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Death with Doctor

Watercolour copy from Dance of Death cycle
Albrecht Kauw (1649)
From the Totentanz Fresco (1516–1519) by Niklaus Manuel Deutsch
Berner Dominikanerkloster, Historisches Museum, Bern
E&V
CARDAN

DEATH
AND
MEDICINE

Cluj-Napoca
E&V CARDAN, Death & Medicine

“IULIU HATIEGANU” MEDICAL PUBLISHING HOUSE CLUJ-NAPOCA

All rights for this book belong to the authors and “Iuliu Hatieganu” Medical
Publishing House. Printed in EU. No part of this work may be reproduced in
any form, mechanic or electronic, nor stored in any database without the
authors and publisher’s express written consent.

Copyright © 2017 AUTHORS
Copyright © 2017 “IULIU HATIEGANU” MEDICAL PUBLISHING HOUSE CLUJ-
NAPOCA

ISBN 978-973-693-765-1

“Iuliu Hatieganu” Medical Publishing House,
Cluj-Napoca, tel. 0040.264.596.089
“Iuliu Hatieganu” University of Medicine and Pharmacie, Cluj-Napoca,
RO — 400023, 8 Victor Babeş, tel. 0040.264.597.256
Copy editor: Livia Lupea
Technical editor: Petru Ureche
Cover and print by
Colorama,
12A Samuil Micu, RO — 400014, Cluj-Napoca, www.colorama.ro
Master Table of Contents
Forewords VI
Acknowledgements IX
Introductory notes 11

1. Death – friend or foe ? 15
2. Ageing 33
3. Terminal illness 49
4. Shock and multiple organ failure 59
5. Vital prostheses 77
6. Cardiac arrest and resuscitation 85
7. Near–Death Experience 121
8. Vegetative state 129
9. Cell death 139
10. Death semiotics 151
11. Natural deaths 163
12. Death and organ transplantation 195
13. Unnatural deaths 211
14. Assisted death 265
15. Ethical and legal aspects 275
16. Capital punishment 287
17. Autopsy 303
18. Cadaver and teaching 315
19. Methods of preservation 325
20. Disposal of corpses 347
21. Decomposition 353

Instead of conclusions 359
Abbreviations 365
References (317 titles) 367
Selected thematic index 391

V
Forewords
This book presents a contemporary approach to one of the social taboos in
our society, the discussion of death and associated peri-mortem situations. The
book begins with three chapters that put death into context within the natural
process of aging and the less natural processes of illness and medical treatment.
It then goes on to examine death in more detail in a variety of patho-physiological
states, including near death experiences and persistent vegetative states.
In medicine we strive to maintain life, often when it is evidently futile
to continue treatment. This book then carries the discussion into this arena
also, covering assisted dying and the role of those who are peri-mortem in
transplantation, coining a new term – i-life, for interactive life – along the way.
This represents a new approach to the perceived utility of death and dying which
is bound to provoke debate.
Later chapters consider ethical and legal issues surrounding death, and
address the issue of the death penalty within jurisprudence. The book concludes
with an examination of some historical aspects of death and dying, considerations
of autopsy and preservation of corpses, and of the process of decomposition.
Emil and Voichita Cardan have combined two lifetimes of experience
gained from living and working in both Romania and the United Kingdom, into a
readable volume that makes us think anew about the social mores around death,
and particularly around the role of modern medicine in the process of dying.
The only lasting record of the lives of the majority of mankind is the registration
and certification of death. This book puts death and dying into a modern social
context, and will be of interest to the youngest medical student and the careworn
older practitioner alike.

David Smith, BMBS, DM, FRCA
Consultant / Senior Lecturer
Department of Anaesthesia, University Hospital Southampton

VI
People do not like to speak about death, doctors even less so.
Physicians spend their careers being taught – and teaching – about the
preservation of life, in spite of the fact that nothing, except perhaps birth, is a
more natural part of life than death.
But everybody would agree that a reluctance to speak about or deal with
disagreeable things does not mean they don’t exist. If this is true, there is a clear
need to discuss, and write about, the phenomenon of death. By doing so, one
can make the natural process more understandable and even acceptable, as a
fact of life.
Death and Medicine is not a simple book about the physiological process of
disappearance. The authors, one of them a teacher and the other a physician,
have succeeded in bringing to the reader the full spectrum of death, approaching
the subject from a philosophical but also a medical point of view.
I am not aware of any other book so comprehensive regarding the process
of death. Nothing, it seems, was left unexamined. The book treats the accidental
causes of death with the same interest as the physiological end of life.
The narrative starts with the process of senescence, a subject of primordial
importance nowadays. A hundred years ago the mean length of life was about
fifty years. Today, in the developed world, it surpasses eighty. This tremendous
evolution has a special implication regarding death. It means that so-called old
people can postpone, voluntarily or instinctively, the thought of death. And once
prolonging life is a realistic hope, they can concentrate their efforts on improving
their quality of life.
Death and Medicine has the merit of bringing us back to reality and offering
a fair chance to see death for what it is, by describing its various aspects and
offering the reader the necessary tools for more easily accepting it as a natural
process. After all, nobody, absolutely nobody, can escape it.
The circle of potential readers is extremely large. The book (I should call it
a textbook!) equally addresses physicians, philosophers, biologists and lawyers,
but it will also appeal to the large general public of readers interested in getting
useful help with understanding and accepting death.
Reading this book is an intellectual feast.
Publication of this book should be an event of both literary and scientific
importance. I have no doubt that it will soon find a place in a great many personal
and professional libraries.

Gabriel M. Gurman, MD
Professor Emeritus, Anesthesiology and Critical Care
Ben Gurion University of the Negev, Beer Sheva, Israel

VII
Professional history of the authors

Voichita Cardan
Technical College, Cluj Napoca
City College, Southampton

Emil Cardan
University Department of Surgery, Cluj Napoca
Westfälische Universitätskliniken, Münster
Fundeni Hospital, Bucharest
Heart Institute, Cluj Napoca
Papworth Hospital, Cambridge
University Hospital, Southampton

ecardan@gmx.net

VIII
Acknowledgements
It is not easy to compile a compendium in a language that is not one’s
native tongue, particularly when dealing with a topic as complex as death
and dying. Publishing of this work was only possible due to unreserved
support from
− the University of Medicine and Pharmacy, Cluj Napoca, for
having agreed to oversee the entire project;
− the technical team responsible for transforming a raw text into
a real book; and
− freelance consultants R. Asyet, who ensured the basic standards,
and R. Colwell, who provided the editing and linguistic expertise
necessary to elevate the narrative to a sound stylistic and
academic level.

Pious thoughts are addressed to the countless patients who have
passed away during my fifty-year medical career, one that was carried out
in both substantive and locum positions in Germany, the United Kingdom
and, mainly, my native country.

Having taken part in, and taken to heart, the field of heart transplantation
– a domain where the deaths of some are rewarded by the lives of others – I
have been able to witness some of the most dramatic cases. This experience
was made possible by the generous mentoring of University of Cambridge
Professor R. Latimer.

Emil Cardan, MD, PhD
Former professor of Anaesthesia and Intensive Care
Heart Institute, Cluj Napoca, Transylvania
Retired clinical anaesthetist
University Hospital, Southampton, England

IX
It is because we know life
and do not know death
that we love one
and dread the other.

Chinese Buddhist Scripture

X
Introductory notes
This book is the result of decades of involvement in intensive care, a
domain where The Grim Reaper is always just around the corner. It is in this
environment that both theoretical and practical medicine has outlined our
professional and moral stature.
As potential authors, the very first step was to find out how much had
been written specifically on the topic. The amount of literature proved to be
huge, from mainstream newspaper articles to full–fledged encyclopaedic
volumes. Despite this abundance, no work dealing medically in toto with
death could be found.
The largest reference (40), at over 1,000 pages, has among its more than
100 contributors none with a medical affiliation. It does not definitively lack
statistics, terms, or comments of a medical type, but it has no chapter, not
even a short one, dedicated to a true medical approach to death. The most
medical source (184) is authored by a high–ranking British pathologist; while
it offers an instructive lecture, the dissertation is clearly structured for and
appeals to non–professional readers.
The limited academic medical interest in death as a selective focus
undoubtedly derives from the hallmark death has for curative medicine –
that of a fait accompli. While from an administrative point of view this is
understandable, for those concerned death is not a simple switching off. It
is a complex process that comes with a price of discomfort and frequently
pain.
It is strange, therefore, that no clinical medical speciality devotes a
chapter in its curriculum to death and dying. They have been with us forever,
occurring inevitably and in so many ways in all walks of life. Pathology and
Forensic Medicine are real sciences, but they largely target the end product
of dying – the corpse.
Having no model and, therefore, constructing a sui generis one, the
result, as you will see, is neither a handbook nor a simple lecture, but a
sort of compendium of general knowledge, largely medical. Having tried
to consider as many peri–mortem issues as possible, the 21 chapters are,
11
Introductory notes
as expected, highly heterogeneous. They explore a varied terrain from
clinical medicine to philosophical perspectives; thus, there are occasional
incongruities as well as some approximations due to the controversial
nature of certain statistical data.
A good part of the text deals with current pathology in terms of the
corresponding degree of fatality as well as the mechanisms causing death.
As the cessation of circulation is an essential aspect of dying, cardiac
arrest and resuscitation are presented analytically in the context of their
pathophysiological dynamics. Due to this approach, disorders of interest to
intensive care receive a great deal of detailed attention. Next in line are the
relatively silent killers such as smoking and alcoholism, while the remaining
conditions are ‘allocated’ a place according to their lethal interference with
the course of life.
After the forms of natural death, the same approach is applied to the
unnatural ones – those generated by human vice, natural disasters, man–
made death in general and the death penalty in particular. Special attention
is given to sudden and suspicious deaths, with their ethical and medico–
legal implications.
As medicine today is no longer rigidly opposed to death, there is a
role for it to play in societal approaches to euthanasia. Moreover, through
organ transplantation, medicine can facilitate a sort of life transfer. This
perspective offered an appropriate place to stress the clinical–biological
sequence of events in dying and the role of ‘brain death’ in the modern
definition of death. We also took the opportunity to use a newly proposed
term, i–life (50).
In addition to the medical issues themselves, various subjects closely
related to death have also been included: mummification, pandemics,
crucifixion, and the guillotine (for a historical perspective), as well as current
developments in postmortem practices such as autopsy, conservation,
medical school use of the cadaver and, for the sake of thoroughness, the
use of cadaveric blood. The reader may be the judge as to whether it is right
to discard this achievement of Soviet medicine for the sake of overblown
peace–time ethics.
An effort has also been made to offer a succinct update to the topic of
near–death experiences, including a nod to paranormal phenomena, these
days increasingly considered in the context of quantum theory.
Regarding references, each chapter includes its own cited quotations,
and a full alphabetical list of 317 sources follows the text. The number of
citations varies per chapter depending on the direct relationship of a given

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Death and medicine
subject to the process of dying. Where some conflicting data had to be
included, those references are mentioned immediately, enabling ease of
access to further sources. The two historical subjects, crucifixion and the
use of cadaveric blood, as well as the controversial near–death experiences
have been structured in a review style so as to be as informative as possible.
Instead of conclusions, the book ends with a series of reflections
inspired by various aphorisms. The reflections are personal while not
deviating from the underlying medical message. It remains to the individual
reader whether to peruse those couple of pages.
In order to make what can be a rather dark and heavy subject more
appealing, care has gone into striking an essayistic narrative tone and
creating an accessible thematic index, a friendly graphic and a robust
structure.
Finally, having tried to sketch a current image of death and dying by
incorporating both facets – friend and foe – and having in the process
grown both more democratic and more realistic, we hope this book of ours,
above all, serves Life.

Authors

13
1. Death, friend or foe?
(6, 17, 41, 117, 200, 202, 234, 306)

1.1. Introduction 15 1.2.3. ‘Acute’ death 21
1.2. Medical approach to death 19 1.2.4. Meeting transplant needs 21
1.2.1. Pronouncement of death 19 1.2.5. Medicalisation of death 22
1.2.2. ‘Obligatory’ deaths 20 1.3. Death demography 23
1.4. Mechanism of death 28

1.1. Introduction
Unlike in the inorganic world, any creature – as a biological unit – displays
on an individual scale a distinct existence with a beginning, middle and end.
This ‘middle’ with its two adjacent events represents life. Irrespective of the
position a creature has on the biological hierarchy, life does appear to be a
sort of precious gift, one that is highly valued. Avoiding dangers and fighting
for safety, all creatures instinctively defend their lives – which is one reason
both philosophy and religions embody the concept of the sanctity of life.
It is the right of any free thinker to wonder whether this sanctity refers
to the life of a given biological exemplar or to life as a sort of supreme
biological construct. This dilemma, however, has already been sorted out,
rather monumentally, by Nature itself in that life is limited for the exemplar
and virtually endless for the construct. Engels was certainly not the only
one wonder if death is not in some way an essential moment of life.
While life is glorified by various sectors of society (literature, art,
civic disciplines, social activists and educators, all competing to formulate
praise), death – a neutral player – remains a process that no mortal has ever
experienced.
Until consciousness is lost, scenarios of dying differ immensely
whereas death itself lacks any description. So, curiously enough, medicine
is not yet in possession of any intrinsic picture of death. This vacuum, the
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Chapter 1
entire postmortem chasm, is de facto a grey domain. Indeed, it is a domain
suitable for an unlimited philosophical repertoire. Thus arose the various
religions which for millennia have preached, each in its particular way, a
theory of life after death.
Death distinguishes itself by being uncompromisingly democratic; one
can, sometimes and by some means, postpone death but by no means can one
avoid it. A good number of famous faces in human history have taken advantage
of their noteworthy achievements and secured special attention in how their
remains were dealt with but no one has ever lived longer than permitted by his
own biological destiny. This fate is derived from Nature’s proclivity to patronise
natural selection by appealing to death. As such, death proves to be a perfect
tool for biological improvement. It is also worth emphasising here that both
the process of dying and the fate of the body, namely decomposition, from a
‘technical viewpoint’, happen entirely flawlessly.
While death is inexorable, it is also inequitable in its approach to when
exactly one dies, both on the level of Nature and that of the individual human
being. In order for Nature to ensure the perpetuation of species, it is vital
that death occur once reproduction is achieved, whereas for the individual
it is always preferable to die as late as possible and that opportunity has
become more and more feasible in recent centuries due to the enormous
progress in human living conditions.
Despite the high standard of existence that humans enjoy, our life
span extremely rarely surpasses 120 years, and this doesn’t seem to have
changed in recent human history. This limit results from genetic wear and
tear that is incompatible with a longer existence (58). It is worth stressing
that even nowadays the large majority of people still live far less than the
ideal span of time. In other words, each individual lives a particular number
of years less than ideally possible. That presents a negative number, a
number derived from a combination of two categories of factors:
− the limits of genetic inheritance and living conditions provided
by mother, family, community and the environment, on one
hand, and
− the scores of hostile factors such as pathology and accidents,
on the other hand.
It has taken an immemorially long time for the probable remaining
years to live – life expectancy – to surpass the 21 years (35) of prehistoric
humans. Unlike animals, which depend exclusively on instinct, the modern
human being has invested a lot in improving the quality of existence and in
reducing the severity of pathology and the number of accidents. The result

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Death, friend or foe?

is such that, during the last three centuries, life expectancy has substantially
increased to the present values.
While the ways of dying vary largely, there are only two major means
of ‘accessing’ death. The large majority of people–about to–die are either
elderly or are suffering from various pathological conditions. These are so–
called natural deaths, the kind of death well depicted by both Shakespeare
(78) and Mullready (Victoria and Albert Museum, London) in their respective
‘The Seven Ages of Man’. A minority, though still a significant proportion,
die of unnatural causes mostly resulting from aggressive human behaviour.
Despite being universal, death has remained an event full of mystery and a
rather elusive concept.
Death is not only universal as an event in every human life; it is also
unique as a self–running process. These two features come into conflict
philosophically if we are to accept that each individual represents a once–
in–the–universe experience.
What is Death in fact?
Although everyone is, in effect, always in the process of dying, death
proves to be medically difficult to define. Controversially, medicine does
not yet have a coherent definition. Even more controversially, but fully
explicable, as will be later explored, death still implies many unknowns.
Absent a concise definition, medical practice operates with a pretty old and
simple one – a definition that satisfies lay standards as well. According to
the Dornald’s Medical Dictionary (76), an authoritative source, death consists
of an irreversible loss of the three vital functions: cerebral, cardiac and
respiratory. Simplifying and codifying it this way, as a negative magnitude,
death in short implies an interruption of life; only somebody alive can die!
The intrinsic mechanism of any death is the cessation of cardiac activity,
irrespective of the causal disease, be it acute or chronic. This explains why a
cardiac malfunction represents the shortest path to death.
As mentioned above, death is, on a private scale, a mysterious
experience. Throughout history society has laudably invested much effort in
liberalising the concept of death. Technological advances in science and the
spread of knowledge have managed to counteract the religious tendency to
use death to enslave generations of believers. Both educated and ordinary
people have shown real progress in dealing with the anxiety generated by
death and dying. It is now therefore time for medicine to actively help its
beneficiaries pursue a more consistent control of their deaths.
The question is when and for what moment exactly might death be
‘booked’? Given that we came to life without being asked for our consent, it

17
Chapter 1
would be ‘rewarding’ for us to at least have a say regarding its termination,
especially when parameters of living are no longer acceptable. As this relies
on a philosophical platform, the medicalisation of or prescription for death
appears to be a sounder option. This is because the person concerned is a
patient, with a diagnosis, who is being treated properly and, moreover, the
same fully qualified professional players are in the best position to prescribe
death. This problem is now hotly debated and countries differ greatly in
how far their legal arrangements satisfy everyday needs.
Members of the medical community are not the only ones confronted
with the implications of death and dying; there is room enough for
improvements in society at large. Two particular issues deserve a comment:
− The modern electronics industry offers countless games that
allow children to imitate the act of killing, at the player’s
discretion. Lacking the maturity to understand the irreversibility
of killing someone, juveniles not infrequently go on to commit
real crimes in their families and communities.
− It is well known that the elderly are confronted with myriad
problems, mainly medical, that conspire to reduce their
physical comfort and quality of life – a social parameter that
will inevitably be affected by advancing age in any case. Quite
often the people concerned are taken by surprise; they are
unprepared to cope with these age–related changes as they
arise. It would be, to say the least, useful for society to inform
and teach people, before they become part of the old–age
community, about the potential dangers that old people face.
In many cultures there is plenty of folklore dealing with ageing;
unfortunately, the tenor tends to be rather more humorous
than constructive or instructive.
In a discussion about death, one cannot ignore the ‘bad nature’ of
human beings; it is no secret that there are many versions of man–made
death, e.g.
− interpersonal conflicts,
− sacrificial death,
− risky sports such as boxing, bullfighting, parachuting, etc.,
− crusades and armed conflicts,
− the so–called robotic death, when robots (more frequently
drones) are intentionally used to kill.
Psychiatric pathology (with the exception of Cotard’s syndrome (18, 21)
sufferers of which believe themselves to be dead) generates a considerable

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Death, friend or foe?

number of suicides and homicides.
In nature there are many curiosities regarding death, for instance:
− Although severed from the body, a rattlesnake head is able to
bite and envenom for hours after decapitation.
− Due to some fine communication channels between the body’s
outer surface and trachea lumen, the cockroach is able to live
up to ten days after the removal of its head.
− There is a killing fly which, when swallowed by a tortoise, lays
eggs into the reptile’s stomach mucosa; from there the resulting
larvae migrate towards the pharynx where, obstructing the
airway, they cause suffocation.
− Finally, in Latin America there lives a scarabaeus, which defends
itself using a sort of flamethrower. From two different kinds of
abdominal glands, it combines hydroquinone and peroxide,
generating a highly exothermic reaction: the resulting chemical
has a temperature of up to 100oC, leading to the fatal spread of
hot vapours.
In any human community, there are circumstances when death can
play a favourable role; candidates for imminent death often take actions
designed to expedite the inevitable before their death occurs naturally.

1.2. Medical approach to death
Branded as a ‘number one public enemy’, death has always been
confronted with ‘forces’ designed to extend the length of life. This
‘declaration of war’ represents an important commitment in the Hippocratic
Oath – an oath now 2,500 years old but still managing to promote one of
the most respected traditions of professional solidarity.
Another significant step forward was achieved once ill people began
to be dealt with in a dedicated place. As inpatients, the people concerned
began to enjoy a sort of maximum medicine of their time and place and,
particularly important for the subject at hand, death could occur in a
professionally supervised environment. As a result, a number of problems
became apparent in medically based facilities, namely as follows.

1.2.1. Pronouncement of death
This represents a finding that attests to a medical ‘passing away’. It
must be made official by filling in an administrative document. It is only

19
Chapter 1
after its issue that the postmortem procedures required by local standards
become possible. Two details are very important:
− Special importance is given to organ donors when the diagnosis
of death is thoroughly achieved and the consent of relatives is
duly indicated in the patient notes.
− In the most common cases, promptness and rigour are not
necessarily imperative but much attention to the particulars of the
death – when, how, etc. should be given for the sake of the patient’s
family. Frequently the importance of this basic requirement is
underestimated, which only serves to further distress a saddened
family. A death is a routine event in any hospital whereas, for the
family concerned, the case is unique. Professor M. Barnard was
quite right in pleading for the pronouncement of death to be
made by the responsible doctor in each case.

1.2.2. ‘Obligatory’ deaths
There are two circumstances in practical medicine when little, if
anything, can be expected in therapeutic terms. These are severe cases
and patients of very advanced age, who no longer warrant intensive and
expensive treatments. This does in any sense equate to ignoring them. It
simply entails switching from a costly treatment to one that promotes what
we nowadays refer to as a good or dignified death. The latter supposes
a treatment designed to reduce pain, discomfort and suffering, while
preserving personal dignity. This approach is encouraged even at the risk
of precipitating both the deterioration of vital functions and death itself.
Patients of this sort are, in general, exhausted, reconciled to their fate and
inclined to give up; they no longer formulate special desires. It goes without
saying that all the above applies to both ambulatory and family–based care.
Public opinion, often enough, interferes with our stance regarding this
category of patients. These viewpoints appear to be in the best interest of
patients but are not always technically possible to take into consideration.
Such concerns are, however, of interest and, for the sake of good faith, are
worth noting:
− being conscious and anticipating death;
− life not being unnecessarily extended;
− being permitted to choose the place of one’s passing away
(hospital, hospice, home, etc.);
− having one’s wishes and decisions respected;
− being in control of what happens around oneself;

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Death, friend or foe?
− having access to the relevant pool of information;
− enjoying emotional and spiritual support;
− being in a position to say good bye to people of one’s choice
and
− above all, not suffering any pain.
In everyday life it is only rarely possible for all such conditions to be
met; it is, however, a matter of common sense to at least try to meet them
– the more the better.

1.2.3. ‘Acute’ death
In chronic pathology, the above strategy is quite easily implemented;
the situation differs substantially, however, in the acute case, in multi–
organ failure and in states of shock. In general, such patients are younger
and, apart from the bodily function(s) primarily affected, their bodies could
well recover satisfactorily.
In younger patients and those in formerly good health, acute pathology
frequently becomes a field of emotionally charged treatment decisions.
In other cases patients are sometimes laboriously treated with costly
measures simply because the department involved is well equipped with
sophisticated machinery and is staffed with skilled people trained to use
it. Despite this technical and human potential, it is nevertheless morally
justified not to launch complex and expensive treatments when there are
no viable options and there are clear signs that the patient will inevitably
die. As such a decision could be disputable, it must be taken or approved by
somebody in the most senior position in the unit at the time.

1.2.4. Meeting transplant needs
Transplantation medicine has made huge progress and in recent
decades has developed quite efficient strategies. ’Inventing’ – to borrow
from legislative language – the so called brain death has made it possible
for today’s organ transplant management boards to offer full scientific
and organisational support to organ and tissue retrieval teams. Today’s
efficiency would not be possible without the consistent support of intensive
care units. It is the role of the transplant team to harvest, transfer and
implant the transplantable organs. While the transplant team is responsible
for placing its patient in transplantation ‘orbit’, the donor’s intensive care
department must contend with a dying body and assume responsibility for
both the legal rigour required by the case and for any problems arising with
the patient’s family.
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Chapter 1
Needless to say, not all patients who are brain dead can serve as organ
donors. Their cases do, however, qualify for the same medical approach – in
other words, interrupting a prolonged expensive and fruitless treatment,
thus facilitating death proper. Such a patient will not have died as a result of
treatment being discontinued; to the contrary, the treatment will have been
interrupted because the patient was, in medical terms, already dead. Such
a scenario was entirely unknown to Hippocrates and his contemporaries;
therefore, the bureaucratic requirements of the Oath regarding a death in
a case such as this should be updated.

1.2.5. Medicalisation of death
Modern medicine offers doctors in charge of clinical cases more options
from which to choose:
− defending life vigorously,
− abstaining from treatment,
− discontinuing a treatment,
− assisted suicide, and
− active euthanasia.
The first option fits in the large majority of cases; it is a battle–field
where good will, lay people and professional cooperation and clinical
excellence routinely combine forces.
How vigorously and how far should we defend life? Vigorously, always;
in terms of how far, in theory, as long as a reasonable hope does exist.
When hope no longer exists and death is deemed inevitable, the vigour
of the ongoing treatment is usually reduced or even discontinued, leaving
the team to attend to the administrative requirements of the death as an
event. Unfortunately, little or even no attention is then paid to the dying
patient proper; the case appears to be more important than the patient.
Often the passing away is not, or does not seem to be, facilitated so as to
avoid being an unpleasant experience. On the contrary, distress, discomfort
and even pain are quite often experienced. Given that death is inevitable
and has proven to be a disagreeable experience, why do we organise first
aid courses and keep qualified midwives on hand yet provide no health
workers whatsoever specifically trained to assist the dying? In other words,
as we have a quality of life, why not have a quality of death as well? It is
here where the remaining four options would have an appropriate place.
It is imperative to brand death as a medical event and not as a purely
administrative one.
Death, not necessarily as a medical failure but as a potentially
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Death, friend or foe?

harmful experience as a whole, does merit a medical approach. As long as
gerontology is able to offer dedicated assistance to the elderly, it should
also be feasible for medical practice to provide such assistance to the dying
person. Dr Kevorkian is credited with christening such a medical sub–
speciality, Obitiatry (12).
What particular sorts of patients would benefit from Obitiatry?
In short, patients who pay too high a price in discomfort and pain for
the quality of life they can expect. Once a compos mentis individual suffers
from an incurable condition and the discomfort of living is higher than what
his life can positively offer, it should be her or his right to decide whether
to live or to die. And, if the person favours dying, it is medicine’s job to
facilitate the death in a professionally organised medical environment.
Conservative and even rigid policies, both in society and medicine, make
such an approach difficult; this is the reason that in complex cases appeals
are sometimes made to the judicial system. In this regard, it might be
possible to find some future positive application of budget cuts and the
extension of the private sector could be brought to bear in medical care.
As will be seen later in this work, legislation in various countries
differs greatly in the above respect. It is worth noting here that this is a
double–edged problem since, under the mask of helping people to die,
there is room for abuse, particularly from patients’ families. This should
not, however, discourage the favourable trend in medicine towards helping
dying people. A dogmatic adherence to the Hippocratic Oath would not
only result in a kind of biological idolatry that meant trying to keep people
alive at any price, but would also potentially stymie the notion of good
quality medical practice.

1.3. Death demography
At the current birth rate and with death being pushed later and later, in
2,000 years the human population may well achieve a weight comparable
to that of the earth. In another 4,000 years it would equal the weight of the
visible universe, expanding with the speed of light. A paragraph from one
of Saramago’s novels (251), referring to a death strike, is very much in tune
with what life without death would be like:
It takes a while for people to realise that nobody is dying. The health
minister gets into a mess by telling the people, as is the instinct with
politicians, that nobody should be alarmed. A cardinal is alarmed however
because without death there is no resurrection and without resurrection

23
Chapter 1
there is no church. Undertakers are the first to ask the government for
support. Next to complain are the directors of hospitals, which have rapidly
filled and become cemeteries of the living. Realising that the end of death
is far from a cause for joy, the people demonstrate their initiative by taking
relatives who are near death over the border, where they die and can be
buried.
Although clearly funny, the novel’s stance is more than realistic. As
Radiscev put it, it is in the nature of Nature for everybody to die. Sooner
or later, we all die. Nobody alive is or has ever been able to escape death.
The dynamic of death rigorously follows that of life. Natural selection is
too important for biology not to appeal to such a ’conscious’ tool as Death.
In the two million years of evolution, the human race does not appear to
have mattered very much for the ecosystem. A first real increase in number
seems to have happened in the Stone Age, ten thousand years ago. As such,
it has been a long way to 2011 when the world’s population reached seven
billion. As for the dynamic of that increase, there were one billion in 1804,
two in 1927, three in 1960, four in 1974 and five in 1987, whereas reaching
six and seven billion took just twelve years each.
This surge in population growth has prompted much debate among
scholars. In their works Essay on Population, 1798, and The Population
Bomb, 1968, Malthus and Ehrlich respectively warned of the dangers of
famine due to a discrepancy between the number of eaters and the amount
of food. Those concerns were addressed by an increase in productivity and
an advanced food industry, which globally sorted out the problem. It is,
however, worth stressing that in some countries limited resources coexist
with an exploding population:
− Nigeria now has a population of 168 million but in 2050 will
have about 350 million due to a birth rate of 7.6 per woman.
− In India the population renewal rate is just 2.6, not too far from
the 1.1 of privileged countries, but its population will surpass
that of China, due to a high proportion of nubile women.
The percentage of births is presently higher than that of deaths, 5.5
and 1.0 respectively; the result is a population gain of 3.5% and that is set
to double in less than twenty years. As revealed by various demographic
reports, the population is increasing by 85 million per year or, put another
way, one million every five days or 150 a minute.
In its turn, death ’diligently’ provides the required proportion of losses
to gains; people die at various ages in a variety of ways but an equal number
of total deaths and total births is ultimately reached. A couple of figures are

24
Death, friend or foe?

of particular interest in this context:
− The total number of people having lived on Earth until now is
130 billion.
− Each individual currently dies along with a proportion of 1% of
the whole population; in the last couple of years ca. 55 million
people per year died, in other words about 150,000 people a
day.
This ’death production’ has a particular dynamic, in a historically
retrospective sense, i.e.
− In the past, the causes of passing away were
• infections and parasitic diseases, with adolescents being
the most common victims;
• armed conflicts, primarily affecting young adults; and
• the elderly, who were consequently few in number.
− Nowadays, the proportions have changed due to
• a good control of contagious pathology;
• sophistication of military strategy; and
• young people being proportionally fewer, the majority
of victims now being the elderly and those dying from
specific conditions, e.g. cardiovascular, metabolic and
neoplastic.
The above model of the past is ’mimicked’ nowadays in those countries
where, due to a scarcity of resources, a person’s life span is a function of
the biological inheritance from his or her parents and good or bad luck in
terms of catching illnesses or suffering accidents. Even here, in these places
the general trend is improving; the progressive reduction in global average
mortality speaks for itself. Calculated on the basis of a thousand inhabitants,
the global average mortality rate was 12.2 in 1900, 9.6 in 1950 and 7.9 in
2000.
Somehow contrary to the basic ’policy’ of Nature, an impressive
two thirds of global deaths have occurred and still occur in the young
populations of underprivileged countries, putting at risk the very process of
reproduction. Infections and obstetrical pathologies as well as malnutrition
resulting from a lack of economic resources explain why:
− Within an overall infant mortality rate of 4 per second, 6 in
1,000 infants die in Europe whereas as many as 82 in 1,000 die
in Africa
− Also in Africa 3,000 children die of malaria in a single day.
In their turn, the affluent countries have their specific death demogra-

25
Chapter 1
phy, as follows:
− infant mortality below 1/1,000,
− 90% of deaths related to advanced age, and
− five times more cardiovascular deaths now than in the early
1900s and four times more than in underprivileged countries.
It is also of interest that currently, at least in some countries, adult
offspring and orphaned adults are common, 90% of newborns reach
adulthood and, as such, the majority of deaths occur in people of advanced
age.
If a list of the present global causes of death were compiled in
decreasing order they would be: pulmonary infections, diarrhoea, perinatal
and cardiovascular diseases, neoplasia, HIV, traffic accidents, depression,
congenital malformations and iatrogenic pathology. Each of these occurs at
particular ages. Then there are auxiliary – albeit important – factors such
as: malnutrition, lack of sanitation, unprotected sex, alcohol, occupation–
related problems, smoking, sedentary life–style, drugs and pollution.
As a consequence of improved living conditions, man has managed to
postpone death and extend life expectancy. The latter is 83 in Japan and
San Marino, 82 in Spain and Singapore whereas it is only 41 in Angola.
Unfortunately, that same man has managed quite spectacularly to ’cultivate’
death. But, as opposed to Nature, he has done so with no noble biological
aim. To offer a comparison, it is worth noting that:
− Nature has operated through a variety of channels:
• genetic limitations on the duration of life;
• many varieties of pathology;
• plague which killed one third of Europe’s 14th century
population;
• influenza which, in two years of the second decade of
the 19th century, took the life of no fewer than 2 million
people;
• diarrhoea and pneumonia which are the cause of death
of about 3 million children per year, one third of which
die in the first month of life;
• a number of infectious diseases, which are still fully
operational in putting an end to millions of lives: TBC,
malaria, HIV (100 million yearly), hepatitis B and measles;
• smallpox which, although eradicated now for more than
30 years, towards the end of its existence claimed a
quarter of a million victims a year in Asia and Africa;

26
Death, friend or foe?

• cardiovascular deaths, of which there have been 16
million per year, in recent years;
• ischaemic coronary artery disease in privileged countries
and trauma, drowning and asphyxia in underprivileged
countries which are major causes of cardiac arrest (half a
million people per year succumb to this particular cause
of death in Europe alone);
• maternal death, which occurs at a rate of 1 to 100,000 in
Ireland and at a rate of 2,100 out 100,000 mothers–to–
be in Sierra Leone (out of 500,000 cases per year, 99%
occur in underprivileged countries); and
• new conditions for high mortality due to displacement
of death to advanced age, namely neoplasia, with
pulmonary cancer representing a quarter of neoplastic
deaths and gastric cancer three quarters of a million,
while small intestine, liver, breast and oesophagus
cancer each represent half a million deaths.
− Man has facilitated many factors that provoke death:
• Alcohol.
• Tobacco: 100 million died of smoking during the 20th
century and 1 billion are predicted to die in the current
century.
• Of over 1 million lethal traffic accidents, 90% have been
due to human error.
• Violence explains nearly 5 million deaths per year.
• About 100,000 people have lost their lives annualy, due
to various iatrogenic episodes.
As the elderly suffer from a multiple–cause pathology, they often get
’lost’ among various medical specialities, all the –isms and –ologies of
medicine.
To add insult to injury, a supplementary but substantial quota of death
has been, from time to time, associated with extraordinary events including
− natural disasters in our era: 27.5 million – famine, 1.2 million –
earthquake, 1.1 million – flood, 56,000 – Vesuvius and Krakatoa
eruptions;
− purely man–made events resulting in the same huge losses: the
8 crusades over 200 years that killed 9 million people, compared
to armed conflicts in the 20th century alone that generated 110
million deaths, 50 million as a consequence of fighting proper

27
Chapter 1
and 60 million due to the consequent hardships and misery.

1.4. Mechanism of death
Renewal is universal in biology; molecules, organelles, each cell and the
cell mass of the human body, all perpetually change. The driving force of
this complex process is cell division – a process of impressive engineering.
In addition to cell multiplication, this dynamic also ensures the direction
and rhythm of somatic accumulation. As such:
− Young people benefit from a vigorous process from which
emerges a high performing functionality and tissue growth.
− This process, together with cell mass, reaches its zenith at
maturity.
− Cell multiplication then begins to decrease, which leads to cell
depopulation, accompanied by a functional depreciation and
morphologic alterations of the remaining cells.
The number of divisions each cell is able to carry out is closely related
to the mentioned succeeding phases: 50 during the maturation, 40 – 20
during adulthood and 20 – 10 during senescence. This trend explains both
the somatic gain in the young and the somatic loss in older people. The
result of the above is that cell division plays an important role both in
evolution and involution.
The relation between the body as a unit and its comprising cells is a
very complex one, displaying a hypothetical image of unequal parallels:
− We are born with already functional neurons and myocardial
cells.
− Over the course of life, a perpetual process of renewing the
entire cell mass is running.
− This renewal, which is vigorous for a good period of time, later
progressively fades (this fading excludes the sexual cells, an
exclusion that plays a colossal role in species perpetuation).
− The fading culminates with the death of neurons and myocardial
cells, the same cells with which the body was born. As a result
of their death, all the bodily cells begin to die, in instalments
and in a particular order.
This complex cell dynamic is backed by a well–functioning metabolism
– well functioning but not perfect. As an aerobic organism, the human
being gets its energy from oxido–reduction reactions which, at various
rates, are run in every cell. Energy support, homeostasis and oxygen are

28
Death, friend or foe?

all quintessentially necessary for those reactions. Irrespective of the cause,
once the genesis of energy at the cell level is severely reduced, cell functions
get altered and, soon afterwards, morphologic integrity is compromised.
This is the moment of cell death. Having higher metabolism requirements,
the neurons are first to die. The rest of the body’s cells follow the same fate,
in an order dictated by their need for energy, more precisely for oxygen. It
is a picture of a real cascade.
When exactly on the course of that cascade could we declare the
moment of death for the entire organism?
More than any other creature, the human being is an interactive one
(i–life) – a feature that requires well functioning neuronal activity (50). As
such, the death of the body as a whole should be considered to be the
irreversible morphologic change at the neuronal level. This neuronal
vulnerability is explained by
− a high proportion of aerobic status,
− a metabolic rate 20 times higher than that of muscle,
− oxygen consumption representing a quarter of the total
amount, and
− curiously, extremely small reserves of glucose.
A hierarchy in metabolism – oxygen requirements – does exist among
the neuronal structures as well, a hierarchy derived from their phylogenetic.
The time required for irreversible morphologic changes to occur is 5 – 3
minutes for cortex, 10 – 5 for sub–cortical units and 30 – 20 for brain stem;
nota bene, it is important to specify that the last is responsible for vital
reflex activities.
Under normal physiological circumstances, our organism is well
equipped to provide the required generous flow of oxygen towards these
tissues. The necessary cerebral arterial blood flow of 55 – 45 ml/100g
tissue/min. is still secured by a medium blood pressure as low as 60 mmHg,
while a dangerous hypoxia only occurs at a PaO2 of 30 or even 20 mmHg.
Sometimes even lower permissive values are met in routine clinical practice.
This critical point can be reached either slowly or rapidly:
− Slowly, as it happens under usual death circumstances and
chronic conditions with terminal states; hypotension, asphyxia
and acidosis lead to advanced homeostasis alterations with a
real autointoxication. As a result, coma, apnoea and collapse
occur. After neurons, it is the turn of myocardial cells to be
irreversibly affected, causing the heart to stop (a circulatory
arrest, thus specific to biological death).

29
Chapter 1
− Rapidly, sometimes suddenly when, without any premonitory
humoral disturbance, the ejecting function of the heart ceases.
While cardiac arrest is a severe development per se (clinical
death), the homeostasis is not, in the first instance, altered and
– of immense importance – there are some oxygen and glucose
reserves in the lungs and blood. From this moment on, the local
cell changes are similar to those pertaining to circulatory arrest.
The time gap between clinical and biological death has taken an
enormous practical significance; it represents a precious arena for
resuscitation procedures – the pride of modern intensive care medicine.
In real time, it consists of the 5 – 3 minutes required for irreversible
morphologic alterations of the cortical neurons to occur.
In addition to its practical achievements, resuscitation nowadays
challenges the definition of death in that
− mechanical ventilation can be provided for years;
− cardiac function can also be supported for years;
− cognitive function (of a sort) can be regained, as in patients in a
vegetative state, also sometimes after many years; and
− finally, in interventional cardiology settings, cardiac arrest can
be dealt with (‘massage’ by commanded cough) before and
even without loss of consciousness.
The most challenging academic interference created by resuscitation
appears to be related to the so–called brain death. As mentioned in the
previous pages, the notion of brain death evolved from transplant practice,
facilitated as a clinical concept by intensive care. To more closely outline
the matter, brain death consists of a circumstance in which a basic cardiac
function still exists but the respiratory function is fully controlled while, as
far as the cognitive function is concerned, not only is it completely absent
but there are distinct signs that it will never be recovered. As a result of
irreversible morphologic changes at the brain stem level (with a hypoxic
tolerance of 30 – 20 minutes), it definitely excludes any cortical recovery
(hypoxic tolerance of 5 – 3 minutes) and thus any interactive life. This
important detail has led to a new version of a death definition, namely the
absence of those respiratory and cardiac functions, which then results in
irreversible morphologic alterations at the brain stem level.
In the courts of justice, this ‘eccentric’ sort of death is considered
to be a human invention. In fact, a clinical scenario of brain death in its
naked version is the direct result of a highly technical alchemy, mise en
scene by an intensive care armamentarium. In applying this legal definition

30
Death, friend or foe?

and extracting fully functioning organs from a dying patient, beating
heart included, transplant medicine flagrantly defies the precepts of the
Hippocratic Oath.
Attempting to select from this chapter elements attuned to Radiscev’s
rhetoric:
− It is miraculous how high–performing and vital the governing
nervous structures are, on one hand.
− On the other hand, given their high–energy demands, it is
surprising even puzzling to learn how vulnerable the supply of
oxygen and energy resources is.
This discrepancy ought to make an inquisitive person suspect a
biological conspiracy: a conspiracy of such cunning engineering that only in
the nature of Nature could it be imagined. In dealing with Death, this book
dares to speculate that this metabolic ‘imperfection’ serves as a tool for the
easy ‘handling’ of death. Being so interdependent, a prolific Life has to be
matched with a handy Death.
Finally, to address the title question of this chapter, a natural, timely
death does have a part to play as a friend – a precious friend. It’s the
inopportune death that can be labelled a foe – a dangerous foe.

31
2. Ageing
(39, 98, 168, 228, 248, 260, 289, 295)

2.1. Introduction 33 2.5. Functional features 39
2.2. Cell aspects 35 2.6. Frequent experiences 42
2.3. Ageing demography 36 2.7. Prescribing medications 42
2.4. A social approach 37 2.8. Mortality in the elderly 44
2.9. Premature ageing 45

2.1. Introduction
Philosophically, ageing has much to do with death. Both are
physiological, universal, and compulsory. Any creature, system, organ,
tissue, or cell – to list the entire series of structural units in biology – has to
get old and eventually die.
Creatures vary considerably in how long they live. The typical life
span of a particular species results from its genetic equipment and its
adaptation achievements. Born with a given vigour, individuals must look
for the requisite amount of nutrients and successfully confront threats in
order to reach somatic maturation. Once reproduction and the required
contribution to species perpetuation are accomplished, death is the next,
and last, important step of existence – a step that plays an important part
in the process of biological recycling. Exactly how long it takes for death to
occur is not desperately relevant. What is relevant – to Nature – is that it
does occur, that it contributes to the process of natural selection.
Be it short or long, the interval between reproduction and death is
euphemistically known as advancing in age or ageing. Not all individuals
‘manage’ to get older and those who do, do it for varying periods of
time. It all depends on genetic inheritance, life–style and the degree of
environmental hostility. While ageing is not, academically, considered a
pathological condition and consequently cannot be used administratively

33
Chapter 2
as a cause of death, the number of deaths rises proportionally with age. As
demonstrated statistically by Gompertz nearly one century ago, over the
age of 30 the quota of deaths doubles after each period of seven years.
This derives from genetic erosion firstly and metabolic wear and tear
immediately thereafter. This decrease in natural resistance exposes old
people to a progressively severe pathology. As such, advanced age is not
a cause of death per se, but a sort of runway for an increasing number of
pathologies, facilitating the fatal course of the conditions concerned.
This degenerative process is derived from the interaction of a multi–
faceted life–style with a genetic background. There are a number of findings
in support of this approach, as follows:
− Genetic component
• Cell changes are similar in monozygotic twins but
different in dizygotic siblings.
• The maximum number of cell divisions is closely related
to the length of life: mouse – 15 divisions, 3 years;
human – 50 divisions, 82 years; Galapagos tortoise – 110
divisions, 175 years.
• In progeria (a specific genetic condition) patients develop
symptoms of ageing even before maturation.
− Living circumstances
• A captive mouse, being protected and sheltered, will live
3 years, whereas in the wild it lives only 10 months.
• After losing their teeth, a goat and an elephant will die
of starvation, while assisted feeding can prevent such a
death.
• As mentioned elsewhere, the human life span has
substantially increased in recent centuries due to the
improvement in living conditions.
As with death, and just as curiously, medicine does not have a coherent
and satisfactory definition of ageing. There is, on the other hand, no lack of
explicative theories; Medvedev is credited as listing no fewer than 300 of
them (88).
Again, like death, ageing is – from a cell point of view – a heterogeneous
process:
− We are born as a ‘federation’ of cells, each having a particular
age, higher than the birth age of the individual. From this point
on, each cell community follows its dynamic of dividing and,
consequently, of ageing.

34
Ageing
− The very background of ageing is a metabolic one; the neurons
and myocardial cells do not divide, but this does not necessarily
mean they do not get older.
− Here is a good place to mention that, whereas we are born with
already functional neurons and myocardial cells, we die not
only after their death but as a consequence of their ageing and
death.
− As such, the cells composing a human body all get older, each
with a given dynamic corresponding to the cell type. One gets
older cells, older cell communities and, as a result, an older
body as a whole. The body gets older with its entire mass of
cells getting older, in terms of a decline in both number and
vigour.
There is, however, a famous exception – that of the germ cells.
Irrespective of the birth age of a parent, as long as the gametes can be
‘produced’, they come to life entirely comme–il–faut, with perfect genetic
equipment, metabolic functionality and no morphologic fault. This
demonstrates, in fact, Nature’s skill at securing a fresh new exemplar
from a predecessor no matter how old. An exhausted organism dies but
a fresh descendant results. This trick still makes a great deal of trouble for
geneticists.

2.2. Cell aspects
Even in a favourable environment, that of a laboratory culture, cell
multiplication is not endless. Hayflick’s number, found in the related
literature, is the maximum division of a given cell. In the case of the
fibroblast – the cell studied in human beings – this number is 50. Once such
a number is achieved, a senescence of replication leads unabatedly to a cell
arrest. This ageing up to death, occurring under perfect living conditions,
speaks for itself of an intrinsic mechanism of metabolic breakdown and cell
milieu impairment. Such a mechanism undoubtedly has a genetically driven
input and, presently at least, very little if anything can be done to tame it:
− Like many other cell functions, the division needs a given
genome stability.
− Telomeres – the ends of chromosomes – are loose DNA
molecules and, consequently, are shortened with each cell
division cycle.
− This, therefore, alters chromosome stability in the nucleic matrix.

35
Chapter 2
− When shortening reaches a critical point, the process of division
ceases.
− The telomeres’ performance can be improved or even recovered
by the action of a specific enzyme, telomerase, which is capable
of re–synthesising DNA molecules; this enzyme is found in high
proportions during embryogenesis, in genetically privileged
germ and stem cells, as well as neoplastic ones.
− In progeria cases, as already mentioned, the degenerative
changes begin before maturation.
− The turnover of genetic structures is quite consistent – 80,000
basic DNA changes/day; this is why an imbalance of genetic
changes between depreciation and recovery seems not only
possible but also a common reality.
Once metabolic erosion is in motion and cell arrest has occurred,
ageing is followed by apoptosis – a cell death also genetically controlled.
Hypothermia, particularly a rapid and profound one, is able to stop ageing–
related changes. Cell recovery has been reported after as long as 32 years.
Finally, the cell is not the sole ‘venue’ for ageing; the interstitial
compartment suffers as well. The proportion of water reduces, membrane
traffic is diminished, and collagen – an important component of intercellular
space – progressively contracts.

2.3. Ageing demography
The Neanderthal hominid used to live no longer than 40 years and,
in their turn, our ancestors lived not much longer. The genetic pattern,
unchanged for tens of thousands of years, should have in theory allowed
for today’s 115 to 125 year maximum. These ancestors did mature both
somatically and sexually, managing to secure reproduction and, thus, the
perpetuation of our species. But this happened in the context of extremely
unfavourable, even cruel, living conditions and, especially, the extensive
pathology related to giving birth and to childhood. It was only in the last
few millennia, and mainly in the most recent centuries, that societies have
managed to better organise themselves and to improve living conditions.
These changes are what have expanded our life span, with a particular
demographic trend. Among the features of this trend, one should mention
the following:
− Global mean life expectancy was 48 years in 1955 and 65 in
1995, with a predicted increase to an estimated 73 in 2025;

36
Ageing
this is due to an infant mortality rate of 148, 59, and 29/1,000,
respectively, and it largely reflects improvements in living
conditions.
− Current extremes of life expectancy are 83 years in Japan and
41 in Angola, with infant mortality of 4.3 and 169.3/1,000.
These values are directly influenced by the economic resources
of the mentioned countries; in Japan the income per capita is
150 times higher than that of Angola.
− China’s rapid economic growth is of a nature to perfectly attest
to the above relationships.
− The earth’s population recently reached 7 billion and is
predicted to reach 9 billion by the middle of this century. This is
partly due to a higher birth rate in countries such as India and
Afghanistan, but mainly due to the global rise in the average
age; as such, more children are growing up while fewer adults
die before reaching a very advanced age.
The direct result of the above trends is an obvious expansion of the
elderly population – a context in which
− in 2000 there were 605 million people over 60 years of age and
there will be 2 billion in 2050 – a doubling, from 11 to 22%;
− an increasing number of old people reach the age of 100 (in
2010 there were half a million centenarians and there will be 2
million in 2050);
− due to a combined man–made surge in economic status and
an imposed lower birth rate, China will certainly be confronted
with an ageing population (the rate of people between age 15
and 59 to those over 60 will decrease from 5/1 to 2/1 in 2040 –
a matter of significant economic concern).

2.4. A social approach
Despite its many achievements, humanity today is confronted with a
new, troubling development, that of an increased number of old people:
− In 1990 two thirds of Americans died before 65 years of age
whereas the same proportion today dies after 65.
− It has been calculated that the rate of people aged over 65 to
those under 20 will increase from today’s 16/100 to 31/100 in
2025.
The combination of genetic inheritance with the large variety of living

37
Chapter 2
conditions in a given society explains the heterogeneity of age achieved
by different communities in different geographical areas. As always and
everywhere in biology, populations stratify themselves according to the age
achieved. The world champion to date is a French woman deceased in 1997
at a documented age of 122. Popular tales and the Bible speak of longer,
even fabulous, ages for their heroes, but without offering any concrete
evidence. Some accounting aberrations have been identified; upon review,
Methuselah – the biblical age patriarch – seems to have been not older
than 72 (161).
Age is not an exclusive parameter of biological performance; one
meets new mothers of 70 years old and genetically verified fathers of over
80, while Cassals gave concerts at 88 and Picasso still painted up to the age
of 90. For Mother Nature, however, the above details are eccentricities. She
is by and large more considerate of her biological obsession with natural
selection and species perpetuation. As far as human beings are concerned
− They were equipped with a generous cellular genetic ‘allowance’,
again of 115 – 125 years.
− Their reproductive abilities are no less generous:
• Ovulation is launched around the age of 10 and, until
menopause, runs unabatedly once a month.
• In their turn, the spermatozoa from a single man could,
in terms of number, populate the entire earth in half a
year.
− It is only due to the vicissitudes of life that the planet has not
been overpopulated; this danger cannot be entirely excluded
today, since
• on one hand, the devastating ‘death operatives’ (infant
mortality and epidemics, for instance) have been brought
under control and,
• on the other hand, military strategy has been changed to
rely less heavily on large scale physical death.
Regarded from a historical perspective, an ever–extending life span
such as what we now enjoy appears to be a fruit of civilisation and, for any
society, a real luxury. But, as with any hard–won reward, there is a down
side:
− Given the pathological baggage of old age, an elderly person
can expect to fall prey to a number of specific clinical conditions
such as cardio– and vasculopathy, cancer and many metabolic
disorders.

38
Ageing
− Advanced age per se is not a cause of death but, with a pathologic
burden such as the above, it does facilitate fatal episodes under
wide–ranging circumstances.
− This geriatric pathology does not come cheap:
• The elderly represent 60% of hospital admissions.
• Old people are responsible for 70% of hospitalisation
days.
• They consume one third of the entire health budget of
the organised world.
One might be tempted to say that the single best way to avoid the
troubles of ageing is a death before getting old!

2.5. Functional features of ageing
Commonly, ageing is a slow but one directional process. From a
medical viewpoint, this process consists first of an increasing number of
malfunctions and, later, organic changes. Both plays a part in promoting
a favourable background for different pathologies which, combined,
represent an obvious pathway to death.
Nervous system
− Neural population (brain weight), blood flow, neurotransmitters,
memory, attention, verbal fluency, logic analysis, reflectivity
and balance components are all reduced.
− Muscular cramps frequently occur, particularly in men.
− Sleep, by far, poses the most common trouble. It is quite
depressing not to have a good, comfortable sleep at an age when
lack of time is no longer a problem. Professional background,
education, and instruction level may to some extent help
people to accept the above inconveniences.
− In addition, in particular men experience micturition difficulties
and snoring.
Sensorial function
− After 65 years of age, visual acuity is reduced in 40% of men
and 60% of women. Cataracts, quite frequently, and sometimes
macular degeneration are the causative factors. The secretion
of tears is decreased in the majority of cases, meaning many old
people experience a sensation of sand in the eyes.
− Hearing troubles are, probably, the most frequently encountered
problem, again mainly in men. In addition to hypoacusis,

39
Chapter 2
frequent tinnitus and poor high–frequency sound perception
make conversation more and more difficult.
− Smell and taste have a higher threshold, a reason the elderly
tend to like foods more sweetened and well salted.
− The lack of balance, sometimes accompanied by dizziness and
headache, is also a frequent complaint.
Endocrine system
− The secretion of most hormones is reduced, including
testosterone, oestrogens and progesterone, growth hormone,
thyroxin, and calcitonin.
− Leading up to andro– and menopause, there is a progressive
hypofunction and hypotrophy of the sexual organs and
diminution of muscular mass and bone density. Interestingly,
hormone replacement therapy does not prevent the above–
mentioned changes.
− Cortisol remains practically unchanged.
− Although produced in the same amount, insulin is only partly
released into circulation, causing a false resistance to it.
Cardiovascular function
− The number of pacing cells reduces by up to 10% from the
initial amount, which explains the occurrence of bradycardia
or even a–v. block, a modest response to any stimulus, various
dysrhythmias and, in one third of the elderly population, atrial
fibrillation.
− Both ventricular distension and filling, as well as contraction
and ejection, are progressively reduced; an atrial compensation
of filling usually occurs, but the mechanism is inoperative in
cases of atrial fibrillation.
− The valves become thick and less mobile.
− Atherosclerosis develops throughout the vascular bed, but it is
more apparent at the carotid and coronary arteries and aorta.
− Arterial hypertension is common, as is postural and postprandial
hypotension.
− Haemodynamic compensation in the elderly is less prompt and
often incomplete.
Respiratory function
It remains satisfactory a good share of the time, dyspnoea occurring
after heavy meals and physical effort.

40
Ageing
− The thorax becomes emphysematous – setting the stage for
obstructive bronchopneumopathy.
− After 65 years of age alveolar diffusion is impaired up to 50%.
− Coughing is efficient for a period of time, sputum retention
occurring later.
− Ciliary activity is decreased.
Oxygen saturation of the blood – a very reliable parameter – goes down
to 75, or even 70 mmHg in those over 80.
Digestive function
− Tooth pathology causes enough trouble to make feeding
difficult.
− The tongue loses its tone, becomes more voluminous, and is
frequently bitten.
− Peristalsis is diminished, intriguingly at the oesophagus and
sigmoid levels.
− Hepatic function is depressed; the number of hepatocytes is
reduced to one third of that in those 30 years of age.
Excretion
− A reduction of 1% per year, 50% at 70 years of age.
− Reduced concentration capacity and, consequently, hyperfiltra-
tion.
− Impairment of hydro–electrolytic balance.
− Due to reduced tone of the pelvic muscles, women lose
urine involuntarily, while men with prostate hypertrophy find
urination laborious.
Locomotor organs
− Osteoporosis exposes vulnerable areas to various fractures.
− As the ligaments and tendons lose their elasticity, the elderly
trunk bends forward, while the emphysematous thorax is an
important part of the appearance associated with old age.
− Many degenerative alterations in practically all the joints also
develop.
− The intervertebral cartilage is ossified and reduced in volume,
resulting in a significant loss of height and a further degree of
bent posture.
− Muscular mass diminishes starting at the age of 30, with 25% by
age 70 and 40% by age 80.
The above series of changes leads to an increased risk of fractures, a

41
Chapter 2
modified gait and slow movement.
Skin and integument
− Thin skin is common, with many pigmentary lesions and basal
cell carcinoma being quite frequent.
− Sweating is reduced, with a less unpleasant smell.
− Head hair greys and thins, moderately in women and drastically
in men who often develop alopecia.
− Additional hair appears in the external auditory canal mainly in
men, and on the upper lip in women.
− Nails grow more slowly and become more fragile.
Blood and the immune system
Anaemia is frequent and hypoxia tolerance low, while the vigour of
produced antibodies diminishes. As a whole, anti–infection capabilities
are reduced in older people; this is, inter alia, why pneumonia appears so
frequently in this age category and so often leads to death.

2.6. Frequent ‘experiences’ linked to ageing
An old person is not a patient by virtue of being old. He may not be
a patient proper, but he is definitely a patient–to–be due to his inevitable
entanglement in the unfavourable functional and organic changes listed
in the previous pages. Taken together, these changes give rise to a series
of well–known gerontological syndromes such as bent posture, unstable
gait, postprandial hyperglycaemia, unstable blood pressure, and loss of
osseous and muscular mass. These are the gerontological syndromes within
which a serious condition can emerge at any given moment. Then there
are, of course, the numerous experiences quite typical of, and specific to,
the elderly community, the most frequent being: falls, urinary and faecal
incontinence, decubitus lesions and dementia.

2.7. Prescribing medications
Although comprising 15% of a given community, the elderly consume
30% of the health budget in western countries, using 40% of total
medications prescribed. Two thirds of those over 65 years of age currently
use medicines, while one third of those over 75 use at least three medicines
each.
Any given old person may use many medicines. There are, however,

42
Ageing
dedicated medicines for the elderly, including cardiovascular, anticoagulant,
metabolic, anti–asthmatic, and anti–rheumatic, as well as sedatives and
sleep facilitating drugs and medicines for the prostate, etc.
As these are taken largely per os, it is important to consider that,
on the one hand, hypotrophy of the gastric mucosa reduces absorption
into the blood and, on the other hand, the decreased hepatic clearance
allows more from the absorbed proportion into circulation. Then, renal
clearance is reduced, while the relevant category of the nervous system
is more sensitive to medications such as benzodiazepines, opiates, and
neuroleptics. As older people always have co–morbidities and are often
on many medications, adverse reactions are not only possible, but more
frequent and often more severe.
Frequent pain is a good reason for prescribing many analgesics:
− After the age of 65, 80% of people suffer various sorts of pain,
mainly those caused by degenerative osteoarticular conditions:
40% joints, 15% various fractures and 10% musculoskeletal
trouble.
− Being ‘experienced’ sufferers and, thus, tolerant to analgesics,
the elderly generally require higher doses.
The postoperative period deserves much attention due to
− the significant number of advanced–age patients, a quarter of
surgical activity being devoted to them; and
− new, liberal surgical policies, which often mean an unrestrained
approach that results in complex clinical settings.
In order to select the best analgesic and its appropriate dose in a
particular setting, it is worthwhile to quantify the level of pain. But pain
scales are notoriously unreliable. Therefore, alternatively, the clinical
response to pain becomes important: assessing apprehension, hypertension,
tachycardia, tachypnoea, sweating and so forth.
As far as postoperative analgesic techniques are concerned:
− The regional one should always prevail.
− Association of an anti–inflammatory is encouraged.
− Opiates may be deliberately used, but an appropriate dose is
essential; pethidine, unfairly undervalued by some hospitals, is a
good analgesic and, additionally, a very effective anti–shivering
remedy. It also could be used for epidurals; muscle relaxation is
modest, but analgesia is good without haemodynamic instability.
While the extension of surgical stimulation is, for certain procedures,
equal to that in other age groups, the analgesic policies are rather restrictive

43
Chapter 2
concerning the elderly. The side effects of strong painkillers are an important
issue and the potential danger often restrains an efficient treatment of
pain. The best way to manage a satisfactory analgesia, with acceptable side
effects, is to administer the drug by titration.

2.8. Mortality in the elderly
Each period of life has its features when one dies. Small children are dying
in considerably fewer numbers, whereas old people are dying progressively
later. They die later, but they do die. There are two ways the elderly die:
− languishing, a demise after suffering a lengthy and wasting
condition such as cancer or a metabolic or cardiovascular
disease, or
− acutely, a sort of switching–off caused by sudden complications
of an on–going illness.
One of the most frequent causes of death in the elderly is infection.
Accounting for about 35% of hospital admissions, infections are respiratory
– 52%, urinary – 25%, or cutaneous – 18%. The intrinsic causes of these
high proportions are
− impaired circulation, reduced cough reflex and ineffective cough;
− diminished immune capacity, both cellular and humoral;
− life–style facilitated infections; and
− invasive equipment such as catheters and pacemakers.
Infections occur predominantly during winter. The proportion and age
structure also differ by geographical area: British statistics reveal that 40,000
cases occur annually in people over 55 – a rate that abruptly increases after
75 years of age. The main causes are
− poor sources of seasonal food;
− less effective thermoregulation;
− weakened haemodynamic and respiratory compensation
mechanisms;
− low level of reflectivity;
− thrombotic episodes of varying degrees of severity;
− extra oxygen consumption driven by cold, which lowers the
coronary and cerebral supply, thus promoting ischaemic attacks;
− cold air which, when inhaled, makes contact with the huge inner
surface of the lungs, often causing severe vasoconstriction; in its
turn, the resultant hypoxia can suddenly increase the pressure
load on the right side of the heart.

44
Ageing
Dangers do exist in summertime as well. Thermoregulation is an
extremely demanding process; this is certainly why 80% of those who die
from subarachnoid haemorrhage are over 55 years of age.
Due to improvement in common living conditions, people generally live
longer. Compared to 30 years ago, 19% of women and 22% of men die after
having reached the age of 80. As these figures reveal, women tend to die
later than their partners. This is not necessarily due to an extra robustness
but rather to a better tolerance of the demands of old age.
Returning to postoperative mortality, nowadays, in elective cases, it is
under much better control. Unfortunately, this is not the case in emergency
circumstances. An advanced pathology exacerbated by an acute episode is
not always easily confronted with a tailor–made surgical approach. As far as
anaesthetic mortality is concerned, the figures are frequently misleading.
This derives, firstly, from the difficulty of precisely allocating the legal and
human responsibilities in a complex medical act such as the anaesthetic–
surgical one. Anaesthetic strategies are, in some places, so strict that a
death caused by the anaesthetic procedure alone is not legally accepted.

2.9. Premature ageing
Obviously, no human being is able to remain young. Apart from those
who have died young, nobody in all of history has ever escaped getting old.
Ageing is typically a slowly progressing process; however, the rate of the
process differs from person to person depending on genetic inheritance,
individual living conditions, and the pathological curriculum. This is why we
can usually only approximate someone’s age and often enough resort to
guessing.
Delayed ageing as a pathological entity does not really exist but
premature ageing does – sometimes even before maturation. Three clinical
entities are of interest.

2.9.1. Progeria
Also named Hutchinson–Gilford syndrome, this is a rare and curious
condition with an incidence of one case in 8 million newborns (about
150 cases reported to date). It essentially consists of premature ageing,
occurring in both sexes and all races. Its etiology is a genetic one, a mutation,
with quite an intriguing pathogenesis. Unlike other mutations, this one is
not passed down in the family. It is a sort of ‘chance occurrence’ affecting
the gametes just before conception, the parents not being carriers. The

45
Chapter 2
LMNA, the affected gene, no longer encodes the prelamin A, leading to a
severe disruption of the building process of the nucleus membrane, thus
compromising necessary cell robustness.
The main feature is early and rapid ageing. The newborn appears to
be normal but slow growth and the loss of hair are the first signs, already
apparent in the first year of life. Later on, ageing continues at a rate about
ten times quicker than normal; as a result, life expectancy is severely
reduced – to about 13 years. Most patients die between 10 and 20 years
of age.
The clinical picture becomes more marked as the child ages, becoming
florid within only a couple of years. The most important signs are
− slow growth, with below–average height and weight;
− disproportionately large head with
• a small and narrow face,
• a small lower jaw,
• thin lips,
• a beaked nose, and
• protruding eyes with incomplete closure of the eyelids;
− hair loss, including eyelashes and eyebrows;
− thin and wrinkled skin;
− loss of subcutaneous fat;
− prominent veins on the scalp and hands;
− hearing loss;
− scleroderma, mainly at the trunk level;
− high–pitched voice;
− delayed and abnormal tooth formation;
− musculoskeletal degeneration, including
• loss of muscular mass,
• stiff joints and hip dislocation, and
• fragile bones.
− rapid advance of degenerative changes in the cardiovascular
system; acquired atherosclerosis, which explains frequent
cerebral ischaemic attacks and myocardial infarction (direct
causes of death in 90% of cases);
− insulin resistance and consecutive diabetes; and
− kidney failure.
To conclude, unlike in ‘real’ old people, metabolic ‘wear and tear’
does not occur and motor and mental development remains normal. It is,
logically, difficult to imagine these patients achieving a fertile status. The

46
Ageing
medical literature mentions, however, the case of a woman who delivered
a healthy offspring.
It goes without saying that, at this stage, there is no cure.

2.9.2. Werner syndrome
Named after a German scientist (who, at the beginning of the previous
century, extensively studied a group of four siblings), this entity is also known
as adult progeria or progeroid syndrome. There are about 1,500 reported
cases. Also genetic in type (a mutation of the gene WRN and a telomeres
instability), this condition has an average incidence of about 1/10 million
but is much higher in Japan and Sardinia – 1/100,000.
The affected individuals typically grow and develop normally until
puberty, the mean age of diagnosis being 24. After this age they exhibit,
very much like in progeria cases, loss of hair, mainly from the scalp, growth
retardation, short stature, premature hair greying, thin and wrinkled skin,
scleroderma–like lesions, beaked nose, loss of fat tissue (mainly from the
arms and legs), high pitched voice, gonad hypotrophy and reduced fertility.
Diabetes, atherosclerosis, vascular changes, osteoporosis, telangiectasis,
cataracts and a tendency to develop malignancies are also an important part
of the pathologic inventory. Heart attack and cerebrovascular ischaemia are
what cause the death of these patients. They rarely live more than 50 years.

2.9.3. Wiedermann–Rautenstrauch syndrome
Also known as neonatal progeroid syndrome, it starts in the womb with
ageing signs already apparent at birth.

47
3. Terminal illness
(4, 14, 99, 133, 213, 267, 295)

3.1. A general view 49 3.3. Medico–legal aspects 55
3.2. Therapeutic needs 51 3.4. Dying soon 56

3.1. A general view
For a long time, ‘healers’ dealt primarily with pain and discomfort, with
making suffering more tolerable. It was only a couple of centuries ago that
medicine started to embrace a more effective approach, by concerning itself
with the causes and follow–up of diseases themselves. Despite advances in
understanding the pathogenesis and identifying appropriate treatments,
there are conditions from which recovery is not possible and for which
significant improvements are no longer achievable. These are incurable
cases that – sooner or later – result in death.
Alive, but with no hope of a better life, such patients have no choice but
to keep living until the moment of death. This ‘carrying on’ – a real burden
for both the patient and his family and the care unit alike – is a period known
as terminal illness. The kind of treatment these particular patients require,
which primarily addresses pain and a good number of complications, is
known as palliative. Together, the two are constituent parts of palliative
medicine. A British concept, it originally dealt with patients in the advanced
stages of cancer, but today it also encompasses many other chapters of
pathology, such as motor neuron disease, HIV, etc.
In concert with other administrative and ethical requirements of the
World Health Organisation (WHO), this modern aspect of medicine follows
particular standards, some important features being
− to support life while, at the same time considering death to be
a natural event;
− as such, to neither hasten nor prevent death;
49
Chapter 3
− to comprehensively address pain and any other sort of
discomfort;
− to include psychological and spiritual assistance;
− to encourage an existence that is as active as possible; and,
finally,
− to help and support the family.
As 70% of deaths are caused and preceded by a disease, it is now
possible to approximate the dynamics of the remaining life and, in theory,
when the patient is likely to die. By definition, such a case is in the terminal
phase and the patient is expected to die in 6 to 12 months (313). Belonging
to this category are
− patients who will die within hours or days;
− those suffering from advanced, progressive and incurable
conditions in addition to having a number of co–morbidities;
− those suffering from a pathology associated with a real risk of
death as an acute event or as the result of a catastrophic event;
− extremely premature newborns with low chances of survival;
− patients in a persistent vegetative state, where an interruption
of the on–going treatment could lead to death.
Considering the above groups as a whole, patients in a terminal phase
represent a very heterogeneous community of all ages and both sexes
suffering from a large variety of conditions. They may all be on different
therapeutic regimens, but the one thing they have in common is that they
have reached a stage of incurability. It is a stage at which there remains for
medicine only one goal: to encourage respect for human dignity, namely to
aim for no pain and as little physical discomfort as possible. Such a patient
has to be able to reconcile himself to his situation and be in a position to say
good–bye to his family and leave behind positive memories.
Two categories of cases require an additional comment:
− When the patient is elderly, this automatically means co–
morbidity, a lower tolerance to any other pathology and more
rapid decompensations.
− Quite a few terminal patients are dependent on high–tech
equipment, pacemakers, defibrillators, cerebral and spinal
stimulators, plexus and epidural catheters, continuous vital
drug infusion or even ventricular assistance devices. All of
these, by definition, come with a heavy pathologic burden,
including supplemental medication to support the functioning
of technical components as well as the numerous problems

50
Terminal illness
bound to arise from the maintenance care itself. For such
patients, the machinery alone often poses technical problems,
potentially with substantial risks.
Given the many and complex therapeutic problems associated with
these cases, the care unit hosting them plays a role as well:
− Apart from patient subgroups requiring high–tech assistance, a
hospital bed is not fully justifiable.
− Home, for the large majority of patients, is quite acceptable; it is
worth noting, however, that not all family members are prepared
or in the position to assume such a level of responsibility; it is
costly, time and labour intensive and sometimes risky.
− Hospices are probably the best place, at least in theory.
Unfortunately, the lack of financial resources and personnel
makes this option not always feasible.
Irrespective of the venue, such cases should be handled by a dedicated
team led by an experienced nurse having permanent access to professional
medical advice, as well as a coordinated team including a care giver,
psychotherapist, psychologist, social worker and, if possible, a church
representative. Given its particular demands, care of this kind is not practised
anywhere with a great deal of enthusiasm. This is because it represents
− a loss for the family concerned;
− an unappealing area of care for providers;
− great expense at all levels; and,
− given that the patient is going to die, the permanent loss of
resources.
Understandably, funding represents a significant problem in any society,
irrespective of its standards. It is, therefore, advisable that individual in-
surance be arranged well in advance.

3.2. Therapeutic needs
Psychologically, the terminal phase is difficult enough to bear.
Unfortunately, quite often if not always under such circumstances, a variety
of unpleasant experiences are also encountered – most notably pain. While
essentially nothing can be done about the causative disease proper, much
is necessary on this front.

Pain appears in 30 to 70% of these patients. Dubbed ‘a sign of life’, pain
nevertheless requires rigorous localisation and treatment irrespective of the

51
Chapter 3
variety, be it nociceptive, visceral, or neuropathic. Secondary effects should
not restrain practitioners from choosing the most appropriate analgesics,
regardless of the required dose. Only under special circumstances should
some restraint be exercised; Maria Theresa, for instance, refused morphine
in order to be mentally clear when she was to meet God.
From the strong painkillers available, non–steroidal (acetaminophen
and ibuprofen) and steroidal (dexamethasone) varieties are tried before
morphine, methadone, or other opiates. It is also worth mentioning that
− a dose limit does not exist; and,
− once again, side effects, if any, do not need to be vilified (85).
It goes without saying that a regional analgesia is always preferable, and
non–drug remedies such as radiotherapy and acupuncture should be tried
as well.

Dyspnoea also frequently occurs and, as it causes much discomfort,
has to be dealt with. Its origin is multi–factorial and there is no practical
need to monitor humoral changes (blood gases, pH, etc.). Dyspnoea can be
caused by
− Co–morbidities such as pleuropulmonary complications
(pneumonia in particular) and compensatory consequences
of a cardiac failure. Being treatable, they must be addressed,
particularly pneumonia.
− Worsening of the underlying condition as in, for instance,
a bronchopulmonary neoplasm. In such cases, there is no
justification for attempting complex and expensive procedures
such as using a bronchial stent.
The most reasonable approach would be to inhibit the respiratory centre
and thus alleviate the level of dyspnoea. Codeine, pethidine, methadone,
and morphine are the drugs of choice in these cases.

