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doi: 10.4103/2221-6189.248026 ©2018 by the Journal of Acute Disease. All rights reserved.
A RT I C L E I N F O A B S T R AC T
Article history: The large amount of classifications about the concept of death from a medical-legal perspective
Received 26 September 2018 leads us to think that there are still many aspects to accurately define that precise moment in
Revision 26 October 2018
which the end of our earthly existence is considered as a final and unalterable fact. An answer
Accepted 15 November 2018
Available online 21 December 2018 to such a question may come from a retrospective analysis of those victims of impending-death
situations that have been rescued after both basic and advanced cardiac pulmonary resuscitation
failure and their consequent medical-legal death declaration. The aim of the following work
Keywords: is to introduce a new phase within forensic thanatology, supported by a complementary
Thanatology
resuscitation maneuver based upon millennial traditional Chinese medicine principles together
Energetic death
Chinese medicine with a detailed analysis of current global agreements on organ transplantation and an avant-
Cell death garde perspective on actual knowledge about cell death. Those terms will then allow us to
Organ transplantation achieve a holistic view of said concept, still loosely defined at present. Such an innovative
diagnostic-therapeutic resource can in turn enable us to evaluate and face the irreversibility of
such extreme situation, analyzing the statistical feasibility of its promising results.
is death reliably diagnosed in the human being? What does the and improving their quality of life and perhaps granting the only
accuracy of such diagnosis depend on? Are there several kinds of possibility of subsistence for certain patients.
death? Can Chinese traditional medicine make any contribution to However, in spite of the many implicit benefits of this practice,
this knowledge? Is there an extended possibility of recovery after it has been necessary to enact a law in such a way as to almost
such terminal diagnosis so that the life of the patient can be “caught” compel the population to become donors (e.g., in Argentina, at
before reaching a “point of no return”? the moment of getting the national identity card), since there is no
spontaneous determination to organ donation after death. Beyond
special religious circumstances, there is still, in the collective
2. Forensic thanatology unconscious, a certain degree of mistrust about the fact that a
person can be “truly dead” at the moment of delivering their body
Although there exists information that the first forensic treatise for benefit of a neighbor.
(or the oldest known) is the work of the Chinese physician called Some fantasy literature, such as the work of Edgar Allan Poe,
Song Ci “Collected Cases of Injustice Rectified” probably written popularized stories of people who “revived” after their bodies had
during the Southern Song Dynasty[2], the term thanatos derives been buried. In fact, between 1870 and 1910, in London and in the
from the name given by the Greek mythology to the goddess of USA, an industry devoted to make “safety coffins” developed, so
death[3]. Forensic thanatology, a term coined around 1901 by the as the “dead” could call for help through vents, bells or flags. Even
Nobel Prize Elias Metchnikoff, is the branch of medicine devoted today some cases, which can make us doubt whether to donate
to the study of all those medical-legal matters related to death, its organs or not, are sporadically published[5].
causes and the different ways of disposing of a corpse[4]. It may be worth stating once more, that the purpose of this work
From a connotative point of view, death involves in itself, three is far from discouraging the donation of organs, as there is no
basic concepts: more altruist act than that of “donating life”. On the contrary, its
--- The medical concept of death: It refers to the permanent and real aim is to establish a measure that adds security at the time
irreversible disappearance of all spontaneous signs of life in a of determining death; not only at an organic level but also at the
given individual; energetic level. In fact, the evidence suggested contains in itself
--- The legal concept of death: It considers the absence of life in an alternative maneuver of resuscitation that could be applied in
an individual with no cerebral activity, which means the end of an case the habitual measures of vital support fail, adding the quoted
individual’s existence; diagnosed possibility as a new opportunity to live.
--- The medical-legal concept of death: It involves the irreversible
stoppage of the cardio-circulatory and respiratory functions as well
as those of the central nervous system of the human being[3]. 3. Classification of different states of death
Nowadays, the irreversible condition of cardiac arrest as well
as that of the definitive loss of electro-encephalic activity (some Surprisingly, mistakes are still being reported at the time of
groups also consider the dynamic echocardiography and the loss of certifying death: the problem is that the definition of death is,
encephalic flow as detected by cerebral arteriogram) constitutes the as we have just seen, only supported by negative data or signs;
evidence determining the inexorable loss of the vital functions. that is to say, by the absence or abolition of the vital constants
Legally speaking, in order to declare the “encephalic death” of an (namely, by absurdity). We agree with Avendaño that nobody
individual, some parameters must be fulfilled, namely: has proclaimed yet a positive or decisive pathognomonic sign at
--- Complete and permanent absence of conscience; the moment of death[5]. We will later see that many of the signs
--- Permanent absence of spontaneous breathing; related to such absences that justify death could be present in
--- Absence of neurological reflexes of the brain stem, including those patients who have not departed yet. Needless to say, that the
pupillary areflexia, reflexes in the presence of nociceptive stimuli referred world legislation about operative transplant procedures
and ocular movements in the presence of vestibular tests. and the consequent selection of “live donors” is based on such an
However, from a tissue-histological point of view, Avendaño issue.
