THE SIGNS OF DEATH.

DEATH may be defined as the cessation of those physical and chemical processes on which the phenomena of life depend. Animal life, however, is a very complex condition, and while the scientific conception of death requires the complete cessation of all the physicochemical or molecular processes of life, practically and before the law, the animal body may be dead long before the complete cessation of all the molecular processes of life. The hair and nails, for example, may grow to a considerable length after death.

There is also a variance between the legal and the scientific conception of a living person. The law, as held in England and in some States of America, recognizes as living beings only those born in a condition capable of maintaining an independent existence. Science recognizes the fetus as a living being, and finds it almost as violent a procedure to interrupt the current of maternal blood circulating about the fetus of three months as to cut off the supply of air from an adult man.

The legal scope of the term "death," thus considerably contracted in comparison with the scientific, involves the final and complete cessation of those vital functions upon which depends the life of an individual capable of maintaining independent existence. The physical processes here concerned are chiefly respiration and circulation, on the activity of which life principally depends, and the cessation of which is, usually, readily determined. The fact, however, that molecular activity may persist some time after respiration and circulation have ceased renders the proof of the final and complete cessation of these vital functions often a matter of difficulty, and necessitates a careful consideration of all the external signs of death.

Hansemann has pointed out the close and almost altruistic interdependence of the molecular processes and the life of the cells of the various organs. The truth of his conception is well illustrated when death occurs through the sudden interruption of a vital function at a time when cellular activity is entirely normal, and, under favorable conditions, is capable of restoring vital functions after their temporary cessation. On the other hand, in death from infectious diseases molecular or cellular decay keeps pace with or precedes the failure of respiration and circulation, and these functions are seldom restored after once ceasing.

The chief importance of determining the reality of death is not, at the present day, the danger of burying the living, but the possibility 1 Die Specifität, den Altruismus, und der Anaplasie der Zellen, Berlin, 1893.

that efforts at resuscitation may not be properly attempted in cases of apparent death. There are undoubtedly some well-authenticated instances in which it has been supposed by fairly competent persons that death has occurred and yet the body has been resuscitated. In cases of prolonged syncope and partial asphyxia by drowning, bodies apparently dead have frequently been resuscitated by draughts of cold air or dashes of cold water, or other nervous stimulus. It is possible also that the hasty burial of bodies during plagues or on the battle-field has led to the interment of bodies in which life might have been restored by appropriate measures. But the idea that, with the present methods of disposing of the dead, in civilized countries, it is possible that a body can be buried alive is not to be entertained. Nevertheless, in some localities and classes of society, and with a very few intelligent persons, the possibility of such a catastrophe constitutes a real source of fear.

Conditions Simulating Death. The conditions marked by a temporary inhibition of the respiration and circulation liable to be mistaken for death are syncope, partial asphyxia, catalepsy, and trance.

Syncope, or the ordinary fainting attack, is usually quickly overcome, and the appearances of death,-failure of respiration and heartsounds, coma and pallor,-though for a few seconds very alarming, are seldom complete, and soon are replaced by a return of the signs of life. Yet ordinary syncope is always a dangerous condition, calling for immediate and vigorous treatment to prevent the heart failure from becoming permanent. In some cases of syncope, therefore, the only means of determining whether or not death has occurred is the result of

treatment.

Partial asphyxia, by drowning or by other means, is a rather frequent cause of apparent death. Attempts at resuscitation have been successful when begun as long as one hour after submersion, and the result in such apparently hopeless conditions shows the impossibility of at once determining the reality of death under such circumstances. is known that infants asphyxiated during a prolonged second stage of labor, or by pressure upon the cord, may be resuscitated several minutes after the pulse and respiration have ceased.