Depression
Given the sort of pathology and the sombre future these patients
have, it is entirely understandable for them to experience sadness, anxiety,
irritability, and nervousness. These are all elements of a depression
epiphenomenon, occurring in as many as 75% of cases. When these
elements are progressive and severe, the depression becomes a condition
in itself, as in 25% of cases. Certain medications, alcoholism, and social and
family isolation are all aggravating factors. With fewer illusions about the
indestructibility of life and with weakened cognitive function, older people

52
Terminal illness
tend to develop less severe depression.
Regardless of its type, depression is difficult to treat and is often
associated with well–known complications such as falls and delirium.
Treatment has little chance of complete success, but any success is welcome
in these circumstances. As pain is so common and, as it plays a real etiologic
role, an appropriate analgesic should always be considered. Psycho–
stimulants, energy boosters, antidepressants, and a benzodiazepine are, or
can be, of help.

Delirium
As the terminally ill do not usually die suddenly, there is time enough
for neurological complications to appear – delirium in the first instance. Its
genesis derives from metabolic and circulatory alterations at the level of
the central nervous system. Occasionally, the delirium takes on a violent
dimension – a circumstance when physical restraint, unfortunately, becomes
necessary until a suitable pharmacological alternative can be found.

Insomnia
This is a ubiquitous component of any terminal phase. Patients either
cannot sleep or have a reversed sleep pattern, both variants substantially
increasing the level of discomfort. The causes are multiple: isolation,
confusion, side effects from various medications and, as in any other
functional disturbance, pain. As such patients always have poor biological
health, it is difficult to construct a realistic sleep schedule. Therefore, quite
often sleep must be replaced by some sort of diversion. It is advisable to
consider the education and the personality of the individual in selecting
the most suitable type of music, videos or reading material, etc.

Cough
So long as a cough has a reasonable frequency and force and is
particularly productive, it must be encouraged. When it is a sine materia
event, however, and occurs during the night time, it should be actively
treated. Possible remedies include
− various antitussive recipes per os, Silomat parenterally;
− simple steam inhalation;
− hot compress on the sternal area;
− bronchodilators and anti–asthmatic medications;
− opiates such as codeine, methadone and morphine;
− nebulisation with 2% xylocaine;

53
Chapter 3
− an appropriate position in bed.
It goes without saying that the causative factor should be identified and,
whenever possible, dealt with.

Digestive troubles
Under palliative care circumstances, the nutrition of terminally ill
patients remains largely dependent upon their own physiology. As the
digestive system consists of many diverse organs distributed over different
bodily areas, it is not at all surprising that a terminally ill person nearly
always confronts a number of digestive dysfunctions. The most common
are anorexia, ‘dry mouth’, nausea, dysphagia and – above all – constipation.
The origins of these conditions lie in the pathology from which the patient
suffers; the organic consequences of surgical treatments, a significantly
impaired life–style and especially the secondary effects of medications. It is
a vast arena in which the following require particular attention:
− Anorexia should not be a cause for concern since an empty
digestive tract causes far less discomfort than a full one.
− Dysphagia is eased by the restraint of feeding.
− Dry mouth is easily managed with good mouth hygiene.
− Nausea, being so distressing, must be diligently addressed;
scopolamine and ondansetron are most frequently used.
− Constipation requires an active approach as, in addition to the
discomfort, it causes anal dysfunction. A low–fibre diet, physical
inactivity, being bed ridden, and opiate medications are the
usual causes. It is worth noting that, selectively antagonising
the peripheral opiate receptors, methylnaltrexone
• does not affect the action of opiates on pain receptors;
but
• does affect it at the level of the large bowel, among other
areas, thereby reducing the probability of constipation.

Hearing and visual loss
Impaired biology, in general, and advanced age, in particular, represent
a common context for various degrees of hearing and vision loss. The
underlying pathologies are the involution of hearing elements and wax
blockage, on the one hand, and cataracts and glaucoma, on the other.
Fortunately, in most cases, these have suitable and rather cheap remedies:
functionally acceptable auditory prostheses and lens implants are now
readily available.

54
Terminal illness
As emphasised, terminally ill patients desperately need particular
medications for their comfort, including those requiring special methods
of administration. In addition, such cases often involve complications in
the use of intravenous and oral administration. This is why it is sometimes
necessary to turn to less conventional methods, such as cutaneous,
subcutaneous, inhalation, sublingual, rectal. The care team has to balance
the expected results with the shortcomings of non–orthodox ways of
administering medicines, fluids, ointments, etc.

3.3. Medico–legal aspects
The dynamics of medical care for the terminally ill are such that
quite often – 42% according to recent statistics – the patient’s opinion is
absolutely required. Furthermore, 70% of terminally ill patients are not
mentally able to offer a valid one. This is why routinely in some places, or
at will in potential cases, legal documents are prepared in advance while
the person concerned is still compos mentis. There are several versions in
general use:
− An advanced health care directive, also known as a living will, a
legal document in which the person concerned specifies what
action(s) should be taken on his/her behalf if no longer able to
decide for him/herself because of illness or incapacity.
− A specific type of power of attorney or healthcare proxy in which
a person authorises someone (a known person who shares the
same philosophy of life and who will take a similar position
in predictable scenarios) to make decisions on his/her behalf
when incapacitated.
− In the event that none of the above documents has been drawn
up, the medical unit may seek alternative methods:
• Asking the most appropriate family member to act on
behalf of the incapacitated patient.
• When nobody from the patient’s family is available,
one may appeal to an independent member of the
community – an advisor – a well–intentioned person
expected to have sound judgment in matters with moral
implications such as those under discussion.
The problems that most often arise in such circumstances usually have
to do with the simplification or even the interruption of on–going treat-
ments.

55
Chapter 3

3.4. Dying soon
As opposed to ‘acute’ deaths, which are unexpected and involve a rapid
disappearance of vital signs, those nearing the end of a terminal illness
move slowly and silently through a given succession of events; this takes a
couple of hours and proceeds through a number of well–known sequences:
− A feeling of extreme weakness and tiredness.
− Movements becoming progressively less coordinated.
− An increasing dryness of the mucosa.
− A rapid worsening of dysphagia.
− Drinking and eating no longer possible.
− Blood pressure decreases and heart rate increases.
− Cold extremities and a patchy skin surface, indicating the so
called livido reticularis.
− Hearing and tactile senses are, allegedly, the last to disappear.
− Urinary and, later, even faecal incontinence.
− Conversation is no longer feasible.
− Irregular breathing; often Cheyne–Stockes rhythm.
− Consciousness level deteriorates via
• drowsiness and lethargy; or
• confusion, agitation, hallucinations, delirium, tremor,
myoclonia and even convulsions, culminating in a semi–
comatose state.
− Progressive coma.
− Cessation of blinking, dry cornea, and dilated pupils.
− Buccopharyngeal secretions, stirred by breathing, causing
respiratory bubbling (‘death rattle’).
− Foregoing a final expiration.
− Less significant for lay people, after a couple of minutes the
heart ceases to beat, marking the moment of death.
It is debatable whether, during these last hours of life, some treatments
would be useful. While logically there is no point, it seems a matter of
common sense, however, to administer a strong analgesic since on the
one hand pain can never be excluded and, on the other hand, under the
circumstances, a painkiller could cause no harm whatsoever.
The reluctance to administer real treatments is fully justified under two
conditions:
− a qualitative basis, i.e. any treatment will be reciprocated by no
result; or
56
Terminal illness
− a quantitative one, i.e. a given treatment administered in 100
cases achieved no result.
In this context, it would be worth explaining to family members that
to refrain from giving further treatment is appropriate because the patient
is going to die and that, moreover, the patient’s death will not have been
caused by refraining from treating them.
Returning to the introductory lines of this chapter, it is worth stressing
that, like the healing practices of ancient medicine, modern medicine’s
primary mandate concerning the terminally ill remains the same – to
alleviate human suffering. Our predecessors were simply unable to do
more; today we can do no more because more is, unfortunately, not helpful.

57
4. Shock and multiple organ failure
(7, 24, 72, 204, 217, 244, 249, 279)

4.1. Introduction 59 4.2.5. Changes in blood rheology 65
4.2. Shock 61 4.2.6. Metabolic aspects 65
4.2.1. Haemodynamic patterns 61 4.2.7. Shock progression 66
4.2.2. Clinical course 62 4.2.8. Shock organs 67
4.2.3. Peripheral vascular 4.2.9. Treatment perspectives 69
tonus and volemia 63 4.3. Multiple organ failure 70
4.2.4. Essential humoral 4.4. Conclusions 75
aspects of shock 64

4.1. Introduction
Positioned at the top of the biological hierarchy, the human being
identifies itself as the best organised entity. As the end result of a laborious
and long process of evolution, its physiology is quite narrow: an amputated
leg does not grow again; it is not able to hibernate; it has a limited tolerance
for lack of food and water; and, in practical terms, it has no tolerance at
all for a lack of oxygen. Moreover, a morphophysiological integrity is a
sine qua non condition for living – an integrity for which a prompt defence
mechanism of ‘fight or flight’ is launched in the face of any aggression. This
ability to react is an inherited one and a phylogenetic acquisition as well.
Known today as stress, this phenomenon was, about half a century ago,
initially given the more inspired name of réaction organique à l’agression
by the French school of medicine – a much more appropriate term for what
it actually consists of.
Irrespective of the terminology, the large majority of reactions – the
tolerable ones – are carried out in a harmonious fashion, moderating on
their own and allowing, thus, the return to a normal physiological status.
There are, however, enough circumstances when the reactions become
59
Chapter 4
pathological:
− When vital organs, the respiratory or cardiac ones for instance,
are targeted by aggression, death may occur quickly, even
instantly, without any orthodox reaction having been triggered.
− In the case of an overwhelming aggression, the incited reaction
will exhaust itself rapidly, also leading to a quick death.
− Finally – and this is most often the case in typical aggressions –
reactions run vigorously for different periods of time, resulting
– with or without treatment – in either a repair and healing
process or an aggravation leading to death.
The clinical fate of a reaction in motion is largely predictable:
− The simple ones, running harmoniously and responding to
an appropriate treatment, tend to follow a positive course,
with tissue repair being the organic counterpart to a restored
physiological status.
− Those that are severe, due to either modest biological resources
or exaggerated reaction levels
• without treatment, are prone to abating, thus leading to
death;
• with treatment, reach a turning point at which either
functional alleviation and tissue repair occur (which
is what happens with the majority of patients these
days) or decompensation and death occur – a serious
possibility still confronting intensive care medicine.
The tissue component of the post–aggressive reaction consists of an
inflammatory process, which entails
− an underlying metabolic state characterised by a sharp and
consistent increase in cell metabolism, including
• a turn towards catabolism, with
• a highly energetic demand, and
• consecutive oxygen consumption;
− a haemodynamic support derived from an augmentation of
local blood flow, a change challenging the entire haemodynamic
system; and
− a real inundation with a plethora of mediators.
To conclude this introductory section, it is worth underlining a couple
of features of the post–aggressive reaction:
− Irrespective of the aggression level, the reaction engages the
entire series of important bodily functions.

60
Shock and multiple organ failure
− Being universal in biology, the inflammatory process appears to
be the most appropriate response, both for the given lesion and
the desired repair; there is no strict interdependence between
the variety and intensity of aggression and the magnitude of the
post–aggressive reaction – which makes it rather intriguing that
the severity of the reaction quite often overtakes the danger of
the aggression itself.
− Given how deeply the microcirculation is involved in any post–
aggressive reaction, it is not at all surprising to have derailing
itself, leading to two entities of haemodynamic pathology,
i.e. shock states and multi–organ failure. They have several
particularities in common, and, upon interacting, they are,
individually or successively, frequent sources of mortality.

4.2. Shock
Except in cases of sudden death, any severe condition implies intricate
and advancing haemodynamic trouble, mainly at the periphery. This is fully
understandable if you take into account that the terminal blood vessels
represent the only delivery system of oxygen and all nutrients to the cell.
It is here that shock terminates its course in any critical state and why it
is associated with a mortality rate as high as 50%. The clinical versions of
shock are numerous, each having its own features. For the purposes of the
topic at hand, however, it seems more important to examine what they
have in common – the pathophysiological tendencies – in order to explain
the above–mentioned high mortality rate.

4.2.1. Haemodynamic patterns
There are two patterns associated with how a shock state appears:
− Hyperdynamic, consisting initially of a low peripheral vascular
resistance, an increasing cardiac output and a good tissue blood
flow. Sooner or later a number of additional changes occur,
eventually leading to a reduction of flow and oxygen delivery as
well as to alterations in homeostasis and metabolic reactions.
From a clinical point of view, this kind of shock can be
• septic, generated by severe infections when microbial
toxins cause peripheral vasodilatation and a depression
of the oxido–reduction reactions in the cell milieu;

61
Chapter 4
• toxic, resulting from the action of certain chemicals in
various intoxications, cyan being the most perilous;
• anaphylactic and allergic paroxysms that can free
substantial amounts of vascular mediators which, in
addition to causing a pronounced vasodilatation, also
affect mitochondrial metabolism;
• spinal, due to a brutal interruption of vascular sympathetic
control, with sudden vasodilatation: traumatic spinal
transection and total or high spinal anaesthesia.
− Hypodynamic, where the peripheral blood flow is reduced as a
consequence of either a turning–point in hyperdynamic shock
or a primary loss of blood volume with a subsequent lowering
of cardiac output. Clinically it can be
• hypovolemic, due to a primary loss of blood volume,
either whole blood (external or internal haemorrhage)
or plasma (severe combustions);
• cardiogenic, a consequence of low cardiac output
caused by a malfunction of the heart including large
cardiac infarction, valve or septum ruptures, or severe
myocarditis; or
• obstructive, when the heart, although able to contract,
cannot provide the expected output, as in the case of
cardiac tamponade, pulmonary embolism and massive
pneumothorax.

4.2.2. Clinical course
Derived from a post–aggressive reaction, any state of common shock
passes, academically speaking, through two stages:
− Compensated, a sort of sympathetic–adrenomedullary system
spike, a vigorous reaction consisting of
• a sharp rise in catecholamine and vasopressin levels;
• an increase in inflammatory cell population (monocytes,
neutrophils and lymphocytes);
• tachycardia and a narrowing of the systolic–diastolic
blood pressure difference; hypotension proper does not
necessarily occur;
• an obvious centralisation of the circulation whereby the
brain, heart, lungs and working muscles are sent the
required high quantity of blood while viscera such as the

62
Shock and multiple organ failure
kidneys and digestive organs, as well as the skin, receive
only the proportion necessary for tissue survival; and
• an understandable switching of the metabolism towards
catabolism, which is driven by adrenaline – a hormone
released and distributed in direct relation to the
increased regional blood flow.
As long as blood flow and oxygen delivery satisfy the metabolic needs,
the above series of events doesn’t imply anything truly pathological either
on the functional side or, even more to the point, on the organic side.
What happens next depends on the outcome of this phase of vigorous
reaction: either an alleviation of the inflammatory process, leading to a
humoral ‘calming’ and ‘tissue repair’ – both premonitory of healing – or a
degeneration to a:
− Decompensated shock which, essentially, consists of an obvious
waning of the foregoing ‘positive’ events, leading to an organic
dysfunction in the first instance and lesions thereafter. Among
the most important pathophysiological features, we should
mention the following:
• The centralised circulation plummets to a global
circulatory failure, the most impaired sector being the
peripheral one; the fall in oxygenation affects the entire
mass of bodily cells, including those belonging to the
formerly privileged organs.
• Following this lack of suitable oxygen with a concordant
increase in acidosis as well as tissue flooding with
inflammatory mediators, cell metabolism is severely
devastated; functional changes are followed by structural
ones.
• Clinically, the most important parameter – of real
prognostic significance – is arterial hypotension.
− Once a comprehensive treatment no longer improves the
haemodynamic, humoral and metabolic changes described
above, the shock can be considered irreversible and it ultimately
leads to death.

4.2.3. Peripheral vascular tonus and volemia
There is a unidirectional relationship between the two:
− Primarily affected, the first eventually influences the second.
− Therapeutically, the second represents the most operational

63
Chapter 4
approach.
Peripherally, the centralised circulation process involves the following
characteristics:
− Various levels of vasoconstriction occur on the resistance sector,
namely arterioles and the pre–capillary sphincters, mainly of the
vascular beds with a large proportion of functional circulation.
− Such a vasoconstriction does not occur in privileged organs.
− This discrimination in the tissue blood flow is a result of
arteriovenous shunting, on the one hand and an increased
speed of the flow on the other hand.
As far as blood volume is concerned, it is not reduced in the first
instance; on the contrary, blood pooling in organs such as the skin, spleen,
and other abdominal organs may be mobilised towards the central parts of
the vascular bed. Once the selective centralisation process is ‘exhausted’,
the microcirculatory vascular bed becomes progressively larger, resulting in
an effective hypovolemia (the same amount of blood has to ‘fill’ a vascular
bed with an increased and ever increasing capacity). It is worth specifying
here that, in real volumetric terms, the microcirculatory sector of a roughly
100,000 km network represents no less than 90% of the total vascular bed.
Later on in shock progression, a genuine hypovolemia appears. The
final severe derangements in tissue metabolism, with a progressive acidosis
and the many inflammatory mediators, lead to a sort of ‘paralysis’ of the
microcirculatory tonus. (It is of interest to mention here that, normally, blood
volume can irrigate just 5% of the vascular bed; once the bed dilates, this
discrepancy soars dramatically). Consequently, vascular fluid shifts towards
a tissue mass with a ‘suction’ hydrophilia and an increased interstitial
volume. These two supplementary factors of hypovolemia explain why,
sometimes, the total volume of fluids administered to these patients can
significantly overtake the patient’s blood volume proper.

4.2.4. Essential humoral aspects of shock
The specific humoral profile of shock is derived from the intricate
combination of the inflammatory mediators and pathologic metabolites.
− As already mentioned several times in this chapter, the post–
aggressive reaction involves, as an important component of
its algorithm, the production of pro–inflammatory mediators,
aimed initially at reducing tissue damage, and later at initiating
a reparative process at the level of the respective tissues.
• The increased level of complement facilitates an activa-

64
Shock and multiple organ failure
tion of immune cells, polymorphonuclears, neutrophils
and macrophages in particular.
• Once active, these cells adhere to the endothelial surface
from which they can also penetrate to the surrounding
tissues. The affected cells, in their turn, produce
mediators themselves – such that a sort of chain reaction
is launched, with a rapid and consistent increase in the
mediators’ density in the tissues. As the endothelial
surface is vast, one can imagine what an amount of
mediators result both in and out of the vascular bed.
The very mechanism of action of the mediators is largely
discussed in the literature, but the issue is beyond the scope of
this book. It is, however, worth mentioning the final result, i.e.
a loss of vasomotor tonus, an increase of permeability in the
entire series of membrane structures and, last but not least, the
beginning of an intravascular disseminated coagulation process.
− As a consequence of hypoxia, cells suffer profoundly from
advanced acidosis and oxygen free radicals, leading to complex
and severe alterations of the entire milieu interieur. Needless to
say, such a dramatic compromise is part of an irreversible stage
of shock – a stage necessarily implying the eventuality of death.

4.2.5. Changes in blood rheology
Its characteristic consists of a progressive increase in blood viscosity, in
its turn derived from
− a water shift from microvascular lumen to interstice;
− a swelling of the blood cells; and
− intravascular sludge following a slowed flow and an increased
haematocrit (as a plastic suspension, the blood becomes more
viscous), which can be so pronounced that the narrow parts of
the microcirculatory bed may become literally blocked.

4.2.6. Metabolic aspects
The entire series of metabolic changes are hypoxic in type:
− The pulmonary uptake of oxygen runs well a good share of the
time, but starts to diminish when a lung of shock outlines.
− Oxygen transfer to the tissues is affected much earlier than
hypoxia proper due to both a blood micro–flow mal–distribution
and an interstitial oedema.

65
Chapter 4
− The cells dispose of a temporary mechanism of avoiding an
oxygen deficit at their level, by an increase of gas extraction
from the blood via the interstice.
− When this active supplement extraction reaches a critical point,
a severe hypoxia overwhelms the cell metabolism.
Marked, in principal, by the neuroendocrine constellation of a shocked
organism – a high level of catecholamines, glucocorticoids and glucagon –
the intermediary metabolism develops, specifically
− a reduction in insulin secretion followed by an increasing
resistance to it;
− a reduced use of carbohydrates and lipids and increased use of
proteins;
− a soaring intra– and extra–cellular acidosis; and
− the appearance and aggravation of a mitochondrial dysfunction.

4.2.7. Shock progression
As long as shock is still compensated, there is – particularly in previously
healthy people – a chance it will reverse on its own; with treatment, often
a minimal one, the reversal is, however, much easier and quicker. Once
the decompensated stage is reached, the only way of ‘coming back’ is by
receiving treatment; this is because, at this stage, important organs have
suffered functional changes serious enough to require specific therapeutic
support in order to reverse the trend. Finally, in addition to the above, when
organic morphological changes are added, the shock becomes irreversible.
It does not matter at this point how complex the treatment is; a stable,
real result is no longer possible – or at least not routinely. It is nevertheless
worth mentioning that recent therapy achievements, largely high–tech in
nature, now make it possible to recover from even the most severe clinical
versions (see chapter 5).
The most affected ‘shock organs’ are the lungs, kidneys, intestines, liver
and skin. The pathophysiological route to organic changes consists of the
so–called lethal triad: acidosis, hypothermia, and coagulopathy.
− Acidosis
• Cell hypoxia leads to a reduction of ATP production, which
in its turn negatively affects highly energy–dependent
cell functions. The first to suffer are the trans–membrane
ion pumps.
• As a compensatory mechanism, one appeals to anaerobic
metabolic means, though less efficient and lactic acid

66
Shock and multiple organ failure
producing; a plasma level of this ion approaching 2 mEq/l
is a fatal heraldic humoral sign.
• It is well known that muscle contraction requires much
energy; both myocardial activity and the tonus of the
microcirculatory vast vascular sector are over–stressed
under circumstances such as those in discussion.
− Hypothermia
• Anaerobic metabolism supposes less energy and
heat production, while heat losses continue both
physiologically and due to the administration of large
amounts of fluids often colder than 370C.
• Enhancing sympathetic stimulation, low temperature
leads to an even higher degree of indiscriminate
peripheral vasoconstriction and to a reduction in the
responsiveness to catecholamines.
− Coagulopathy
• The complement initiates the cascade of the coagulation
process.
• This is a process favoured by the slow peripheral
circulation and rheologic unfavourable changes.
• Hypoxia driven activation of plasminogen promotes
fibrinolysis.
• Acidosis eases the fibrinogen breakdown, leading to an
extended intravascular coagulation.

4.2.8. Shock organs
As specified, during the post–aggressive reaction there are privileged
organs from the point of view of circulation. Once the reaction turns
pathologic, the privilege is disrupted and each organ concerned is
progressively engaged in its particular way to shock. With the notorious
exception of the placenta (an organ that can be but, for good reasons, is
statistically rarely involved in such pathology), no other organ is protected
for long. The participation quota of a particular organ varies according to
its function and the extension of its vascular bed, as well as the achieved
homeostasis alterations.
− Lungs
• They will have managed to ensure good oxygenation
through hyperventilation.
• The increased respiratory drive leads to a functional

67
Chapter 4
struggle; consequently, atelectasis soon follows, making
for an important organic event.
• When the respiratory centre is co–affected in a trauma
implicating the central nervous system, the above
compensatory mechanism cannot be initiated.
• It goes without saying that any respiratory or
cardiovascular pathology will inevitably aggravate the
shock.
− Kidneys
• An initial reactive vasoconstriction which, along with an
increased secretion of ADH and aldosterone, explains an
adaptive reduction of the glomerular filtration.
• A real hypo–irrigation then leads to a renal insufficiency.
• This is facilitated by any foregoing renal parenchymatous
pathology.
− Digestive sector
• Being multi–organ, topographically extensive, and hav-
ing a vast vascular bed, this large group of heteroge-
neous components quite quickly exhibits rapid involve-
ment.
• Upper digestive haemorrhages and hepatic cytolysis
specifically participate in the advancing portrait of shock.
− Heart
• Its privileged circulation is time limited.
• At the same time, unlike other organs, it is deeply
involved in every step of the process.
• Any previous heart pathology, ischaemic heart disease in
particular, or a pulmonary co–morbidity can complicate
events.
− Brain
• It is a notoriously privileged organ.
• It also makes the highest energy and oxygen demands.
• A derailed homeostasis has substantial deleterious
effects on the neuronal cell population; as a result,
agitation and confusion are important clinical signs in
any state of shock.
• Interestingly enough and quite intriguingly, a humorally
driven coma only rarely occurs.

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Shock and multiple organ failure

4.2.9. Treatment perspectives
− When clinical realities allow it, an etiologic treatment should
always be instituted including
• anti–infectious medication,
• myocardial revascularisation,
• drainage of a collection, or
• external dialysis where and when appropriate.
− With or without an etiologic treatment, the pathogenetic
one is compulsory with any form of shock; its most important
components are
• volemic replacement, in order to counteract both the
external and ‘internal’ losses, blood, plasma, electrolyte
solutions and – to ‘re–possess’ the extra–vascular space
– concentrated (3%) NaCl solution;
• vasoactive medications, adrenaline, noradrenaline, and
substitutive doses of corticosteroids;
• intra–aortic pumping balloon, in cases of poor myo-
cardial contractility without any revascularisation re-
source;
• appropriate attention to the many and advanced
homeostatic derailments such as oxygen, anti–acidotic
fluids, rheologic support, adequate calories, and insulin;
and
• immunomodulation, using anti–inflammatory drugs
such as the recently acquired Drotrecogin – an activated
C protein – given intravenously for several days (in a dose
of 25 μg/kg/h).
An interesting concept in the treatment of severe shock evolved in the
late 1980s. Administering a treatment aimed at supra–normal parameters,
it is possible – according to its author, Shoemaker – to test the reversibility
of the patient’s affected physiology. Practically speaking, one targets
− delivered oxygen of ca 600 ml/min/sq.m,
− oxygen consumption over 170 ml/min/sq.m,
− oxygen saturation of venous mixture blood of over 70%, and
− cardiac index of over 4.5 l/min/sq.m.
When, despite an intensive and comprehensive treatment, the above
parameters are not achievable, the patient’s case can be declared
irreversible. (245) Sound enough in terms of clinical judgment, the concept
has, nevertheless, remained largely an academic issue.
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Chapter 4

4.3. Multiple (Multi–) organ failure
Although modern medicine is technically capable of adapting to a variety
of critical clinical settings, the rate of success is quite disappointing. The
explanation relies on the early and severe, often irreversible, morphological
changes.
Initially christened, for scholarly purposes, multiple organ dysfunction
syndrome, everyday practice gives preference to its simpler alternative
multi–organ failure. More important than this semantic incongruence is
the fact that, once begun, its progress towards a fatal point is only a matter
of time, and without treatment, death represents a certain outcome.
There is solid evidence attesting to how severe a multi–organ failure
can be:
− It occurs in nearly half a casuistry of intensive medicine.
− It is associated with an average mortality rate of 50% (40 –
100%, depending on the number of organs involved).
− The mortality rate is 50% when three organs are involved and
over 90% in cases involving six organs.
− 60% of the deaths occur in the first 72 hours.
Having in common a severe alteration of homeostasis and affecting at
least two organs, a large variety of conditions end in multi–organ failure. As
a clinical course, it can be
− primary, launched ab initio by a pathology already severe enough
itself, for instance, chemical pneumonia and rhabdomyolysis
– two conditions consisting of profound tissue damage in the
lungs and kidneys, respectively; or
− secondary, developing in organs other than those initially
affected; this occurs in the majority of cases and takes a number
of days to reach a florid state.
Much pathophysiological blame for its genesis has been assigned to
the septic syndromes (infection, septic shock and sepsis) (55), representing
− 50 cases per 100,000 citizens in the USA, and
− over one third of ITU cases in the UK.
It is worth stressing that, much to medical analysts’ surprise, a more
aggressive surgical treatment in patients with a septic syndrome fails to
reduce the incidence of multi–organ failure and a primary infection does
not appear to be a sine qua non condition. Many other pathologic entities,
very different in type, have proved to be starting points for a multi–organ
failure, including extensive surgery, large trauma, tissue destruction, acute
70
Shock and multiple organ failure
pancreatitis and post–ischaemic perfusion syndromes. Moreover, there
have been cases occurring in a biphasic sequence; an initial small aggression
primed a weak or feeble reaction which, after a couple of days, could be
aggravated by a second, consecutive, even small aggression such as an
extracorporeal circulation, blood transfusion, modest surgical procedure,
or merely a ventilator–associated pneumonia.
Since, with or without a septic starting point, the same end result
can occur, namely a multi–organ failure, it has become logical to suppose
a common way; indeed, intensive and meticulous research has in this
context managed to outline the so–called systemic inflammatory response
syndrome. This ‘common manner’ is identifiable by any two of the following
six pathologic values:
− central temperature over 380 or below 360C,
− tachycardia over 90/min.,
− tachypnoea of above 20/min., or
− leukocyte number over 12,000 or below 4,000.
As mentioned earlier in this chapter, the modus operandi for the course
of the above syndrome consists of an inflammatory process; considering
the pattern exhibited by this inflammatory process, it has been speculated,
and later proved, that the digestive system represents a source of the above
mentioned mechanisms. There are two reasons for this:
− In any case of pathologic post–aggressive reaction, one
encounters myriad similar abdominal complaints and clinical
signs: loss of appetite, gastric stasis, nausea and vomiting,
abdominal distension, diarrhoea, haemorrhagic stress ulcers,
ischaemic colitis, and acute pancreatitis. They develop slowly,
progressively, and often silently.
− Known to be metabolically very active, the tubular digestive
structures are, in addition to their role in digestion, host to dense
immunological mechanisms in the walls and a packed microbial
flora dwelling in the lumen. All these characteristics indicate a
substantial implication in any inflammatory development. In
support of this the positive haemocultures for staphylococcus,
enterococcus and Candida come into play. As such, based on the
above findings, corroborated with recent pathophysiological
findings, it has been possible to clearly incriminate the digestive
tract in the pathogenesis of the systemic inflammatory response
syndrome.
Details of the structure, physiology, and pathology of the digestive

71
Chapter 4
organs offer good reasons for understanding the part they play in multi–
organ failure:
− The inner cell layers of the digestive mucosa renew themselves
in quite an assertive manner, within about one week; together
with peristalsis, this cell renewal protects the subjacent cells
from contact with the lumen content.
− The inner surface is covered by a film of mucus – a protective
material itself but also a good culture medium for anaerobic
flora. This flora is 100 to 1,000 times denser than the gram–
negative one of the lumen, creating a barrier and thereby
promoting a resistance to its colonisation.
− The same cells produce immunoglobulin A; by blocking the
membranal antigens of the suprajacent microbial flora, it avoids
the adherence of this to the cell layer.
− The biliary salts present in the lumen get combined with
endotoxins, however they are generated, neutralising them.
− If, nevertheless, some microbial germs manage to attack the
mucosa in question, there are lymphocytes or lymphoid follicles
and even lymphoid nodes in the mucosal layers attached
to vascular pedicles, acting as an additional barrier against
microbial invasion.
− Finally, in the event that some toxins do escape into the
circulation, the hepatic macrophages represent a good site for
neutralisation.
This pyramidal mechanism of barriers manages to be, under
normal circumstances, rather tight. Things change dramatically when an
inflammatory process as powerful as that of the post–aggressive reaction
itself is put into motion. This reaction differs from patient to patient, but all
cases do share a common pattern.
So, what is the primum movens for entering the pathologic scenario?
This is the same ischaemia other organs suffer from as well. The
difference, in terms of consequences, originates in the above listed
peculiarities. Combined, they make the digestive tract a septic reservoir,
its hepatic portal circulation a means of microbial translocation and the
digestive system as a whole a septic motor. As such, any pathologic post–
aggressive reaction leading to a multi–organ failure will end up also being
a septic one.
Once the barrier control of the digestive sector is lost, profound
changes in its immunologic function follow. It is impressive to learn that

72
Shock and multiple organ failure
only one gram of mucosa contains about ten million polymorphonuclears –
a number susceptible to increase in hypoxic conditions. When you include
the hepatic macrophages, which implicitly suffer in the context of a systemic
inflammatory response, it is no exaggeration to brand the digestive organs
as the largest un–drained septic abscess in the human body.
As far as the inflammatory mediators are concerned, they are produced
– as repeatedly mentioned – in great excess and are spread by circulation
throughout the entire body. There are about 100 identified chemical
compounds causing what is termed in the profiled literature as immunologic
dissonance.
Returning to tissue hypoxia, this occurs irrespective of the initiating
pathology and the variety of shock that develops. Eventually the
neuroendocrine control of microcirculation is replaced by a real vasoplegia.
Its genesis derives from hypo–irrigation, acidosis, distortions of glycaemia
and the invasion with inflammatory mediators. Among these, an important
role is played by the nitric oxide generated by the huge endothelial surface
of a vascular bed, which is indiscriminately open. As already mentioned,
the low oxygen level in the blood is compensated for, temporarily, by a
supplementary cell extraction of oxygen – a mechanism that is operational
up to a consumption of 330 ml/min/sq.m. Once this critical point is reached,
the mitochondria become deprived of oxygen; largely responsible for the
production of energy, this organelle uses 85% of the entire supply of oxygen
extracted. It also has other functions: hem synthesis, Ca ion modulation
and the production of cytoplasmic pro–apoptosis factors – all of which are
affected as well. In addition to this hypoxia of circulatory origin, there is also
a cytotoxic one, resulting from the effect the circulating endotoxins have on
the oxidative enzymatic cytochrome tissue chain, thus lending dysoxia an
extra gravity.
The final outcome of this calamitous combination of a drastic humoral
effect (both locally and ‘exported’ from the digestive organs) on a functionally
disorganised peripheral circulation leads to a so–called horror autotoxicus:
− The polymorphonuclear cells, pathologically hyperactive in the
context of the systemic inflammatory response, are implicated
in a pathologic synthesis of hypochlorous acid (from ions of
chloride and water); this metabolite, known to have an oxidant
activity 100 times higher than H2O2, is responsible for part of
the cell damage proper.
− As a result of the profound change in cell homeostasis, the
following – all of which are important for cell survival – are

73
Chapter 4
compromised:
• electrolyte trans–membranous exchanges,
• cytoplasmic protein integrity, and
• membranous lipidic structure.
This process results in a lysis of lysosomes; lytic by nature, the
escaped enzymes cause a sort of auto–digestion and, thus, cell
disintegration.
− It depends on the extension of this process whether apoptosis
and necrosis (see Cell Death chapter) manage to repair the
damage or the body proceeds to a death in toto.
One by one, the entire series of important organs are implicated in
this process of auto–destruction. The order of the mise en scene and the
severity of the co–morbidity are derived from the physiological role of a
given organ, its level of exposure to the lack of oxygen and, last but not
least, the significant role of the inflammatory processes itself. This is why,
citing sound statistics (120), the most important organs are listed according
to a pyramidal participation: lungs – 16, kidneys – 15, cardiovascular system
– 7, haematological system– 6, and central nervous system – 2. We can
attempt to describe this in detail as follows:
− The lungs are the most affected organs as they represent,
anatomically, the very first ‘filter’ for everything passed through
the hepatic portal circulation. This is why, irrespective of the
original starting point of infection, the lungs develop septic
complications in as many as 40% of cases.
− The frequent participation of the kidneys is explained by their
richness in vascular structures.
− Despite its ab initio circulation privilege, the myocardium is not
exempt; it is privileged in terms of flow but is eventually affected
by a significantly deteriorated homeostasis. This explains the
roughly 45% myocardial participation in septic pathology.
Unlike other pathologic scenarios and as a direct consequence
of homeostatic alterations, both myocardium contractility and
the lusitropic feature belong to the haemodynamic portrait.
− The central nervous system, equally privileged in terms of
blood flow for a good period of time, is ultimately affected by
the same ‘compromised’ homeostasis. Confusion, agitation,
delirium, and coma are the corresponding clinical signs.
− The blood as an ‘organ’ becomes more viscous with disseminated
foci of intravascular coagulation; when the hem formation is

74
Shock and multiple organ failure
already toxically reduced, a degree of medullar inhibition is not
far behind.
Looking at the above list of events, it is undoubtedly surprising not to
find any digestive organs. They have not been overlooked; on the contrary,
they have their ‘dedicated’ place – a compulsory one in any multi–organ
failure, irrespective of how many other organs are involved or how severely
they are affected. The intestines and the liver are not listed, as they are
profoundly involved anyway.
To conclude, ‘technically’ speaking, current medicine does have
the necessary armamentarium to deal with a chapter of pathology such
as multi–organ failure. Unfortunately, this ability is not backed by real
therapeutic results. The explanation lies in the complexity of the pathology
under discussion. Why the pathology of multi–organ failure follows such a
risky route, even exceeding the danger of the pathologic primum movens
itself, appears to be a matter for serious attention by medicine of the future.

4.4. Conclusions
As with any other chapter of pathology, the post–aggressive reaction
can benefit from the full attention that modern medicine is able to offer
it today. While the level of technicality is impressive, the strategy is
standardised:
− A prophylactic approach is always beneficial; it aims at reducing
the impact of aggression on the body.
− Timely attention to case co–morbidities at the start can improve
the success rate.
− Treatment proper of the patient concerned and, in response to
the particular clinical version of the post–aggressive reaction,
should be prompt, complete, and case–related.
− ‘Case–related’ does not necessarily mean sans frontières; once
a stage of documented irreversibility is reached, any oversized,
expensive, burdensome (in terms of patient endurance) and
hopeless treatment should be responsibly replaced with one
aimed at alleviating discomfort and pain and allowing for a
dignified death.
The above ‘machinery’ designed to deal with a given case is set in
motion by the clinical strategist, but this should be adapted to the individual
profile of the reaction. We differ greatly in whether we do or do not react;
in how promptly and, especially, how consistently we react; in how long we

75
Chapter 4
cope with our reaction; and, lastly, in the final price we pay for this reaction.
There are no scales, scores, or tests of real help, but analysts are already
working on a possible genetic approach to explain individual differences.
As a medical philosophy, the systemic post–aggressive reaction represents
perhaps one of the most challenging problems:
− While a reaction is, in a sense, a matter of biological ‘wisdom’,
the lack of proportion is surprising.
− Following the same humoral pattern of changes, the reaction
can either moderate on its own or degenerate into a pathologic
sphere, but its ‘direction’ is identifiable only in retrospect; we
are not yet in possession of any strategy more useful than
guessing.
− Both tissue repair and what follows pathologically occur by the
same inflammatory phenomenon.
− Quite often the harmful effects of a reaction are, by far, more
extensive than the damage from the aggression itself.
− Finally, it is puzzling to realise that
• while an external infection is considered a frequent
aggression,
• the course of a post–aggressive reaction includes adding
the digestive organs to its own source of infection.
Given the knowledge of current medicine, all the above could be
labelled biological ‘incongruities’, if not faux pas. To draw a parallel with
what can happen by choice in private life, a pathologic post–aggressive
reaction is, essentially, a suicidal act.

76
5. Vital prostheses
(63, 68, 96, 195, 204, 209, 211, 212, 292)

5.1. Mechanical ventilation 77 5.2.2. Enhancing ventricular
5.2. Supporting cardiac functions 79 ejection 80
5.2.1. Pacing 79 5.3. External dialysis 82
5.3.1. Haemodialysis 82
5.3.2. Peritoneal dialysis 83

In the human body there are organs which, from a given point of
incapacity, need various degrees of support, or prosthesis, in order to
remain functionally operational. Some of these sorts of support are life–
saving, thus qualifying as vital. Without them, the patient dies, usually
rapidly; as such, it remains for the individual reader to consider this sponte
sua approach.
Some transplantations are also life–saving or, perhaps better phrased,
death–postponing. This is a hybrid circumstance in which an individual – by
dying and thus enabling a life–saving transplant – prevents the death of a
fellow human being. It is a sort of ‘life–transfer.’ As death is deeply involved
in transplantations, of vital organs at least, the two will be discussed
together in a further chapter (vide 12).

5.1. Mechanical ventilation
In resuscitation settings, it is possible to support ventilation manually
or orally; although extremely useful for short periods of time, they do not
qualify as prostheses. Various naso–oral and oropharyngeal masks and
bags are equally useful, but they remain just technical adjuvants. A genuine
respiratory prosthesis is represented by mechanical ventilation only.
Unimpeded tracheal gas flow is a sine qua non for any successful and
safe mechanical ventilation. This is at best assured by tracheal intubation,

77
Chapter 5
a technique known since the end of the 19th century. It was originally
assimilated for anaesthetic purposes in the 1920s. Its real consecration
came about decades later, during the European epidemics of poliomyelitis
when mechanical ventilation evolved as an optimal alternative to the iron
lung and the cuirass.
The second half of the century brought revolutionary concepts as well
as remarkable technical achievements, which combined to make mechanical
ventilation a supreme method of treatment for some of the most severe
cases in medical care. In order to emphasise the large range of ventilation
strategies – of the sort able to fit any pathologic scenario – let us simply list
the most well–known: volume–controlled, pressure–controlled, assisted,
proportionally assisted, intermittent positive pressure, intermittently
synchronous, positive end–expiratory pressure, reduced current volume,
pressure support, biphasic, independent (each lung separately), permissive
hypercapnic, etc. Not only has the pneumatic component benefitted from
today’s degree of sophistication; the temperature and humidity of gaseous
flow, as well as performing mechanisms of drug delivery, have increased
the technical diversity.
Unlike any other therapeutic tool used in medicine today, mechanical
ventilation addresses a vital organ – the lungs – which requires both robust
functional support on one hand and local conditions for healing on the
other hand – two de facto incompatible aims. In order to emphasise this
particular feature, let us illustrate it with what happens at the lung level in
the case of chemical pneumonia:
− From an anatomicopathological viewpoint, the lesion consists
of severe lung tissue destruction, having been caused by caustic
gastric content with its notorious low pH.
− Locally, oedema, bronchospasm, hypersecretion and even
necrosis quickly develop.
− The resulting deterioration of haematosis leads to the need for
mechanical ventilation.
− In order to recruit as many alveoli as possible and facilitate gas
diffusion, ventilation has to be done with high pressure.
− Otherwise, for an already traumatised lung area, high pressure
with the incumbent tissue stretching causes further trauma – a
local situation severely unfavourable to tissue healing.
The only option in such a case is to sort out the haematosis by
alternative means, allowing the lungs to heal. There are a number of such
ways to ensure a sustainable gas exchange:

78
Vital prostheses
− Membrane oxygenator
This is a sort of extracorporeal circulation, inspired by the
clinical practice of cardiac surgery, and used for weaning the
patient from the heart–lung machine. It essentially consists of
• a silicone membrane, in place of a gas exchanger
• a blood centrifugal pump, and
• disposition between the two lines of a v–a arrangement,
i.e. venous – from the right atrium, and arterial – to one
of the two femoral arteries.
Both lungs are kept mildly inflated for a couple of days at a
constant ‘protective’ pressure, a pressure obtained with a flow
of 10 – 15 ml/kg of air enriched with oxygen. This flow keeps the
large majority of alveoli open, a favourable condition for local
tissue healing while ensuring gas exchange of the passing blood.
Such a device currently has a ‘technical life’ of three weeks,
although in cases such as those in discussion one generally only
appeals to it for no more than a week.
− High frequency ventilation involves either a thorax oscillation
of about 180/min. at a sub–atmospheric pressure using a tight
cuirass, or a tracheal jet of 1 – 3 ml/kg and a frequency of 100
– 300/min.
− Liquid `ventilation’ involves a high solvability for O2 and CO2
and a very low surfing tension; per–fluorocarbon is instilled, by
turn, in one lung while the contralateral one is ventilated in a
usual fashion. The main reason to appeal to such ventilation is
the positive effect on alveolar recruiting.

5.2. Supporting cardiac functions
As they advance, the various forms of heart pathology reach a point
where the most important cardiac functions are irreversibly affected: either
the genesis of impulse is disrupted or the process of contraction itself is
disturbed. In either case, modern cardiology is in the position to organise
and deliver the required support.

5.2.1. Pacing
At the end of the 19th century, an electrical current was recognised
as being able to contract the ventricular muscle. The first pacing models
were later designed for Adams–Stokes patients. In 1958 in Stockholm the

79
Chapter 5
first pacemaker implantation took place. The patient lived nearly 90 years,
surviving both the inventor and the implanting surgeon, and receiving no
fewer than twenty–six replacement units.
In only five decades since the first external version, weighing 45 kg,
technological progress has proven to be enormous:
− Miniaturisation has taken impressive steps to create devices of
less than 30 grams, greatly improving cosmetic implantation
standards.
− Most devices now use lithium batteries with a half life of up to
150 months; some versions even use nuclear batteries which
survive any device bearer.
− There are hundreds of different models in use today.
− Modern pacemakers are programmable, either on site or
remotely.
As defibrillation is largely used, the functionality of a pacemaker must
be rechecked once any shock has been administered. There is no age
completely exempt from heart rhythm troubles; this is why a child with a
pacemaker is no longer a wonder.

5.2.2. Enhancing ventricular ejection
A good number of devices have been imagined; the most important
are the following:
Intra–aortic pumping balloon (IAPB)
In the middle of the last century, cardiac surgeons found that an
assisted, staged weaning of the repaired heart from the heart–lung
machine (in other words the functional recovery of the left ventricle) is
much safer. No more than ten years later, Clauss imagined a pump which,
via a catheter introduced in an iliac artery, suctioned blood during systole
and reintroduced it in diastole. In the same decade, Moulopoulos and
Kantrowitz manufactured and used an intra–aortic pumping balloon, with
CO2 as driving force. The current version has a capacity of 25 – 50 ml and is
operated by helium.
As for the principle behind how it functions, it is a matter of physiological
improvement:
− The balloon being inflated during the entire diastole increases
the pressure in the suprajacent aorta and enhances coronary
output.
− Releasing the balloon at the beginning of the systole, when
the subjacent aorta is virtually ‘empty,’ results in much less

80
Vital prostheses
resistance to the advancing of the systolic blood; that means
less left ventricular effort, requiring less energy as well as less
oxygen consumption.
The use of this technique has gained worldwide favour with well–
standardized indications:
− a urinary volume of less than 100 ml/h,
− left atrium pressure of over 15 mmHg,
− mixed venous blood saturation below 60%, and
− adrenaline needs over 0.5 μg/kg/min.
Cardiogenic shock and high–risk cases of myocardial revascularisation
represent well–established indications of IAPB. The general statistics speak
of about 150,000 cases a year – just one fifth of the number of cases
requiring IAPB.
Ventricular assist devices
This is a heterogeneous group of technical achievements; varying in
concept and mode of action, they all offer a temporary support (relatively
short or long) of one (left) or both ventricles, by reducing their effort. This
sort of technology is one of the most expensive in modern medicine and is
almost exclusively the pride of the American school of medicine. There are
two groups among these kinds of devices:
− For shorter periods of time, hours or days, there are those
suitable for
• severe medical conditions, when a maximal medical
treatment and IAPB do not satisfy;
• immediate postoperative patients, when weaning from
extracorporeal circulation is too risky, and
• after heart transplantation, when the ‘new heart’ does
not meet the basic haemodynamic needs.
In all the above settings, the strategy aims at a bridge to recovery.
The standard indications of such a bridge include
• arterial pressure below 80 mmHg,
• pulmonary capillary pressure above 20 mmHg,
• mixed venous blood saturation of O2 below 60%, and
• cardiac index below 2 l/min/sq.m.
− For longer periods of time – month or years – representing a
bridge towards a heart transplant (alone or with other organs);
there are several among many categories that should be
mentioned:
• extracorporeal: centrifugal and pulsatile pumps;
81
Chapter 5
• in thorax implants;
• in ventricle implants, including VentAssist and Impella;
and
• artificial heart.

5.3. External dialysis
In close tandem with the lungs, the organs ‘in charge’ of CO2 clearing,
the kidneys are responsible for humoral clearing: of final catabolites, ionic
‘residue’ and water. Irrespective of the sort of functional compromise of
the kidneys, acute or chronic, the results consist of a rapid and progressive
humoral degradation leading to a fatal autointoxication. The intrinsic
mechanism of that fatality is the metabolic inability to generate the
necessary amount of cell energy at a given moment.
Being keenly aware of the dynamics of such a failure, nephrologists are
in a good position to stage a timely required ‘dose’ of functional support
in a manner that avoids any precipitous course of events. They can deliver
either short but substantial assistance in cases of acute failure, or longer
lasting support towards the radical solution of renal transplantation. As far
as the technology is concerned, there are two main options in extra–renal
dialysis: haemodialysis and peritoneal dialysis.

5.3.1. Haemodialysis
Hass from Giessen and Kolff from Groeningen are credited as having
performed the very first dialyses nearly one century ago. Shortly thereafter,
Scribner created the arteriovenous cannula and Brescia envisioned the
arteriovenous anastomosis. Other important advances were haemofiltration,
haemodiafiltration and ultrafiltration as well as technological improvements
in the medical procedure itself: biocompatibility, membrane quality, fluid
‘geometry’ of the circuits and the machinery as a whole. There are a large
number of versions suitable for the entire range of patients, for instance
intermittent, daily, diurnal, nocturnal, and slow nocturnal, or sequential
ultra filtration. It is also worth noting that a number of current improvements
are due to advances in digital technology.
As chronic patients represent the majority of dialysis cases, it is worth
knowing the following:
− Chronic renal failure develops slowly; as such there is time
enough to establish the appropriateness of dialysis and the best
moment to start it.

82
Vital prostheses
− An early dialysis programme avoids unnecessary changes in the
patient’s biology; proceeding as such, any major subsequent
treatment, transplantation inclusively, is easier to implement.
− In general, the humoral parameters heralding the need for a
dialysis programme are
• glomerular filtration less than 10 ml/min., and
• creatinine clearance of 20 – 15 ml/min.
Any co–morbidity should expedite the indication.
− Regardless of how early and well conducted a dialysis
programme is, it never fully accomplishes the kidneys ‘work;’
the metabolic and endocrine roles remain largely uncovered.
− As a matter of fact, the humoral component itself is not entirely
replaced either; a usual ‘dialysis dose’ (3 sessions of 4 – 5 hours
each week) manages a week’s urea clearance/l water (Kt/V)
of 3.6 – that is not more than a quarter of the functional
performance of a healthy kidney.
− As extrarenal dialysis is typically an extracorporeal circulation
technique, it includes a number of known complications; these
are, as a whole, fewer in number in a dialysis programme with
shorter but daily dialysis sessions.

5.3.2. Peritoneal dialysis
Simpler from a technical viewpoint and less risky, peritoneal dialysis
is used particularly in acute cases. After conventional animal trials, also
begun one century ago, it was assimilated into clinical practice as a result of
advances in medical technology.
Unlike some other bodily areas, the peritoneum is a good example of
anatomical and histological robustness. It happens that a number of natural
structural details are compatible with the requirements of external clearing:
− For the space provided, the peritoneum has an enormous
surface, 1.7 – 2.0 sq.m or approximately the entire surface area
of the body.
− This surface consists of a layer of polygonal and mononuclear
cells, the mesothelium:
• Towards the lumen, both the cytoplasm and its organelles
become lamellar and consecutively more resistant.
• The (outer) surface is villous – which increases the
contact exposure by no less than 20 times.
• It produces a ‘lubricating’ agent, some phospholipids, as

83
Chapter 5
well as inflammatory substances.
• Finally, it is ‘equipped’ with aquaporins.
− The interstice has, in its turn, a fibro–cellular structure; a
network of collagen ‘channels’ significantly eases fluid migration
– a feature that explains how, at a hydrostatic pressure of not
higher than 10 cm H2O, peritoneal dialysis is still possible.
− Behind this interestingly structured layer, there lies an
equally fascinating vast network of capillary vessels; with 2%
fenestration and full of aquaporins, very active metabolically,
they ensure about half of the local water circulation.
There are numerous practical versions of peritoneal dialysis: ambulatory,
intermittent, continuous and nocturnal intermittent, cyclic and automatic.
It is interchangeable with haemodialysis and the two can be combined.
In conclusion, as with any medical procedure, peritoneal dialysis is not
free from shortcomings, complications, or even fatal outcomes. Compared
with haemodialysis, its mortality rate is lower in the first two years, but
it reaches the same rate after five years. Representing about 10 – 15% of
extrarenal dialysis, the peritoneal version is known to provide a survival
rate of 70%.

84
6. Cardiac arrest and Resuscitation
(27, 38, 45, 69, 101, 204, 253, 305)

This is a chapter devoted to two topics linked together. Both have
dedicated places in the medical literature but neither has a clear etymology.
Defined as a negative magnitude, the death proper cannot be actually
addressed. One may address however the process of dying and, committed
to deal with peri–mortem issues, this is exactly what the present book tries
to do, in the first instance.
Having to deal with perspectives of death, medicine gets differently
involved:
− witnessing, in natural deaths,
− assisting passively, in cases serving as organ donors,
− helping actively the process of dying, in euthanasia,
− acting aggressively to either return to life or abandon.
In the cases of the first three versions from above, the circulatory
standstill supposes an exhausted heart, unfit for any form of help – an
organic ceasing. In those from the forth, it is a matter of an arrest only, a
functional ceasing, the heart having in fact a too good biology to give up its
function forever. By usage, this sort of stopping is known in cardiology as
sudden cardiac arrest. It is just this entity which follows to be discussed, in
tandem with resuscitation.
In professional terms, resuscitation means stricto sensu a treatment
featured by promptness, firmness, rigour and insistence. In general, it has
to be preceded by the therapeutic domain concerned, i.e. haemodynamic,
respiratory, hydro–electrolyte, anaphylaxis, etc. As the cardiac arrest
requires by virtue always promptness, firmness, rigour and insistence, the
term resuscitation is used in its case alone, naked.
As well known, the cardiac resuscitation consists in a series of very
precise manners of acting, real algorithms, available in consecrated
handbooks. It is in this context that this chapter deals more with rationales
and policies, issues not easily founding place in manuals.

85
Chapter 6

6.1.Cardiac arrest

6.1.1. General view 86 6.1.3. Epidemiology 93
6.1.2. Pathophysiological essentials 88 6.1.4. Diagnostic 94
6.1.2.1. Primary 88 6.1.4.1. Arrest proper 94
6.1.2.2. Secondary 91 6.1.4.2. Electrical variant 95
6.1.5. Prognostic 95

6.1.1. General view
Trying to set a hierarchy of the major functions in human physiology,
three are not only the most important for defining life but also more than
closely interrelated: cardiac activity, respiration and consciousness. Once
one, anyone, from this triad compromised the other two mandatorily follow
it, leading to death.
Although all the three are vital, a hierarchy may be set among them as
well. Thus:
− with the consciousness lost, breathing and then cardiac activity
follow to vanish;
− the loss of breathing leads to coma in minutes whereas the
cardiac activity, in its turn, ceases;
− when this is the cardiac activity which disappears first, the
consciousness and the breathing follow it much sooner, often
immediately.
This hierarchy of functional dependency – cardiac activity, respiratory
function and consciousness – is to be found in clinical settings; one can live
in a vegetative state years long, an artificial ventilation may keep somebody
alive months, even years, but a replacement of the cardiac activity is
possible only for short periods of time.
This primacy of the cardiac function results from the sort of continuous
activity the heart carries out, with a short diastolic rest. During a period of
one year, a normal heart beats not less than 37 million times. Nota bene,
in addition to its own problems, the heart is confronted with many others
from around the body. Thus it proves to be a vital organ by functioning and,
on the contrary, virtually fatal halting.
As event, the arrest of the heart represents a distinctive boundary
between life and death. If these are of a multidisciplinary interest –
86
Cardiac arrest and resuscitation
philosophy, religions, sociology, ethics and justice – there remains for
medicine to largely deal with the proper crossroad. It is its vocation to define
the sort of cardiac arrest having to deal with, a natural or inadvertent one,
in order to label it incontestably fatal or potentially reversible, respectively.
Since the cardiac activity is a sine qua non condition of life, it is not
surprising at all that death consists necessarily in a cessation of the cardiac
activity. The complexity of this activity is of a nature that the etymology of
cessation cannot cover in detail the dynamics of the factual realities at the
proper heart level.
− Nearest to the etymologic meaning, cessation can be defined
as one occurring in the context of an advanced deterioration of
homeostasis, a sort of autointoxication. This is a consequence
of a global haemodynamic failure, in its turn the inexorable
result of a variety of pathologic entities. The homeostatic
alterations affect both the excito–conductive component and
that of the contractile one, an in tandem effect at the heart
level. Electrically, one evolves a bradyarrhythmia leading finally
to asystolia. This kind of cessation is one of exhaustion, finalising
a circulatory failure which also supposes a loss of consciousness
and apnoea. It is the way of occurring in the majority number of
deaths, those timely, natural ones.
− There are, unfortunately, enough cases when the heart beating
is interrupted unexpectedly, following a very rapid course of
pathologic events; these are the so called sudden cardiac arrests.
A sufferance of the heart, particularly of its excito–conductive
component, may exist but in a large proportion of cases it is not
so severely affected to stop forever. Unlike the previous one, this
arrest does not culminate any circulatory failure; on the contrary
– as it will be later detailed – this is the arrest proper which
causes such a failure. Also different from the above, the loss of
consciousness and respiratory depression do not precede it but
are its direct consequences. An additional frequent feature of the
cardiac arrest – abating from the etymological stricto sensu – is
an intriguing motility status. The myocardial fibres do contract
but do this chaotically, with no finalisation in terms of ventricular
ejection; it is a functional arrest.
As physiological phenomena, both are cessations of the cardiac output
but, as a dynamic of occurrence and development, they differ very much.
Occurring as an end product of advanced haemodynamic and metabolic

87
Chapter 6
degradation, the real cessation represents an acquired phase in the process
of dying and, so, does not qualify for any therapeutic measure. On the
contrary, the sudden cardiac arrest – term consecrated by usage – qualifies
for an aggressive approach, resuscitation representing actually a pride of
the intensive care medicine of our time.

6.1.2. Pathophysiological essentials
The sudden cardiac arrest has two distinctive variants, primary and
secondary, differing as genesis, electrical background and therapeutic
approach.

6.1.2.1. Primary
The heart excels in a complex structure and a laborious function; from
the autogenesis of the necessary stimulus to an appropriate ejection of
every chamber and of all the four together, it impresses with its miraculous
engineering. Unfortunately, the diversity in functioning patterns and the
large span of necessary cardiac outputs make the heart a vulnerable organ.
The close co–work of the excito–conductive tissue and the myocardial
muscle mass is a frequent source of functional failure; and this is because
of two reasons:
− The tissue responsible for the genesis of stimuli, essentially
nervous as a biological concept, has a higher requirement of
oxygen, getting hypoxic earlier than the muscle mass.
− The (myocardial) muscle mass, supposing an in toto functioning
– demanding in itself – has in its turn also a high oxygen
requirement.
As such, it is not surprising that the very first way in causing the two
components to suffer is ischaemia. Once an ischaemic threshold is reached,
the very first to manifest is the most sophisticated function – the genesis
and conduction of the electrical auto–impulses. In other words, the rhythm
alterations are first to exteriorise an inner trouble. Needless to say, the
rhythm changes do not necessarily reach always a phase of affecting the
ejection function but, when they do, they take the shape of the so called
arrhythmogenic cardiac arrest.
Focussing on the electrical backing of such an arrest, two are the
arrhythmic versions:
− Ventricular tachycardia, 62% of cases in one of the recent
statistics, which
• may still generate some ventricular ejection;

88
Cardiac arrest and resuscitation
• may reverse spontaneously, representing the local reality
of what is known as auto–resuscitation;
• is reversed in a proportion of 90% by the internal
automatic defibrillators;
• has, challenged in time, the best chances of resuscitation
as during a cardiac procedure, for instance, when the
patient is being under full monitoring and a skilled
medical worker like a cardiologist is stand by;
• remaining for the rest of cases, the large majority, to
degenerate in ventricular fibrillation.
Unfortunately, the overall opportunities of resuscitation are
entirely a matter of chance. As it takes not more than a couple of
minutes for a ventricular tachycardia to advance to fibrillation,
it happens only rarely, in about 2% of cases, for the rescue
teams to find the patient still in ventricular tachycardia. In 75%
of cases, the patients reach in between the next phase.
− Ventricular fibrillation. While in the first minutes it represents
only ca. 8% (in the same statistics), until the rescue teams arrive
the proportion surges up to 75%.
This is why the ventricular fibrillation represents the electrical version
most frequently identified by the rescue teams. As mentioned, the chaotic
contractions of the myocardial fibres do not finalise with any blood ejection.
Consequently
− coronary blood flow ceases already in one minute while that of
carotidal one follows in other four;
− with no pulsation input, there occurs a progressive but quick
pressure equalisation of the two perfusion sectors, with a blood
transfer from the arterial to the venous one which, in terms of
volume, means a real circulatory arrest;
− it was proved experimentally that, for the above mentioned
transfer, only about 5 minutes are necessary;
− as a result, the right ventricle gets enlarged while the left one,
loosing from its volume, gets smaller;
− a sort of ischaemic contracture (similar to the rigor mortis of the
striate muscles) occurs, leading to what is known as a ‘stone heart’.
If no resuscitation is started, the proportion of surviving reduces with
10% for each minute of ventricular fibrillation whereas, after 15 minutes,
no recovery whatsoever can be expected. This trend is backed by some
relevant multilevel changes:

89
Chapter 6
A. Electrical phase
It lasts up to about 4 minutes only. This is the period during which the
myocardium, like any other tissue, is found by the event with the usual
amount of ATP reserves. It is an interval when the defibrillation alone is able
to restore a sinus rhythm – a scenario met in two circumstances:
− in the cases with an implanted internal automated defibrillator,
a tool able to intervene instantly,
− when, by chance, an external defibrillator is at hand, as in
hospital settings and, sometimes, crowded places, airports,
sport facilities, etc.
This favourable background is attested on the ECG by a vigorous fibrillation.
B. Circulatory phase
This lasts for 4 to 10 minutes. Without any refreshing blood flow, the
energy reserves – ATP – get consumed and, because an increasing hypoxia,
lactic acidosis with a cell K efflux develops and advances. Due to the
fibrillation, the myocardial cells exhaust quicker their energetic reserves, a
process quite clearly revealed by the progressive reduction of the fibrillation
waves amplitude. If resuscitation is possible,
− an immediate defibrillation has no chance of success because,
even if the fibrillation is suppressed, it degenerates towards
electromechanical dissociation or asystolia;
− the single way to maximise the chance of recovery is a
restoration of the energy resource, the ATP; or, this is possible
exclusively by bringing oxygen to the cells, for which the blood
flow is mandatory. Fortunately, this can be done, at least tried,
sustaining a minimum level of artificial circulation, feasible by
thorax massage.
Ventilation would be welcome, if practically possible, but it is not of a
paramount significance yet. The blood to be mobilised by the massage is
that one of the moment of arrest, namely oxygenated in its arterial bed.
As such, to summarise, the chance of defibrillation and resuscitation in
general, cerebral inclusively,
− is good in the very five minutes, with or without massage,
− reduces obviously with each minute spent,
− to be later improvable only by thorax massage for a couple of
minutes.
C. Metabolic phase
After 10 minutes, the energetic resources are well consumed;
resuscitation has little chance of success and, if this however happens,

90
Cardiac arrest and resuscitation
an obvious sufferance of reperfusion usually occurs. The recovery, if any,
supposes a period of coma and also neurological sequelae. The single cases
having sometimes a better prognosis are those drowned in low temperature
water, when the needs of oxygen at the moment of arrest or soon thereafter
were sufficiently low to be covered by the own oxygen available at the very
moment of arrest.
To conclude, the succession of the three phases explains why the
act of defibrillation is crucial for cardiac resuscitation – act which, after a
couple of minutes, should be preceded and followed by cardiac massage for
generating a coronary (and cerebral) blood flow. Needless to say, artificial
ventilation becomes also necessary.
It is worth emphasising that the circulatory standstill caused by the
primary version of cardiac arrest has a favourable pattern for resuscitation:
− The blood from the arterial sector of the vascular bed is fully
oxygenated at the physiological levels of the person concerned:
• at the capillary level, the diffusion forces continue to
transfer O2 and electrolytes;
• while the rest of blood occupying the arterial sector
remains arterial also in composition.
− At the lung level, the circulatory arrest supposes no further
alveolar – blood gas transfer; as a result the alveoli keep their
usual concentration of oxygen, while the blood keeps its content
of oxygen.
− A gasping occurs in some cases, being able sometimes to ensure
a surrogate of haematosis. Generated by the spinal part of the
respiratory centre, this gasping
• is a sign of vigour, with a better prognosis of recovery,
• if the gas volume generated is more than that of the
dead space, it could ensure a minimum (and enough)
ventilation,
• is maintained by a well performed resuscitation.
To end with the ventricular fibrillation, there are rare cases of
primary cardiac arrest which electrically are bradyarrhythmia or even
asystolia. Occurred during general anaesthesia or as a consequence of
neurocardiogenic syncopes, they have distinctively better prognoses than
those electrical equivalents resulted from the ventricular fibrillation.

6.1.2.2. Secondary
This is the arrest occurring to a heart either in good shape or not too

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diseased, unable to finalize its pumping function. The pathologic entities
leading to circumstances for such an arrest could be grouped in what is
mnemonically known as 5h5t, i.e.
hypoxia cardiac tamponade
hypovolemia tension pneumothorax
hypo/hyperkalemia pulmonary thrombembolia
hypothermia coronary thrombosis
acidosis (hydrogen ions) intoxications (tablet)
These entities may lead even healthy hearts to an arrest but the
accident occurs easier in the suffering ones. From the electrical point of
view, there are two forms:
− Electromechanical dissociation or, preferably, pulseless
electrical activity (PEA): there are QRS complexes but they are
not followed by a volume ejection, namely cardiac output. This
type of cardiac arrest are met in
• cardiac tamponade, tension pneumothorax and
pulmonary thrombembolia – all circumstances under
which the heart is impeded mechanically to empty;
• pathologic scenarios in which the myocardial contractions
are not able to materialise the generated electrical
impulses: advanced cardiomyopathia, severe ischaemic
episodes or after laborious resuscitations.
With some differences, the major arrest mechanism is a
mechanical one.
− Bradyarrhythmia and assystolia occur in those 5h5t with a
homeostatic alteration. Unlike the primary variant, this type
of arrest is the result of co–suffering of both pacing tissue and
the myocardial muscle mass; in other words, both the auto–
regulation component and that of contraction one. This duality
explains, in addition to the low ejection fraction, the slow
pattern of the electrical aspect.
The circulatory arrest takes shape progressively, as such the blood from
the arterial counterpart of the vascular bed is no longer oxygenated – an
important feature for the therapeutic approach. The humoral genesis of
this sort of arrest resembles quite much the circulatory cessation from the
process of natural dying.
There remains, however, a difference – a difference important from the
therapeutic point of view: the heart as an organ has a better biology and
the arrest generating pathology is treatable – a matter of importance as

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Cardiac arrest and resuscitation
prognostic. From that particular pathology, it is worth mentioning:
− different variants of respiratory insufficiency,
− conditions with primary homeostatic disturbances: pH
extremes, severe electrolyte changes, anaphylactic paroxysms,
thermic deviations, different intoxications, final hypovolemia.
It is also important to know that the slow rhythm cardiac arrests,
electromechanical dissociation, bradyarrhythmia and asystolia (these
representing about 30% from the entire arrest casuistry),
− could also be a degenerated form from fast rhythm arrest too
late or inappropriately dealt with,
− whereas, appropriately treated, may be upgraded to a version
with more vigorous waves.

6.1.3. Epidemiology
It is well known that both the cardiac pathology, in general, and the
sudden cardiac arrest, particularly, have proven to be major causative
factors of death.
A couple of statistical data are self explanatory:
− 3 million people die annually worldwide due to cardiac arrest.
− A quarter of them are under 65 years of age.
− Patients with coronary arteriopathy die consequently to the
cardiac arrest in a proportion of 60%.
− Together with other conditions like myocardiopathies,
valvulopathies, anomalies of the excito–conductive tissue,
cardiac arrests represent about 40% from Europe’s fatalities in
under 75 year olds.
On such a background, there always occur additional pathologic elements
like haemodynamic changes, electrolyte extremes, vegetative fluctuations,
pro–arrhythmogenic medications, alcohol abuse, smoking, sustained
physical effort (athletics).
The proper frequency of the cardiac arrest varies largely according to a
number of factors, geographical and social in particular:
− 0.6 – 14 to 1,000 inpatients
− 38 – 66 to 100,000 inhabitants outside hospital, from whom
three quarters are at home.
There are, undoubtedly, also special circumstances facilitating cardiac
arrest as respiratory insufficiency, metabolic changes, trauma, drowning,
anaphylactic paroxysms, drug abuse and postprandial (copious meals, in
particular (247)).

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Chapter 6
6.1.4. Diagnostic
Although cardiac arrest does not lack a firm identity, its diagnosis
may in given cases not be as easy as expected. Similar to any pathologic
circumstance, the difficulties originate from the infinite diversity of patients
and, most important, due to the dramatic clinical picture and the pressure
to take a blitz decision. Then, needless to say, those involved in doing a
diagnosis vary as medical competence from an experienced rescuer to a
genuine novice.

6.1.4.1. Arrest proper
The major clinical signs are:
− The loss of the muscular tonus, the victim being found in what
is said gravitational position
− The so called life signs disappear:
• the victim does not speak and does not react to verbal
stimuli,
• breathing is replaced, in about half of cases, with gasping;
while the gasping has an important prognostic value, it
could inadvertently be labelled real breathing and, on
this basis, resuscitation not initiated.
• voluntary, deliberate movements do not occur;
involuntary limb movements may, however, be
sometimes seen, even later (Lazarus phenomenon).
− The lack of blood flow pulsations (checked bilaterally):
• the radial one is exposed to confusions; it is considered
only when it does exist,
• the femoral pulse is more reliable but its exploration
requires time,
• the carotidal one is the easiest to be checked; as any other
artery, the carotis could be affected by an obstructive
atherosclerotic process, becoming non–pulsating and
consequently impalpable.
− Ocular reflexes:
• the corneal reflex disappears,
• light reflex, as well; iridic adhesions may interfere,
• mydriasis, very important as significance, could be falsely
caused by different vagolytic medications.
− Suggestive scenarios:
• suffocation,
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Cardiac arrest and resuscitation
• drowning,
• unusual medications,
• electric contacts.
When a diagnosis is difficult to be done categorically, it is by far
preferable to start resuscitation in a case which is not actually in cardiac
arrest than to waste time in one which really is. Of a great help is always a
bystander, a personage able to give the alert.

6.1.4.2. Electrical variant
In the very first instant, the approach is similar irrespective of the
electrical variant. But very soon thereafter, it is going to differ. As the
electrical variant becomes essential, an ECG is of a paramount importance.
Since the majority of cases statistically qualify for defibrillation, for which a
defibrillator is also essential, the screen of this device becomes very useful
in itself.
Practically:
− The slow rhythms are easy to be identified
• bradyarrhythmia and asystolia do not rise problems,
• the QRS complex of an electromechanical dissociation
has, of course, to be confronted with the pulse.
− Real problems occur in cases of fast rhythms.
• Once again, the ventricular tachycardia is short lived.
• Ventricular fibrillation varies in amplitude according
to the vigour of the effective myocardial fasciculation.
Then, the amplitude can change towards better or
worse, related to the myocardium local metabolic trend.
The height of the fibrillation waves differ from case to
case; sometimes they are so peakless that the picture as
a whole can be mislabelled as asystolia. In such a case
the administration of an electrical shock to the asystolic
heart is by far less harmful than abstaining from it in a
confusing case of ventricular fibrillation.

