SIGNS OF DEATH.
THE absence of respiration is the most ordinary sign of death, but at
the same time perhaps the one most likely to deceive. To ascertain
whether breathing be entirely suspended, it is a practice to hold a
looking-glass to the face.
“Lend me a looking-glass;
If that her breath will mist or stain the stone,
Why, then, she lives.”--_King Lear_, Act v., Sc. 3.
The common belief is that, if the operations of the heart or lungs be
arrested for ever so brief a period, they will never be resumed, and
upon a hasty diagnosis and perhaps a trifling experiment the person
is declared dead. It would appear presumptuous to attempt to doubt or
deny a theory so widely accepted by both the lay and medical world, but
numerous well-attested facts show that the action of the vital organs,
with life itself, may occasionally be actually suspended, as proved by
the most rigorous tests known to science, and that various forms of
suspended animation taking on the appearance of actual death are of
not unfrequent occurrence. Scepticism, prejudice, and apathy on this
subject have led to thousands of persons being consigned to the grave
to return to consciousness in that hopeless and dreadful prison.
[VARIOUS TESTS CONSIDERED.]
One of the most distinguished physicians in London informed the author
that, being called in to decide a case of apparent or real death, he
had applied the stethoscope and failed to detect the faintest pulsation
in the heart, and yet the woman recovered. The danger of premature
burial he believed to be very real and by no means an imaginary one,
and his opinions were well known in the profession.
THE RESPIRATORY TEST.
Sir Benjamin Ward Richardson, in his paper on “The Absolute Signs and
Proofs of Death,” in the _Asclepiad_, No. 21 (1889), vol. vi., p. 6,
says:--
“About the existence of respiratory movements there is always some
cause for doubt, even amongst skilled observers; for so slight a
movement of respiration is sufficient to carry on life, at what I have
in another paper designated ‘life at low tension,’ the most practised
eye is apt to be deceived.”
“The cessation of the indications of respiratory function, although
useful in a general sense, is not by any means reliable. It is quite
certain that in poisoning by chloral, and in catalepsy, there may be
life when no external movement of the chest is appreciable.”--_Ibidem,
pp. 13, 14._
CARDIAC AND ARTERIAL FAILURE TEST.
“Equal doubt attends the absence of the arterial pulsations and heart
sounds. It is quite certain that the pulses of the body, as well as the
movements and sounds of the heart, may be undetectable at a time when
the body is not only not dead but actually recoverable.”--_Ibidem, p.
14._
In a review of several works on the “Signs of Death” in _The British
and Foreign Medical and Chirurgical Review_, vol. XV. [1855], p. 74,
W. B. Kesteven writes that Bouchut’s test of the cessation of the
action of the heart for one or two minutes is not to be relied upon
as a certain sign of death. “M. Josat has recorded several instances
wherein newly-born children have been most carefully examined during
several minutes without the detection of the slightest cardial sound or
movement, and yet these have rallied and lived. M. Depaul has collected
ten similar instances. M. Brachet has recorded[14] an instance of a
man in whom neither sound nor movement of the heart could be heard for
eight minutes, and who, nevertheless, survived. Another adult case
is mentioned by Dr. Josat as having been witnessed by M. Girbal, of
Montpellier.... Sir B. Brodie and others have described children born
without hearts. The circulation is maintained at one period of human
life without the aid of the heart. It is, besides, quite consistent
with the facts observed in hysterical and other conditions of the
nervous system, that the action of the heart, like that of other
muscles, should be so extremely feeble as not to be cognisable by any
sound or impulse, and yet it may have sufficient movement slowly to
move the blood through the system, whose every function and endowment
is suspended and all but annihilated. In cases of catalepsy, and of
authentic instances of apparent death, the respiratory muscles have not
been seen to move, yet inspiration and expiration--however slowly and
imperceptibly--must have taken place.”
THE PUTREFACTIVE TEST.
[THE PUTREFACTIVE TEST.]
Dr. Roger S. Chew, of Calcutta, whose personal experiences of apparent
death are elsewhere recorded in this volume, says:--
“Numerous expedients have been suggested as means of ascertaining
whether a body is really dead or whether the animation is temporarily
suspended; but, though these suggestions may collectively yield a
correct diagnosis, still they are valueless when separately considered,
and cannot compare with the ‘putrefaction test.’”
In the “Principles and Practice of Medicine” of the late Dr. Hilton
Fagge, edited by Dr. Pye-Smith, vol. i., p. 19, of the second edition,
is the following:--
“In most cases there is no difficulty in determining the exact moment
at which death occurs. But sometimes it cannot be fixed with certainty,
and there are some altogether exceptional instances (though I have
never myself met with one) in which for hours, or even for days, it
remains uncertain whether life is extinct or merely suspended. _I
believe that the only sign of death which is both certain to manifest
itself in the course of a few days, and also absolutely conclusive and
infallible, is the occurrence of putrefaction_, which is generally
first indicated by discoloration of the surface of the abdomen. And in
any case admitting of doubt, the coffin should not be closed until this
has shown itself.” (Italics ours.)
