathology,
NorthwesternUniversity,TheFeinbergSchoolofMedicine

StephenJCina,MD,FCAPisamemberofthefollowingmedicalsocieties:AmericanAcademyof
ForensicSciences,ArthurPurdyStoutSociety,CollegeofAmericanPathologists,andNational
AssociationofMedicalExaminers

Disclosure:Nothingtodisclose.

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