6.1.5. Prognostic
As already specified, soon after bursting, a ventricular fast rhythm
may, rarely, reverse on its own; this would be the electrical correspondence
of what clinically is known as spontaneous, self resuscitation (vide infra,
6.2.9.3. A).
Apart from such a rare alternative, cardiac arrest proves to be a cruel

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Chapter 6
reality; without treatment it leads steadfastly to death. It is a reality of such
intransigency that an attempt to address it should be imperative, more
obligatory than in any other chapter of pathology. Its treatment has to be,
in addition to obligatory, prompt, energetic, uninterrupted, insistent and
comprehensive.
All these musts derive from the severity of this entity and its dynamic,
in the first instance. There follow the human and instrumental therapeutic
realities of the very moment of declaration of the accident. Subsequently,
its prognosis depends on the amalgam resulted from the combination of
the above factors. The following are important to be commented in detail:
Declaring the event
− Circumstance of occurrence. Cardiac pathology may cause or
facilitate arrest anytime and anywhere.
• There are however circumstances under which the
cardiac arrest is more probable, as dedicated hospital
departments, highly demanding sports, drowning,
electrical workshops.
• Due to the night hypervagotonia, many arrests in cardiac
patients occur during sleep, at home – the so called
heart attack. The episode is silent, the patient being
found next morning, in bed, immobile and cooled.
As already specified, the presence of a bystander is of a great
importance for initiating the required alert or, if able, to start
the resuscitation.
− An early diagnosis is fundamental. In real terms, this is possible
• when the patient has internal defibrillator implanted
which, by design, administers the necessary electrical
shocks immediately, and
• in some of the hospital settings like cardiology and
cardiac surgery, where the patients are the subject of a
continuous monitoring.
− From this moment onwards, every second counts.
To summarise from the pathophysiological considerations previously
discussed:
− In the cases with fast rhythm, when the blood has a physiological
content in O2, there exist 4–5 minutes of manoeuvre space,
until the ATP reserves consume and the arteriovenous pressure
equalization takes place. Nothing apart from defibrillation is
strictly necessary.
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Cardiac arrest and resuscitation
− As the alveoli content is also physiological, with the usual
proportion of O2, an immediate ventilation is not imperative.
− In slow rhythm cases, there is no reserve of O2 and ATP, the
hypoxia cell lesions being on their route; there remains for
resuscitation to reduce from the developing sequelae as much
as possible.
How prompt could be the diagnosis
The ‘compact’ clinical picture of cardiac arrest is notorious. Moreover,
unlike any other clinical setting, mistaking it is preferable to ignoring.
Occasional restraining factors like the following ones have to be considered:
− unusual body position,
− local unfavourable changes for pulse exploring as anatomical
variations, haematomas, overweight,
− tight clothes,
− error generating factors of the pupil diameter.
Declarations and descriptions related by people from around should be
taken into consideration only whether they are pro–diagnosis ones.
Technical equipment
While thorax massage is learnt and practiced by any well intentioned
person, the defibrillator has no alternative. Any brand, even a basic one, is
better than no defibrillator. This is in this context that:
− The dedicated clinical departments use to implant automatic
internal defibrillators to their vulnerable patients.
− The hospitals have in their norms to equip their departments
with portable defibrillators, as well as to train all the staff
potentially involved,
− Crowded public places are endowed with defibrillators; robust,
safe and easily manoeuvrable units.
− Needless to say, all first aid teams, fire fighter vehicles – civil
and military as well – are equipped with reliable defibrillators.
− The drone technology promises to improve the availability of
defibrillators on the spot.
The echograph is also a promising facility, both in diagnosis and assisting
resuscitation.
Time spent up to resuscitation
Once again, an early alert favours the case. It happens only sometimes
that the alerting person is able also to start resuscitation. Therefore, these
are the arrival and involvement of the first aid team which represent the
very moment of both the diagnosis and the start of resuscitation.

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Chapter 6

Landscape with Charon Crossing the River Styx
Joachim Patinir (1484 – 1524)
Museo del Prado, Madrid

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Cardiac arrest and resuscitation
Expertise level
For a given case, it varies largely from a Good Samaritan to a skilled
professional. As far as the health care level is concerned, it depends on the
standards exercised by those responsible for a particular community, area,
locality or country. One combines matters of concept, equipping, training
and organizing.

6.2. Resuscitation
6.2.1. Historical data 99 6.2.8. Monitoring 109
6.2.2. General view 100 6.2.9. Miscellaneous 110
6.2.3. Chest compression 101 6.2.9.1. Post–resuscitation
6.2.4. Ventilation 104 syndrome 110
6.2.5. Defibrillation 106 6.2.9.2. Complications 112
6.2.6. Venous access and 6.2.9.3. Specific circumstances 113
medication 107 6.2.9.4. Ethical considerations 115
6.2.7. Auxiliary treatments 108 6.2.10. Present and perspectives 118

6.2.1. Historical data
Resuscitation as an idea is a very old one, dating back to Antiquity,
some biblical quotations (2 Kings 4:34) (310) being associated as having
such a symbolic message. Restarting the heart beating has preoccupied
the human communities along the two millennia. The very first clinical
attempt to materialise the idea followed experimental work carried out by
physiologists two centuries ago. From the most cited promoters, it is worth
mentioning
− Weiler, direct heart massage by thoracotomy,
− Sicard, trans–diaphragmatic massage,
− Bencini and Perola, massage by pericardial insufflations,
− Turoff, heart stimulation by intra–cardiac adrenaline injection,
− Jianu, internal stimulation by a trans–jugular catheter,
− Crile is the author of the idea of massaging heart from outside
the thorax.
The real problem evolved at the middle of the past century with
significant steps done round the ’60s by American clinicians:
− external defibrillation electrodes made their appearance;
− Stephenson described the internal cardiac massage;
− Safar and Elam launched the mouth–to–mouth ventilation;

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Chapter 6
− Kouwenhoven, Jude and Knickerbocker made known their
external heart massage.
Combined, the oral ventilation and the external approach for heart
massage have conquered the world’s medical community by their remarkable
simplicity and surprising efficiency. This was of nature to stimulate the
creation of emergency services, a very first one having been materialised
in Belfast. Subsequently, more rapidly than in any other medical domain,
the clinical research, laboratory backing, industrial interest and different
social bodies have developed large and various achievements. It has taken
no more than half a century to have an International Liasion Committee of
Resuscitation (ILCOR), a norms forum – Utstein (the name of the Norwegian
venue of setting up) and a compendium of regulations renewed every five
years, 2015 being the last one (305), to which this material fully adheres.
The development of Resuscitation as a medical domain is a good
example of human investment and achievements in health care; of interest
are:
− it soon reached a renowned place in research;
− it is a mandatory detail in the curriculum of each medical
school and an obligatory training for occupying any health care
position;
− important social organisations, police, fire–rescuers, security
personnel, require taking hold of resuscitation techniques;
− the medical school students are regularly trained;
− moreover, the instruction process is disseminated in common
environments as well;
− needless to say, the medical schools have resuscitation as a
crucial task in their instructive process;
− needs a good standard training.
It is no wonder that the organising standards and required human
competence make resuscitation a highly demanding domain. Unfortunately,
the high cost and relatively modest results are of nature to discourage the
financial planners to allocate appropriate funds.

6.2.2. General view
As mentioned before in different parts of this book, resuscitation is
organically related to the cardiac arrest, due to a second to none severity of
the clinical picture this has. It is in the essence of the cardiac arrest to occur
under a large variety of circumstances and it depends enormously under
what a particular one this occurs. It is then again of a great significance

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Cardiac arrest and resuscitation
whether a bystander is present and, if one does, how determined to be
involved he is and how experienced he could be.
Considering this multitude of factors, resuscitation is necessarily
carried out on a strictly standardised basis, following a given algorithm. This
algorithm represents the end product of an amalgam of research, experience
and norms, as a background, as well as simplicity and large acceptance, as
organisational criteria. Considering the rapid depreciation of the achieved
degrees of training, both the national and international forums monitor the
results and implement obligatory programs of instructions.
The approach practised by this book is not compatible with any
detailing of the algorithm in discussion, an algorithm representing the
didactical message of various manuals. What this material aims at is to
explain different pathophysiogical alternatives and the way these influence
the course of a case. Essentially, any resuscitation action has to play the
role of a functional prosthesis of the two major vital functions – breathing
and circulation. This functional prosthesis is not a simple replacement; it
has to be performed of such a manner that the two functions become able
to restart and carry out on their own; it would be a creative prosthetics. As
far as the consciousness is concerned, its fate will result from how well and
mainly how quickly the first two are recovered.

6.2.3. Chest compression
It aims at generating, in any case of cardiac arrest, a blood flow towards
and from the heart. For what it consists in, the chest/thoracic compression
is, term–wise, preferable to the cardiac massage. Its mechanism of working
is not, as it would seem to be, a unique one.
− Initially, at the end of the ‘60s, Kouwenhoven formulated the
hypothesis of cardiac pump. Compressed between sternum
and spine, the two ventricles are partially emptied by the blood
contained, which is pushed to the aorta and pulmonary artery.
During the decompression, the aortic and pulmonary valves
close, facilitating a ventricular refill with blood suctioned from
the two atriums with their extensions, the cavae and pulmonary
veins.
− Later, in the ‘70s, Criley and Niemann came with an alternative
hypothesis, that of thoracic pump, according to which the
compressions involve the entire intra–thoracic cardiovascular
structures. The compression generates a pressure gradient
between the cardiovascular lumens from the thorax and those

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Chapter 6
of the venous structures outside the thorax cavity – a gradient
for which the venous valves are also involved. Seen that way,
the heart plays the role of a merely passive conduct. In support
of this hypothesis, one should mention that
• during the compression, the pressure changes in the two
thorax vascular sectors, arterial and venous, are equal,
• when, accidentally, respiratory insufflations fall on the
chest compression, the result is a sum up pressure,
• by coughing, the intra–thoracic pressure increases,
facilitating so an auto–resuscitation.
− The trans–oesophageal echography during resuscitation
brought some light showing that, initially, the compression
acts as a cardiac pump while, started later, provides a thorax
pumping. This transition could be caused by organic hypoxic
changes of the two ventricles (‘stone heart’). Undoubtedly, due
to the thorax elasticity, in young victims a cardiac pump pattern
operates preponderantly, turning with the age to the thorax
one.
The number of compressions also plays a role. In terms of the resulted
flow, the ideal figure would be 120/min. As this rhythm is unequivocally
tiring, today’s recommendation is 100.
As far as the blood flow generated by compression is concerned
− it manages only 40 – 25% from the usual victim values,
− the proportion reduces centrifugally: coronary 25 – 20%,
cerebral 15 – 10%.
Even being severely reduced, these flows are in general enough not only
for the tissue to survive but also to avoid neurologic sequelae. This explains
surprising events during resuscitation as spontaneous movements, often
requiring sedation.
The largest part of the blood volume moved by the resuscitative
manoeuvres, towards 95%, remains and is circulated in the upper part of the
body, mainly chest–head. This ‘lucky’ centralisation is a pattern favouring,
under circulatory arrest circumstances, useful sectors of the vascular bed,
namely carotidal, coronary and pulmonary. With a shortened circulatory
time, a given specimen of blood can be better oxygenated at the lung level,
reaching quicker the area of vital significance, brain, myocardium and lungs.
Haemodynamic realities specific for resuscitation are as follow:
− The rhythmic compression causes a biphasic change of pressure,
generating a sort of arterial pulsation.

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Cardiac arrest and resuscitation
− The cerebral sector is, from the haemodynamic point of view,
favoured by the supine position of the victim, facilitating a strait
access of the aortic blood to the carotidal arterial network.
− That coronary one is unfavoured by its physiological
precariousness; possible only during the (resuscitation) diastole
– decompression – it needs a particular gradient between the
aorta lumen and the right atrium of at least 15 mmHg.
After a number of compressions, the new artificial haemodynamic
pattern manages its maximum parameters by cumulation. Once a
compression series discontinued, the achieved haemodynamic pattern is
immediately lost; another set of compressions is necessary for the pattern
to be reached again. This is of nature to encourage the abstaining from any
interruption of compressions, apart those to make possible other essential
components of the resuscitation.
The following signs attest successful compression:
− peripheral pulse, reflecting the biphasic flow generated by the
compression alternation,
− invigorating or at least persistence of the gasping,
− improving the amplitude of the ventricular fibrillation waves,
− ECG changes from a low rhythm pattern to a fast one,
− awakening during the procedure,
− finally, recovering of spontaneous heart activity.
The thorax wall movements supposed by the vigorous chest
compressions are, in general, able also to circulate some air towards and
from the lungs, representing a sort of artificial ventilation.
Being so important, the chest compression deserves particular
attention.
− It is discontinued only if the own circulation is recovered or,
unfortunately, the case is abandoned.
− The compression is the very first gesture when a cardiac arrest
comes into consideration; it should be started not only when
a cardiac arrest is substantiated but even when there is just a
supposition.
− Given its dual effects, haemodynamic and ventilatory, the
compression could be sometimes done alone (cases when, for
any reason, ventilation may not be initiated).
− Due, as well, to its significance, a good standard in performing
it is an encouragement for the lay people and a must for
professionals.

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Chapter 6
− When there are two rescuers, the compression has not to be
discontinued for
• insufflations,
• charging defibrillator, or
• establishing a venous access.
− There are only three circumstances under which the chest
compression may be discontinued:
• discharge of defibrillation shock, for just 5 sec.; in order
for compressions to be restarted immediately, the
expected arterial pulsations are checked under way, at
a later moment,
• for the moments necessary for the two insufflations (to
30 compressions in adults and 15 for paediatric cases),
strictly when there is a single rescuer,
• for tracheal intubation – a technique which has not to
take more than 5 sec.; otherwise, it is postponed.
As the pressure achieved in the thorax counts so much for a successful
resuscitation, there are several technical adjustments, as for instance:
− A combination of compressions with insufflations, performed
concomitantly.
− High energy compressions. A longer compression–time per time
unit can be achieved by a higher frequency of compressions. A
good figure, 150, is not, unfortunately, practical due to the early
fatigue and also risk of visceral damage.
− A number of auxiliary techniques have proven to be unpractical:
abdominal binding, pulsatile thorax vest, compression/active
decompression.
− The automatic compression piston (coupled with a ventilator),
rather laborious, has been used during transfer trips.

6.2.4. Ventilation
Different from the chest compression, the ventilation needed by
cardiac arrest patients is subject to a good number of variables. As already
commented, not always in a cardiac arrest case ventilation is necessary.
Then, when necessary, generous insufflations do not undoubtedly mean
a quality ventilation. This intriguing relation derive from the specific
homeostasis features at the very moment of the arrest variant, on one
side, as well as the new haemodynamic pattern under the resuscitation
circumstances, on the other side. Trying to detail:

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Cardiac arrest and resuscitation
− Occurring in about 50% of the cases, the gasping overpasses
sometimes the dead space volume.
− In sudden arrests, with a high ECG rate, the homeostasis is well
preserved following to deteriorate only after a good couple of
minutes.
− On the contrary, in those arrests featured by slow rate, with
an advanced compromised homeostasis, there is no reserve of
oxygen, neither in blood nor in alveoli.
− Then, irrespective of how successful resuscitation proves to be,
the amount of blood reaching the lungs is smaller than under live
circumstances; or, in order to keep a perfusion/ventilation ratio
similar to that of a healthy individual, the ventilation should be
adjusted. Insufflating the lungs too generously, both the above
ratio and the venous return could be negatively altered.
− A certain ventilation results from the chest compressions; in term
of thorax wall movements, this signifies a passive ventilation.
This means no negative pressure results in the thorax – a
development, of course, unfavourable to blood return.
As such, the ventilation support has to take into consideration:
− the presence of a possible gasping,
− the type of cardiac arrest, namely fast or slow ECG waves,
− the ventilating quantum of the chest compressions.
Ideally, an appropriate ventilatory support could consist of:
− Free airways and airway protection against the tracheal
contamination with gastric content, polluted water and any
foreign material. This desideratum is achieved with tracheal
tubes, laryngeal masks, Goedel pieces, head hyperextension.
− Pulmonary air refreshing, carried out with a ventilator, by bag
or orally (directly or with an interposed piece). After half a
century, the oral ventilation, branded initially as kiss of life and
so enthusiastically disseminated both as idea and practice, has
disappointed due to both hygienic and medical (contagious
potential) reasons. Anytime mandatory and possible, 10 – 12
insufflations per min. are recommendable.
As shown discussing the chest compression,
• the gasping (about 50% of cases) manages quite often an
air flow in the lungs,
• in its turn, the compression itself represents a passive
ventilation, some air being drawn by the negative pres-

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Chapter 6
sure in the thorax consequently to decompression.
− Oxygen supplementation is understandably welcome as a
higher FiO2 could ‘compensate’ the too small tidal volumes –
which is quite frequently the case.
In the context of the above details, it is worth mentioning that:
− one always tries to select the most appropriate technique for
the setting in discussion,
− the most productive ways of doing require a certain level of
instruction,
− many useful procedures suppose technical facilities,
− secondary effects occur quite often.
Eventually, how well is it carried out in a case like the cardiac arrest
depends very much on the number of rescuers; the more the better. A team
of three is ideal; one for compressions, one for ventilation and the third
for defibrillation, tracheal intubation and venous access. When only two or
even one rescuer is involved, compressions have priority as proportion but
the insufflations have not to be ignored either.

6.2.5. Defibrillation
Together with the chest compression, defibrillation has become a sine
qua non requirement in any resuscitation action. There rises legitimately the
question; once the heart lost its sinus rhythm status, would it be possible
and meaningful for it to return to a regular rhythm? If scholastically this
could be a good question, in real terms
− in the great majority of cases the ventricular fibrillation is
the result of a functional disorder, a sort of ‘temperamental
behaviour’ of a highly sophisticated physiological process like
that of the cardiac pacing, so vulnerable that minimal hypoxic
insults are enough to trigger a disorder,
− statistically, the recovered hearts from ventricular fibrillation
continue, or may continue, to beat long time thereafter.
As a spontaneous reversal of ventricular fibrillation is extremely rare, the
routine practice has no other choice than to try to reverse it therapeutically.
This is actually the reason of defibrillation.
As shown in the previous pages, the electric activity of the heart
represents, under resuscitation circumstances, a faithful image of its
intimate vigour. Either degenerating from a ventricular tachycardia or
representing an improvement from a slow rate, the ventricular fibrillation
supposes (and everyday practice does attest this) such a metabolic status

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Cardiac arrest and resuscitation
that a returning to sinus rhythm is not only possible but also meaningful.
Defibrillator
An essential device in any resuscitation environment, the defibrillator
stocks direct electrical current being able to deliver it when necessary. The
discharge can be done:
− intracardial, as it is the case of the internal automated version,
so miniaturised that can be implanted,
− directly on the heart via two electrodes, as in cardiac surgery,
− transthoracic, as in various in– and out–hospital settings, when
the necessary discharge should be 30 – 40 A.
As mentioned previously, any defibrillator, be it a very basic one, is
better than no defibrillator. However, modern technology has managed to
produce very sophisticated versions aiming at introducing the minimum
amount of required electrical current. Important features of these models
are:
− automated compensation of impedance;
− the single phase electric power was replaced with biphasic,
simple or pulsate;
− truncate instead of sinusoidal waves;
− the recharging is now so rapid that the necessary set of three
shocks does not need more than 30 sec.
Both the handling and the technical use are so well optimised that the
defibrillators can now be used safely even by lay people. This does not mean
to abuse its use, since there occur however incidents both for rescuers and
particularly for patients. It is important to know in this context that:
− in a sudden cardiac arrest it is possible to defibrillate the
patient immediately, as it takes 90 sec for the O2 and energetic
resources to start their deprivation;
− on the opposite side, after 30 min of unsuccessful attempts, the
patient can be declared dead;
− an extra care is taken in paediatric cases which require an electric
current of only 4 – 2 J/kg; there are special defibrillators but, in
case of unique alternative, even a version for adults can be used.

6.2.6. Venous access and medication
At a given moment, any resuscitation implies an intravenous
administration: as such a venous access has to be necessarily set up. A
couple of practical considerations:
− a central one is ideal but, for good reasons, it counts only if the

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arrest found the patient already catheterised;
− a peripheral one is tempting but a puncture of peripheral veins
is only by chance successful; in such a case,
− any drug administration should be pushed to the central
circulation by injecting about 20 ml of isotonic solution;
− a useful practical alternative proved to be the intra–osseous
(proximal tibia epiphysis or iliac crest) administration, via a
trocar; dedicated sets of such devices are now part of a rescue
team armamentarium.
The endotracheal way, so praised last decades, has not proved to meet
the expectations of a real intravenous approach.
There are, overall, a good number of medications currently used in
case of cardiac arrest. Unfortunately, none has proved its characteristic
actions. Much in terms of indications and dosage derives from the theoretic
pharmacologic considerations. From the long list, a couple have however
academic significance:
− adrenaline is administered usually in doses of 0.5 – 1.0 mg but
there are schools going to 3 – 5 and even 20 mg once;
− atropine, 0.04 mg/kg, up to a total of 2 mg, is given in arrests
of vagal origin;
− Na bicarbonate, 50 mEq, could be given with no laboratory
values available due to the undoubtedly occurring metabolic
acidosis.

6.2.7. Auxiliary treatments
In addition to what is addressed to the circulatory arrest proper, several
worthwhile treatments could be done:
Therapeutic hypothermia
It had been observed that the patients with cardiac arrests occurred by
drowning in cool water were recovered much better from the neurological
viewpoint. It was then found that the moderate hypothermia of 34 – 320C,
preventing the post–resuscitation hyperthermia (so usual in the first days
after resuscitation), did facilitate better results. These details have led to
the engrafted concept of neurocardiopulmonary resuscitation, to underline
the neurological rigour in any resuscitation; a real recovery does suppose
an interactive life. As far as the mechanism is concerned, the reduction
of the metabolic rate and oxygen requirements (5 – 8% for each 0C) ease
the humoral recovery and reduce the irreversible damage of the neuronal
structures. A good local and accessible sign is the reduction of the brain

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oedema.
Once the decision of hypothermia is taken, this has to be materialised
as soon as possible and quickly, so much as its benefits are better in the first
12 – 14 hours. Technically, the hypothermia is achieved with:
− an external approach;
• cooled blankets, 1 – 20C/hour efficiency,
• ice packing or immersing in cold water, up to 30C/hour,
• ice and graphite, 40C/hour,
− internally;
• cold drips: 30 ml/kg saline 40C,
• intravascular heat–exchanger,
− extracorporeal circulation, when practical,
− a cooling helmet of 24 hours, managing good results with fewer
inconveniences.
The therapeutic hypothermia is not free of side effects while the
beneficial ones do occur in only one from six patients. This represents a
reason for the lack of enthusiasm among the intensivists.
Adjacent approaches
Once the case was successfully resuscitated, the immediate
preoccupation should aim at avoiding an arrest recurrence. In this direction
it could be of interest:
− Pacing; done earlier is more beneficial, which is possible in
dedicated hospital departments. Otherwise, it will be taken
into consideration when, basically resuscitated, the patient
remains rhythm–wise unstable. Technically, it can be done via
endocardial, trans–thoracic, percutaneous or with external
electrodes.
− Removal, when practical, of causative factors:
• surgical in nature: haemopericardium and haemothorax
drainage, tension pneumothorax exsufflation, coronary
disobliteration;
• humoral: aggressive correction of hypovolemia,
anaphylactic collapse and extreme changes of potassemia
and pH.

6.2.8. Monitoring
To the disappointment of the research community, its achievements are
difficult to be implemented in a scenario like resuscitation of cardiac arrest.
− Fortunately, the single irreplaceable element of monitoring is

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the ECG – a parameter not only easily available but quite well
standardised. As defibrillation represents a dominant issue
in any resuscitation, the screen of the defibrillator sorts out
the problem on its own. Otherwise, an extra–monitor, be it a
modest one, is, of course, more than necessary.
− End expiratory CO2 is a notorious respiratory parameter but, in
a cardiac arrest case, it speaks much more about metabolic and
circulatory trends:
• shortly after the arrest declaration, it drops from the
usual 4 – 5 to around 1%; due to the lack of blood
circulation, the tissue CO2 is no longer circulated to the
lungs for haematosis;
• how much CO2 follows to be ‘expired’ later on depends on
how much O2 is delivered to the tissues as well as the cell
energetic reserves, on the one hand, and the dynamic of
CO2 transport to the lungs, on the other hand;
• when the resuscitation is efficient, expiratory CO2 is
increased towards 1/4 – 1/3 from the normal values;
• a sudden increase suggests the restarting of the
circulation, enabling the tissue CO2 to reach the lungs for
being expired;
• a value less than 1% reflects an inefficient resuscitation,
unable to bring the tissue CO2 to the lungs for depuration.
There is a hope for CO2 to become quantifiable by colorimetry.
− Pulsoximetria, relevant once the peripheral circulation is re–
established.
− Cardiac echography, potentially so valuable, is not backed yet
by a reliable equipment.

6.2.9. Miscellaneous

6.2.9.1. Post–resuscitation syndrome
While a restoration of the spontaneous cardiac activity is a good reason
of satisfaction, the fate of such a case is, by far, far from being stable. On the
pathological background having led to the arrest, an entire range of potential
problems are added. They consist in long lasting sequelae, generated by
the circulatory arrest and its treatment. A patient like a cardiac arrest
one has usually to head to a couple of important other steps, namely the
neurological recovering, hospital discharge and one year surviving. It will be

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Cardiac arrest and resuscitation
only then that such a case could be considered, de facto, a real success. As
such, in terms of stable results, it is understandable that their percentage
may vary from 20 to as low as 0.
The very first to confront a newly recovered patient is the so called
post–resuscitation syndrome – an entity coined already by Negovski. The
clinical context corresponding to this syndrome is very well understood
from the following series of figures:
− More than half of those recovered display various degrees of
haemodynamic instability;
− 80% remain unconscious for different periods of time;
− 40% develop convulsions;
− From those about 18% leaving hospital, only 12.5% live next
year.
Analysing what particularly happens with a recovering organism,
another series of alterations should be mentioned:
− an inappropriate tissue blood circulation;
− an invasion of the central organs with catabolic acid compounds
from the ischaemic peripheral tissues;
− cell lesions caused by products resulted from an anaerobic
metabolism: free radicals, proteo– and lipolytic, and
inflammatory agents;
− post–hypoxic multi–visceral lesions;
− rheological disturbances acquired during the circulatory arrest;
− a systemic inflammatory response.
The overall consequence is a multi–organ dysfunction, significant
particularly in the nervous, cardiovascular, pulmonary, renal and metabolic
sectors. The clinical issues, in general combined, deriving from the above
described amalgam could be:
− haemodynamic instability up to forms requiring continued
support with inotropic medications or even intra–aortic
pumping balloon, extracorporeal circulation or artificial heart;
− recurrent dysrhythmias for which, sometimes, pacemakers or
automated defibrillators are necessary to be implanted;
− hypoxic encephalopathy with various clinical forms, from
confusion to an advanced coma; a nervous component is found
in as many as three quarters of the cases;
− pneumopathy of aspiration, ventilator or combined;
− other organs may also be involved: kidney, liver or suprarenal
gland.

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To conclude, a typical post–resuscitation patient is one in a (various)
degree of coma, with an intensively assisted haemodynamic, undoubtedly
mechanically ventilated and extensively lab–monitored. It is a case
confronting the majority, if not all, medical areas.

6.2.9.2. Complications
A pathologic scenario of ‘high density’ like a sudden cardiac arrest as
well as the understandable component of emotion and panic, what the
resuscitation supposes as amount and cascade of treatment gestures,
explain why such a confrontation is not favourable at all for exercising the
adage of primum non nocere. Separately, a good number of complications
have been or will be mentioned in other chapters of this book. Summarising,
they could be grouped here as follows:
− Chest compression: thoracic wall contusions, rib, sternum and
even spine fractures, pulmonary and myocardial contusions,
haemopericardium, subcutaneous and mediastinal emphyse-
ma, esophagogastric, hepatic, splenic and venae cavae lacer-
ations.
− Ventilation: lesions caused by in a hurry attempt to reach
the glottis area (buccal, tongue and, in particular, pulmonary
aspiration of gastric content, often with a chemical pneumonia).
− Defibrillation;
• marks and burns caused by electrode contacts,
myocardial ‘electrical’ lesions – in patients,
• paresthesias, experienced by the person delivering
the shock; in theory (and in instructions manual) the
electrical shocks are considered possible to occur not
only in the medical workers – a reason why nobody from
the assistance is allowed to touch the victim during the
shock deliverance;
− venous access: subcutaneous sanguineous suffusions, para-
venous injecting, arterial punctures and lesions;
− examinations: corneal lesions of various degrees;
− tentative of intracardial injections (where, despite a discouraging
advice, they are still practiced) may cause severe lesions:
myocardial, coronary and valve contusions, intra–myocardium
haematoma and haemopericardium.
As far as the rescuer is concerned, he is warmly warned to avoid
becoming a second victim.
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Cardiac arrest and resuscitation

6.2.9.3. Specific circumstances
As everywhere in pathology, the cardiac arrest as clinical entity displays
both common, irrespective of etiology, and particular features generated
just by the etiological factors. The latter are sometimes so specific that each
of them requires particular approaches.
A. Self resuscitation
A sort of (partial) self resuscitation could happen during various
procedures of interventional cardiology. In such a setting the patient is, of
course, continuously monitored (ECG, X–ray, intra–luminal blood pressure
and, sometimes, echography) and a cardiologist is involved in performing
the procedure. As such a heart arrest (more often ventricular tachycardia/
fibrillation) could be immediately detected. What this setting has in
particular consists in the lack of losing consciousness; the diagnosis is so
early that the consciousness ‘had no time to disappear’. ‘Ordered’ loudly to
cough, the patient not only may hear and understand but also obey, namely
carry out a couple of coughs. An intra–tracheal pressure of 60 – 100 mmHg,
necessary to generate a carotidal blood pulsation, is entirely realistic. And
so the patient can ventilate his lungs, massage himself his heart and sustain
a circulation of such a degree so as to avoid the loss of consciousness and,
once again, with a spontaneous return possible. Needless to say, if this
does not happen, an electric shock is technically, under the circumstances
in discussion, feasible anytime.
This self resuscitation is also known as cough CPR, a model vulgarised
in the last years by various internet outlets, ‘encouraging cardiac patients to
act on their own in the very first seconds of angina’.
An intriguing clinical picture occurs sometimes in the context of
abandoned resuscitations – the so called Lazarus phenomenon (discerned
by Linko, 1982, and coined as term by Bray, 1993, inspired by a biblical
story). Essentially, it consists in the relieving of a self-PEEP developed by
the foregoing resuscitative hyperdynamic overinsufflations – a relieving
said to be haemodynamically favourable, from where the hint at a self
resuscitation.
B. Different variants of respiratory insufficiency
Consequently to the progressive deterioration of haematosis, the
homeostasis reaches an advanced level of metabolic exhaustion, of nature
to lead to ceasing heart activity, with circulatory arrest. For such a course,
it takes some time; as for instance, blocking the trachea completely, under
experimental circumstances in pigs, it takes 10 min. for the arrest to occur.
Apart from these arrests by exhaustion, there are a couple of versions of
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Chapter 6
respiratory insufficiency which could lead to typical sudden cardiac arrest:
− Café coronary (linguistically an elaborate medical term, coined
by Roger K. Haugen), an acute suffocation caused by chocking,
mainly in elderly and other debilitated people.
− Drowning represents a circumstance under which there occur
more elements facilitating a cardiac arrest: the event itself with
its panicky valence and the sudden contact with (cold) water.
− Asthmatic paroxysms, in their turn, also gather some vitally
threatening elements, originated from a quick fall in O2 availability
due to the dramatic course of generalised bronchospasm. The
bronchial hypersecretion due to the hypervagotonia, specific to
this sort of condition, always contributes to the pathogenesis.
C. Arrests of electrical etiology
Due to the vulnerability of the heart excito–conductive tissue – a
functional entity having much to do with electricity – and the overwhelming
physical parameters of the electrical current, the occurrence of cardiac
arrests does not surprise.
− Electrocution represents a second to none circumstance to
materialise its fatal danger by a cardiac arrest. Direct electrical
current causes usually asystolia while that alternative, ventricular
fibrillation. Different from the entire human pathology, young age
and good health are not protective factors for electrical pathology.
− Commotio cordis is difficult to categorise as sort of arrest; it
excels by the suddenness of occurrence. When the precordial
thump falls on the vulnerable part of ECG (the pick of T wave)
the probability of a ventricular fibrillation is high. Fortunately,
the victims are young, with enough bystanders around, of
nature to ease a timely resuscitation.
D. Anaphylaxis
The huge discrepancy between the total vascular capacity and total
blood volume (as mentioned elsewhere, able to fill just 5% of it) is ‘sorted
out’ physiologically by the extremely versatile panoply–like vascular tonus
which ‘harmonise’ the two variables. In anaphylactic events, it is exactly this
harmonising element which is affected; sometimes the vascular network
becomes so béant that the amount of blood arriving at the heart is not
sufficient for backing a ventricular ejection. Under such a circumstance, the
coronary arterial bed does not receive the necessary amount of blood and
O2 – situation potentially leading to a cardiac arrest.
Fortunately, the readjustment of vessels capacity to the blood volume

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may help either to prevent the arrest or, once this declared, to ease
resuscitation.
E. Consumption of cocaine and alcohol
Consumed together, they generate coca–ethylene – a cardiotoxic
compound able to enhance the cardiac negative pharmacologic effects
of cocaine; sometimes, these are so pronounced that they may lead to
cardiac arrest.
F. Pregnancy
In addition to the common threats, the pregnant woman could be
confronted with other two, very specific in type:
− amniotic embolism, with haemodynamic changes similar to
that from anaphylactic events;
− vena cava inferior compression by the pregnant uterus in
advanced state of pregnancy.
Under both these circumstances, the venous return to the heart may
fall so much that, as detailed above, a ventricular ejection can reach vitally
dangerous levels, with the possibility for a cardiac arrest to occur.
As far as the foetus age is concerned, until 23 weeks it does not
influence the way the resuscitation of the mother is carried out. Thereafter,
both organisms have to be considered.
G. Young ages
Small children and adolescents may have (undiagnosed) congenital
cardiac abnormalities known as having in their course possible cardiac
arrests: coronary defects, ventricular arrhythmogenic dysplasia, long QT and
Brugada syndromes. Then, with their physiologic tachycardia, a commotio
cordis probability is higher.
For resuscitation purposes,
− a cuffed tracheal tube should be favoured anytime a placement
is possible,
− the use of a laryngeal mask is encouraged after 2 kg in weight,
− the compressions/insufflations ratio should be usually 15 –
30:2, with 3:1 in newborns,
− while 2 J/kg is the amount of electrical current used for
defibrillation.

6.2.9.4. Ethical considerations
An event occurring anywhere and anytime worldwide, cardiac arrest
has however a higher incidence in Europe and the USA; this is due to the
dominance of the cardiac pathology as cause of death in those two areas.
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Chapter 6
Coronary arteriopathy leads actually to such a denouement in up to 60%
of the patients, many not really old. This is why these cases represent
notoriously a confrontation for their families.
Not only the families but also the medical workers are, due to their
heterogeneity in knowledge and training, confronted with an event like the
cardiac arrest.
Patient
− Laudably, the rights of the patients are defended by the so called
Helsinki Human Rights Declaration which stipulates: autonomy,
benevolence, keeping away from inflictions, a democratic
distribution of resources, a full respect of dignity, as well as the
liberty to agree or not with the ongoing care and treatment.
− A good deal from the intensive medicine runs with non
compos mentis patients, no longer able to express their will.
Therefore, their position could be made known by an advance
directive, formulated while still mentally capable and meeting
current judicial needs. Such a document has to be verified
at the admission (as many patients could meantime change
their mind), placed in the patient’s notes, shared to all the
team members and posted at sight. Bearing a bracelet with
the inscription DNR (do not resuscitate) is an arrangement
satisfying all the necessary requirements, medical, legal and
moral as well.
Team
A medical worker is morally obliged to carry out an ongoing procedure
until either the scope is achieved or the incumbent person becomes
exhausted. There are just two circumstances in which resuscitation is
intentionally not started:
− when an advance directive is in force, or
− when, for good medical reasons, any resuscitation would be
fruitless or not in the favour, real or potential, of the patient.
For such a case the department in charge prepares an appraisal,
written in the patient’s notes and signed by the responsible
person from the team. As such a decision could disappoint the
family, it is sensible to have a second opinion worked out.
There is an exemption when a DNR patient should be however,
resuscitated, namely when that patient has also signed in advance an
organ donor declaration. In practical terms, such a patient ultimately dies
anyway, but after having been addressed a resuscitation in the favour of

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death!
Once resuscitation started, it is technically carried out according to
the standards and policies of the medical institution concerned. When the
resuscitation is not successful, it becomes necessary to give up:
− when the rescuer is a professional, this is of course able to
decide the moment of interrupting;
− a more difficult situation occurs in settings where the rescuer
has no medical competence. As it takes too long to wait for
advanced signs of death, an advice and a proxy decision could
be obtained by phone; fortunately today’s communication
technology facilitates such a manner of doing.
For professionals there are a number of useful considerations regarding
the decision of giving up resuscitation and declaring the case unsuccessful:
− despite a technical correctness, the ECG loses from its vigour,
degenerating from ventricular fibrillation to a low rhythm
pattern and, eventually, asystolia;
− when, despite a well conducted resuscitation, an unfavourable
ECG does not turn positively;
− lack of any stable effect of generous doses of adrenaline (when
this was used);
− lack of return to a smaller pupil diameter or even an advance
of mydriasis.
Under normothermic circumstances, a common resuscitation carried
out for 30 min. without result can be interrupted. Also, if a case of asystolia
does not respond to 20 min. of resuscitation, it can also be abandoned.
There are two occasions when one waits and insists longer:
− when the arrest occurred in hypothermic environment;
− in case of small subjects and this for two reasons:
• emotional considerations,
• their tissue viability is better in comparison with that of
the adults.
The ubiquity of the cardiac arrest as medical reality gives the problem a
note of routine, common and usual. As biological and socio–familial event,
both the cardiac arrest and the resuscitation giving up, in particular, are of
huge significance. Therefore, both de facto and formally, such a decision
has to be taken by the highest rank from those involved, on the spot or after
necessary telephone consulting contacts.
Family
Being so demanding emotionally for the family, it is both right and

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Chapter 6
empathically for it to be involved in anything, in particular potentially
litigious cases, as organ donation and resuscitation training attempts; there
is also an increasing tendency to accept somebody from the family on the
resuscitation area, mainly in paediatric cases.

6.2.10. Present and perspectives
Different from any other forms of treatment, resuscitation has to be
addressed to a pathologic event occurring largely unpredictable, namely
anytime and anywhere. For the same reason, the well established principle
of distribution of the medical competence according to the degree of case
difficulty does not work. Surprisingly for our times, it is very much a matter
of chance whether a certain case is resuscitated or not and, if it does, how
well this resuscitation is run.
In ideal hospital settings, resuscitation may reward the medical teams
involved with a proportion of up to 65% survivals. In common, out of hospital,
circumstances, the proportion of success is much smaller, fluctuating from
20% to even 0. This is due, once again, to the huge discrepancy between the
complexity of the unexpected medical challenge and the infinite diversity
of resuscitation human and instrumental resources. In other words, while
one develops arrest as a patient during a cardiology intervention, another
does it over the night, home, sleeping alone.
Although the interest for cardiac arrest and resuscitation is constantly
high, a real prophylaxis in practical terms cannot be done whereas any
research meeting today’s standards is difficult to be carried out. All what
medicine, in a larger social context, can in lieu do is to organise itself in a
manner for the event to be timely discovered and approached in the most
productive way the local conditions allow.
Laudable for the resuscitation intelligentsia, an entire variety of the
scientific information is available, handbooks and periodicals, whereas the
academic life is in step with the adjoining specialities. What those dealing
with resuscitation have differently to do is a particular care of the event,
a specific derived from the above mentioned anytime and anywhere. The
ways for confronting this unpredictability are well standardised, consisting
essentially in the indoctrination, everywhere possible, with the goals of
resuscitation:
− a high standard teaching at all levels of education,
− a well interconnected competence of public services involved
in resuscitation: first aid and emergency services, fire rescue
teams, public events organisers, police and military,

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Cardiac arrest and resuscitation
− practical instructions structured according to basic education,
− early involvement of young generations, mainly in schools,
− periodical updating.
In order to work together, the above principles have to be part of a
unique concept, aiming at obtaining from given circumstances maximum of
benefit. Engineered symbolically, the so called chain of survival (1 – early
recognition and call for help, 2 – early cardio–pulmonary resuscitation,
3 – early defibrillation and 4 – post–resuscitation care) consists in sets of
measures according to the on the spot realities of each particular case.
There remains to each individual involved in resuscitation to further act
voluntarily (a professional or well trained bystander) or to follow diligently
the steps, according to the algorithm provided.
The sets of instructions are basic, purpose–built for people without
medical instruction, aiming at time gaining until a rescue team arrives and
starts the required resuscitation professionally.
To comment in short the chain of surviving, this is an end product of
the worldwide experience in the domain of resuscitation. It incorporates;
− profiled scientific acquisitions selected by consensus by
prominent personalities in the domain
− medical principles largely accepted,
− consecrated techniques, as well as
− leaving to the individual rescuer the possibility of choosing for
his patient the most appropriate recommendations.
The above cited personalities are thoroughly stratified in local, national
and international bodies, carrying out an essential, generous activity
of advice and support. Their position is made known in toto in five year
reviews, the latest one being dated 2015 (305). In this geographical area,
the European and International Resuscitation Councils work together,
coordinated worldwide by ILCOR (International Liaison Committee of
Resuscitation), mentioned already in this chapter. Interestingly enough,
none of their recommendations is in any way mandatory and there is no
institutional forum of supervising. It is entirely up to the organisations
concerned, medical units, teams and even individual professionals to rely
or not, to follow or not the issues in a manner presented by the above
specified bodies.
If the reader puts in balance world preoccupations of such a scale, for
a medical area of practical medicine with so modest results, it is certainly
worth emphasising an adage circulated in the American Heart Association
headquarters according to which ‘doing something is by far better than

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doing nothing at all’. While this quotation sounds somehow in tune with the
rate of successes, it is morally nevertheless a good occasion to remember
V.A.Negovsky as saying, in a free translation, that resuscitation is one of the
most praiseworthy human medical act.

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7. Near–Death Experience

7.1. Introduction 121 7.2. Case diversity 123
7.3. Scientific handling of NDE 125

7.1. Introduction
Known in many languages by its English acronym, NDE, the near–death
experience is an intriguing concept ambitiously disputed by neurophysiology,
psychology, and transcendentalism. Essentially hallucinogenic, NDE remains
beyond any scientifically grounded approach and, consequently, is of equal
interest to non–medical domains. While the experiences themselves are
typically personal, they do have two common features:
− they occur in the immediate proximity of death (5, 48), and
− they are quite similar in description.
The most complete picture consists of details such as
− detachment from material existence with a sense of absolute
dissolution;
− out of body experience with impressions of being outside the
physical self, often including observation of medical personnel
at work on one’s own body;
− a ‘life review’;
− a feeling of comfort, peace, and the absence of pain;
− an intense feeling of unconditional love and acceptance;
− various positive emotions, including levitation, warmth, and
serenity;
− rapid movement through a dark tunnel towards a powerful,
immersing light;
− visions of deceased relatives and religious figures;
− a personal interpretation of the events that often corresponds to
the cultural, philosophical, or religious beliefs of the individual

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concerned;
− a pleasant environment with a pervading sense of relief, the
presence of attractive people, flowers, music, and the like – all
encouraging an instinctive reluctance to go back.
This collection of experiences is attributed to an altered state of
consciousness, that occurs, curiously, under the circumstance of having lost
consciousness (52).
Academically, the study of NDE began half a century ago and has
developed along with the increasing interest in and improved efficacy of
resuscitation. This occurred particularly in hospital units, such as cardiology,
that deal with cardiac arrest and which are in a position to build orthodox
evidence. Nevertheless, the subject is far from being a new one:
− As long ago as the 4th century BC, Plato’s book Republic
described a deceased soldier, Er, who upon ‘awakening’, related
details very similar to those in descriptions of NDE today. That
case is considered the very first to have survived for posterity
(242).
− Towards the end of the 19th century, Victor Egger proposed the
term expérience de mort imminente – a French expression later
translated by the English as near–death experience.
− In the 1970s NDE gained attention through two books: The
Vestibule (1972) by Jess Weiss and Life after Life (1975) by
Raymond Moody (190).
− Later, NDE was embraced by psychology and psychiatry (10, 25).
The International Association of Near–Death Studies (IANDS)
came into being, and two new profiled publications, Journal of
Near–Death Studies and Visual Signs, were launched. Between
1975 and 2005 about 3,500 cases have been the subject of
study, e.g. by E. Kübler Ross.
− A sort of codification is currently in use (48):
• Ring’s “Weighted Core Experience Index”, measures
the depth of NDEs, and Greyson’s scale is useful for
differentiating NDEs from organic brain syndromes and
nonspecific forms of stress (102).
• There is a system for grading the most representative
five feelings: 1) comfort and a sense of peace, 2) an
impression of being outside one’s own body, 3) entering
a darkened tunnel, 4) exiting into light, and 5) a sense of
beauty and sublime love. In not all cases does one pass

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Near—Death Experience
through all five grades; 60% of the cases remain at the
first grade while just 10% advance to the last one (80,
184). For the moment this grading system has a scholarly
significance only.

7.2. Case diversity
As already mentioned, NDE is a domain largely lacking hard facts. To the
very small amount of ‘concrete’ evidence, if any, one can add an amalgam
of history, a great many anecdotes, and more than a few inferences. The
single factor in support of any analysis is the phenomenon of uniformity;
from its ‘demography’ the following details deserve medical consideration:
− Having scrutinised writings from old civilisations, Gregory
Shushman was surprised to find throughout a basic pattern of
NDE.
− No particular ethnic or geographical association has been
identified.
− The experience is known to occur irrespective of religion or
religiosity.
− There is no significant sex difference; it may be slightly more
common among women.
− There appears to be no age correlation; the age extremes from
various statistics are 3 (193) and 92 (163) years.
− Public surveys have found an incidence of 3% of Americans and
4% of Germans, again with slightly more women and young
people reporting NDEs. This proportion increases substantially,
up to 50% of adults and 80% of children, in life–threatening
circumstances.
− Folk tales are not credible sources since, as a paranormal issue,
NDE is already regarded with suspicion.
Attempting to explore a possible medical significance, the most
common scenarios for NDEs involve the proximity of death and highly
stressful events:
− The most frequent clinical setting is that of cardiac resuscitation;
this is why cardiology intensive care units are where most cases
occur and also where relevant evidence can best be obtained.
The few rigorous studies have had such units as a source of
information (163, 210).
− There are plenty of other dramatic circumstances in human

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experience, such as the entire range of shock states, drowning,
electrocution, varieties of syncope, intra–cranial traumatic and
vascular conditions, high fever, human violence and asphyxia
paroxysms (89).
− The variety of life–threatening events is, of course, unlimited in
modern life, but frequently cited are climbers’ falls and high–
speed flights.
− Suicide attempts and torture, notoriously arduous from a
psychological point of view, are also on the list, although they
do not necessarily cause more or more severe NDEs (60).
Curiously, there are reports of NDEs related to the Valsalva effect,
severe depression and after the use of ketamine, LSD, and Salvia divinorum
extract (61,130); there are also cases where no etiologic correlation could be
found (89,184).
Underlying the role played by intensive care settings, much credit is
given to a Dutch study involving 344 cases of cardiac arrest. All the cases
included full ECG documentation and a picture of professionally diagnosed
clinical death. There are a number of details of interest that derived from
the study (163):
− Two thirds of the cardiac arrests occurred in in–patients.
− Of these, 509 occasioned resuscitation.
− Circulatory arrest and coma varied largely in duration.
− 4% of cases had had NDEs in their history.
− From the study group, 18% reported a NDE: 6 at a low depth on
the Ring index, 12 at moderate depth, and 6 profound.
− There was a higher incidence and a more profound Ring index
depth in women and in those under 60 years of age.
− There was a higher proportion of NDE among people having
survived several resuscitations.
− NDE cases were only declared once the resuscitated patients
had reached a stable clinical status, generally after five days.
− Later, the rate of mortality was found to be higher among NDE
cases than in the control group.
− Reassessed 2 and 8 years later, the NDE picture proved to be
remarkably stable.
What happened later with these patients was interesting. The
experience remained stable, positive, and not at all regretted; on the
contrary, the patients concerned reported that they were quite prepared to
have it again. Only rarely was the event regarded as negative (103).

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After NDE, a number of interesting behavioural changes – the so–called
transformation – have been reported by many who have experienced it (48):
− It is moral in type, and fully positive, regarding the person
concerned, the family and community members.
− Recently there seem to be more preoccupations with collective
matters such as pollution, climate change and the ecology of
the planet.
− Psychologically, those who have NDEs show no fear of death
and a firm belief in the afterlife. A notable example is an atheist,
whose near–death experience led to his determination to
become a priest.
− Alcohol and drug tolerance is markedly reduced.

7.3. Scientific handling of NDE
As already stated earlier in this chapter, NDE as a whole seems to be
beyond the reach of a coherent method of study and understanding. This
has certainly not equated to a lack of interest from medical sciences such
as neurophysiology, psychology, and psychiatry. What these sciences have
done is to explore links with every detail of the NDE picture in the hope of
facilitating a more holistic approach (185):
− There is a sort of similarity between NDE and Cotard’s syndrome
(21).The patients suffering from this condition feel and consider
themselves to be dead, while actually being very much alive.
In NDE, on the other hand, the patients are virtually dead but
experiencing sensations known from life.
− Patients describing NDE have by and large been victims of
either circulatory arrest or a similar neurologic ‘disaster’ always
involving a cerebral hypoxia. Pavlov’s concept of sub–cortical
structures escaping the control of a suffering cortex is no longer
a mere dogma, having since been documented by positron
tomography. Moreover, cerebral hypoxia is known in neurology
to cause dissociative disorders such as seeing a powerful light
and having hallucinations (26).
− The oxygen free radicals, generated in excess under any hypoxic
circumstance, could explain an increase in the amount of
bioluminescent bio–photons (29). Similar to the changes in visual
field experienced by high–speed pilots, these pathologically
occurring bio–photons may play a role in creating that light at

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the end of a tunnel so often described by NDE patients (286).
− The fight or flight phenomenon, to which NDE has also been
associated, is credited with the release of endorphins (187).
These mediators have hallucinogenic properties and, in addition
to pain relief, can create sensations of comfort, euphoria, and
beatitude – all found in NDE descriptions. If this hypothesis were
to be confirmed, it could be regarded as a rather ‘rewarding’
and merciful arrangement by Mother Nature – one that equips
us for our confrontation with an otherwise unhappy and hostile
end.
− As of now, too little if anything from neurophysiology can be
correlated to the elusive inventory of experiences associated
with a phenomenon such as NDE. The metabolic version of
neuroimaging has been a tempting resource, although no real
facts have come to light for the time being. Thus, the many and
sophisticated attempts of neurophysiologists to explore NDE
have generally resulted in a sort of narrowness in the approach,
an attempt to ensure a rigorous divide between sound science
and a realm that is readily classified as paranormal. It will
remain quite difficult for the two to come to terms so long as the
features of NDE are defined as products of consciousness while,
during circulatory arrest (a major circumstance prompting NDE),
not only consciousness but even the EEG and evoked potentials
are gone. A conciliatory angle of seeing things is, however,
represented by the concept of a given dynamic of death. As the
irreversible changes of neuronal population develop gradually,
the last to die being the brainstem with a hypoxia tolerance
of about 20 minutes, it would appear possible for neurons,
neuronal structures, and the brain as a whole to be in different
stages between life and death. That state of affairs could
`accommodate’ the coexistence of consciousness and a lack of
consciousness at different levels of the central nervous system –
a seemingly incompatible coexistence that nevertheless leaves
a margin for further consideration. A more obvious display
of this dynamic of death, occasioned by hypothermia, is very
tempting (210).
That potential margin offers a means of explaining many things in
the context of NDE: meeting deceased people (relatives in particular);
detachment from the body (even by a blind person); the sensation of

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Near—Death Experience
giving birth by natural delivery despite having had a caesarean section;
seeing divine and religious figures; NDE occurring in small children with
underdeveloped neuronal circuitry; drawing images from a previous life;
‘seeing’ an object outside the visual field – all of which are branded today
as paranormal.
To conclude, and without attempting to compete with religious notions
of life after death, NDE invites consideration of phenomena and things
beyond both consciousness and the body. Without deserting scientific
principles, scholars of the day must ask themselves whether a modus
vivendi with what dogmatically has been declared paranormal is not
actually viable. Beliefs and practices that have derived from experiencing
a modified consciousness such as meditation, myths, divine inspiration,
mystic experiences, ghosts, metempsychosis and reincarnation may very
well be sources of spirituality and not necessarily a result of spirituality.
As a product of the mind, spirituality found itself hijacked during the
Inquisition and monopolised by a theology aimed at soul manipulation. It
is not impossible that one day the mind and spirituality can share the stage
with medical science. If the mind remains active after its separation from
the body, this could very well be a matter for quantum physics. At the end
of the day, neither a theological a priori acceptance nor a medical a priori
denial has proved entirely productive.
If, for today’s practitioners, NDE is of no significance in terms of scientific
analysis, there remains enormous work to do. Taking inspiration from the
language of NDE, let’s hope we emerge from the long dark tunnel into a
powerful light. Until humanity manages to acquire any certain sign of a life
after death, however, it does remain largely a matter of credo.

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8. Vegetative state
(124, 125, 128, 176, 189, 229, 269, 282, 287)

8.1. Introduction 129 8.5. Auxiliary examinations 133
8.2. Genesis 130 8.6. Follow up 134
8.3. Clinical picture 131 8.7. Treatment 135
8.4. Lesion aspects 133 8.8. Ethical considerations 136

8.1. Introduction
Any state of coma may lead to one of the following: recovery, vegetative
state, brain death, or death. Thus, the vegetative state is not a proper
condition but an evolutionary stage of many other pathological entities.
Patients in a vegetative state display a number of typical features, as follows:
− stable spontaneous breathing and haemodynamics with a
proportional reaction of tachypnoea, tachycardia and blood
pressure increase;
− functional digestion but no inclination to feed on their own;
− apparent wakefulness, open eyes, nictitating, and sleep–wake
cycles not necessarily with a circadian rhythm;
− no awareness of self and surroundings; rather like a partial
awakening from a coma;
− reaction to external, visual, auditory, touch and pain stimuli;
reaction is indiscriminate and not related to the stimuli details
– suggesting unawareness of reaction;
− no reaction to visual threats;
− no awareness of being verbally addressed;
− display of grimaces;
− rudimentary vocalisations, smiling, teeth grinding, laughter,
and weeping, all lacking any motivation;
− ability to suck, swallow, and cough;
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Chapter 8
− urinary and faecal incontinence;
− spastic paralysis of the limbs; and
− poor trophicity, with a tendency to develop trophic lesions,
eschars in particular.
Considering the above details all together, the term vegetation from
the dedicated dictionaries (e.g. 76) satisfies both lay and professional people.
These patients are neither in a coma nor awake, and do react but in a
basic way, involuntarily and aimlessly. They have no spontaneous mobility,
do not understand, do not follow instructions, neither speak coherently
nor communicate, and are incapable of any vocational or recreational
activity, which is essential for an interactive existence (i–life) (50). These
patients experience a very basic existence, trapped in their bodies, with no
satisfaction whatsoever. Such an existence does appear worse than death.
The term vegetative state had a laborious metamorphosis and took
several decades to crystallise. It was preceded by several versions in many
languages, English in particular; some of them are difficult to translate.
Let us enumerate a couple of them in their initial formulation: das
apallische Syndrome, severe traumatic dementia, post–traumatic dementia
encephalopathy, minimally responsive state, minimally conscious state,
decorticate state, permanent post–traumatic unawareness, post–comatose
unawareness, decerebrate state, decorticate state, coma vigile, neocortical
necrosis, cognitive death, pie vegetative and vegetative survival.
Considering the above list of terms and correlating them with the
descriptive details, vegetative state appears to be the most appropriate.
It was launched by the same Scottish team responsible for today’s largely
recognised Glasgow scale (132), and has been further improved by a
European–American co–operation; two names deserve much credit for the
advancements achieved, namely B. Jennett and F. Plum (131).

8.2. Genesis
Vegetative state is an intriguing clinical reality, having challenged
pathology analysts with its intricate components. The sort of clinical picture
displayed has led relevant scholars to ask themselves how it is possible for
these patients to breath spontaneously but not employ a fully operational
digestion since nourishing is an equally vital, instinctive function. The above
lack of orthodoxism seems to result from a multifunctional hierarchy in how
the neuronal structures work under normal and pathologic circumstances:
− Classically, the multi–storeyed anatomical structures correspond

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Vegetative state
to a multi–storey functionality, i.e:
• the brain stem hosts autonomous vital centres;
• the cortex is responsible for the integration of the above
centres as well as for consciousness; and
• the two ‘storeys’ are linked to one another by
intermediating structures, mainly the thalamus.
− This sort of vertical anatomical arrangement has a rigorous
metabolic correspondence, recte oxygen needs; in other words,
the resistance to hypoxia is
• 5 – 3 min. for the cortex,
• about 10 min. for the sub–cortical structures, and
• about 20 min. for the brain stem.
− Many other intricate factors take part at the same time in any
pathologic process in the nervous system:
• details of local conditions, homeostatic parameters, and
intracranial pressure;
• an adaptive running metabolic algorithm since a
‘dormant’ status is accepted in the physiology of the
central nervous system as well; and
• presumably, the existence of a mechanism of rotation
for the physiological metabolic requirements.
Considering all the above variables, the extension of a post–hypoxic
pathology results not only from the degree of proper hypoxia but also from
the functional `snapshot’ of that particular momentum. This should be
the reason for the clinical diversity, on one hand, and the relevance of the
clinical signs of a condition such as the vegetative state, on the other.
Strictly bound to the above pathophysiological principles, the list of
pathological conditions leading to a vegetative state is a very long one;
the most frequent and severe forms are derived from brain trauma and
post–hypoxic states secondary to cardiac arrests. There are plenty of stable
vegetative states; many are, however, temporary, en route to either a
recovery, such as many post–traumatic versions, or a worsening, such as
those of humoral etiology (mostly sequelae of the action of inflammatory
mediators and oxygen free radicals).

8.3. Clinical picture
In addition to those listed briefly at the beginning of this chapter, the
following features are also known:

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Chapter 8
− no awareness of what happens to or around them, but not in a
comatose state;
− no vigorous vegetative functions;
− presence of reflexes requiring cranial nerves (corneal, light, and
oculo–vestibular), as well as spinal and primitive reflexes;
− reflex reaction to pain but not related to the kind and intensity
of pain;
− uncoordinated bulbar and pontine functions, which is why
these patients are able to swallow but not feed themselves;
− reactivity to elements of discomfort such as a full urinary
bladder or wet nappies;
− reflexive, aimless behaviour;
− lack of real cognitive function; and
− psychologically, no personality and no sign suggesting any
suffering.
Taking the French coma scale as a model, from vigile to depassé, the
vegetative state can be:
− temporary, up to 4 weeks;
− persistent thereafter, saying nothing of its prognosis but
depending very much on the nature of the pathology involved
and, of course, the extent of the process proper; it may reverse
to recovery or lead to a permanent vegetative state; or
− permanent, with no or only insignificant changes indicative of
recovery; refers to cases lasting at least six months for non–
traumatic, or one year for traumatic cases.
There are, rarely, patients who recover after even longer periods spent
in what is now defined as a permanent vegetative state. This generally
happens in young people with traumatic pathology; the recovery is always
partial, with more than a few sequelae. Over–enthusiastic media venues
publicise such cases without an adequate medical perspective, misleading
readers. It is part of the involved neurologist’s responsibility, therefore, to
prevent inappropriate information from reaching a devastated family.
Despite the many specific clinical signs associated with a vegetative
state, a differential diagnosis is both academically and practically worth
pursuing. Similar in some respects, the following clinical entities are
potentially confounding:
− Coma. The patient is undoubtedly unconscious, does not open
the eyes, and does not demonstrate any sleep–wake cycles.
− Minimal consciousness state. Similar to the French version of

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Vegetative state
coma vigile, when some conscious responses occur but they
are obviously limited.
− Akinetic mutism. The patient is fully conscious but has a
low range of mental activity, does not speak, and displays
movements of low amplitude.
− Locked–in–syndrome. Also fully conscious and with reduced
mental activity; does not speak and has no spontaneous motor
function, but is able to communicate in a codified manner.
When a distinction of vegetative state has to be made from among the
above pathologic entities, it is good to remember the frequent transitory
behaviours, either to a given recovery or to an even more severe stage,
meaning coma or death!

8.4. Lesion aspects
The lesion inventory consists of a heterogeneous combination of
changes at the level of the most important nervous structures: cortex,
white matter, and thalamus:
− The amount of nervous tissue in discussion – cortex, thalamus,
and hippocampus – is decreased, with the corresponding
microscopic details of neuronal decimation.
− De–myelinisation of the white matter, including
• descendent tracts toward the brain stem – the so–called
diffuse axonal lesion; and
• associative intra–cortical tracts.
− Curiously, the thalamus, as lesions go, is more severely affected
than the cortex although, considering the oxygen needs, it
should be more resistant.
− A global progressive atrophy leading to
• a loss of brain weight of 200 g in Alzheimer’s disease,
400 in metabolic driven vegetative states, and even 500
in post–traumatic cases; and
• development of an ex vacuo hydrocephaly.
Given the above details, it unfortunately makes sense not to expect too
much from a ‘stabilised’ vegetative state.

8.5. Auxiliary examinations
As the clinical course of the vegetative state may be bidirectional, the

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Chapter 8
modern, sophisticated paraclinical methods of investigation have raised
much hope:
− EEG. 5% of cases show an isoelectric trace, a trace lasting a
number of years; apart from this, specific details have not been
encountered, either in improved cases or in worsening ones.
− Functional examinations. In their turn, they are also
disappointing for the lack of expected specificity. For instance,
typical cases of vegetative state have shown no particular
change while some changes were found in patients without any
cognitive impairment.
− Neuroimaging. A means of examining the anatomic alterations
in a vegetative state case: cerebral atrophy, enlarged ventricles
and herniation of cortical layers. Unfortunately, they are
not specific, also occurring in post–traumatic cases without
cognitive participation. There is currently some hope for the
functional metabolic version of magnetic resonance aimed at
identifying some prognostic features.
− Cerebral blood flow is adaptively lower in these cases – a
parameter also lacking specificity.
Considering these auxiliary investigations all together, a vegetative
state is well defined but provides very little information about the direction
of the clinical course. Remaining in the `functional’ domain, the above sorts
of investigations, corroborated, reveal a metabolic rate reduced by 40%
from normal, for both the cortex and the cerebellum. Comparatively, this
is well below the 13% found in sleeping volunteers and also well below
the figures found in patients under general anaesthesia. Moreover, the
vegetative state patients have a lowered oxidative metabolism of glucose.
As such, considering all the above functional data, it does not make sense,
once again, to expect too much from a ‘stabilised’ case of vegetative state –
une cause perdue in other words!

8.6. Follow up
In clinical practice there are plenty of instances of vegetative states
advancing in a positive direction, recovering different proportions of their
previous cognitive function and even reaching the stage of independent
existence. As mentioned many times in these pages, such cases tend to be
young patients with traumatic pathology not having spent a very long time
in a persistent vegetative state. Otherwise, the ‘stabilised’ vegetative state

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Vegetative state
is a sad pathology, obliging its bearers to a pessimistic future. It represents
an unrivalled condition in which it requires from the patient’s entourage a
competent neurologist, a dedicated care team, a medical institution of high
standards with a generous budget and, last but not the least – if this is the
case – a devoted family. Needless to say, this is an idealistic scenario, which
no society can really afford. The world record for vegetative longevity, 49
years, is held by an American woman (246, 312).
The vegetative state is, at the same time, a humiliating disease. These
patients are bed or wheel chair–bound, often with poor personal hygiene;
they are unable to communicate their thirst or hunger; and they may have
pain or other discomfort, but are incapable of indicating the bodily areas of
their complaints. Unable to eat, they are fed via nasogastric or (nowadays,
mainly) a fine–bore gastrostomy tube. Being nourished exclusively this way
ultimately leads to large–scale biological degradation, which explains the
high rate of morbidity and mortality:
− the most frequent complications are infectious in type, including
pneumonia and urinary infections, as well as various eschars;
and
− in descending order, death is caused by infections – 50%, multi–
organ failure – 30%, sudden death – 9%, respiratory insufficiency
– 6%, and common pathology – only 3%.
Among those with a traumatic etiology, about 33% live more than one year,
20% are alive after three years, and only 5% after five years. Comparatively,
the non–traumatic cases rarely survive more than one year.

8.7. Treatment
Regardless of the clinical version, there is always a great deal of care
involved in any case of vegetative state. In principle, these patients are
looked after in a hospital, a social establishment, or at home by their own
family. The main care points are the following:
− Feeding is essential, perhaps more so than in any other kind of
pathology:
• per os is too laborious and nearly impossible;
• via a nasogastric tube is, of course, relatively affordable
and easy, but with the risk of respiratory exposure to
gastric content reflux; and thus
• a gastrostomy is generally the method of choice, particu-
larly since the tubes can be inserted laparoscopically.

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Chapter 8
− Bodily hygiene, in addition to usual washing, requires
• anti–decubitus and dressing of eschars, and
• tooth brushing, which always proves difficult.
− Tracheostomy care (as is often the case) is required, if necessary.
− Regular and insistent physiotherapy must be provided.
− There is no evidence–based treatment definitively advised;
anecdotally, and derived from the theoretic pharmacology, the
following deserve a mention:
• antidepressant drugs: tricyclics, methylphenidate; and
• stimulants, such as dextroamphetamine.
− Techniques of physical stimulation are employed, including
sensorial, kineto–muscular, and tactile interaction.
− Therapeutic attempts include:
• Stimulation – brain stem, cortical (extradural bifocal,
magnetic transcranial) and medullary; and
• Subdural baclofen.

8.8. Ethical considerations
The vegetative state is a by–product of a high–standard, expensive, and
socially demanding medical practice. Such cases represent the price that
successful intensive medicine pays for its overall good results. Unfit health
care systems do not, therefore, produce patients in a vegetative state.
Consequently, a valid demography of this condition is impossible.
The vegetative state is, undoubtedly, a regrettable human tragedy and,
in its stabilised stage, numerous problems are to be considered:
− The patient seems neither to suffer nor to experience any
satisfaction, and the vegetative state is a far cry from an
interactive existence (i–life, again, (50)).
− As far as the family is concerned, a loved one neither dies nor
lives, and there is a slow progressive blunting of positive feelings.
Budget restraints are also to be taken into consideration in
some cases.
− Finally, willingly or unwillingly, social services expend
considerable resources on someone who will never be
productive again.
As such, as mentioned earlier in this chapter, a vegetative state
looks worse than death. The patient lives artificially, in the absence of
any happiness, with no given consent, and without any perspective for a

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Vegetative state
rewarding existence. This has proven to be a good niche for many non–
medical approaches, including the philosophical, ethical, religious, and
judicial. The number of websites dedicated to this subject exceeds 1,000
(one thousand).
As medicine has no choice but to deal with this category of patients, it
is the right and obligation of its ethical arm to try to sort out the problems
that have a medical tangency:
− Perhaps, apart from the pain, a cognitive implication in the life
of these patients is questionable.
− Without any satisfaction, even the most basic one – related to
food – these patients’ existences can hardly be termed life.
− Living strictly biologically, with no social participation, a patient
in a vegetative state is in fact no longer ‘a person’, if we accept
that personality is linked to biography, interrelationships and a
way of life, and not exclusively to biology.
− Unfortunately, the high cost of care must also be taken into
consideration – the reason being that at any given moment,
the families concerned may either require societal help or must
resort to abandoning the patient.
The fate of a patient in a vegetative state depends on a number of
issues, with real confounding factors:
− These patients do display the life triad: spontaneous breathing,
stable haemodynamic, and (according to some) a rudiment of
cognitive function – as such one confronts the argument that
life is sacred!
− Neurological improvements do occur from time to time;
while never leading to an independent existence, such cases
nevertheless represent documented facts, difficult to ignore
bureaucratically.
− As brain death consists of brain stem death, it is worth looking
at the controversial behaviour of this nervous structure, namely
that
• it loses all function in the event of brain death, which
represents the cases usually used for beating–heart
organ donation; and
• as it is still (partly) viable in the case of a vegetative
state, facilitating the death of such a patient is legally
susceptible to being considered a crime.
− Eventually, religious and civic involvement also comes into

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Chapter 8
consideration, both strongly advocating a noli tangere.
Given the ‘jungle’ of so many intricate stands and viewpoints, it is not
at all surprising that in many countries major decisions concerning the
handling of vegetative state cases fall to the courts. The most frequent
scenarios involve weighing a decision to interrupt life support.
The very first step in a judicial procedure is a legal petition forwarded
by either the family or the hosting hospital department. In both cases, the
reason for such an action is essentially similar, i.e. termination of a hopeless
and costly existence. Needless to say, a judicial procedure such as this, full
of traps, has to be meticulously conducted and professionally documented;
inter alia, the patient will be represented by a high–ranking member of the
court. Once the clinical case ‘qualifies’ for a discontinuation of on going
treatment, the responsible team proceeds to enacting the court’s decision.
The simplest way is a passive euthanasia. This usually entails the ‘switching
off’ of hydration and feeding mechanisms. In practical terms, there is a
given sequence of steps:
− the patient is placed in a single room;
− the nasogastric or gastrostomy tube is removed;
− all hydration, i.v. included, is discontinued; and
− one i.v. route is left in situ, a cannula for analgesia and any
urgent medication required under unforeseen circumstances;
for analgesia the most efficient chemical option, dose and
timetable are used.
In doing so, death occurs in roughly a fortnight. Needless to say, no
resuscitation techniques enter into discussion.
If the patient, while still compos mentis, by chance left a living will,
the family or the hosting hospital department (if no family is available)
takes into consideration transplant organ donation and the final days of
the patient’s care are conducted in cooperation with the transplant team,
according to its policy governing organ harvesting.

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9. Cell death
(107, 169, 178, 180, 274, 280)

9.1. A general view 139 9.2.4 Oxygen free radicals 144
9.2. Causative factors 140 9.2.5. Various in nature 145
9.2.1. Physical 140 9.2.6. Interacting factors 146
9.2.2. Toxic in nature 141 9.3. Cell death versions 146
9.2.3. Hypoxia 142 9.3.1. Necrosis 146
9.3.2. Apoptosis 147

9.1. A general view
A somatically mature human body is comprised of somewhere between
75 and 100 trillion cells including 200 various types. Their morpho–
functional features derive from the genetic pattern, a pattern which usually
also dictates the life span.
Using a method similar to that of radiocarbon dating, famously used
in archaeological practices, it is possible to elaborate a sort of cell panoply
(254):
− those living a couple of hours, such as the neutrophils;
− others, which we are born with, such as neurons and
myocardiocytes, living as long as the respective individual (a
division of these cells would be incompatible with the basic
physiologic model of a running existence); and
− a long series of intermediary positions:
• 2 to 3 days – spermatozoa;
• a couple of days to up to one week – epithelial cells from
the digestive lumen;
• 10 days – thrombocytes;
• 2 to 4 weeks – epidermal cells;
• 4 months – red cells;
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Chapter 9
• a couple of months to one year – lymphocytes and
macrophages;
• over one year – pancreatic and hepatic cells;
• around 15 years – muscle cells; and
• 25 – 30 years – osseous cells.
The life span of the cells has a physiologic ‘logic’: the allegro detachment
of the digestive covering layer cells, for instance, keeps away the moving
in aval caustic gastro–intestinal content, thereby protecting the viable
subjacent younger cells.
The average cell life is about ten years; this physical life that is shorter
than the birth life of the individual attests to a renewal process. This process
implies death and birth of a given number of cells – a number of around 300
million per minute. Without cell death, the multiplication would lead to a
gigantic body. Curiously, the physical life of the neurons and myocardiocytes
is longer than the birth life; this is because these two types of cells come
into being in the process of embryogenesis, do not divide during the lifetime
and die physically only after the death of the individual concerned.
The integrity of a cell is affected
− either violently, due to an incompatible damage by different
aggressive factors; or
− naturally, genetically programmed, as a final stage of the ageing
process.

9.2. Causative factors
9.2.1. Physical
There are many in number and a variety of types: mechanical
traumas, electricity leaks, irradiation and intolerable changes in pressure
and temperature (burns, frostbites). The mechanism causing cell death
consists of irreversible changes in the structural components. Apart from
some experimental settings, when death lesions interest a small number
of cells, this category of causative agents affects very different bodily
areas, from a needle prick to 100% burns. In general, the severity of the
impact derives from the extent of the resulting lesion. There are, however,
circumstances under which, despite a limited extent of damage, it may
die; injury to respiratory centre cells or the cardial excito–conductive
tissue by an electrical current is a good example of this version of physical
aggression.
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Cell death
9.2.2. Toxic in nature
There are many mechanisms of cell toxicity:
− Although important physiologically, dextrose and salt may
become toxic. For instance, by increasing their concentration in
the cytoplasm, they can alter homeostasis, more precisely the
osmotic and electrolyte physiologic values.
− Specific toxins materialise their effects as follows:
• Some water soluble ones reach the cytoplasm and
inadvertently combine with constitutive molecules,
altering the milieu intérieur and cell organelles.
Particularly exposed are those cell communities which,
by nature, play a part in captation, taking up and
excreting chemicals having inadvertently reached the
cytoplasm. A famous example is HgCl2 which, having a
high affinity for the sulfhydryl group, gets combined with
different proteins from the cell structures and inhibits
the ATP–ase, compromising essential cell functions such
as the vital trans–membranous exchanges.
• There are other chemicals, liposoluble in particular,
which, while harmless in themselves, become toxic
by their metabolites. As with those above, they get
combined with proteins and lipids from the membranous
structures. Generating oxygen free radicals, they are
also able to cause dangerous reactions involving lipidic
peroxidases.
− Irrespective of the way, cell enzymes essential for life can be
denatured:
• P450 oxidase from the detoxification arsenal of the hepatic
plasmatic reticulum – the famous case being of carbon
tetrachloride and the over–dosage of acetaminophen,
otherwise a banal medicine. As a result, the alteration
of mitochondria and cell membranous structures leads
to a loss of their selectivity; consequently, interstitial Ca
ions ‘invade’ the cytoplasm, inadvertently activating the
organelles enzymes.
• A special mention has to go to the cyanide ion which,
affecting cytochrome–oxidase, directly prejudices cell
usage of oxygen.
The toxic aggression of external provenance causes an obvious reduc-
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tion of ATP production and availability; as a result, all the energy–consum-
ing processes, both of degrading and synthesis, get progressively dimin-
ished, affecting trans–membranous ‘traffic’ and all that this implies for the
cell’s economy.
Modern societies constantly use a large variety of chemicals:
in households, the agricultural and food industry, the cosmetic and
pharmaceutical industry, and in the social sphere and the realm of street
narcotics. With the exception of the last two, their usage is currently well–
controlled and, as such, biological damage does not come into consideration.
In the event of abuse, however, they become dangerous, health–wise. The
background of this danger is metabolic in type, each chemical having its
specific mechanism.