The _Medical Examiner_, Philadelphia, vol. vi., p. 610, says:--
“A recent French reviewer in the _Gazette Médicale_ closes a survey
of the differences between real and apparent death, by the following
remarks:--‘Experience,’ says he, ‘has shown the insufficiency of
each of these signs, with one exception--_putrefaction_. The absence
of respiration and circulation, the absence of contractility and
sensibility, general loss of heat, the hippocratic face, the cold
sweat spreading over the body, cadaveric discoloration, relaxation of
the sphincters, loss of elasticity, the flattening of the soft parts
on which the body rests, the softness and flaccidity of the eyes, the
opacity of the fingers, cadaveric rigidity, the expulsion of alimentary
substances from the mouth;--all these signs combined or isolated may
present themselves in an individual suffering only from apparent
death.’”
Prof. D. Ferrier, in an article on “Signs of Death” in Quain’s
“Dictionary of Medicine,” pp. 327, 328, says:--
“It is not always easy to determine when the spark of life has become
finally extinguished. From fear of being buried alive, which prevails
more abroad than in this country, some infallible criterion of death,
capable of being applied by unskilled persons, has been considered
a desideratum, and valuable prizes have been offered for such a
discovery. The conditions most resembling actual death are syncope,
asphyxia, and trance, particularly the last. We cannot, however,
say that any infallible criterion applicable by the vulgar has been
discovered.”
The writer then proceeds to describe the various symptoms usually
considered to denote death. The chief of these is putrefaction, but he
observes that putrefaction may occur locally during life, and general
septic changes may occur to some extent before death.
Dr. Gannal, in “Signes de la Mort,” p. 31, says:--
“I share the opinion of the majority of authors who have written on
this subject, and I consider _putrefaction_ as the only certain sign of
death.” The author then shows that all other signs are uncertain, and
adds “that it is possible, by taking certain measures, to wait until
putrefaction is well manifest, without injuring the public health.” If
the attending medical practitioner could always be relied upon to look
for any such combination of signs as above suggested, there would be
much less danger of premature burial than at present almost everywhere
prevails; but personal investigation obliges the author deliberately to
declare that these are looked for only in a comparatively few instances.
_RIGOR MORTIS._
[RIGOR MORTIS.]
With reference to _rigor mortis_, one of the signs many physicians
regard as infallible as putrefaction, and to which the _British Medical
Journal_ attaches much importance, I cite the following:--
Dr. Samuel Barker Pratt says that _rigor mortis_, which is regarded as
an absolute proof of death, is in itself a life-action, caused by a
gradual withdrawal of the nerve-forces from the body, and is distinctly
akin to, and the same in effect as, the tightening of a muscle, and
other similar physiological actions in the living body.
Dr. Roger S. Chew observes:--
“_Rigor mortis_ is a condition that seldom or never supervenes in the
hot weather in India, and is often a feature of catalepsy.
“Ecchymoses, or _post-mortem_ stains, are sometimes of value, but very
frequently they do not appear, even though there are strong evidences
of putrefaction having set in, and in some cases this cadaveric
lividity, as it is termed, may be the result of violence received
before animation was suspended, and, the vital spark not having been
extinguished though the body was apparently dead, echymosis had
asserted itself as a process of life, and not death.”
Ebenezer Milner, M.D.Edinb., L.R.C.S.E., observes in a paper on
“Catalepsy or Trance” in the _Edinburgh Medical and Surgical Journal_,
1850, vol. lxxiv., p. 330:--
“Patients labouring under an intense and prolonged paroxysm of
catalepsy have been supposed to be dead, and have been interred alive.
[VARIOUS OTHER TESTS.]
“There are numerous cases of this kind on record, and many more where
individuals, after being laid in their coffins, have fortunately
recovered from the attack before the period of interment. In such
cases respiration is insensible, and the heart’s action is almost in
abeyance; the surface of the body is nearly cold, and presents the
pallor of death; and the articulations are stiff. Although it is no
doubt a difficult task to distinguish this state of trance from the
state of death, yet a careful examination of the body, and time, would
lead to a correct diagnosis. The limbs after death are first lax, then
stiff, and ultimately lax again. The stiffness of the limbs, known
as the cadaveric rigidity, or _rigor mortis_, lasts for a longer or
shorter time, according to circumstances; the sooner it supervenes, the
shorter is its duration, and conversely. Now the stiffness of the limbs
accompanying this intense form of trance supervenes at once, and lasts
as long as the paroxysm continues. This is consequently a valuable
diagnostic sign.”
It may be observed that only in rare and very exceptional cases is time
allowed for careful and accurate diagnosis.