It

Catalepsy. This phenomenon in its most pronounced forms is characterized by complete loss of consciousness, of which the onset is usually sudden. The muscles of the whole or a part of the body become rigid, but the limbs may usually be moved and placed in various positions, where they remain for some time. Superficial reflexes are abolished. The sensibility to touch and pain may be lost. The temperature is lowered. The respiration and heart's action are much reduced. "A deficient control of the motor centers of the cortex, permitting their overaction, regulated by different impulses, and repeated in the spinal cord, is the best theory we can at present frame of the condition" (Gowers). The simulation of death produced by catalepsy is usually not marked, and the diagnosis presents no great difficulty.

In trance the appearances of death are much more striking, and the condition has in several instances ended fatally. Consciousness may be

entirely abolished. The face is extremely pale. The limbs usually remain flaccid, but may become rigid or show spasmodic movements. The reflexes may be lost, and the pupils may be dilated and immobile. Sensation, although frequently retained or heightened, may be abolished. The pulse and respiration may become temporarily imperceptible. The combination of these symptoms persisting for some hours may present a very close resemblance to death. In the diagnosis Gowers recommends attention to the following points: (1) The absence of signs of decomposition; (2) the normal ophthalmoscopic appearance of the fundus oculi; (3) the persistence of the excitability of the muscles to electricity.

"The

Of the pathologic basis of trance nothing is known. phenomena, viewed in the light of the induced varieties, suggest a state of inhibition or at least an inaction of the nerve-cells subserving the higher psychic functions, and that the morbid state spreads to the lower centers in varying degree" (Gowers).

1

A partial physiologic counterpart of trance is to be seen in the hibernation of some animals: when the heart-beats fall to eight to ten a minute, the respirations are still lower, and the temperature is subnormal. It is said that some Indian Fakirs have the power of holding their breath and passing into a state of trance in which the heart-sounds become inaudible. Tidy has collected a number of cases in which the various phenomena of cataleptic trance were fully or partially presented. A well-authenticated and very peculiar case of voluntary suspension of the heart's action and respiration is the well-known story of Colonel Townsend. Cheyne, in describing the case, says: "He told us he had sent for us to give him an explanation of an odd sensation he had for some time observed in himself, which was, that, composing himself, he could die or expire when he pleased, and yet, by an effort, he could come to life again. This it seems he had sometimes tried before he had sent for us. We all three felt his pulse first; it was distinct, though small and thready. He composed himself on his back and lay in a still posture some time. While I held his right hand Dr. Baynard laid his hand on his heart and Mr. Skrine held a clear looking-glass to his mouth. I found his pulse sink gradually, till at last I could not feel any by the most exact and nice touch. Dr. Baynard could not feel the least motion in his heart, nor Mr. Skrine discern the least soil of breath on the bright mirror he held to his mouth. Then each of us in turn examined his arm, heart, and breath, but could not by the nicest scrutiny discover the least sign of life in him. This continued about half an hour. As we were going away, thinking him dead, we observed some motion about the body, and upon examination found his pulse and the motion of his heart returning; he began to breathe gently and speak softly. This experiment was made in the morning and he died in the evening. On opening the body, nothing was discovered but disease of the kidney, for which he had long been under medical treatment, all the other viscera being perfectly sound."

1 Legal Medicine, i., p. 139.

2 Treatise on Nervous Diseases, p. 307.

SPECIAL SIGNS OF DEATH.

It need hardly be said that, as a rule, the ordinary signs of death are too well known to need description and too striking to admit of doubt. Under some conditions, however, the cessation of the breathing and pulse is not accompanied by any changes in the countenance other than those of sleep. When death occurs in a condition of venous or arterial hyperemia the stoppage of the circulation is at once marked by pronounced changes in the color of the skin; but with gradual heart failure, especially in afebrile states, there may be little or no change in the countenance. It has been noted also that some hours after the signs of death are apparently conclusive the rapid onset of decomposition may produce a flushing of the face and a partial return of life-like appearance. Even the experienced observer, relying usually upon the appearance of the countenance as the readiest indication of death, is sometimes forced to make a careful physical examination before he is able to convince himself as to its actual presence.