9.2.3. Hypoxia
As the human being is an aerobic creature, oxygen is vital for every
cell. Highly oxygen dependent are the membranous ‘traffic’, the entire
range of syntheses and, of course, the running of some specific functions.
These include emission and transmission of impulses, muscle contraction,
and locomotion – to give just a few examples. The required energy is
provided by the catabolic splitting of larger molecules, proteinic, lipidic, and
carbohydrate; ATP, ATP–ase and mitochondria are quintessential players in
‘cell energy handling’.
While from the clinical viewpoint the sort of hypoxia does play an
important role, for the cell itself any hypoxia leads to the same metabolic
and organic consequences. Hypoxic cell damage has two phases: reversible
and irreversible.
Reversible phase
Following is an attempt to order the events that occur in a hypoxic cell:
− A reduction of O2 delivery immediately leads to a drop in ATP
production and, inherently, energy availability. The metabolic
state is reflected in different cell functions according to their
energetic requirements; a good example is the contraction of
myocardial fibres, which show signs of sufferance not later than
60 seconds from the coronary occlusion.
− Consequently, phospho–fructokinase and phosphorilase are
stimulated.
− This leads to an anaerobic glycolysis, which, together with cre-
atinephosphatase/creatinephosphate, represents an (uneco-
nomical) alternative means of ATP production, with an energy

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output as low as 2, as opposed to 38 mol/mol of dextrose.
− This implies glycogen consumption and lactic acid and inorganic
phosphate accumulation, with an obvious lowering of the
intracellular pH.
− The reduction of energy also affects the selectivity of the
membranous permeability, leading to more proteins and Na in
the cytoplasm and more K outside of it.
− The accumulation of Na in the cell, together with an increasing
number and amount of catabolites, means a higher osmotic
pressure, bringing in more H2O with a resultant cell oedema.
− This oedema also affects the organelles; ‘dilating’ the plasmatic
reticulum, it facilitates the detachment of the ribosomes and
the dissociation of polysomes in monosomes.
Irreversible phase
If the hypoxia persists, both the intra– and extra–cellular changes
advance towards an irreversible stage. The speed of the process depends
on the type, age, metabolic needs, and functional profile of a given cell; this
is why the hypoxia is tolerated 1 to 2 hours by the hepatocytes but only 5 to
3 minutes by the cortical neurons. Despite the many morphological details
of an advanced hypoxia of a cell, there is no prime biochemical defining
detail of the irreversibility. Academically, this is considered to be the
moment when such cells no longer use the expected amount of O2 despite
its re–established physical availability. From a biochemical point of view,
the accumulation of oxygen free radicals represents a common feature in
all sorts of hypoxia, irrespective of the type of dying cell.
The advancement of metabolic pathology finally conducts to the
lysosomes’ lysis, with an intracellular dispersion of their enzymatic content.
Having escaped from such a well–regulated organelle, the enzymes become
anarchically active on the cell’s own structural elements, culminating with
cell destruction. No longer selective, the membrane allows extracellular
components to enter the cytoplasm and intracellular ones to leave it for
the interstitial space and beyond, towards the vascular lumen. Taking as an
example the ischaemic myocardial tissue, specific cell enzymes easily reach
circulation; this is the local explanation for the presence of transaminases
and the newly acquired vinculin in the patient’s serum. Cell death implies a
biochemical dégringolade, leading to structural disintegration.
It is interesting, from a metabolic viewpoint, what happens to hypoxic
tissue when good blood flow and oxygen delivery is re–established. Due
to the above–described biochemical events, the mitochondria become no

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longer capable of cleansing their territory of the acid excess and oxygen
free radicals. As a result, the local picture of both the biochemical and
the acquired lesion continues to deteriorate for a period of time. An
inflammatory process gets involved, outlining what is clinically known
as reperfusion syndrome. The superoxide ions and endothelial xanthine
oxidase, released in the developing inflammatory process, represent
important additive biochemical components. Needless to say, the cells with
irreversible biochemistry go on to develop morphologic lesions, specific
first to the loss of vitality, and to real death thereafter.

9.2.4. Oxygen free radicals
Each cell is equipped, both morphologically and metabolically, such
that it is energetically independent and functionally fit. As far as energy is
concerned, in addition to the amount necessary for its own ‘management’,
the cell has to be able to cover its entire function(s). Staying awake and
processing all the sensorial functions, thinking, and intellectual deliverance
all prove to be highly energetically demanding – which is why the cortex
neurons do not usually tolerate a lack of oxygen (or energy) longer than 5 to
3 minutes. In contrast, the skin cells are self–sufficient with so little oxygen
that cutaneous tissue is still alive 24 hours after the death of the individual.
The required energy at the level of each cell is obtained by running
particular chemical reactions:
− separately, in cytoplasm, lysosomes and even membranes; and
− for the entire cell, at the mitochondria level – an oxidative
phosphorylation supposing a cascade of redox reactions,
generating the necessary ATP.
The oxidative process, in itself, is not a perfect one. Up to 2% of the
processed oxygen becomes a sort of intermediary product, only partly
reduced – the oxygen free radicals being a metabolic residue; in order
to be re–introduced to circulation, they have to first be neutralised. A
biochemically vigorous cell is able to neutralise the entire amount of resulting
free radicals. With time this biochemical vigour weakens and, progressively,
more radicals remain un–neutralised. Being chemically unstable and by
definition reactive, they get easily involved in inadvertent reactions with
various cell molecules, actually materialising an oxidative aggression.
A similar sudden aggression occurs under circumstances such as ionising
rays, some intoxications, immunologic paroxysms, various inflammatory
processes and, mainly, metabolic decompensations caused by oxygenation
deficits. Intriguingly, this ‘aggression’ can also occur on its own, leading

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Cell death
to metabolic wear and tear; more and more radicals are produced while
fewer and fewer are neutralised. This is exactly what happens in ageing and
degenerative conditions.
The most well known oxygen free radicals are superoxide, hydrogen
peroxide, and hydroxyl ions; nitric oxide, a chemical mediator, may itself
have free radical behaviour. All mentioned agents develop their specific
deleterious action as follows:
− lipidic damage by peroxidase;
− oxidative changes of various proteins; and
− by interfering with thiamine, alteration of the DNA proper,
which can affect the entire future cell chemistry.
The fate of the free radicals depends on the chemical climate of the cell:
− Some may disappear on their own as the superoxide which,
being unstable, decomposes to O2 and H2O2.
− A clearance can be facilitated with substances such as
polyphenolic antioxidants.
− There are, then, antioxidants of external provenance, such as C
and E vitamins and glutathione.
− There are a number of more efficient ways, enzymatic or non–
enzymatic, of managing inactivation and eradication, such as:
• antioxidants, which block and inactivate the radicals in
question; and
• dedicated enzymes of decomposition: superoxide
dismutase, catalase, and glutathione peroxidase.
− In the interstitial space, the antioxidative capacity is modest,
with uric acid being the most important agent in man.
The young and vigorous cell manages to keep its intracellular space
free of oxygen free radicals for various periods of time. As it gets older and
more chemically stressed, the balance between production and clearance
of the radicals inclines towards accumulation and a sort of autointoxication,
with a functional decrease in the biochemical gearing of the cell.

9.2.5. Various in nature
The nature of the agents matters in itself; at the same time, their
mechanism of action matters even more:
− Infections: toxins are released by the long series of microbial
germs, viruses, Rickettsia, fungi and different parasites.
Especially vulnerable are glycolysis, the Krebs cycle, and
oxidative phosphorylation – all essential for cell existence. The

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Chapter 9
phospholipase of the anaerobic germs and the endotoxins of
those that are gram–negative denature phospholipids of the cell
membrane, compromising its permeability and thus enabling it
to cause cell death.
− Immunologic conflicts lead to inter–proteinic reactions able to
affect cell integrity. The complement, in its turn, plays a humoral
role in this respect.
− Genetic: DNA alterations and the congenital lack of some
essential enzymes can very well cause cell fatalities.

9.2.6. Interacting factors
The two essential cell elements, biochemical and structural, are
interdependent; irrespective of which one is damaged first, they are both
eventually affected.
The order of vulnerability is
− aerobic reactions: oxidative phosphorylation and ATP
production; and
− membrane integrity: osmotic homeostasis of the cell and a
good function of the organelles.
The morphologic changes materialise after a particular time – the time
required by the biochemical ones to reach a critical point:
− a reversible cell oedema occurs in minutes,
− ultra–structural alterations follow in 20 to 60 minutes, and
− meanwhile it takes the ischaemic myocardiocytes 10 to 12
hours to become microscopically visible.
The effect of the toxins can be reversible, irreversible, or instantly fatal.
The functional role of a given structure is crucial in how severe
the lesions are going to be; as a permanent functioning structure, the
myocardium is particularly vulnerable.

9.3. Cell death versions
There are two distinct ways that cell death concludes: necrosis and
apoptosis.

9.3.1. Necrosis
This way consists of the entire series of changes to both the cell and its
environment:
− cell lysis: organelles disintegration, nucleus disaggregation,
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Cell death
and membrane dismemberments; needless to say, the genetic
equipment loses any operative attribution; and
− setting into motion an inflammatory process of recycling the
material that results from de–vitalisation.
There are a couple of anatomicopathological versions:
− Coagulative, found in the myocardium, the kidneys and the
suprarenal gland. The local biochemical realities facilitate proteic
coagulation instead of proteolysis. The cell becomes enlarged
and ‘explodes’ into pieces, which are then phagocytised. The
leukocytes involved then complete the clearance process up to
a molecular level.
− Liquefied, occurring in nervous structures as well as after
infectious aggressions. The liquefaction is the result of an action
of leukocyte lysosomes, via their hydrolases.
− Caseous, found in fatty tissues such as the breast, as well as the
pancreas. The pathognomonic steatosis for acute pancreatitis is
just a version of this necrosis.
− Gangrenous, caused specifically by ischaemic insults; the
gangrene can be dry, humid, or gaseous.
In a live organism, the necrotic cell suffers either an enzymatic digestion
and phagocytosis or a dystrophic calcification.

9.3.2. Apoptosis
This is a way of cell death that is controversial in terms of biological
philosophy. It is also interesting as a mechanism and beneficial as a
modality of execution. Apoptosis is also responsible for a long series of both
physiological and pathological events. It represents a modus operandi for
− renewal of proliferative cell populations such as the digestive
and cutaneous epithelia;
− renewal of leukocytes and osseous cells;
− programmed destructions of cells from
• embryogenesis, a good example being the intrauterine
clearance of the inter–digital membrane, and
• metamorphosis;
− hormonally driven involution, including
• the thymus,
• menstrual endometrial detachment,
• breast regression, once lactation is over, and
• ovarian follicle regression after menopause;

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− atrophy of hormonal dependent organs such as prostate
involution after castration;
− cell death consequent to chemotherapy;
− cell disappearance after viral aggregation;
− death of immune cells such as B lymphocytes; and
− cell death induced by T cytotoxic cells.
Apoptosis runs as follows:
− preparation: synthesis of required enzymatic equipment;
− progression:
• disappearance of intercellular bends,
• reduction of global cell volume,
• condensing of nucleus chromatin, and
• splitting of chromosomes into nucleosomes.
− degradation: a very rapid phase, lasting only a couple of hours,
and consisting of cell partition into more apoptotic bodies, with
a nucleus fragmentation;
− eradication, execution in two manners:
• either by phagocytosis, proportionally prevalent; or
• autophagy, in which the cell components are digested
by its own lysosomal enzymes.
Reviewing the above details, apoptosis is clearly very different from
necrosis and, teleologically, by far more useful:
− it can ‘focus’ on just a single cell;
− once fragmented, the resulting pieces go on to be phagocyted
by neighbouring cells;
− proteolysis is run ‘economically’ by the cell’s own proteolytic
enzymes, i.e. caspases; and
− both the switching on and the process of running proper are
genetically programmed.
Unlike necrosis, where the cell enlarges its volume up to a stage of
exploding and requiring an inflammatory process for cleansing, apoptosis
runs in situ; it is ‘tidy’ and orderly and, by contrast, is a sort of imploding.
As such, a selective process of auto–destruction and a programmed death,
apoptosis does play a positive role of ‘constructing’ death. It is a process
that takes part in the regeneration of cell communities and is also involved
in the fine–tuned remodelling of the body called for by advancing age.
x
What happens as a result of cell death depends very much on the
functional involvement of the cell concerned. Those without an important

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Cell death
role are either removed from the ‘inventory’ or replaced with new ones. On
the other hand, if a functionally important cell is affected, particularly in the
event that it is not a renewable one, it – again – depends on which one and
how many of them die. In the event that cells from the respiratory centre or
excito–conductive myocardial tissue are going to die, despite their modest
‘geographical’ and proportionally small bodily representation, one leads to
the death of the entire body – an in toto death. In real terms, this happens
in instalments, in close relation to the resistance to hypoxia of various cell
groups.
According to Korotkov’s electromagnetic field studies (149), the death
of the entire mass of cells takes about 24 hours – allowing enough time for a
successful retrieval of human cells for fertilisation and cloning requirements.

149
10. Death semiotics
(19, 40, 83, 110, 126, 137, 141, 148, 243)

10.1. A general view 151 10.3.2. Hypostasis 154
10.2. Initial signs 153 10.3.3. Cooling 156
10.3. Further signs 154 10.4. Signs various in type 158
10.3.1. Muscular tonicity 154 10.5. Identifying the deceased 159

10.1. A general view
One of the imperatives of the Hippocratic Oath, now two millennia old,
has been a tireless stance against death, an adversary portrayed in everyday
parlance as an enemy number one. This stance is well supported by the
mortality rate in various medical units. But, nowadays, medicine is getting
progressively more involved in the process of dying itself.
A distinct speciality, Pathology has constructed from its study of the
dead a valuable methodology, one that essentially represents the raison
d’être for this medical specialty. Unlike Pathology, Forensic Medicine does
not deal indiscriminately with all lifeless human bodies; its focus is on the
unexpected, suspicious and mainly unnatural deaths. Like pathologists,
Forensic Medicine specialists are highly analytical in their approach. They
must also identify and quantify outcomes, but within sometimes very
amalgamated scenarios in which everything even tangentially related to
the case must be considered to potentially play a role – making the forensic
specialist the Sherlock Holmes of medicine.
Intriguingly enough, death is not really known to us, at least not to the
same extent of its significance for any living being. The two stages of death,
clinical and biological, have an enormous importance for modern medicine
– and not just technically. To the former we can correlate the famous NDEs,
although such experiences become public in a relatively reduced proportion
(fewer than 10% of the people having recovered from clinical death). As far
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as the latter is concerned, there has been no description whatsoever from
any mortal human in entire recorded history. If some such experiences have
occurred, they are lost to posterity along with the deceased in the grave.
Regarding the process of dying, the sequence of events is of great
importance for those concerned:
− The loss of consciousness in advance of death proper certainly
facilitates the dying process, in terms of moderating sensations
and discomfort.
− Consciousness is also lost in rapid deaths such as those by
drowning, fire, capital punishment and human conflicts. In
any event, up to the very moment of losing consciousness, the
experience seems to be terrifying.
− The release of endorphins – a scholarly mantra regarding
circumstances of great struggle – would be an enormous
relief for the individual concerned. It is rather surprising that
despite the multitude of hypotheses, no significant conclusion
is available in this respect.
It is then of real academic importance to explore how people actually
die, whether naturally or inadvertently, from the biological point of view.
− Candidates for death with chronic conditions have in common
a slow, progressive process of metabolic autointoxication of the
entire mass of cells, on a scale governed by oxygen needs or
hypoxia tolerance. Once coma and apnoea occur and the heart
ceases to beat the rest of the body mass cells then deteriorate
further and die in successive groups directly related to their
oxygen demands.
− In people dying of acute conditions, things happen as a whole
in a reverse manner. First to suffer, to a functionally impaired
level, are the cells involved in the life triad. The heartbeat,
consciousness, and breathing cease quickly; as such, the body’s
cell mass is, in the first instance, metabolically unaffected. Its
involvement follows once asphyxia reaches compromising
levels, in an order, again, depending on oxygen needs.
Irrespective of the method of hypoxic impairment, the neurons are
first to suffer, both biochemically and structurally. Once the lesion reaches
an irreversible stage, recovery is no longer possible. This seems perfectly
in tune with Haldane’s 1930 formulation, according to which hypoxia not
only affects motor functioning but also impairs the machinery itself (184).
An interesting scenario in this respect is dying in one’s sleep. The person

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Death semiotics
concerned is not comatose but not awake either; the body’s entire cell
mass is in a ‘dormant’ status, with reduced oxygen consumption.
Oxygen requirements, namely the resistance to hypoxia, determine
the very moment of death in a certain cell community. This is the reason
leukocytes are still viable 8 hours postmortem while a culture of cutaneous
cells harvested 24 hours after death can still grow.
It is, then, worth noting here
− on one hand, the rapid, even instant, death of the body’s entire
cell mass in cases of massive irradiation; and
− on the other hand, the favourable influence of hypothermia
upon the rhythm and extent of the deleterious effects of
hypoxia, the profound version not only delaying neuronal
structural changes but also preventing them altogether.

10.2. Initial signs
− Neuronal impairment explains the loss of both consciousness
and spontaneous breathing as well as the loss of important
reflexes, namely that of the cornea and the reaction to light,
explaining the corresponding pupil dilation.
− As a direct consequence of circulatory arrest, there occurs at the
retinal level a red cell alignment, a sort of flow ‘fragmentation’
that is visible with an ophthalmoscope and, of semiotic
importance, lasts no longer than 10 minutes.
− Tonicity of the eyes reduces rapidly.
− Striate muscles lose their tonus, becoming flaccid (primary
flaccidity).They continue to respond for a while to mechanical
and electrical stimulation; spontaneous short–lived contractions
of small muscles are possible.
− The smooth muscles relax as well; as such the sphincters
become inoperative, with
• emissions of urine and sperm;
• faecal incontinence; and
• regurgitation of gastric content into the pharynx, where
it can accede the lungs.
− Conjunctiva and skin become pale.

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10.3. Further signs
10.3.1. Muscular tonicity
The exhaustion of ATP and an increased level of lactic acid lead to an
irreversible combination of myosin with actin, resulting in a sort of gel, which
explains the subsequent muscular hardening – rigor mortis. Its dynamic
depends on temperature and muscle type. Under moderate climate
conditions, first to display this change are the small muscles of the face
(eyes, lips, and mandible) in 1 to 4 hours, after which rigor mortis descends
to the limbs in 4 to 6 hours. There are relevant points worth detailing:
− This cadaveric change is more pronounced in individuals with
voluminous muscle mass, or intense muscular activity (from
strenuous athletics, tetanus, status epilepticus, electrocution,
and strychnine intoxication), as well as under circumstances of
hyperthermia such as malignant hyperthermia or even torrid
environments.
− To the contrary, it is nearly insignificant in cachectic people,
as well as in accidental hypothermia and in colder climates –
circumstances under which ATP consumption is known to be
low.
− Rigor mortis explains the difficult passive mobility compared to
living individuals. Nota bene, passively moved limbs may return
on their own to their initial positions during the first 8 hours.
Once hardening sets in, it takes 24 to 50 hours for secondary flaccidity
to occur.
It is also of forensic significance that the intracellular background
of rigor mortis develops in smooth muscles as well. This is certainly the
explanation for two signs:
− a later emission of sperm at meatus level, and
− a contraction of the piloerectile muscles, making body hair
stand up, which, together with dehydration, causes the false
impression of postmortem beard growth.
An interesting sort of muscular contraction is cadaveric rigidity. Occurring
at the finger level, mainly the forefinger used to pull a trigger, this rigidity
can be found in self–murderers and individuals killed on the battlefield.

10.3.2. Hypostasis
Although not universal, hypostasis – however it occurs – represents a

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Death semiotics
truly consistent source of changes. Once circulation ceases, the vascular
network loses its tonus up to a real paralysis – a change allowing the blood
mass to redistribute gravitationally. This mechanism of redistribution leads
to a few significant postmortem signs:
− When someone dies unexpectedly, with the vascular bed
uninvolved in any pathology, this quickly becomes a sort of
system of communicating vessels. Its extent sometimes allows
forensic investigators to consider it as a possible modality
of drug redistribution. Unlike this model, there are clinical
scenarios in which the vascular bed is involved in different
pathological processes. In accordance with the neurohumoral
backing of these processes, the vascular bed changes its details,
which matters in the later haemodynamic developments. The
most frequent alteration of this kind occurs in shock with its
two major versions, compensated and decompensated.
− Red cells become sedimented, which causes a declivous bluish–
red colouring. How this colouring takes shape depends on the
position of the corpse:
• Most frequently, the body remains lying in a horizontal
position; consequently the colouring interests the dorsal
aspects of the neck, trunk, buttocks, thighs and heels.
• The topography is vice versa if the corpse remains in a
face down position.
• The blood moves towards the feet in cases of hanging.
• The blood remains at the trunk and head level in those
partially fallen, head down, from bed.
− As the blood no longer has any driving force, it is pushed out
by compression from those body areas lying on hard surfaces.
− These bloodless areas become pale and whitish, with a
‘geography’ exactly reproducing the position during the first
hours of death. The same effect of compression may come from
tight clothes and prolonged contact between body parts.
− The colour feature of hypostasis is typically influenced by
multiple factors:
• it is irrelevant in cases of significant skin pigmentation;
• it does not develop in those having suffered an anaemic
condition or in haemorrhagic cases;
• hypercapnia looks very similar to cyanosis;
• there is a reddish nuance in hypothermic patients, due

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to a lower consumption of oxygen, with an increased
level of oxyhaemoglobin;
• it is cherry–red in carbon monoxide intoxications;
• it is dark–red in cyanide intoxication;
• there is a bronze nuance in the case of infection with
clostridium perfringens; and
• it is masked in cases of dermatologic pathology.
− Hypostasis is confoundable with the flotation level, when
freshly dead bodies spend hours in a full water container (most
often bath tubs), in rivers, or in the sea.
Despite being governed by physical laws, due to the large number of
variables, the above signs cannot always be absolutely relied upon.

10.3.3. Cooling
Once death has stepped in, each individual cell continues its metabolic
‘duties’ up to the exhaustion of the available oxygen and energy resources.
The amount of resulting heat is small, however, the issue having a rather
more academic interest. Nevertheless, there are cases where body
temperature may increase marginally, but not for long, for example in
malignant hyperthermia, fulminant infections and in very muscular people.
Of much greater importance is the body temperature of the subject at
the moment of death. That temperature can vary according to numerous
factors, both physiological and pathological in type.
− Physiological:
• Circadian rhythm – there is a 2oC variation between
morning and evening.
• Digestive status – a rich meal requires more digestive
effort and, as a result, generates more heat.
• Age – children, teens and young people normally have
higher body temperatures.
• Gender – female subjects have a higher temperature
than males of the same size.
− Pathological:
• Hyperthermia is particularly important as it has its
malignant version.
• Heat production rises with violent physical effort and the
use of cocaine and some neuroleptics as well as under
stressful circumstances.
• To the contrary, heat is reduced in hypothyroidism,

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Death semiotics
cardiac failure, and lethargic states.
The cooling process has a particular dynamic. According to Newton’s law,
the body loses heat to the ambient environment, slowly or quickly, strictly
in relation to the temperature gradient. Needless to say, in a hot desert the
body gains heat and is subject to a consequent increase in temperature.
Furthermore, the constitutive parts of the body cool with different
speeds, some more quickly than the others. The cooling process can be
influenced as follows:
− environmental conditions – ambience (air, water or, rarely,
other liquids); atmospheric humidity; and heat conductivity of
the surface on which the body rests;
− bodily characteristics – mass, surfaces, fat proportion;
− position – any variety, from straight to foetal; and
− clothing – amount and textile structure.
For a non–specialist, it is quite enough to know the following:
− by palpation, a fresh cadaver gives the impression of being cool
starting at 32 – 30oC;
− in a temperate climate, the lowering of temperature is about
1oC/hour; and thus
− within 24 hours, body temperature equals the ambient one.
The forensic specialist operates with standards that are by far more
sophisticated, exceeding the scope of this compilation. For an overall
impression, let us simply mention a few of them:
− The lowering of body temperature follows a rather complex
pattern including a linear decrease between plateaus at the
two extremes.
− The so–called Henssge nomogram is used, which considers
three important parameters: body weight, body temperature
and ambient temperature.
− In the same context, the body area where the temperature is
measured does matter:
• that from the axilla does not satisfy;
• the rectal one is valid, with the caveat that the area is
discouraged, for good reason, in cases of sexual assault;
• the oesophagus is accessible and reliable; and
• there are cases of special interest, where intra–
hepatic and intra–cerebral temperature are taken into
consideration.
In conclusion, there is sometimes a discrepancy between the great

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expectations of forensic science and the amount of information actually
available in common practice. The complexity of the problems faced by
forensic colleagues are so extensive that they often appeal to domains
related but quite different to their own, such as anthropology and
entomology; forensic scientists are academically famous for paying attention
to everything from ant to lion – to cite the language of their vocation.

10.4. Signs various in type
A number of common bodily changes may contribute to establishing
the time of death. The best known are:
− Muscular excitability: the distal third of the quadriceps tendon
structure is struck, and a short muscle contraction is obtained
in the first 2 to 3 hours after death (Zsako’s response).
− Ocular changes
• cornea opacity occurs quickly when the eyes remain
open; if they are closed, 24 hours are necessary for that
to happen; and
• the iris in Caucasians loses its colour after 24 hours – an
unreliable parameter in other races.
− Gastric content
The dynamics of gastric digestion offer so many factors for time
calculation that the forensic approach of this is more inquisitive
than the clinical one; sometimes the gastric content is even
examined microscopically.
• Stomach chemical digestion continues after the moment
of death.
• Liquids leave the stomach quite quickly, even when
consumed with solids; this move is slower in older people.
• The time necessary for the stomach to empty is
proportionally longer for rich meals.
• Strong alcohol (liquid in itself) takes longer to reach the
duodenum, even when consumed with solids.
• Stress delays gastric emptying.
− Vitreous dextrose and potassium
• Dextrose continues to be used; in the vitreous space it
disappears in approximately one hour. It persists longer
in cases of hyperglycaemia.
• As the vitreous space is functionally an extracellular one,

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Death semiotics
its K level rises as a consequence of the loss in selectivity
of the membrane permeability; there is a special
equation for its dynamic. Sampling follows a special
technique in order to avoid any blood contamination,
this being entirely technically feasible.

10.5. Identifying the deceased
When death is a natural event in somebody’s life, the identification of
the deceased is just an administrative issue. Real problems of identification
are raised by the cases of unnatural death, in those occurring under unusual
circumstances and also as a consequence of human violence. As long as
identification is done soon after death, the appearance of the deceased is or
may be of a real help; later, due to decomposition, morphological changes make
the identification progressively more difficult. Substantial difficulties confront
the teams in charge in cases of natural and man–made disasters, criminal
activity, or when human remains are occasioned by archaeological work.
Morphological features
These are many, and all are very important: general conformation;
race, assessed through facial details (nostrils, mandible, palpebral slot);
basic corporal parameters (top–to–heel height, weight); skin (and iris
in the first 24 hours); pigmentation; hair distribution and peculiarities
(length, colour, beard, moustache, baldness); scars (umbilical and surgical,
circumcision, tribal); nevi and pigmented spots; ear and lip conformation;
venous ‘topography’ on the hand dorsum; and signs of advanced age such
as grey hair, hyperkeratosis, arcus senilis, and wrinkled skin with plenty of
pigmented spots.
Implants
Practically, the entire range of prostheses ‘mounted’ during the life
time can be found in a fresh corpse: hip, knee and vertebral replacements;
pacemakers; defibrillators; cerebral stimulators; pain pumps; entire or
partial ocular prostheses (crystalline, contact lenses); and skin accessories.
Cell individuality
The combination of many cell markers such as ABO, Rh, Kell, Duffy,
Lewis, haptoglobins, and some enzymes have ensured an identification rate
of up to 90% of cases (an identification of exclusion).
Tattoos
Known for a very long time, they have become wide spread due to

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Chapter 10
both technical improvements and, importantly, to fashion trends. There
are a number of dedicated pigments in use including carbon derivatives for
black, K dichromate for green, and HgCl2 for red. The dermal depositing of
pigment is done with needles, manually or by vibration. Some people also
practise mucosa tattooing on the back aspect of the lips. The spontaneous
(under circumstances of immersion) and man–made detachment of the
epidermal layer makes the tattoos more visible. Chemical studies of the
deposited pigment are also in use.
Fingerprints
The skin on the ventral aspects of palms, soles, and fingers is micro–
undulated in a highly individual pattern. Essentially, two similar cubital
and radial interrupted arches display from the midlines. The result is a
specific relief ensuring a uniqueness of one to 64 billion. Even monozygotic
twins, famously genetically identical, actually have different fingerprints!
Detachment of the epidermal layer, as happens in immersion, does not
alter the natural embedded model. A similar biological performance is
exemplified by the oral aspect of the lips as well as other mucosa. Tattooing
of the sclera also has a place among today’s eccentricities.
It is not a current medical duty to collect fingerprints. The forensic
specialist must, however, help the investigator in charge to do it any time
this proves to be difficult.
DNA
This is a domain where sophisticated modern technology has met
Nature’s fascinating biochemical engineering. The issue is beyond the scope
of this book; it is nevertheless worth mentioning these truly ‘mindboggling’
facts: each nucleus has about one million DNA molecules, of which only
10% are used for genetic coding in a variety of information–storing genes,
totalling a couple million in a single DNA molecule.
What’s more, laboratory technology has added some useful practical
achievements to Nature’s performance. Transferring the natural coding
of a given person to a sort of bar–code–like system such as that used in
today’s supermarkets provides a personal `signature’ of the individual from
whom the DNA sample was taken. This signature is so personal that, apart
from monozygotic twins, the probability of coming across a similar one is,
according to the method pioneer, Alec Jeffreys, one to 1015 (one quadrillion).
For the investigation in discussion
− only a minuscule amount of sample tissue, in theory just one
single nucleus, is necessary;
− there also exists a method of DNA enrichment, the so–called

160
Death semiotics
chain polymerase reaction;
− there are some tissue preferences (muscle, spleen, and bone
marrow) although a small bit of dental pulp or a hair root will
generally suffice; and
− needless to say, as red cells and thrombocytes are non–
nuclear cell structures, in the case of blood samples, they must
necessarily involve leukocytes.
Inspired by the high degree of specificity inherent to genetic information
the electronics industry has synthesised a DNA–like entity where the
alternation of 1 and 0 replaces that of the helix bases; so engineering has
managed to create a facility for data storage at an unequalled density
compared to the digital system (314a).
Teeth
Very resistant to all three modes of decomposition (spontaneous,
chemical erosion, and burning), the teeth are second to none in serving the
process of identification. Dental eruption, bite, occlusion, dental imprint,
edentation and the entire series of dental prostheses are all of great help.
Moreover, today it is possible to reconstitute from the dental formula, a
person’s gender and even his or her age (Gustafson’s technique).
Osseous remains
These represent an important and not rare object of study at
archaeological sites. There are always a number of questions raised under
such circumstances: is the artefact a real bone? Is it human? Is it unique or
a part of a group? What is the sex, age, height and race of the defunct?
In addition to the rough details offered by the usual X–ray examinations,
two modern advancements in identification are of great interest nowadays:
− facial reconstructions, pioneered by the Soviet Mikhail
Gerasimov (photo superimposition, classic and computerised
video), and
− CT&3D printing technique, recently (2015) used for certifying
the remains of Richard the Third.
In conclusion, the area of identification has now gained a new dimension,
progressing from a science of exclusion to a highly precise, accurate
identification methodology.

161
11. Natural deaths

11.1. Contagious pathology 164 11.3. Perioperative deaths 181
11.2. Common pathology 173 11.4. Sudden deaths 185

The number of death causing conditions is significant and
continuously increasing. Their listing falls in the responsibility of the
medico–administrative institutions governed by the known World Health
Organisation (WHO). Currently, there are 113 for adults’ pathology and as
many as 130 for paediatrics, with the great majority being natural in nature.
Each valid death certificate should specify the exact condition leading to
death as well as, where necessary, the circumstances of death.
This chapter deals with those deaths, expected or unexpected,
generated by conditions known as occurring without any interference apart
from the pathology itself. From that pool, it was possible to outline, for
scholastic purposes, a couple of groups, each of them with its characteristics:
contagious, common, perioperative and sudden.
The sudden deaths are consequence of a deficient reflectivity; the organs
often do not have any structural change. On the contrary, in the other three
categories, death originates from a wear and tear of one or more organs.
As specified, the death causing pathology is huge, being rather difficult
to list all its entities. Alternatively, it would seem worth elaborating an in
principle assortment where each disease could find its right place. A bona
fide stratification would be one focusing on the role of oxygen, the thread of
life in such a passionate aerobic creature like human being. The right place
depends on where, when and how the pathogenesis of a given disease
interferes with the oxygen course from the atmosphere to mitochondria, on
the one side and, in terms of resultant catabolic products, their clearance
from the body, on the other side. Needless to say, there also takes part
the milieu interieur, whose quality derives from the functioning of the first
two. The most important points, unique or multiple, on the thread are: O2

163
Chapter 11
availability, its access to respiratory way, supra– and subglottic passage,
accessible alveolar space, good alveolar arterial diffusion, right amount of
Hb and a good transport from the blood to the cells via interstice.

11.1. Contagious pathology
(46, 57, 184, 222)

11.1.1. Introduction 164 11.1.2. Current contagious diseases 165
11.1.3. Epidemics 168

11.1.1. Introduction
Identified as having confronted mankind along its entire history, this
pathology has had distinct dynamics. For millennia, the human being had
been an easy prey for Yersinia pestis, Vibrio cholerae and Mycobacterium
tuberculosis – to mention just a couple from the most famous ones. During
the last centuries, the infectious diseases have however been obviously
restrained. Different from other chapters of pathology, the contagious one
highly depends on the society pattern, a well organised one being able to
better back medicine in dealing with infectious diseases.
Considering the high morbidity and mortality as well as the significant
proportion of young cases, only a combined social and medical aggressive
approach has proved to be efficient in the difficult process of eradication.
This immense human achievement was a direct result of two coordinated
factors:
− The identification of the causative agents and their dynamic,
as well as the skilled engineering of vaccines, on the one hand.
− On the other hand, an increase in natural resistance to infections
as result of better nourishment and an improved life style; it is
the reason why the less affluent countries continue to be still
seriously confronted with contagious pathology.
Despite the consistent social and medical achievements we are
nowadays proud of, the overall mortality caused by the contagious pathology
is still as high as 26% (no. 2 position, after cardiovascular) – a percentage
where two thirds are children younger than five years. Comparatively, one
dies due to this pathology in a proportion of 4% in the affluent societies,
24% in developing countries and as much as 38% in less affluent ones. It
is to emphasise that, along its history, mankind has been confronted by a

164
Natural deaths
merciless contagious pathology The resulted trend has an obvious academic
significance, context in which the following pages offer also a concise history
of the most life–threatening contagious diseases

11.1.2. Current contagious diseases
Counting all its variants, the contagious pathology consists of more
than one hundred entities, generating together a disquieting fatality. A
recent WHO statistics is relevant in this respect: respiratory – 6.1% (3.46
mil), diarrhoea – 4.3% (2.46 mil), HIV – 3.1% (1.78 mil) and tuberculosis
– 2.4% (1.34 mil), representing the 3rd, 5th, 6th and, respectively, the 8th
cause of death from the overall world list.
Malaria
Together with tuberculosis and HIV, malaria is part of a fatal triad.
As old as Homo sapiens, it is found in the Greek documents of the 5th
century, having been well known to Hippocrates. Brought and spread in
the Mediterranean perimeter from North Africa, malaria seems to have
contributed to the fall of the Roman Empire, what attests its nickname of
Roman fever.
During the Middle–Ages and the Renaissance, malaria did not cause too
many problems until the 17th and 18th centuries when headed towards the
British Isles and Scandinavia. The American natives did not know malaria,
this having been brought by colonisers.
Interestingly, the pathogen agent of malaria (Plasmodium) was
identified late, only towards the end of the 19th century. Italy and the USA
have managed to eradicate it but 300 – 500 million cases are still declared
annually, 90% in Africa. Currently, malaria confronts 100 countries with a
yearly morbidity of 200 million and a mortality of 500,000.
Tuberculosis
Tuberculosis is caused by Mycobacterium tuberculosis. Human being
is the single reservoir, with respiratory transmission. The disease history
goes back to the 5th BC millennium, being found in Egyptian mummies and
among Han dynasty communities.
Maybe more than in any other disease case, both tuberculosis morbidity
and mortality proved to be directly related to the settling density, a reason
why it was met with predilection in urban communities:
− In London and Japan, one fifth of the overall mortality was due
to tuberculosis.
− Real epidemics occurred in the industrialised countries, e.g.
France, the British Isles, the USA; in practically all the autopsy

165
Chapter 11
certificates issued in Paris and London medical institutions,
lesions of tuberculosis were mentioned.
− In the two Americas of the 19th century, the mortality of
tuberculosis used to be 400 – 500 cases in 100,000 people.
In addition to the advanced standards practiced in sanitation, a
number of medical achievements along the 20th century were of nature to
significantly reduce the ravages of tuberculosis. It was the time when, inter
alia, chemotherapeutical agents (hydrazide, streptomycin, rifampicin and
vancomycin) made their appearance. Together, they sharply reduced the
mortality; in the middle of the 20th century, in only ten years the mortality
lowered with the rate achieved one century ago in as many as 90 years.
Unfortunately, nowadays, the above trend suffers a rebound, with a
consequent increase in the number of tuberculosis cases. There are two
major reasons for this setback:
− development of a germ resistance to chemotherapeutic agents,
− HIV patients particularly lack the resistance to tuberculous
infection.
As such, in 2000, approximately 2 million people died of tuberculosis,
3% from the total deaths. It is estimated that, in the next 20 years, a
morbidity of 200 million and a mortality of 35 million of cases are expected.
HIV infection
HIV is a real challenge for modern medicine. This new viral infection
raises many social problems difficult to be dealt with:
− It took to it no longer than 30 years to spread to 200 countries,
practically the entire world.
− A cumulative number of over 40 million cases has generated
a mortality of 5.2%, what makes HIV the most dangerous
contagious condition of today.
− The women exceed as gender representation and the foetal
direct transmission is a second to none one.
It happens that the HIV transmission is facilitated by notorious practices
which are difficult to be handled as the use of drugs, unprotected sex and
homosexuality. The required discipline has low chance of success when
there comes into discussion factors like sexual instinct and promiscuous
communities.
Typhus (exanthematous)
It is caused by Rickettsia prowazeki and transmitted by lice, the human
beings being the unique reservoir. After an incubation of 1 – 2 weeks, it
generates a clinical picture dominated by fever and a specific eruption,

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Natural deaths
offering life immunity. The level of fatalities increases with the age, varying
between 10 and 40%, facilitated by cold weather, hunger and poverty, so
common on the battlefields.
The oldest documents available mention dramatic epidemics, 450 BC in
Athens and Salerno monastery AD 1083. Then:
− During the 15th century, the illness spread in Europe: 17,000
deaths in Granada fight, 30,000 in the French troops near
Naples, occasioned by Metz assault, and 80,000 in the Balkans.
− In the 17th century, ravages were mentioned among Americans,
both native and colonists. Interestingly, the typhus interfered
in no way with the Civil War.
− In 1812, the typhus even changed the course of the European
history; having been associated to a very cold Russian winter, it
really decimated the Napoleon’s troops, with an estimated loss
of half a million soldiers. From those battlefields, the survivors
brought the disease to Western Europe, the whole British Isles
being turned into a hospital.
− In the 20th century, there occurred 150,000 death in Serbia,
30,000 (one in ten from three million cases) during the October
Revolution whereas, between 1918 and 1922, other three
million lives were lost. It is worth mentioning that DDT did avoid
any interference of the typhus infection with the Second World
War.

Miscellaneous
From the rest of the many infectious diseases, a couple are known
these days for their mortality:
− Dysentery: about 150 million cases and 150,000 deaths a year.
− Rabies: about 50,000 fatal cases each year.
− Poliomyelitis, tetanus and hepatitis are quoted to generate
together nearly one million deaths annually.
− Diphtheria: one of the first three causes of infantile mortality
15 years ago, it continues to kill nowadays more than 30,000
each year.
− Leprosy offers a good example for medical and social
cooperation: from a total number of 10.5 million cases in 1966,
its present mortality is only 0.01%.
− Ebola, a viral disease, appeared in D.R. Congo, 1976, and spread
in many African countries; over 4,000 deaths to date.
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Chapter 11
11.1.3. Epidemics
Historical data, mainly the statistical ones, differ consistently from the
source chosen, some being quite controversial. This is due to the issue itself,
firstly, and to the difficulties of any retrospective approach, thereafter. This
text deals with those matters relating specifically to the fatal impact of the
contagious pathology upon the human history of the last millennia.
Plague
It is a bacterial disease, zoonosis, having rodents, mainly the rat, as
a reservoir. The plague is caused by Yersinia pestis. Its transmission has
proved to be:
− Largely indirectly, by the rat flea, for the bubonic clinical version;
the term derives from the adenopathy developed in the groin
or armpit, depending on the bitten place. From the nodes pus,
the pathogen agent has access to the blood flow and so to the
lungs.
− Hence, a direct spreading becomes possible by cough and
sneeze; this is the pulmonary clinical variant, much more severe,
with a mortality of up to 100%.
Thought to have affected the Philistines about 1000 BC, the plague
became famous by having confronted the world periodically, with
devastating waves:
− The first one, in the 6th century, remained known in history as
Justinian plague, having decimated 40% of the Constantinople
population. From the Roman Empire it spread to Europe, Asia
and North Africa, practically the entire world of those times.
After one century of ravage, it disappeared having left the
population halved
− and confronted with many political troubles and economic
difficulties.
− It reappeared towards the middle of the 14th century and
in only a couple of years, 1347 – 1351, killed half of Europe
population, one third of England’s, 75% from Venice and 90,000
from Florence. In Norway, 2 out of 3 inhabitants died.
Due to the darkened fingers and nose lesions, the plague was
baptised as Black Death. During this epidemic, it was realised
that the spreading of the disease was through direct contact;
it was in this context that, during the London epidemics of the
famous 1660s, the Quarantine Act came into being – an act of a
real significance later.
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Natural deaths
− The third wave occurred again in Europe towards the end of
the 18th century. It was then that both the causative agent and
the transmission way were identified. With the extension of
the trade practices and navigation, the plague reached the New
World territories, China, India and America.
− That particular extension took progressive proportions while
the quarantine practices exercised by the Austro–Hungarian
Empire managed largely to protect the 19th century Europe. It
is estimated that that fourth epidemic killed about ten million
people.
Presently, foci of infection occur sporadically in India, Burma,
Indonesia, Mongolia and Vietnam, with an overall fatality of up to 60%.
Interesting, plague is considered nowadays as one of the bioterrorism
weapons. It is calculated that 50 kg of Yersinia pestis aerosolising material
could affect not less than 150,000 people in a densely populated area
(314b).
Cholera
Also a bacterial disease, caused by Vibrio Cholerae – an agent identified
by Pacini and intensively studied by Koch. Stimulated by heat and alkaline
pH, this vibrio found easily its endemic ways in the Ganges delta as well
as in areas with algae rich swamps. The main symptom of this condition
consists in tormented emesis leading to dramatic dehydration; it is of
clinical notoriety that 500 ml of fluid can be lost in just one hour time – a
reason of early collapsing and death in not more than a couple of hours.
The transmission results from drinking water infested by emesis and faecal
content. The human being is the unique reservoir and the mentioned kind
of transmission attests without any doubt a poor sanitation.
The disease was first identified in India, in the 16th century, and spread
worldwide next centuries. Heading initially to Russia, it conquered the rest
of world through the then commercial routes. There were no less than
seven epidemics along a period of 200 years.
The British Isles were accosted towards the 19th century causing
about 50,000 deaths, while one century later 200,000 people died in the
Philippines. Between the two mentioned centuries, cholera spread to
Egypt, North Africa and finally Japan. Towards the end of the 20th century,
78 countries were confronted by the disease, the most severe epidemic
having been one from Peru, in 1991, with 500,000 cases and 250 deaths.
Improvements in sanitation and therapeutic techniques of rehydration
significantly reduced both morbidity and mortality.
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Chapter 11
Smallpox
Viral in type, smallpox has two clinical variants:
− Minor, with a fatality of only 1%, a reason why it is underesti-
mated by the relevant establishments,
− Major, with a violent course, known as reaching a mortality
of 40% in adults and 80% in children. After an incubation of
7 – 17 days, fever and other general flu symptoms follow.
Soon, there erupt pustuliform, mucous and cutaneous lesions
which, by healing, lead to typical ugly scars. The malignant and
haemorrhagic versions are inevitably fatal.
The very first document about the disease could be a literary one,
a Chinese manuscript four millennia old, while an unequivocal proof is
represented by the typical scars found on Ramses’ mummy, in the 12th
BC century. Having human being as single reservoir, this disease became
a real collective health problem along the agricultural civilisations around
the large rivers from Egypt, Asia Minor and China. There resulted a good
number of epidemics, as follows:
− Without being medically documented, more waves seemed
to interest first the Roman Empire and later the Middle East,
France, Italy, China and Japan. In the 900s, a first description
meeting the medical standards appeared, written by the Persian
Rhazez.
− Expectedly, Crusades proved to be events facilitating the spread
of smallpox. After 1500, the Spaniards brought it to the West
Indies and Mexico. Considering now the relatively small number
of the conquistadors and the well–known socially organised
Aztecs, it seems possible that it was the smallpox that decided
the military developments. It is estimated that about 3.5 million
people died during those events.
− In the 17th and the 18th centuries, smallpox confronted
Western Europe affecting all ages and social groups. It did not
even exempt the royal families; Queen Mary, 1694, Joseph
the Austrian Emperor, 1711, as well as queens and kings from
France, Spain and Sweden all lost their lives.
− During the 18th century about 400,000 met with death. 18,000
out of 50,000 of Iceland population died. The New World was
not exempted either; only in Boston there had been eight
epidemics with an estimated mortality of 52%.
− There continued to die of smallpox along the entire 20th
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Natural deaths
century, totalising somewhere between 300 and 500 million
people.
− Australia, a country having not known what the smallpox
meant, acquired it as a side effect of colonisation. The
aborigines proved to be extremely vulnerable; during the 19th
century, the continent was confronted by seven epidemics with
a devastating mortality.
The world medical community has invested much endeavour in isolating
the pathogen agent. Consequently to the pioneering work of Jenner, a British
scientist, national programmes of vaccination were launched. Only in 1801
alone 100,000 people were inoculated in England, whereas two million
vaccinations reported in Russia between 1804 and 1814. The immunisation
practices were adopted by entire series of industrialised world. Towards the
end of the 19th century, those countries with a rigorous social discipline
managed to reduce the smallpox mortality to zero: Iceland in 1872, Sweden
in 1895, Norway in 1898, followed in the 20th century by Denmark in 1901,
Ireland in 1907, Great Britain in 1934, USA, Japan and South Korea at the
end of the WW II and finally Portugal in 1953.
There remained countries in Asia, Oceania, Africa and South America
where smallpox is still encountered with. In 1967, WHO reported 15 million
cases with a mortality of 15%. The year 2011 is considered as the world
eradication year.
Measles
It is also a viral disease; after an incubation of 8 – 18 days, it appears
with many inflammatory complications as otitis, enterocolitis, encephalitis
and various respiratory entities. Humans are the single reservoir, the
transmission is respiratory, through the aerosols generated by cough and
sneezing. Having a ‘productive’ spreading way, it depends very much on
the individual’s natural resistance to fall sick or to resist against the disease.
For this reason the population of the less affluent countries and the
undernourished people are more exposed to this disease.
Apparently five millennia old, this disease differed in its severity from
the geographical areas and time of appearance; a couple of important
details:
− Together with plague, measles represented the most important
causes of depopulation.
− During the 17th and 18th centuries, the American Indians died
in proportion of 40%.
− In 1875, Fiji epidemic had a mortality of 25 – 30% while that
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Chapter 11
from Alaska 1900, also 40%.
− In 1940, the overall mortality was reduced to one in ten.
Having the life standards increased and inoculating all the vaccine
qualifying people, the affluent countries have gradually reduced measles’s
morbidity and mortality, whereas in those less affluent about 1.5 million
people die annually.
Flu group of diseases
Referring first to the flu, its inoculation is extremely short, 1 – 3 days;
human beings are the unique reservoir, the clinical picture is tumultuous,
while the collateral pathology is huge.
Known for about five millennia, flu was medically described by
Hippocrates for the first time, becoming largely known after Middle–Age
and Europe epidemics. Some important historical details are:
− a couple of epidemics of large proportion erupted in the 16th
century,
− about 30 epidemic waves followed during the next three
centuries,
− in the 17th and 18th centuries it conquered North and Latin
America,
− other three epidemics turned up in the 19th century,
− towards its end, 250,000 people died in Europe and three times
more from all other parts of the world, Asia in particular.
The Spanish variant, 1918 – 1919, remains famous in human history; it
disappeared after just six months but its victims exceeded those of the entire
WW I. Given the antigenic instability of the virus, it has proved unrealistic to
generate a vaccine. Excelling to be everlasting, the flu remained a permanent
medical challenge in all societies. Moreover, there have appeared a number
of genetically related viral entities as SARS, swine and bird flus. Fortunately,
WHO was particularly instrumental in controlling their spreading.
Of a distinct historical interest is the so–called Sudor Anglicus. It was a
mysterious infectious disease met in England in the 16th century. Its victims,
usually young people, were described as developing fever, headache,
dyspnoea, muscular aches and profuse sweating – hence the name. Its
transmission seemed to be the respiratory one. As far as the causing agent
was concerned, the identification could not be contemplated on at those
times and, having disappeared altogether, the Sudor Anglicus remains for
the pathology science a maladie d’archive.

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Natural deaths

11.2. Common pathology
(19, 30, 45, 46, 92, 167, 181, 265, 291, 306)

11.2.1. Cardiovascular diseases 173 11.2.4. Important organ
11.2.2. Respiratory pathology 174 insufficiencies 175
11.2.3. Digestive pathology 175 11.2.5. Traumatic pathology 178
11.2.6. Thermic accidents 179
11.2.7. Miscellaneous 180

11.2.1. Cardiovascular diseases

Cardiac
An important part of a vital function, the heart has many vulnerable
facets: rhythm pacing, contraction process, intracavitary blood ways, blood
ejection and its own nutrition. The mechanism of death relies on either
single, more rarely, or combined derangements originated from their
malfunction. As an organ, the heart can be affected primarily by an intrinsic
pathology or secondly by a process outside its structure. Then, additionally
to a cardiac pathology proper, the heart is always involved in all sorts of
cardiac arrest to which this book gives the deserved attention in a dedicated
chapter (no. 6)
Vascular
Due to the increase of life duration, the vascular bed has enough time
to accumulate many intricate pathological changes. High mortality have the
aortic aneurism, intracranial vascular processes and hypertension. The first
excels by severity, while others interest a large number of patients.
Embolism
An embolus consists of any material other than fluid blood anywhere
in the vascular bed. The seriousness of the abnormality depends on the
nature of material, size, origin and mainly the intravascular area having been
reached. They may originate from inside or enter from an outer source. The
local, mechanical, and particularly reflective consequences are determined
by many factors, the very first being the physical stability. The most usual
are gas, fat, amniotic fluid, own clots and foreign bodies.
Haemorrhage
It may be of interest for any reader that:
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Chapter 11
− a loss of up to 10% from the blood volume has no real deleterious
haemodynamic effects, this being actually the reason for the
usual amount withdrawn for blood donation;
− around 20% loss causes tachycardia first and hypotension later,
leading together, ultimately, to a state of shock;
− whereas 40% is potentially fatal.
The lost blood may gush from a wound, leak into surrounding tissues
or inter–viscerally as well as exteriorise from stomach, lungs, or uterus.
Patients frequently met are those with upper digestive haemorrhage,
haemoptysis and placenta praevia.

11.2.2. Respiratory pathology
It generates frequent causes of death, both in– and mainly outside of
medical facilities – a reason for being more detailed than other categories.
Considering the oxygen availability, the following entities need attention:
An ‘irrespirable’ atmosphere:
− rusting metallic industrial reservoirs (the process of rusting
consumes large amounts of oxygen) suppose hypoxemic
ambiances;
− silos with large amounts of cereals are also known as big oxygen
consumers;
− deep calcareous wells where fatal concentrations of CO2 can be
reached;
− high alpine altitude and flying machines depressurisation;
− breathing from a bag tightly closed around the head.
Supraglottic way obstruction:
− neck strangulation: violence and hanging,
− strange asphyxias:
• stampede events,
• postural, when abdominal viscera impede free movement
of diaphragm,
• ventral position, mainly in overweight individuals.
Subglottic obstruction:
− Subglottic oedema: small children are very much exposed due
to the small diameter of their trachea and a rich sub–mucosa
layer; a 1 mm oedema causes a reduction in diameter of as
much as 65%.
− Respiratory inundation with water (drowning), blood (haemop-
tysis) or gastric content (regurgitation).
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Natural deaths
− Status asthmaticus and bronchospasm are both high death risk
paroxysms due to the involvement of the entire bronchial tree.
Advanced reduction of alveolar space
− Massive pneumonia and bronchopneumonia.
− Chemical pneumonia – an anaesthetic accident (respiratory
inundation with regurgitated acid content).
− Huge atelectasis caused by compression from neighbourhood,
pleura in particular, tension pneumothorax being a typical
example.
Reduction of alveolocapillary diffusion
− Advanced pneumoconiosis,
− Pulmonary sclerosis,
− Acute severe pulmonary oedema of any source.

11.2.3. Digestive pathology
Sooner or later, the various digestive conditions lead to death by
various mechanisms as:
− massive upper digestive haemorrhage, causing severe anaemia
and, sometimes, respiratory inundation,
− extended peritonitic processes,
− intestinal obstructions, mesenteric infarct, organ torsion
and acute pancreatitis – all four having the state of shock in
common, and
− toxic hepatitis and cirrhosis, leading to hepatorenal insufficiency.

11.2.4. Important organ insufficiencies
The living human body has a number of systems, amalgamated and
functionally interdependent. These systems stratify themselves according
to the speed with which, once compromised, lead to death. In other words,
some are ‘more vital’ than others. If it is to shortlist them, ‘the most vital’ are
brain, heart, lung, liver and kidney. This was certainly the reason of so many
preoccupations and huge efforts to minimise their level of fatality. Apart
from the brain, one has managed to make substantial steps in developing
technical solutions for functional prosthesis and transplantation. The real
progress obtained today in this respect makes possible not only avoidance
of death for short, but even a long extension of life. Undoubtedly, the patient
pays a price for this in terms of discomfort but, for the family, community
and medicine as a science, the achievements can be considered epochal
ones.

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Cardiac insufficiency
Simplistically defined, it is a reduction of the pumping function of
the heart, irrespective of the cause. Varying geographically, by race and
economically, it steadily increases with age. From the overall proportion of
1%, 10% are aged people and, from those over 85 years in age, 9 out of 10
individuals have cardiac insufficiency. There are 25 million patients at a final
stage of cardiac failure, occupying 5% from the entire number of hospital
beds. As far as the causing disease is concerned, the highest rate is held by
ischaemic cardiopathy. The mortality to 1,000 people is 50 women and 70
men (9% diastolic and 20% systolic insufficiency) (219).
While the acute variant is quite satisfactorily handled, in the chronic
cases the chances are, comparatively, rather limited – a reason why, after
five years of sufferance, the mortality is as high as 50%. The course–steps of
a cardiac insufficiency are:
− putting initially in motion its own compensatory mechanisms
(venous return, blood volume, vasoconstriction and
tachycardia),
− the diseased heart manages to cope with modest efforts
following,
− later, to cope with resting conditions only,
− up to an irreversible stage of failure.
When the heart muscle is unresponsive to major treatments, inotropic
drugs, vasodilators and diuretics (under invasive monitoring circumstances),
the case becomes a candidate for heart transplantation. As finding a donor
is often a timing problem, the current policies often appeal to a bridging
solution. Once the ventricular ejection fraction falls towards 5%, the patient
is usually placed on a ventricular assist device. For low rates of success,
heroic treatments are not initiated after the age of 60.
Respiratory insufficiency
The high rank functional role respiration plays is well reflected by its
place in the vital triad (together, as mentioned in different other parts of this
book, with the state of consciousness and cardiac activity). This high role
undoubtedly means also a vulnerability to various functional and organic
abnormalities. There are two major therapeutic developments in the
respiratory domain, namely the sophisticated technology of ventilation for
acute insufficiency cases, and lung transplantation for chronic insufficiency.
Maybe more than in any other chapter of pathology, a relatively benign
inter–current acute respiratory process, occurring on a chronic already
evolutive lung condition, may worsen the clinical course to decompensation.
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Natural deaths
Very exposed in this respect is the bronchopneumopathy, condition affecting
as many as 5% of the entire population.
The perspective for lung transplantation of an advanced respiratory
insufficiency case appears in the moment when a typical combination of
three major changes, renal acido–basic compensation, polycythemia and
cor pulmonale, occur.
A proper transplantation may be done sequentially, simultaneously or
together with the heart. Regardless of the variant, the technique supposes a
close co–work between doctor and surgeon, clinical science and technology
and, last but not the least, an appropriate case optimisation. In order to
increase the chances of success, a procedure like this is not, however,
considered after the age of 55.
Hepatic insufficiency
Being a unique organ and involved practically in all the major
metabolisms running in the body, the liver is, understandably, involved
frequently and sometimes heavily in various pathological processes.
Hepatitis, infectious or viral, frequently leads to chronic forms which, along
with the alcoholic sequelae, severely incapacitate the liver.
Keeping the patient as long as possible in a compensated stage of chronic
hepatitis is undoubtedly in the case’s favour. Once the decompensation
signs (ascites, upper digestive haemorrhage and encephalopathy) appear
and a renal co–affecting becomes obvious, the best perspective is the
liver transplant. Anatomico–topographic realities of surgical interest and
difficulties in running the medical treatment make the liver transplantation
one of the most demanding domains; it is therefore remarkable that the
one year postoperative surviving rate is as high as 80%. Surgical technique
is not the single difficult part of the care; the medical counterpart at its turn
is not much easier. In support of this assertion, the insufficiency stage plays
an important role for the 5 years surviving rate: 90% in compensated forms
and only 50% in those decompensated.
Renal insufficiency
A critical fall in glomerular filtration and the inability to keep a viable
homeostasis may materialise in days or even hours, in acute cases, and in
months – years, in those chronic ones. The etiology is extremely various
with two main categories: pre– and post–renal.
The immediate support available nowadays is a functional replacement,
partial or total, represented by the external dialysis (haemo– and
peritoneal). It can be used temporarily or permanently, as a supplement,
for the reduced renal function, or an extensive one, either a la longue or as

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Chapter 11
a bridge to transplantation.
The present policy for a chronic renal insufficiency is
− as long as the serum creatinine does not rise over 3 mg/100 ml,
a conservative medical treatment is the best choice;
− later,
• either a permanent programme of extra renal dialysis,
• or a renal transplant.
In terms of death delaying, the rate of success is high; regarding the
homeostatic ‘service’, an external dialysis manages about 10 – 15% from
what a healthy kidney delivers. The transplantation, in its turn, has its own
rate of performance; unfortunately, the shortage of organs leaves most of
the patients on the alternative extra renal dialysis. Given this, the algorithm
conservative treatment, external dialysis and renal transplantation should
be thoroughly respected.
Finally, the mechanism of death results from major heart rate
disturbances (due mainly to hyperkalemia) and lung oedema, in acute
forms, and the associate cardiovascular pathology, in the chronic ones.

11.2. 5. Traumatic pathology
It is an extremely heterogeneous pathology; in practical terms, each
body area may be involved in a trauma. It depends on what particularly
one or how many are affected by the traumatic agent. From the vital risk
viewpoint the lesions can be:
− shock producing, as a result of tissue destruction, haemorrhage
and, frequently, added infections; good examples are the
extensive abdominal trauma and those involving limb
amputations;
− interesting vital organs as heart and large vessels, as well as
essential parts of thorax, or
− involving body areas ‘of command’ as typically the craniocerebral
traumatisms are.
A detail of ‘deadly’ significance in the above cases is represented by the
cerebral oedema. Occurred as a consequence of a running inflammatory
posttraumatic process, this development may reach a fatal dimension.
Interestingly, this oedema can cause such an increase in the pressure of the
(non–extensible) cranial cavity that the lumen of entering arteries (internal
carotid and basilar) get completely suppressed. From this moment on, the
brain death is, understandably, a fait accompli and no return in the clinical
course of that particular patient is to be expected.

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11.2.6. Thermic accidents
Protected, the human beings remain active along a large range of
temperatures, from as high as + 55oC to as low as – 55oC. Unprotected, the
fate of the human body differs greatly.
Hypothermia
Hypothermic is that body which reached a central temperature of below
35 C: 35 – 32 light, used therapeutically, 32 – 28, moderate and under 28,
o

profound. The usual victims of hypothermia, mainly fall in cold water, are:
− unsupervised children, having proportionally a larger body
surface, and elderly;
− people with altered state of consciousness: intoxications, drug
users, hypoglycaemia, epileptics;
− mental, un–cooperating, patients;
− alcoholic people;
− marine and alpine disasters.
The physiology of such a victim suffers profoundly; the extension
and algorithm of the body reaction vary according to the surrounding
temperature, time of exposure and biologic resources of the individual
concerned. Tachycardia, vasoconstriction and shivering are all parts of
an alerted sympatheticotonia triggered by low temperature. Once 30oC
reached, there follows step by step a number of significant changes for
hypothermia:
− Shivering, breathing and cough are depressed.
− Cardiovascular: bradycardia, atrial fibrillation, worsening a–v
block, 28oC being a point when ventricular fibrillations usually
occur.
− Brain blood flow drops 1% for each C degree.
− Loss of consciousness,
− ileus and muscular rigidity,
− amount of insulin decreases,
− metabolism rate is progressively reduced, 6% for each degree,
being halved at 28oC,
− O2 consumption from normal: 75% for 30oC, 45% at 26oC and
25% at 20oC.
− On humoral side: mixed acidosis, higher level of HbO2 due to a
reduction in O2 consumption, which explains the rose nuance
of skin colour.
− Multi–organ failure may occur in cases with slow temperature
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Chapter 11
lowering.
− If the patient survived the critical temperature of 28oC (not
having developed a ventricular fibrillation), towards 20oC EEG
becomes flat and franc apnoea is followed by asystolia.
As the hypothermia is largely used by modern medicine, it would be
worth specifying that:
− O2 consumption decreases more and quicker than the cerebral
blood flow.
− 20oC offers full protection to hypoxia.
− In cases of cardiac arrest having occurred in a very low
temperature environment, like submersion in iced water, the
neurological recovery is better.
− Such low temperatures could be the reason for the famous
good fossil conservation, like the Siberian mammoth, and are
certainly the right background for the cryonics concept.
Heat
The skin, the very first tissue of thermic contact, develops lesions in a
couple of hours even at temperatures not higher than 45oC and requires
not more than just 3 sec at 60oC.
There are two basic sorts of heat; dry and moist.
Dry, causing the classical three degrees of burns; at 50% from body
surface, even a first degree is severe. The toxic gases inhaled under arson
circumstances, phosgene, carbon monoxide, nitrogen oxide and cyanides,
substantially increase the vital risk.
The forensic practice has in its list of interest the so called extradural
heat haematoma. This is an extrameningeal haemorrhage caused by a
venous rupture secondary to local heat. The extravasated blood contains, in
real arson victims, the same level of HbCO like the rest of the blood while it
remains free of this ‘marker’ if the victim was thrown into fire setting after
death, having had the respiration already ceased.
Moist heat causes, in its turn, various lesions depending on the sort of
fluid. They occur domestically in children and industrially in adults. In the
latter variant (as it is, specifically, the fall in a container with melted metals)
a rapid, if not instant, death may occur – a circumstance of typical sudden
death of the entire body cell mass.
11.2.7. Miscellaneous
A lot of pathology entities have not been commented nominally in this
chapter dealing with natural deaths, degenerative, neoplasm, haemato-
logical, metabolic – to mention just a couple. They are all conditions also
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Natural deaths
leading to death. They do this by altering the tissue and cell environment,
namely the homeostasis. At a given moment of their compromising course,
the milieu interior becomes so deeply pathologically altered that the essen-
tial metabolic reactions are no longer possible.
Finally, some conditions have such a slow dynamic that, in between,
others – with more alert rate of advancing – reach faster `the right point
to kill`. A good example in this respect is the prostate cancer, a condition
found at autopsies of patients having died of other conditions, more diligent
killers.

11.3. Perioperative mortality
(8, 28, 145, 170)

By its nature, any surgical operation is physically an aggressive
procedure.
‘Cutting and sewing alive tissues on a conscious, shrieking patient took
strong nerves. The patient spent the entire surgery fighting, many assistants
being necessary to hold him down. The resulting stress and pain had to be
a terrifying experience. Performing the procedure as quick as possible was
the single way to reduce from overall struggling’.
One of the speediest surgeons, one says, was Robert Lyston, 1794 –
1847, a University College of London professor, who used to perform a leg
amputation in only 28 seconds. Speed had however its price, a collateral
pathology and mortality inclusively. According to the legend, the same
professor is credited as having had a case with mortality of ... 300%: the
patient and an assistant, who had one finger sliced accidentally during
operation, both developed fatal gangrene while an elderly onlooker
collapsed due to a heart attack triggered by the event (308).
The things only turned better once (general) anaesthesia was
introduced. That epochal development was of nature to make from the
surgical procedure a real healing act. Surgery becomes not only useful but
also acceptable for the patient. The two done together, anaesthesia and
surgery, have evolved as one of the important achievements humanity may
be proud of.
As any medal, there is a reverse side too; despite combined services,
they are not free of any drawback, fatal events inclusively. Done in tandem,
it is sometimes not easily to define the very responsibility of each of them
– a detail of a real significance in current statistical practices.
It is estimated that nowadays 230 million major surgical procedures

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are performed per annum. Reported to one million of surgical patients, the
following figures are important for the purpose of this book (11, 13):
− Anaesthesia strictly related deaths, during the first 48 hours
postoperatively: 357 before 1970, 52 between 1970 and 1980
and only 34 from 1900 to 2000.
− Number of cases where the anaesthesia played a contributory
part, in the same periods of time: 650, 323 and 143, respectively.
− Number of cardiac arrests: 1,872 between 1970 and 1980 and
719 from 1990 to 2000.
− Total perioperative losses during the same three periods of time
mentioned above, irrespective of the causes: 10,603, 4,533 and
1,176, respectively.
Corroborated with other sources (i.e. 215), the specified display of
figures attests a progressive reduction of global perioperative mortality:
− In the first 48 hours: from 1.06% before 1970 to 0.12% between
1990 and 2000.
− In the first 30 days: from 1.5% to 0.8% in the same periods.
The comparative significance of the above values is even more relevant
if it is to consider the extension in the last half of the century of surgical
activities, on the one side, and the amount of co–morbidities, on the other
side. The latter one, at its turn, derives from the increasing number of the
elderly on the theatre programmes as well as from both the diversity and
sort of the surgical techniques. Facts in support of this assertion are:
− The relatively high postoperative mortality, both European and
on an international stage, of 4% during the first 7 days (216) and
5 – 10% yearly (13).
− The determinant part which ASA risk category plays; in one
million operated cases:
• the number of cardiac arrests was 191 for ASA 1 and
234,121 for ASA 5,
• that of death in the first 48 hours, irrespective of the
causes, was 557 for ASA 1 and 273,534 for ASA 5,
• a direct correlation between the number and severity of
the hypotensive intraoperative episodes and the first 24
hour mortality,
• postoperative morbidity of the first 28 days significantly
correlates with the subsequent mortality.
Coming back to anaesthesia, it has a very special position in the
medical practice; while a surgical procedure, once indicated, is decided

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Natural deaths
depending on the surgeon, theatre and time available, there is lesser – if
any – space of manoeuvre for anaesthesia as far as the three variables are
concerned. In other words, the surgery is done being case–strategically
compulsory, whereas the anaesthesia is just case–technically necessary.
This ‘stratification’ is not entirely byzantine since many differences rest on
it.
Needless to say, both do serve the patient but the ways of doing this
have different prices; as far as the anaesthetic mortality is concerned, a
couple of details are in tune with the mentioned description.
− The global world anaesthesia mortality has been drastically
reduced in the last 50 years, specifying that this progress is
not unanimous. Referring now to one million of anaesthetic
procedures and comparing the industrialised countries with
the developing ones, the number of deaths was 32 and 101
between 1970 and 1980 and, 25 and 141 (!) from 1990 and 2000
respectively. The last number, by far high, is explained by an
enthusiastic extension of the surgical approach and increasing
of high risk patient groups in countries with advanced health
care (13).
− This obvious difference derives primarily from strict professional
policies; in the affluent countries the theatres run compulsorily
an ‘anaesthetic triad’, a rigorous case sorting, a comprehensive
simulating training and intraoperative pulseoximetria, whereas
in less affluent ones, it is no secret, one anaesthetises by the
rule of chance.
− It should be added that the equipment does play an important
part but not a definite one. Even more important is an
anaesthetic work discipline in terms of case optimisation.
It is certainly worth detailing a work reality from the United Kingdom
– a country with an undisputed supremacy in terms of anaesthetic
rigours. There, apart from an emergency, the anaesthetist has the right
and professional obligation to refuse a case if there are clear proves of a
very probable death along the procedure. On the other hand, any death
consequent to an elective anaesthetic represents a medico–legal case.
It would be, in the context, of interest that the anaesthesia mortality of
Britain is lower than that caused by the common road accidents.
The anaesthetic causes of death are many; as far as the prevention and
a combative treatment are concerned, the most important are:
− Anaphylactic events: the massive release of histamine may

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Chapter 11
cause brutal falls in the vascular tone, venous return and
cardiac output; usually they can be counteracted, although fatal
cases are not rare. By the nature of the profession, the case
anaesthetist is the person who technically administers potential
trigger agents: anaesthetics, prophylactic antibiotics and, more
recently, medications required by prosthetic practices;
− Severe dysrhythmias: high rate atrial fibrillation, bradycardia,
supra–ventricular tachycardia, ventricular fibrillation, heart
blocks;
− Respiratory airways inundation with gastric content;
fatal bronchospasm, various degrees of asphyxia and
bronchopneumonic processes are usual complications;
− Total spinal, as a complication of epidural, when a large amount
of anaesthetic solution is inadvertently injected subdurally; a
rare but dramatic accident;
− A relatively frequent event is the cardiovascular depression
caused by an ‘exposed’ aortic stenosis. The rapid induction and
extensive epidurals/spinals often generate a fall in the vascular
tone; or in this category of cases the ventricular ejection is
restricted and notoriously unable to adjust to a new vascular
capacity.
The overall improvements reached in the last decades are the result of
numerous concerted measures like:
− as good as possible compensation of the affected functions;
− a reduction of both surgical and anaesthetic risk;
− step–by–step counteractions of the changes occurred in the
patient’s physiology;
− a selection and adjustments of the perioperative medication;
− a multimodal analgesia, giving preference to loco–regional
techniques;
− anti–inflammatory medications;
− purpose built postoperative care.
For good reasons, originated from both the pregnant woman and
her baby–to–be, the caesarean section, medically justified or simply on
demand, represents a genuine surgical intervention of our times. It is not as
simple as it appears to be; being quite often performed under emergency
circumstances, it affects virtually two sensitive human beings. As for the
anaesthesia, it should be also adapted to both organisms, often having
different physiological priorities.

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Natural deaths
Taking Britain as an example again, an obvious improvement was
obtained in this country. Two verified statistics (145) show a net reduction
of the caesarean section mortality in the last two decades of the last
millennium, from 11.4 to 6.7 for 100,000 deliveries. Generous schedules
of antibiotic therapy and selective regimens of fluid handling are the
background of the above results.
Consistently more problems confront both the obstetrician and
anaesthetist in multifoetal pregnancies, quite frequent with artificial
fertilisation.

11.4. Sudden deaths
(73, 77, 127, 150, 156, 173, 177, 205, 227, 233)

11.4.1. Introduction 185 11.4.3. Congenital cardiac
11.4.2. Death sine materia 186 structural defects 192
Respiratory in type 186 Pont myocardique 192
Arrhythmogenic syndromes 188 Cardiomyopathy 192

11.4.1. Introduction
As number, the large majority of deaths represents, as seen in the
previous subchapters, the endpoint of common pathological entities, each
of them having its features in terms of age, length of sufferance and span
of medical manoeuvring. As an event, such deaths are not only natural
but also expected. This is the reason why an autopsy is not institutionally
mandatory, requiring the agreement of the deceased’s family.
There are, on the other side, a number of deaths which occur
unexpectedly and suddenly. In forensic terms, a sudden death is the one
occurring in less than 24 hours since the beginning of the illness. The
categories of death presented in the following pages happen even more
speedily than coined by the forensic offices.
The cause of such deaths is a matter of an inappropriate ‘functionality’
of the two vital functions, respiration and haemodynamic. As the organic
background either lacks or is insignificant, this kind of death is known as
sine materia.
The clinical entities generating sudden death, irrespective of the amount
of materia, derive from a discrepancy between the miraculous design of
the two vital functions and the imperfection in how they effectively run.