CADAVEROUS COUNTENANCE.
Anthony Fothergill, in “A New Inquiry,” 1795, p. 92:--
“Nor can even the cadaverous countenance be, separately considered,
an infallible test of life’s total extinction. Nay, even putrefaction
itself, though allowed to be the most unequivocal sign of death, might
chance to deceive us in that syncope which sometimes supervenes on the
last stage of the confluent small-pox, sea-scurvy, or other highly
putrid diseases.”
REGARDING CLENCHED JAWS.
A. de Labordette, Chirurgien de l’Hôpital de Lisieux, states in a
letter to the Secretary of the Royal National Lifeboat Institution:--
“I have collected manifold observations relating to persons drowned or
asphyxiated, in whose case contraction of the jaws was remarked, and
who were subsequently restored to life,” Dr. Brown-Séquard concurred in
this, and declared further that such contraction is rather a sign of
life than of death.--_Lancet, 1870, vol. i., p. 436._
THE DIAPHANOUS TEST,
for the discovery of which a prize was given by the French Academy
of Medicine, is regarded by Sir B. Ward Richardson as of secondary
importance. It has certainly failed in many instances.
The following communication on
THE PROPER VALUE OF THE DIAPHANOUS
TEST OF DEATH,
by Edwin Haward, M.D.Edin., F.R.C.S.Eng., appears in the _Lancet_ of
June 10, 1893, p. 1404:--
[THE DIAPHANOUS TEST.]
“A case has come lately under my observation in which the value of
the diaphanous test of death has been illustrated at its just worth,
and, as the matter is one of supreme practical moment, I think it may
be considered deserving a brief notice in the pages of the _Lancet_.
Readers of the _Lancet_ need scarcely be informed that the diaphanous
test consists in taking a hand of a supposed dead person, placing
it before a strong artificial light, with the fingers extended and
just touching each other, and then looking through the narrow spaces
between the fingers to see if there be there a scarlet line of light.
The theory is that if there be such a line of scarlet colour there is
some circulation still in progress, and therefore evidence of vital
action, whilst if there be no illumination, then the circulation has
ceased and death has occurred. The French Academy of Medicine was so
impressed with the value of this test that it awarded, I believe, to
the discoverer of it a considerable prize. The illustration I am about
to give indicates, however, that this test must be received with the
utmost caution. The facts run as follows:--I was called in January last
to visit a lady seventy-three years of age, suffering from chronic
bronchitis. She had often suffered at intervals from similar attacks
during a period of twenty-five years. The present attack was very
severe, and as she was obviously in a state of senile decrepitude her
symptoms naturally gave rise to considerable anxiety. Nevertheless, she
rallied and improved so much that after a few days my attendance was
no longer required. I heard nothing more of this lady until February
6--a period of three weeks--when I was summoned early in the morning
to see her immediately. The messenger told me that she had retired
to bed in the usual way, and had apparently died in the night, but
that she looked so life-like there was great doubt whether death had
actually taken place. Within half an hour I was by her bedside; there
was no sign of breathing, of pulse, or of heart-beat, and the hands,
slightly flexed, were rather rigid, but the countenance looked like
that of a living person, the eyes being open and life-like. I believed
her to be dead, and that the rigidity of the upper limbs indicated
commencing _rigor mortis_; but this curious fact was related to me by
a near relative, that once before she had passed into a death-like
state, with similar symptoms, even to the rigidity of the arms and
hands, from which state she had recovered, and after which she had
always experienced the direst apprehension of being buried alive. Her
anxiety, it will be easily conceived, was readily communicated to her
relatives, who urged me to leave nothing undone for determining whether
life was or was not extinct. Under the circumstances I suggested
that Dr. (now Sir) Benjamin Ward Richardson, who has made the proofs
of death a special study, should be summoned. He soon arrived, and
submitted the body to all the tests in the following order:--1. Heart
sounds and motion entirely absent, together with all pulse movement.
2. Respiratory sounds and movements entirely absent. 3. Temperature
of the body taken from the mouth the same as that in the surrounding
air in the room, 62° F. 4. A bright needle plunged into the body of
the biceps muscle (Cloquet’s needle test) and left there shows on
withdrawal no sign of oxidation. 5. Intermittent shocks of electricity
at different tensions passed by needles into various muscles and
groups of muscles gave no indication whatever of irritability. 6. The
fillet-test applied to the veins of the arm (Richardson’s test) causes
no filling of veins on the distal side of the fillet. 7. The opening
of a vein to ascertain whether the blood has undergone coagulation
shows that the blood was still fluid. 8. The subcutaneous injection of
ammonia (Monteverdi’s test) causes the dirty brown stain indicative
of dissolution. 9. On making careful movements of the joints of the
extremities, of the lower jaw, and of the occipito-frontals, _rigor
mortis_ is found in several parts. Thus of these nine tests eight
distinctly declared that death was absolute; the exception, the
fluidity of the blood, being a phenomenon quite compatible with blood
preternaturally fluid and at a low temperature, even though death had
occurred. 10. There now remained the diaphanous test, which we carried
out by the aid of a powerful reflector lamp, yielding an excellent and
penetrating light. To our surprise the scarlet line of light between
the fingers was as distinct as it was in our own hands subjected to the
same experiment. The mass of evidence was of course distinctly to the
effect that death was complete; but, to make assurance doubly sure, we
had the temperature of the room raised and the body carefully watched
until signs of decomposition had set in. I made a visit myself on a
succeeding day to assure myself of this fact.