explains in his work “Medical-Legal Concept of Death”: “.... It occurs as the consequence of ageing or complications due to
death is just a mere event”. “From this point of view, death is a any known disease, accidental or not.
prognosis, since the organism does not die simultaneously”[5]. As stated by a medical-forensic study, several phases of death can
The above-mentioned statement cannot be truer: at present, be differentiated. We shall try to arrange them according to a pre-
world legislation regarding the transplant of organs is based on established progression from the moment there is a suspicion to the
such a concept. We could not deny said train of thought, since it accredited confirmation of death.
has already helped millions of patients, prolonging their existence From ancient times various phases, physical as well as spiritual,
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It implies total and absolute disappearance of all biological Premature babies and those having low birth weight are also
activity of the organism. Every vital function irreversibly ceases included in this category. Post-mortem examination does not reveal
to function once an attempt to rescue the patient has been carried any apparent reason that may justify death.
out for 10 min. The “Do Not Resuscitate Order” is based on Expected death: It is the fatal sudden end of an individual’s life
the previous concept. Said Order is in force in some European who has been suffering from some acute or chronic illness with
countries (such as Spain), in view of the potential neurologic a somber prognosis. Somehow, the notion seems to refer to those
damage that occurs as from that period of time and the consequent subjects affected by an irreversible condition (that is to say, those
eventual cost for the State[4]. who inevitably are expected to die due to an already known cause),
On the other hand, total death can be declared 36 h after death; despite an unexpected rapid progression.
that is to say, when there is no more life at anatomical as well as at Transitory or momentary death: This sub-group forms part of
histological level. the causes of real death, though it may be reverted if resuscitation
Types of absolute or real death refer to all those conditions in maneuvers are applied even after 3 or 4 min after death has
which the absence of vital constants is verified, either by the occurred. It has neither relation with that of the theological
semiology of the physical check-up or by the complementary resurrection nor with any other similar “miraculous” phenomena.
studies used for diagnosis. This condition occurs according to the It seems to refer to a stage immediately previous to relative death.
following parameters: absence of signs of life and presence of For example: cases of electrocution-asphyxia -submersion[4,5].
signs of death. Slow or agonizing death: It is the one that occurs in a gradual
Inhibition death occurs when there is a chaotic appearance of way, progressively exhausting the individual’s vitality. Example:
extreme environmental or emotional stimuli (“coup de chaleur”), terminal illnesses.
and a series of reactions is triggered. Said series block, restrict, Distant death: It is known in this way as it occurs at the beginning
reduce or suspend the normal psycho-physiological regulation of the abiotic and/or transformative cadaveric phenomena[4]. The
of homeostasis, cancelling the habitual integration between so called “cadaveric phenomena” are principally of two types:
apparatuses and systems, leading to multi-organic failure and 1) Abiotic manifestations: They appear due to the extinction of the
the subsequent actual death of the tissue. For example: the acute vital functions. These include algor mortis (cadaveric cooling), that
suprarenal necrosis that used to happen with “the suicidal passing means body temperature gradually decreases (one grade per hour)
of grenades” described by Gregorio Marañón during the Spanish from the moment of death. It levels with the temperature of the
Civil War[4]. environment within 24 h;
Real death, tissue or somatic death presupposes the definite 2) Transformative manifestations (consecutive to the previous ones.
presence of all the physical signs of death. They are the effects of bacterial flora and of environment over inert
tissues). The following are among them:
--- Livor mortis (postmortem lividity): a settling of the blood by
4. Death classification considering time variable action of gravity in the capillary venous networks which continue
moving until 24 h after death; after that, they locate in a fixed
Recent death: It comprises all deaths previous to cadaveric place;
phenomena of putrefaction. --- Rigor mortis (cadaveric rigidity): It is the effect of the
Rapid death: It refers to a death that occurs immediately or in coagulation of myosin over the flat and striated muscular system of
a short period of time. This concept is sometimes mistaken with the corpse. It begins between 3 to 5 h after death and finishes 24 h
sudden death, as in most cases it is accidental[4]. later;
Unexpected or unforseen death: It happens in an apparent healthy --- Rotting: abiotic destructive sign that appears about 36 h after
individual, with no previous history or known cause through which death, when organic matter begins to decompose causing putrid
it could be explained[13]. gases by disintegration of proteins[11].