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Chapter 11
A decrease of only 10% in PaCO2 initiates an imperious need of air and a
consequent deep inspiration, while the cardiac output is maintained with a
large variety of heart rates, from as low as 35 to as high as 150/minute. As
a medical philosophy, such a register of performance does make room for
faux pas.
Needless to say, a sudden death case should compulsorily be autopsied;
there is no need for an agreement of the deceased’s family. The autopsy is
the ultimate proof to attest the naturalness of such deaths.

11.4.2. Deaths sine materia
Respiratory in type
There are a couple of entities which, both academically and practically,
have more in common than specific:
− a respiratory insufficiency as a malfunction in the respiratory
driving and, respectively,
− specific ages, circadian occurrence and a particular body
conformation.
a. Sudden infant death syndrome (SIDS) or cot death
Met in suckers, it consists in an entirely unexpected death; with no
premonitory signs of any sort, it happens usually during the night – hence
the popular saying laid alive and awaked up dead. From its features:
− a not rare incidence
• up to 10% of cases, in the first year of age
• more frequent in premature and immature babies,
• currently decreasing in number, probable as a result of
declining smoking in pregnancy and respecting standards
of baby positioning for night sleep.
− occurs between 2 and 8 weeks of baby age,
− more frequent in boys and cold weather,
− quite often the autopsy finds some petechiae on pericardium
and pleurae – forensic details used in the past to accuse mothers
for suffocating their babies.
Numerous recent pathologic findings have led to the concept of
a malfunction in both the reception and integration of humoral and
homeostatic respiratory parameters, a malfunction congenital in type.
b. Ondine’s curse
With as many as 11 synonyms in the devoted literature, this is a
mysterious and much studied condition. It is an inherited respiratory
insufficiency occurring during sleep, hence the name inspired from the

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Natural deaths
Nordic mythology (240). From its characteristics:
− an incidence of 1 to 200,000 children;
− it becomes obvious soon after birth;
− with a nocturnal hypoventilation up to apnoea, with the
expected alteration of blood gases;
− whereas they look perfectly normal in day time.
Additionally to the infantile variant, there also exists an acquired one,
met later in childhood and even in adults, as a sequela after poliomyelitis
and encephalitic episodes.
The pathogenesis of the Ondine’s curse (congenital central hypoventi-
lation syndrome) relies on a defective chemoreception and its integration,
in their turn genetic in nature (93). Mortality is high, understandingly during
sleep. If death is to happen later, there is time for a compensatory poly-
cythemia and even a cor pulmonale to occur.
c. Sleep apnoea
This condition occurs in two versions:
− A central one, consisting in a hypoventilation during sleep,
up to apnoea. Different from Ondine’s curse, it appears at a
later age and consequently to some central nervous alteration
(poliomyelitis, cerebral infarct) and chronic intoxications.
Specifically, it is clinically silent and no respiratory muscle effort
is initiated; the resulting apnoea may lead to death.
− Another one, peripheral or obstructive, a sleep disorder as well,
known for long time. Its most important aspects are
• cycles of significant reduction of breathing rate up to
zero, ten to hundred episodes a night, with apnoea
duration of 10 – 150 seconds
• with an expected alteration of blood gases homeostasis.
• This breathing dynamic consists in a progressively
increasing inspiratory effort as a consequence of a
muscular tonus loss of the tongue and neck surrounding
muscles. Such cases also have quite often macroglossia
and micrognathia. This self obstruction of the upper
respiratory way generates the well known snoring of this
category of patients – a self obstruction having led to the
idea of lingual pacing.
• Interestingly, the sleep of these patients is not restful at
all and, during day time, they feel tired, anxious and may
have concentration and memory difficulties; it is quite

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Chapter 11
frequent for them being involved in traffic accidents.
• Frequent co–morbidities: diabetes, hypertension,
hepatic dysfunctions.
• These patients have a low threshold of tolerance to
sedatives and general anaesthetics.
• After years of bad sleep and troublesome days, fatal
events are always possible, death not being a rare
encounter.
Corroborated, the sort of the respiratory homeostasis behaviour and
the obvious involvement of the nervous system raise the problem of the
real identity of this ‘peripheral’ variant. As specified, it is clinically certainly
obstructive but the entity as a whole does seem peripheral only in how it
‘operates’. The following sequence of events, a real conveyer – triggered by
the hypoxia – underlines this approach:
− The consequent vasoconstriction of pulmonary bed leads to a
hypertension in the small circulation.
− Oxygen de–saturation causes bradycardia, while the resuming,
on the contrary, tachycardia.
− Nocturnal awakening increases the catecholamine levels,
worsening any degree of arterial hypertension.
− Combined, tachycardia and hypertension often lead to coronary
ischaemia.
− Finally, towards 70% HbO2 there could appear intra–cardiac
conducting troubles while, below 60%, ventricular tachycardia
or even ventricular fibrillation.
It is easy to understand from the above ‘conveyer’ that a fatal end is
always possible in such cases.
Arrhythmogenic syndromes
They all have a genetic background, consisting in a malfunction of some
ion channels (Ca, Na, K) conducting to severe developments, each in its way.
a. Arrhythmogenic dysplasia of right ventricle
Some fibro–adipose enclosures in the right ventricle structure could
explain the ECG changes these patients have, enlarged QRS and
inverted T waves.
b. QT syndromes:
• Short QT, a detail which is not, specifically, influenced by
changes in heart rate,
• Long QT, as a result of a lowered repolarisation, a
local predisposition to torsades de pointes and even
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Natural deaths
ventricular fibrillation; low levels of serum K and Mg are
facilitating factors.
c. Brugada syndrome
It is an intermittent ST depression and a bundle branch block,
unrelated to vegetative paroxysms the patient may experience.
d. Catecholaminergic polymorphous ventricular tachycardia.
They are all heart troubling conditions and, consequently, worsened
under stress and stress–like circumstances as anxiety, fear, sustained
physical effort. They also prove the role of the sympathetic hypertonia,
appearing in the context of struggling episodes as well as in athletic probes.
Neurocardiogenic syncopes
It is common in the everyday cardiologic practice to expect and treat
heart rhythm troubles; they are frequently part of an advanced stage of
disease and, unfortunately, frequent cause of dramatic events, death
inclusively. They even have a sort of prognostic value, as for instance the
ventricular tachycardia, met in 5% of the elderly, implies a triple risk of fatal
myocardial infarct while the bradycardia – sinus or a–v block – precedes a
cerebral vascular accident in 13% and 5%, respectively.
Intriguingly, potential fatal cardiac rhythm changes and haemodynamic
derangements may also occur out of a known cardiovascular pathology.
It is in fact quite surprising how vulnerable can be a function of such an
importance like that of excito–conductivity. Without an obvious pathologic
background, the ventricular ejection may decrease to such an extent that
not only the carotidal flow but even the coronary one drop to dangerous
quotas. Hence, additional to the loss of consciousness (syncope), circulatory
arrests (actually, death) may also become possible.
The clinical scenario of such a development is known generically as
neurocardiogenic syncope, an event occurring unexpectedly and fatally
dangerous (173). The term derives from the above mentioned loss of
consciousness due to critical reduction in the cerebral blood flow caused
by the lowering of both the rate and pressure (171). How this combination
is reached remains controversial for both the clinician and the researcher
as well.
The main pathophysiological factors, hypotension and bradycardia –
par excellence a concordant combination for a critical reduction in cerebral
flow – is the direct result of loss of the vegetative balance, finalising
in sympathetic hypotonia and vagal hypertonia. In its turn, this lack of
balance is generated by a malfunction of the reflex activity governing the

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Chapter 11
haemodynamic process of adaptation. The main components of the reflex
arc involved are:
− Starting from:
• cardiac chemoreceptors and
• baroreceptors of ventricles, aorta and carotid sinus, as
well as those largely distributed at the vascular bed level.
− The afferent way consists of:
• glossopharyngeal nerve, from carotid sinus and
• vagus nerve from ventricles and relevant vascular bed
areas; it is to note that this nerve also transmits impulses
generated by abdominal viscera.
− The centres are represented by nucleus solitary, located in the
brain stem, and vasomotor antero–lateral medulla centres.
They could also be affected by intense emotions, via limbic
sympathetic inhibitory centres. It is unclear how and where
does pain interfere, as its involvement is out of any doubt (!).
− The efferent way is ensured by the two vegetative components:
sympathetic for vascular bed and vagus for heart; the suprarenal
gland and a parasympathetic involvement of the digestive
sector should be by all means taken into consideration.
The above presentation underlines the important part played by the
vagus nerve and the vascular bed in causing hypotension and bradycardia
– hence the two new pathogenetic synonyms of the old Bezold–Jarisch’s
reflex, namely vasovagal and, more recently, neurocardiogenic syncope.
Despite much efforts done in the research of this domain, few – if any –
results have been achieved, let alone the lack of a sensible teleological
significance. There remains for the practitioner to improve his work by
knowing the etiology and clinical forms. There comes across a good number
of clinical entities, as follows:
Orthostatism
The standing up, mainly sudden, implies a gravitational move of
about 500 ml blood from the upper part of the body to the legs. An
operative vascular tonus enhances the venous return and, consecutively,
the ventricular output (84). In elderly, people with small blood volume,
extensive varicose veins and cardiac preload dependent patients as well
as, sometimes, in apparently healthy individuals, the above position
change may lead to bradycardia and hypotension (276). The circumstance
is somehow similar to what happens in the falling down sentinels;
different from the patients, once horizontally, the blood return of these

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Natural deaths
cases increases and the heart filling and ejection volume restore, hence the
quick regaining of consciousness (147).
Cava inferior compression
Considering the consistent flow cava inferior has, its compression
could, in principle, reduce significantly the blood return to the heart. This is,
of course, reversible once the person concerned changes position but this
is not always the case. This means that severe hypotension and bradycardia
of a syncope extent may occur, cardiac arrests being reported in the domain
literature (146). By far, the most frequent scenario of this kind is met in late
pregnancies, although big and mobile abdominal tumours are even more
dangerous. From the pathogenetic viewpoint, a Bezold–Jarisch reflex may
also play a role (156).
Spinal anaesthesia
Both hypotension and bradycardia are common in any standard spinal
anaesthesia, requiring sometimes potent reversing medications. The
high level anaesthesia and particularly the total spinal block, a dramatic
complication of the epidural, are clinical settings when the syncope and
cardiac arrest are self–explanatory. The overwhelming vegetative imbalance
mimics very well a vasovagal reaction.
Carotid sinus compression
Important and interesting clinical facts appear in support for an
inhibition of the heart rate initiated by a (firm) compression of carotid sinus:
− A rapid heart rate can be sometimes reversed by neck
compression in the sinus area – a usual cardiologic technique.
− Severe bradycardias are realities during carotid
endarterectomies, a reason why a vagolytic medication is
usually given preoperatively.
− Bronchospasm, caused under such circumstances is,
undoubtedly, a sign of hypervagotonia (23).
− Real syncopes could appear during human violence incidents
when neck is strangulated,
− as actually, according to the forensic concepts, in cases of
suicides by hanging.
Deglutition and micturition
A vasovagal reaction occasioned by exercising the two functions is an
intriguing development and a controversial event in the same time.
− During deglutition, young people using to swallow big
alimentary boluses can also develop such syncope. A genetical

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Chapter 11
predisposition may play a role and a pacemaker is implanted in
well documented cases.
− During micturition, it is met in older men, especially during
night time, for various reasons as for instance:
• while a full bladder is known as a source of
vasoconstriction, its voiding could expectedly cause a
vasodilatation,
• a Valsalva effect may result from strenuous micturition,
• for prostate troubles, old men are frequently on alpha–
adrenoblockers,
• finally, the parasympathetic hypertonia is a nocturnal
reality.
Hypertension
Without treatment, this condition leads to death by cerebrovascular
accidents and cardiac failure. One may die sooner, especially after an over–
enthusiastic treatment, due to hypotension and bradycardia of syncope
dimensions (204). The hypertension is, in the end, a result of an improper
barofunction.
Other pathologic reflexes
A number of curious clinical events have in common a sudden fall in
the cardiovascular function. They are backed by ‘visceral’ reflexes with
an apparently controversial physiological value, put in motion under
circumstances of supraliminal stimulation. There find here their right place
the oculocardiac reflex, inadvertent hitting of the testicle and striking of
celiac plexus, with its version of solar plexus punch and negligent ventral
diving (229).

11.4.3. Congenital cardiac structural defects
They are strange structural defects, a possible cause of early deaths,
before 35 year age; different from the foregoing conditions, the autopsy of
these cases is far of being inconclusive.
Pont myocardique
Some muscular strips crossing coronary arteries may compress them
during their contraction. The explanation of the fatal events is rather
controversial since the respective strips contract during the systole, while
the coronary flow is a diastolic reality.
Cardiomyopathy
Irrespective of the clinical variant, obstructive or congestive, the
cardiomyopathy is a quite frequent cause of sudden death in young people.
192
Natural deaths
It is an intriguing condition since, in addition to a defective contraction,
such a voluminous heart muscle (up to 1 kg) does need large amounts of
oxygen.

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12. Death and organ transplantation
(100, 128, 184, 188, 206, 207, 229, 239, 287)

12.1. General view 195 12.5.1. Circulatory death 200
12.2. Transplant ischaemia 196 12.5.2. Brain death 202
12.3. Current retrieval sources 197 12.6. Proper retrieval 206
12.4. Ethical considerations 199 12.7. Cadaveric blood transfusion 208
12.5. Medical issues 200 12.8. Conclusions 210

12.1. General view
As mentioned several times in the present work, life leaves a human
body when its organs are no longer able to co–exist. This insolvency refers
to an in toto system and not to individual component parts. This means,
in other words, that once the death of an organism is declared, its organs
continue to live, each on its own, for various periods of time. As such, death
implies the availability of certain still viable organs.
This opportunity, however, necessarily requires immediate attention –
which is rendered virtually impossible given that people can die anywhere,
at any time, and from any number of causes. It is therefore a merit of
intensive care medicine that, in addition to saving lives, it is also death’s
caretaker. While intensive care units manage to ward off death in even
extremely severe cases, they also inevitably must cope with irrecoverable
patients. As such, the ICU is in one sense a sort of death recruitment camp.
It is in this camp that the practice of transplantation often begins.
Before removing organs of vital significance, it is necessary to establish
the irreversible loss of the functions that define life – consciousness,
breathing, and cardiac activity. This must be irrevocably different from a
temporary coma or an anaesthetic sleep (243). The usual pattern of dying
supposes circulatory arrest, when the heart stops as the result of the loss
of the other two life–triad functions: consciousness and breathing. Through
developments in intensive care, it became possible to split the triad in a
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Chapter 12
manner such that the old definitions of death gained more leeway.
It so happened, fortunately, that intensive care achievements met the
practical needs of transplantation. This coupling resulted in a way to define,
detail, and standardise their respective domains based on the behaviour
of the nervous system under circumstances of death (204). The result was
the concept of brain death (22) – a human invention (to cite a medico–legal
view) that allows the two specialities to each optimise its approach.

12.2. Transplant ischaemia
Transplantation consists basically of a transfer of an organ from one
(donor) to another (host) human body. It implies a time, relatively short or
long, necessary to remove, transport, and implant it again. During this time,
the transplant organ is not irrigated. The length of this ischaemic period
depends on the appropriate method of transplantation:
− Warm ischaemia is a lack of oxygen confronting the organs
from the very moment of death, defined by circulatory arrest,
until the substitution of the blood with a preservation solution.
During this period of time there is no blood or oxygen supply. As
still part of the freshly dead body and retaining its temperature,
the organ continues to need its usual O2 quota. Given these
details, it is crucial to shorten the period of warm hypoxemia as
much as possible. The time necessary for this first step was, in
the past, about 40 minutes.
− Cold ischaemia is better tolerated due to the low temperature
of the organ during transplantation. It starts once the blood of
the organ is substituted with the above–mentioned solution
and lasts until the implanted organ is again benefitting from
circulation, this time of the host’s blood. Transplant teams are
well organised and exercise standards of excellence; due to
the transport, however, a good number of hours are required
for this stage to be accomplished. Only rarely, mainly in multi–
organ transplantation, the number of hours necessary may
‘climb’ to 20. There have been, nevertheless, successful kidney
transplants after as many as 48 hours.
− Warm ischaemia again, occurs from the start of blood re–
supply, this time with host blood. The cold solution, partly
warmed between times, is replaced with blood, and the O2
supply becomes physically sufficient. The length of this period

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Death and organ transplantation
will depend on the extent of the ischaemic derangements,
functional and mainly organic ones. A full integration of the
new organ in the host’s system usually takes some time, and
with the present strategies, recovery is remarkably good.

12.3. Current retrieval sources
For rejection reasons, the first transplanted organs were non–
vascularised ones, such as the cornea (1905, Germany) and cartilages. The
first vascularised organ to be transplanted was a kidney, in 1954.
Throughout the next half of the century, organs were retrieved in
cases of circulatory death. Results have improved from many viewpoints;
the main difficulty was that, affected by warm ischaemia, the transplanted
organ also faced adaptation and integration challenges in the host body.
Along with rejection problems, ischaemia lesions often compromised many
cases. Much depends on the original vigour of the organ concerned, the
heart in particular. The literature of the day (1967) recorded the epic start
of the very first heart, transplanted by Dr Christiaan Barnard, after just one
electrical shock.
Things improved once the concept of brain death emerged. As a result
of improved ventilation techniques and sophisticated haemodynamic
support, an increasing number of young patients, victims of road accidents
in particular, could be maintained in a clinical status of ‘alive’ despite
irreversible neurologic lesions. Since, in a matter of days, most of these
patients would die anyway, they became suitable for organ donation.
Commendably, the families of these patients generally agreed to the
removal of their loved ones’ organs before the moment of death.
An international institutional patronage was quickly put in motion
– a context in which the so–called Harvard Protocol came into being, a
stimulating step in the transplantology curriculum that resulted in
− a surge in the number of transplantations,
− important advancements in surgical techniques,
− more research in immunosuppressant medications,
− an increase in transplant indications, and
− the organising of dedicated national and international medical
centres.
A series of social achievements (a decrease in alcohol consumption,
a marked reduction in the number of road accidents and, in particular,
the relatively good protection offered by seatbelts, helmets, and air bags)

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significantly reduced the number of hospital admissions for craniocerebral
injuries, thus reducing the number of brain death cases. This deadlock was
so serious that transplantation practitioners had no choice but to return
to circulatory death for organ donation casuistry. A revision followed, as
did many policy improvements and much institutional input. The Pittsburgh
Protocol introduced better case optimisation and substantially stimulated
research in the domain.
The good news at the time was that despite differences between the
two major means of organ procurement, the results à la distance ended
up being quite similar. This statistical finding represented a good reason
for better organising this re–embraced method of organ retrieval. Among
other things, the time of warm ischaemia was reduced to just 20 minutes.
Naturally, the pool of donors increased substantially; there remains,
however, room for improvement since one–fifth of patients on transplant
waiting lists die before a suitable donor is found. In its turn, organ retrieval
does not work much better, since only (again) one–fifth of cases reach the
stage of having organs removed.
This is why, in addition to the usual donors, transplantation medicine
has begun to look to additional sources:
− Permanent vegetative state. As mentioned in the chapter
dedicated to this issue, there have been some anecdotal
cases of neurological improvement. They are nevertheless not
substantial enough to discourage active policies notably that,
after a status quo of 12 months, such patients can be used as
donors provided their families agree.
− Anencephaly. It is an interesting condition, highly tempting for
transplantation: these newborns have well developed viscera
and, for neurologic reasons, do not live more than one week.
There is, however, an overriding moral obstacle: it is difficult for
any team to pose such a delicate question to an already very
distressed mother.
− After successful resuscitations in cardiac arrest. Three ethical
issues must be resolved as a matter of institutional policy before
confronting clinical cases of this kind:
• If a heart is so ‘cardio–sick’ that it goes into arrest, how
can it fulfil the haemodynamic needs of a host also
cardio–sick enough to require a heart transplant?
• If a patient with a DNR order and an organ donation
agreement in place goes into cardiac arrest, that patient

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Death and organ transplantation
should be resuscitated in service of the timing needs
associated with circulatory death. If so, it would amount
to resuscitation in the service of death!
• In cases of judicial execution, where it is legally permitted,
the predominantly young age and good health of the
potential donor, as well as the organised nature of the
facilities all bode favourably for organ retrieval.

12.4. Ethical considerations
1. The general public is favourable to the transplant movement. It is
impressive how many citizens fill in their names in the Donor Register. On
the other hand
− the rigid, prohibitive attitudes of some religious philosophies
such as Scientology, Orthodox Judaism, and Jehovah’s
Witnesses, are surprising; and,
− inspired by tales of people being buried alive, there are some
who fear that the medical establishment’s efforts to facilitate
in–hospital deaths are actually only a means of supporting
transplantation practices.
2. Irrespective of the bureaucracy involved, the donor patient remains
primarily a sufferer and someone in need of full medical attention; a
donation should always be a secondary problem. Under no circumstances
should a medical gesture suggest that the handling of the patient’s case be
subordinate to the interests of organ donation. Moreover, the patient must
be offered the full extent of human consideration, and his agreement and
reasonable wishes are to be respected. His individuality and dignity are the
priority, and every effort should be made to diminish his discomfort and
pain.
3. The family is a key factor among the many issues surrounding an act
of donation. When the patient is no longer compos mentis, the family has
the right either to support or to dissent from a previously expressed stance
of the patient. Also, in the event of any initiative taken by the medical
institution, it is the right of the family to agree or not.
4. In its turn, the medical institution exercises reasonable pragmatism,
attempting to support a transplant action while not interfering with the
basic human rights of both its patient and the family. In principle
− the patient’s living will or most recent decisions are fully
respected and/or revised with the family if the individual is no

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Chapter 12
longer compos mentis;
− the family’s wishes are solicited and respected;
− when the family is not available, the hospital’s ethics committee
or a judicial body should be consulted;
− the medical institution is responsible for organising the retrieval
as well as everything else once the transplant team has left; and
− meticulous documentation is kept concerning the case.
5. Paediatric cases pose additional and difficult problems arising from
the mothers’ psychological trauma. In some countries, such Australia, the
retrieval of paediatric organs is forbidden by law.

12.5. Medical issues
The two versions of death can both be sources of transplantable
organs. From a technical point of view, though not the only point of view,
the version of death – circulatory or brain – is essential for determining the
manner of retrieval.

12.5.1. Circulatory death
In order to expedite the case to the moment of procurement, a largely
accepted algorithm is respected in clinical practice. The most important
steps of the protocol are as follows:
− The relevant transplant officer is notified of the availability of
an organ or organs.
− Suitability is checked by a dedicated group.
− An appropriate retrieval team looking after a case matching the
donor’s traits is advised.
− The best mutually convenient approach is established.
− The entire treatment of functional support, ventilation, and
inotropic and vasoactive medication in particular is carried out,
not only until the retrieval team arrived but also during the
necessary preparations in the theatre. As previously mentioned,
in general these teams are well organised; however, working in
an unfamiliar unit with unfamiliar staff is never easy.
− Once the retrieval process begins, the patient is taken to the
theatre by the department’s people, who ideally have an
established relationship with the patient’s family and any other
involved parties.

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Death and organ transplantation
− What follows is a moment marked by grave responsibility,
namely the switching off of all life–support systems and the
discontinuation of all treatments with the express purpose
of easing the patient’s passing away. Although fully justified
from a medical viewpoint, this moment is a challenging one
for families, even for those with previous similar experience;
technically speaking, the gesture may essentially border on
murder. It is usually done by a senior staff member.
− Two sorts of treatment must always be considered:
• One that avoids, by all means, any discomfort and pain.
• A second one that aims to minimise the eventuality
of warm hypoxia lesions by ensuring a systolic blood
pressure of at least 80 mmHg and a PaO2 of 80 mmHg.
This sounds well justified, but it is not technically always
easy to achieve in a patient expedited toward death!
− For various reasons relating to such needs an experienced
intensivist should be standing by.
The surgical approach itself is organised in a manner designed to
shorten, as much as possible, warm hypoxia. The supreme task is retrieving
the organ and irrigating it with the cold preservation solution. This process
cannot be started until death is decisively declared. In this respect, the
following points are important:
− In most cases of natural circulatory death, there is no urgency
to sort out postmortem concerns; unlike this common scenario,
the retrieval team desperately requires the exact time of death.
− It so happens that, recently, a judicial intervention adjusted the
definition of circulatory death, namely such that it is considered
to be an irreversible arrest of cardiac activity.
− As a result, to be absolutely certain that cardiac activity has
irreversibly ceased, it was decided by consensus that, in order
to exclude any auto–resuscitation (the much disputed Lazarus
phenomenon), there must be a one–minute wait before making
any incision. But when exactly does this minute start?
− In highly equipped medical establishments such as those
patronising transplant activities, asystolia is declared in a high–
tech style: iso–electric ECG, a lack of any (invasively monitored)
arterial pressure and, very recently, an echographic picture of
heart standstill.
− To reconcile all parties, it was ‘decided’ that the wait–time from

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Chapter 12
the moment of asystolia to that of incision could be somewhere
towards 10 minutes, with most transplant schools agreeing on
2 to 5 minutes.
The usual time from the interruption of life–support treatment to
death is one hour. If, respecting the entire above algorithm, death does
not occur, the case is considered unsuitable for donation as, during the last
hours of neither life nor death, unacceptable ischaemic changes will have
necessarily occurred.
In conclusion, it is, from the standpoint of medical philosophy, intriguing
to regard an irrevocable death as a case simultaneously lending itself so
well to resuscitation.

12.5.2. Brain death
History.
The main steps in the evolution of the concept of brain death have
been the following:
− Coma depassé was a term suggested by Mollaret and Goulon
around the middle of the 20th century (188) to mean any
irreversible loss of consciousness.
− In 1968, an Ad–Hoc Committee at Harvard University equated
brain death with an irreversible coma (119).
− It was Mohandas and Chou who launched the idea that, in the
context of neurological compromise, it is an affected brain stem
that determines irreversibility (186). This was of great practical
significance since it generated a reliable method of dealing with
dying patients.
− The Conference of the Medical Royal Colleges of Great Britain,
which convened in 1976, released a memorandum stating that
once the nervous structures are irreversibly compromised,
the permanent functional alteration of the brain stem may be
equated to brain death (302).
− Finally, in 1979, the same forum equated brain stem death
with death proper (119). Thus were ‘established’ the organic
underpinnings of the strong relationship between the
components of the life–death triad: consciousness, respiration,
and heart activity (317).
In addition to transplantology, intensive care medicine itself was given
an important tool toward sorting out the patient category in discussion. It
was agreed in concert by the intensive care strategists that

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Death and organ transplantation
− as, in general, no rebate is tolerated in terms of treatment cost
and efforts as long as a case involves a minimum of justified
hope, one should equally optimise the care in cases involving
no hope whatsoever, including patients with brain death; and
consequently
− transplant teams were freed to retrieve organs from heart–
beating donors, including the heart, and intensive care units
were legally allowed to end hopeless treatments and were
instead encouraged in such cases to facilitate death.
The brain stem, mesencephalon, pons, and medulla – definitely vital
for life – are involved in the wake–sleep cycle, consciousness, breath pacing,
vasomotricity, both reflex and voluntary activities, and ocular movements.
The heart is an organ with its own excito–conductive system; however, it is
also brain stem dependent. This is why, in a brain dead patient, spontaneous
cardiac activity ceases in a couple of days despite good ventilation and
laborious treatments.
For the same reason, all comatose patients with the brain stem involved
have profound functional changes:
− Myocardial depression, ‘paralytic’ vasodilatation and,
frequently, different degrees of hypovolemia underlie a
cardiovascular failure.
− Any cerebral hypoxic tissue generates thromboplastin, which
may initiate a disseminated intravascular coagulation; the
affected lung is sometimes so extended that it can compromise
respiratory support.
− The endocrine sector is not exempt: thyroidal and hypophyseal
hormones are reduced with a clinical picture of diabetes
insipidus.
− Hypothalamic changes are reflected in a metabolic depression
– one reason these patients are usually hypothermic.
The above criteria for a compromised brain stem have been thoroughly
standardised by relevant British and American bodies and are used
worldwide in the clinical handling of this category of patients.
How a potential donor is identified
In principle, such a patient is in a coma caused by irreversible
cerebral lesions. Traumatic etiology makes the clinical judgement easier in
comparison with others, especially in the case of hypoxia.
There are several accompanying pathologic changes which make a case
unsuitable for donation:
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Chapter 12
− Humorally advanced derangements, including
• hypoxia, a PaO2 less than 80 mmHg;
• hypercapnia, a PaCO2 above 60 mmHg;
• serum acid–base deviations, a pH of under 7.30 and
above 7.45;
• glycaemia, under 3.0 and above 20 mmol/l; and
• serum electrolytes outside the range of Na 115 – 160,
Mg 0.5 – 3.0, PhO4 0.5 – 3.0 and, importantly, K under
2.0 mEq/l.
− Hormonal ‘extremes’ – myxedema, Addison, and thyrotoxicosis.
− Hypothermia of less than 34oC.
− Intoxications; in general most toxins are eliminated within 12
hours, although tables with blood dynamics may be useful (22).
− The same judgement applies to medications such as sedatives,
hypnotics, and tranquillisers, whereas muscle relaxants may
need to be antagonised.
− Blood pressure, in terms of medium value, should be above
60 mmHg.
How is brain stem involvement tested
There are certain nervous reactions that demonstrate brain stem
involvement, namely reflexes that imply the activity of cranial nerves that
have centres in the brain stem:
− Pupils are dilated (a paralytic dilatation) with no reaction to
light; in some ocular conditions, for local reasons, mydriasis
may not occur.
− Corneal reflex is negative.
− The vestibulo–ocular reflex is suppressed.
− Motor reaction of the face is negative.
− Peripheral reflexes such as the patellar and plantar may
be present; being spinal, they are not suppressed by brain
stem death; the same is true for some myoclonias and arms
movements in Lazarus phenomenon.
− There is an absence of a pharyngeal reflex (tested by stimulating
the ovulum) and cough reflex (tested by introducing a catheter
through the tracheal tube deeply towards the tracheal
bifurcation); these provide important evidence for irreversible
structural changes in the brain stem.
Apnoea testing is crucial. It relies on the potent driving effect of CO2 on
the respiratory centre, a central nervous entity located in the medulla. To
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Death and organ transplantation
test this, one raises the PaCO2 to values considered powerful stimulators
of the respiratory centre, while carefully maintaining normoxia. With
the ventilator switched off and an intra–tracheal O2 flow of 5 l/min, one
measures sequentially the PaCO2 until irrevocably stimulating values are
obtained. These are 50 mmHg in formerly healthy individuals and 60 in
patients who may have suffered from a hypercapnic condition such as
chronic bronchopneumopathy, emphysema, or sleep apnoea.
Once this setting is reached, one waits 5 minutes, carefully monitoring
the self ventilating behaviour of the patient. If no independent inspiratory
effort whatsoever is produced, the apnoea test is positive and the brain
death diagnosis may be formulated.
In cases of coexistence of facial lesions or in any other unusual clinical
scenario, an ophthalmologist or ENT specialist as well as a neurologist must
be involved in testing. Sometimes sophisticated examinations such as EEG,
CT, RMN and angiographies are done in complex cases.
Again, the above testing is a clinical judgement, and a very sensible and
reliable medical act. This does not mean it is beyond criticism. There are
arguments put forward by some groups that by being relatively elaborate,
this method is a two edged sword wielded primarily in order to facilitate
organ donation. As specified before, switching off the ventilator in the case
of a human being whose heart is still beating is always challenging and, in
a dogmatic sense, ethically wrong. The fact remains, however, that in over
1,000 cases of brain death to date, involving patients kept on a ventilator
for various reasons and with many other life–support treatments running,
they all, nevertheless, resulted in asystolia within a couple of days (119)!
Organising issues
Rules vary not only from country to country but even from medical
centre to medical centre. In any event, one has to meet both medical and
legal needs. Following are some relevant details:
− Testing is done by two competent medical staff members. They
must have full medico–legal clearance and neither can be a
member of the transplant team.
− The two members alternate roles, leading and assisting,
respectively.
− Initial testing can be done after only four hours of care in the
unit and after 12 hours in the case of a hypoxic coma such as
that secondary to cardiac arrest.
− The time between the two tests is at the team’s discretion; the
essential thing is to allow for full recovery of gas homeostasis,
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Chapter 12
so there is no effect from the first test.
− In paediatric cases it is advisable that everything be allowed
additional time due to the generally better chance of recovery.

12.6. Proper retrieval
This is an important part of a procedure as significant as organ
transplantation. As such, the retrieval should be carried out respecting
the entire series of surgical, administrative, medico–legal, and ethical
requirements. From a technical point of view, the process takes place in
a hybrid surgical setting: a theatre run by the organ donating institution
and a team representing the organ receiving institution. The two may, and
certainly do, exercise different standards and have different work habits. It is
also necessary for them to exercise a certain level of mutual understanding,
considering the end result of their cooperation.
Practically, as previously mentioned, the patient is brought to the
theatre when the retrieval team is ‘on the ground’ and when everything
required in terms of staff, equipment, and drugs has been arranged. The
manner of approach depends on the type of death that has claimed the
donor’s life.
Circulatory death
In order to minimise warm hypoxia, it is essential to irrigate the organ(s)
of interest as soon as possible with the cold preservation solution – as
specifically and repeatedly mentioned in this chapter. Various tissues have
various tolerances to hypoxia, for example the cornea 6 hours, the skin
12 hours, but the parenchymatous organs are more sensitive. Concerning
these, it is a current standard to place two large bore cannulae into the two
femoral vessels as soon as possible; some teams try to do this even earlier,
before the asystolia is declared. Once this has been done, an exsanguino–
perfusion is carried out, with different amounts, according to individual
protocols, of cold solution (the substitution previously mentioned). It is then
the turn of the awaiting teams to proceed, one after the other, according to
the priority of the organs concerned.
Brain death
The organs are retrieved while the heart is still beating, which differs
substantially from the previous category. Anaesthesia is not necessary,
although some teams administer a strong painkiller – not necessarily for
analgesia needs but to avoid any vegetative reaction to the tissue handling.

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Death and organ transplantation
In the case of multi–organ retrieval – which is the most common case – the
priorities are the same, with the last organ retrieved being the heart, or the
heart and lungs together. Functional life–support treatment is maintained
throughout the retrieval procedures until the last organ of interest is
removed – that organ, once again, with rare exceptions, being the heart
itself.
A valid detail for both manners of retrieval consists of how the lungs
are removed. In circulatory death, the trachea is extubated earlier as this
gesture has been found to expedite asystolia. Once this occurs, the trachea
is intubated again because, as in the case of brain death, the airway must
be protected from any potential reflux of gastric content. As for the delivery
of the lungs, this is done with them slightly inflated, in order to avoid
atelectasis, until implantation in the host’s body.
After retrieval, each team in its own way prepares the organs for the
journey to their respective institutions. The essential detail in this context
is that cold storage be done in the most ‘cutting edge’ manner. Once
everything is done, each team leaves for its destination. When travel is by
road – which is usually the case, at least in the European countries – the
transport vehicles are, in order to reduce length of ischaemia, exempt from
the standard traffic regulations that would otherwise slow the journey. For
longer distances (sometimes the retrieval is done in neighbouring countries)
air travel is often used.
After the departure of the visiting team(s), it is the responsibility of the
host institution
− to close the acceded cavities and organise the embalming of
the deceased and transfer to the mortuary;
− to support and assist the family with any remaining necessary
procedures; and
− to meet documentation requirements including
• clinical details of the intensive care case;
• justification of treatment interruption;
• necessary agreement from the patient and family;
• an agreement from the hospital ethics committee;
• a list of all the stand–by facilities; and
• issuance of a death certificate; as specified, the moment
of death is 5 minutes after asystolia is declared in
circulatory death, or the time of the first apnoea test in
the case of brain death.
Copies of all the above documents are sent to the delivering

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department, the host intensive care unit, the transplant office,
the hospital administration, the judicial authority (if involved),
the on–call team and the hospital chapel.
To conclude this section, in matters of death it may be worth underlining
that, while in the circulatory version of death retrieval procedures can’t
begin until asystolia occurs, in brain death the retrieval procedure itself
causes it. This, along with a few other similarly delicate issues, may well
pose a challenge to the conservative followers of Hippocrates as well as
scholars involved in formulating pro forma definitions.

12.7. Cadaveric blood transfusion
Etymologically, a transfusion is related to a transplant. Currently a
transfusion is only carried out provided there is a certainty of restoring the
donor’s blood volume. This condition does not matter when it concerns
a cadaver’s blood, and considering this particular source, the topic is
appropriate in a work such as this one dealing with death.
The use of human cadaveric blood was a Soviet inspiration. The idea
was made known after experimental work carried out by Shamov (241).
Yudin was quick to take it over for clinical trials in 1930. He brought it to
the attention of Western medicine (296, 297) and, within five years, he had
already reported thousands of transfusions. So it was possible to reconcile
the cadaveric transfusion reactions and accidents with a similar number
of those caused by blood from living donors. The matter interested many
researchers and professionals, and a good number of studies were published
in many languages, English in particular. Unfortunately, as Kevorkian – one
of the modern pioneers in the domain (144) – found, cadaveric blood was
undervalued for emotional, political, and fear–based reasons.
Despite Western reluctance, the Soviets continued to both study and
use cadaveric blood. It was used extensively during WW II while Moscow’s
Sklifosovsky Institute had the necessary equipment to use this blood
routinely. Half a century ago, the number of transfusions performed with
cadaveric blood totalled already 30,000 (218, 262).
The reasons to use cadaveric blood were numerous (191):
− Removed from the deceased a couple of hours after death, it
becomes incoagulable due to fibrinolysis – a process taking place
in 60 to 90 minutes (143, 144). This simplifies the retrieval and
makes the appeal to an anticoagulant unnecessary; moreover,
the citrate normally used has some deleterious effects for the

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Death and organ transplantation
recipient.
− The amount obtained from a single source is substantially higher
– up to 3 litres – compared to the average smaller amount from
volunteer blood donors.
− Such availability reduces the number of tests and, more
importantly, the number of subgroup incompatibilities.
− It may be used either as whole blood or in the form of derivatives,
i.e. erythrocyte suspension or plasma.
− About 80% of red cells have the same survival rate as those
retrieved from living people, 21 and 25 days respectively.
− The dynamics of storage and testing are also identical.
Needless to say, there are some limitations too:
− Lacking coagulation factors, cadaveric blood cannot be used
for massive transfusions in shock cases or in cases involving
coagulation deficiencies.
− As the health status of the deceased is not known, cadaveric
blood should be kept on stand–by until an autopsy is performed
and common biochemistry and microbiological tests are done.
Generally being obtained from young people and in cases of sudden
death, it is reasonable to assume that the parameters of vital importance
were not significantly altered. The single factor affected was serum
potassium, which rose 2 to 3 times; due to dilution in the recipient’s volume,
there was – from this point of view – no reason for concern.
The retrieval of cadaveric blood differs to some extent from the
standards used for living donors:
− review of the available personal data;
− positioning on an operating table of forensic use;
− meticulous cleaning procedures;
− surgical standards for the staff involved;
− surgical preparation of the large vessels of the right side of the
neck – carotid artery and internal jugular vein – a preference
derived from the linearity with the vena cava superior;
− placement of large bore cannulae;
− attachment to the vein of a container, 0.5 – 1 l. capacity, in a
closed, sterile system; and
− head down positioning on an inclined table of about 60o.
Due to the high venous pressure resulting from the above position,
blood drainage is rapid, needing not more than 30 seconds for 500 ml. The
usual amount of drainage is 2 – 3 l. If some small clots form there is time

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Chapter 12
enough before the transfusion for them to be fibrinolysed.
Via the arterial cannula, a couple of litres of 5 – 10% dextrose and
polyelectrolyte solutions are introduced in order to reduce the effects of
dehydration and ease the embalming procedure. The obtained blood is
carefully labelled and sent for the necessary testing.
To conclude, once again, it is surprising and intriguing that a technique
associated with no cases of hepatitis C transmission, less than a 1% rate
of post–transfusion reaction (277) and suitability for both whole blood and
plasma use – not to mention the availability and low cost – has not been
embraced by clinical practice (281). Somehow, regrettably, the idea was
eventually even forgotten in Russia.

12.8. Conclusions
The transplantation movement may legitimately be proud of the
immense progress made in less than half a century: operative techniques,
immunosuppressive medications, as well as the algorithm of practical
activities. The multiple organ transplants, the repetitive transplantations
and the re–use of transplanted organs speak for themselves.
It’s also important to emphasise the part played by intensive care
departments:
− On one hand, terminal cases can be kept alive while a suitable
host for transplantation is found.
− On the other hand, due to the optimisation derived from on–
going cooperation, it has become possible to ‘generate’ more
cases of donation.
For procedures such as transplantation, the deaths that occurred
everywhere, under any number of circumstances, and at any given time
were of no use; nor were the overly strict confines of earlier algorithms. It
was the concentration of death in intensive care units that really facilitated
the transplant movement. 90% of transplantations carried out today involve
organs that come from such units. It is to the credit of this speciality that
death has a new role in biological recycling.

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13. Unnatural deaths

13.1. Intoxications 212 13.10. Iatrogenic mortality 241
13.2. Alcoholism 218 13.10.1. General view 241
13.3. Smoking 221 13.10.2. Chemical pneumonia 243
13.4. Accidental suffocation 226 13.10.3. Malignant hyperthermia 245
13.5. Starvation 227 13.11. Content of pregnant uterus 246
13.6. Falls 227 13.12. Radiation sickness 249
13.7. Suicide 228 13.13. Transport accidents 251
13.8. Electrocution 231 13.14. Armed conflicts 254
13.8.1. General view 231 13.14.1. Chemical warfare 255
13.8.2. Technical considerations 231 13.14 .2. Nuclear weapons 256
13.8.3. Clinical aspects 233 13.14.3. Biological weapons 257
13.8.4. Special circumstances 235 13.15. Natural disasters 257
13.8.5. Conclusions 236 13.16. Homicide 259
13.9. Drowning 236 13.17. Terrorist acts 261
13.9.1. Introduction 236 13.18. Large scale industrial
13.9.2. Elements of accidents 262
pathophysiology 237 13.19. Various unnatural deaths 263

Real unnatural deaths actually do not exist; every death is, per se, a
natural event. Natural or unnatural is de facto the rightness of occurrence.
Thus, an anencephalic newborn dies in the first week of life of a natural
death, whereas drowning causes an unnatural death irrespective of age
and circumstance. The entire series of deaths discussed in the chapter 11
were caused by common conditions and after an expected time of suffering.
Different from those groups of diseases, deaths following to be presented in
this chapter occur after pathological events unusual for a current existence.
Their list is quite long, reason why only the most important, as etiology and
mechanism of causing death, will be discussed.

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Chapter 13

13.1. Intoxications
(95, 97, 184, 243)

Nowadays, modern societies use a huge number of various chemical
substances; the main categories are industrial, agricultural, domestic,
pharmaceutical and recreational. Apart from the last ones, criminalised,
relatively strict regulations of how to be utilised have been formulated;
nevertheless, everyday life offers a good number of inappropriate uses.
This is the explanation of a large diversity of intoxications. They occupy
about 15% of the hospital beds, whereas 250,000 cases worldwide die every
year. However, not only external chemical substances, such as toxins, may
interfere with the physiology of a patient; CO2, for example, an essential
player in the homeostatic physiology, may also become real poison once its
blood level, for various reasons, overtakes the normal values.
For the topic this book deals with, the most important viewpoint is
the mechanism of causing death. Therefore, only the most representative
toxins are presented in the following pages.

Carbon dioxide
Under normal physiological circumstances, CO2 has a performing
mechanism of clearing: collected from the cytoplasm and carried as HbCO2
to the lungs, it achieves an alveolar expiratory concentration of 3 – 4%. This
is something more than 100 times than that of entering atmospheric air. The
usual hypercapnias are biochemical realities but they do not really intoxicate
the patient. Real intoxications take place when the blood–atmosphere ‘free
flow’ is severely affected; the alveolar CO2 is either produced and cumulated
from the body metabolism or brought from an outside source. Figures of
CO2 concentration with clinical significance are
− 3% in usual expiratory air,
− 25 – 30% already could cause death, and
− 60% leads to death suddenly.
The proper mechanism of death consists in the severe homeostasis
derangement caused by the resulted acidosis. Sudden deaths occurring at
lower concentrations are explained hypothetically by a vasovagal syncope
as a consequence of a supraliminal stimulation of the inspiratory centres.

Carbon monoxide
This gas has a couple of features which make it a dangerous poison.
− It is produced by a partial and incomplete combustion
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Unnatural deaths
• of wood, coal and methane gas used for making fire of
domestic needs, and
• habitual vehicles; the old ones may generate up to 10%
from their exhaustion gases while even the modern
variants, equipped with high–tech converters, do
generate some CO.
• This is why breathing in the atmosphere of an
unventilated garage with a 2 l. engine working, one can
die in no longer than 5 min. This is also the reason why
the above setting is used for suicidal purposes.
− Intriguingly, vitally essential for human being, Hb has an affinity
for CO 250 times higher than for its inherent physiologic partner
O2. Two important factors result from this behaviour:
• Comparative to the naturally useful instability of HbO2
(essential actually for tissue oxygenation), HbCO excels
by stability, blocking so various proportions of Hb and
impeding its participation in homeostasis.
• The presence of HbCO reduces the peripheral dissociation
of HbO2, worsening even more the tissue hypoxia.
− The dynamic of the alveolar gas changes generates permanently
free Hb, thereby ‘offering` it to any amount of CO, resulting in
HbCO, somehow contrary to the action of mass law. This is why
• breathing in an atmosphere containing only 0.1% CO,
one reaches, in 2 – 3 hours, a proportion of HbCO of up
to 60%
• whereas, breathing in an atmosphere with just 1%, the
coma occurs in 20 min.
The two facts are explained by a cumulative filling up.
− Avid for any hem chemical structure, CO also combines stably
with
• myoglobin, a chemical detail explaining the deleterious
effects on both the striated muscles and myocardium, as
well as vascular sphincters, and
• cell respiratory enzymes (cytochrome, cytochrome
oxidase and hydroxyperoxidase), causing so a histotoxic
hypoxia; nota bene, working like a ‘combustion cell
engine’, the mitochondrion itself generates some CO. Its
proportion increases slowly in the context of cell process
of ageing.

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Chapter 13
− Once the respiratory enzymatic equipment of the cell is affected,
the recovery in O2 supply does not necessarily provide an
improvement of the cell combustion reactions. This is because,
during hypoxia, oxygen free radicals were generated, required
being now a metabolic repairing effort. The situation resembles
in principle with the clinical picture of the post–vascularisation
syndrome.
To end with the mechanism of causing death, a proportion of HbCO of
30 – 40% causes nausea, vomiting and sight difficulties while at 40 – 50%,
coordinating troubles and coma precede death.

Cyanide
This chemical group represents the toxic ‘arm’ of the hydrocyanic acid
and the two Na and K cyanides. It is considered the most powerful of all
toxins. It was infamously used as a chemical weapon in the gas chambers of
WW II. 200 – 300 mg orally or breathing 3 min of a poisoned atmosphere
are considered lethal. According to some legends, it is a good choice for
professional suicides.
The substance enters the cells rapidly, where it promptly combines
with the ferric ion of the cytochrome oxidase, known as the last step of
the cell respiratory chain. The oxidative phosphorylation and the energy
production are dramatically decreased with the development of a severe
metabolic acidosis. There are, also, a number of other vulnerable metabolic
points leading together to cytotoxic hypoxia. It has a pronounced affinity for
the red cells. The first sign of intoxication occurs at 20 mmol/l, at 40 mmol/l
the case is considered of a medium severity, while 100 mmol/l represent
actually a fatal concentration.
Additionally, it stimulates the central nervous system resulting in
agitation and hypersympaticotonia followed by depression on all sectors,
somatic and vegetative as well.

Organophosphates
The worldwide agriculture uses over 100 organophosphate compounds
as pesticides. The most known are chlorpyrifos, phenitoyn, malathion and
parathion. Despite the strict regulations of use, accidental intoxications
are always possible. The toxin may enter the human body by inhalation,
transcutaneously and orally. The toxicity of the organophosphates is due
to their anticholinesterasic effect – the one backing actually their pesticide
action. As a consequence, the acetylcholine transmission is exaggerated

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Unnatural deaths
in all sectors where it is physiologically involved: central and vegetative
nervous system and neuromuscular junction.
As any other toxin having reached the tissues, the organophosphates
are subject to a metabolic breakdown, particularly at the hepatic level.
Different from any other toxin, the resultant chemical individuals are
also anticholinesterasic, some of them even more potent. Due to this
self enhancing action, its specific effect is increased and prolonged.
Consequently, the clinical picture continues to aggravate in the next 2 – 3
days.
The dramatic clinical signs could be categorised as
− muscarinic: vomit, diarrhoea, myosis and hyperproduction of
tears, bronchospasm, hypersalivation, bradycardia and a–v.
conduction troubles,
− nicotinic: myoclonus, sweating, uncoordinated muscular
contractions, tachycardia and hypertension, and
− central nervous: excitation, confusion, depression of the entire
nervous functions, finalising with coma and occasionally
convulsions. Needless to say, death is possible anytime on any
point on the above mentioned intoxication course.

Paraquat
Largely used as herbicidal agent, paraquat may accidentally (by
inhalation, ingestion or transcutaneously) accede the circulation. It is so
toxic that a single bolus of 20% solution swallowed can lead to multiple
organ failure. This toxicity derives from a number of dynamic particularities:
− such a rapid body distribution that, in order to reach its peak,
requires not more than one hour, and
− paraquat has a selective affinity for
• renal cells, what reduces the toxic elimination, and
• pneumocytes, explaining a secondary pneumonia and a
depositing even after complete blood clearance.
The toxic effect consists in an interference with the cell respiration
chain, of nature to cause hyper–production of acid free radicals and lipidic
peroxidase. In their turn, they lead abruptly to metabolic acidosis and a
drastic reduction in the energy production, as well as a compromise of
membrane structures, respectively. This curious toxic effect is, intriguingly,
enhanced by the oxygen therapy, somehow similar to what happens
metabolically in the same post–hypoxic revascularisation syndrome – a
quite controversial clinical entity in its turn.
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Chapter 13
Arsenic
Famous in the human history, it has been extensively used in various
criminal practices. Being still in use as a pesticide, an accidental poisoning is
possible. The toxic effect is overwhelming; 200 – 300 mg is enough to cause
death. The mechanism of toxicity derives from two actions:
− Combining with SH of the mitochondrial oxidative enzymes, it
compromises the energy production of the cell.
− Altering the NO synthesis, it interferes with the peripheral
vasomotor dynamic.
The clinical correspondents of the above metabolic details are
respiratory and cardiovascular depression.

Strychnine
Having caused havoc along the entire crime history, it is still used
nowadays as pesticide. Thus, despite the tough standards of use, accidental
poisonings may however occur. Strychnine is a powerful stimulant of the
nervous system, particularly spinal cord. A dose of only 50 mg is enough to
kill, developing a clinical picture featured by
− Muscular contractions of a particular sort:
• prompted by minimal stimuli,
• degenerating in convulsions,
• frequent opisthotonus,
• sometimes producing ligament and muscular rupture or
even real fractures; and
• all, extremely painful.
− The consciousness is not affected. This is a good reason to brand
a crisis like that as barbaric.
The modern intensive care copes with such episodes, provided the
patient reaches the hospital unit in right time.

Recreational drugs
The feeling of comfort and stimulation represents the background of the
habit embracing, eased by curiosity and imitation or, sometimes, a spirit of
solidarity with consecrated user. The best known and preferred are heroin,
cocaine, amphetamine, LSD and Ecstasy. Opiates, barbiturates, organic
solvents and some gases as butane, propane and bromofluorocarbon also
belong to this group. Ketamine, an already consecrated general anaesthetic,
tempts the drug addicts for its secondary hallucinogenic effect.
They are used by inhalation, intranasal, per os and also by injection,
216
Unnatural deaths
preferably intravenously.
How do they harm and, in particular, how do they kill?
− acutely; reactions of hyper–sensibility, as it happens in cases of
heroin and other opiates,
− overdoses; consequent to wrong labelling and confusion,
− after long use; by biologic degradation, and
− indirectly, due to:
• aggressions facilitated by hallucinations,
• traffic accidents, and
• falls and drowning.
The mechanism of causing death varies:
− barbiturates and opiates through respiratory insufficiency;
− amphetamines: hyperthermia, hypertension, cardiac arrhyth-
mia, subarachnoid haemorrhage;
− cocaine and its ‘crack’ version: hyperthermia, hypertension,
confusion, respiratory insufficiency, cardiac arrhythmia;
− LSD: reactions of hyperexcitability, suicides or hallucinatory
paroxysms;
− organic solvents and gases: myocardial sensitisation to
catecholamine as well as a possible direct toxic effect on
different nervous structures and myocardium;
− Ecstasy (methylene–dioxy–metamphetamine): rhabdomyolysis
and intravascular coagulation leading to pulmonary oedema
and multiple organ failure.
Heroin, statistically the mostly used recreational drug, does not kill by
itself. It may however finally cause death – after long use – by the biological
degradation, its mortality being approximated to 3%. Cannabis, per se,
does not cause death either. For ketamine, both the clinical experience and
statistical data are yet at their beginnings.

Miscellaneous
A large variety of creatures produce, for purpose of defence or hunting,
various toxic substances; they are secreted by highly specialised glands,
stored in a manner to be ejected in case of needs. These substances are
known, generically, as venoms. Snake, scorpion, spider, octopus, jelly fish
– to mention the most known – are all venomous. The mechanism of
being venomous consists in a real ‘toxic chemical engineering’ aiming at
causing to the victims severe dysfunctions of the neuromuscular junction,
intravascular coagulation, rhabdomyolysis, respiratory insufficiency and
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Chapter 13
cardiovascular depression. These vitally dangerous troubles can be put
therapeutically under control; the problem is that the circumstances under
which the creatures in discussion bite are generally too far from a competent
medical unit – what is of nature to make the prognostic rather gloomy.

13.2. Alcoholism
(40, 98, 178, 180, 204, 226, 287)

A general view
Alcohol is a fermentation product, easily obtainable, to which humanity
has shown its interest for millennia; one drinks wine for 5,000 years and
beer for even 8,000. Any reader might find useful to know that:
− At a concentration higher than 15%, the yeast is inhibited
and the fermentation stops by itself. In order to get stronger
concentrations, distillation has to be adopted.
− For more accuracy, the amount of alcohol from a given beverage
is expressed in both percentage and grams.
− As the% & g. vary from product to product, it was convened to
speak of units of alcohol. Although the number of correspondent
grams differs from place to place (1 u = 8 g in the UK and about
13 on the Continent), the notion of unit proved however to
be useful in finding a recommendable amount to be safely
consumed, namely 14 u/week for women and 21 for men.

What is the fate of the ingested alcohol
Its fate consists of:
− About 10% is eliminated unchanged by urine, sweat and
exhaling.
− The entire rest is metabolised by the liver to CO2 and H2O.
− The first metabolic step is the acetaldehyde which, habitually,
is further decomposed; this reaction does not take place in
some Asian people, Chinese and Japanese in particular. This
metabolite causes nausea, vomits and discomfort and, rarely,
respiratory depression, and sometimes, even death.
− In chronic users, the liver ‘optimises’ its metabolic breakdown
of the alcohol – the so called enzymatic induction. Therefore, it
becomes possible to have metabolised as much as 8 g alcohol
per hour – about 5 times more than in an occasional drinker.
This is understandably operative as long as no organic changes

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Unnatural deaths
occurred at the liver level.

What are the effects of alcohol
Before its metabolic breakdown, alcohol has a good number of specific
actions which lead to its common effects – biologic, social, psychic and
behavioural in particular. All these are collectively termed alcoholism – an
issue which, curiously enough, does not meet the required needs for it to be
declared a condition. This does not mean by far that it does not represent
a real pathology.
In small amounts – that is socially known as responsible drinking – alcohol
provides an immediate gustative pleasure and soon thereafter a relaxing
comfortable feeling. Derived, according to a Pavlovian interpretation, from
a cortico–subcortical dissociation, this feeling is branded in our days as an
alcohol induced myopia. But, irrespective of these scholastic details, this
feeling of being in good spirits represents the reason of the unrivalled
role of alimentary adjuvant the alcohol does play, a role backing a hugely
profitable industry.
Used in a larger amount (formally, irresponsibly), alcohol has typically
an action pattern of general anaesthetic, namely neuro–depressive. A series
of figures could be of help for a better understanding:
− The tissue oxidation clears the blood from about 20 mg/100
ml/hour of alcohol; a complete clearance after a banal drinking
takes 4 hours while not less than 24 hours after a real intoxication
(100 mg/100 ml blood content).
− As alcoholemia increases, particular signs add to the clinical
picture; over the values listed below, there occur given signs as
follows:
• 30 mg/100 ml – changes in behaviour;
• 100 – motor coordination affected;
• 200 – vomit, stuporous state, coma;
• 300 – depressed reflectivity which may lead to
regurgitation of gastric content and respiratory
inundation; and
• 400 – respiratory ‘paralysis’ and heart arrest.
Different from the general anaesthetic model, alcohol exerts additional
actions of interference with
− all what means neurotransmission and its mediators; and
− playing a part of surrogate in opioid transmission, it may
explain the comfortable feeling and, what is more important,
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Chapter 13
developing the alcohol drinking habit.
An interesting physiological detail makes the women more sensitive and
vulnerable to alcohol in comparison with men. The female gastric mucosa
has in its enzymatic equipment less alcohol dehydrogenase; as this enzyme
splits alcohol, more from the amount ingested may enter the circulation of
a female drinker. This can be the reason, at least partly, of the significant
pathologic changes of the foetus in a case of pregnant woman.

How does alcohol kill
A chronic use of alcohol leads, as already mentioned, to alcoholism,
more nasty a habit than a certified disease. Some of the important features
include:
− The nervous system structures are, by their nature and functions,
affected by practically any alcohol blood concentration;
cognitive, memory and judgement alterations followed by
those sensorial, and motor functions occur of a progressive and
successive manner.
− Being caloric, the alcohol may cover up to 50% of the needs. This
apparent advantage is of little significance if it is to consider the
general picture of biologic degradation, consisting essentially in
malnutrition and immunosuppression.
− The most common and unfortunately severe consequence of
the long lasting and mainly heavy chronic alcohol use is hepatic
cirrhosis. This alcohol variant represents half of the entire
number of cirrhosis cases. The most frequent pathogenetic
ways of dying by cirrhosis are:
• hepatic insufficiency;
• Wernicke encephalopathy;
• upper digestive haemorrhage due to the portal
hypertension;
• and cardiac insufficiency.
− Alcohol may also lead indirectly to fatalities such as:
• craniocerebral injuries consequent to falls;
• three quarters from suicides;
• half of homicides;
• one quarter from the traffic accidents, half of them being
fatal;
• and involved in more than 10% of drowning events.

220
Unnatural deaths
Miscellaneous
The hepatic enzymatic induction and the chronic use in itself make
the person concerned more tolerant to alcohol. Additional to this common
increased tolerance, there exist in the world certain incredibly resistant
communities. Thus, some Australian chronic users:
− drive with a blood alcohol level of over 500 mg/100 ml, as
shown earlier, usually fatal;
− artificially ventilated, they are recoverable after alcoholemias
of over 1,500 mg/100 ml (243).
The chronic use of alcohol
− has a particular demography:
• 35% of population is tea total;
• 55% drink responsibly; where as
• 12%, 10 males and 2 females (18 – 44 year age), consume
half of the total amount of alcohol delivered on the
market.
− There is, from socio–cultural viewpoint, a sort of stratification –
a stratification which may have a genetic backing, namely:
• Muslims and Mormons are abstinent;
• Chinese and Jews use occasionally; where as
• Europeans and Americans have the highest alcohol
consumption per capita from the entire world.
If the ‘drugs’ used worldwide are to be considered, the alcohol attracts
90%, nicotine – 55%, and heroine – 12%. Additional to the high incidence of
cirrhosis with its implication in care cost and, implicitly, high mortality, the
alcohol notoriously causes huge problems for the family, work place and
society as a whole. As such, it is at least surprising to see so many influential
national and international key factors not being able to cope in real terms
with problems by far entirely man–made.

13.3. Smoking
(19, 98, 181, 184, 243)

Introduction
This subchapter deals with smoking as an acquired, pathological habit
and does not refer to the occasional, recreational smoking. Needless to say
this latter one may easily degenerate in a real habit.
It is assumed by the relevant international bodies that there are on
the planet about 1 billion smokers, a number supposed to continuously
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Chapter 13
increase. This trend derives from a lucrative partnership between a more
than profitable tobacco industry, on the one side, and an aggressive taxation
of smoking products so tempting for any economy, on the other side. There
remains, unfortunately, for societies to cope with financial burdens of
smoking and for medicine to deal with ill–health problems it generates. For
those interested in more details, a comprehensive work appeared not long
ago (162) could be of real help.
Any independent thinker would be right asking himself what is the
rewarding factor for a smoker since:
− financially, smoking is not cheap at all, having serious
repercussions on the family budget with all the potentially
deriving problems; and
− the everyday life of a smoker becomes progressively difficult
considering
• tobacco procurement,
• reduced appetite, smell and taste,
• specific unpleasant halitosis,
• erection and sexual desire affected, and
• social isolation,
− looking older than the calendar age and the preference for
non–smokers in the competition short–listings,
− various health problems, including death, as it will be discussed
later, confront the smoker.
A rewarding factor proper does not actually exist; all the above do
represent the serious consequence of a habit – a habit which, like any
other drug use, mediates a non–shareable, short lasting and questionable
pleasure.
How is the habit acquired
Tobacco is used differently depending on geographical areas and
tradition. In the UK and Sweden, one still meets people chewing tobacco
and inhaling the resulting aroma. The largest manner is, however, that of
inhaling tobacco smoke generated by cigarettes, pipe, cigars or hookah. As
with any other habit, the ‘candidate’ starts smoking either out of curiosity,
by imitating known smokers or, mostly the case of young people, simply to
boast.
The tobacco smoke is a complex aerosol consisting of water, tar and an
impressive number of chemicals, around 4,000 (four thousand). It has two
components:
− a gaseous one, containing carbon monoxide, nitrogen oxides,
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Unnatural deaths
formaldehyde, acrolein, acetone, benzene, menthol, ammonia,
− and a suspension–like, having nicotine and many other alkaloids,
hydrocarbons and metals (cadmium, arsenic, nickel, lead and
even polonium 210).
Being so many, it is not surprising at all that the ill effects are disastrous.
The main culprit is nevertheless nicotine:
− When the smoker ‘draws air’ into his thorax through the
lightening tobacco column, the smoke is spread towards the
farthest alveoli. This makes possible a nearly instant contact
of nicotine with a huge alveolar surface – equating that of the
entire body, nearly 2 sq.m.
− Consequent to this physical detail and due to a good diffusion,
the lung blood is instantly loaded with the ad libitum available
nicotine.
− The blood returns to the heart from where, with the very first
contraction, it is spread into the arterial vascular bed. It takes no
longer than 15 sec for nicotine to reach the cerebral circulation
and overwhelm its receptors.
− The abundant stimulation of receptors, nicotine–cholinergic in
nature, generates the feeling of supreme pleasure which is so
much appreciated by smokers.
It results from the above sequence that the lung spreading of nicotine
is facilitated by inspiration, an essential functional act. After various periods
of time (from individual to individual), there results a physical dependence
to nicotine. It is in this context that, apart from the pleasure of smoking,
there occurs an intrinsic desire to smoke. After progressively shorter and
shorter intervals from the last cigarette, the smoker becomes desirous for
lighting a new one. If this cannot happen, in several hours one declares
an abstinence syndrome: ardent desire to smoke, irritability, unrest, even
anxiety; sleep disorders and depressive feelings are also possible. A number
of behavioural changes regarding menu details, siesta, coffee consumption,
office work, socialisation and, last but not the least, the smoking gesture
may become more obvious.
The things happen in a similar manner in cases of tobacco chewing,
fewer in number, but also in those of passive – second hand – smoking; in a
room where somebody smokes, the witnesses are exposed to not less than
75% from the amount of nicotine the smoker concerned produces.
Ill–health problems generated by smoking
The longer period of smoking, the more severe the ill health problems.
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Chapter 13
The resulted pathology is a multi–factorial one.
− Cardiovascular
Smoking creates cardiovascular problems and aggravates the
former ones:
• With its stimulating pharmacodynamic profile, the
nicotine induces a cardiovascular hyperdynamic with
tachycardia, hypertension and dysrhythmia.
• The chronic exposure to CO leads to polycythemia with
consequent increase in blood viscosity.
• Changes in the lipidic metabolism facilitate atheroma
formation.
• The reduction in NO synthesis affects the vasodilatation.
These alterations explain the 3 times higher incidence of the
ischaemic attacks in smokers. Angina and myocardial infarction,
a decrease in the effort tolerance and an obvious tendency to
the hypertensive disease are also to be mentioned.
− Respiratory
Many, if not all, from the smoke components act first locally.
This is why the respiratory way is so frequently interested
• A physicochemical irritation of such a large, practically
the entire, surface of the airway conducts to chronic
tracheobronchitis with inherent cough, expectoration
and often fever.
• The lung elastase is reduced, facilitating the appearance
of pulmonary emphysema.
The chronic inflammation makes the airway more receptive
to both viral and microbial infections; this is why the mortality
secondary to them is, at a given age, 10 times higher in smokers.
The chemical irritation also backs the carcinogenetic potential,
a reason for a 22 times higher incidence of the squamous
carcinoma in smokers.
Miscellaneous
The deleterious effects of smoking do not limit to the above mentioned
areas; many other pathologic entities are possible
− Carcinogenetic events anywhere on the smoke way, starting
with lips and nostrils, and even at distance as the urinary tract,
colon and rectum.
− Leukaemia occurs in 20% from the total number of the smokers.
− The gastric reflux consequences and gastro–duodenal ulcers
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Unnatural deaths
are enhanced.
− The reproduction does not remain unaltered; additional to the
erection problems the male smokers may have, the women
are confronted with more miscarriages, premature births and
earlier menopause.
− Typical features of advancing in age, cataract, lowered bone
density, endocrine hypofunction and a conjunctive prevalence
do occur.
− In case of buccal use of tobacco, the inflammatory local
process has a carcinogenetic potential. From the tobacco
additives, aiming at speeding local absorption and improving
the chewing aroma, the derivative glycyrrhizic acid proved to
be carcinogenetic itself.
Conclusion
A number of statistical data attest the pathology extension of a habit so
common and only apparently inoffensive:
− During the 20th century not less than 100 million people died
of smoking related conditions.
− Nowadays, 6 million smokers die per year: China – over 1
million, India – nearly 1 million, Russian Federation and USA –
500,000 each, to mention just the largest contributors.
− 1 in 5 Americans dies as a consequence of smoking.
− To stress the above figures, it was calculated that 16,000
smokers die per day.
− The smokers live on average 10 – 15 years less than their non–
smoking counterparts.
− While men represent the dominant proportion of the total
number of smokers, it is worth understanding the 5 times
recent increase in smoking female population.
− Considering the preventable causes of death, smoking
overpasses those of traffic accidents, alcohol, suicides,
recreational drugs and HIV infections taken together.
Whereas persisting in habit brings certainly much pathology, the giving
up may avoid it if done earlier, before 35 years of age, or half the proportion
if done later, after 50. These figures attest, with no doubt, the assertion that
smoking is a preventable cause of premature death.
Giving up smoking is difficult to achieve; undoubtedly, it is an
exemplary matter of determination and, given this, varies largely among
individuals. It is meritorious for medicine not only to treat smokers but also
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to try helping them to give up the habit. The key ‘technical’ factor for a
successful abandonment is a progressive reduction of the nicotine provided
to the receptors, in order to minimise the tolerance. Aiming at this, the
pharmaceutical arm of medicine offers to hospital practice and open market
as well
− patches for transcutaneous nicotine delivery; and
− electronic cigarettes which have more advantages:
• maintain the smoking gesture,
• the amount of nitrosamine and formaldehyde is 1,000
times lower than in the genuine tobacco smoke, as such,
• the alveolar deliverance of vapour nicotine makes its
titration more accurate.
Laudably, there are countries where the social services are prepared to
assist and encourage any personal initiative of giving up the habit.

13.4. Accidental suffocation
(42, 98, 161, 184)

For academic purposes, a couple of accidental suffocations will be
described:
− Children often ‘inhale’ by sudden inspirations small solid pieces
from the mouth: food, fruits stones, parts of toys, coins. It is not
only an extremely panicking episode since such events may lead
to real dramas and even death. Once the foreign body entered
the respiratory way, a laryngo– and bronchospasm could be so
pronounced that a fatal end is always possible. Nota bene, the
high oxygen tissues’ needs of a young victim leads to earlier
irreversible nervous hypoxic lesions.
− Older people have their version of suffocation. As their reflectivity
has lost from its promptness and vigour, an alimentary bolus
partly masticated or regurgitated as well as, sometimes, parts
of dentures also may, during inspiration, ‘threaten’ the glottis.
The result is a sort of combination of deglutition with breathing.
Having in forensic language a term with an interesting spelling,
café coronary, such an occurrence not only causes obstructive
respiratory insufficiency but may often precipitate a sudden
death.
− Erotic suffocation. It derives from a deliberate association of
an auto–suffocation to an en route masturbation, in order to

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Unnatural deaths
enhance by dizziness the degree of orgasm. It happens that the
dizziness ‘tuning’ be escaped from control, reaching so a level
of irreversible hypoxia and death.
− Finally, irresponsible competitions of ‘buried alive’ may lead to
a de facto death (307).

13.5. Starvation
(40, 184, 243)

Starvation is a progressive reduction of the body tissue mass following
lack of required ingestion. It differs from other tissue ‘melting’ due to
running pathologies like Addison’s disease, advanced neoplastic entities
and congenital metabolic defects. As proportion, it is met particularly in
young individuals due to their physiological higher caloric needs.
Starvation is not a proper condition; nevertheless, once florid, it
unabatedly leads to death. The lack of any food causes death in 50 – 60
days, while 10 days are enough in case of water.
As a clinical entity, it can be
− dry, the commonest, or
− moist, with ascites and peripheral oedemas due to
hypoalbuminemia.
The mechanism of death relies on cardiac insufficiency; due to a lack
of the required energy supply, the cell metabolic reactions are no longer
possible.

13.6. Falls
(42, 213, 267, 295)

Having a good balance, the young people do not usually fall. They fall
under special circumstances only, like mountaineering and building sites.
As, for such settings, the height of falling is always significant, the resulting
injuries are generally severe and not rarely fatal.
The falls occurring in the elderly have different characteristics.
− They are primarily due to balance deficiencies caused by
• an omnipresent neurologic pathology,
• bad sight,
• habitual dizziness, and
• secondary effect of the many medications these category
of people are on.

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Chapter 13
− 60% of these occur at home, 30% outside and as many as 10%
during hospitalisations for other reasons.
− Despite the lack of a real level difference, the poor biology is
that which explains the frequent and various lesions; fractures,
that of femoral neck in particular, are the commonest clinical
realities.
The respiratory complications, mainly pneumonia, are facilitated by
the same poor biology, lack of mobility and the bad nutrition supposed
by any hospitalisation at advanced age. Slow healing and eschars are also
attributes of those clinical settings. It is fully explicable why the rate of
mortality in these patients is very high.