[INADEQUACY OF DIAPHANOUS TEST.]
“The results of these experimental tests were satisfactory, as
following and corroborating each other in eight out of the ten
different lines of procedure; but the point of my paper is to show the
utter inadequacy of the diaphanous test, upon which some are inclined
entirely to rely. Sir Benjamin Richardson has reported an instance in
which the test applied to the hand of a lady who had simply fainted
gave no evidence of the red line; she therefore, on that test alone,
might have been declared dead. In my case the reverse was presented;
the body was dead, whilst the red line supposed to indicate life was
perfectly visible. Hence the test might possibly lead to a double
error, and ought never of itself to be relied upon.
“It is a question worthy of consideration whether the colouration
observed was due to the fluid state of the blood after death; it is not
unreasonable to suppose so but I prefer merely to offer the suggestion
without further comment.”
Dr. Gannal, in his “Signes de la Mort,” p. 54, says:--
“The loss of transparency of the fingers is an uncertain sign, because
with certain subjects it takes place some time before death; next,
because it does not always occur in the corpse; and finally, because
it exists under certain circumstances in sick persons--in intermittent
fever, for example, when the skin loses colour, the hands get cold, and
the nails blue, as happens at the onset of the fits.”
Orfila, “Médicine Légale,” vol. i., p. 478, 4th edit., observes:--
“This sign can be of no use, because it is easy to prove that the
fingers of corpses placed between the eye and the flame of a candle are
transparent, even when this experiment is made one or two days after
death.”
Sir Benjamin Ward Richardson read a paper before the Medical Society
of London on “The Absolute Signs and Proofs of Death,” published (in
1889) in No. 21 of the _Asclepiad_. The circumstance which originated
his investigation was a case of the revival of an apparently dead
child immediately before the funeral. Dr. Richardson has seen persons
apparently dead, and presenting all the signs of death, but who were
really living. Amongst these he cites the following:--
“A medical man found dead, as it was presumed, from an excessive dose
of chloral. To all common observation this gentleman was dead. There
was no sign of respiration; it was very difficult for an ear so long
trained as my own to detect the sounds of the heart; there was no pulse
at the wrist, and the temperature of the body had fallen to 97° Fahr.
In this condition the man had lain for some hours before my arrival;
and yet, under the simple acts of raising the warmth of the room to 84°
Fahr. and injecting warm milk and water into the stomach, he rallied
slowly out of the sleep, and made a perfect recovery.”
More remarkable is the case of a man struck by lightning, details of
which Sir Benjamin received, in 1869, from Dr. Jackson, of Somerby,
Leicestershire.
“The patient reached his home in a state of extreme prostration, in
which he lay for a time, and then sank into such complete catalepsy
that he was pronounced to be dead, and heard the sound of his own
passing bell from the neighbouring church; by a desperate attempt at
movement of his thumbs he attracted the attention of the women engaged
about him, and, being treated as one still alive, recovered, and lived
for several years afterwards, retaining in his memory the facts, and
relating them with the most consistent accuracy.”
[SIR B. W. RICHARDSON’S ENUMERATION.]
Medical practitioners tell us that the signs of death are quite easy
and impossible to mistake. Dr. Richardson, who has had the best of
reasons, as already shown, for observation and investigation, holds a
different opinion, and enumerates the signs of death as follows:--
(1) Respiratory failure, including absence of visible movements of
the chest, absence of the respiratory murmur, absence of evidence of
transpiration of water vapour from the lungs by the breath.
(2) Cardiac failure, including absence of arterial pulsation, of
cardiac motion, and of cardiac sounds.
(3) Absence of turgescence or filling of the veins on making pressure
between them and the heart.
(4) Reduction of the temperature of the body below the natural standard.
(5) Rigor mortis and muscular collapse.
(6) Coagulation of the blood.
(7) Putrefactive decomposition.
(8) Absence of red colour in semi-transparent parts under the influence
of a powerful stream of light.
(9) Absence of muscular contraction under the stimulus of galvanism, of
heat, and of puncture.
(10) Absence of red blush of the skin after subcutaneous injection of
ammonia (Monteverdi’s test).
