CHAPTER X.

MODES, SIGNS AND TESTS OF DEATH.

Just as surely as we are born, just so surely must we die, and just as it is the physician's duty to care for the living body, if possible to keep it in a strong and healthful condition, so it is the embalmer's duty to care for the body after death, not so much for the body itself, but from a sanitary standpoint, namely, to see that the body is well disinfected and embalmed so that there will be absolutely no chance for the spread of disease.

Any one who is familiar with hospital work must know that all do not die in the same way. For some it is the long lingering disease, chronic in form, which after a long and tedious course the thread of life is finally broken, and we hardly know the instant at which the change was completed. For others, it is the short, acute attack, which snaps the life away in a very instant, only after a very short duration. For some it is to die from accidental causes, while for others it is only the passing out from the period of old age. For some the mind may be active and the intellectual faculties useful up to the last moment, while for others the contrary is all but too true.

Although there may be many different kinds of disease infecting the human race, yet we find that death ultimately results from the stoppage of any one, or maybe, all three of the vital organs, namely the heart, brain or lungs. Anything whatsoever which plays upon the body, to such an extent, as to affect the functions absolutely, of either the heart, brain or lungs, will result in the death of that body. And since these organs are of such vital importance to us, and since the stoppage of any one of them will result in death, they have been termed the vital organs.

=Modes of Death.=—There are, then, only three modes of death: syncope, or the stoppage of the heart; coma, or the failure of the brain to perform its functions; apnea, or the stoppage of the lungs.

_Syncope._—For the heart to properly perform its function, namely that of propelling the blood to all parts of the body, it must first be properly nourished itself. If for any reason the heart does not get this proper nourishment, say the coronary arteries should become clogged, or a fatty infiltration, or a lack of red blood corpuscles, we would have a condition in the body known as anemia.

The heart must also have a proper nerve supply from the brain, and if because of any disease, the vaso-motor or the vaso-constrictor fibers should become affected, the heart would cease to contract and expand, and hence the complete stoppage of the heart. A condition of this kind is known as asthenia.

But whether it is death by anemia or asthenia, the state of suspended animation, common to both these forms is expressed by the single term—syncope.

_Coma._—In cases of apoplexy, where we have the blood escaping from the ruptured vessels, compressing the brain, we find death ensuing. Also in accidental cases such as fracture of the skull, the injury will often cause death. These are examples of coma, and can be explained in this way, viz.; the power of the brain becomes inactive either through the result of an injury or a disease, and when this inactivity occurs the respiratory apparatus subsides and the heart deprived of its normal stimulus through the vaso-motor and constrictor fibers, soon ceases to beat, and death is the result.

_Apnea_, _Asphyxia_.—If for any reason the supply of oxygen is cut off from the lungs, we will have the body dying the result of asphyxia or apnea. The most common forms found of this mode of death are those of hanging, drowning or coal gas poisoning.

=Signs of Impending Death.=—The signs of impending death are those conditions which exist on the body or the peculiar features of the body which aid the physician in ascertaining the exact condition of the body. These signs assume many different forms and in no two instances may they be found alike. They of course, are not positive in themselves, but are sufficient to guide us in forming an opinion as to the approach of death.

One of the first signs to be noticed is the coldness of the extremities. In this case the coldness begins at the extreme tips of the fingers and toes and gradually extends toward the trunk. This, of course, is due to the gradual diminishing activity of the heart to propel the blood to the extremities.

The brain also fails to receive its proper blood supply and becomes weakened and we find the mind wandering. This wandering results in the patient going through movements representing the playing with flowers, or picking at the bed clothing. A further result of this weakness is that the patient may have visions of angels and heaven.

Speech begins to grow thick, and a large lump of phlegm gathers in the throat.

The hands now feel cold and clammy, and if they are raised they instantly fall. One cannot detect the act of respiration, as the movements of the thoracic walls are so slight as to be scarcely perceptible.

The heart loses its power to propel the blood and the stoppage of every organ in the body ensues.

The eyes become fixed with a staring look as though they were not focused on anything directly. The eyes lose their lustre on account of the lachrymal glands refusing to secrete.

The vital organs, the heart, brain and lungs come to a halt, and we find the body passing from life to the great beyond.

=Tests of Actual Death.=—From the large number of statistics that have been gathered together for our purpose, we find that the time of greatest mortality is in the early morning hours between three and six A. M., for it is between these hours that the body is in a perfect state of relaxation, and at the lowest ebb of vitality.

The time of least mortality is between the hours of eleven and two P. M., as the body is in a relatively high state of vitality during these hours.

The tests of actual death can be placed in two classes, the common tests and the expert tests.

The common tests are those that have long been used by the inexperienced to ascertain the fact of death. They are not necessarily conclusive in themselves, but when all are taken together there can not be much doubt.