13.7. Suicide
(10, 18, 41, 71, 82, 95, 167, 309)

Animals unanimously defend by instinct from the physical and corporal
hurting and never resort to self inflicting. Stupefying, the human being – an
intelligent creature – is ‘able’ not only to harm him but also to cut the course
of his own life. For both medical terminology and everyday language, such
an act is known as suicide. As significance, suicide represents a paroxysm
in existence, happening mostly in the context of various life confrontations
like sentimental fiascos, financial disasters, political failures or despairs on
the job market. These are usual trigger factors in individuals emotionally
vulnerable or used to exercise uncompromising principles of living and
doing.
Known from Antiquity and having cut the lives of great personalities,
such as Mark Antony, Cleopatra, Socrates, Van Gogh, Hemingway, suicide
has preoccupied philosophers, social workers, judicial factors, theologians
and, of course, medicine.
From the demographical viewpoint, a couple of figures may be of
interest (40, 161, 184):
− it is estimated that there are worldwide three quarter million
suicides per year;
− of these, 150,000 occur in Europe;
− the Baltic countries have the highest proportion;
− while Greenland has the highest rate, 127/150,000;
− Russian Federation, Belarus, Ukraine, Hungary and China have
all a high incidence rate;
− whereas before 15 years of age, suicides are rare, later on all

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Unnatural deaths
ages are interested by the vice, the highest proportion occurring
during decades 3, 6 and 7;
− except China, men are those who predominate in the rest of
the world;
− the professions from which the suicides are mainly recruited
are those making the event easily possible, such as medical
workers, sailors, army personnel, woodmen, etc.;
− the long lasting stress (prisoners, artists, students, etc.)
represents an obvious favourable factor;
− schizophrenia and depression are often important contributing
factors.
Technically, suicide has been committed along the history with the
available technologies. Trying to recall the most frequently used according
to the ‘chance of success’, the list would be as follows:
− Shooting
It is, in good hands, very efficient. Affecting highly vital organs,
brain and heart, death occurs either instantly or without delay.
It happens, unfortunately, that, in addition to those individuals
having access to fire arms by the nature of their profession
(policemen, security personnel), there are countries where
ordinary people have also easy access to them. In the USA, at
least half of the householders have at least two weapons.
− Breathing an atmosphere rich in CO
A dangerous toxic gas, it can be voluntarily inhaled in unventilated
garages, produced by internal combustion engines; even the
best converted exemplars do not manage to fully avoid CO
generation.
− Strangulation
This is a very old method of suicide. Easily to be organised and
carried out, strangulation is one of the most frequent modalities
of life self–cutting. Technically, it consists in sudden hanging of
the entire body which, by its weight, strangulates the neck of
the self murderer. The hanging material, rope, varies largely
from sophisticated stripes to all sorts of improvised variants.
Medically, strangulation causes an acute obstructive respiratory
insufficiency. The forensic experts add an extra mechanism,
that of syncope triggered by the brutal pressure exerted, often
with a fracturing of laryngeal bones, on the two carotid sinuses.
Aged and debilitated individuals try and sometimes manage

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to strangulate hanging themselves by the bed head or door
handle. In such cases, death does not occur – when it does
occur – quickly allowing, different from the typical version of
strangulation, the development of cyanosis.
− Self intoxications
This is the result of a deliberate use, largely by ingestion, of potent
toxic chemicals like organophosphates or of an overdosing of
recreational drugs and current medicines, mainly sedatives,
hypnotics, and neuroleptics. Once the suicide candidate is
in possession of the necessary amount, the carrying out is
relatively simple, just ingesting the supposed high, fatal dose.
There are enough successful suicides of this type although the
current intensive care techniques are able to recover a large
proportion of cases.
− Diving into deep water, to drown
The Golden Gate from San Francisco is famous for this manner
of suicide. Since its opening for public use, 1937, over 2,000
people managed to break their lives.
− Self exposing to fatal accidents
Throwing under train or in front of a running vehicle is always
followed by such severe lesions that death is surely achieved.
As one could imagine from the above comments, suicide seems to
be an easy target. On the contrary, it supposes initiative, planning, some
resources, organising and, before anything, much determination. What
makes the action special is its carrying out under the pressure of the
decision justification, with all what this could imply. This is certainly why
the proportion of success is just 1 in 10.
In addition to the banal suicide, there are a number of ‘distinct’ suicides
such as:
− honour, hara–kiri;
− of sacrifice, kamikaze;
− ritual, suttee;
− political: Ghandi, suffragettes, various sorts of monks;
− conjugal, mainly after the passing away of the better half;
− of despair, in cases of incurable disease;
− non surrendering: Rajput, India, 14th century and Puputan,
Bali, 1906;
− imitation, of some celebrities, and
− collective, for reason of solidarity:

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Unnatural deaths
• Masada, near The Dead Sea, AD 73 – 960 cases, and
• Jonestown, Guyana, 1978 – 789 cases.
Habits like smoking, alcoholism and drug abuse could be assimilated to
a chronic suicidal behaviour as they lead invariably to biological degradation
and, eventually, death.
Religions differ in their stance facing suicide, from Hinduism which
accepts it to Islamism which, apart from that politically motivated, considers
suicide a crime. Other religions exercise a large variety of viewpoints, being
however unanimous, as a whole, in discouraging the self–cutting of the
course of life, a precious divine gift.

13.8. Electrocution
(45, 95, 235, 243)

13.8.1. General view
It is no exaggeration to consider electricity a sine qua non presence in
the life of any modern society. The reason of an industry of big proportions,
electric current supposes production, transport, distribution and delivery
services. The industrial, traffic and domestic use is enormous while the
medical one excels in sophistication. Despite the strict regulation of use,
related ill health problems, death inclusively, are not rare. Victims may
become even professionals although the accidents are by far more frequent
in amateur manipulators of electrical products, being an instrument of both
suicide and crime.
As electricity is a form of energy, its damaging potential for any live
tissue depends on its physical parameters. Apart from the medical use
circumstances, the presence of any electrical current in the body tissues
represents a pathological incident. When this happens, the flow of electrons
has to run necessarily from the point of inopportune entrance to the one it
chooses to leave through. If the electrical current only surrounds the body,
it exerts no deleterious effect, irrespective of its power; this is exactly the
case of some laboratory settings (van de Graaf generator) or lightning, a
natural phenomenon known as developing millions of volts.

13.8.2. Technical considerations
For an electrical accident to occur, more factors have to contribute
together.
A. First requirement is an itinerary the electron flow uses for its passage;
it supposes, as already shown, two points: one of entrance and other

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Chapter 13
of exit. The most frequent setting is the inappropriate manipulating of
electrical conductors.
1. The entrance port is usually one of the hands, especially the
dominant one.
2. The chosen exit, allowing the electron flow to leave the body, in
order to close the circuit, is either the other hand or one of the legs.
The closure of the circuit itself happens either at the level of neutral
wire of the conductor or by grounding.
3. From the two circuit versions, arm–arm or arm–leg, the second is
more dangerous as it is perpendicular on the heart axis.
4. In case of entrance to the cranium, the electron flow running from
head to legs passes through the brain stem, with all what this means
for the respiratory pacing.
B. Physical parameters of electrical current.
1. Sort of current: it is proved that the alternative current is three times
more dangerous than the direct counterpart. As far as the latter is
concerned, one survives even 250 mA and, for cardio–version and
defibrillation, one can safely use as much as 4 A.
2. Important parameters of the alternative current include:
− Voltage, expression of the current ‘power’
• below 50 V has no biological effect;
• below 100, accidents occur rarely; and
• over this value, the extent of injury parallels voltage.
It is a misfortune that the values of the two voltage systems currently
used in the world, i.e. 110 and 220 V, are in the zone of biological
dangerousness.
− Amperage points out the ‘amount’ of electricity, to which the
extent of the biological effects is directly related:
• 1 mA, causes paresthesia;
• 10 mA, causes muscular tetany;
• 30 mA, the maximum voluntarily tolerated;
• 40 mA, consciousness may be lost;
• 50 mA, respiratory difficulties may occur; and
• 100 mA is a trigger value for ventricular fibrillation for
which validation takes no longer than 1/5 sec.
− Frequency. The dangerous zone runs from 40 to 150 Hz. As in
the case of voltage, the frequency used worldwide, 50, also falls
in the dangerous zone.
3. Tissue resistance varies largely. In a decreasing order, the most

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Unnatural deaths
resistant are: bones, fat, tendons and skin. As the skin is the first
to be met by the electrical current, it is good to know a couple of
related details:
− When dry, it opposes a resistance of up to 100,000 Ohm – the
thicker the skin the higher the resistance. This means that, in
the case of a 240 V current, it allows the passing no more than
2.4 mA, the trigger value for feeling.
− When wet, the resistance decreases to 1,000 Ohm allowing the
passing of a current of even 240 mA capable of inducing, as
already mentioned, a ventricular fibrillation.
− Already over 10 mA, the electrical current facilitates the
transpiration which, containing electrolytes and ‘wetting’ the
skin, pushes the resistance down to even 2,500 Ohm.
− Not to forget that, once entered into tissues, electrical current
causes itself different electrolyte changes of nature to potentiate
its passage, with tissue resistance values of as low as 380 Ohm.
4. Length of contact with the biological structures contributes to
the amount of acceded electrical current and its cumulated
consequences. A rapid freeing reduces the damages whereas, on the
contrary, a closer contact resulted usually from o tonic contracture
of the hand flexors increases them.

13.8.3. Clinical aspects
They are external, internal and functional:
A. External
− Between the two points of the itinerary, entrance and
exit, operates the Joules effect. At the level of contact, the
temperature reaches quickly 100oC (nota bene 50 are enough
to cause tissue damage in 25 sec), producing a burn known
as mark. These marks usually occur at hands or plants. Buccal
lesions may be met in children, while the sexual eccentrics
develop lesions at genitals.
− In the case of consciousness loss, the victims often fall.
Depending on the height, various secondary lesions could
result, craniocerebral injuries and different fractures being both
frequent and severe.
− At the entrance level, the temperature could reach values as
high as 4,000oC, a reason why fine particles of conductive metal

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may be sometimes found in the affected necrotic tissues.
B. Internal
Once the electrical current flow passes through the entrance port,
usually through skin, it follows the shortest way, affecting the entire range
of tissue structures met on its way:
− Cardiovascular and neurological changes are multiple and
extremely various.
− Muscular changes consist in so powerful contractures
that myoglobin and phosphocreatine kinase are freed into
circulation and real fractures may occur. The thorax muscle
are not exempted, diaphragm inclusively, resulting a sort of
respiration blocking. A potent contracture is expected to occur
at the hand manoeuvring the electrical wires concerned; as the
flexors are dominant muscles, a strengthening of the contact is,
as commented earlier, possible.
− Later, in case of surviving, a cataract is occasionally also met.
C. Functional
In cases of surviving, they are predominantly cardiovascular and
neurological: sinus tachycardia, atrial fibrillation, ECG–ST deviations, mental
changes, motor deficits and convulsions.
When inventorying the deleterious effects of the electrical current, one
always has to remember that they are life threatening by themselves. Death
occurs mostly as a consequence of a ventricular fibrillation, that meaning
heart arrest. It remains little, if any, time for organic changes to occur;
however, some tissue alterations continue to take place, adding to the in
vivo changes. The swiftness of producing ventricular fibrillation suggests a
direct interference of the external electricity to the functioning of the excito–
conductive system of the heart. When, rarely as incidence, the electrical
shock falls on the vulnerable part of the ECG, asystolia is also possible.
It is worth mentioning that sometimes some tissue alterations continue
on their own in surviving victims – a reason to justify the admission of such
cases for at least a couple of hours in a hospital with intensive care facilities.
As specified in the introductory part of this chapter, electricity is
currently largely used for medical purposes as
− Automated internal defibrillation by implanted devices.
− Electro–conversion and defibrillation of the heart from outside
is nowadays more than common:
• different from accidental circumstances under which the
alternative current enters the body and, reaching the

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Unnatural deaths
beating heart, causes ventricular fibrillation,
• the two techniques introduce intentionally a desired
amount of direct current in a body with a malfunctioning
heart in order to restore a normal pacing; it uses for such
a purpose currents of up to 360 Joules and, as already
mentioned, up to 4 A.
− Various procedures of intensive care and interventional
cardiology are carried out in such a manner that, accidentally,
electric current may be ‘discharged’ into cardiac cavities or in
their very proximity. Metallic wires and catheters filled with
electrolytic solutions are both good electricity conductors;
thus, the electrical shocks into the heart are possible, and of
course, serious events.
− Electro–convulsive therapy (Cerletti shock) is largely used
worldwide in the psychiatric therapy. As the current is delivered
via two symmetrical temporal electrodes, there is in theory
no cardiac risk; a risk exists however, always, for the handling
personnel.
Finally, another severe functional consequence is the central respiratory
insufficiency, occurring accidentally in those individuals who, standing on
high platforms, deal with high voltage electric conductors. Entering from
above, the current passes through vertically, affecting the brain stem with
its vital centres and often causing fatalities.

13.8.4. Special circumstances
− A pregnant woman is herself a potential victim as any other
person. As far as her pregnancy is concerned:
• The foetus is surrounded by more well vascularised
layers and floats in the amniotic fluid, both good electric
conductors.
• The foetus itself is also a good electricity conductor.
That is why, an exposure to an electrical shock of not higher
than 100 V and 25 mA may lead to the death of that respective
foetus. This is the case for both electric accidents and electric
resuscitation needs.
− Bath represents a special setting for electrocution as:
• Humid atmosphere, plenty of immersion water, nudity
and many water pipes serve as excellent electricity
conductors.

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Chapter 13
• Whereas, according to the modern regulations, bath
rooms are not fitted with electrical sources.
• It resorts to numberless improvisations, making the bath
room a dangerous place.
• An important difference from other settings consists in
the lack of marks, as water largely enlarges the surface
of both the entrance and the exit of the electric current.

13.8.5. Conclusions
Being aware of the danger of the electrical shock, it exercises
institutionally high standard regulations. Despite these, both genuine
professionals and in particular the improvisers become electrocution victims.
The medical help they need, from the very first aid to high skill resuscitation,
differs hugely from any other circumstance by a stringent preconditioning
factor. The electrical current should necessarily be interrupted before doing
anything else; otherwise, both the Good Samaritan and the medical worker
may become second victims.
Considering that the ventricular fibrillation is the main ‘operative’ cause
of death, the defibrillation is quintessential for the resuscitation. Nowhere
in medicine the same entity such as electricity, can do equally the bad and
the good.

13.9. Drowning
(45, 122, 204, 235, 243)

13.9.1. Introduction
An air breathing creature, such as the human being, does not tolerate
the presence of water in its airways. The main reason is simply a physical
one; the two mediums are consistently different in density and viscosity,
water having 770 and 58 respectively, which are significantly higher than
that of air. Bronchial lavage and pulmonary oedema also suppose extra
water in the lungs; nevertheless, they do not necessarily imply an immediate
risk of death as it is the case of drowning which notoriously occurs under
immersion circumstances. The difference the last one does make results
from the challenge the airway entrance of water represents for the victim
physiology. As it will be detailed later on, it is this challenge which generates
the dramatic clinical course. In other words, the entrance of water as an
event signifies more than the water itself.
There are more clinical versions of drowning. Some of them have inter-

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Unnatural deaths
esting pathogenesis and also intriguing names like dry, wet, secondary, etc.
As water is extensively used, the circumstances of immersion are
infinite; several categories of individuals are however, particularly exposed:
− small children, under the age of five, reach a 10% proportion
of drowning due to lack of supervision and their uncoordinated
gesture;
− teens, as a consequence of bravery;
− five times more men than women;
− in nearly half of the accidents, alcohol plays a role;
− tourists prevail the locals;
− modality of suicide;
− those practising dangerous sports, as surfing and diving; and
− a good number of conditions as depression, mental retardation,
epilepsy, ischaemic cardiopathy and cardiomyopathy favour the
event.
Apart from the deserts, there is plenty of water: domestic facilities,
pools, lakes, brooks, rivers of different flows, cascades, seas and oceans. In
principle, one can drown everywhere although:
− The great majority, 90%, of the cases occur in salted water,
− mainly in risky places, without organised prevention policies.
− Inappropriate infrastructures and institutional preoccupations
for public training explain a 90% occurrence in less affluent
countries.
− However, even industrial countries like the UK, Australia and
the USA have their statistics with a fatality of 1 to 100,000
inhabitants.

13.9.2. Elements of pathophysiology
Not any person struggling in the water is in a real danger of drowning.
However, when mouth and nostrils go, uncontrolled, down below the
water level, an en route drowning can be declared. The course of events is
alarmingly silent; despite some uncoordinated movements of the limbs, no
vocalise and no shout for help are produced. From this moment onwards, a
number of particular steps take place.
Respiratory sequences
− Except comatose cases, the very first ‘measure’ a victim takes is
a voluntary defending apnoea. (When the immersion water is
cold, below 10oC, some children and teenagers may ‘appeal’ to
the ancestral reflex the seals resort to in their everyday life. This

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Chapter 13
reflex consists in a sudden apnoea, a drastic lowering of the
heart rate, peripheral vasoconstriction and a strict centralisation
of the circulation. The ‘trapped’ oxygen is used for a slow
beating heart function and to avoid hypoxic irreversible lesions
at the level of central nervous structures. This is possible due
to the decrease in O2 requirement of a quickly cooled body
mass, brain inclusively. This model explains surprisingly good
neurologic recover after apnoeas of as long as 45 min, under
hypothermia drowning circumstances).
− Quite often a physical agitation follows, of a manner to increase
the consumption of decreasingly available O2.
− As far as the blood gases are concerned, there happen vitally
important events as:
• An increasing hypercapnia which is a potent physiologic
inspiration stimulus. When the CO2 arterial values head
towards 55 mmHg (considered a ‘breaking point’), an
uncontrolled thorax movement of inspiration erupts.
Once the glottis is opened, the water could accede the
airway.
• A reduction of O2 saturation parallels the CO2 loading.
− The water contact with glottis causes various degrees of
laryngo– and bronchospasm. Depending on the degree of this
spasm, more or less water reaches the airway. Sometimes, these
spasms are so intense that little or no water can enter (the so
called dry drowning). Usually 3 – 4 ml/kg body weight enters
the trachea which means about 10% from the lung volume.
− A determinant part played in a case of drowning by the degree of
water salinity could not be documented. The matter remained
largely an issue of academic exercise. It was initially asserted,
more on theoretical basis, that an osmotic equalisation takes
place between the water and the opposite counterpart, the
plasma at the alveolar–capillary membrane level. Consequently
it is to expect:
• in case of fresh water: volemic overloading, serum
hypoosmolality, haemolysis and hyperkalemia, and
• vice versa in case of salted water: hypovolemia, serum
hyperosmolality and interstitial oedema.
− In real terms, for such a dynamic to happen, it would be
necessary an amount of water and a distribution of this in the

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Unnatural deaths
airway arborisation which are impossible to be reached under
drowning circumstances. 20 ml/kg water, reckoned as necessary
for such a development, means for a normo–ponderal subject
pretty much above one litter. Or, this is an amount impossible
to be accommodated into lungs engaged with their airways in a
struggle like that supposed by the drowning.
− Reaching the airways, the water itself, even in small amounts,
initiates pulmonary vasoconstriction and shunting. This
increases, sometimes enormously, the airway resistance. Later,
an interstitial thickening occurs, with a decrease in pulmonary
diffusion and compliance. When regurgitated gastric content
(known for being highly aggressive for such a delicate tissue
structure like that of the lungs) contaminates the aspirated
water, a destruction of surfactant and even chemical necrotic
lesions may complicate the case.
− The above mentioned changes do not need more than a
couple of minutes to lead up to severe homeostasis alterations.
When hypoxemia reaches critical values of PaO2, 30 – 25
mmHg, the neuronal cells suffer irreversible organic lesions
while the cardiovascular depression heads even further to
cardiac arrest. Such an advanced hypoxemia may be reached,
apparent curiously, without expected increases of CO2 values,
even without an opening of glottis and, consequently, without
any entrance of water towards the lungs. This is a scenario of
death with so called dry drowning, occurring mostly in diving
activities, known for their preemptive hyperventilation.
− As a result of the entire range of functional derangements,
severe organic lesions appear in the lung structures, lesions
which start dramatically but need however some time to
develop. Therefore, the florid variants are possible to be
observed in survivors but not in cases having died earlier during
the event of drowning proper.
Cardiovascular
The sudden and frequently unexpected contact with water, the panicky
attempts of going to safety, as well as all what the first stage of drowning
means, suppose tachycardia, a degree of hypertension and an increase in
cardiac output. These all imply a high O2 and energy consumption. Meta-
bolically, a mixed acidosis develops dramatically. Once this reaction fades,
it is replaced with a depression, consisting in a decrease in cardiac output,
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Chapter 13
hypotension and heart rhythm abnormalities leading to cardiac arrest.
It is important to specify that many sequences, single or combined, of
drowning are typical circumstances for ventricular fibrillation to occur. This
can explain the earlier and sudden death in drowned cases. The ventricular
fibrillation is impossible to be documented under a dramatic circumstance
like drowning; nevertheless, it is logical to be accepted – what the forensic
science unreservedly encourages.
Brain
In a case having a normal homeostasis before drowning, hypoxia takes
5 – 3 min to cause cell lesions in nervous structures starting with the cortex.
What happens next depends on the fate of the victim:
− If hypoxia advances, the cerebral death is the single direction.
− On the contrary, in survivors, the clinical neurologic picture,
from confusion to decerebration, is closely related to the
extension of the ischaemic lesions.
The relation between hypothermia and clinical neurologic course has
been much debated. To prevent or delay irreversible lesions of the neuronal
cells, that hypothermia should have been achieved at the entire brain
level. Such scenarios could take shape, as already mentioned, under two
circumstances:
− temporarily, in cases of the ancestral reflex of circulatory self–
protection, and
− falls in water with a very low temperature, under 10oC which,
in cases of small subjects, children in particular, are able to
cool rapidly enough the whole body in order to reduce the O2
requirements of the brain.
The temperature plays an important role in the entire clinical course of
a survivor:
− A profound hypothermia as a result of the drowning itself is
favourable, as the brain has its O2 needs reduced to protective
levels.
− Any hyperthermia is unwelcome due to the increase in O2 needs
of an already affected brain.
− In between, there are two zones of mild hypothermia:
• controlled, 32 – 34oC, where the brain enjoys a protective
effect, and
• uncontrolled, over 34oC, where the consequent increase
in O2 needs of the brain are of nature to reduce even
more the chances of its recovery.
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Unnatural deaths
The survivors of drowning combine two factors favouring infections:
− contaminated water from different external sources or simply
the regurgitated gastric content, and
− the lung ‘wound’ represented by the structural destructive
lesions.
Thus, it is not surprising that 50% of the cases usually develop various
degrees of lung infections.
Summarising how the drowning kills, the following details are to be
taken into consideration:
− Drowning is a notorious accident of immersion. As water
is usually a sine qua non condition for it to happen, it is no
nonsense to consider it the (main) culprit of the consequent
developments. This is true but only as circumstances and by no
means as a direct cause.
− When such a patient dies later, days after the episode, one
finds enough severe organic alterations – up to ARDS – to justify
the death. Infected lesions always complicate the things to an
extent that the autopsy inventory is quite substantial.
− Otherwise, when the victim dies soon, the lesion inventory
found by the autopsy is quite modest. This is explained by the
lack of time for changes to develop, a lack of time due to a quick
death.
− Death is undoubtedly expedited by the drowning process itself.
Sudden contact of the body with the water, often cold, the panic,
the airway reflex obstruction and, mainly, the brutal aggression
to the airway exerted by the pharynx content are, all, precipitous
events. Some water, more or less, does enter trachea but
definitely not in such an amount to cause death by itself.
− This is why the forensic science asserts the death as syncopal,
the result of a cardiac arrest. Documentation is not possible but
the events run in a manner to suggest ventricular fibrillation as
an intrinsic mechanism of death.

13.10. Iatrogenic mortality
13.10.1. General view
(40, 59, 86, 139, 151, 153, 230, 250)

Medicine is by virtue structured to deliver only useful and good

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Chapter 13
doings. It is, therefore, surprising to learn that, when the doctors of a given
department are away, the number of inpatient deaths decreases (59). Then,
− in the USA, comparatively to the 700,000 cardiovascular and
550,000 malignancy deaths, there are as many as 750,000
deaths caused by reactions of intolerance to different medicines,
− from which 50,000 happened in hospitals,
− whereas in the UK, from 600,000 hospital admissions, 18,000
lead to death.
Or, the two countries have high standard health care networks.
When a parameter like mortality comes to be quantified, there interfere
a variety of factors of nature to influence the true figures: political, ethical,
moral and also of national pride. Nevertheless, it is important to know that
50 million people die worldwide due to medical causes.
The above mentioned figures are, undoubtedly, worrying particularly
for ordinary people. For professionals, one finds enough explanations; thus,
corroborating the clinical complexity with the vast therapeutic alternatives
and patients features, it results a probability of billion errors. In a single
intensive care case only, 170 different acts are carried out in 24 hours; each
from all these may generate its ‘cascade’ of sequences and consequences.
The genesis of this figure panoply derives from many factors like:
− overall increase of the elderly proportion;
− sophistication of the paraclinical explorations;
− increase of high–tech medical domains as artificial fertilisation,
interventional cardiology, laparoscopic and robot surgeries,
intensive care proper;
− recent developments in transplantology and prostheses;
− continuous increase in number of medicines; and
− multinational teams of work, with inevitable communication
difficulties.
As far as the etiology of the fatalities is concerned, the following factors
are to be decrescendo listed: adverse reactions, eschars, medical errors,
infections, useless treatments and those linked to the surgical procedures.
The last category includes more error generating components: exploratory
acts, medications, transfusions, surgical techniques and intensive care.
Therefore, for the 4 million operations carried out in the Netherlands over
a period of the recent 5 years, there was a global mortality of 1.85% (201).
When the mortality refers strictly to errors, it is understandably much
higher, i.e. 14% from an American statistics on 420,000 cases (208).
Since the medical acts often include stressing components, there is

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Unnatural deaths
frequently a human factor involved as:
− in only one week, there appear 500,000 scientific titles dealing
with Medicine;
− the American pharmacies honour about 25 billion prescriptions
a year, a reason why;
− in only 10 years, the fatal errors have increased with 25%; and
− finally, a doctor operates at a given moment, with no fewer
than 2 million pieces of professional information (8).
Anaesthesia is an area exemplarily exposed to error; ‘serving’ other
specialities, it is always under pressure to make the ends meet. Then, in
addition to the human factor, it needs many technical devices and countless
drugs. As both the anaesthesia practiced and the anaesthetist involved differ
largely from teaching school, training area and surgical domains allocated
to, coherent statistics are impossible to obtain. A good idea evolves however
from the trend of the British anaesthesia, the world’s leading one:
− the first death caused by chloroform occurred after only 11
weeks from the very first anaesthesia with this agent,
− to be proud of having nowadays a general mortality of 1 out of
200,000 only (252).
It happens that two of the most severe conditions in the entire
pathology are iatrogenic in type and of an anaesthetic genesis. Why exactly
is it so and what de facto they consist in deserve a short description.

13.10.2. Chemical pneumonia
(32, 166, 172, 182, 197, 275)

The aero–digestive carrefour is, as tissue architecture and functionality,
of great biology engineering. Under physiological circumstances we are able,
awake and standing, to freely breath, speak and swallow anytime and eructate
in case of need. With a miraculous functioning, the existence triad – breathing,
deglutition and speaking – proves to be, however, rather vulnerable. Snoring
and the so called micro–regurgitation are met in people enjoying otherwise
a good health, while the co–work of the two major functions, respiration and
deglutition, is affected in various proportions more than frequently.
While the air is hosted with no problems in the digestive areas,
reaching airways, any amount – no matter how little – of gastric content
triggers a vigorous reaction of intolerance. This discrepancy derives from
the quintessential difference in their histology, robust on the digestive slope
and fragile on the respiratory one, on the one hand, and the acid content of

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Chapter 13
the stomach, on the other hand.
The clinical picture of the pulmonary aspiration – of gastric content
more often but not only – is various as event and dynamics. As far as the
severity of the process is concerned, it is directly related to the content pH
− Above 2.5, the lesion inventory is less severe, the respiratory
insufficiency being caused in principal by the amount of
‘aspirated’ material into the lungs, leading to nosocomial
pneumonia.
− Below 2.5, the gastric content is more aggressive (the lower the
pH the more harmful the effect), leading to real lung tissue burns
known in pathology as chemical pneumonia or Mendelson’s
syndrome, with a much worse prognosis. If a patient like this
survives, the airways inundation often leads to lung shock,
ARDS or ALI. An infection may additionally occur, adding insult
to injury, leading together to a dramatic inflammatory process.
The obvious distinction of the clinical picture derives from details of the
pathogenetic course. Rarely does one meet such a scenario in pathology, a
scenario featured by:
− Severe local and regional tissue destructions of the lung, a
vital organ so profoundly affected that it produces a significant
respiratory insufficiency.
− This insufficiency would need for correction such a ventilation
that its parameters – pressure of insufflations in particular – are
incompatible with the degree of the lung lesions.
− A modus vivendi between the ventilation and the lung lesions is
often impossible, hence resulting a bad prognosis.
− The single viable alternative consists in giving the lungs a couple
of days of ‘rest’ – keeping them mildly inflated at a ‘protective’
pressure – the gas exchange following to be accomplished by a
prosthesis like the membrane oxygenator.
There are enough explanations for a bad prognosis and modest
treatment results in chemical pneumonia. As for the mortality:
− the global one varies between 25 and 100%,
− 20% from ARDS cases are generated by chemical pneumonia,
contributing so substantially to the whole mortality of this
syndrome,
− 10 – 30% from the anaesthetic deaths,
− 1 case in 3,000 elective anaesthesias, and
− 1 in 1,500 emergency ones.

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Unnatural deaths
Additional to the experimental work, this was in particular the
obstetrical anaesthesia where the concept of Mendelson syndrome took
shape. The comatose patients frequently develop aspiration pneumonia,
due to a lowered reflectivity at the eso–tracheal junction level. Problems
of low or absent reflectivity confront even more the anaesthesia practice.
There are strict professional regulations, but it is not always possible to be
fully respected, mainly in emergency surgery and intensive care settings.
Therefore, the anaesthesia as a speciality generates the utmost severe cases.

13.10.3. Malignant hyperthermia
(64, 106, 115, 123, 204)

Malignant hyperthermia is an acute metabolic condition consisting – as
the name suggests – in a dramatic increase in heat production. This results
from a sustained contraction interesting the entire striated muscle mass.
The event is triggered
− either by a stressful episode, bearing some resemblance to the
stress porcine syndrome; or
− by administration of particular medications.
As the two circumstances combine in the anaesthesia practice, this is
the most frequent setting of occurrence.
Having a genetic background, defective ryanodine receptors, the muscle
contracture is the consequence of a Ca channel malfunction; being not
recovered to the reticulum, the released Ca ions remain into the cytoplasm,
perpetuating the contraction process. The hyperthermia is due to a high
catabolic input, on the one side, and the low output of the contraction as a
physiologic process, 20 – 30% (the rest of 80 – 70% generating heat only), on
the other side. This overheating surpasses the maximum, also physiologic,
thermolysis hence the ‘malignant’ increase of the body temperature.
The temperature increases of such a dramatic manner that leads to
histological tissue destruction. There are a number of specific humoral
elements:
− exhaustion of energy resources and ATP reserves with an
alarming increase of CO2 production;
− an early switching to an anaerobic metabolism, generating
large amounts of lactic acid;
− with a severe mixed acidosis;
− hyperpotassemia;
− disintegration of muscular cells; myoglobin and creatinekinase

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Chapter 13
leave the cytoplasm, reaching the blood flow via interstitial space;
− an overwhelming inflammatory process with an enormous
production of cell and circulating inflammatory mediators; and
− finally, a state of shock and multiple organ failure.
As a consequence of all the above derangements, there result some of
the worst humoral abnormalities from the entire pathology, such as:
− blood level of catecholamines up to 30 times more than normal;
− level of lactic acid, 15 – 20 times higher;
− PaCO2 up to 100 mmHg; and
− plasma pH even below 7.0.
Eventually, these patients become comatose, while the cardiac
dysrhythmias lead to a heart arrest ‘operated’ by a ventricular fibrillation.
Coming back to the anaesthesia practice, two of its usual medications
are mainly known as being able to trigger malignant hyperthermia,
succinylcholine and halothane. Therefore:
− This genetic condition occurs in a proportion of 1 to 250,000
anaesthesia cases as a whole, and 62,000 when the two
substances were used.
This impressive difference led to the concept of the so called
susceptibility. When, the heredo–familial and personal history
spots any suspicion, a couple of substantiating investigations
are available: serum creatinkinase, myoglobinemia and, in
particular, the muscle biopsy after caffeine and halothane
exposure.
− When a susceptibility was documented, the occurrence rates
were 1 to 16,000 anaesthesia random cases and 1 to as few as
4,200 when the two drugs in discussion were used together.
Two clinical ‘eccentricities’ are of nature to make the malignant
hyperthermia a condition to be, academically, remarkable; the highest fever
reported was 43oC and the youngest sufferer was an in utero one. In its
turn, the treatment (not of interest for the topic of this book) has achieved
such a progress that the global mortality has decreased from 70 – 80 to
30 – 20%; additional to the formerly mentioned susceptibility concept, the
specific drug Dantrolene has played a decisive role.

13.11. Content of a pregnant uterus
(184, 235, 243)

In only nine months, sometimes less, the pregnant uterus generates

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Unnatural deaths
life, bringing into being human beings. Playing the role of a ‘conveying
band’, from fertilisation to birth, gestation is an extremely complex process.
When does actually a content of a pregnant uterus become a human
being?
If death is emphatically defined as a ceasing of the heart beats, we
should exercise the same approach in defining life – recte the existence of
such heart beats which, in the context of the general vigour, would allow
the surviving outside the uterine cavity. This miraculous event happens at
24 week intrauterine age. This is also the borderline between miscarriage
and premature birth.
While giving birth is an event related primarily to the pregnancy age,
the miscarriages have to comply with different criteria, particularly the
legality. This is so because, although far to fulfil the identity rigours, this sort
of uterus content represents, however, an organised biological structure
able to potentially develop to a human being.
Illegal interruption
− Various herbal extracts have been used for millennia, but their
rate of success proved to be a matter of coincidence with the
spontaneous miscarriages.
− Not a long time ago, a series of chemical substances found
as contracting the uterine muscles have also been used;
unfortunately for those interested in terminating a pregnancy,
they do not exert their expected action in the first months of
pregnancy, when an interruption would have been looked for.
− Intrauterine irritation by chemical instillation and mainly
mechanical destruction of the intrauterine content with
improvised traumatic objects proved disastrous in terms of
women safety.
− The single efficient and safe interruptions were managed
by surgical procedures, performed by professionals with
consecrated instruments; unfortunately such settings were
difficult to be run under illegal circumstances.
Legal interruption
It represents an efficient and already well standardised modality
of family planning. Having been known to the Greeks and Romans, it
is nowadays practiced at a large scale by the Chinese and Japanese. In
principal, a pregnancy may be discontinued:
− In the favour of the pregnant woman, when the course of
pregnancy supposes a threat for her health or sometimes even

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life. The decision is taken at a medical level, the woman having
however to agree with.
− On demand. This is in fact a major social lever in handling
with the population of given communities. It is organised in a
manner that
• complies with the administrative, professional and
technical requirements of a surgical act; and
• meeting the local legal needs, a consent in particular; if
the pregnant woman is not compos mentis, the family or
a tutorial body should back the act.
There is much debate on the everyday walks of life on the interruption
of pregnancy course:
− In the spirit of Hippocrates’ Oath it is definitely discouraged.
− In the so called Oslo 1970 Declaration, the medical workers are
allowed to interrupt the course of a pregnancy if the legislation
of their countries is a permissive one.
− Otherwise, they are not obliged to perform it if their ethical
convictions differ; the medical department in charge has to
allocate the case to colleagues practising more liberal ethical
views.
The act of interruption of pregnancy is not completely risk free:
− As any surgical procedure of such kind, it supposes given
complications; while statistically they are accepted as a whole,
it comes sometimes with a price for the woman concerned.
− Sometimes the women remain with a feeling of guilt particularly
when the foetus had movements – a sentiment difficult to be
dealt with.
− Finally, a secondary sterility is not excluded.
Stillborn
This is a foetus, over 24 weeks of age, which leaves its carrying uterus
lacking signs of life, such as: heart beats, umbilical cord pulse, breathing,
crying, movements, etc. The possible causes are many, particularly
prematurity and congenital defects. It also may die during birth. This would
be a dying before birth! Such a foetus does not meet the legal requirements
to qualify as a person; as such, no birth and death certificates have to be
issued. Administrative evidence will be however thoroughly run under such
circumstances.
Infanticide
Infanticide is the killing of a child of up to one calendar year of age,

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Unnatural deaths
by its mother. Rare nowadays, it was ‘practised’ in the remote past due to
a variety of reasons: religious, ‘tactic’, of selection, driven by poverty or
lack of an orthodox social status. Usually, it is carried out by mentally ill
mothers. Technically, the suffocation has been and still is the most frequent
way of carrying it out. When an infanticide happens soon after birth, a
differentiation from a stillborn becomes necessary from the legal point
of view. The classical criteria relying on lung density are not decisive; the
details of the umbilical cord and particularly the presence of milk into the
child’s stomach are more useful findings.

13.12. Radiation sickness
(54, 75, 114, 199, 236)

General view
Our environment has a given, usual level of radioactivity. It originates
from both the soil, with its vegetal production, and the cosmic space. How
much from natural radioactivity reaches a particular person depends on
the geographic area, altitude, sort of buildings, air movement and time
spent outside. The total amount of radiation generated around is 2 mSv/
year (Sievert – the unit of ionising radiation dose). This is an average value
since the quantum is higher at higher altitudes, in industrial zones and mine
regions; nowhere do these amounts reach dangerous levels.
The human activities add to the natural sources by:
− the extensive use of X rays (for a single thorax film one generates
1/10 of mSv),
− the entire range of radioisotope examinations,
− there are countries where electricity is produced using nuclear
energy; strict industrial regulations explain an additional
radioactivity at public levels of only 1/10 from 1% of natural
amount, having so no significant negative effect,
− the atomic bombs and detonations as well as accidental military
and civil explosions have added extra radioactivity but, having
been dispersed into the entire earth atmosphere, they do not
represent any danger at the individual level, and
− radiotherapy which uses intentionally high, fatal doses, but
technically directed strictly to the pathologic areas concerned;
as such it does not exert any harm on the rest of the body and
the people around.
The number of the countries that are members of the so called atomic

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Chapter 13
club is not small but there operates a mechanism of discouragement at an
international scale.
Cell aspects
From the calculated 60 trillion cell population of the human body,
a couple of millions die and are replaced every day. The secret of this
replacement is the cell division; with a few exceptions, the entire series of
the body cells carry out the so called process of mitosis, in which the genetic
equipment is essential. The high biological engineering of this equipment
makes it miraculous and vulnerable in the same time.
Depending on the amount of radioactivity and level of ionisation
caused, the cell may suffer:
− DNA changes with an increasing implication in cell division and
next generation inheritance: transitory, minimal, pronounced
and lethal.
− The cancerous cells, with their more alert rhythm of dividing,
are more sensitive to the radiation; even more sensitive are the
cancerous cells of the young people. This is actually the reason
of radiotherapy in cancer pathology.
− An interesting sort of cell alteration is the cell ballooning: the
chromosomal material is only able to get together but not to
proceed to dividing. Consequently, the cell activity leads to a
volume increase generating a giant cell – hence the name –
until it explodes and dies.
The critical dose of radiation is 500 times higher than the natural level.
Actions on the whole body
This is in theory a sum of the actions exerted on individual cells. Both
in therapeutics and industry and also both in peace time and conventional
wars, consistent protective policies facing the people’s health are vigorously
run. As a result, there are no current harmful effects of radiation origin.
A hybrid scenario is met in a case of therapeutic radiation when a lethal
dose at an affected level is administered. Despite being high, lethal for the
cells concerned, even 1 Sv, the surrounding areas are not affected at all. As
such, radiotherapy is not dangerous for the life proper of a given patient.
The situation is totally different when a similar high dose interests the
entire body. A complete picture of effects was ‘built’ combining the effects
reckoned after the two atomic explosions, different accidents at military and
civil nuclear facilities, as well as the much experimental work. Therefore, it
was possible to coin a comprehensive description of what is known today

250
Unnatural deaths
as radiation sickness.
As the different cell communities of the body have different degrees
of vulnerability, they are affected differently by a certain dose of radiation:
− at a low dose, only the most sensitive cells (in terms of mitosis
rhythm) – germs, digestive and hematopoietic – are affected;
− at a high dose, the entire mass of cells are interested, leading
to death; whereas
− at medium doses, the higher the dose the more affected the
cell communities.
As far as this dose–effect relation is concerned:
− at small dose, 2.5 – 5 Gy (Gray – the unit of absorbed dose), one
dies after about one month with an hematopoietic syndrome
known to specialists as death of bone marrow;
− at medium dose, over 10 Gy, one dies in 10 – 3 days with a
gastrointestinal syndrome; and
− over 100 Gy death occurs in 48 – 24 hours with neurologic and
cerebrovascular syndromes.
This relation is well exploited in the criminal practices when a well
chosen dose, administered via a particular way, ensures a high rate of
damage. Mostly used is Caesium 137 for external radiation and Polonium
210 for digestive one. The media is full of ‘creative’ comments with any
such occasion but due to the secretive aspects of the issue, a real scientific
documentation is not publicly available.
What is known with plenty of statistical support has derived from
the many Japanese patients, victims of the WW II American atomic
bombardments.
x
In comparison to human being, for which 10 Gy are fatal, a number
of creatures are surprisingly resistant to radiation; in a crescendo order,
they are: cockroach – 200, Drosophila – 640, Parasitic wasp – 1,800 and
Deinococcus radiodurans – 15,000 (!) (161).

13.13. Transport accidents
(40, 82, 204, 224)

Road accidents
The total number of accidents is directly related to that of vehicles.
Therefore, the countries differ very much in the number of deaths, 5 – 21 to
100,000 inhabitants from a total amount of about 1,250,000 a year. Having

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Chapter 13
the busiest road traffic, the USA also has the highest number of accidents,
almost 34,000 fatal cases in 2013, for instance – what means one case in 15
min or 95 per day. The highest proportion is generated by young motorcycle
riders (316).
Needless to say, there are enough technical reasons to explain the above
mentioned figures; nevertheless, the main causes are largely human in type:
− Alcohol consumption represents a major factor
• 40% from the total number in the USA,
• one fatality every half an hour, and
• 25% from the deceased bicycle and motorcycle riders,
mainly young, were found with illegal level of blood
alcohol.
− Safety equipment, the belt in particular, child seat and air bag
have all proved really useful; unfortunately, they are not always
used.
− Sleep deprivation is also a statistical reality, leading up to fall
asleep at the wheal
• more cases after night shift;
• more cases at the biannual hour change, and
• understandably, after long trips.
− A too high speed generates one third from the total amount of
cases
• mostly between 15 – 25 years – an age of bravery behaviour;
• 8% motorcycle riders; and
• mainly young.
The fatal lesions are generated by craniocerebral, thorax and spine
injuries. Not only the drivers and the car occupiers suffer such traumas; the
pedestrians are equally exposed.
Not only the road accidents cause fatalities; the death of a driver at
wheal may also cause accidents. The ischaemic attacks are mostly the case.
It is worth mentioning that, in general, the vehicle stops before driver’s
proper death avoiding so possible tragedies. This is certainly the reason
why the underlying condition does not legally represent a ban of driving.
To conclude:
− A real protection is managed for the entire range of cars and
bicycles by the belts, airbags and helmets, respectively.
− In the case of motorcycle riders, the helmet eventually proved
inefficient due to the too high speed of the vehicles involved.
− The airbag designed for the front of the vehicles is a too new

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Unnatural deaths
acquisition to allow a valid conclusion.
− Last but not the least, the main obstacle in any improvement
remains the human factor – a factor notoriously difficult to be
dealt with.
Naval accidents
If road accidents are responsible for the largest proportion of transport
fatalities as a whole, the naval activities, both civil and military, have
generated along the history the highest number of human deaths ‘per
accident’. Now, already for one century, the seas and oceans have also been
the scene of an increasing roaming of submarines; going sometimes down
for ever, they become real sub–aquatic cemeteries.
Recently, in 2012, 100 years from the sinking of the Titanic were
commemorated. Being the largest ship ever sunk, some details may be of
interest:
− the biggest cruiser of its time: 262/28 m, 29 knots (1 knot =
1850 m/hr) speed;
− built at the Belfast shipyard and, as all other big ships, registered
in Southampton, UK, under royal patronage; and
− featuring all the then luxury standards: pool, gym, library, café
and dinner facilities for serving 500 people at a time.
Bound for New York, she left the hosting port on 12th April 1912 with
2207 people on board out of which 900 were crew members. After only
two days, it was hit by an iceberg and it took no more than 3 hours for the
Titanic to sink.
Equipped arrogantly with saving boats for 1,200 people only – declared
otherwise as unsinkable – the Titanic sank with more than 1,000 people;
712 travellers were saved and 328 bodies were recovered.
Located in 1985 by an American team of divers at a depth of 4,000m, the
wreck consists in two halves, half a kilometre apart from one another (253).
Considering the rhythm of erosion caused by ferro–phagous microorganisms,
the wreck is expected to disappear altogether around 2030.
Air accidents
These can happen on airports and mainly on cruising. The most known
disasters of the last decades are:
− Airports: Ermenoville 1974 – 364 victims, Tenerife 1977 – 583
and Ryad 1980 – 301.
− Cruising: Chicago 1979 – 273 victims, Ireland 1985 – 329, Lockerby
1988 – 270, Indian Ocean 2014 – 239, Java Sea 2015 – 162.
− Crashing in the air: New Delhi 1996 – 349 victims, Sinai 2015 – 224.

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− Crashing to a mountain: Japan 1985 – 520, French Alps 2015 – 150.
− Shut down: Sakhalin 1983 – 269, Persian Gulf 1988 – 290,
Ukraine 2014 – 298.
Considering the velocity details of such destructions, this is only by
chance that human remains can be recovered; the speed of fall, the impact
angle and the soil relief all play their role in the final picture.

13.14. Armed conflagrations
(82, 134, 165, 183, 184, 222, 223, 311)

From the early tribal to the current military block confrontations, the
human beings have exercised along entire history a collective violence. In
terms of human losses, the most important were:
− Various empires, including Babylonian, Chinese, Persian,
Mongolian, Roman, Ottoman as well as the colonial ones, were
built and maintained by using force, what implicitly meant huge
losses of lives.
− With a religious platform
• repetitive Crusades, the 11 – 14th centuries, with about
20,000 victims each,
• christianisation by Spaniards of the Caribbean, 15 –
16th centuries and South America, 15 – 19th, 1,000,000
victims each,
• Inquisition reprisals supposed many victims as well, with
a large number of deaths.
− The colonisation of North America in the 16th century and
Australia in the 18th century meant nearly the extinction of the
native population, about one million Americans and 700,000
Aborigines.
− Internal conflicts of a genocide proportion – ethnical, religious
and political – happened recently (1950 – 1990) on different
continents such as Asia, South America, Europe and mainly
Africa. The estimated number of losses was: Congo – 1,700,000,
Rwanda – nearly 1,000,000, Cambodia – 300,000, Indonesia
and the Balkans – 200,000 each.
− The largest number of losses has been generated by the modern
wars:
• From the conflicts of Napoleon, the Russian campaign,
1812, is known as having caused over 500,000 deaths.

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Unnatural deaths
• The WW I is known for 8.5 million military personnel and
a couple of millions of civilian deaths.
• The WW II, towards 50 million representing 20 million
military personnel, about 10 million exterminated and
20 million victims of the Stalinist regime.
• After 1945, the regional conflicts continued to produce
victims; it has been estimated that 150 conflicts have
caused about 20,000,000 deaths.
From the events listed above, several numbers are really fabulous:
− From the War of Independence until present, the American
nation has lost over 42 million people, from which 650,000
were on the battlefields.
− There are locations particularly known for the number of losses;
Borodino 1812 – 500,000, Verdun 1916 and Stalingrad 1942 –
1,000,000 each, Auschwitz 1942–1945 – 1,500,000, Hiroshima
and Nagasaki 1945 – a total of about 400,000.
− Ethnic cleansing continued to generate death until very recently,
such as Timor 1975–1999 – 200,000 and Rwanda 1990–1999 –
ca 1,000,000.
− During the entire 20th century, there were 110 million deaths of
which 50 were on the battlefields and 60 for connected causes,
mainly epidemics.
13.14.1. Chemical warfare
It is not a new concept; already in the Middle Ages a powder resulted
from grinding Euphorbia was used by dispersion. In the modern wars the
following have been used:
− Toxic gases, ‘launched’ on a battlefield by artillery weapons,
proved to have two tactic advantages:
• Obliged to breathe, the enemy had no other way than to
inhale them.
• They affect biologic creatures, leaving the material
values untouched.
− The WW I
• Chlorine which, being instantly irritant and difficult to be
dispersed, was replaced by
• Phosgene and yperite which, in a prime interval of time,
are not irritant but following later to cause a dramatic
bronchospasm with fatal respiratory insufficiency.
− The WW II acquired new toxic substances; due to their
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Chapter 13
anticholinesterasic action, the organophosphates proved to be
extremely dangerous. For political reasons, tabun, soman and
sarin were not eventually used on the battlefield; but they were
in gas chambers, for operations of extermination.
− In peace time, they were used a couple of times for:
• ethnic reprisals in Iraq, 1987, generating 5,000 victims;
• a terrorist attack, in the Tokyo underground, causing 12
deaths, and
• more recently, the Syrian civil war, resulting in thousands
of deaths.
A binary chemical weapon; two chemical substances, each
inoffensive by itself, are transported separately following to
combine and react once the target is achieved.
13.14.2. Nuclear weapons
Having massed on their territory the entire intelligentsia in terms of
nuclear research, the American machinery of war finalised towards the
middle of the past century the concept of the atomic bomb. At a distance
of only a couple of days, 6 to 9 August 1945, the two versions (uranium and
plutonium) were dropped on the Japanese towns Hiroshima and Nagasaki.
From the infamous features of those two explosions it is to mention:
− the detonation force of 20,000 TNT;
− the central pressure of up to 8 tonnes/sq.m;
− the pressure propagated as two waves of shock of 800 km/hr –
waves which swept away everything on a distance of 3 km and
being discerned by the returning bomber crew, cruising at 10
km altitude;
− in the centre of the ‘fire ball’, the temperature reached 5,000oC,
while at a distance of 1 km it was still 600oC; the metallic ports
were vaporised and the sand was transformed into glass;
− it resulted in an immense amount of gamma and neutron
radiations, the entire surrounding relief became radioactive,
affecting the whole population for years; and
− there resulted a 15 km high mushroom of smoke, dust and
debris which, falling down on the soil, spread the radiation.
Consequently to the above mentioned developments, everything was
carbonised and pulverised to a distance of 1 km radius, while to a distance
of 3 km the physiognomies were totally disfigured. For many decades, on
large areas, various degrees of radiation sickness caused much secondary
pathology, malignancy and congenital in particular. To illustrate the
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Unnatural deaths
magnitude of the drama:
− 45,000 deaths in the very first day;
− 60,000 suffered various degrees of combustion; and
− survivors continued to die, 50% in the first week due to injuries,
combustions and radiation sickness; after 5 years the losses
reached 250,000 cases.
As far as the second explosion, from Nagasaki, is concerned, it differed
to some extent but, as a whole, the two bombs caused similar destruction.
Despite the incalculable losses presumed by the already available
modern weaponry, the research has unabatedly continued. From the
acquisitions:
− Only seven years after the Hiroshima and Nagasaki attacks, a
new atomic weapon, of hydrogen, one thousand times more
potent than its predecessors, was invented.
− 13 years later, the neutron bomb has to culminate in the
weaponry arsenal; it destroys everything alive and saves
anything inert.
13.14.3. Biological weapons
Without having realised its significance, the Crimean Tatars of the 14th
century used a biologic weapon. They catapulted corpses of plague victims
on the enemy territory; Caffa (222) remained famous for this practice. More
difficult to stock and use, these weapons represented, however, an important
military acquisition and threat. In practical terms, it has not been used in
the modern history, remaining more a matter of mutual discouragement.

13.15. Natural disasters
(40, 243, 256)

Natural phenomena
Along the history, the human being has managed to organise itself of a
manner to cope with many hostile factors of the environment. When these
factors imply overwhelming developments for human capacity to resist,
the deleterious effects affect huge amounts of individuals, causing them
extensive destructions. Trying to list those having occurred in the last two
millennia they were:
− Famine,
• China 1959–61, 30,000,000 and 1969–71, 20,000,000
victims;
• Ethiopia 1971–1973, 1,500,000
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Chapter 13
− Avalanches,
• Peru 1962, 4,000 victims; and
• Himalaya 2015, 2,000
− Storms (cyclones, typhoons, hurricanes);
• Texas 1900, 8,000 victims,
• Hong Kong 1906, 10,000,
• Pakistan 1970, 200,000,
• Bangladesh 1991, 130,000, and
• Honduras 1998, 11,000
− Tsunami;
• Johnstown, Pennsylvania 1889, 2,200 victims, and
• Indonesia and Sumatra 2004, 150,000
− Floods;
• Holland 1228, 100,000 victims, and
• China 1887 and 1939, 1,000,000 each
− Earthquakes;
• Mediterranean 1201, 1,000,000 victims,
• China 1556, 850,000 and 1976, 250,000,
• Japan 1923, 100,000,
• India 2001, 20,000, and
• Italy 2009, 300
− Volcanic eruptions;
• Vesuvius AD 79, 20,000 victims,
• Krakatoa 1883, 36,500, and
• Martinique 1902, 28,000
− Great fires;
• London 1666, and
• Chicago 1902, each with a huge number of victims.
Thunderbolt
The atmospheric electrical phenomena derive from the friction of
the immense number of micro–particles which the clouds are formed of
(water, ice, dust, smoke) – up to one million/cubic metre. The discharge
may take place either between two clouds, covering a distance of up to
150 km (being a danger for aeroplanes) – the lightning, or between a cloud
and different relief elements of heights of up to 15 km – the thunderbolt. It
penetrates the earth surface via trees, buildings, animals and humans, as
well as lightning rods, when available.
The physical features of the thunderbolt are really impressive:
− electric potential of up to 1,000,000,000 V,
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Unnatural deaths
− intensity of up to 250,000 A, and
− duration of 1/100 – 1/1,000 sec.
When a human being, like any other living creature, becomes a way of
drainage of such a huge electric energy, the consequences are multiple and
severe:
− sudden death, due to asystolia; interestingly, it is easy to be
recovered but the heart often remains with ischaemic sequelae;
− contusions and fractures, as a result of the shock waves;
− ruptures of the tympanic membrane;
− flaccid paralysis of limbs, lasting no longer than 24 hrs;
frequently, a vasoconstriction explains a temporary lack of
peripheral pulse;
− skin lesions of combustion occurring in a couple of hours, having
an interesting shape of fern and, although severe, healing quite
soon; interestingly, metal pieces accidentally in place may be
affected up to melting;
− myo– and haemo–globinuria, caused by the firm muscular
contractions induced by the electrical current;
− cataract, retinal detachment and various degrees of optical
nerve damage; and
− sensorial deficits, vestibular in particular.
If the victim is a pregnant woman, it is less probable for the uterine
content to survive.
Different from the usual electrical accidents, where any resuscitation
could be started only after the interruption of electricity, in a case of
thunderbolt one may proceed with the resuscitation straightaway – what is
an obvious practical advantage from the therapeutics viewpoint.
Deaths caused by animals
Either defending themselves by instinct or attacking for feeding, many
animals use to kill; from the most dangerous, one should enumerate: shark,
lion and tiger, snakes and scorpions and a large variety of insects. Two
specimens have always to be kept in sight: an exemplar of African crocodile
kills approximately 1,000 people yearly while our faithful friend the dog
frequently attacks, sometimes fatally, small children.

13.16. Homicide
(40, 161, 192, 259, 278)

It is depressing to realise how much from the human preoccupations
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have been and, unfortunately, still is focussed on violence. If sociology is
able to find some explanations for the collective violence, the individual
one is purely a matter of aggressive character. This composition is not a
right place for philosophical considerations; it will deal rather with the so
called technical aspects derived from the intrinsic bad nature of the human
being.
From the judicial point of view, homicide (manslaughter or murder)
supposes an interruption of the physical course of a human life. The
motivations vary very much, hence the numberless sorts of homicide. The
most frequent versions reckoned nowadays can be domestic, economic,
self–defence, political, honour (duel), compassion (euthanasia), ideology,
religion, robbery and revenge related; being in the wrong place at a wrong
time is also not too a rare event!
The utensils and ‘technical’ manners used may be:
− fire arms – the gun being so easily accessible in some countries,
notoriously in the USA;
− sharp tools and instruments – knife, axe, machete, etc. – stubbing
representing the second modality used for killing;
− blunt contusing tools, hammer in particular;
− direct strike;
− explosives and poisons; and
− arson.
Taking as example the USA – once again, the country with the highest
rate of fatal violence (in the last decade 5 – 10/100,000 citizens per year)
– the proportions of the above entries were 65, 13, 7, 2, 5 and 10%,
respectively (40). From the same statistics:
− half of the perpetrators were young, 35 – 20 years;
− 9 out of 10 were men, predominantly black people; and
− any American child is offered by the available TV channels, until
the age of 16, not less than 18,000 images of killing.
− Or, it is well known that children are not able to distinguish
between what they look at on the screen and what happens in
real life.
A homicide with an important social impact is the assassination – a
killing often designed by professionals and carried out by contractual killers.
Such a crime is organised aiming at removing from a community scene a
personality otherwise impossible to be annihilated. Sound names in the
history were Cesar (AD 44), Charles de Bourbon (1527), Tsars Alexander
the Second (1881) and Nikolai the Second (1917), the American presidents

260
Unnatural deaths
A. Lincoln (1865) and J.F. Kennedy (1963), Prince Ferdinand (1914) and the
Beatles singer John Lenon, (1980).
Serial killers
Undoubtedly, repetitive killings are manifestations of a pathological
psychiatric behaviour: schizophrenia, sadism, maniac, cannibalism and
sexual perverts. The modus operandi is sometimes so ingenious that it is
possible for such cases to be active for years. As far as the scenarios are
concerned, they can vary from very sophisticated ones to others with no
curtain whatsoever.
Listing them in a decrescendo order, the most known infamous killers were
− H. Shipman 1998, UK, associated to 215 victims;
− H.W. Mudgett 1896, USA, 150;
− T. Bundy 1989, USA, over 100;
− J. Jqbal 2001, Pakistan, about 100;
− Sisters Gonzales de Jesus 1964, USA, over 90;
− M. Petiot 1944, France, 63;
− D.L. Evans 1970, USA, 60;
− A.R. Chikatilo 1990, Russian Federation, 56;
− A. Onoprienko 1996, Ukraine, 52; and
− H. Drenth 1932, USA, 50.
It may be of interest that two of them, Shipman and Petiot, were medical
doctors, having committed their crimes under professional circumstances;
the first at the patients’ domiciles and the second at his private clinic.
Eventually justice played its part, administering severe punishments
as, for example in two cases, 547 years detention and 10 life sentences,
respectively.
Mass killers
Human history has had enough tyrants who, each in his way, caused
the death of significant numbers of people. In a historic order, the following
must be mentioned: Caligula, Attila, Thomas de Torquemada, Vlad the
Impaler, Ivan the Terrible, Adolf Hitler, Iosif V Stalin, Pol Pot, Idy Amin and
Saddam Hussein. Their reasoning has always been an official one, based
upon particular platforms valid for those times, no matter how they seem
today.

13.17. Terrorist acts
(223, 315)

The concept of such actions is neither new nor a recent one:

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− the so called The Reign of Terror during the French Revolution
at the end of the 18th century,
− the infamous Ku Klux Klan, the 19th and 20th centuries, USA
− the Red Brigades from the ‘80s, Italy, and
− Red Army of the ‘90s, Federal Republic of Germany.
From the events that happened in the last decades, the following have
to be mentioned:
− American Marine Casern, Beirut 1983, 241 victims;
− US Air Force Casern, Saudi Arabia 1996, 20;
− American Embassies Tanzania and Kenya 1998, 200;
− The World Trade Center, USA September 2001, 2628 life losses;
− Madrid train 2004, 191;
− London Underground 2005, 52;
− Utoya Island, Norway 2011, 77;
− Westgate Shopping Mall, Nairobi Kenya 2013, 75;
− recent (2015–2016) urban attacks: Paris – 234, Brussels– 32 and
Nice – 84;
− the endless terrorist confrontations from the Middle East; and
− also the endless car bombing across the different conflict
regions.
The real reasons differ very much in what they aim at. They have, on the
other side, a couple of common features: violence is used by surprise, under
constrained circumstances, with unnecessarily much force, in very crowded
places. Needless to say, for those involved to carry out such actions, there is
often a high life risk. Morally dubious, such acts have always both political
and ideological platforms.

13.18. Large scale industrial accidents
(40, 82, 224, 287)

The modern man has imagined grandiose projects and built industrial
objects which have proved to never be trouble free. The more complex
the industrial equipment the more probable the malfunction:
− The highest number of victims, 3,828 deaths and 207,297
people severely affected, has been reported in 1984 from an
American chemical factory, Union Carbide, operating in Bhopal,
India.
− Different nuclear installation, military as well as civil, suffered
different degrees of malfunctioning. The material losses were

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Unnatural deaths
difficult to be quantified; in terms of human deaths:
• Three Mile Island, USA 1979;
• Fukushima, Japan 2011, each of them with thousands of
people exposed to radiation;
• Windscale, UK 1957, 32 victims;
• Chelyabinsk 1957, over 200; and
• Chernobyl 1986, 56, both of them in the former USSR.

13.19. Various unnatural deaths
(33, 82, 120)

High altitude
The high altitude mountaineering, an elite sport, is demanding and risky
at the same time, combining physical effort, low temperature and severe
hypoxia. Being the highest summit on the earth, the Everest (8,848 m) has
proved to be extremely dangerous, having caused hundreds of deaths.
The temperature runs from –19oC, in July, to as low as –60oC, in January
causing frostbites to 10% of climbers and freezing the entire body of those
who die.
The most dangerous feature is by far the hypoxia. At an atmospheric
pressure of one third from that of the sea level, the O2 partial pressure of
the ambient rarefied air is not able to generate an alveolar–blood gradient
higher than 5 mmHg and a PaO2 more than 25 mmHg. As a consequence,
the O2 saturation of the arterial blood reaches a value of only 50%. This low
O2 availability under circumstances of a sustained physical effort explains,
in an un–acclimatised person, a tachypnoea of up to 90/min, consciousness
being lost in 2 – 3 min. (104, 284).
In order to increase the hypoxia tolerance, the climbers spent a
number of months in successively higher altitude camps. The amount of
Hb is enhanced towards 18 g/l (usual amount in native people) of a manner
that O2 content of the blood increases, at its turn, towards 150 ml/l. If
supplementary O2 is used, its cell availability improves, improving mental
and physical capacities. For reasons derived from the sportive stance, some
climbers are reluctant to appeal to added O2; these are those 5% who
reached the summit breathing only air.
Under effort circumstances, hypoxia leads to cerebral oedema,
with the behavioural disturbances, of nature to alter the judgement and
cooperation. This is why most of the deaths occur at the descend leg of the
journey. The last kilometre of the summit height is known as death zone

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Chapter 13
or open graveyard because it is here where one dies mostly. From 1924
till date, there have been 283 victims (170 foreigners and 113 Sherpas).
Approximately 50 ‘watch’ in open air along the routes, the rest having not
been identified yet. The physical challenge is so intense that, once a climber
gets in difficulty, there is no way of rescue.
Being the highest, Everest is the most dangerous peak but not the
single causing fatal accidents; altitudes over 8,000 m add, everywhere
on the planet, increasing hypoxias to the common low temperature and
physical effort.
Circus artists
It is not unusual in this profession to encounter risky events:
− falls during unprotected settings; and
− various injuries, even fatal, caused by the beasts either in
training or during real performances.
Honour killing
This is a sort of crime driven by tribal institutions, particularly carried
out by parents or older siblings, ‘executing’ (mainly by manual strangulation)
descendants (mainly daughters) for not complying with the family decision
in accepting a marriage partner. Despite the bizarreness, the practice
amazes by happening among immigrants (particularly from South–East Asia
and not necessarily first generation) in countries, cities and places with high
standards of community life.

264
14. Assisted death
(67, 74, 91, 105, 138, 203, 258, 266, 272)

14.1. General view 265 14.2. Dr Jack Kevorkian 269
14.3. Dignitas Clinic 271

14.1. General view
While preventive medicine deals with improving and maintaining
health parameters of a given community, its curative sister aims to help
those members of the community who have lost their usual biological
wellbeing.
With its scientific achievements and technical acquisitions, modern
medicine is often able to cure patients confronted with severe disabilities. The
large diversity of prostheses, complex surgical procedures, transplantation,
and intensive care medicine available today are managing to reduce the
mortality rate and give many patients the chance to become active again or
even achieve an enhanced quality of life. Unfortunately, this is not always
the case. Certain recognised and accepted proportion of patients, due to a
lack of necessary biological resources, deteriorate and die.
Between the two polar alternatives, there is a third category of patients
who neither enjoy a minimum comfortable life nor die ‘on their own’. This
category is mostly a by–product of the intensive care branch of modern
medicine. More precisely, this high–tech medicine is able to avoid death
but not necessarily able to offer patients an acceptable level of existence.
Finally, there are also medically incurable conditions that exclude an
acceptable quality of life, which leave its sufferers ‘suspended’ somewhere
between life and death.
All the above categories of cases have in common incurability; they
lack any prospect for an improved level of existence and quite frequently
involve varying degrees of discomfort or pain. Faced with such challenging
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Chapter 14
and unavoidable burdens, many such patients prefer to die.
This is a new facet of medicine, one that shifts its gaze from the classical
standards of preserving life and casts an eye towards facilitating death. As a
matter of medical philosophy, this approach has its challenges. If a compos
mentis patient declares his preference to die, why shouldn’t medicine deal
with his death as well as his life?
Facilitating the death of a patient who ‘qualifies’ for help with dying is
termed euthanasia; along with other similar medical terms of interest, it is
explained in a short glossary in chapter 15.
There are a number of practical problems worth noting:
− The cases in discussion have in common a physical, mental, or
mixed condition; they are clinically advanced and irreversible;
and they make the life of the patient concerned unbearable.
They are marked by the following:
• an incurable disease manifesting in the reasonable
future,
• severe pain, both difficult to bear and causing intractable
side effects,
• an inability to commit suicide, or
• an unacceptable dependence on technical devices such
as ventilators, IAPB, or an artificial heart.
− Adequate examples of the above are metastatic cancer,
post–traumatic tetraplegia, paralytic and advanced chronic
respiratory insufficiency, and advanced cardiac insufficiency
without a transplantation prospect.
− The file should be legally opened by the patient or the family,
and consent must be recent. This requirement derives from
a certain medical ‘asperity’, but also from the many changes
of mind on the patient side. Needless to say, the medical
counterpart accepts that such a decision is never simple or
easily taken.
− The stance of the medical institution is, as a whole, a conservative
one – the result of a 2,500–year–old ethical dominance of the
Hippocratic Oath, the supremacy of life in any human mind,
and an instinctive opposition to death and everything related
to it. Some ideological changes in the medical community
have, however, taken shape in recent decades in response to
public opinion, which is increasingly critical of the ‘inhumane’
technicalisation of intensive care. Indeed, the ‘sanctity’ of life

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Assisted death
becomes devoid of meaning when the notion is applied to a
life only artificially maintained and without any interactivity.
Keeping somebody alive without any personal participation
amounts to a kind of biologic idolatry.
− At this stage, euthanasia is a subject of no interest to the health
care networks of developing countries. In their hospitals, due to
low budgets, patients don’t reach the point of over–treatment
– a threshold they would then, in theory, be carried back over.
Such patients are actually under–treated, the medical staff
unwillingly participating in an involuntary euthanasia.
If the debate regarding euthanasia is wholly sound, mainly in the media,
the official legal position in the relevant countries has far more significance.
The approach is basically twofold:
− In the majority of countries, any assisted dying is illegal; the
patient’s position and any application, no matter how compos
mentis he is, are not given any institutional attention.
− In various versions, euthanasia is legal in Oregon, USA (as of
1997); the Netherland (2001); Belgium (2002); Luxembourg
(2008); and Canada and California, USA (2015). At the end of
the 20th century, an Australian province legalised euthanasia,
but a federal institution later blocked the decision. In Ireland,
the passive variant of euthanasia is allowed, while in Mexico
patients and families may oppose a life–saving treatment
(which constitutes a sort of passive euthanasia).
The reluctance of judicial bodies is not entirely or always unjustified;
not rarely, both the families and the medical institutions aim to reduce the
burden of cost associated with care. Even more determined are the social
activists who regard euthanasia practices as a means of rationing costs by
targeting society’s most vulnerable, particularly the elderly and disabled
(the so–called slippery slope argument).
As for the practical act of passive euthanasia – this being the version
most often chosen – it consists of the following:
− There is a thorough review of the required documentation.
− The patient is transferred to a single room with secure
intravenous access.
− The attendant doctor prescribes a lethal dose of a barbiturate
or sedative of choice.
− The patient voluntarily ingests the medication.
− The prescribing doctor need not necessarily be standing by but

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Chapter 14
should be easily summoned as necessary.
− A nurse, known to the patient, should be at the bedside.
− Once death is declared clinically, the doctor in charge checks
the validity and fills in a death certificate.
Curiously, neither the doses nor the procedure are topics addressed in
the dedicated medical literature. The event is decided upon, organised, and
carried out rather in strict accordance with regulations of internal use. This
is, perhaps, a practice of choice – with as few direct, nominal responsibilities
as possible.
Even fewer comments can be found on some of the technical problems
sometimes encountered:
− The prescribed agent does not enter circulation due to
• difficulties in deglutition;
• digestive intolerance or vomiting;
• a state of obnubilation after the first part of the dose,
making subsequent portions difficult to be swallowed;
• secondary effects that compromise the course of the
procedure, such as spasms, myoclonus, or convulsions;
or
• a simple absence of the expected effect despite an
appropriate dose.
− The solution is to switch to the active alternative of an
intravenous injection of an appropriate dose.
− Under such circumstances, often marked by a great deal of
emotional strain, it is not uncommon for the patient or family
to change their minds.
− In addition to the professional aspect of such arrangements, the
medical team is sometimes the victim of judicial ambiguity. This
is why a conservative stance by staff is also fully understandable;
adhering to a respected Oath handed down over millennia
is always simpler and less risky than interpreting new and
potentially ambiguous edicts.
− On the other hand, there are various statistics showing some
euthanasia excesses, particularly in the Netherlands and
Belgium.
Two details from American society helped stimulate a more tolerant
attitude towards death: former president Richard Nixon refused to be
terminally ventilated and Jacqueline Kennedy, suffering from severe
pneumonia, refused antibiotic therapy. Both, it was said, died earlier than

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Assisted death
they otherwise would have done had the respective treatments been
carried out.
To protect the personnel involved against charges of malpractice – a
necessity not entirely rare – it is important to note the following:
− The patient’s file must cover the entire range of essential points:
• a fully justified personal application,
• a valid certification of compos mentis,
• irreversibility of the patient’s condition,
• the prognosis of an intolerable life, and
• the action being unquestionably in the patient’s best
interest.
− From the perspective of the institution and the doctor, empathy
and good faith are essential.
− If, nevertheless, a punitive decision is taken against the attendant
doctor, this is generally only a formality.
It seems important to point out that, due to improvements in pain
treatment, the applications for euthanasia have reduced significantly. It is
also worth noting two surrogate euthanasia alternatives:
− Terminal sedation requires the same documentation, technically,
but it is definitely simpler. If the euthanasia leads straight to
death, the sedation facilitates and hastens it.
− Rejecting food and fluids is, in theory, trouble free and does not
require any bureaucratic forms; it is not, however, as simple as
it seems. Putting it into practice can sometimes take several
weeks to succeed.
In the event of both these surrogate methods, a good quality palliative
treatment should be applied.

14.2. Dr. Jack Kevorkian
Born in 1928 to an American family of Armenian descent, he qualified
as a medical doctor in 1951, specialising in Pathology. A gifted researcher,
Dr Kevorkian authored scientific work on several subjects of great interest
for his time:
− a history of autopsy in the context of the Alexandria School of
Medicine,
− rigor mortis and the lack of accuracy in determining the moment
of death,
− the fundus occuli and the determination of death in the terminal

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Chapter 14
phase (140), and
− the use of cadaveric blood in the Korean War.
He stands out in the history of medicine as a pioneer in the area of
physician assisted suicide, for which he attempted to create a speciality
(142).
The challenge his ideas represented in medicine of his time was, on
one side, the right of each individual to choose the moment of death
and, on the other side, the obligation of medical practice to make this
moment a fully dignified one (141). He was quickly confronted with both
the conservative stance of those involved and the lack of a permissive
legislation. Having contacted the relevant authorities, he suggested adding
to the medical specialities register one that would consider and support
suicide applications. Such applications would be from people suffering from
conditions with an inexorable negative outcome or incurable pain, those
with an unbearable infirmity, and the terminally ill. The utmost importance
was given to consent – an action involving the patient’s family whenever
possible.
From a technical point of view, the procedure would prove to be
a professionally assisted suicide. The most important elements of the
procedure appeared to consist of
− a final oral review of consent;
− the availability of a fully operating intravenous system for
administering the relevant medications;
− an empty stomach;
− injection, manu propria, of the lethal dose of barbiturate and
potassium chloride by the patient pressing the button of an
automatic syringe (known as Tanatron or Mercitron);
− the presence of a forensic specialist to certify the death; and
− a film of the entire procedure, which is subsequently delivered
to the relevant police department.
Dozens of disabled people, depressives, terminally ill individuals, socially
isolated people suffering severe illnesses and patients with unbearable pain
were assisted to die in what did seem to be a very well organised event. As
a result, Dr Kevorkian was arrested many times and, eventually, his right
to practise was withdrawn. The latter action was designed to deprive him
of access to the necessary injectable medications. As an alternative, he
continued his practice by replacing the intravenous medication with inhaled
carbon monoxide. Instead of pushing the button of a syringe, the suicide
candidate had to open a CO valve.