The full examination thus occasionally required involves the following considerations:

1. The condition of the circulation.

2. The condition of the respiration.

3. The condition of the muscular system.

4. Changes in the eye.

The Condition of the Circulation.-Following from the principle stated at the beginning of this chapter, that life, or the possibility of restoration of a vital function, remains longest in that organ where molecular or cellular activity is most persistent, the condition of the heart and circulation becomes the most important inquiry in the determination of death. In man the heart's action nearly always continues after respiration has ceased, the chief exceptions being seen in deaths from poisoning by cardiac depressants. The heart of a decapi

tated criminal has been observed to beat for fifteen minutes. In executions by hanging and electricity in this country the pulse commonly persists some minutes after breathing has ceased. In the asphyxia of new-born infants comparatively little attention need be paid to the absence of breathing so long as the heart beats plainly. The anatomic basis of this life tenacity of the heart is found in the high development and automatic character of the cardiac nervous apparatus.

An important factor affecting the possibility of resuscitation after failure of the heart is the coagulation of the blood. When large parietal thrombi form during the last moments of life the vitality of the heart muscles is of little avail in any attempt to restore the circulation. In many instances of sudden death, and in the last stages of wasting diseases, when the coagulation of the blood is feeble, it is possible, by active stimulation, to elicit a few heart-beats or even, in the latter case, to prolong life for some hours.

The only safe method of determining the presence or absence of the heart's action is by careful, prolonged, and repeated auscultation, with

entire freedom from all distracting noises, and it may be confidently expected that when these conditions are properly secured, the stethoscope will give entirely trustworthy information in every case. Such favorable conditions being rarely found, the examiner has often to rely upon the unaided ear in auscultation, and the result of the examination may not be convincing.

Further, as is well known, in very corpulent persons the normal heart-sounds may be rather indistinct because of the thickness of the chest-wall. Some pathologic conditions may increase the natural difficulties of the case. In chronic interstitial or fatty myocarditis the heart-sounds are usually feeble and may be indistinct. With pericardial effusions the heart-sounds may be very obscure; while cases of transposition of the viscera or of displacement of the heart from chronic inflammation of the lungs are occasionally encountered.

When the results of auscultation remain unsatisfactory, resort may be had to some of the numerous tests devised to demonstrate the condition of the peripheral circulation. In using these tests it must be admitted that they are necessarily less reliable than direct auscultation, for the reason that the peripheral circulation may be practically at a standstill, although the heart is still feebly beating.

One of the most reliable of these tests is that suggested by Magnus.' If a ligature is applied to a finger or, if the skin is horny, to a lobe of the ear, so as to cut off the venous channels without occluding the arteries, when the circulation has not entirely ceased the distal area will become gradually engorged with blood, and its color will become first reddish and finally cyanotic. At the same time the capillary anemia about the ligature produces a white ring plainly marked off from the surrounding area of congestion. The success of this test will naturally depend on the exact adjustment of the pressure so as to compress the veins without occluding the arteries.

It has been stated here that if wet cups are applied to the skin a few hours after death, no blood will flow, while if the circulation still feebly persists, blood will readily appear under the cup. The result in this case depends upon the condition of the blood in the small vessels incised, which is well known to be variable. Wounds have been found to bleed for two or three hours after death.

The diaphanous test of death has been the subject of considerable recent discussion. It has long been known that if the hand of a living person be held before a strong light, it almost invariably appears scarlet or very red, while after death the appearance of the hand under similar conditions is usually opaque. It has been claimed that opacity of the hand after death is caused principally by the coagulation of the blood, for in cases in which the blood has remained fluid in the large veins this life-like scarlet color has been demonstrated after death. But the opacity indicating death has been observed in syncope, when the blood must always remain fluid. While the exact conditions determining the appearances in the diaphanous test must, therefore, be regarded as

1 Virchow's Archiv, 1872, Bd. lv.