Sudden death: By definition, under this situation death happens
unexpectedly (that is to say, there is neither a suspicious sign nor
an external violent cause) in a subject who is apparently in a good 5. Development of resuscitation maneuver over Shaoyin
state of health. As can be seen, this kind of death is formed by energetic level
the previous types, which are possibly confused because of the
adjective “sudden” that, in turn, involves both concepts: “quickness” 5.1. The Shaoyin energetic level
and “without warning”[13].
Sudden infant death (also called crib death or nocturnal death): The Shaoyin, an axe composed by the heart and the kidneys and
It may happen in newborns or infants up to four months of life. a polarized pair of the elements water and fire, commands the vital
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The difference here is also confirmed to be statistically significant; as proposed by the randomness principle upon a prospective non-
demonstrating once more the comparative value of the Yongquan intervention group.
method[18,20]. The aforementioned implies that such association Except for very few situations, only 8 cases, with prior application
did not rely merely on fate. We are, then, theoretically qualified to of the “rescue box” (with 100% recovery), the rest of the victims
reject Ho hypothesis and accept Ha, definitively proposing the K-1 of cardiac arrest were treated, as already stated, after failure of the
Yongquan resuscitation as a “quality guaranteed” method[17]. basic and advanced CPR[14,15].
Even though today there are updated statistics in which manual
CPR reached 17% survival rate (see, e.g., www.ymca.org.ar)
actual survival rates would be noticeably lower. According to what 6. Discussion
Dr. Custodio Calvo, member of the Spanish Cardiopulmonary
Resuscitation Association, has mentioned, such estimated indices Since ancient times, in China there existed maneuvers aimed
of out-of hospital survival would not go further than 5% [21]. at recovering patients in terminal stages. Some of the treatments
Other studies later claim a rise up in extrahospital survival rate to derived from amazing “master recipes” such as the one revealed by
10%[22] which, as they estimated, may result in an increased value the current personal physician to Pope Francis, Prof. Liu Ming. It
if population had more knowledge on CPR technique and would was a “magic mushroom” called Dui Kou Jun (literally, “that which
make use of it. comes out of the mouth”) that grew in the inner lid of coffins,
Regarding the survival percentages due to the application of precisely at the level of the mouth of the deceased (Figure 2).
cardio version, recent studies presented by Dr. Emilio Marín- According to Eastern Medicine, said mushroom grew in the place
Huerta show that premature defibrillation increased this scale from of the coffin that received the “last breath” of the dead person. As
24% to 30% in cases of cardiac arrest[23]. it is gifted with a predominantly Yin nature, it was able to nurture
As a matter of fact, statistics referring to extrahospital extremely weak or agonic people. It was cooked in “old” hen broth
resuscitations seem to have stuck at a 6.4%, a figure which (older than 9 years; that is to say, with a great Yin potential) and
coincides with prior evaluations of the previous statistical analysis it was capable of contributing to recovery in extraordinary cases.
presented in other works[17]. Today, this kind of mushroom has almost disappeared because
It should be mentioned that, if cumulative rates of positive dead bodies in China and Japan are cremated due to lack of space
responses to the maneuver be considered (verified by pulse in cemeteries.
recovery and ECG record), the rate reached an 85.72%; i.e., over
89 cases, 12 patients could manifest objective responses to K-1
stimulation.
Consequently, all the above data has made clear that there
actually exists a difference if one takes into account as control the
group of “deceased patients” instead of considering among them
“patients that may be deceased” (Table 1). Such apparently simple Figure 2. Dui Kou Jun fungus.
consideration, thanks to the cohort retrospective study model,
manages to efface the contingency of a possible “fatal damage” This comment, apparently anecdotal, is useful to determine that
Table 1
Resuscitation statistical sequence referred to Yongquan maneuver application.
Source Date Total case (n) Death (9) Survival rate (%) Ref
50th Argentina Acupuncture Society Congress November 2005 19 5 73.68 [24]
despite knowing that this action would ease the arrival of death[31]. Conference on Drug Discovery and Therapy; 2013.
However, we shall remember, for the other cases, what article 32 [14]Inchauspe AA. Traditional Chinese medical criteria about the use of
of the “F” Appendix, section “C” of the Declaration of Helsinki of Yongquan as a life support maneuver. In: Kuang H, editor. Recent
the World Medical Association[32] reads, emphatically allowing the advances in theories and practice of Chinese medicine. Rijeka: InTech;
possibility of using new therapeutic procedures in cases of life risk 2012, p. 362-366. DOI: http://dx.doi.org/10.5772/29138
of the patient. [15]I nchauspe AA. Traditional Chinese medicine K-1 Yongquan
and resuscitation: Another kind of lazarus phenomenon.
Resuscitation 2010; 81(4): 505-506. DOI: https://doi.org/10.1016/