Brain Death - Too Flawed to Endure, Too Ingrained to Abandon

The concept of brain death has become deeply ingrained in our health care system. It serves as the justification for the removal of vital organs like the heart and liver from patients who still have circulation and respiration while these organs maintain viability. On close examination, however, the concept is seen as incoherent and counterintuitive to our understandings of death. In order to abandon the concept of brain death and yet retain our practices in organ transplantation, we need to either change the definition of death or no longer maintain a commitment to the dead donor rule, which is an implicit prohibition against removing vital organs from individuals before they are declared dead. After exploring these two options, the author argues that while new definitions of death are problematic, alternatives to the dead donor rule are both ethically justifiable and potentially palatable to the public. Even so, the author concludes that neither of these approaches is likely to be adopted and that resolution will most probably come when technological advances in immunology simply make the concept of brain death obsolete.     

Histological examination of the carotid bifurcation in case of violence against the neck

The carotid body and carotid sinus are localized in the area of the carotid bifurcation and respond to pressure fluctuations in the arterial blood vessel system. In case of irritation or stimulation, nervous impulses can reflexively increase the ventilation or slow down the heart rate and blood pressure, respectively. The external stimulation of the carotid sinus by neck compression with subsequent bradycardia or asystolia, especially in pre-existing heart-disease, is discussed controversially in the literature. Histological examination of the tissue of the carotid bifurcation, particularly with regard to haemorrhage as an indication of tissue trauma, should be carried out in terms of simple and easy feasibility in routine diagnostics. In 20 cases of violence against the neck and additionally 82 cases of a control group without neck trauma and variable causes of death, the carotid bifurcations were examined histologically. Only in one case of violence against the neck haemorrhage was found, which suggested a direct trauma to the tissue of the carotid bifurcation, but evidence of lethal cardiac reflex was not found in any case.     

Local vital reaction following injuries of the neck

Sixty-one cases of hemorrhaging of the laryngeal muscles are reported among 86 deaths due to compression of the neck (strangulation by ligature and/or with the hands, blunt force); the results of histological examinations of these cases (laryngeal muscles; hemorrhaging of the cervical muscles and tongue in numerous cases) are discussed, as well as 55 comparative cases (natural, violent death) with regard to vital changes from the hemorrhaging aspect. Although sanguineous infiltration of the laryngeal muscles can occur after death (prone position), it differs macroscopically and in some cases also microscopically from the vital type: extensive bleeding on the inside of the larynx or dorsally above the larynx (PCA muscle), possible combined with histologically detectable ruptures of muscle cells, must be viewed as the result of laryngeal compression suffered when still alive. No clear-cut evidence of emigration or infiltration of leukocytes was found in the cases of immediately fatal strangulation, but there was occasional evidence (6 cases) when protracted maltreatment had taken place. Although there was no clear correlation with age, sex, type of impact, cause of death, or amount of laryngeal bleeding, in 25 of the 61 cases leukocytes were sometimes detectable in enormous amounts within the extravasation; the ratio exceeded that to be expected from the composition of the blood. Findings of this nature have also been made in cases of vital bleeding in other violent or natural deaths; they are not a cell reaction in the proper sense but, when distinctly marked, a vital event--at least in the laryngeal region. These findings can support the assumption of the amount of hemorrhaging in deaths in which the survival time was inadequate for a leukocyte emigration. In 20 cases such findings were combined with localized leucocytosis, which is regarded as an early vital reaction.     

Lethal manifestations of systemic lupus erythematosus in a forensic context

Systemic lupus erythematosus is an autoimmune connective tissue disorder that affects multiple organs. While the clinical manifestations may vary in intensity over time and be associated with chronic disease, occasional cases occur where sudden and unexpected death has occurred. Cardiovascular disease is common, with accelerated atherosclerosis, intravascular thrombosis associated with antiphospholipid syndrome, and hypertensive cardiomegaly. Vasculitis with superimposed thrombosis may result in critical reduction in blood to vital organs, such as the heart and brain with infarction. Mesenteric ischemia may be caused by vasculitis, thrombosis, and accelerated atherosclerosis and may result in lethal intestinal infarction. Other diverse causes of sudden death include myocarditis, epilepsy, pulmonary hypertension, pulmonary thromboembolism, and sepsis. The autopsy evaluation of such cases requires careful examination of all organs with extensive histological sampling to include blood vessels, and microbiological sampling for bacteria, viruses, and fungi.     