(11) Absence of signs of rust or oxidation of a bright steel blade,
after plunging it deep into the tissues. (The needle test of Cloquet
and Laborde.)
Sir Benjamin sums up as follows:--
“If all these signs point to death--if there be no indications of
respiratory function; if there be no signs of movement of the pulse
or heart, and no sounds of the heart; if the veins of the hand do
not enlarge on the distal side of the fillet; if the blood in the
veins contains a coagulum; if the galvanic stimulus fails to produce
muscular contraction; if the injection of ammonia causes a dirty
brown blotch--the evidence may be considered conclusive that death is
absolute. If these signs leave any doubt, or even if they leave no
doubt, one further point of practice should be carried out. The body
should be kept in a room, the temperature of which has been raised to a
heat of 84° Fahr., with moisture diffused through the air; and in this
warm and moist atmosphere it should remain until distinct indications
of putrefactive decomposition have set in.”
Dr. Franz Hartmann, whose recent monograph[15] has excited much
attention both in the English and American Press, observes:--
“Apparent death is a state that resembles real death so closely that
even the most experienced persons believe such a person to be really
dead. In many cases not even the most experienced physician, coroner,
or undertaker can distinguish a case of apparent death from real
death, neither by external examination nor by means of the stethoscope,
nor by any of the various tests which have been proposed by this or
that writer, for all those tests have been proved fallible, and it
is now useless to discuss them at length, because many of the most
experienced members of the medical profession have already agreed that
there is no certain sign that a person is really and not apparently
dead, except the beginning of a certain stage of putrefaction. All
other tests ought to be set down as delusive and unreliable.”
[RULES FOR OFFICIAL INSPECTORS.]
In the Royal Decree issued by the Government for examining the dead
in Würtemberg, dated January 24, 1882 (_Dienst-Vorschriften für
Leichenschäuer_, Stuttgart, 1885), various signs and experiments for
enabling the official inspector of deaths to ascertain if actual death
has taken place are laid down. Among these are:--
(1) “The cessation of sensibility may be assumed if, on raising the
eyelid, the pupil remains unaltered when a lighted candle is held
close to it; or if pungent odours, such as those derived from onions,
vinegar, sal-ammoniac, or severe friction of the chest, arms, or
soles of the feet, the application of mustard, or burning tinder,
or if sealing-wax dropped upon the chest produces no reaction, and
particularly if in the latter case the skin does not blister.
(2) “The stoppage of the circulation of the blood, apart from the
absence of heart beating, if, after tying a tight bandage around the
arm, the veins do not swell up, upon the hands being firmly gripped;
also if, upon pricking the lips, no blood escapes; furthermore, if, on
holding the hand in front of a bright light (the diaphanous test), the
finger-tips are no longer translucent as in the living.”
Nor should the inspector ever neglect to examine the heart to ascertain
the complete absence of all sound, and to test the absence of breath by
other experiments.
The rescript further adds that these experiments “may not furnish
absolute proof of death,” and describes what further proceedings to
institute. These are referred to in this volume in the chapter devoted
to Death Certification.
An editorial note in the _Lancet_, January 29, 1887, p. 233, shows the
difficulty of distinguishing real from
[CASES FROM THE “LANCET.”]
APPARENT DEATH.
“It was only last year that we commented in our columns upon the ‘signs
of death,’ drawing attention to the more important criteria by which
a skilful observer may avoid mistaking cases of so-called suspended
animation from actual disease. Quite recently two instances have been
recorded, in which, if report be true, it would seem there is still
room for maturing the judgment upon the question herein raised. At
Saumur a young man afflicted with a contagious disease apparently died
suddenly. His body was enshrouded and coffined, but as the undertaker’s
men were carrying the ‘remains’ to their last resting-place they
heard what they believed to be a knocking against the coffin-lid, and
the sound was repeated in the grave. Instead of testing at once the
evidence of their senses, they, in accordance with judicial custom,
sent for the Mayor, in whose presence the lid was removed from the
coffin. Whereupon, to the horror of the spectators, it was observed
that the dead man had only just succumbed to asphyxia. The above
narrative seems on the face of it too ghastly to be true, especially as
the occupant of the coffin must have been shut up in a space containing
oxygen in quantity totally inadequate to sustain an approximation
to ordinary breathing. But in cataleptic and similar states the
organic functions are reduced to the lowest ebb, and history records
several instances in which, for a time at least, the determination
of the living state was a matter of uncertainty. In our issue of the
15th inst., p. 129, the reader will find an account of ‘Post-mortem
Irritability of Muscle,’ in which the phenomenon was manifested in a
marked degree two hours after death from a chronic wasting disorder--a
condition which favours early extinction of vital action in muscle.
