DEATH-CERTIFICATION.

A Select Committee of the House of Commons, under the chairmanship of Sir Walter Foster, M.D., was appointed on March 27, 1893, to inquire into the subject of death-certification in the United Kingdom. Fourteen sittings were held, and thirty-two witnesses examined. All the witnesses practically agreed as to the serious defects in the law, and a number of recommendations were made. It was shown that in about four per cent. of the cases the cause of death was ill-defined and unspecified, many practitioners having forms specially printed for their own use, in which all mention of medical attendance is omitted, the object being to enable the doctor to give certificates in cases which he has never attended. Numerous deaths attended by unqualified practitioners were certified by qualified practitioners who had probably never seen the cases; and deaths were certified by medical practitioners who had not seen the patient for weeks or months prior to death, and who knew only by hearsay of the deaths having occurred. Deaths were also certified in which the true cause was suppressed in deference to the feelings of survivors; these last in particular are reported to be very numerous.

In Q. 2552-83, remarkable evidence was produced as to the reckless mode of death-certification. One medical witness testified that he saw a certificate of death, signed by a registered medical practitioner, giving both the fact and the cause of death of a man who was actually alive at the time, and who lived four days afterwards, with facts of even a more startling character described as “murder made easy.” It was pointed out that fraud and irregularity in giving false declarations of death are by no means infrequent. Various other matters are treated, and the following are some of their recommendations:—

From the Times, May 23, 1896:—

A well-known physician in large practice, writing to the author from a Midland town, October 10, 1895, says:—“Medical men, attending patients seriously ill, accept the statement of the friends that the patient died in the night, and give a certificate at once, without any inspection of the body. This is the regular practice.”

In Ireland matters are no better, and clergymen and others, with whom the author has been in correspondence, say they are much worse, and the danger of premature burial is, if possible, greater than it is in England. The Rev. W. Walters, writing from Ventry Parsonage, Dingle, Ireland, September 16, 1895, says:—“In Ireland interment usually takes place the day after decease, and no certificate as to the cause of death is ever required. There is no safeguard whatever, and amongst the ignorant poor I fear premature burial is terribly frequent.”

A prominent medical officer of health, having charge of a populous metropolitan parish, wrote to the author, October 8, 1895, in reply to inquiries:—“When a doctor attends a patient in an illness, and the patient dies, he usually accepts the word of the friends as to the facts of death, and if they are poor, or in moderate circumstances, he grants the certificate in the ordinary way. If he is satisfied as to the cause of death he dare not refuse the certificate. You will see by the form I send you that he need not actually satisfy himself that the patient is dead; if he is not satisfied he writes, ‘As I am informed,’ in the space left for the words.... On one occasion I was directed by a lady to drive a very long hat-pin through her heart after death, to ensure that she should not be buried alive. I have given so little attention to the matter that I cannot say if the Continental practice in this respect is better than ours. Signs of decomposition are, I believe, the only ones of any real value. The form of certificate of death referred to is marked, ‘Printed by authority of the Registrar-General,’ and a request marked ‘N.B.’ is to read the suggestions on page ii. In this other form, which is entitled ‘Suggestions to medical practitioners respecting certificates of the cause of death,’ elaborate instructions are set forth under ten separate clauses, with examples showing in what way the death-certificates are to be filled up, but not one word of instruction or caution as to the fact of death—whether it be real or apparent—the absolute signs of death, or the steps to be taken in doubtful cases, or in the various forms of suspended animation, such as coma, trance, catalepsy, etc.”

The Times, January 19, 1878, p. 9, foot of column 6, reports a singular case in point:—

“Premature.—A poor woman lay very ill in her scantily-furnished home in Sheffield. The doctor was sent for, and came. He at once saw that hers was a very grave case, and that she had, as he thought, little chance of recovery, even if she could get the nourishment her illness required. As he was about to leave, the question was put, ‘When should we send for you again, doctor?’ ‘Well,’ was the reply, as he looked at the poor woman and then at her wretched surroundings, ‘I don’t think you need send for me again. She cannot possibly get better; and to save you further trouble I’ll just write you out a certificate for her burial.’ And he did. After the doctor departed the woman—women always were wilful—got better rapidly. She has now completely recovered, and goes about carrying her burial certificate with her.—Sheffield Telegraph.”

Dr. Charles Cameron, M.P., in moving the introduction of the Disposal of the Dead (Regulation) Bill, in the House of Commons, on April 30, 1884, said:—“A very large number of our population die without any medical attendance at all, or at least without having ever received sufficient medical attention to enable a certificate of the cause of death to be given worth the paper on which it is written. In many of these cases some sort of worthless certificate is procured and presented to the registrar, but many thousands of persons are each year buried in the United Kingdom without even this formality.”

The contrast between the laxity at home and the regulations laid down by authority in WÜrtemburg, Bavaria, and other Continental States, is remarkable, and should receive the attention of the Registrar-General without delay.

From the Lancet, 1890, vol. i., p. 1440:—

“UNCERTIFIED CAUSES OF DEATH IN ENGLAND.