The routine use of C-reactive protein in forensic investigations

In clinical medicine, C-reactive protein (CRP) is extensively used as a general marker for immune system activation, and post-mortem applicability has been established [M.Q. Fujita, B.L. Zhu, K. Ishida, L. Quan, S. Oritani, H. Maeda, Serum C-reactive protein levels in postmortem blood-an analysis with special reference to the cause of death and survival time, Forensic Sci. Int. 130 (2002) 160-166; L. Uhlin-Hansen, C-reactive protein (CRP), a comparison of pre- and post-mortem blood levels, Forensic Sci. Int. 124 (2001) 32-35]. We have analysed the routine use of CRP in non-selected cases. Scarcity of blood available for analysis is a common problem in forensic investigation, and in response to this we have developed a method using liver as a source. In 50 consecutive autopsy cases, we have evaluated method, validated results and discussed their interpretation. In three cases the analysis was not possible. For each of the remaining cases (n=47) we have analysed whole blood, serum and/or liver samples. 57% (n=25) had serum CRP > 10 mg/L. Serum levels were higher than in whole blood or liver. CRP levels in serum and whole blood samples were stable in more than one month after death, making storage for later analysis possible. Liver levels peaked at one week, but after one month putrefaction was obvious. CRP levels were independent of the post-mortem interval. The use of liver as a source has not yet been described in literature. Our results in liver samples correlate well with plasma results, and liver is a good post-mortem alternative when blood is not available. We conclude that CRP measurements are easy, viable and inexpensive in a forensic setting, and that the number of cases with CRP elevation is high in a non-selected forensic material. In cases of doubt, marked elevation of CRP is an indicator of natural mode of death, and in cases of trauma, it indicates vital reaction. It can be used as a pre-autopsy screening, leading to a more extensive search for diseases not easily diagnosed, such as sepsis or ketoacidosis.     

Hemorrhage of the head and neck in death by burning

The 202 deaths connected with burns in 1976-1986 included 134 in which death occurred during the fire. In 49 cases the face was so badly charred that it was not possible to judge whether hemorrhage had occurred in the eyelids and/or conjuctivae. Such blood extravasation was seen in 14 of the remaining 85 cases, taking the form of petechiae in some cases and in others the form associated with more extensive extravasation, in some cases hemolytic. No other features known to cause such hemorrhages were present, so that they are attributed to the burning process itself. Signs of extensive pronounced burns were found in 13 of these cases, and it seemed that high-degree burns on the neck and trunk with less severe burns on the head were particularly likely to be associated with such hemorrhages. In most cases the flames had quickly come into direct contact with the body (clothing, bed or chair had caught fire), leading to rapid death, as documented by the fact that usually very little or no soot at all had been aspirated and by the low level of carbon monoxide intoxication (max. COHb 22%). One plausible explanation for the development of hemorrhage is the supposition first expressed over 20 years ago that when the circulation is maintained rapid burn-induced shrinkage of the skin of the neck has the effect of strangulating the victim; hemorrhage of eyelids and/or conjunctivae in such cases be could regarded as a vital reaction to the effect of fire. This is particularly significant, insofar as evidence of hemorrhage of this kind was found predominantly in bodies in which other vital signs indicative of the effects of burning were sparse and slight or even totally absent. In addition, specific examination of the laryngeal area revealed congestion-induced extravasation at various points, as well as petechial hemorrhage in the mucous membrane.     

Effects of Family Violence on Child Behavior and Health During Early Childhood

Looking at families where children have been abused/neglected in early childhood, this study examined measures of child behavior and health to see if they tended to be worse when domestic violence is or has been present in a family. Further, caregiver and family characteristics as well as other case factors were examined, as possible moderators or mediators of the effects of domestic violence. Results indicate that domestic violence, of the type and severity occurring in our sample, does not have a direct effect on child outcomes by Age 6, when other associated variables are taken into account, but has considerable indirect effects. There is a pronounced impact of domestic violence on family functioning, the caregiver's general health and well being, and the quality of the caregiver's interaction with the child, which in turn are significantly associated with decrements of child functioning related to behavior problems and health. Some implications of this study for research in the area of domestic violence and child maltreatment are discussed.     