It may be argued, then, with some show of reasonableness, that it
is quite possible for the heart to stand still, as it were, and yet
retain the power of action, although experience tells us but little on
the question as regards the human subject. Experiments on the lower
animals, however, show that over-distension of the right cavities of
the heart causes cessation of cardiac contraction, and that relief
from the distension may be followed by resumption of the function of
contractibility. It must not be forgotten that an analogous condition
is witnessed at times in patients suffering from capillary bronchitis
or other physical states underlying acute distension of the right
heart; for, in these cases, venesection is not uncommonly instrumental
in arresting the rapidly failing cardiac contractions. The second
case of apparent death alluded to above happened in ‘the land of big
things.’ An inhabitant of Mount Joy, Paramatta, was believed to be
dead, and his supposed remains were about to be committed to the
earth, when a mourning relative startled the bystanders by exclaiming,
‘I must see my father once more; something tells me he is not dead.’
The coffin was taken from the grave to the sexton’s tool-house, and
there opened, and was found to contain a living inmate, who justified
the presentiment of his son by ‘slowly recovering.’ As no mention is
made in either case of the period that elapsed between the occurrence
of apparent death and the body being placed in the coffin, or of the
time during which the encasement lasted, special and minute criticism
is uncalled for. Enough has been said on the subject to emphasize
the exhortation, ‘Get knowledge, and with all thy getting get
understanding.’”
The _British Medical Journal_, of September 28, 1895, in a leading
article on the “Signs of Death,” says:--
“The question of the possibility of the interment of living beings
has recently been exercising the minds of a portion of the public,
whose fears have found expression in a series of letters to some of
the daily papers. It is a matter of regret that so much irresponsible
nonsense and such hysterical outpourings should find a place in the
columns of our great daily press. No attempt at the production of
evidence in support of their beliefs or fears has been made by the
majority of writers, whilst the cases mentioned by the few are either
the inventions of the credulous or ignorant, or are destitute of
foundation. It cannot be said that the few medical men who have joined
in this public correspondence have either contributed any useful
information or have seriously attempted to allay the fears of the
public. One medical gentleman managed to earn for himself a cheap
notoriety by employing, with very scanty acknowledgment of the source,
copious extracts from Dr. Gowers’ article on ‘Trance’ in Quain’s
‘Dictionary of Medicine.’
“The possibility of apparent death being mistaken for real death can
only be admitted when the decision of the reality of death is left to
ignorant persons. We are quite unprepared to admit the possibility of
such a mistake occurring in this country to a medical practitioner
armed with the methods for the recognition of death that modern
science has placed at his disposal. Moreover, even by the ignorant the
reality of death can only be questioned during the period preceding
putrefaction. During this period various signs of death appear which,
taken collectively, allow of an absolute opinion as to the reality of
death being given. To each of these, as a sign of death, exception may
perhaps be individually taken, but a medical opinion is formed from a
conjunction of these signs, and not from the presence of an individual
one.”
[THE “BRITISH MEDICAL JOURNAL.”]
The writer must surely have overlooked the able treatises by Winslow,
Kempner, Russell Fletcher, Hartmann, Gannal, and others, supported by
evidence in the aggregate of thousands of cases of premature burial
or narrow escapes, or have forgotten the dreadful cases which have
appeared from time to time in the columns of the _British Medical
Journal_ itself. Commenting upon the case of a child nearly buried
alive, this medical authority in its issue of October 31, 1885,
under the head of “Death or Coma,” sensibly refers to some of the
difficulties in distinguishing apparent from real death as follows:--
“The close similarity which is occasionally seen to connect the
appearance of death with that of exhaustion following disease, was
lately illustrated in a somewhat striking manner. An infant, seized
with convulsions, was supposed to have died about three weeks ago at
Stamford Hill. After five days’ interval, preparations were being made
for its interment, when, at the grave’s mouth, a cry was heard to
come from the coffin. The lid was taken off, and the child was found
to be alive, was taken home, and is recovering. Such is the published
account of the latest recorded case of suspended animation. We need
not now attempt a dissertation on the physical meaning of coma. It
is well known that this condition may last for considerable periods,
and may at times, _even to the practised eye_, wear very much the
same aspect as death. In the present instance, its association with
some degree of convulsion may easily have been mistaken by relatives,
dreading the worst, for the rigid stillness of _rigor mortis_. This
is the more likely, since the latter state is apt to be a transient
one in infants, though it is said to be unusually well marked in death
from convulsions. One cannot, however, help thinking that the presence
of the various signs of death was not, in this case, very carefully
inquired into. It is hardly possible that, had the other proofs as well
as that of stiffening been sought for, they would have been missed. _It
is true that hardly any one sign short of putrefaction can be relied
upon as infallible._ In actual death, however, one may confidently
reckon on the co-existence of more than one of these. After a period of
five days, not one should have been wanting. Besides _rigor mortis_,
the total absence of which, even in forms of death which are said
not to show it, we take leave to doubt, the _post-mortem_ lividity of
dependent parts afford sure proof, as its absence suggests a doubt,
of death. Then there is the eye, sunken, with glairy surface, flaccid
cornea, and dilated insensitive pupil. Most practitioners, probably,
are accustomed to rely upon stethoscopic evidence of heart-action or
respiration. These alone, indeed, are almost always sufficient to
decide the question of vitality, if they be watched for during one or
two minutes. There is no information as to whether the child so nearly
buried alive was seen by a medical man. It is difficult to believe
that, if it had been, some sign of life would not have been observed.