“Considering the general progress that has been made in public health during the last twenty years, it is seriously to be regretted that this matter of unknown and uncertified causes of death has been practically left untouched, and its settlement is, therefore more urgently needed now than when so often pressed upon the public notice by the late Dr. William Farr during his connection with the Registrar-General’s department.”

The Parliamentary Committee above referred to omitted an unexampled opportunity of inquiring into the facts of premature burial. They could have summoned pathologists, who had made trance and catalepsy a subject of close and searching investigation, as well as physicians, who, in their practice, have been called in to decide upon cases of apparent death, and of witnesses up and down the country who know of such cases, and others who have met with narrow escapes from these horrible mishaps. Instead of taking this reasonable course of procedure, the Committee contented themselves by examining two or three medical men, who had been summoned to give evidence upon the irregularities of death-certification only, and whose negative and apathetic replies showed either that the subject had never engaged their attention, or that they were unwilling to charge any member of the profession with a fault so ruinous to his professional reputation as to be unable to discriminate between the living and the dead. No questions were submitted to the witnesses as to the signs of death, the characteristics of catalepsy, trance, asphyxia, syncope, etc., or how to distinguish these from death, or as to the submission of tests in doubtful cases in order to ascertain the fact of death. Indeed, it may be observed that the investigation regarding a most vital point connected with death-certification appears to have entirely escaped the notice of this tribunal. As a specimen of the proceedings under this head are the following (“Report,” p. 116)—Mr. John Tatham, M.A., M.D., being under examination by the chairman, Si Walter Foster, M.D.

Further questions were asked of the same witness by Dr. Farquharson.

A correspondent of the Undertakers’ and Funeral Directors’ Journal, July 22, 1893, p. 92, writes:—

VERIFICATION OF DEATHS.

“In Paris and the large French towns medical inspectors, called mÉdecins verificateurs, are appointed, whose business it is to visit each house where a death occurs, and ascertain that the person is really dead, and that there are no suspicious circumstances connected with his or her decease. More than eighty qualified medical men are employed for this purpose in Paris.

“In the rural districts of France this system is not in force; two witnesses making a declaration to a civil officer that a death has taken place, is considered sufficient. The burial is not allowed to take place until at least twenty-four hours after the declaration.”—Blyth: Dictionary of Hygiene and Public Health.

Dr. LÉonce LÉnormand, in his admirable work “Des Inhumations PrÉcipitÉes,” p. 140, accuses the mÉdecins des morts in France with culpable carelessness in the exercise of their function, which consists in verifying the reality of the death. Instead of making a minute examination of the body to ascertain the fact of death, this writer says they are content (except in cases of death from violence) to merely glance at the body, and immediately to hand the family the necessary authorisation for interment.VERIFICATIONS ILLUSORY. The inspector knows that if he examined every part of the body, as in duty bound, he would be accused of barbarism and profanation. Those, therefore, who think that premature burial could be prevented in England by means only of a more stringent law of compulsory death-certification, would, if it were carried, find themselves in hardly any better position than at present, where the fact of death is left to a great extent to the judgment of friends, if the deceased has any, or to the perfunctory inspection of the undertaker. It is in France where probably, in spite of mÉdecins verificateurs, more premature burials occur than in any country in Europe except Turkey, immediate burial after real or apparent death being the inexorable rule. Dr. LÉnormand attributes the frequency of premature burials in France, first of all, to the negligence and prejudices of the families of the deceased; then to the carelessness of the doctors charged by the State with the inspection of the dead; and lastly, to the imperfection of the police regulations.

From the British Medical Journal, January 28, 1893, p. 204. (Special Correspondence, Paris.)

“PREMATURE BURIAL.

“The question whether premature burial occurs, and how to prevent it, is, notwithstanding the all-absorbing interest of the Panama question, attracting some attention here. The ‘Union Medicale’ devotes one of its feuilletons to it, in which two or three nouvelles À sensation are reproduced, and easily proved to be untrue. Premature burial cannot occur, the writer says, when a death is duly verified. The 77th Article of the Code obliges the officier de l’État civil to visit the death-bed and verify every death; but this Article is a dead letter. The officer in question has neither time nor knowledge sufficient to put it in practice. In small country places, rarely any precautions are taken to prevent premature burials. In more important villages and towns, the mayors delegate the doctors of the locality to verify deaths before burial. Throughout the whole of France, it appears that there are not fifty towns where the death-verifying service is well organised; and, on an average, there are from twenty thousand to thirty thousand burials without previous verification of death. The declaration of two witnesses is sufficient, who obtain their information from those around the deceased. In Paris, the two mortuaries already in existence—one at the Montmartre Cemetery, the other at PÈre La Chaise—are rarely used. The bodies of those who die in the streets, from accident or sudden death, are taken there when there is no domicile; also, those of foreigners who die in lodging-houses. In the course of eighteen months the mortuary of Montmartre received five dead bodies, and PÈre La Chaise one. In Germany the mortuaries are much used, and every arrangement made is in order that any who come back to life may be able to easily summon help. At Munich, a ring in connection with a bell-cord is put on one of the fingers of the hands of the dead. At Frankfort, similar precautions are taken.”