Can we handle the truth? Legal fictions in the determination of death

Advances in life-saving technologies in the past few decades have challenged our traditional understandings of death. People can be maintained on life-support even after permanently losing the ability to breathe spontaneously and remaining unconscious and unable to interact meaningfully with others. In part because this group of people could help fulfill the growing need for organ donation, there has been a great deal of pressure on the way we determine death. The determination of death has been modified from the old way of understanding death as occurring when a person stops breathing, her heart stops beating, and she is cold to the touch. Today, physicians determine death by relying on a diagnosis of total brain failure or by waiting a short while after circulation stops. Evidence has emerged that the conceptual bases for these approaches to determining death are fundamentally flawed and depart substantially from our biological and common-sense understandings of death. We argue that the current approach to determining death consists of two different types of unacknowledged legal fictions. These legal fictions were developed for practices that are largely ethically legitimate but need to be reconciled with the law. However, the considerable debate over the determination of death in the medical and scientific literature has not informed the public of the fact that our current determinations of death do not adequately establish that a person has died. It seems unlikely that this information can remain hidden for long. Given the instability of the status quo and the difficulty of making the substantial legal changes required by complete transparency, we argue for a second-best policy solution of acknowledging the legal fictions involved in determining death. This move in the direction of greater transparency may someday result in allowing us to face squarely these issues and effect the legal changes necessary to permit ethically appropriate vital organ transplantation. Finally, this paper also provides the beginnings of a taxonomy of legal fictions, concluding that a more systematic theoretical treatment of legal fictions is warranted to understand their advantages and disadvantages across a variety of legal domains.     

Massive pulmonary embolization by cerebral tissue after head trauma in an adult male

We report a case of an adult man who was run over by a car, suffering severe head trauma. After 3 hours in the hospital, he experienced sudden and severe hemodynamic deterioration, dying immediately. The autopsy showed massive cerebral tissue pulmonary embolization (CTPE), confirmed by immunohistochemistry. Multiple fractures of the skull, tear of the transverse sinus, and brain laceration of the occipital lobe were present. CTPE is very infrequent. In children and adults, it occurs as a complication of severe closed or penetrating head trauma. Although laceration of a large cerebral venous sinus is not always essential, in some cases (like in the present one) this laceration is the mechanism of entry of the cerebral tissue to the blood circulation. The clinical repercussion of CTPE is variable. In some cases, it could be an incidental finding of autopsy. In other cases, coagulation abnormalities and disseminated intravascular coagulation have been reported. Finally, such as in the present case, the immediate cause of death is the sudden hemodynamic failure due to the massive CTPE.     

The Right to be Free from Domestic Violence in Macau

Domestic violence is a problem which historically has not received adequate attention in Macau. At the outset, it explains why the right to be free from domestic violence matters in Macau. I contend that the treatment of domestic violence is a human rights issue under international human rights law, focusing on the shift in the conceptualization of domestic violence from a private matter into a human rights issue. I denounce domestic violence as human rights violation. The second part depicts the draft law on Combating of Domestic Violence Act and analyzes the possible effects of Combating of Domestic Violence Act that can occur. Then, I intend to highlight the absence of attention to the positive duties of states—not negative duties to restrain from acting (such as a duty not to infringe upon the right to be free from domestic violence), but positive, affirmative duties to protect women.     

Oronasal blood in sudden infant death.

Oronasal secretions are observed frequently in sudden infant death syndrome (SIDS), but overt blood is uncommonly reported. The literature on oronasal blood in sudden infant death is limited. The goal of this study was to determine the frequency of oronasal blood in sudden infant deaths and to examine possible causative factors. Oronasal blood was described in 28 (7%) of 406 cases of sudden infant death. Oronasal blood could not be attributed to cardiopulmonary resuscitation in 14 cases, including 10 (3%) of 300 cases of SIDS, 2 (14%) of 14 accidental suffocation cases, and 2 (15%) of 13 undetermined cases. Eight of the 10 infants in cases of sudden infant death were bedsharing: 5 with both parents, 2 between both parents. The infant in 1 SIDS case was from a family that had had three referrals to Child Protective Services. Oronasal blood not attributable to cardiopulmonary resuscitation occurs rarely in SIDS when the infant is sleeping supine in a safe environment. Bedsharing may place infants at risk of suffocation from overlaying. Oronasal blood observed before cardiopulmonary resuscitation is given is probably of oronasal skin or mucous membrane origin and may be a sign of accidental or inflicted suffocation. Sanguineous secretions that are mucoid or frothy are likely of remote origin, such as lung alveoli. The use of an otoscope to establish the origin of oronasal blood in cases of sudden infant death is recommended.     