Still, the case is a teaching one, even for medical men, and warns us
to look for a combination of known tests where any doubt exists as to
the fact of death.” The italics are ours.
Prof. Alex. Wilder, M.D., in “Perils of Premature Burial,” p. 20,
says:--
[DR. ALEXANDER WILDER’S OPINION.]
“The signs of total extinction of life are not so unequivocal as many
suppose. Cessation of respiration and circulation do not afford the
entire evidence, for the external senses are not sufficiently acute to
enable us to detect either respiration or circulation in the smallest
degree compatible with mere existence. Loss of heat is by no means
conclusive; for life may continue, and recovery take place, when no
perceptible vital warmth exists.”
M. B. Gaubert, in “Les Chambres Mortuaires d’Attente,” p. 187, Paris,
1895, says:--
“One of the most celebrated physicians of the Paris hospitals,
according to Dr. Lignières, declares that out of twenty certified
deaths, one only presented indubitable characteristics of absolute
death.”
The difficulty of diagnosis in many cases being allowed renders
the obligation and necessity for a radical change in our methods
of treating the supposed dead a very urgent one. Medical writers,
whilst admitting the unsatisfactory nature of the current practice of
medical certification, allege that the remedy lies with Parliament
to make compulsory a personal medical inspection of the dead, and to
allow a fee as compensation for the trouble. This, however, would be
very far from meeting the difficulty. How many general practitioners
would be willing to submit half-a-dozen, say, of the eleven tests of
death formulated by Sir Benjamin Ward Richardson, in any given case,
and if willing, how many, having regard to the fact that these tests
are not taught in the Medical Schools, and form no part of the usual
medical curriculum, would be competent to make them with the requisite
skill? In most of the Continental States there are State-appointed
surgeons to examine the dead, _médécins vérificateurs_, and in
some of these--Würtemburg, for instance--the official is obliged
to examine the corpse several times before his certificate is made
out. But notwithstanding this careful official inspection, cases of
premature burial and narrow escapes are telegraphed by _Reuter_ and
_Dalziel_ every now and then to the English Press, as we have seen, and
additional details, with the names and addresses of the victims, are
furnished by responsible special correspondents.
[CONFUSION OF MEDICAL OPINIONS.]
The best proof that one can give of the uncertainty of the signs of
death is the great divergence of opinion amongst medical experts. Dr.
Gannal, in “Signes de la Mort,” Paris, 1890, p. 27, observes:--“If
any of these signs had presented characters of absolute certainty, it
is unquestionable that the unanimity of authors would have recognised
it; now, there is none. One sign held to be good by some, is declared
bad by others.” Dr. Gannal affirms with iteration that there is only
one unequivocal sign and proof of dissolution--decomposition. All
authorities agree that whatever degree of doubt attends the ordinary
appearances of death, none dispute that this amounts to a demonstration.
When standing round the bed of a sick patient, reduced to a state
of coma or suspended animation, to which death is the expected
termination, as soon as the doctor utters the fatal words “all is
over,” no one present thinks of doubting the verdict, or putting it to
the test. Mr. Clarke Irvine, who has had a wide experience, writing in
the _Banner of Light_, December 14, 1895, Boston, U.S., says:--
“I have known of hundreds of deaths in my experience, and never have
I known of any instance wherein a bystander has doubted save once,
and then the person supposed dead was revived, and is now living out
in Colorado. The mere accident of a stranger coming in just previous
to the enclosing in a coffin prevented the man from the awful fate of
burial alive, so far as we can see.
“In one other, the supposed dead man came to life a little before the
time set for his funeral, by the accident of some one seizing hold of
his foot: he is still living, and a resident of this country. The case
was widely published in the newspapers after he was interviewed by a
reporter in Chicago, where the rescued man was visiting at the time of
the great Fair. He is known as Judge William Poynter. I saw him a few
days ago, and have heard him relate the experience.
“The case of the little girl who was rescued while the funeral was
in progress, at St. Joseph, Missouri, I have already contributed to
_The Banner_. These people were saved by a mere chance; how many have
passed underground forever, of whom nothing was ever suspected! All
through the country, people are dying or apparently dying, or falling
into death-like trances daily, and being placed in their coffins _as a
matter of course_, and hurried to and into their graves, _as of course_
also--and in the very nature of things it must be and must have been
that hundreds upon hundreds have been and are being consigned to that
most awful of all the dooms possible. The horror of the thing is simply
unspeakable.”
