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.

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.

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.

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.

“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:—

“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.

“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.”

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.”

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

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.CASES FROM THE “LANCET.” 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 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 THE “BRITISH MEDICAL JOURNAL.” 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:—

“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.

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.

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:—

Appendix to the Police Instructions as to Corpse Inspection and time of Burial, of 20th November, 1885.