Cocaine-related deaths: an enigma still under investigation

In recent years there has been an increase interest in cocaine-related death reflecting the rising trend in cocaine use in Europe. Nevertheless it is still now very difficult to attribute a death to cocaine. We can affirm that cocaine can be responsible for the cause of death only when there is a reasonably complete understanding of the circumstances or facts surrounding the death. Isolated blood cocaine levels are not enough to assess lethality, and should be always considered and evaluated in relation to concentrations of cocaine and benzoylecgonine concentrations in body tissue compartments, especially in brain and blood. We have reanalyzed all of our cocaine-related cases from 1990 to 2005, applying the methodology used by Spielher and Reed over 30 years ago. Our aim was to try to validate this model and verify its applicability and effectiveness after 20 years.     

FIGHTING OVER TRIVIAL THINGS: EXPLAINING THE ISSUE OF CONTENTION IN VIOLENT ALTERCATIONS*

Violent altercations can lead to serious injury and death, and yet some interpersonal disputes that prompt physical violence originate over what are seemingly trivial issues. This study evaluates the theoretical premise that violence stemming from what typically are defined as trivial altercations can be explained by what is at stake in these conflicts; trivial altercations, or fights about “nothing,” actually represent symbolic contests of dominance and deference. These status contests are necessary primarily when the social relationship between opponents is symmetrical—when a dominance hierarchy is not clearly established. Data from interviews with incarcerated women in Ontario, Canada, show that relationship symmetry strongly predicts the issue of contention in their physically violent altercations. These findings suggest that, when violence erupts over trivial issues, both parties to the altercation essentially are locked in a battle for social rank.     

论“网络暴力”致人自杀死亡的刑事责任

随着互联网科技的发展,虚拟空间与现实生活的联系越来越紧密,网络暴力事件层出不穷,出现了不少因不堪忍受凌辱而自杀的案例。我国刑法通常认为自杀死亡结果和网络暴力之间不存在因果关系,自杀死亡结果只是情节严重中的结果,但这并不合理。网络暴力的特质在于对精神的强制以及对身心的持续伤害,网络暴力高于普通的精神伤害行为,在特定的情况下网络暴力能成为杀人罪的实行行为并与自杀死亡结果有因果关系。相应地,刑事责任也应重新评价。     

Retrograde blood aspiration: a vital reaction

Blood aspiration, which is based on an intact breathing activity, is one of the forensically most important vital reactions. On the example of 11 forensic cases it is shown that the aspiration of blood into the lung tissue is possible not only when the bleeding source is situated above the trachea or main bronchi, but also in a retrograde way, taking its origin from an injury of the peripheral lung tissue itself. Equally to 'classical' blood aspiration, the findings of retrograde blood aspiration are to be diagnosed by means of macroscopical and histological examination of the lung tissue. The lung tissue presents with roundish, reddish spots, which are situated close to, but separate from a lung contusion or other lung tissue injury, and microscopical examination reveals blood in the alveoli and the bronchioli. Retrograde blood aspiration may be a helpful vital sign in the forensic assessment of thorax trauma cases where no other vital reactions are present.     

Fatal brodifacoum rodenticide poisoning: autopsy and toxicologic findings.

This report details the pathologic and toxicologic findings in the case of a 15-year-old girl who deliberately and fatally ingested brodifacoum, a commonly used rodenticide. The mechanism of death, massive pulmonary hemorrhage, has not been previously reported. Brodifacoum was quantitated in liver, spleen, lung, brain, bile, vitreous humor, heart blood, and femoral blood using HPLC with fluorescence detection. The highest brodifacoum concentrations were detected in bile (4276 ng/mL) and femoral blood (3919 ng/mL). No brodifacoum was detected in brain or vitreous humor. A brodifacoum concentration of 50 ng/g was observed in frozen liver while formalin fixed liver exhibited a concentration of 820 ng/g. A very high blood:liver brodifacoum concentration ratio suggested acute poisoning but the historical and pathologic findings suggested a longer period of anticoagulation. Though most cases of brodifacoum poisoning in humans are non-fatal, this compound can be deadly because of its very long half-life. Forensic pathologists and toxicologists should suspect superwarfarin rodenticides when confronted with cases of unexplained bleeding. Anticoagulant poisoning can mimic fatal leukemia or infectious diseases such as bacterial sepsis, rickettsioses, plague, and leptospirosis. A thorough death scene investigation may provide clues that a person has ingested these substances.     