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In 1998, approached by a patient with amyotrophic sclerosis, whose
condition rendered him unable to operate any kind of switch, Dr Kevorkian
found it appropriate to perform the injection himself, thereby practising
an active euthanasia. The film, which aired on national television, was
subsequently sent, as usual, to the police. Through this one event, Dr
Kevorkian managed to trigger debates in all three of the relevant arenas:
medical, legal and public (135, 136). The result was a large debate but also his
arrest and a sentence of 10 to 25 years for second–degree homicide.
Faithful to his own doctrine, he managed to effectively help 130
patients by organising and assisting with their dignified deaths, thereby
demonstrating the positive role a medical worker may play in facilitating
a smooth, trouble free death. Dr Kevorkian also found an appropriate
and succinct name – Obitiatry – for a medical speciality charged with
‘administering’ the ‘civilised’ death of a living compos mentis person who
has determined that life is no longer worth living. In short, it would remain
the full responsibility of the respective human being to decide whether
or not to continue living, whereas it would be a medical and technical
responsibility to ensure a dignified death.
Dr Kevorkian was a medically controversial personality. And he was
no less controversial for the media attention he received than for the
harassment he endured from the justice system. He remains a brave
ideologue and a real knight of death, with the alias Dr Death (196, 198).

14.3. Dignitas Clinic
This is the most well known of the Swiss associations practising assisted
suicide. The cases the association deals with are of the same varieties
mentioned earlier in this chapter. Additionally, any potential candidate may
appeal to have his or her death processed on demand. As with all venues
everywhere that deal with death, a comme il faut consent document is
of primary importance; this association also requires the compos mentis
status to be attested to by a professional with psychiatric expertise. As in
other similar scenarios, there isn’t sufficient credible data of a professional
nature. As such, the present work also includes a reference to lay sources.
It’s important to specify from the outset that Swiss law does punish any
person who, out of self–interest, helps someone else to commit suicide. As
the association is administratively a non–profit one, and it carries out its
activity exclusively on a volunteer basis, it manages to keep itself clear of
any illegal activity.

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Organised in 1998 by a lawyer, Ludwig Minelli, with its headquarters
in Zürich, the association runs a sort of waiting list. There are no exact up–
to–date figures available, but the number appears to be in the thousands.
The association accepts anybody from anywhere, as such practising a sort
of suicide tourism. Its motto is “To live with dignity – To die with dignity.”
The method is a very well managed one:
− A Medical file
• includes documentation attesting to the disease and its
stage,
• attests that an association doctor has scrutinised the file
and performed an independent examination, and
• indicates that a re–examination of the case is scheduled
for a later date in order to check the firmness of the
patient’s decision.
− A Legal file
• demonstrates that the person concerned has signed
a consent in the presence of an independent witness
according to Zurich canton regulations; and
• in the case of physical disability, includes the
implementation of a video proxy.
These two steps qualify the person as a genuine candidate, with
the understanding that the candidacy will be re–evaluated at a
later date. About 70% of initially processed people never come
back.
− At the suicide itself
• the candidate is questioned once again as to whether he
or she persists in the decision;
• a dose of antiemetic is given 30 minutes in advance; and
• three lethal doses of a barbiturate, affirmative
pentobarbital, is dissolved in water or juice and given per
os in a medium–sized glass.
In about half an hour a coma usually ensues, and the patient
gradually proceeds to death. Sometimes, instead of barbiturate,
oxygen is replaced with helium.
− Once death is medically declared, a forensic specialist and a
representative of the local police are asked to verify the death.
− The next and last step consists of cremation and delivery of the
urn to the family, or funeral and burial arrangements.
Finally, the cost should also be considered. Although Dignitas Clinic

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operates under a non–profit status, there are many costly components of
the procedure. Prices are not fixed; as such only estimates are available:
5,000€ excluding a funeral, and 8,000€ with a funeral. To this ‘tourism’ cost,
one has to add travel expenses, both for the person concerned as well as for
those accompanying him or her. This is the reason, inter alia, social activists
in many countries are appealing for various ways to make home–based
assisted suicide legal and, consequently, more affordable.
The media is also very determined; press, films, and TV programmes
worldwide continually keep the public well informed, and the appeal of
celebrities and public personalities to the services of Dignitas and other such
associations has given rise to much debate. As such, the topic has attracted
a great deal of scrutiny and, finally, is becoming better understood.

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15. Ethical and legal aspects
(37, 47, 53, 71, 109, 116, 155, 175, 203, 232, 266)

15.1. Advance directive 275 15.4. Death declaration and
15.2. Do not resuscitate (DNR) 276 certificate 280
15.3. How to discontinue intensive 15.5. Various legal implications 282
care 278 15.6. Miscellaneous 283
15.7. Glossary 283

Life has been subject to a variety of abuses throughout human history;
the physically stronger and the socially dominant, not to mention those
with political and military authority, have exercised nothing less than
dictatorial control over the less powerful. It has taken millennia, in terms
of safeguarding life, for the situation to become more sensibly democratic
and standardised. It is now the norm for judicial systems to consider life
sacred, to unreservedly defend it, and to strongly punish those attempting
to violate its integrity.
As death puts an end to life, the law is quite often involved in matters
concerning death. This involvement doesn’t always concern the medical
profession proper, but there are plenty of situations when the two must
‘cooperate’.

15.1. Advance directive
This is a sort of living will, drawn up while still in reasonably good
mental health, in anticipation of the possible loss of one’s compos mentis
status. Such a document may
− stipulate a given preference under certain circumstances, and if
pertaining to an existing condition, such a document generally
indicates a refusal of complex, demanding, or risky procedures;
− name a proxy, someone known to share similar principles, to
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make decisions on one’s behalf regarding procedures (usually
in intensive care) such as mechanical ventilation, parenteral
nutrition, intensive inotropic treatment, and resuscitative
techniques – all of which have the potential to generate various
sequelae; or
− endorse an institution or person to decide in matters such as
organ donation or questions of didactical use of the body, in
parts or in toto, although for these two options separate and
more focused paperwork is required.
An advance directive often proves to be a valuable document since,
in about half of intensive care cases, patients are no longer in the position
to judge for themselves. Not all families are aware of their loved ones’
most recent positions, and patients themselves may change their minds
in regard to the condition from which they are suffering. This is why it is
always advisable for an advance directive to be reviewed and reconsidered.
This is also why the medical institution always reserves the right to
judge the course of events in the patient’s favour.

15.2. Do not resuscitate (DNR)
Known worldwide under its acronym, DNR, this patient instruction is of
great significance for at least two reasons, namely that resuscitation
− is the most heroic procedure, and
− it is in first place for causing sequelae.
This is why to resuscitate or not to resuscitate is of equal importance
for both the patient and the hosting institution. The single best way to avoid
the prospect of a detrimental resuscitation is to refrain from doing it when
the chances of success are decidedly low.
At the level of an admitting hospital unit, a DNR may be
− already in force as part of an advance directive – a recommended
option, particularly when the admission is for a condition likely
to reach a stage when resuscitation will become an issue;
− expressly requested by an admitted patient soon after the first
clinical review, usually when, in principle, resuscitation has
been deemed distinctly possible; or
− initiated by the medical unit when there is a high probability that
resuscitation, if necessary, either stands no chance of success

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Ethical and legal aspects
or poses a high risk of sequelae; this may well prompt some
administrative complications, but it is institutionally justified. It
proceeds as follows:
• The decision is brought to the attention of the patient
and, if possible, his or her family.
• If the patient and family understand and accept the
medical approach, it is documented in the patient’s file
and shared with other medical personnel involved: the
referring doctor, the care team, and the on–call staff.
• If, for any reason, the patient does not agree with the
medical initiative, he or she has the statutory right to a
second opinion, which must be arranged by the hosting
unit.
• If, in the end, the patient insists on being resuscitated,
the only alternative is to transfer him or her to another
unit with a medical stance nearer to the patient’s
expectations.
In ambiguous situations, a more trenchant position is available for
the professional counterpart in the dispute, that of the unilateral DNR.
For emotional reasons concerning the patient and the family, medical
personnel tend to exercise a sort of restraint before availing themselves of
such a bureaucratic approach.
The DNR order is ignored under two special circumstances:
− in settings highly favourable for both early diagnosis and,
especially, successful resuscitation, such as an exploratory and
interventional cardiology laboratory; and
− in places where the so–called Seattle standards are exercised
(when less than 3 minutes have elapsed between the
summoning and arrival of a resuscitation team).
Despite the good conditions for resuscitation available in dedicated
hospital units, there remain difficult cases prone to severe consequences.
It is easy to envision the much higher degree of risk associated with
resuscitation attempts in settings ill equipped to cope with cardiac arrest.
Under such circumstances, appropriate signalling ‘tools’ such as DNR
bracelets or pendants can indicate an unconscious patient’s wishes. These
are affordable and efficient measures for avoiding pointless resuscitation
efforts that are not only unwanted but, if technically successful, quite likely
to worsen the patient’s pathologic inventory.

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15.3. How to discontinue intensive care
Struck by disease, any patient can be considered a victim of
indiscriminate fate. Given this, in addition to the required treatment, every
patient deserves an attitude of understanding and support – the derivatives
of human solidarity. This is true in all medical/patient echelons, and all
the more so in an intensive care environment. Here, by virtue of age and
pathology, patients are often near the end of life. This is the main reason
this medical sector is subject to continuous ethical scrutiny.
Another good indicator of current relations between patients and
medical institutions is the place where people die. More and more people
today, mainly in affluent countries and in urban locations, die in hospitals
(up to 90% in the USA). Consequently, hospitals operate a sort of patient–
doctor partnership:
− Patients have become progressively more informed and they
are better able to understand what is happening to them. This
is also a good place to mention that modern digital technology
and the Internet make it possible for people today to be more
aware than ever before of medical options available both locally
and around the world.
− In their turn, medical workers are no longer the sole source
of information or the unquestioned authority for patients and
their families. To put it bluntly, the digital age emancipation of
the patient community means that the days of granting doctors
a sort of super–human status are long gone.
The principles of the patient–medical unit relationship have recently
been better delineated:
− The medical side is committed to working only for good, to
avoiding all wrong doing, to respecting the patient’s autonomy,
and to dispensing treatment democratically.
− On the other hand, patients must assume a certain degree
of medical responsibility by accepting, altering, or refusing
proposed care, all through documented consent.
A clinical setting in which the above relationship can be altered occurs
when a laborious and costly treatment plan is not taken into consideration or
has to be discontinued. A concerted effort must always be made to protect
the patient from secondary pathologic entities, sequelae in particular, while
also making reasonable judgments about the appropriate use of the host
unit’s resources.
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Ethical and legal aspects
What then, in effect, must the two sides do?
The medical side
The patient and the family are informed that a particular treatment
is not or is no longer in the best interest of the patient’s on–going care.
A detailed explanation can be added in cases when the patient is able to
comprehend it and understand the consequences. This method, a kind of
consent, is essentially the same as the consent obtained for administering a
treatment, and has the same legal significance. Needless to say, emotionally
this is an uncomfortable sequence of events. A great deal of understanding,
empathy, and careful attention to describing treatment options must
therefore accompany the message.
The patient side
There are essentially two ways this can go:
− The patient accepts the situation, which, once again, is never
easy, particularly since such a decision to discontinue therapy
almost always heralds a negative turn of events and possibly
the beginning of the end. Sometimes a patient’s acceptance is
available from a pre–existing advance directive.
− When, to the contrary, the patient does not find it appropriate
to cooperate, the hosting unit
• must arrange for a second opinion, or
• transfer the case to another unit with a more flexible
stance.
The latter is never pleasant for either the patient, or the medical
staff. This must, however, be accepted so long as, despite the patient’s
‘inconvenient’ feelings, the institution is able to respect and responsibly
follow its own policies. It is no secret that 10 to 15% of intensive care
patients are confronted with such a turn of events, a proportion substantial
enough to generate a good number of court cases.
Medical units have their regulations, privileges and constraints. It is a
context in which good faith and good manners are not only welcome, but
ultimately constitute the most productive practice. When necessary, there
is a way to statistically demonstrate the futility of the disputed treatment:
− Quantitative futility – the treatment has recently been tested,
and in a group of 100 patients it proved to be inefficient.
− Qualitative futility – the treatment is administered to the
patient concerned for 48 hours to check its effect; the lack of
any expected improvement makes the prediction valid.
When decisions to discontinue treatment must be made once the

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patient is no longer responsible, there are, in descending order, several
options from which to choose:
− following instructions in an advance directive, if available;
− seeking consent from the patient’s family, with or without an
advance directive;
− consulting the patient’s representative, if one is named in the
directive;
− bringing in an independent representative;
− applying the Bolam Test, which relies upon the standard of
practice by a responsible body of medical professionals; and
− in complex cases, appealing to a court of law.
Once the entire series of formalities is sorted out
− the case team is assembled;
− an alternative treatment strategy is devised, emphasising a
palliative approach that prioritises eliminating discomfort and
pain;
− the patient is transferred to another room, preferably single
occupancy;
− as the change in care quite often includes discontinuation of
ventilation, due attention must be given to antagonising any
muscle relaxants;
− a generous sedative is administered to minimise the patient’s
experience of unnecessarily confusing stimulation; and
− a maximum of emotional support is offered to both the patient
and the family.
If for any reason the patient’s neuropsychiatric competence must be
proven, such proof must consider whether the patient,
− is able to listen, seems to understand,
− realises what is going on, and
− is able to formulate a decision.
If psychiatric expertise is necessary, which is rarely the case, any
complex medical unit capable of dealing with such patients certainly
includes a relevant department competent to deal with such matters.

15.4. Declaration of death and death certificate
Death has so many implications for any family, community, or
administrative office that not only must it be declared but it must be
done in good time. A new born remains with us, allowing plenty of time

280
Ethical and legal aspects
to register the event when convenient. In the case of death, however, the
person concerned disappears physically and forever. This is why, from an
administrative point of view, a death declaration must be far more precise
and prompt.
In order to register a death, it must first be unequivocally pronounced.
For ordinary people, a person is dead when cold and livid; for this stage to
be reached, however, it is necessary to wait a good number of hours and,
depending on the circumstances, season, and pathology, there are always
pitfalls. All told, reports of dead people turning in the coffin or rising up
during the funeral are not entirely rare, even today.
These events are not necessarily surprising since the medical approach
to the definition of death is so demanding and complicated. Determining
‘death of the brain stem’, for instance, is a challenge even for many doctors
and many medical specialities.
Irrespective of the viewpoint we take, very liberal or rigidly professional,
two neurologic phases can be of help for routine purposes:
− preagonal, marked by psychic changes; and
− agonal, marked by the loss of contact with reality, vegetative
chaos, oneiric revivals, delirium, and anaesthesia.
Legislation differs greatly from country to country in terms of the
strictness applied to death registration. Ideally, the confirmation and
certification of death is done by either
− the responsible ward physician who is generally familiar with
the case or has valid and efficient access to the file, or
− a forensic specialist, on the basis of enquiry and, frequently,
upon autopsy, which takes place
• routinely for inpatients;
• in clinical cases with an unknown cause of death;
• under suspicious circumstances;
• in cases of unnatural etiology;
• if (in some places) the deceased has not been seen by a
physician within a fortnight;
• when death occurs during a surgical procedure; and
• when a patient dies while unconscious under a general
anaesthetic.
The required paperwork must be completed in detail considering that
− in any modern balanced society (with a similar birth and death
rate), the renewal of the population is about 10%, which is
quite high; and

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− insurance companies and pension administrators are always
eager for the utmost precision in death certificates.

15.5. Various legal implications
Some chapters in this book contain consistent medico–legal paragraphs
such as those dealing with organ transplantation and assisted death; there
remain a variety of legal matters, such as the following, which may find a
good place in a heterogeneous group.
Death perspectives in the case of Jehovah’s Witnesses
This protestant church exercises a strong opposition to receiving
blood or blood derivatives. Irrespective of the reader’s opinion of this
religious platform, the law defends their credo as a fundamental human
right. Consequently, the medical team must cope with the limits but is also
protected by the law in the event that death results, providing this is well
documented.
There are countries where, once admitted to hospital, a child becomes
the legal responsibility of the medical institution. This creates a sort of
hybrid scenario in which a legal parent has no legal right to take decisions
regarding his or her child; if the parents do want to assert their rights, they
must take their child out of the hospital – a nonsensical situation to say the
least, especially in the case of a severe condition.
Curiously, the medical profession has benefitted from the intransigence
of this religion: it turns out that one can survive with much lower values of
Hb and Ht than previously thought: 3.4 g% and 10% respectively (155).
Product of conception
− The foetus is not given a legal identity until it is able to exist
independently – practically speaking, to breath spontaneously
outside the uterus.
− For the same reason, a stillborn is not considered a person and
the medical institution does not fill in either a birth or death
certificate, thereby complying with the assertion that he who is
not alive cannot die.
− Pregnant women declared brain dead are kept on a ventilator
until the foetus becomes suitable for caesarean section (49); a
living human being results from a dead one!
− Gametes, as sperm, are retrieved from recently dead men for
artificial fertilisation at a later date.
− Copying Nature’s model of identical twins, we can envisage a

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Ethical and legal aspects
cloning of so–called genetically pure lines – a means of avoiding
rejection reactions and immunosuppression.
Death abroad
Any repatriation requires time, which is why embalming has to meet
certain standards, while navigating the differences in legislation and official
documents is the responsibility of the relevant diplomatic offices.

15.6. Miscellaneous
− During life, legislation exercises a rigorous hierarchy of rights
pertaining to one’s assets and possessions: spouse, adult child,
parent, siblings, and grandparents. Once dead, the body itself
does not interest the legal institution; it is due more to a ‘lack of
competition’ that the family has to deal with the body.
− Administrative details of the dead continue to be confidential.
− Finally, there are a good number of strange practises with dead
bodies, all illegal, such as necrophagia, lying in bed with a corpse,
performing obscure experiments on the dead, using human
skin to bind books, using craniums for artistic performances,
grinding bones for powdering wounds, etc.

15.7. Glossary
Death is defined as a termination of all biological functions that
sustain a living organism. This definition satisfies legal, medical, and social
requirements. There are also a number of euphemisms, such as passing
away, passing on, expiring, being deceased.
There are some circumstances colloquially termed ‘death’; thus they
are not really deaths:
− Apparent death – for lay standards, a person fits the definition,
but in fact not all three major functions are absent.
In the animal kingdom, death is sometimes a survival ‘technique.’
Some animals, to avoid attack by a predator, make themselves
appear unresponsive and presumably dead, while in fact they
are still alive.
− Black death – a pandemic plague.
− Good death – the treatment of a patient in accordance with his or
her stated (usually written) wishes and with pain management
through appropriate palliation.

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− Bad death – when there are few to no elements within the
patient’s or family’s control, and he or she dies in agony and
distress.
− Local death – death of a body part or portion of tissue by
necrosis.
− Social death –when a person is excluded, shunned, or ostracised
by society.
Due to the complexity of death, from institutional and social viewpoints,
there are a great many terms in use. They are not all semantically related to
the process of dying, and it is sometimes difficult to distinguish the medical
and legal implications; this text gives priority to the medical viewpoint.
Among the many versions of dying, those below, arranged in an
alphabetical order, are the most frequently used:

Assisted death or assisted suicide – death by a lethal medication
administered by a medically qualified person.
Capital punishment (death penalty) – a death carried out institutionally
as punishment for a crime.
Cerebral death (commonly known as brain death) – consists in a
stable lack of any sign of nervous activity at the brain stem level under
normothermia.
Circulatory death – a cardiac arrest as a result of advanced humoral
autointoxication, most often following a respiratory depression and a
comatose state.
Clinical death – is the interval between the disappearance of vital
functions and the occurrence of irreversible nervous lesions; usually of 5 to
3 minutes in duration.
Delictual – involuntary manslaughter (varying in detail from place to
place).
Euthanasia – from the Greek, meaning a good, easy death; it is a
deliberate intervention undertaken with the express intention of ending
a life to relieve suffering and intractable physical pain. There are various
versions:
− Passive entails the withholding of a given treatment otherwise
necessary for the continuance of life.
− Active entails the use of lethal substances or forces.
− Voluntary is conducted with the person’s consent and the
assistance of a medical worker.
− Non–voluntary is conducted without consent.

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Ethical and legal aspects
− Involuntary is conducted against the patient’s will.
Fatality – death resulting from a disaster.
Foetal death – the spontaneous intrauterine death of a foetus at any
point during pregnancy.
Functional death – the absence of central nervous system activity while
vital functions are artificially supported.
Genetic death – death of a bearer of a gene at any age before having
generated offspring; compatible with good health and a long life.
Homicide – death of a human being caused voluntarily or involuntarily
by another person, with or without intention (murder and manslaughter,
respectively), and with or without premeditation. The murder of prominent
public persons in a planned attack, with a political or ideological motive,
sometimes carried out by a hired or professional killer, is known as
assassination.
Natural death – death occurring under usual circumstances due to an
illness.
Premature death – a death occurring before a person reaches an
expected age, which today is around 75 years (average life expectancy);
many of these sorts of deaths are preventable.
Programmed death – referring to cells, the death of a cell in any form
mediated by an intracellular programme; carried out in a regulated process
during the organism’s life cycle.
Real death – death with postmortem changes, putrefaction, and cooling
inclusively; irreversible.
Selfie death –an accidental death that occurs in the act of taking a
photograph known as a selfie (thereby immortalising the moment).
Somatic death – a state in which the body irreversibly loses its sentient
personality, is unconscious and unaware of or unable to interact with the
environment, and can no longer appreciate sensory stimuli or initiate
voluntary activity. Reflexes are intact as is the cerebro–respiratory activity.
Stillbirth – semantically, an interesting version of a proper death; the
evacuation from the uterus of a well–developed but non–viable foetus
after 24 weeks of gestation.
Sudden death – occurs rapidly, unexpectedly, or from 1 to 24 hours after
the onset of symptoms, with or without known pre–existing conditions.
Suicide – the intentional taking of one’s own life; generally linked to a
psychiatric emergency (suicidal behaviour).
Unexpected death – occurs earlier than anticipated.
Violent death – death resulting from an accident, disaster, or human act

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that does not respect the vital integrity of an individual; it can be accidental
or criminal, and includes patricide, fratricide, infanticide, or genocide.
There are also deaths of medical origin, which, as discussed earlier in
various parts of this book, can be rather difficult to comprehend at first
glance. They can be caused by iatrogenic reactions, technical errors, or
negligence. Until an official decision is reached, such deaths are regarded
as suspect.
There are also a number of terms derived from ancient Greek:
Thanatos – death
Thanatology – scientific study of death
Necrology – statistics on or a record of deaths; list of the recently dead;
an obituary
Necrophagia – eating cadaver meat
Necrophilia – sexual intercourse with or attraction towards corpses
Necrophobia – extreme or irrational fear of dead bodies
Necropolis –ancient cemetery
Necropsy – autopsy
Nekros– corpse
Necrosadism – mutilation of a corpse for the purpose of exciting or
gratifying sexual feelings
To conclude, human remains are termed cadaver, corpse, body, or a set
of remains. A carcass generally connotes animal remains.

286
16. Capital punishment
(40, 56, 141, 161, 165, 184, 222, 224, 243, 315)

16.1. Beheading 288 16.5.4. The case of Jesus 295
16.2. Hanging 289 16.5.5. Conclusions 296
16.3. Burning at the stake 289 16.6. Stoning 296
16.4. Impalement 290 16.7. Duelling 297
16.5. Crucifixion 290 16.8. The gas chamber 297
16.5.1. Introduction 290 16.9. Shooting/Firing squad 298
16.5.2. Technical problems 291 16.10. The electric chair 299
16.5.3. Medical aspects 293 16.11. Lethal injection 299
16.12. Other versions 300

Designed to eliminate incompatible individuals from community life
and to discourage bad social behaviour through fear, capital punishment
(death penalty) has a long history. To generate fear, executions used to be
staged publicly with as much fanfare as possible and incorporating a variety
of humiliations. It has been a long road to the modern versions that simply
aim to remove the person in question from public life.
According to current social standards, capital punishment remains a
brutal procedure. There is a strong international movement in support of
human rights working to eliminate capital punishment from current judicial
sentencing practices. Indeed, 97 countries have abolished it, 34 have not
used it for more than ten years, and 8 are keeping it in reserve, while
only 58 countries actively apply it today. According to current statistics,
approximately 3,000 convicts have been executed during the last decades
and another 9,000 are awaiting execution (300).
A short historical retrospective may be of interest.

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16.1. Beheading
In a literal sense, it is used on an industrial scale for slaughtering animals,
but legally it has also been and still is a method of capital punishment in
some countries.
Going back in time, it was used extensively due to its technical simplicity
and its high rate of ‘success.’ In the Middle Ages, it was reserved for nobles
and other political or influential figures. Some famous decapitations include
Mary Stuart, Louis XVI, Marie Antoinette, Robespierre, and a number of
popes. To ‘add insult to injury’, postmortem decapitations were sometimes
carried out, as was the case with Thomas Cromwell and Vlad the Impaler. It
is, today, in regular use in Saudi Arabia.
From the ‘technical’ point of view
− beheadings have been carried out for millennia, with either
a sword or halberd, and it was very much a matter of the
executioner’s skill; not rarely could one witness a real slaughter;
− going back to the 13th century, a precursor to the French
guillotine had already been used in England.
Having to sacrifice a great many aristocrats, the French Revolution
desperately needed a rapid and reliable method of decapitation. Under the
guidance of Dr Joseph Ignace Guillotine (1738 – 1814), Schmidt, a German,
crafted a device that operated gravitationally – an instrument which came
to be known worldwide as the guillotine.
Installed in public places with a large capacity, the guillotine consisted
of a large, solid wood frame hanging from the middle of a heavy socket with
a robust and very sharp blade mounted in such a way that, when freed,
it fell by its own weight onto the convict’s neck, which was immobilised
just below. The severed heads were collected in nearby baskets. The
sudden interruption of the blood vessels of the spinal cord and neck
certainly produced an instant death and was undoubtedly pain free. Some
movements of the eyes, eyelids and other body parts were all caused by
disparate neuronal discharges.
It is worth mentioning the real injustice of Dr Guillotine’s fate: while
his main goal and success was to reduce human suffering during execution,
because of the device’s name he became essentially synonymous with the
role of executioner.

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16.2. Hanging
Mentioned in biblical scripts, hanging has endured due to its simplicity
and low cost. By hanging the convict suddenly, his own weight straightens
the rope looped around the neck. As for the mechanism of death, there are
several contributing factors, such as
− suppressing the lumen of the neck vessels to and from the
brain;
− obstruction of the respiratory passage;
− possible spine fracture and sectioning of the spinal cord; and
− an inhibitory vagal reflex leading to neurocardiogenic syncope,
causing a rapid death.
As with other traditional capital punishment methods much depended
on the executioner’s skill. Albert Pierrepoint, cited as having hanged over
500 criminals, was known for visiting his victims in advance (184).
Similar to other punishments, hanging represented an efficient
modality of social control. Henry VIII (1491 – 1547) remains famous for
having hanged no fewer than 72,000 disobedient people during his 34–year
reign. Nowadays, hanging is rare and, when used, it is most often done
inside prisons. Some public executions are, however, performed from time
to time. Despite modern technical advances, failures are still possible. An
Iranian case, recently reported in the media, involved a hanged prisoner
who was found alive in the prison’s mortuary the evening after his execution.
Having been officially sentenced to death, the convict was transported to
hospital and, after the necessary clinical improvement, was hanged again
(314c).

16.3. Burning at the stake
Burning at the stake, known since ancient Greek and Roman times,
has long been used for various sorts of social disobedience. Appealing to
the symbolic significance of fire, the Inquisition adopted it as a method
of purification in response to witchcraft and heretics. Slave owners also
systematically used this brutal type of punishment for rebellious slaves,
and the indigenous Americans used it for captured European invaders. Two
historically famous victims were Joan of Arc, 1431 and Giordano Bruno,
1600.

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The convict would be immobilised on the stake; pieces of wood were
placed beneath the feet and set on fire, producing heat, flames, smoke,
carbon monoxide, burns, pain, and blood loss. Over the centuries, a number
of technical ‘improvements’ were implemented, such as
− dousing the clothes with petrol or other flammable substances;
− covering the convicted person’s body with pitch;
− stringing a necklace of small purses filled with gunpowder
around the neck, which meant that when the fire approached
the head it caused serial explosions; and
− a modern version consisting of placing the victim upright inside
a stack of tyres, which are spread with petrol and then set on
fire.
− This last variant is presently used as a suicide method as well.
Nowadays, this barbaric method is illegal in the light of international
legislation. It is used, however, in various versions on the Asiatic continent,
for suttee (a practice by which widows burn themselves at their husbands’
graves) and for political suicide among monks.

16.4. Impalement
Of Germanic origin, impalement was used in France by Louis XI. It was
not only a cruel punishment but also a method of terrible social constraint.
It consisted of placing the victim on a high stake (to be easily seen from
a distance), head up or head down, in such a manner that the body was
run through either from the neck or the anus. In this position the convict
remained, naked, for several days and nights until, as a consequence of
a complex state of shock – pain, dehydration, blood loss, and infection –
death occurred.
The Romanian leader of those times, Vlad III, was a passionate user of
the method, hence his morbid nickname, ‘the Impaler.’ He is said to be Bram
Stoker’s inspiration for his novel Dracula. Reputed to have impaled nearly
100,000 disobedient people, his reign ironically ended when he himself was
impaled by his Turkish enemies.

16.5. Crucifixion
16.5.1. Introduction
Throughout its history, crucifixion has been intrinsically linked to death.
Its first use is unknown but ancient Babylon has been suggested. Over time,

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thousands of prisoners of war, pirates, rebelling slaves, political agitators,
and religious fanatics have had their lives ended in this way. The Romans
are renowned for having developed crucifixion as both the cruellest form of
capital punishment and a powerful instrument of social control. Spartacus
and about 6,000 rebellious followers, among many others, were crucified
(73 –71 BC). After more than 500 years of extensive use, the emperor
Constantine abolished crucifixion in AD 315. It continued to be used,
however, by the Inquisition in France, Japan, and even during WW II in
Dachau concentration camps. Today, crucifixion is occasionally reported in
South Korea and Saudi Arabia, while in some countries there are people
who engage in devotional non–lethal crucifixion (174).
The Romans were a highly organised society recording many aspects
of their lives, but no written technical instructions for this frequently used
punishment have been handed down for posterity. Aside from a few secular
sources (Seneca 65 – 4 BC and Josephus AD 37 – 100), historians have had
to rely mainly on biblical descriptions, which of course are conflicting and
distorted by the symbolic context of the Gospels (Matthew, Mark, Luke, and
John) (310), the Torino Shroud (283, 238), as well as the imagery in paintings (20,
160). In 1968, on a Jerusalem construction site (Giv’at ha–Mivtar), a nailed
heel bone was excavated but, instead of being thoroughly investigated and
preserved for analysis, it was hastily reburied (108, 273, 298).
An interesting cultural fact is that the Romans reserved crucifixion for
the low social classes, slaves, and foreigners. Educated people seem to have
been excluded, although Alexander the Great infamously crucified a doctor
for failing to cure a close friend. While the large majority of the victims were
male, the few female victims were recruited from the category of witches
(118, 184).

16.5.2. Technical aspects
As already specified, the Roman methodology is best known.
Crucifixion was a public spectacle involving batches of victims and was
supervised by the military. One of the fascinating features of the process
was that the executioners were able to control the length of time it took
for death to occur. They were in the position of manipulating the method
applied so that the time of death was at their discretion (118). There were a
few important features of the method (225, 257):
A. The crucifixion candidate was physically abused. He received no food
or water, and his back was scourged with specially designed whips with
small pieces of bone and metal attached to the leather strands. These

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produced contusions and wounds.
B. After the above preparation, the victim had to carry the cross himself
to the dedicated execution site, usually over a distance of about half
a kilometre, which served to thoroughly exhaust and fatigue the
tormented man. The cross actually referred to the horizontal beam,
since the weight of the vertical shaft would have been too heavy for
most individuals.
C. The victim was secured, naked, either onto both the crossbar and
shaft – which was then raised from the ground as a whole or onto the
crossbar only – which was then lifted onto the already sunk vertical
beam. Methods of securing of the body varied; by using different
combinations of techniques, the degree of weight endured by the
hanging body could be controlled, which in turn influenced the amount
of time the execution took to run its course:
− The outstretched arms were either tied with rope to the
crossbeam or firmly nailed, usually through the wrists.
− Similarly, the feet could be tightly bound or nailed either
individually or together on the upright shaft.
− Depending on the executioner’s discretion, ledges could be
fixed to the upright post to support the buttocks or the soles of
the feet, or both.
A. The final part of the crucifixion was a brutal piercing of the right thorax.
The reason for this manoeuvre can be explained either as a coup de
grace for a human close to losing any residual vigour, or as confirmation
that death had occurred (79).
B. On some occasions different atrocities were added to the methodology.
Sometimes a head–down position was used or the private parts were
skewered. Bitter beverages were offered to the thirsty individual or
smoke–producing fires were lit at the foot of the cross. Wives and
children could be forced to witness the event. For these very reasons,
Seneca drew the conclusion that suicide is preferable to crucifixion.
C. The length of time for death to occur ranged from hours to days. The
controlling factors were the initial state of health of the victim and
the particular selection of techniques applied by the executioner. The
longest recorded time was nine days.
D. The whole procedure was overseen by the military, and the soldiers were
known to exhibit a great deal of arrogance, mocking and humiliating
the victim.
E. After death, most victims were left hanging to decompose or to be

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scavenged by predators. Some were taken down and given to families
for burial.

16.5.3. Medical aspects
History does not document any cases of people surviving crucifixion. It
was a technique that ended ‘organically’ with death. Only a single case is
reported of someone having survived an aborted crucifixion, an individual
already on the cross who received a late reprieve of sentence (174). As
stated previously, it was only the time it took for death to occur that varied.
A combination of physiological and biochemical changes led to a biological
exhaustion.
Modern medical science certainly has the necessary knowledge to
explain the pathophysiological changes leading to death, but since crucifixion
is no longer practiced, it is impossible to perform the necessary research.
Without raw data with which to test different hypotheses, it is only possible
to make deductions from historical observations found in biblical texts and
painted imagery (20, 160), mainly involving Jesus Christ himself (263). There
are books and publications, but the nuances of language are such that our
final medical explanation can only remain conjectural (174).
From the many hypotheses postulated, the following, all related to the
case of Jesus Christ, are realistic: asphyxia (15, 16, 154), acidosis (238), cardiac
insufficiency (65), arrhythmia (79, 159), coagulopathy (20) and pulmonary
embolism (36). The initiation of these pathophysiological states can be
attributed to
− profound psychological stress;
− lack of any water and food;
− pain from flagellation, nailing and lower limb fractures;
− hypovolemia due to fluid shifts, and fluid and blood loss from
trauma to various areas of the body;
− hypothermia, due to naked exposure and environmental diurnal
temperature changes; and
− bacteraemia from wound infection.
Asphyxia offers one of the most tempting explanations for the
mechanism of death, but in the final analysis it is probably not the decisive
mechanism. It was first formulated 100 years ago (154) and has recently
been revisited (16). The details of this hypothesis are as follows:
− The hanging body stretches the arms and consequently the
entire group of scapular muscles, such that the rib cage is then
fixed in an inspiratory position.

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− The expiratory intercostal muscles are too weak to counter this.
− That vitally important muscle for breathing, the diaphragm,
is from a dynamic point of view predominantly a muscle of
inspiration.
− Hence the respiratory cycle is maintained in a permanently
inspired state, similar to a serious asthmatic attack or severe
case of chronic obstructive airway disease (20).
− The only way for the victim to improve his breathing is to reduce
the traction on the group of scapular muscles by reducing the
weight of the body on the arms. To do this, he must push up on
his feet or make use of any ledges placed at the discretion of
the executioner and, by so doing, taking the weight of his body
off the arms. But this manoeuvre would be tiring on the leg
muscles and painful on the feet.
− Hence the victim would find himself pitting a need for air against
tired aching muscles and painful feet.
− If the weakened body and unbearable pain were not sufficient
deterrents to supporting the body, the executioner could hasten
the outcome by shattering the leg bones.
But the contribution of asphyxia is controversial if only because of the
following contradictory observations:
− At the Dachau camp (during WW II), it was reported that
fracturing the tibia and fibula quickened the death of the
crucified victim.
− On the other hand, reliable contemporary observers such as
Seneca and Josephus did not mention cyanosis – a definite
clinical sign of respiratory insufficiency – in victims, and neither
do the four Gospels refer to any cyanosis in their recounting of
the crucifixion of Christ.
− In addition, modern studies failed to reproduce severe asphyxia
in human volunteers.
Although asphyxia seems a logical mechanism, it can be neither the
single nor a major factor. The fundamental mechanism appears to be severe
hypovolemia with asphyxia a coexisting factor only. Hypovolemia leads to
freely advancing multiple organ failure through acidosis, coagulopathy,
pulmonary embolism, and cardiac failure. Asphyxia and hypothermia are
simply adjuvant or co–factors in the production of pathophysiological
changes (20, 94, 174, 263, 299).

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16.5.4. The case of Jesus
A number of aspects of Jesus Christ’s crucifixion, which are unique to
his crucifixion and are not described in routine common cases, have been
found in biblical texts (310). The most noted and discussed of these are the
following (121, 159, 160, 290):
− Before the crucifixion, Jesus Christ showed beads of blood sweat.
There actually exists a rare eccrine condition, haematidrosis, in
which, under extremely stressful conditions, sweat becomes
sanguineous (79, 94).
− Jesus declared himself the king of the Jews. When the Roman
soldiers mocked him by placing the crown of thorns on his head,
the blood loss and pain would have been compounded (79).
− As Jesus hung naked on the cross, there was a period of darkness,
perhaps due to an eclipse of the sun. That loss of warmth would
have accelerated hypothermia of the body and shivering (160).
− The fact that Jesus spoke while on the cross and gave a final cry
suggests asphyxia was not a paramount mechanism in his death
since vocalisation requires repeated expiratory dynamics. It is
also worth noting here that his legs were not shattered (79).
− The cry referred to above was said to be during Jesus’ final
moment of life, so death must have occurred suddenly during
this cry. The sudden death has been attributed to the following
different hypotheses:
• Syncope is suggested by the prolonged orthostatic–
induced hypotension and arrhythmia (70, 159).
• Pulmonary embolism cannot be excluded bearing in
mind that hereditary thrombophilia is frequently found
in that particular region (36).
• Pulmonary aspiration of liquid from the sponge,
containing vinegar (310), offered to Jesus may have
occurred and been facilitated by depressed pharyngo–
tracheal reflexes (79).
• Rupture of a cardiac wall is a possibility. Although only
written up in the last 150 years, many religious groups
have embraced the concept of a ‘broken heart’ (20).
− John 19:34 (310) writes that a puncture of the right hemithorax
produced blood and water. Pure blood would originate
from a cardiac chamber only, while ‘pure’ water might have
originated from the pleural cavity, pericardial sac, or stomach.
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Combinations of both would be found in any large oedematous
bullae that might have developed (34, 160).
According to the Gospels, unlike his two co–sufferers, Jesus died on
the cross without having his legs shattered. This detail combined with
the lack of information about events following the sudden death, have
led to speculation that resuscitation was organised. This speculation was
originally put forward by Venturini (3) and followed up by Lloyd Davies (157,
160). Fainting, a collapse or an apparent death have been postulated; such
a course is, however, highly questionable and would have been difficult to
accomplish for such a charismatic figure who was centre stage in a public
event.

16.5.5. Conclusions
a) Not only did Cicero consider crucifixion one of the most horrific ways
of dying, but history has also shown it to be one of the cruellest
forms of capital punishment.
b) A lack of raw data has compelled medical science to settle for
hypotheses and theories in explaining the mechanism of death.
c) A multiple organ failure secondary to hypovolemia seems to
have been the primary mechanism of death, with asphyxia as an
additional component. Although inducing asphyxia by fracturing the
legs may also have been a final strategy open to the executioner.
d) The significance of Jesus’ death was that he appeared again on
the third day. This has led the scientific community to propose
resuscitation theories, while the other side of the coin has allowed
the church to repeat its mantra of resurrection.

16.6. Stoning
Stoning, or lapidating, is an extremely old method of capital punishment,
administered by religious institutions. It consists of a collective killing by
throwing stones at people, both men and women, as punishment for
violating community standards of marital behaviour, adultery in particular.
Although it was once practiced by Greeks and Jews, it is today unequivocally
associated with Islam and Muslim culture, albeit there is no mention of it
in the Quran.
There are a number of particularities in how a stoning is carried out:

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− The condemned person is buried up to the waist (men) or neck
(women).
− A group of volunteers throw stones at the victim.
− The stones are selected on the basis of shape and dimensions
so as not to cause death in a single strike.
− The course of the execution is discontinued from time to time in
order to assess the stage of tissue damage.
The mutilation caused by stoning is more than obvious and the
death undeniably agonising. Medically, the mechanism of death is either
craniocerebral injury or traumatic shock.
Despite the orchestrated protests of human rights organisations, stoning
continues to be used in some countries with a questionable judicial system.

16.7. Duelling
Recorded as far back in history as Roman times, duelling is conceptually
an interesting death penalty, in that it is mutually agreed upon by the
participants. Following are some notable features:
− It grew out of a medieval code of chivalry.
− It made its zenith between the 17th and 19th centuries, mainly
on the European continent and particularly in France (the word
duel is French).
− It had two technical versions, involving either pistols or swords.
− It was even embraced by women (petticoat duels).
− Although generally practiced by military officers and members
of the nobility and upper classes to gain ‘satisfaction’ rather
than to kill, plenty people lost their lives; during the reigns of
Henry IV and VIII there were approximately 4,000 and 8,000
deaths respectively.
− It was adopted as an event in the Intercalated Olympic Games
at the beginning of the 20th century, but the interest in fighting
duels has finally faded, the last episodes having taken place in
France in 1967 and Mexico in 1971.

16.8. The gas chamber
This form of execution was used extensively in concentration camps
during the WW II, for the purpose of mass extermination. For a single
convicted person, the technique is much too laborious to be economical.

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However, it has been used sporadically in the United States.
Technically, the procedure runs as follows:
− The convict is seated on a chair.
− Beneath the chair there is a reservoir containing granules of
potassium cyanide.
− Once the execution order is given, sulphuric acid is poured on
the granules.
− The resulting gas, hydrocyanic acid, saturates the tightly sealed
room.
− Death occurs instantly or very rapidly.
− The gas is neutralised by ammonia; once this is done, the
forensic doctor is able to declare the death.
The mechanism of death is the blockage of respiratory cell enzymes,
in itself a rapid process; however, the onset of this stage takes 10 to 15
minutes from the release of the gas, a period during which the victim is
tormented by headaches.

16.9. Shooting / Firing squad
This represents, globally, the most widespread modality of capital
punishment. Extremely common in the military, it is also used in civilian
settings. It consists of firing one or more bullets, targeting the head for the
brain, the thorax for the heart, or sometimes the victim’s entire body.
There are two technical variants:
− A direct shot, using a pistol, either to the head from behind or
laterally to the neck.
− More commonly, execution by a firing squad:
• In general, there are five firing guns.
• The riflemen are assembled either simply in a row facing
the convicted person or behind a wall with holes through
which the gun barrels are aimed at the victim who is
placed 6 metres away.
• Not all the guns are loaded with live rounds; for ‘ethical’
reasons, the members of the firing squad do not know
whose guns are loaded with a real bullet.
• The condemned person is usually blind–folded, and to
assist the shooters in aiming at the heart, a paper target
is often affixed to the chest.
If, for any reason, the shooting fails, the squad commander has to

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kill the condemned individual himself.
As the integrity of the brain is brutally compromised or its blood flow
suppressed, consciousness is lost instantly; as a result, death is presumed
to be instant and pain free.

16.10. The electric chair
This sort of capital punishment uses an electrical shock to kill the
victim. Imagined by Thomas Edison in person, the ‘chair’ was designed by a
dentist, Alfred P. Southwick. The mechanism consists of a massive discharge
of electrical current into the convicted person’s body. In order to be sure
of the effect, the voltage hugely surpasses the biological tolerance of any
tissue.
It was used for the first time in 1890, and remained a preferred American
method of execution for quite some time. The Ethiopian emperor at the end
of the 19th century ordered three such instruments of punishment from
the American manufacturer only to realise upon delivery that his country
did not yet have the electricity needed to power them.
From a technical point of view
− the victim is bound to the metallic chair;
− the two electrodes are secured,
• one on the head, and
• the other on one of the calves;
− the face is masked with a hood;
− an electrical current of 2,000 V is discharged in under 15
seconds, 2 to 3 times, resulting in
• immediate loss of consciousness,
• generalised convulsions,
• a rise in body temperature to 60oC, and
• the appearance of electrical burns at the entrance and
exit points.
The mechanism of death is a ventricular fibrillation or an asystolia;
either occurs as a consequence of the very first shock. The method is
laborious and harrowing.

16.11. Lethal injection
Of American inspiration, lethal injection is undoubtedly the most
‘civilised’ method of capital punishment. First envisioned towards the end

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of the 19th century, in 1982 it became the official procedure in some states
from the American federation; since then, more than 1000 individuals have
been executed. It stands out as a method that is implemented without any
humiliation and, speaking for the executioner(s), conducted with complete
anonymity.
The most important steps of this method are as follows:
− The condemned person is prepared, which includes receiving
proper hygiene, an appropriate meal and, sometimes, sedation.
− The condemned is provided with light and comfortable clothing.
− The condemned is positioned, slightly bent, on a simple
operating table such as those used for ambulatory surgery.
− Two operational external venous lines are connected to fluid
containers and dropping chambers, which are placed, via a
glass wall, outside the victim’s room, in an auxiliary space.
− The condemned person is offered the opportunity to make a
recorded personal statement before starting the procedure.
− Upon delivery of the execution order, successive injection of
what is known as the lethal triad, takes place. This consists of
• Pentobarbital 5 g,
• Pancuronium 100 mg, and
• Potassium chloride (concentrated solution) 10 g.
− The three are in current use as medications in hospitals; in the
above combination, the doses are immense. The profound
sedation and muscle relaxation cause an equally profound
tissue hypoxia, while KCl completes the death by asystolia.
− A doctor attests to the death, after which a forensic specialist
and a prosecutor finalise the case file.
The above–described procedure respects the victim’s dignity, avoids
any pain and discomfort as well as any eye contact with the executors.
There are at least two executors; both or all concurrently inject the same
amount of fluid without knowing who among them administers the lethal
dose. Finally, the dynamic of the procedure by and large satisfies human
rights organisations. The convicted person is quite simply removed from
society without any humiliation.

16.12 Other versions of capital punishment
The above–described methods are those that are somehow
‘standardised.’ The list is much longer, and rather impressive in terms of

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how creative societies have been in their approach to punishing people
for the endless varieties of violence, felonies, and delinquency throughout
history. Due to improvements in social structures and increased community
cohesion, many forms of capital punishment have fallen out of use given
their unnecessary cruelty. For the reader’s curiosity, here is a compact list
of selected defunct methods,: snake and spider bites; boiling to death;
being crushed to death; being crushed by elephants; being devoured by
animals (lions, crocodiles, sharks, piranhas); disembowelment (seppuku);
dismemberment; drowning; evisceration; flaying; gibbeting; hanging
from gallows; keelhauling; scaphism; death by sawing or sawing asunder;
smothering (suffocation in ash); scorpion sting; garrotting; being torn apart
by horses, camels or boats (2 or 4); being thrown into a quagmire; and
trampling by horses.

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17. Autopsy
(40, 90,184, 235, 243, 271, 303)

17.1. Historical considerations 303 17.5. Medico–legal features 309
17.2. Who can take part 307 17.6. Auxiliary examinations 311
17.3. Practical course 307 17.7. Inconclusive autopsy 312
17.4. The aims of autopsy 308 17.8. Findings in resuscitated cases 312
17.9. Final report 314

17.1. Historical considerations
Three terms are in current use:
− two from the Old Greek
• necropsy, meaning to look at something without life,
linguistically the most appropriate, and
• autopsy, to see for yourself, the mostly used version, and
− a third, derived from the everyday spoken English, that of
postmortem examination, which always needs a specification
concerning the sort of examination, external or complete.
Autopsy is a surgical procedure, having in itself a particular strategy,
with a given purpose, a consecrated technology and a precise timetable;
evisceration and dissection, similar in some respects, are not autopsies.
There are more types of autopsy primarily according to its goal as:
− investigational or medico–legal, practised by forensic specialists
in order to find the cause of death,
− clinical or academic, for hospital and teaching purposes, aiming
at inventorying the pathologic findings and correlating them to
the clinical picture and mechanism of death,
− public, carried out for educational reasons addressed to lay
people, having always an emotional message; neither in the
past nor nowadays has this sort of autopsy been done on a
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regular basis, and
− scientific, in the context of some research projects.
As autopsy is by virtue disfiguring, religions have not favoured it openly
since, for life after death, the body integrity is essential. Then, along the
centuries, it has fed an instinctive reticence. Despite these two drawbacks,
autopsy has had in its early history remarkable moments:
− already during the 3rd century BC, autopsy was done by notable
personalities like Erasistratus and Herophilus in Alexandria;
− around 150 BC, the Romans had a set of regulations dealing
with the practical aspects of the procedure;
− in 44 BC, Caesar in person was autopsied; and
− half a millennium later, Justinian promulgated a law according
to which an autopsy was obligatory in all cases of suspect death.
During the next millennium, with its Arab dominance, autopsy was
given little attention. It was only in the 13th century that the autopsy
started to be used again for establishing causes of death and even for public
demonstrations. The Chinese of those times also had a set of practical
instructions.
Renaissance was the epoch when a real professional attention was
given to the autopsy. After its ‘launching’ by Giovanni Morgagni (1682 –
1771), the founder of Pathology, the autopsy flourished both as a concept
and technical details in France, Britain, Germany, etc.
A number of achievements have been reached in the turn of the
19/20th centuries:
− In the USA and Britain, the autopsy skills became a compulsory
certification requirement for those aiming at exercising high
professional responsibilities.
− An Austrian set of autopsy regulations, appeared in 1856, had
no less than 134 paragraphs – an administrative approach more
substantial than even in industrial sectors.
− Two titans appeared later in the science and practice of
Pathology:
• Karl von Rokitanski (1804 – 1878) who autopsied the
entire number of his cases, about 30,000, and
• Rudolph Wirchow (1821 – 1902) who built the modern
concept of cell pathology.
− In the USA, again, W. Osler, R.C. Cabot and the so called
Flexner’s commission, 1910, managed to introduce autopsy in
the curriculum of any doctor on an academic position.

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Progressively, autopsy has become increasingly standardised reaching
an international consecration; a Model Autopsy Protocol was issued under
the United Nations patronage in 1991, according to which an ideal version
of autopsying unit has to
− have a dedicated place;
− be an affiliated unit of a Pathology institution;
− be served by enough auxiliaries;
− possess special instruments;
− be able to organise useful laboratory examinations; and
− have access to special investigations as CT, NMR, etc.
Meeting such needs, a medical institution should also have a well–
established personnel strategy and the necessary budget resources. Private
units of such profile have not been usual.
Two social factors have always had something to say in the autopsy
domain
− As mentioned before, church has been in general formally
reserved to it; reserved but not quite ostentatiously hostile.
Maybe, on the contrary
• Pope Clement, for instance, ordered in person autopsies
for plague victims;
• whereas the conjoined twins used to be autopsied for
having ‘their souls rigorously inventoried’.
− As far as the families of the deceased are concerned, their
positions depend on the circumstances such as
• When an official order is issued for an investigative
autopsy, the family has no space of manoeuvre to oppose
or raise any condition.
• At its turn, the medico–legal team in charge does its
best to perform the procedure in time and with as little
disfigurement as possible.
• In common cases, these are the families who are in
control. The medical team is that which, for clinical and
academic reasons, courteously asks them for permission
to organise and perform the autopsy with the strictly
necessary anatomical disruption.
• Finally, when a premonitory agreement for an autopsy
with a research purpose is in force (according to an
advance directive, for instance), it is a matter of common
sense to also have family approval.

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− Difficult situations have resulted in the past when the dead
and family belonged to a religion with a very strict stance in
terms of corporal integrity, as the case of Orthodox Jews and
Jehovah’s Witnesses. In recent times, there has evolved a sort
of emancipation of their ideologies while, in their turn, the
forensic officials contact in person pre–emptively the religious
representatives. An interesting approach has taken shape in the
last time by embracing a creative interpretation of the Thick
Book. Appealing to a particular quotation (Deuteronomy 21:23),
the autopsy is branded as ‘an action in support of life’ (what is
actually perfectly right) and, given this, easier accepted.
Considering the family consent for any clinical autopsy and the
indiscriminative opposition the so called human rights organisations
exercise, the matter deserves a wider consideration:
− An inexorable natural disfiguration follows to happen anyway,
no later than weeks or months, due to the decomposition
process.
− What the families do not also know is that
• in half of the autopsied cases important, sometimes
essential, pathologic data are obtained,
• in 1/3, diagnostic discrepancies are present,
• in 1/4, the cause of death is a huge surprise,
• while the proportion of diagnostic failures of autopsy
proper is of only 5%.
− Or, the entire series of the above findings are lost by not
performing autopsies. Consequently, these are, unfortunately,
the hospital institution and affiliated medical schools which are
the real losers!
It would be therefore, a good reason for the human medicine to take
the example of its veterinary sister in doing autopsy without any exemption
in any case of death. Such a policy would be of nature to substantially
reduce the dubious court actions initiated by some ambitious lawyers and,
in particular, laborious and costly exhumations.
As stated earlier, an external postmortem examination (in fashion
these days in Canada, France and Germany) offers very little but it can,
at least, represent a starting point for further considerations in case of a
deadlock. Its contributions could be improved by combining it with high
tech investigations also used for clinical purposes as CT, NMR, helical
tomodensitometry; such an interpretation based on imagery data is known

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as virtopsy.

17.2. Who can take part in the autopsy
The responsibility of the autopsy belongs to the attendant pathologist or
the forensic specialist in charge with the case. Their teams are accompanied
by
− those who had treated the patient, in case of a clinical autopsy;
− all human factors involved in an investigational one: prosecutor,
police representative and, possibly, a doctor chosen by the
family;
− students from various clinical units, Pathology and Forensic
medicine;
− research people, in case of a scientific autopsy; and
− when the autopsy is run for public demonstration purposes,
more or less common people.
The final autopsy report has to list the (main) participants, particularly
in medico–legal and controversial cases. While the details of the autopsies
vary, the main facets are very similar; this is the background which
makes the two main sorts, clinical and investigational, essentially pretty
interchangeable.
Finally, there are circumstances and cases which give the autopsy an
aura of secret – settings where, for good reasons, a restricted number of
participants are given the required permission to take part.

17.3. Practical course
Autopsy is a procedure usually run in the first 2 – 3 days after death. A
number of practical details are important:
− The venue could be specific, hospital or forensic units, although
a unique establishment with a flexible timetable is the most
common variant.
− The cases are sent for autopsy either by the hospital where the
death occurred or by a prosecution office.
− The families are informed and asked for cooperation.
The main purpose of a clinical autopsy consists in verifying the
correctness of the premortem medical interpretation. In its turn, the
investigational autopsy has as main interest to find the definite causes of

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death
− aggressions;
− unusual deaths: natural disasters, industrial and traffic accidents,
suicides and medical guilt (surgical or therapeutic version);
− suspect deaths: sudden, obscure, litigious; and
− cases unseen by a doctor during the last two weeks are also
autopsied in some health networks.
The two less usual sorts of autopsies, scientific and public, are run with
a small number of research people in the first case and, on the contrary, a
large number of participants in the second one.

17.4. The aims of autopsy
The purposes of an autopsy aim at a number of details as:
− exact identity of the case; some anthropometric and nutritional
body features could be of help;
− in case of a newborn, whether it was delivered alive;
− any external sign;
− the entire series of pathologic findings in unexpected deaths as
valve rupture, aortic aneurism, regurgitation of gastric content,
pulmonary embolism;
− exact causes of death;
− any sort of body lesions; and
− the approximate death time and possible mechanism.
Sometimes parts or entire organs may be ‘retrieved’ postmortem. In
this respect
− a premortem agreement should be in force,
− the family is undoubtedly involved if available, and
− the forensic specialist could oppose to the retrieval of any organ
in the case that that particular organ is of a present or a later
forensic interest; in the case the organ to be retrieved is not of
forensic interest the person in charge with the autopsy has no
right to make any opposition to any retrieval.
− the most frequent auxiliary examinations are of histology,
toxicology and microbiology type. Sometimes, organ(s) or
whole body are stored for such complementary examinations.
Once the required steps passed through, the cavities are thoroughly
closed and the cosmetic standards met.
As it dies everywhere, quite often the forensic cases have to be sorted

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out by not fully qualified medical personnel – a real problem for health
authorities.
Irrespective of the authority responsible for autopsy, this has to be the
object of a detailed final report.

17.5. Medico–legal features
Autopsy ‘scene’
In general the bodies are transported to the pathology facility of a
given medical centre. Once the identity sorted out, the corpse in discussion
is secured in a frigorific cell until the autopsy time, when it is made available
for the team in charge.
There are cases where, for the sake of accuracy, the autopsy is carried
out in the very environment of death, using a campaign set of instruments
and everything else necessary. In densely populated areas, with multi–
disciplinary hospitals, one runs on call forensic services.
Case history
Any case has its history; in forensic terms, even ‘no history could
signify consistent history’. Different from the clinical settings, various false
information may be forwarded to abate the case from the truth, aiming at
benefitting a so called ’third part’.
Body identification
This is not primarily a medical problem, belonging in fact to the inquiry
team. The medical counterpart is however in the position to be of a real
help taking into consideration
− the former use of medical items: syringes, hearing aids,
spectacles, inhalers, crutches, pacemaker, defibrillator,
prostheses (leg, femoral neck, ocular, dental implants);
− scars, eye(iris) colour; and
− genetic details, of a great value in cases of body disfiguration as
are those secondary to air crashes.
The family could also be of a real help.
Temperature
It has an important role in finding the death time. The body temperature
is variously affected by the environment and eventual premortem fever.
The body area where the temperature is measured counts very much. A
basically reliable one would be the rectal ampulla; unfortunately it is not
advisable to interfere with the rectal lumen since it is sometimes used for
sexual intercourse, an event of forensic interest itself.

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External appearance
It has a real significance for the two major types of autopsies, clinical
and investigational:
− Postmortem changes reduce the body length; given the early
cadaveric alterations, the real body length does not run from
top to toe but from top to heel.
− Corporal integrity (hair, nails, ears and eyelids), permanent
tattoos, skin colour, jewellery, etc should all be considered, if
and when possible, on the death site.
Internal examination
In a case of investigational autopsy, the internal findings are not so
important as in the clinical ones – a reason why in this respect the two sorts
of autopsies are not interchangeable. What take priority for the forensic file
are the cause and mechanism of death.
Infections risk
Many infectious sources are peri–mortem realities: HIV, tuberculosis,
anthrax, plague and in particular hepatitis. It was surprising to learn that HIV
is transmissible after as long as a fortnight from the moment of death. The
modern protocols of work require special anti–infectious policies for each
microorganism but it is worth mentioning that, thoroughly used, the simple
classical anti–infectious measures (gloves, mask, boots and impermeable
costumes) are practically efficient.
Putrefaction
Quite often an autopsy is carried out or redone at different stages of
putrefaction. Or, the degree of decomposition varies consistently with the
time elapsed since death. Body parts get decayed with different dynamics;
one quickly decaying is the brain while histological structures with much
constitutive conjunctive tissue, as blood vessels are, on the contrary, quite
resistant.
Exhumation
This is an ambiguous term, speaking not what it means ad litteram.
Only that body is exhumed which was genuinely inhumed. A fraudulently
buried body is simply brought out! The technique is laborious and costly –
two good reasons for the procedure be organised appropriately and well
in advance. The services brought by an exhumation vary; barbiturates, for
instance, could be found in the remains even after eight years while, in an
acid soil, even the bones loss their essential features after such a period of
time, disappearing later altogether.

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Transport
Soon after the description of the relevant local details, the body is
transferred to the dedicated facility of the pending medical centre. This
transfer is carried out well wrapped up in order to avoid any additional
unwelcome body changes.
Video documentation
The classical facilities continue to be used throughout on the planet.
Additionally, digital, ultraviolet and infrared photographing are
nowadays norms. As a curiosity, there are cases where, for well justified
reasons, any necessary documentation has necessarily to be done in
complete darkness.
Forensic activities for foreigners
When a suspect death occurs abroad, the consular officials have to
harmonise the requests with the local standards and possibilities. A collegial
solidarity is welcome; the most difficult problems to be dealt with are the
incongruities resulted from differences in the running policies.
An International Death certificate will be issued only once the autopsy
expectations of the two legislations concerned are fully met.

17.6. Auxiliary examinations
There is no autopsy in the current practice without several auxiliary
examinations; the mostly done are:
− Histology: due to many and various versions – histological,
immune–histochemical and fluorescent microscopy – it is
advisable to use for fixation a recipe with a concentration of
formaldehyde not lower than 15%.
− Toxicology: for each toxic one disposes of consecrated sets.
− Microbiology: germs, viruses, fungi and haemoculture. The
early decomposition of the digestive organs is of nature to
largely interfere with the microbiological investigations.
− X–ray examinations. The technical units routinely necessary are
classical X–ray machine, computing tomography and magnetic
resonance, as well as portable and mobile X–ray devices. These
all require for use technicians, developing accessories and
information digital stocking facilities. The forensic departments
covering the entire variety of investigations are usually in the
position to also run coronary and vertebral angiographies.
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17.7. Inconclusive autopsy
For bureaucratic reasons and not only, each case of death has to have
its cause clarified although this is not always a simply issue:
− There are severe conditions like epilepsy, asthmatic attacks,
SIDS where, in case of death, the autopsy does not find any
particular pathologic changes.
− Those having died due to hypothermia, their possible tissue
changes reverse once the body warms; this is the reason why
such cases have to be stored at the death temperature until the
autopsy moment.
− On the other hand there are cases, mainly elderly, where the
autopsy finds plenty of pathologic alterations. Irrespective
of number and extension, they did not necessarily cause the
death, having actually been just accompanying lesions.
The above alterations do represent real professional challenges
particularly for young doctors known as inclined to ‘tick all boxes’, even
elaborating. In fact, it is not just rarely when the autopsy remains inconclusive
and a death certificate has to be circumstantially issued.

17.8. Findings in resuscitated cases
Resuscitation represents an area of so many and complex medical
acts that no other equals it in discrepancy between summum of severe
pathology and diversity of medical help competence:
− A resuscitation case is always one with terminal and rapidly
fading life resources as elderly, complex chronic and acute
pathologies.
− The help provider largely differs, from a well trained team to
any Good Samaritan.
This discrepancy is the background of the numberless complications
of resuscitation. It is, then, in the human nature to display under critical
circumstances much determination, often overenthusiasm. Or, combined
to the lack of appropriate knowledge and experience, these are of nature
to facilitate a large variety of complications. Nota bene, when resuscitation
is successful, any sort of complication – even a severe one – is accepted
by all involved. This is not at all the case in a case of death – when even

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an insignificant complication has compulsorily to be documented in the
autopsy file.
The most of them are actually common while a few quite controversial:
Common:
− The chest compression, as
• contusions of the compression area;
• ribs and even stern fractures;
• visceral lesions: haemopericardium, pulmonary rupture
– with or without pneumothorax;
• cardiac lesions – atrial, septal and vascular ruptures,
mechanical (post–injecting) haematoma of the cardiac
wall; and
• contusions of large vessels.
These are more frequent and more severe in the elderly.
− Relating to head manoeuvres are
• face and neck contusions, secondary to positioning for
oral ventilation, and
• gingival and tongue contusions, edentations as a
consequence of intra–buccal handling of different
instruments.
− Pre–thorax marks and real burns consequently to defibrillation.
− Due to the attempts of venous access, peripheral and central:
• subcutaneous haematomas,
• tissular tracks of various catheters,
• pneumothorax, and
• haemothorax.
− Sequelae at distance:
• retinal, and
• subarachnoid haemorrhage.
− Respiratory inundation with gastric content.
Rare complications like
− bone fractures: larynx, hyoid, mandibula, cervical vertebrae;
− ventricular wall rupture;
− rupture of esophagus;
− pneumothorax under pressure, consequently to hyperbaric
oxygenotherapy manoeuvres; and
− fat embolism, in lungs and myocardium.

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17.9. Final report
Once the autopsy finalised, the corpse is embalmed and given over to
the family in the perspective of burial. In between, a detailed final report is
prepared. Its structure and detailing have to respect both the general and
local standards. Copies are sent to the primary health care unit while every
effort is exercised to manage an adapted version for family needs. On its
details, the responsible health care office issues a death certificate.

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18. Cadaver and teaching
(83, 137, 184, 214, 235, 285)

18.1. Anatomy teaching 315 18.4. Recent acquisitions 319
18.2. Body Farm 317 18.4.1.Plastination 319
18.3 Artistic preoccupations 318 18.4.2. Thiel’s preservation 322

18.1. Anatomy teaching
Despite significant recent progress in digital imaging, 3D, and holography
inclusively, cadaver dissection with an unaltered psychomotor valence (62)
has remained valuable for anatomy teaching (268).
The very first dissections were carried out by Herophilus, in Alexandria
around the year 300 BC. Soon after, studying cadavers, Hippocrates, Celsus,
and Galen managed to describe the anatomy of the internal organs (231).
After the fall of the Roman Empire, anatomists had to face the opposition
of the Christian Church, which declared dissection incompatible with the
biblical concept of resurrection. It took nearly another millennium before
Leonardo da Vinci disseminated techniques of topographic dissection and
encouraged the opening of museums of anatomy, while in 1543 Andreas
Vesalius published his famous De Humani Corporis Fabrica.
The procurement of human bodies was a problem for centuries, making
life difficult for both tutors and students of anatomy:
− Initially, for social reasons, only bodies of criminals were used.
− Some anatomists used bodies from their own families for
dissection. William Harvey (1578 – 1650), for example, dissected
his father and one of his sisters.
− Others resorted to the risky practice of personally exhuming
bodies. Thomas Sewall, despite having been the personal
doctor of the then American president, was sentenced in 1818
for such an offence.
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− A black market quickly flourished in which a lucrative practice of
grave–robbery took shape. Being simpler to access, the graves
of the poor were preferred by these ‘body snatchers’.
− Medical schools in Scotland and England (which took the lead
in anatomy teaching from Italy in the 18th and 19th centuries)
managed to secure the necessary number of bodies by
employing body snatchers for the disinterment of corpses from
graves – a new and very well paid job for the time. One London
institution paid such workers to exhume about 300 bodies over
a single teaching season.
− The good pay and the resulting cadaver trade even led to
regrettable serial killings (293).
Scotland was the first place where the medical schools were able to
sort out this troublesome problem. The so–called Anatomy Act, legislation
is sued in 1832, permitted the use of abandoned bodies (from hospitals,
asylums, and labour camps) for teaching purposes.
Closely related to this have been the many preoccupations with finding
ways of tissue and body preservation:
− The Italian school of anatomy quite successfully used metal
amalgams after an initial tissue drying and treatment with
various oils. Some human parts obtained in that way are still
displayed on the shelves of museums, in Italy and elsewhere.
− Going back to Northern Europe
• Robert Boyle used full immersion in alcohol,
• Jan Swammerdan injected viscera with a mixture of wax
and turpentine, and
• Joshua Brooks left a set of instructions on how to
preserve bodies for dissection.
− Once William Harvey described circulation, Frederick Ruysch
(1638 – 1731) had the idea of injecting preservation solutions
directly into the vessels. Curiously enough, he did not leave any
instructions derived from his successful formulas; only a liquor
balsamicum is known.
− Two chemicals, already in use two centuries ago for preservation
purposes, have both proved suitable:
• Glutaraldehyde alone met the essential needs, apart
from the colour: the yellow of the resulting pieces
interfered with the process of observation and research.
• Not too long thereafter, formaldehyde followed, with a

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promising preservation career: good and stable quality,
some tissue flexibility, acceptable uniform grey colour, as
well as formula versatility (concentration of up to 40%).
• Combined in various proportions, sometimes with
phenol added, these solutions, in terms of practical
results, have rewarded many efforts.
In search of quality anatomical parts at the disposal of students, it was
recognised that the entire mass of tissue had to be impregnated diffusely
and as uniformly as possible. To obtain such a result, the only method was
to fill the entire vascular bed of the specimen concerned or of the entire
body. The following was required for such a purpose:
− The calculated necessary amount was introduced
• either under pressure, via an arterial access; or
• slowly, over the course of hours, intravenously, drop by
drop.
− The excess fluid
• either came out via an open vein, or
• was helped mechanically (with massage) to diffuse into
the tissues.
A well–treated body appeared uniformly grey in colour and without
irregularities in its contours.

18.2. Body Farm
This is an extremely interesting and highly efficient recent didactical
invention. American in origin, its short history only goes back to the late
1980s. As the name suggests, these ‘Farms’ use cadavers but not for
dissection; their use consists of a large, diverse, complex and intricate set
of dismal scenarios.
Like any department of anatomy, the Farms have to procure the bodies
themselves, which they do from any source possible: dead people without
families originating from asylums, prisons or – and this represents the most
significant proportion – from self–donation (through an advance directive).
Unlike anatomy departments, which always prefer adult, well preserved,
and whole bodies, the Farms are interested in any version possible, human
parts inclusively. This derives from their policy of simulating a large range of
possible death scenarios.
The beneficiaries of these Farms are or can be any candidate in
any profession having a minimal tangency with death and the corpse.

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Pathologists and forensic specialists in training could theoretically benefit,
but they do this in more appropriate medical environments. There are,
nevertheless, plenty of professions which, despite the lack of a real medical
curriculum, have much to do with death and its implications: prosecutors,
investigators, police forces, interested journalists, employees of various
funeral sectors, cremation technicians and anthropologists.
− The death scenarios, like in everyday life, are innumerable and
they essentially consist of placing a body in a variety of settings
such as in a car boot, beneath a pile of dry leaves, on the beach
or a river bank, under running water, immersed in a swamp,
locked in a suitcase, placed in various coffins or boxes, dropped
in a fountain, or subjected to mock strangulation.
− There are also special services offered by the Farms: the
dynamics of immersion and fire as well as how microbial flora,
parasites, and predators ‘organise’ and run their involvement;
dog training sessions and acts of arson are also available.
These didactical facilities also use high–level technology for research
purposes; it is possible to produce diagrams of temperature, humidity, or air
composition to identify the effects the environment has on decomposition.
A chapel and a modern mortuary are also parts of any respectable
Body Farm.

18.3. Artistic preoccupations
Looking at things retrospectively, the educational interest in notable
personalities fascinated by anatomy was sometimes doubled by artistic
preoccupations:
− Leonardo da Vinci is famous not only for his anatomically correct
drawings, but also for having rendered them more artistically
attractive.
− Dr Tulp’s Lesson in Anatomy (1631) is not only an artistic
production but proof of the painter’s interest in anatomy as
well.
− The prodigious Frederick Ruysch
• had a long academic career as a Danish professor of
anatomy;
• described lymphatic valves, bronchial vessels, and
vascular plexus of the myocardium;
• created special dioramas using anatomical details for

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particular messages (biliary and renal stones in a geologic
context, dry arteries used for a violin bow).
His legacy includes the success of two remarkable productions,
Thesaurus Anatomicus and Opera Omnia. Interestingly, his
dioramas were acquired by Peter the Great.
− Honoré Fragonard used death as a source of artistic inspiration.
His technique consisted of preparing anatomical arrangements
which, after carving, were injected for preservation with a
special (low melting point) metal alloy. The method proved to
be very efficient since twenty–one anatomical parts are still on
display at the National Veterinary School in Paris, in the district
of Maisons–Alfort.
− Two other anatomical artists should be added:
• Cornelius Huyarts (1669 – 1712), engraver, a close
collaborator of Ruysch; and
• Rosamond Purcell, a complex contemporary figure and
sort of Ruysch apostle, also a photographer, museum
curator, and writer displaying a strange interest in
anatomic anomalies combined with historical monsters.

18.4. Recent acquisitions
Under the circumstances of a continuously increasing world
population, more and more medical staff is becoming necessary. This staff
must be trained appropriately – a context in which, despite the successes
of digital technology, dissection remains of permanent interest for anatomy
and some surgical subspecialties. It is in this same light that some recent
acquisitions in the teaching process are more than welcome. Two new
methods of cadaver preservation hold great promise for any medical school
of excellence: plastination and Thiel’s preservation.