Extracts from “Regulations for the Domiciliary Examination of the Dead in the City of Brussels Civil Government (Medical Service).”

This verification, as well as the identity of the person deceased, shall be certified by a procÈs-verbal [statement, or description, for which a blank is furnished “A”], which they shall leave at the house of the deceased.

EXAMINATION AND CERTIFICATION OF THE DEAD IN WÜRTEMBURG.

A Royal Decree, entitled “Dienst-Vorschriften fÜr LeichenhaÜser,” for the inspection and burial of the dead, promulgated by the King of WÜrtemburg, January 24, 1884, provides for the appointment of medical inspectors of the highest integrity and qualifications in every commune, the position being justly regarded as one of great responsibility.

Immediately after a death, the body must under no circumstances be interfered with, and must not be removed from the death-bed until after the authorised inspection. Post-mortems can be made only if the fact of death has been previously clearly established. Precise instructions are laid down, so that the inspector, who is to examine the entire body, may see that the various forms of suspended animation are not certified as actual death. Amongst these are the following:—

After detailing instructions as to a variety of experiments to ascertain whether the death is actual or apparent, this Royal Decree proceeds:—

“Section viii.—These experiments may, however, not give absolute certainty as to the complete extinction of all life. If, therefore, the slightest doubt remains as to the reality of death, the inspector is to take the necessary precautions for the protection of the deceased, by frequent inspections, and the most careful examinations, and to obtain the assistance of the nearest physician or surgeon, who is to co-operate with him to promote resuscitation. If these attempts prove abortive, he must see that nothing is done which would be detrimental to reanimation, or resumption of life.”

Then follow minute instructions how to proceed under the varied circumstances which may have produced the symptoms known as apparent death. In no case must the burial certificate be handed over by the inspector until he has thoroughly satisfied himself of the presence of unmistakable signs of actual death.

One cannot help contrasting these carefully considered rules with the lax and haphazard methods of dealing with the dead and apparent dead both in England and in the United States. As a consequence, cases of premature burial in WÜrtemburg are of very rare occurrence, and sensible people in that country, knowing that the danger of premature burial has been reduced to a minimum, are not consumed by an ever-abiding anxiety as with us, nor is it the custom for testators in WÜrtemburg to give instructions to their executors for piercing the heart or severing the jugular vein, or some other form of mutilation, as in France, Spain, and other countries, where the risks are so terribly great.

The only case of the danger of premature burial that has come to the author’s notice in WÜrtemburg is related by Bouchut, in his “Signes de la Mort,” p. 48:—

In the United States the subject of Death-Verification has only recently begun to engage public attention. The following appears to be the only instance in which reasonable, although not altogether adequate, precautions are adopted.

Mr. A. Braxton Hicks, Barrister-at-Law, and Coroner for London and Surrey, states that—

A DOCTOR FOR THE DEAD.

Dr. J. Brindley James, in a communication to the Medical Times, May 23, 1896, pp. 355-356, calls attention to the insufficient safeguards against premature burial under the present system of death-certification, and observes—“The dread possibility of premature interment ever hangs like a gloomy sword of Damocles over all our heads, and fearful indeed is the authentic record of persons buried alive, who have recovered consciousness; too late, alas! to be rescued from their frightful dungeon. How often does our overworked—we do not say careless—practitioner sign the death-certificate of a patient whose death-bed he did not attend—whose corpse he has not visited? And even assuming him to have done so, and conscientiously too, in how many of the fearful cases above alluded to have not these formalities proved insufficient, clearly suggesting the advisability of a specialist, experienced in post-mortem inspection, solely sanctioning interment in all cases.” And Dr. Frederick Graves, writing in the same journal of July 18, 1896, says:—

The Daily Chronicle, London, September 16, 1895, in a leading article on the danger of premature burial, says:—“The truth is, the whole system of certifying for burial needs to be reconsidered and reformed, and that for other reasons than the danger of entombment before life is extinct. We do not want a coroner’s inquest, with its jury, for every death; but the doctors should be compelled, under severe penalties, to discover the certain sign of death before they authorise the burial, and to know the cause of death in every case.STRINGENT LEGISLATION SUGGESTED. We trust now too much to individuals in a generally trustworthy profession, who may not reach the high general standard of their class, or may grow listless through the indifference wrought by use and wont, or who think they can detect the rigor mortis at a glance, never having seen the severest form of catalepsy. There would be no difficulty in getting Parliament to pass a more stringent regulation for death-certificates without much discussion, and there is no reason why Sir Matthew White Ridley should not turn his attention to the matter, and, with such medical advice as the Health Department of the Local Government Board will be pleased to lend him, propose a necessary little bill to the House of Commons next February.”

The following letter by a German resident in England appeared in the Times of September 20, 1895:—