A transnasal intracranial stab wound by a plastic-covered umbrella tip

A 48-year-old man died from a transnasal intracranial stab wound caused by an umbrella. The track of the stab passed from the right nostril, through the sphenoid sinus, the left side of the sella turcica and anterior clinoid process, and finally reached the surface of the brain. The stab wound crossed the left internal carotid artery, causing an exsanguination and aspiration of blood into the airway, resulting in death. It is extremely rare that an umbrella tip used during a struggle would stab the nostril of the victim. Transnasal intracranial stab wounds can be overlooked and require sensitive handling.     

法院在防治家庭暴力中的作用实证研究——以重庆市某区人民法院审理涉及家庭暴力案件情况为对象

通过实证调研,其结果显示家庭暴力的发生率仍然较高,并且当事人呈现出性别、年龄、职业等方面的特点。人民法院在涉家庭暴力案件的审理过程中,既有家庭暴力认定、举证责任分配、人身安全保护裁定送达、调解方法上的有益经验,也面临着防治家庭暴力立法及反家庭暴力联动机制不完善、人身安全保护裁定的局限性、取证难等一些困境。建议我国尽快制定一部统一的"家庭暴力防治法",在加强防治家庭暴力宣传的同时,明确规范各相关部门的职责与责任,加强各部门之间的联动协作。     

Hypothermia Secondary to Glioblastoma Multiforme? Autopsy Findings in Two Cases

Death due to accidental primary hypothermia in cold climates is relatively common, with previous case series reflecting this. In contrast, hypothermia‐related death as a result of an underlying medical cause, such as a brain tumor, is rare. The literature clearly illustrates a theoretical causal relationship between brain neoplasms and hypothermia through the infiltration of the hypothalamus; however, the number of reported cases is minimal. Two cases are presented where autopsy confirmed hypothermia as the cause of death with both cases revealing widespread glioblastoma multiforme in the brain. Both decedents were elderly with a number of comorbidities identified during autopsy that could explain death; however, hypothermia was deemed the most likely cause. It is proposed that both decedents died of hypothermia as a result of the tumor's effect on thermoregulation. These cases underline the importance of forensic pathologists to be aware of the relationship between brain tumors and hypothermia and to not dismiss death as being due to other disease processes.     

Interpreting results of ethanol analysis in postmortem specimens: a review of the literature

We searched the scientific literature for articles dealing with postmortem aspects of ethanol and problems associated with making a correct interpretation of the results. A person's blood-alcohol concentration (BAC) and state of inebriation at the time of death is not always easy to establish owing to various postmortem artifacts. The possibility of alcohol being produced in the body after death, e.g. via microbial contamination and fermentation is a recurring issue in routine casework. If ethanol remains unabsorbed in the stomach at the time of death, this raises the possibility of continued local diffusion into surrounding tissues and central blood after death. Skull trauma often renders a person unconscious for several hours before death, during which time the BAC continues to decrease owing to metabolism in the liver. Under these circumstances blood from an intracerebral or subdural clot is a useful specimen for determination of ethanol. Bodies recovered from water are particular problematic to deal with owing to possible dilution of body fluids, decomposition, and enhanced risk of microbial synthesis of ethanol. The relationship between blood and urine-ethanol concentrations has been extensively investigated in autopsy specimens and the urine/blood concentration ratio might give a clue about the stage of alcohol absorption and distribution at the time of death. Owing to extensive abdominal trauma in aviation disasters (e.g. rupture of the viscera), interpretation of BAC in autopsy specimens from the pilot and crew is highly contentious and great care is needed to reach valid conclusions. Vitreous humor is strongly recommended as a body fluid for determination of ethanol in postmortem toxicology to help establish whether the deceased had consumed ethanol before death. Less common autopsy specimens submitted for analysis include bile, bone marrow, brain, testicle, muscle tissue, liver, synovial and cerebrospinal fluids. Some investigators recommend measuring the water content of autopsy blood and if necessary correcting the concentration of ethanol to a mean value of 80% w/w, which corresponds to fresh whole blood. Alcoholics often die at home with zero or low BAC and nothing more remarkable at autopsy than a fatty liver. Increasing evidence suggests that such deaths might be caused by a pronounced ketoacidosis. Recent research has focused on developing various biochemical tests or markers of postmortem synthesis of ethanol. These include the urinary metabolites of serotonin and non-oxidative metabolites of ethanol, such as ethyl glucuronide, phosphatidylethanol and fatty acid ethyl esters. This literature review will hopefully be a good starting point for those who are contemplating a fresh investigation into some aspect of postmortem alcohol analysis and toxicology.