Signs of death 11
Chapter 1
Signs of death
The detennination of the time of death is
an important question in forensic medi-
cine. However while many methods have
been developed establish the exact time of
death, we can hardly speak of definitive
results. In most cases of death, it is not re-
levant. However during many criminal
and civil proceedings such questions may
be presented which make the establish-
ment of the time of death important. One
of the most exact definitions given about
the onset of death, is linked to the name of
GENERSICH: "Death is the final and com-
plete paralysis of the central nervous
system, the consequence of which is the
decline to the minimum of the physio-
logical activities of the circulatory and
respiratory functions, which, in a short
time cease completely."
Three factors detennine the function of
a living organism: circulation, respiration
and integrity of the central nervous
system. Any damage to one of the three
results in functional disturbance to the
other two. In clinical practice, the cessa-
tion of breathing or circulation determines
the onset of death. In a significant number
of cases, heart function can be observed
for a short time after respiration ceases.
There fore cessation of breathing and heart
function mean clinical death. In this state,
a number of organs and tissues survive.
This state is called intermediate life. The
L. Buris, Forensic Medicine
© László Buris 1993
time of survival of the tissues is relevant
from the standpoint of transplantation.
Those tissues with a low oxygen demand
can be used for transplantation hours after
death, whereas the organs with a greater
metabolism or oxygen demand suffer ir-
reversible damage after a short period of
time and biological death sets in. The
widespread use of transplantation has
made a demand for the precise diagnosis
of the onset of death.
One is declared dead when:
a) circulatory and heart functions irre-
versibly cease
b) there is complete and irreversible
cessation of cerebral function.
Signs indicating irreversible cessation of
brain function:
a) unconsciousness, (coma)
b) absence of spontaneous breathing,
c) moderately or more frequently max-
imally dilated pupils, pupils which do not
react to light,
d) absence of the oculocephalic reflex,
e) absence of corneal reflex,
f) absence of reaction to painful sti-
mulus in the area of innervation by the tri-
geminal nerve,
g) absence of laryngeal and bronchial
reflexes.
The ability to elicit the autonomic spi-
12 Signs of death
nal reflexes does not exclude the determi-
nation of brain death. Extensive exami-
nations have been developed for the de-
termination of brain death, since medical
technology makes possible the mainte-
nance of respiratory and circulatory func-
tion - in the presence of irreversible brain
damage. These tests are, at present, on-
ly of theoretical significance. PASZTOR
described the existence of brain death in
detail. Brain death can be declared with
certainty if,
1. the capacity for reception of stimu-
lation and reaction to stimulation are
completely absent,
2. spontaneous breathing is completely
absent,
3. reflexes are absent.
This is reflected by the flat EEG. In
brain death circulation in the brain stops,
and thus numerous supplementary tests
are necessary.
The literature lists the criteria for es-
tablishing brain death, which are:
1. EEG silence; isoelectric curve, with
examination of the brain with deep elec-
trode, absence of spontaneous discharge,
2. caloric vestibular test; no eye move-
ment,
3. electronystagmography; flat curve,
4. echo-encephalography; no echo pul-
sation,
5. the temperature of the brain lower
than that of the body,
6. intracranial pressure measurement,
very high pressure,
7. carotid and vertebral angiography,
no contrast filling of the brain vessels,
blood flow measurements; no circulation.
8. determination of brain oxygen con-
sumption.
9. radioisotope scintigraphy, or gamma
chamber examination; verifies cessation
of cerebrospinal fluid circulation.
The MOLNAR test for extremely high
pyruvate and lactate concentrations in the
cerebrospinal fluid may be of value as a
sign of brain death. In certain instances the
determination of brain death is not a
simple task. Of the above mentioned
diagnostic procedures each one has its
own disadvantage which, when applied to
different forms of death, does not provide
sufficient information as to the time of
death. For example, the flat, isoelectric
EEG curve does not necessarily means
brain death, and must be considered with
caution in the cases of death due to drug
overdose or hypothermia, as well as in ca-
ses of death due to metabolic and endo-
crine disturbances or following neuro-
muscular blockade.
The cessation of circulation, breathing
or brain activity brings about individual
clinical or somatic death. Despite the
above assertion that the diagnosis of death
is not a simple task, it may be simple if the
last minutes of a person's life are spent
under the supervision of a physician. The
atony of the musculature, the cessation of
thoracic expansion and pulse all indicate
the onset of death. These changes indi-
cate that circulation and breathing have
stopped and within a few minutes irre-
versible brain damage will occur. Practi-
cally speaking, however, these signs merit
careful consideration. The detection of
cessation of heartbeat by auscultation
is made significantly more difficult if the
patient is obese, or the presence of se-
vere emphysematic changes make the
sounds of a weakened heart undetectable.
As mentioned above, the diagnosis of
the time of death is more difficult in cer-
tain manners of death, such as in the
cases of electric shock, drowning, hypo-
thermic death, and sleeping pill overdose.
In these cases intense efforts must be di-
rected toward resuscitation.
Somatic death is followed by, molecu-
lar biological death. Biological death of
the central nervous system occurs within