OFFICIAL REGULATIONS FOR THE PREVENTION OF PREMATURE INTERMENT IN
BAVARIA.
[BAVARIAN REGULATIONS.]
The following are extracts from the Police Regulations for the
inspection of the dead, and the prevention of premature burial in
Bavaria, and issued by the Royal State-Ministry for Home affairs:--
§ 4.
In public hospitals, penitentiaries, charitable or other similar homes
or institutions, the duty of inspection falls upon the physician in
chief.
Outside these institutions the inspectors must be chosen, in the
first instance, from among physicians, after them surgeons, former
assistants of military hospitals, and lastly, in default of such, from
lay people. The latter must, however, be of undoubted respectability,
and, before their appointment, must be properly instructed by the
district physician, and subjected from time to time to an examination.
§ 6.
As a rule the inspection of dead bodies must be made once if by
doctors, and twice if by laymen. In communities which possess a
mortuary a _second inspection_ has to be made, even though the regular
inspection has previously been made by doctors or laymen.
§ 7.
The first inspection has to be made as soon as possible after death,
and, where practicable, within twenty-four hours, and in cases
described under § 6, sec. 2, at least before removal of the body to
the mortuary.
The second inspection must take place just before burial.
§ 8.
The body, until the arrival of the Inspector, must be left in
an undisturbed position, with the face uncovered, and free from
closely-fitting garments.
The instructions of the Inspector, for the resuscitation of a body
suspected of apparent death only, are to be followed most strictly.
§ 9.
The Inspector has to give a certificate of corpse inspection
confirmatory of his inspection, but he must only issue the same if he
has fully ascertained the actuality of death.
§ 10.
(1) As a rule the bodies must not be interred before the lapse of 48
hours, but not later than 72 hours, after death.
The Police Authorities may, however, at the recommendation of the
Corpse Inspector, exceptionally grant permission for the burial before
the expiration of 48 hours if a _post-mortem_ dissection has taken
place, also if decomposition has set in, and if on account of lack of
room the body has to be preserved in an overcrowded habitation.
APPENDIX to the Police Instructions as to Corpse Inspection and time
of Burial, of 20th November, 1885.
I.
The purpose of corpse inspection is to prohibit the concealment of
deaths by violent means or resulting from medical malpractices;
to detect infectious diseases, and the establishment of correct
death lists; and particularly _to prevent the burial of people only
apparently dead_. For this purpose each corpse is to be closely
examined on the first inspection as to any signs of death, both in the
front and the back of the body.
II.
The Inspectors have primarily to establish the actuality of death by
observing and notifying all the symptoms accompanying or following the
decease.
Indications of death may be noted:--
(1) If there is no indication of any pulsation noticeable, either in
the region of the heart, at the neck, at the temples, or the forearm.
(2) If the eyelids when pulled asunder remain open, and the eyes
themselves appear sunken into their sockets, dulled, and lustreless,
also if the eyeballs feel soft and relaxed.
(3) If parts of the body are pale and cold, if chin and nose are
pointed, if cheeks and temples are sunken.
(4) If the lower jaw hangs down and immediately drops again if pushed
up, or if the muscles feel hard and stiff (rigidity).
(5) If the skin of the fingers held against one another, held towards
light, do not appear reddish.
(6) If a feather or burning candle held against the mouth show no sign
of motion, or if there is no sign of moisture upon a looking-glass
held before the mouth.
(7) If on different parts of the body, particularly the neck, back, or
posterior, or the undersurface of the extremities there are bluish-red
spots (death spots) visible.
(8) If the skin, particularly at the sides of the stomach, show a
dirty-green discoloration (decomposition spots).
The non-Medical Inspector has to observe at least all the symptoms 1
to 4.
In doubtful cases the Medical Inspectors are advised to test the
muscles and nerves by electric currents.
IV.
If the inspection gives rise to suspicions of apparent death
(Scheintod), the inspector must (if he is not himself a doctor)
immediately call for the assistance of a practised physician, so as to
establish the actual condition, and to adopt the necessary measures
for resuscitation, as follows:--
(1) Opening of the windows, and warming the room.
(2) Efforts at artificial respiration.
(3) Applications of warm mustard-plaisters to the chest and the
extremities.
(4) Rubbing with soft brushes, with cloths saturated in vinegar, or
spirit of camphor, also with hot woollen cloths.
(5) Irritation of the throat with a feather.
(6) Smelling sal-ammoniac.
(7) Dropping from time to time a few drops of “extract of balm” or
similar essences into the mouth.
Unless medical aid has meanwhile arrived, the application of these
measures must be continued until the apparently dead comes, back to
life, and begins to swallow, in which case he ought to have warm
broth, tea, or wine, or until there is absolutely no doubt as to the
total ineffectiveness of all attempts at reanimation.