18.4.1. Plastination
As already specified, the best teaching in anatomy continues to rely on
open access to anatomic models (158).This need has been met by the large
acceptance of plastinated models for use in the educational process (43).
Developed three decades ago (111), plastination consists of an improved
version of formaldehyde impregnation (270). Technically, there are four
stages (2, 111, 113):
A. Fixation. The body part or the entire body is injected with and

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immersed in formaldehyde. Doing so, the process of decomposition
is avoided and the model is given a degree of rigidity, which ensures
the desired shape. In the case of body parts, it is only after this that
the dissection is carried out with an aim of achieving the planned
model.
B. Dehydration. The body or specimen is placed in a bath of acetone at
its freezing temperature, i.e. – 25oC.
C. The acetone is replaced by a liquid polymer (silicon, polyester, or
epoxy resin) by placing the model in a vacuum, which facilitates its
evaporation.
D. The polymer has to harden in order to give the model the desired
shape; this is managed by heating and exposing the model
concerned to ultraviolet rays. This process is highly versatile;
the desired parameters are easily achieved while durability is
remarkable.
There are numerous versions of models, depending on the body
area, the size, and tissue structure. It has taken more than twenty years
to develop the right formula for a range of specimens, from small animal
parts to large bodies. Dedicated teams have managed to plastinate a large
series of models up to an entire human body; the most recent one took
about 1,500 person–hours of work. The record for the relevant laboratory
was the plastination of an entire standing giraffe. This took three years (ten
times more than for the human model) and ten people to manipulate it (a
plastinated model generally retains the original weight of the body). A life–
size crucifix in full detail was also prepared for the Vatican.
Prof. Gunther von Hagens
Inventor of plastination, he has proved to be a controversial figure, from
both a medical and a public viewpoint. His achievement has demonstrated
huge educational potential but has also generated much ethical and public
debate. Combining information from medical and lay sources, the following
details may be of interest.
Born in Poland in the 1940s as Gunther Gerhard Liebchen, he studied
medicine in Jena and Lübeck. He earned a PhD from the University of
Heidelberg in 1975 and worked for twenty–two years as lecturer in Anatomy
and Pathology. In the interest of promoting and shaping his own image, he
adopted the more sonorous name of his wife and he used to wear a black
fedora during his tutorials, taking inspiration from Dr Tulp.
Invented in 1977, plastination was promptly patented and brought
to the attention of the scientific world (111, 113). Additionally, plastination
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Cadaver and teaching
represented an unrivalled technical tool for laboratories dealing with
material support of the educational process.
Similar to Dr Pierre Spitzner (who, in the 19th century, organised an
itinerant Great Museum of Anatomy consisting of wax models designed to
demonstrate the ravages of tuberculosis and syphilis), von Hagens launched
a Body World exhibiting astonishing plastinated models of smokers’ lungs,
brains after cerebrovascular accidents, and hepatic metastases, which have
proved to have a strong public impact (112). The Human Museum, conceived
as a comprehensive collection of anatomic plastinated models, represents
yet another great idea of the professor. Finally, he has left his wife precise
instructions on what to do with his body after his death: it is to be divided
into parts which, once plastinated, are to then be distributed to various
units of anatomic education in a variety of countries.
In addition to his invention and his great ideas of disseminating its
beneficial services, professor von Hagens has been involved in decades of
many collaborative but important activities:
− He has organised a meticulous record of all those having given
their consent for postmortem plastination, around 10,000 in
number.
− He has selected donors from Germany, Siberia, Kirgizstan and
China.
− He has opened Institutes of Plastination (in addition to the one
in Heidelberg) in Dalian, China, and Bishkek, Kirgizstan.
− He has supervised the recruitment of hundreds of useful
collaborators for international exhibitions.
− He has rewarded the good will of donors and generously
supported financial actions of interest; a famous case is that of
Alexander Sizonenko (thought to be the tallest person to date
on the planet, with a height of 2.48 m) to whom von Hagens
offered a considerable sum followed by a generous life–long
monthly indemnification for consenting to donate his body for
plastination after death.
− In 2006 he had a cameo role in the film Casino Royale, in a scene
focussed on his exhibitions on plastination.
− He has taken part in TV programmes, including a 2012 UK
Channel 4 series in order to disseminate the importance of
anatomy in modern education.
While abroad professor von Hagens has received much attention
and appreciation, being granted inter alia the title of professor by two

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prestigious universities (in Dalian, 1996 and in New York, 2004) at home,
in Germany, he has been harassed by various human rights groups and
religious organisations, fined and even sentenced following dubious court
actions. It is, unfortunately, also worth noting the arrogance of the domestic
academic authorities, which have deprived him of the many honours that a
figure of his complex range would seemingly deserve.
On a final note, a project of Professor von Hagens currently underway
does speak highly of him, for professionals at least, more than anything else:
a practical demonstration focussed on possible anatomic improvements of
the human body – a show of intellectual bravery and a determination not
common among free thinkers.

18.4.2. Thiel’s preservation
As mentioned several times, surgery practice is a serious competitor
of the anatomy community, in terms of accessing and using cadavers for
dissection for educational purposes, particularly for its laparoscopic variant
(1, 214). Unfortunately, the lack of flexibility of cadaver parts represents a
definite drawback in any dissection setting for laparoscopic surgery.
In the 1990s, Walter Thiel – professor of anatomy at the Austrian
University of Graz – managed to materialise a hybrid anatomical model,
cadaveric and impregnated, but impregnated in a manner such that the
model in discussion combines a rigidity ensuring appropriate shape with
enough suppleness allowing for the necessary degree of flexibility (264) .
The preservation formula features a concentration of formaldehyde as
low as 0.8% to which dimethylphenol, various salts for fixation, boric acid
for disinfection, and ethylene glycol for providing tissue plasticity are added.
After injection, the cadaver, tightly wrapped in a plastic tubular sheet, is
placed in a vacuum, at a temperature of 4 – 6oC. Such a cadaver has a usage
life of approximately one year.
There are a number of advantages to this sort of embalming:
− Colour, consistency and flexibility of organs are maintained, and
any parts are well preserved.
− Natural cavities remain closed; as such one may obtain reliable
pneumothorax and pneumoperitoneum and the joints can be
instilled and punctured.
− The lungs can be ventilated.
− No rigor occurs.
− Large vessels rarely host clots.
− There is a minimal degree of toxicity.

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Cadaver and teaching
− Efficient disinfection is achieved; the specimen does not mould.
Virtually any part of such a cadaver provides a perfect simulation.
There are also drawbacks to the method: it is costly (requiring dedicated
technicians and expensive chemicals); it has a tendency to promote
mummification; and it requires short sessions of use and refrigeration
between times – reasons for which the method is only used in academic
institutions with high standards.

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19. Methods of preservation.
(19, 40, 49, 66, 87, 95, 111, 113, 148, 164, 221, 231, 304)

19.1. Mummification 325 19.3.4. Modern concept 335
19.2. Smoking 330 19.3.5. How embalming is
19.3. Embalming 330 achieved 336
19.3.1. Embalming in the past 330 19.3.6. Embalmed personalities 339
19.3.2. Contemporary embalming 333 19.4. Taxidermy and wax sculpture 340
19.3.3. Chemistry of embalming 334 19.5. Cryonics 342
19.6. Computerised ‘preservation’ 345

Human beings like all other species, encounter confirmation of death
by their physical withdrawal. The overwhelming proof of this is the natural
process of decomposition.
Throughout history the elite classes have made a wide array of attempts
to evade the compulsory physical disappearance. Initially, there were
religious imperatives, followed by hygienic and practical considerations,
while more recently some rather special approaches have emerged and
been embraced. After millennia of mummification, embalming has been
and still is largely practised, while cryonics and computerised versions of
preservation have evolved in recent decades.
Although taxidermy refers only to animals and wax replicas only
preserve the external appearance, they will also be briefly presented at the
end of the chapter.

19.1. Mummification
The old Egyptians, as early as 6000 BC, were the very first in history
to have dealt with the preservation of the body. The religious doctrine
supporting preservation was aimed at the perennial soul. Once someone
was dead, they believed, the soul would run a ‘cycle of necessity’ for about
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3000 years and then come back to re–join the former host in his physical
body. Together, they were to spend a divine life in godlike company. This is
why the body had to be preserved as quickly and as well as possible.
From a technical viewpoint, the Egyptians reached a remarkable level
of craft. Their accomplishments were very much facilitated by the local
climate, more precisely by the considerably long periods of warm, dry
weather. Indeed, preservation was initially, achieved by simply placing the
dead body beneath the hot, dry sand. The bodies underwent such rapid
and advanced dehydration that any on–going degree of decomposition was
halted and ultimately eradicated.
Starting around 3000 BC, in the context of the social and political
progress, (in which the succession of dynasties played an important role),
the process of mummification became progressively more complex and
successful (164). There are, however, many archaeological incongruities.
As such the following description gives preference to understanding
the biological significance of how simple desiccation led to elaborate
mummification:
− Simple coffins containing the bodies of recently deceased people
were placed beneath a compact layer of sand. Such bodies,
found 1,500 years later, were remarkably well preserved.
− Natron (spread in cavities or used for immersion), an important
chemical adjuvant, proved to be a good desiccation enhancer,
of great significance for the preservation practices of those
times. A mixture of sodium salts, it was used at such a high a
concentration that the treated bones had a sodium content
twelve times higher than untreated ones. This certainly
explains not only the rapid and advanced desiccation but also
the complete sterility of the remains (231).
− Identified as having their own dynamics of preservation, the
viscera were dealt with differently:
• Special attention was given to the heart; considered
the headquarters of the soul, it had to remain in place,
untouched.
• The abdominal viscera were removed either by incision
or eviscerated through the anus;
• The brain, in its turn, was removed either by lifting the
brainpan or curetting through the nasal fossae.
− Once out, they were immersed in natron and re–introduced to
their original places – the cavities having first been cleansed

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Methods of preservation
with a similar solution.
− Throughout the process of mummification, much attention was
given to perfuming; both the outer surface of the body and
the open cavities were abundantly washed and rubbed with
various oils, resins, wax and bitumen. Modern science has since
identified many chemical properties explaining the effects and
supporting the use of these substances (231).
− Once the desired degree of mummification was achieved,
which took forty to seventy days, the dried body was wrapped
in fabric, mainly linen dressing, in a variety of geometrical
patterns.
− The proper cosmetic valence for mummies was given a great
impetus during the 21st dynasty, the goal being a result that
resembles, as near as possible, the deceased as he or she was
in life. To achieve this, they employed a range of cosmetic and
grooming practices (40):
• hair extensions and hairdressing according to the fashion;
• henna drawings on the skin;
• re–attachment of nails when, due to the caustic action of
natron, they detached from the fingertips;
• thematic drawings on the textile wrappings;
• gypsum masks (mummy masks);
• artificial (glass or stone) eyes; and
• even artificial legs.
− When the degree of mummification was not satisfactory,
additional exposure to the sun was provided. Once the
adequate degree was achieved, the mummy was placed in an
appropriate sarcophagus (usually of wood), and laid on gypsum
powder, as an extra measure to ensure stable preservation. The
positioning might be
• left sided or supine and
• with arms crossed or straight along the trunk.
− Once the chemical treatment of viscera proved to have good and
stable results, it was concluded that, apart from desiccation, the
outer part of the body does not need any special preservation.
Consequently, mummification became standardized as an easily
achievable technique.
The burial place of the Egyptians had always received attention.
However, after 3000 BC, the sophistication of burial sites such as mausoleums

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became a matter of both cult practices and social stratification:
− In the case of a pharaoh, after the entire range of body
treatments, rare and expensive chemicals were used; the
coniferous oil undoubtedly represented an extravagance
in desert conditions. The mausoleums were big buildings,
situated in special areas (necropolis) and surrounded by similar
constructions like chapels, cenotaphs, or even temples. These
were full of inscriptions and were used to store personal
and valuable items. The burial place reached its apogée de
grandeur – the pyramid – during the next millenium. It is still
considered the most grandiose human funerary achievement:
it is important to mention that the pyramids represented a
symbol of economic prosperity and, at the same time, an
efficient instrument of social control.
− Neither anthropology nor written records give an account of
the burial practices of females and children. One can conclude
that, except for privileged men, mummification was a pretty
basic one.
After the 21st dynasty, around 1000 BC and in the context of an on–
going economic decline, two burial trends took shape:
− Simplified, meaning evisceration and desiccation, followed by
an external treatment as described previously but on a smaller
scale; and
− A sort of democratisation of the funeral practices:
• The royal versions were rationed and the graves were
less monumental;
• Funeral inscriptions and other privileges, previously
only available to the elite, were also made available to
common people; the Book of the Dead, inter alia, has
been found in simpler graves.
For a millennium or so, the Egyptians continued to give much attention
to their dead, giving progressively less importance to the rich and gradually
reaching a non–discriminatory approach. The same attention was given to
the final resting place, which began to be built and equipped in anticipation
of death.
The next religious sects to intervene in burial practices were
− the Christian religion which, having advocated the notion
of resurrection, did not go well with the idea of a perennial
existence, and as such discouraged long lasting preservation;

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Methods of preservation
and
− the Arab invasion of the civilised world, around AD 600, with
their strict burial customs (the dead had to be buried before
sunset) represented a sort of coup de grace in the eradication
of any sophisticated preservation practices.
In the context of cult–based preservation, the craftsmen who
implemented those practices were well organised and all lived in the same
necropolis area, in close proximity to the priests’ community.
The scientific literature is unanimous in its plentiful accounts of the
Egyptians’ advances in body preservation and their concept of life after
death. It is, however, worth knowing that, despite the elaborate treatment
of some dead people and the magnificent ways of laying them to rest, they
did not
− leave any compact description of the mummification process or
any practical instructions;
− formalise their philosophical concept, which generated a cult of
such magnificence; or
− generate any school of anatomy (231) – something quite difficult
to understand.
It is therefore surprising to find that the first description of
mummification is credited to a Greek, Herodotus, a historian and a traveller,
round 450 BC.
‘To look like an Egyptian mummy’ was a widely used expression,
suggesting the Egyptians’ historical involvement in the physical process of
mummification. While they did manage the utmost in body preservation and
its adjacent religious cult, there had also been other populations that paid
attention to mummification as a method of preservation: the Chinchorro
(ancestors of the Chileans), the Aborigines, the Incas, the Peruvians, and
the ancient Ethiopians – all of whom also took advantage of the dry climates
of their geographical areas.
x
Natron
Taken separately or in the context of mummification, natron was
certainly a matter of Egyptian eminence. Widely used in technical English,
the term was successively derived from the Greek word nitron and the
Egyptian netjeri. The Mendeleev symbol of Na, in its turn, derived from the
new Latin natrium, inspired by Wadi El Natrium – an Egyptian valley rich in
extraction mines.
In modern chemistry, natron refers, in practical terms, to the Na
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carbonate, which represents the largest proportion; the other components
are Na bicarbonate, sulphate, and chloride. Useful for mummification,
natron
− facilitates water absorption, as it acts as a drying agent; and
− leads to an increase in pH when exposed to humidity, the
resulting solution becoming incompatible for microbial
multiplication.
In addition to mummification, the old Egyptians also used it as
− wound disinfectant;
− insecticide;
− for meat (mainly fish) preservation;
− component in a mixture with castor oil that forms a flammable
compound that does not generate smoke (appreciated for use
inside monuments);
− material for curing leather.

19.2. Smoking
Since time immemorial, this has represented a natural way of corpse
preservation; due to its impracticality, however, it was abandoned for
human use in favour of other, more reliable, methods.
The mechanism of preservation was used extensively for meat, due
not only to its dehydrating and antiseptic actions, but also to the complex
effects of numerous chemical elements found in wood smoke:
− non–condensable gases: CO2, CO, H2, CH4;
− organic vapours: acids, alkaloids, acetones, and aldehydes;
− fine liquid particles: aromatic hydrocarbons, phenols, cresols,
guaiacol and xylenol;
− soot; and
− ash.

19.3. Embalming
19.3.1. Embalming in the past
As previously stated, for various reasons much attention has been given
throughout history to the preservation of the body:
− first, for undoubtedly religious reasons, as in the Egyptian case;
− second, for teaching/learning purposes; and

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Methods of preservation
− finally, and most commonly, for social and hygiene reasons.
From the moment and place of death (notoriously different) to the
laying to rest (undoubtedly compulsory), the itinerary and time required in
any given case is unique. It has been, and still is, the role of body preservation
to address this inherent variety. Embalming – the chemical treatment of the
body (originally part of mummification) – has progressively gained much
importance.
The chemistry of embalming has made use of a great many
compounds. The most used substances have included: alcohol, various
acids, oily solutions (lavender, turpentine, cinnabar, camphor, purples and
rosemary), antimony, colophony, creosote, copper salts, mercury, sodium,
zinc, aluminium, potassium, arsenic and glutaraldehyde. Of course not
all methods still remain in use; Ruysch’s famous liquor balsamicum, for
example.
An important step forward in the process of embalming came with
Wilhelm von Hofmann’s discovery of formaldehyde. Affordable in terms of
cost and sourcing, it quickly proved extremely versatile and superior to any
other agent used in the past. It has now been in use for 250 years and is still
considered the best preservation agent.
Embalming was not practised at all during the Middle Ages; it was re–
embraced after other achievements in the field of medicine, as a way to
promote the treatment of corpses.
Among the most significant steps, the following should be mentioned:
− Leonardo da Vinci (1452 – 1519) had the idea of using intravas-
cular injections during his dissections.
− Dr Frederick Ruysch (1638 – 1731) had the idea of intravenously
injecting his liquor balsamicum.
− Dr William Hunter (1718 – 1783) is credited as having
successfully adopted the intra–arterial injection. Injecting as
much as possible into a given vascular territory, he managed
higher quality embalmings. There was a notorious case of a
dentist (Martin van Butchell) who, for some financial reasons,
embalmed his wife Mary and kept her in his flat for many
years. It was only when the dentist’s second wife decided to
remove the body from their home that Mary was relocated to
a museum, which Dr Hunter had established in the meantime.
This was the place where Mary spent 166 years until the WW
II bombardments when the museum was destroyed and Mary
accidentally incinerated.

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What really spurred the use of embalming were the realities of the
battlefield and the need to send dead soldiers home to their families for
burial. In order to accomplish this, effective body preservation was a must.
Initially, embalming and sending the body home were only done for the
elite, but the service was later extended. Embalming thus began to be done
at an increased rate during various times of war:
− The crusades;
− Napoleon’s campaigns – during which a special contribution
came to eminency, that of Jean Gannal (1791 – 1882). Having
an educational background in chemistry with experience in the
pharmaceutical and textile domains, he was made responsible
for the medical services in the French Army. Having previously
dealt with gelatine, he later got involved in animal dissections
and model preservation. By the year 1831, he managed to
extend his interest to humans, initially for medical institutions
and eventually in the interest of public health. His research led to
a patented method of preservation for which he was also given
a scientific award, Monthyon, in 1836. This was followed by a
public service established in 1837 and the publication in 1838
of a History of Embalming. His method was later succeeded by
a newer and better one, based on zinc chloride.
− The American Civil War erupted in a quite well organised society,
which meant the claiming of dead soldiers for family burial
promoted the practice of embalming. It is worth mentioning
here the contribution of Thomas Holmes (1817 – 1900):
• He addressed the negative effects that embalming had
on dissection as practiced by medical students. Serving
as captain in the Washington Medical Corp of the Army,
he became a district attorney for New York.
• He became famous for having managed to embalm
Colonel E. Ellsworth, an important collaborator of
President Lincoln. The colonel’s body was displayed at
the White House, generating favourable opinions from
notable visitors. As a result, before being sent home,
thousands of dead soldiers were embalmed.
• Later, Dr. Holmes dedicated himself to research in the
chemistry of embalming, developing an acclaimed
formula known as Innominata.
− President Lincoln was an active supporter of embalming – a

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Methods of preservation
process to which he was also subjected.
The organised practice of embalming decreased drastically when the
instance of armed conflict diminished. Being left to the care of technicians,
scientific input and valence also suffered an obvious setback.

19.3.2. Contemporary embalming
Nowadays, preservation no longer needs to meet religious or political
criteria, or the interests of certain eccentric people. Its reasons are very
practical and technically standardised. It protects the environment from
any negative biological effect and postpones decomposition until the dead
body, under observation, is laid to rest.
Given the above considerations, the following administrative and
socio–familial policies are taken into account:
− When someone dies away from home, especially abroad, and
the transfer of the body will take time (at least a couple of days),
embalming becomes compulsory.
− In densely populated communities, where burial takes time,
embalming is highly advisable and is largely carried out.
− There are religious communities (Jews, Muslims, Baha’i) for
whom embalming is not welcome at all, apart from in medically
or legally prescribed cases. As these communities bury their
dead very soon after death (‘before sunset’), embalming is
actually not necessary.
− In small communities, particularly in villages, burial is possible
in less than three days. This is the interval during which
decomposition does not reach a critical point and no hygienic
risk is posed.
− In a case involving autopsy, the embalming may be carried out
in the mortuary. In larger communities, those people dying
outside hospitals, mainly at home, and not being autopsied, are
embalmed in a facility belonging to the funeral services.
Embalmers represent a craft and a profession organised according to
the current norms of the labour market and subject to rights and obligations.
The latter aims at respecting institutional standards on the one hand, and at
dealing with the family of the dead on the other hand.
To conclude, embalming provides
− conservation, in a manner designed to supress the natural
but unpleasant smell and appearance that would otherwise
develop during the time required before interment can occur;

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− disinfection, as the compound used for embalming is also
antiseptic; and
− restoration, through the use of various cosmetic techniques,
from the basic to the sophisticated, designed to achieve an
appearance as similar as possible to that before death.
The formulas for embalming solution being diverse, here are the criteria
for their differences:
− Concentration of formaldehyde: the longer the contemplated
period of preservation, the higher its concentration. Despite
respecting this relationship, the degree of success varies largely,
from a negligible preservation to a surprisingly long lasting one.
− The number of ingredients is substantial when more and special
cosmetic targets must be achieved.

19.3.3. Chemistry of embalming
Unlike the old embalming alchemy, the biological preservation of our
times is well served by a highly regulated chemical industry. The main
ingredient of the majority of recipes is formaldehyde (with formalin and
formol as commercial versions). Its chemical features are the following:
− In pure state, it is a gas.
− It is available as an aqueous solution in various concentrations.
The most concentrated solution is 40%, but in alcohol it can be
increased up to 50%.
− Being caustic for biological structures, it is used in much smaller
concentrations.
− In storage, formaldehyde follows the spontaneous process of
polymerisation to paraformaldehyde, a process directly related
to its concentration; this is a strong disinfectant at the same
time but a useless strong fixation agent.
The dynamics of its embalming action involve the following:
− Reaction with the proteins of any biological structure, the
essential ones being intracellular. The soluble albumins are
transformed to albuminoids and gels, which actually represent
the chemical ‘fixation’. To bring uniformity to this process,
formaldehyde must reach every cell and all microorganisms.
Therefore, for a stable fixation, the distribution has to be
uniform and thorough. Fixation leads to tissue contraction and
a grey colour. These effects are not desirable, therefore
• formaldehyde concentration has to be reduced as much

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Methods of preservation
as possible, even below 5%; and
• some adjuvant substances are added.
− As previously mentioned, formaldehyde is also an efficient
antiseptic, an action coincidentally useful in the process of
preservation. However, it is not an antifungal or an insecticide.
Other ingredients have to be added to the embalming formulas in
order to facilitate the process of preservation, such as
− phenol, hydro–soluble, a supplementary disinfectant;
− Na citrate, as anticoagulant;
− boric acid/borax and Na bicarbonate/disodic phosphate as
buffer substances;
− humidifiers, sorbitol in particular, in order to counteract the
dehydration effect of formaldehyde;
− surfactants, mainly Na sulphate, to ease the fluid passage
through the tissues;
− colouring agents, especially eosin, in order to counteract the
grey colour caused by formaldehyde and pathologic colours
such as yellow from biliary pathology;
− oils, lanoline being the most common, which facilitate tissue
penetration and reduce the degree of dehydration;
− metallic salts, Mg and disodic sulphate, for the same reason;
− perfumes, lavender, rosemary, sassafras, cloves, wintergreen,
or orange flowers to mask both the smell of the many chemicals
and the odour of decomposition; and
− disseminating solvents, including water up to 90%, alcohol and
others.
The concentration of formaldehyde should be lower for tissue injection
(2 – 3%) but may be higher for cavities (3 – 4%). There are places where
the fixation solutions are used warm, although the majority of laboratories
keep them at room temperature.

19.3.4. Modern concept
In order to meet the preservation requirements as soon as possible,
embalming solution has to be distributed in the entire mass of body tissues.
To achieve this, an exsanguinous perfusion proves to be the best choice:
− In principle, the solution should be introduced under pressure
in the arterial sector of the vascular bed.
− The passage of the peripheral vascular bed is facilitated by the
pressure of perfusion and an insistent thorough massage of the

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body’s peripheral parts.
− Subsequently, the amount recovered at the central venous
level is progressively replaced by further portions of embalming
solution.
Some postmortem realities hinder this exsanguinous perfusion:
− Despite the operative process of fibrinolysis, some clots may
occur, creating an obstacle in the distribution of embalming
solution.
− The microcirculatory vascular bed is vast and, under the
circumstances of vasoconstriction occurring in the majority of
the in vivo pathologic events, it represents another obstacle; it
does cease after death but this does not happen instantly.
− Rigor mortis supposes a hypostasis and, consequently, a quite
random distribution of the blood volume in a rigid vascular bed.
In its turn, this is another obstacle in the way of exsanguinous
perfusion.

19.3.5. How embalming is achieved
This consists of some common techniques, applied in all cases, and
special ones, applicable in certain cases only. The process varies with the
cause of death, associated pathology, age, sort of autopsy, etc. While an
embalming candidate can differ greatly, the ‘final product’, the embalmed
body, has to comply with specific standards as follows:
− the avoidance any decomposition, in order to assist the family
with meeting the demands of burial;
− an appearance of the body that is as acceptable as possible;
and
− the exclusion any risk of infection for those coming into contact
or proximity with the body.
Among the most important steps in embalming, the following details
are significant:
Preparation
− In addition to identifying the deceased, embalmers must verify
that their ‘client’ is really dead. This intriguing course of events
derives from the many ‘traps’ implicit in the pronouncement of
death. Embalming is more easily managed when done shortly
after death, preferrably in the first 24 hours.
− In order to reduce the degree of dehydration, the outer surface
of the body, the skin, should be properly covered with various

336
Methods of preservation
ointments, irrespective of the season.
− Passive movements of all major joints and a firm massage of
all soft body parts facilitate the imbuement of tissues with
embalming solution.
− Use of protective gear by the embalming team is compulsory.
12.5% of American embalming professionals have been infected
by the bodies they embalmed.
Tissue imbibition
Embalming is carried out using a haemodynamic approach:
− The haemodynamic model consists of an arterial ‘arm’, used
to introduce the embalming solution into the central aorta,
and a venous ‘arm’, to recover it via a large vein. Between the
two arms, the fluid goes through the microcirculatory vascular
bed. The movement of the fluid can be controlled manually,
gravitationally, or with a peristaltic pump. To facilitate the
passage of the microcirculation bed, it is sometimes necessary
to provide a higher pressure of perfusion.
− Vascular access may vary greatly, particularly in autopsied cases,
and is often a matter of the embalmer’s inspiration, whereas, for
non–autopsied cases, the consecrated model called restrictive
cervical represents a standard.
− The proper distribution is easily quantified by taking into
consideration how the system works, what pressures are
required, and how much fluid is retained in the body. Significant
indications are that
• the colour of the body has changed from the original to
an expected pink,
• the peripheral veins are filled and well visible, and
• there is a progressive, smooth colour turn.
− Considering the final complete opening of the vascular bed,
quite a lot of fluid is required for it to be filled; for a medium
weight body about 10 litres of embalming solution is used. This
is very much in tune with the physiological detail according to
which the entire blood volume may fill no more than 5% of the
vascular bed.
Variants of embalming
There are two main options in dealing with a given case:
− The non–autopsied case is, for technical reasons, preferred by
embalmers for the simple reason that the body is untouched.

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− In an autopsied case (the autopsy itself can vary from limited
to very intricate), the embalmer can no longer rely on known
anatomical details. Vascular access is a good indicator of how
complex the case is. In support of this, the standardised vascular
access is one known as ‘six point injection’. When a standard
embalming is unsatisfactory, additional approaches such as
hypodermic infiltration and targeted injections are necessary.
Difficult cases
In clinical practice, embalmers are often confronted with difficult
cases, such as deaths due to infectious diseases, asphyxia, burns, cerebral
haemorrhage, jaundice, oedema, or gangrenous lesions.
The standards practised for an infectious disease are quite demanding.
Therefore, it is advisable in ambiguous cases, to consider them meticulously
rather than underestimate the risk involved.
− Those belonging to category A, mainly tropical diseases and
fortunately rare in Europe, are not subject to autopsy or to
embalming. The body is placed in several concentric waterproof
envelopes, sealed, and transported directly for incineration.
The conditions for this sort of treatment are simian herpes,
Lassa fever, smallpox, Marburg’s disease, Crimea haemorrhagic
fever, Ebola fever, and Venezuelan equine encephalitis.
− The bodies in categories B and C, less dangerous than A, may
and should be embalmed. They are: brucellosis, botulism, TBC,
anthrax, Creutzfeld–Jacob’s disease, salmonella, hepatitis B,
and HIV.
Children pose different sorts of difficulties for embalming. This mainly
depends on the embalmer’s abilities in dealing with such cases. The single
standard to be respected originates from the anatomy details associated
with small body size; the vascular approach is largely via the abdominal
aorta and vena cava.
Completion of embalming
Efforts are made to achieve a reasonably good standard in order to
avoid any disappointment on the part of the family. To finalise the process
− the viscera are reintroduced to their cavities after proper
treatment with concentrated embalming solution;
− the cavities are then tightly sutured;
− in the case of wounds, these are dressed;
− the eyes have to be firmly closed sometimes necessitating the
application of glue; and

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Methods of preservation
− the mouth, in its turn, should also remain firmly closed; the
mandible can be attached to the upper maxilla or, if needed, to
the face bones.
The procedure is completed with the appropriate cosmetic work.
This requires much effort and the appeal to specialists in cases when the
deceased was well known to the community or the public.

19.3.6. Embalmed personalities
In the case of historic figures, official and political considerations have
always created pressure to achieve the utmost of embalming. Throughout
history, there have been both remarkable and disappointing cases; below
are the most representative examples:
− Abraham Lincoln was successfully embalmed (1865) but, for
family reasons, he was later buried.
− Nikolai Pirogov was embalmed according to his personal
instructions. Deceased in 1881, his body has been kept at room
temperature, and it is said that other than periodic wiping away
of dust, no maintenance is required.
− Kemal Ataturk’s embalming has proved to be a successful one.
− Rosalio Lombardo, a little girl deceased at the age of one year,
and embalmed in 1920, has since remained unchanged; she is
known as the Sleeping Beauty.
− A number of popes were embalmed in the 19th and 20th
centuries but, unfortunately, without the expected result. To
the contrary, Pius XII (1958) suffered a fast decomposition.
− Medgar Evers, a murdered human rights activist, is a remarkable
case. He was so successfully embalmed that, upon re–autopsy
a couple of decades later, it was possible to identify the killer.
− The famous communist leaders were all embalmed:
• Some of them, Stalin, Dimitrov and Gotwald, were
eventually removed from their mausoleums and buried.
• Both the embalming and funeral monuments continue
to endure in the cases of Mao Tse–tung, Ho Chi Minh,
Kim Ir Sen, and Kim Young–il.
− V.I. Lenin had an interesting embalming trajectory:
• he was embalmed initially for a couple of days;
• a new approach extended the preservation to 40 days
thereafter; and
• a new embalming technique (using an undisclosed

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formula), combined with hypothermia, has managed to
maintain a good appearance of the dead body ever since
1920; along with various hypotheses as to ‘the what and
the how’, the remarkable thing is that Lenin is still on
display to the public.
− The very last embalmed political figures were Eva Peron
and Ferdinand Marcos; for reasons beyond the outcome of
preservation, they were later buried.
Interesting embalmings were carried out on Alexander the Great and
Nelson, using honey and brandy respectively. Inspired by the practices
of food preservation, the formulas used allowed repatriation of the two,
which for that particular period, took a long time indeed.

19.4. Taxidermy and wax sculpture
These are two additional methods of preservation. While the
first actually preserves only the outer part of an animal, including the
integument, fur, feathers, scales, and the like, the second, by emphasising
external appearance, attempts to immortalise the image of certain human
beings. Neither has anything directly to do with the actual bodies, nor
are they really tangential with medicine. They do, however, concern the
‘products’ of death; short descriptions are therefore included here, in the
interest of thoroughness.
Taxidermy
An ingenious amalgam of science, handicraft and real art, taxidermy
(despite an unfair lack of academic respect) provides many useful services.
Placing an animal in a specific position and representing its habitat, the
taxidermist enables a zoological museum visitor to experience feelings less
disturbing than, and preferable to, those evoked by a dead animal. The life–
like appearance is a sign of artistic merit and offers a tempting adventure
for children.
Recruited from museum personnel, this category of craftspeople
now make use of a number of new technologies in addition to their talent
including prostheses, skin and hair accessories and, undoubtedly, more
resilient stuffing material.
Here are the main results of taxidermy:
− Artefacts for museums. In addition to habitat settings, a stuffed
exemplar may be an appropriate exhibit item in any museum
anywhere in the world – a tremendous educational opportunity.

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Methods of preservation
− Home decorations or so–called trophies. Parts of animals are
incorporated in various objects of domestic use: knife handles,
lamp shades, chair and table legs, candle and thermometer
stands, tortoise shell ashtrays and various objects made of ivory.
They are not cheap and, in general, are offered as presents.
− In the advertising industry, for instance
• deer and snakes in display windows of restaurants and
shops;
• bizarre combinations such as horned rabbits or double
headed cats;
• tableaux mort: animals miming human characters in
weddings or other comical or social events.
− Objects of decoration: large specimens in places of public
attraction and smaller ones, in private homes. They can now be
ordered online. Organic versions are also available nowadays.
− Nostalgic taxidermy. When emotionally unstable individuals
and children in particular lose a pet (cats, dogs, parrots, exotic
fish, and even horses), the animal can be ‘replaced’ for a period
of time by stuffed models.
− Fashion is a very lucrative domain using animal parts: snake
skin, for handbags, fox fur for collars, feathers of rare birds for
ladies’ and hunters’ adornments, inkpots made from horse
hooves, and claws of small animals mounted in jewellery, to
name a few examples.
Two adjacent trends deserve special consideration:
− Since the growing recognition of animal rights, the use of
expensive furs has become largely discouraged.
− Advances in high–tech procedures mean freeze–drying is most
often used today.
Wax sculpture
As detailed in chapter 18, wax pieces were used as alternatives to
corpses in order to facilitate the dissemination of anatomy teaching to the
public. An itinerant Great Museum of Anatomy was successfully organised
by Dr Pierre Spitzner in the middle of the 19th century. It’s worth mentioning
that life–size wax modelling of the entire human body had already been
in use for about hundred years, the Swiss doctor Philippe Curtius having
been the major player. The craft was inherited by a French woman, Marie
Grosholtz, who later became Madame Tussaud.
Making use of death masks where possible, she managed to produce a
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veritable gallery of well–known figures of her time, thereby establishing an
artistic movement of great public success. From her initial London exhibition,
opened in 1835, successors have developed a network of subsidiaries in
many large cities around the world. Celebrities, political and royal figures,
film and sport stars as well as notorious murderers can be found in the
hypostases considered most relevant to their worldly existence – a sort of
personality preservation.

19.5. Cryonics
The lowering of temperature, particularly rapid lowering, has already
been used extensively in medical practice. Tissue preservation (stem cells,
embryos, blood and transplantable organs) and cryosurgery (both ablation
and repair) are in continuous improvement.
There have also been a number of naturally occurring cases:
− A frozen mammoth was found, not long ago, in Siberia; having
lived 30,000 years ago, it proved to be perfectly preserved.
− A small forest frog (vide infra) experiences an extremely strange
mode of hibernation, spending months in a clinical death–like
state.
− Finally, there are the notorious cases of drowning victims
recovered from very cold water who are resuscitated after
longer periods of time and with fewer sequelae than those
recovered from warmer water.
Concerned about the risk of species extinction, contemporary biologists
have frozen a number of specimens to be used in the future as sources
of DNA in hopes of ‘re–launching’ the species. A couple of years ago the
media reported the attempts of a Japanese team to clone a mouse that had
been kept frozen for sixteen years.
After gaining significance, a well–organised and well–operated
movement called Cryonics was established in the United States. It deals
with frozen parts or whole human bodies. In short, the program operates
in anticipation of
− future medical achievements in resuscitation and eventual
cures of deadly illnesses;
− an eventual ability to restore life to the frozen bodies; and
− the advent of an eternal existence.
This idea is credited to an American war veteran, Robert Ettinger (261)
who was inspired by the contemporary achievements of French biologists.

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Methods of preservation
It took twenty years to set up the Cryonics Institute. The first to take
advantage of the service were the famous handball player Ted Williams and
professor of Psychiatry Dr. James Bedford. The former had his head deep–
frozen while the latter had his entire body.
Founded in Michigan, Cryonics is an organisation that fully complies with
institutional requirements: an orthodox registration, a budget, a network of
societies with an official statute, publications (from which two books, The
Prospect of Immortality and We Froze The First Man, and the periodical
Esquire are the best known) and, no doubt, financial backing for the entire
range of activities and the running of hugely expensive equipment.
Refrigeration aimed at achieving the strict requirements of Cryonics is
carried out approximately as follows:
− Immediately after the pronouncement of clinical death, the
corpse is kept at 10oC, and as much blood as possible is drained.
− In order to avoid the formation of ice crystals during the next,
more profound, hypothermia, the vascular bed is filled with
liquid glycerol.
− The body is wrapped in aluminium sheeting to protect it against
white frost forming on the outer surface, and it is temporarily
stored in an ice coffin at a temperature below 0oC.
− The cooled remains are then transferred to the place of
indefinite preservation – an entirely isolated capsule containing
liquid nitrogen at –200oC. At this temperature, all cell activity
stops, preventing any structural lesions.
In order to reduce to a maximum the structural cell lesions, neuronal in
particular, the entire series of the above steps must be started as soon after
clinical death as possible. The best thing to do is to send a dedicated team
in advance to remain on stand–by near the patient’s room. Once clinical
death is declared, the team is supposed to commence and follow the entire
process described above. When such an arrangement is not feasible, the
hosting hospital unit can heparinise the patient and place the body on
extracorporeal circulation until the team in charge arrives.
The ideal goal is complete preservation, even of memory, intellectual
performance, and personality. To realise such a ‘dream’, there is no room
for any neurological damage. Hypothetically, this would require neuronal
hypothermia before clinical death!
Currently each case is slated for on–going management for a period of
500 years. The hope is that medicine will eventually develop the necessary
cure for the relevant deadly condition, allowing the ‘reinstatement’ of the

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individual into life in a future generation. One might even hope to reverse
the process of senescence.
It goes without saying that such laborious technology is extremely
expensive. There are two American companies offering this service, Cryonics
Institute and Alcor. Similar in their technology, they largely differ financially.
In the case of Cryonics, the current fees are (US $) the following:
− variable annual membership fee for one of the dedicated
societies;
− 500 per year for the entire waiting period;
− ‘launching’ on the cryogenic orbit: 90,000 for the head and
150,000 for the entire body;
− 10,000 for the cryogenic team; and
− 500 for each year of preservation for an anticipated period of
500 years.
An estimated total reaches half a million dollars. This is clearly not
an overly prohibitive sum since more than 100 bodies have already been
placed in liquid nitrogen and more than 500 are on the waiting list.
x
The above procedure is expensive and assumes extremely specialised
activities and high performance engineering.
A completely alternative approach was chosen by Nature in the case of
the little frog Rana sylvatica, briefly mentioned before. This small creature
lives in the forests of various cold areas. It is famous for spending the
freezing winters entirely frozen (237).
Things run as follows:
− As the temperature falls, in parallel to this rate of decrease
• the frog’s body releases, from its supply of hepatic
glycogen, a large amount of glucose, which floods the
entire mass of cells;
• on the extracellular side, urea increases its concentration;
• together, glucose and urea act as anti–freezing agents,
preventing the formation of ice crystals; and
• only about one third of the constitutive water (mainly
subcutaneous and inter–muscular) is frozen.
− As a consequence, the little frog becomes immobile; breathing,
circulation, and the heartbeat cease – the equivalent to any
clinical death.
− And so, the little Rana spends a good number of months in this
state. Once the hibernation period is over and the weather

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Methods of preservation
warms, the block ice thaws and the heart starts beating;
circulation and breathing, in their turn, resume.
− The animal begins to move and regains all its former life
attributes, mating included. This is certainly the explanation for
its being christened the Rip Van Winkle of Nature (129).
It is believed that such a capacity would not be possible without genetic
programming.

19.6. Computerised ‘preservation’
This is a digital processing of both the image and the structure at the
same time. The dead body is photographed and undergoes tomographic
reconstruction, allowing the database to offer countless external and
internal details. Common colour family photos are also possible.
Although a truly prodigious manner of dealing with such a volume of
information, the method represents, for cost reasons, a tool of research
only available in high standard units, and has not yet been assimilated for
routine use.

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20. Disposal of corpses
(152, 221, 222, 243)

20.1. General view 347 20.4. Immersion 351
20.2. Burial 348 20.5. Green (ecological) disposal 351
20.3. Cremation 350 20.6. Unusual methods of disposal 352

20.1. General view
Unimpressed by the glorified life in philosophy, art and medicine, death
gloriously leads to a physical disappearance forever. While emotionally this
fate sounds awful, in real terms it avoids – according to Schweitzer (66) and
Saramago (251) – an unimaginable biological and social deadlock. It appears
therefore advisable to reconcile with ourselves and to alternatively take
advantage of any day and hour still to live.
Although the physical disappearance is even more depressing than the
event of proper dying, it is essential for any biological renewal. There are
eccentric people who try, by all means, to extend their physical existence.
The complexity of such an action and the enormous cost speak for
themselves about the lack of naturalness.
Once deprived of life, the body becomes not only unattractive, but also
unpleasant sensorily and a source of uncomfortable feelings. As such the
disposal does appear necessary – what socially has been given a regimen
of compulsory action. The manner in which this is done has varied and still
varies from culture to culture, religious traditions, ethnicity and, needless
to say, social appurtenance. It is a matter of both history and everyday life
that the act of disposal reflects quite well who the deceased was. From the
throwing into a mass grave to the pompous entombment in a mausoleum
or a pyramid, the versions have been infinite.

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20.2. Burial
By consensus, the place where a deceased is laid to rest is known as
grave. The earth dug grave has been mostly used both along the human
history and in the modern time. The good reasons for that rely, first, on
the availability but equally on the appropriate spontaneous conditions for
decomposition: slow rate, due to a lower temperature, tightness and lack
of smell. Still dominant as proportion, it had been proceeded by caves,
grottoes and followed by crypts, burial vaults, mausoleums and pyramids.
First burials of human beings are documented to be occurred 400,000
years ago in the caves of China. Neanderthal hominid did the same 300,000
years ago. Similar ‘graves’ have been found in many countries dating back to
tens and hundreds of millennia. Additional to a matter of human wisdom,
these entombments aimed at avoiding scatological and anthropologic
outbursts, as well as keeping the decomposition process away from the
communities.
Once the decomposition ‘processed’ and the flash disappeared, the
remaining bones used to be collected and placed in mass graves, so freeing
the caves dedicated places for those recently died. Such large burial facilities
became quite common under circumstances of an overwhelming number
of dead people: endemics, armed conflagrations, massacres, genocides or
natural disasters.
The religious ideologies got involved, as expected, in how the
communities were dealing with death and its final product:
− Consequently to the spread of Christianity, the churches
became a place of burials; initially inside, later in the afferent
yards. Family vaults, also patronised by churches, used to be
built at the periphery of cemeteries.
− In some places, the acceptance for burial was quite selective:
• the unbaptised children and suicides were not accepted
by some cemeteries;
• a special cemetery was organised in London for agnostics
and religious dissidents.
Due to public health concerns, the graves started to be made outside
the community life facilities and deeper dug.
Progressively, the ‘classical’ cemeteries have become crowded. Taking
example from the urban traffic with its parking facilities, the modern
municipalities built multi–storey cemeteries: Brooklyn has one of 2,500
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Disposal of corpses
vaults while Genoa another one, of 10 store and 45m high.
At their turn, the coffins have themselves a particular history:
− made initially from stones, different building materials have
been later tried, lead, bronze, ceramic, glass, rubber – no one
being preferred to wood;
− the main model, that in use nowadays, followed a variety of
others such as sarcophagus, anthropoid, amphora, cube,
parallelepiped, forms imitating various vegetables, animals and
even famous cars (Chevrolet and Mercedes being preferred for
‘their comfort’);
− in a world of service, there had to exist rented variants;
− the position in the coffin has also varied: the two arms crossed
or straight, huddled, sitting and standing.
Both the cemeteries and the coffins vary according to the rank of the
community and the premortem social position of the dead. They could also
be dictated sometimes by social events:
− A good example attesting the role of the social status is what
happened with the drowned passengers from the Titanic; the
209 from the first class were embalmed, placed in coffins and
returned to their families for private burial, while the rest of
118 of the second and third class were simply introduced in
fabric sacs and thrown back into the ocean water.
− For reasons out of biologic interest special coffins were designed
and built:
• Wellington was placed in a set of four concentric coffins,
• whereas J.F. Kennedy in one of bronze, double walled,
locked and sealed.
The grave and cemeteries have always represented a community
feature, with specific characteristics of the place, such as: mounds, mastaba,
ziggurat, tumulus, saccara, catacombs. There are, by design, empty graves
as the Cenotaph and that of the Unknown Soldier.
Irrespective of the sort of coffin, the entombment – inhumation in
particular – has always fuelled the fear of being buried alive. As mentioned
earlier in this book, events like dead people turned in their coffins or
‘descending’ from the catafalque continue to occur from time to time even
in our days. To avoid such experiences, one waits in general a number of
days before inhumation in order to leave the necessary time for an apparent
death to reverse or an ‘auto–resuscitation’ to happen. In the past, some
coffins were equipped with an alerting system: a pressing button used to

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be placed in the dominant hand of the buried person – a button able to
activate a noisy bell mounted outside on the grave (American patent).
For religious considerations, some communities from some countries
bury their deceased ‘before sunset’. There are, contrary, circumstances
where for good reasons the inhumation is done with delay, sometimes
quite long, mainly repatriations after deaths abroad. It goes without saying
that such cases need a longer lasting embalmment.
Finally, despite the fact that the burial is branded as laying a dead
person forever, there happens quite often that that particular place does
not prove to have been forever: cemetery restructuring, exhumation, body
snatching and social up or downgrading are all reasons of moving bodies.

20.3. Cremation
The decomposition implies such body changes that it is not surprising
at all that it generates repulsion and disgust. This was the reason why the
alternative of cremation had been tempting already in antiquity; Caesar,
Augustus and Caligula are known for having chosen this way for their bodies
to be dealt with. In addition, cremation is hygienic, clean and economical as
well as, in general, less expensive.
It appeals to cremation, in principle, under two main circumstances:
− In case of severe, dangerous, infectious disease when, as
detailed in the previous chapter, without any embalmment, the
body is transferred tightly packed and sealed, from the hospital
directly to be cremated expeditiously.
− As a premortem desire of the deceased, according to the family
instruction or sometimes of a social office.
From the technical viewpoint, cremation is operated in dedicated
places, crematories, at temperatures of 800 – 1,0000C. The self–powered
implants (pacemakers, defibrillators) should be removed before cremation
while those inert ones (especially orthopaedic) are taken away from the
resulted ash.
What happens with the resulted ash, about 2 kg/person, varies very
much:
− in countries like India, where cremation is a main way of
disposal, the ash is thrown in big rivers like the Ganges;
− thrown into the sea or ocean water;
− used as fertiliser;
− placed in containers made of different materials (cardboard,

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Disposal of corpses
plastic, stone, marble, common or precious metals) and given
back to the families to be buried or kept home, in church or
columbaria;
− shared by different members of the family, in medallions for
instance;
− there are very eccentric manners as well:
• launched in atmosphere by fireworks, shells or even
rockets;
• entombment on non–habited artificial isles.
It goes without saying that such an unnatural way of disposal could be
done only in cases where the death was unequivocally a natural one and
there is no matter of any concern whatsoever.

20.4. Immersion
This is a method relying on decomposition in water and body
‘consumption’ by various predators. These are so voracious that in a couple
of days there remains practically nothing to be buried in terrestrial terms.
Used long time ago on vessels with no possibilities of storing, the
immersion became well known and very differently carried out:
− either with a ceremonial message, practised by the Vikings who
put to sea bodies placed in boats put on fire,
− or simply throwing bodies over the board, during the WW II.
Nowadays, there are companies which deal with immersion on demand.
Essentially, the bodies are thrown either from an aircraft or a boat into the
territorial waters, over 5 km away from the coast and 200 m deep.
Having sunk, the classical warships along history and the submarines in
recent times became real subaqueous cemeteries.

20.5. Green (ecological) disposal
There are social groups militating for an as simple and ecologic disposal
as possible. Managing just for own cases only, their point is a very reasonable
one since:
− the usual ways are costly, consume many materials (for grave,
coffins, commemorative plates, embalming, cremation), taking
later often much time for maintaining; in case of lack of relatives
there remains, also, the perspective of being abandoned,
− whereas the green one consists simply in placing the body,

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wrapped in a thin fabric layer, in a biodegradable material
(cardboard for instance) and left either in a garden, dedicated
public places or out of settlements among the trees.
In the UK, it says, there are tens of so called parks of return to nature.

20.6. Unusual methods of disposal
With no biologic reason and bizarrely imagined, some people are
looking for an immediate postmortem celebrity status: added to manure,
frozen and dried, dissolved in lye or in an acid bath, electro–galvanised with
cooper, cooper and gold gilded, ash dispersing in different flows of water
or in the atmosphere, exposing to the predators (larvae, tortoises, vultures,
sharks, alligators, various carnivorous mammals).

352
21. Decomposition
(9, 31, 44, 49, 95, 126,221, 255)

The human body consists of 60 – 80% (varying from area to area) water,
with the rest being comprised of dry substances: 20% carbohydrates, 18%
lipids and 7% minerals. As these components are truly universal in nature,
the above composition undoubtedly attests the fact that the human being
does take part in the global process of biological recycling.
Taking part in recycling supposes understandably physical
disappearance. Only rarely, some eccentricities may occur both naturally
and mainly by human handling; while scientifically these are issues to be
considered, globally they have themselves no significance.
By burning – the most radical way of decomposition – the biological
material is transformed in water, CO2 and ash, the latter one representing
just 5% of the initial weight. This way is not ‘profitable’ from the recycling
point of view as such Nature opted for a more preferable version –
decomposition. In support of this
− a mechanism of auto–ignition is operational,
− once switched on, it runs on its own, and
− last but not the least, it facilitates life and growth of a good
number of other creatures.
This process displays an impressive determinism. Once the
oxidoreduction reactions are stopped, the every cell and the entire body
are suddenly deprived of any defence. In the same time, aggressions –
dormant until that moment – become operative:
− Various real attackers, both
• from outside, against which the organism had been able
to protect itself, and
• from inside, microbial flora in particular (microbiome),
with which the organism had cohabited.
− While those from outside need some time to organise
themselves, the insiders need nothing to start their aggression
immediately. It is typically the case of the intestine whose
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lumen is full of potent multi–microbial populations.
− Either from outside or from inside the body, the aggression in
discussion is one out of the cell, external in provenance and
infectious in type. The microbiome changes have such a dynamic
that, for a particular geographical area, its stages reflect quite
well the time elapsed from the moment of death. Very resistant
genomes like that of Helicobacter pylori is of an amazing help in
searching the human migration along millennia (179).
− The second aggression is enzymatic in nature, represented by the
destructive action of the own enzymes on the own morphologic
structures left vulnerable by the metabolic deadlock caused by
hypoxia and its immediate consequences.
− This is actually a sort of auto–digestion running to various
extents in all sorts of cells but more pronounced in those
containing naturally larger amounts of enzymes. This process
of micro–digestion has a macro–counterpart in the intestinal
lumen where the own enzymes attack the own wall tissues.
Summarising, a comprehensive auto–destruction, infectious and
enzymatic, is launched brutally in motion. This process interests all the cells
and the entire body, in a tempo and extent depending on the physiological
part which a particular morphologic entity had played.
How the decomposition of a given body is run differs, as it will be
discussed later, according to a variety of factors, temperature in particular.
A typical model is that one happening in a temperate zone and open air.
There are more phases (51):
Immediate
Starting from the moment of death, it involves the following steps:
− No longer in motion, blood is redistributed gravitationally in the
vascular bed: patches red–bluish in colour, of different size and
forms, occur – livor mortis.
− Once the cell metabolism halted, the production of heat ceases
leading to a continuous fall in body temperature – algor mortis.
− After 3 – 6 hours, the muscular tissue loses its ability of
relaxation, becoming stiff – rigor mortis.
− Due to autolysis, the body tissues get liquefied – a background
for occurring papules.
− Once the small amount of available oxygen spent, the anaerobic
microorganisms flourish with an increasing production of
organic acids (mainly lactic) and gases (ammonium, hydrogen
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Decomposition
sulphide and mercaptan). This process of putrefaction prompts
the invasion and growth of an abundant fauna.
The fauna acceding to a putrefying body is, or can be, extremely
diverse depending on the geographical area, season and environment. For
our temperate zone, the first to arrive are the ants, followed by bees, wasps
and a plethora of flies. The latter ones are extremely active, laying as many
as 2,000 eggs by a single fly. The maturation cycle is so quick that, in a short
time, the corpse becomes a sort of mound. Attracted by the specific smell,
the next comers are the larvae which, equipped with very aggressive lytic
enzymes, manage a direct access through the skin and an expedite assault
to the subjacent tissues.
Often, small creatures like moths, ticks, night butterflies and ‘coffin’
flies (controversial for professionals) also come to the spot. Then, mice,
rats, dogs, foxes, ravens and vultures are also attracted. Needless to say, as
anywhere in the nature, the competition is a fierce one.
‘Inflation’
Inside the body, there takes place an alert process of putrefaction:
− an increase in corpse volume and a bad smell;
− a tissue degradation generating a fluid material which facilitates
the cleavage caused by the resulting gas which, in its turn,
− leaves the body through many skin dissolutions and, together
with secretions, through natural orifices, especially nostrils.
The specific changes in the tissue chemistry lead to many unusual
alterations; a distinctive one is the transformation of haemoglobin in
sulfhaemoglobin – a derivative explaining the marble aspect of the corpse
skin.
One full week is usually necessary for the first two phases to complete.
Active decomposition
Taking about another week, the corpse suffers an obvious reduction in
volume due to
− a real consumption of the soft parts, on one hand, and
− on the other hand, a leakage around of fluid resulting from the
process of putrefaction.
Advanced decomposition
Once the ‘fodder’ diminishes, the number of ‘uninvited guests’ (real
beneficiaries in fact) reduces progressively. An increased proportion of
calcium, phosphorous, magnesium, potassium and mainly nitrogen is
identifiable around the corpse in the case this lies on soil.

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Dry remains
Skin, cartilages and bones continue the process of dehydration, known
as skeletisation.
Considering the described phases and their end products, there is no
doubt that decomposition takes part by virtue in biologic recycling. From
the decomposition of a human body, there result not fewer than 400 (four
hundred) chemical individuals.
As the decomposition does not commonly happen in open air, its
dynamic is not observed as described. It is influenced by certain factors:
Environment
− Low temperature: the external ‘visitors’ do not invade whereas
the microbial flora (own and from outside) do not get the usual
violence. Once frozen, the body stops any decomposition.
− Humidity, as the rainy weather, facilitates the process.
− Heat, on the contrary, inclines it to the process of dehydration.
− Thrown in water, initially the body sinks only to resurface after
a number of days due to the described ‘inflation’.
− Oxygen availability is undoubtedly an important factor.
The usual inhumation, at a low temperature and without oxygen,
provides a convenient way of decomposition: slow, unnoticed and socially
acceptable. This is also the reason why, with an exhumation occasion, body
maintains a certain time its initial appearance.
Related to environment
The fodder beneficiaries are important factors for a quick decomposition.
Body conditions like
− the amount of ingurgitated food before dying,
− the sort of embalmment, if any,
− clothes and manufacturing material, and
− possible skin breaks: wounds, autopsy access.
Cause of death
External chemicals, as the case of intoxications, could play a role in
changing the speed of decomposition.
As the speed of decomposition is influenced by so many factors, the so
called Casper’s law proves to be quite useful. According to it, when all the
variables are the same, the speed of decomposition in open air is twice that
under immersion circumstances and eight times faster than that inhumed.
Different organs have different speeds of decomposition: the brain is
the quickest whereas the uterus and prostate are surprisingly resistant.
Embalming and inhumation are, in many areas of the globe, standard
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Decomposition
ways to deal with fresh bodies nowadays. As mentioned many times,
different from open air, the decomposition is, as a result, much slower. In
addition, there are more versions of decomposition due to the interference
of different chemical substances:
− Bones may need more than hundred years for drying completely,
due to their structural peculiarities,
− On the contrary, certain acids from both the soil and mainly
water are able to decompose the osseous components. It is
presumed that this could be the explanation for the complete
disappearance of any human remains in the Titanic wreck,
even from the ship areas where access of the predators was
not possible. It is further presumed that the substantial amount
of acids, resulted from the huge metallic mass, denatured and
dissolved till the disappearance any human remains.
− Children and elderly bones, with lower calcium content,
degrade quickly.
− There are places on the Planet where the inhumed bodies
suffer a process of saponification leading to a pasty composition
(adipocere) which, inhibiting the intestinal flora, slows down
the process of putrefaction.
− Unusual soil circumstances, featured by an ‘imperturbable’
chemical stability, have favoured in tens of thousands years the
formation of fossils. Essentially, the natural mineral component
is replaced on the same organic structure with a local ‘recipe’,
which is more robust and durable. This seems actually to be the
explanation of their perennial attribute.
A similar process also seems to lead to intrauterine formation
of lithopedions. A 90 year old Chilean woman was recently
reported to have carried a calcified foetus for 50 years (301).
− The teeth, the hardest tissue structure in the human biology,
are most resistant to decomposition. Their ‘geometry’ in the
mouth, as in the case of any other creature, represents an
important descriptive detail – something of great significance
for palaeontology.
As specified above, putrefaction is initiated and driven in principal by
the own, intestinal, microbial flora. This flora is introduced in the body of a
newborn with the occasion of the very first food ingestion. This is why the
babies who die before any ingurgitation do not get putrefied; they instead
suffer a process of mummification.

357
Chapter 21
Finally, having to deal with so many variables, it is not easy at all for the
forensic colleague to determine the exact moment of death. He proves to
be sometimes a real Sherlock Holmes.

358
Instead of conclusions
As with any other major life event, Death has inspired thinkers to
formulate a variety of proverbial sayings. Some are full of significance for
the topic of this work. As such, instead of formal conclusions, we have
chosen to offer – as personal reflections – a few such sayings, selected for
their alignment with the medical message of this book.

For the old horse even the tail is heavy.
Arabic proverb
The elderly, on the whole, have quite an unrewarding existence;
they consume much from society, and their plight often disheartens their
families. The greatest difficulties, however, by far appear to be for the person
concerned. Dizziness and mental confusion, nausea and incontinence,
dysphagia and dyspnoea, not to mention the many varieties of physical pain,
severely reduce the quality of life, often leading to personal humiliation.

A life worth nothing but nothing is worth a life.
André Malraux
It is laudable that, considering life a gift, modern man has attached a
moral and legal sanctity to it. This standard of decency is, unfortunately, not
always nor everywhere upheld:
− In children’s story books, the big fish swallows the small one,
the wolf eats the lamb, the cat caches the mouse, and so on –
an interdependent chain of survival. But today’s human beings
kill animals for pleasure and economic reasons. Justifying this
with the assertion that animals can’t perceive the future does
seem extremely questionable.
− Even if such a justification is considered satisfactory in the case
of animals, real decimations have been committed in the name
of disputable ethical–social platforms: the crusades, genocides,
and countless wars have all been ‘eminent’ productions of
mankind.
359
Instead of conclusions
These two categories are versions of real instruments of death, and
there has never been any lack of patents.

Thinking that he will live forever, man becomes the clown of the
Universe.
Georg Klein
Both the old techniques of mummification and cutting–edge cryonics
had and have, respectively, the same aim: to avoid the natural obligation
each of us has – not only to die but also to disappear.
There are plenty of ways of dying. There are natural deaths – the
majority – that are the result of ageing or succumbing to any of the large
number of pathological conditions. And there are deaths generically named
unnatural – of which there are more than a few. It is by no means the role
of a book such as this one to assign ‘blame’ for this fate; let us, however,
comment on some aspects of interest for the medical profession.
It is assumed by proponents of creationism and evolution alike that
each living creature is utterly unique, displaying an inherent miracle. While
this truly does seem to be the case in principle, there is unfortunately no
perfection when it comes to the details – the fine points in the biological
machinery and how it really works. For those involved in clinical practice,
it is no secret that the human organism has plenty of ‘weak points’ of the
sort apt to self–facilitate a variety of pathological phenomena. Without
any mandate, we found the following to be the most representative:
syncope sine materia, ventricular fibrillation, cerebral oedema, masseter
contracture, anaphylactic reaction, tracheobronchial inundation, glottis
and bronchial spasm, malignant hyperthermia, systemic inflammatory
response, and shock/multiple organ failure.
For those having dealt with some or all of these – which is particularly
the case in intensive care – these pathologies appear to be a sort of faux
pas. In each of the ten, one may spot things that do not serve a purpose.
In the case of malignant hyperthermia, for instance, halothane and
succinylcholine are synthetic chemicals, whereas stress – also a proven
trigger in horses, dogs, cats, and in particular pigs – represents a very
natural ‘fight or flight’ response. At a certain moment one will die in any
case; however, being confronted with such derangements, the chance of
dying earlier is substantially higher.

We are born in order to die.
Oda Nobunaga

360
Death and medicine
This statement by a Japanese thinker sounds philosophical but at the
same time is rather disquieting. As it happens, in light of what we currently
know about genetics and ageing, the dictum actually makes sense. Due to
their genetic functionality, both dividing and non–dividing cells are known
to undergo metabolic wear and tear with a consequent erosion of nucleic
acids – with such erosion leading to the loss of vigour and, eventually, death.
Remarkably, Mother Nature protects the chromosomal equipment of
the gametes – a feature of paramount biological significance – allowing
the progeny to begin its existence with an untouched freshness. From this
double standard results the useful combination of a limited life for the
individual and a perpetual one for the species. Seen thus, death itself is an
extension of life. (Anonymous)

Resuscitation is the noblest part of medicine.
Alexander Negovski
If the dynamic of dying is to be taken into consideration, it is decidedly
appropriate for a book such as this one, dealing with death, to confer a
central role upon cardiac arrest. After all, it is this event that represents the
modus operandi of dying. This is why the structure of our dissertation has
followed Charon’s itinerary (page 98):
− Candidates for death are essentially recruited from the inventory
of those afflicted with pathologies, natural or man–made, that
lead to death.
− Dying itself, with its infinite versions, resembles the de facto
crossing of the River Styx.
− Everything happening thereafter corresponds to disembarking
in Hades’ kingdom.
Resuscitation techniques could very well find a place in this allegory –
as an act of piracy perhaps. But to have any chance of success, it should be
carried out well before the victim is given over to Cerberus. There is already
a subsidizing scheme for Charon – that of euthanasia.

I should like to record the thoughts of a dying man for the benefit of
science, but it is impossible.
G.M. Beard
This rhetoric certainly refers to the process of dying, a process known
to us only as seen from the outside, since the area is so difficult to explore
(294). Everything that happens inside disappears forever, together with the
dead. What’s more, as seen from the outside, there is no proof whatsoever

361
Instead of conclusions
to suggest that it is a pleasant experience.
There are, however, in the imagined picture of dying two tempting
details to cling to: namely, endorphin release and the inevitability of losing
consciousness. This tandem should serve to ease the struggle of dying – a
sort of recompense in the clutches of death.

Good to eat and wholesome to digest as a worm to a toad, a toad to a
snake, a snake to a pig, a pig to a man, and a man to a worm.
Ambrose Bierce
Here again is the chain of survival. Having an ‘honoured’ place on such
a carrousel, perhaps man can take pride in being such an eccentric meal.

Having left for warmer pastures, the crow was found later hanged; the
autopsy revealed it did not speak English.
V. Baran
In addition to its universality, death also challenges us with its
considerable variety of ways. The innumerable causes of death represent
an important domain of professional preoccupation for Pathology and
Forensic Medicine. Unfortunately, the cause of death cannot always be
easily identified, which is why a degree of mystery will almost certainly
remain associated with death.
x
The cruel truth is that, despite the popular hope that “it has lost its
seeds” (220), death has unequivocally proven to be hereditary. This intrinsic
feature inspired P. Skrabanek to brand life “a sexually transmitted fatality”
(250). Moreover, Nature is not desperately concerned about when exactly
someone dies; as one writer for The Independent put it, “dying sooner,
one spends more time dead”. Or there’s this take, from The Times: “Death
differs substantially to tax in not being increased in rate by each session of
parliament”.
Finally, in the words of philosopher and poet George Santayana, “there
is no cure for birth and death save to enjoy the interval”. C’est la vie.

362
Unbeing dead
isn’t being alive.
E. Cummings

363
... Tiel come tu es je antiel fu
Tu sera tiel come je su ...
(As you are now, so once was I,
As I am now, so you must be).
Verses from the
Epitaph (in Norman French) of
Edward the Black Prince (1330 – 1376) tomb,
Canterbury Cathedral
Abbreviations
3D – Three–dimensional PaCO2 – Arterial pressure of CO2
A – Ampere PaO2 – Arterial pressure of O2
AD – Anno Domini PEA – Pulseless electrical activity
AHA – American Heart Association PEEP – Positive end expiratory pressure
ALI – Acute lung injury RNA – Ribonucleic acid
ANDS – Association of Near–Death Studies SARS –Severe acute respiratory syndrome
ARDS – Adult respiratory distress syndrome SH – Sulfhydryl
ASA – American Society of Anesthesilogists SIDS – Sudden infant death syndrome
ATP – Adenosine triphosphate TB – Tuberculosis
a-v – atrio–ventricular TNT – Trinitrotoluene
BC – Before Christ v-a – venous–arterial
CO2 – Carbon dioxide V – Volt
CPR – Cardiopulmonary resuscitation WHO – World Health Organisation
CT – Computed tomography WW I – World War 1
DDT – Dichlorodiphenyltrichloroethane WW II – World War 2
DNA – Deoxyribonucleic acid
DNR – Do not resuscitate
ECG – Electrocardiogram
EEG – Electroencephalogram
ENT – Ear, nose and throat
FiO2 – Fraction of inspired oxygen
H2O2 – Hydrogen peroxide
Hb – Haemoglobin
HbCO – Carboxyhaemoglobin
HbO2 – Oxyhaemoglobin
HIV – Human immunodeficiency virus
Ht – Haematocrit
IAPB – Intra–aortic pumping balloon
ICU – Intensive Care Unit
ILCOR – International Liaison Committee
of Resuscitation
LSD – Lysergic acid diethylamide
MH – Malignant hyperthermia
NDE – Near–Death Experience
NMR – Nuclear magnetic resonance
NO – Nitric oxide
O2 – Oxygen

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390
Selected Thematic Index
Contents
1. Thematic art reproductions 392
2. Adages referring to death 392
3. The deadliest current conditions 392
4. Pre-mortem pathophysiological alterations 392
5. Vital prostheses 393
6. High mortality actions and events 393
7. Circumstances and ways of dying 393
8. Famous suicides 393
9. Famous people killed 393
10. Mass and serial killers 393
11. Death terms 393
12. Specific mortis changes 394
13. Postmortem issues 394
14. Materials used in funeral practice 394
15. Famous people embalmed 394
16. Interesting behaviour related to death 394
17. Closely related to the notion of death 395
18. Legal issues 395
19. Documents and concepts related to death 395
20. Artists and artistic issues dealing with death 396
21. Names cited from the death literature 396

391
Index
1. Thematic art reproductions Total spinal block, 184, 191
Black Prince Tomb, Canterbury Cathedral, Tracheobronchial inundation, 174, 241,
364 360
Kauw, Death and Doctor, II
Patinir, Landscape with Charon Crossing 4. Pre-mortem pathophysiological
the River Styx, 98 alterations
Acidosis, 66, 67
2. Adages referring to death Apnoea, 86, 87, 204 – 205
AHA, 120 Asphyxia, 174, 294, 338
Anonymous, 361 Broncho-laryngo-spasm, 191, 226, 238,
Arabic proverb, 359 360
Baran, Vasile, 362 Cardiac arrest, 30, 85 – 87, 100, 114, 198,
Beard, George Milles, 361 239, 240, 241
Bierce, Ambrose, 362 asystolia, 87, 91, 92, 95
Buddhist Scripture, X bradyarrhythmia, 87, 91, 92, 95
Cummings, Edward, 363 electro-mechanical dissociation
Independent (Newspaper), 362 (PEA), 92, 95
Klein, Georg, 360 ventricular fibrillation, 89, 95, 103,
Malraux, André, 359 180, 234, 360
Negovski, Alexander, 361 ventricular tachycardia, 88, 95
Nobunaga, Oda, 360 Cerebral oedema, 178, 360
Santayana, George, 362 Cheyne-Stokes breathing, 56
Skrabanek, Peter, 362 Coagulopathy, 66, 67
Times (Newspaper), 362 Coma, 112, 130, 132, 152, 202, 214, 272,
362
3. The deadliest current conditions Death of bone marrow, 251
Amniotic embolism, 173 Diffuse axonal lesion, 133
Anaphylactic paroxysm, 114, 360 Extra-dural heat haematoma, 180
Asthmatic attacks, 114, 175 Fibrinolysis, 67, 210
Café coronary, 114, 226 Final hypovolemia, 64
Chemical pneumonia, 243 – 245 Gasping, 91, 94, 103, 105
Drowning, 114, 174, 236 – 241 Hypothermia, 36, 67, 108, 179, 240, 294,
Hepatic cirrhosis, 175 343
Ischaemic coronaropathy, 27, 93, 116 Hypoxia, 65, 67, 102, 131, 153, 180, 203,
Malignant hyperthermia, 154, 245, 246, 204
360 Horror autotoxicus, 73
Neurocardiogenic syncopes, 115, 190 – Immunologic dissonance, 73
193 Ischaemia, 196, 207
Ondine’s curse, 186, 187 Lysosomal lysis, 74,
Pneumonia, 26, 52, 71, 244 Microbial translocation, 72
Progeria, 34, 45 Multiple (multi-) organ failure, 59, 61, 70,
Pulmonary embolism, 173 179, 360
Radiation sickness (disease), 153, 249 – NDE (mort imminente), 13, 121 - 127
251 Organ insufficiencies, 175
SIDS (cot death), 186 Oxygen free radicals, 125, 144 – 145
Status epilepticus, 154 Réaction organique à l’aggression

392
Death and medicine
(postagressive reaction), 59, 75 Gas chamber, 256, 297, 298
Septic reservoir, 72 Hanging, 289
Shock, 59, 61, 178, 360 High altitude, 263, 264
compensated, 62 Homicide, 260, 261
decompensated, 63, 66 Iatrogenic, 241 – 243
irreversible, 63, Impalement, 290
Stress, 59, Infanticide, 248, 249
Subglottic oedema, 174 Intoxication, 212 – 217
Systemic inflammatory response, 71, 73, Lethal injection, 299, 300
111, 360 Lightning, 259
Natural disasters, 257 – 259
5. Vital prostheses, 77 – 84, 107 Nuclear weapons, 256 – 257
Peri-operative, 181 – 184
6. High mortality actions and events Shooting/firing squad, 298 – 299
Avalanches, 258 Smoking, 221 – 226
Crusades, 18, 170, 332 Starvation, 227
Death zone (Everest) climbing, 263, 264 Stillbirth, 248
Earthquakes, 258 Stoning, 296 – 297
Epidemics, 168 – 172 Strangulation, 229, 289, 318
Famine, 257 Suffocation, 226, 227
Floods, 258 Thunderbolt, 258 – 259
Nuclear explosions, 256 Terrorist acts, 261 – 262
Risky sports, 93, 263
Ship sinking, 253 8. Famous suicides, 228, 231
Stampede, 174
Storms, 258 9. Famous people killed
Thunderbolts, 258 – 259 Alexander the Second, Tsar, 260, 261
Tsunamis, 258 Bourbon, Charles de, 260, 261
Volcano eruptions, 258 Bruno, Giordano, 289
Wars, 254 – 257 Caesar, Julius, 260, 261
Cromwell, Thomas, 288
7. Circumstances and ways of dying Ferdinand, Prince, 261,
Accidents, 251 – 254 Joan of Arc, 289
Alcoholism, 218 – 221 Kennedy, John. F., 261
Anaesthesia, 182, 191 Lincoln, Abraham, 261
Armed conflagrations, 254 – 257 Louis XVI, 288
Beheading, 288 Marie Antoinette, 288
Biological weapons, 257 Nicolai the Second, Tsar, 260, 261
Burning at the stake, 289 – 290 Robespierre, Maximilien de, 288
Chemical weapons, 255 – 256 Spartacus, 291
Commotio cordis, 114 Stuart, Mary, 288
Crucifixion, 13, 290 – 296 Vlad the Impailler, 288, 290
Duelling, 297
Electric chair, 299 10. Mass and serial killers, 261, 289
Electrocution, 114, 154, 231 – 236
Extermination camps, 256, 294, 297

393
Index
11. Death terms Autopsy, 303 – 314
Abroad, 283 Computerised ‘preservation’, 345
Assisted, 265 – 269, 269 – 271, 271 – 273 Cremation, 350 – 351
Biological, 29