(a) _The Feather Test._—In this test a feather is held to the nostrils to observe whether it moves. The feather being so light, the slightest respiration of the lung would be apt to move it.

(b) _The Mirror Test._—In this test a mirror is held to the mouth and nostrils. If moisture collects on the mirror it is evident that respiratory movements are going on. If there is an absence of moisture we are quite safe in saying that the patient is dead.

(c) _The Bandage Test._—In this test a bandage is placed around the arm and then twisted very tightly. If there is the slightest circulation existing in the body the blood will accumulate back of the bandage in the venous system and thus demonstrate the fact. There will also be no swelling or discoloration beyond the ligature.

(d) By placing the ear to the chest over the heart, no sounds will be heard.

(e) If the ear is applied over the lungs, no sounds will be heard.

(f) If a cup of water is placed on the chest there will be no movement of rays or ripples on the surface.

(g) If the skin is cut, no blood will flow, nor will the wound close.

(h) If heat, say for instance a burning match be applied to the skin it will not blister, or if ammonia is hypodermically injected under the skin there will be no redness, but rather the skin will turn to a yellowish color.

(i) The living hand when held to the light shows pink through the inner edges of the fingers, but with the dead hand it shows opaqueness.

(j) When a strong light is brought before the eye the pupil of the eye will not dilate or contract.

(2) The expert tests are those which a doctor or coroner might use to ascertain the fact of death. These tests are made with the stethoscope and the ophthalmoscope.

(a) By the use of the stethoscope the physician can hear the sounds of the heart and if there is the slightest sound he can detect it. In the absence of any sound the body is pronounced dead.

(b) By the use of the ophthalmoscope the physician is enabled to look into the pupil of the eye and if there is life he can see the blood circulating through the tiny capillaries of the retina. If he does not see this capillary circulation he is quite safe in saying the body is dead.

(c) Another method consists in the hypodermic or intravenous injection of certain substances, and ascertaining whether these substances have been dispersed throughout the body. If they have, then a circulation exists and life continues, although the pulsation of the heart may not be detected by auscultation. Among the substances recommended for injection are fluorescin, sodium iodide, lithium iodide and potassium ferro-cyanide. The injection of the small quantities as used will not cause death should the patient still be living.

Fluorescin is usually injected, one gramme dissolved with an equal weight of sodium carbonate in eight cubic centimeters of water, and the whole quantity injected hypodermically. If the circulation is persisting, the skin and the mucous membranes after a very few minutes assume a greenish color; about twenty minutes after the injection, the portion of the eye within the iris assumes a green color from penetration of the fluorescin into the vitreous and aqueous humors, and in the blood the fluorescin may be detected by the following method: One or two threads of cotton are passed under the skin in the form of a seton, and when saturated with blood are transferred to a test tube, and boiled with a little water. As the liquid clears the green color of the fluorescin becomes evident, if that substance has been absorbed into the blood.

(d) Another method for the distinction of real from apparent death consists in picking up a fold of the skin and compressing it with a pair of artery forceps. If the skin does not completely settle down, and if the fine furrows produced by the teeth of the forceps continue indefinitely, then death has occurred. Whereas, if the circulation is continuous, the fold and the marks of the forceps would disappear. Moreover, if death has occurred the portion of the skin compressed by the forceps assumes a parchment-like appearance.

(e) The electrical current affords a means of determining death. It is now known that the muscles, after cadaveric rigidity has set in, do not respond to electric stimuli. The faradic current will cause, when death has occurred, muscular contractions until a short time before post-mortem rigidity occurs. The faradic stimulus is lost first and the galvanic stimulus soon after. We may be enabled to approximate the time at which death occurred, for, if we find any response to either the faradic or the galvanic current, we know at once that post-mortem rigidity has not yet occurred.

No person should be buried as long as the muscles contract when stimulated by either the faradic or the galvanic current. If the electrical test were always applied before a death certificate was signed, there would be absolutely no possibility of a person being buried alive and the public would soon lose the morbid fear of such an occurrence.

=Later and More Positive Signs.=—(a) After a few hours the blood gradually sinks to the dependent parts of the body giving a reddish-blue discoloration, known as post-mortem discoloration, or cadaveric lividity.

(b) The eyes become sunken in the sockets, the eye balls become flattened, the cornea opaque and the pupil irregular in shape.

(c) The eyelid loses its elasticity, and the white transparent color of the conjunctiva is lost, often becoming black or gray.

(d) Rigor mortis may or may not be present.

(e) The body gradually cools to the temperature of the surrounding atmosphere.

(f) On opening an artery it is generally found to be empty after death.

(g) The latest and most positive sign of all is putrefaction, and when this is found to be present all other signs may be ignored.

(h) Skin slip present on the body is only another manifestation of putrefaction, and also signifies that the body is dead.