When Does Human Life End?
The moment human life begins in the human fetus is a subject of dispute, but the moment human life ends is a mystery—we have no method of determining exactly just when the soul leaves the body. Daily throughout the world the priest reaches a patient who has just died. Conditional absolution, extreme unction, baptism might have been administered if there were signs of life, but the heart and lungs are still, "the patient is dead," and the priest leaves without doing anything. Yet it is always probable that the patient does not die at once even in a case of decapitation.
Bichat, at the beginning of the last century, called the brain, lungs, and heart "the tripod of life," and from time immemorial we have based our judgment of the presence of somatic death on the lack of consciousness, respiration, and circulation in the patient. The heart, however, beats after consciousness and respiration cease (and sometimes respiration continues after the pulse cannot be felt), and this cardiac activity may go on for more than a half hour after all the normal clinical signs of death have appeared—after respiration has quit, when no heart-sounds can be heard by the stethoscope and muscular relaxation indicates death.
The stimulus of the heart-beat probably starts at the juncture of the superior vena cava with the right auricle of the heart. Some biologists think that in this spot life takes its last stand before the final retreat, but that fact is disputed of late. In the hospital of the Rockefeller Institute for Medical Research in New York, Dr. G. Canby Robinson[60] made records from about eight patients before and during the actual stopping of the heart, using the electrocardiograph, which can be employed without disturbing the patient. He thus found—only in one case, however—that the heart may beat for a half hour after all vascular and circulatory sounds have ceased to be audible. In a letter to me Dr. Robinson said: "Undoubtedly the heart continues to show activity sufficient to be recorded by the string galvanometer very frequently after respiration has ceased, both in man and the lower animals; but this does not necessarily mean that it continues to be an efficient pump, maintaining the circulation. Undoubtedly also in other instances the cardiac activity ceases before the respiration, but I have never obtained electrocardiographic records of such cases."
Crile's experiments upon dogs show that it is possible to resuscitate these animals after they have been apparently dead for periods of time up to seven and a half minutes. The cessation of the blood circulation causes degenerations in the nerve cells and fibres, and these lesions may last even if the animal has been resuscitated. Crile thinks the human respiratory centre may survive anemia from thirty to fifty minutes; the vasomotor and cardiac centres, about twenty to thirty minutes; the spinal cord, eight to ten minutes; the motor cortex, eight to ten minutes; the portion of the brain used in conscious activity as such, six to seven minutes. The higher neurons have been stimulated into reflex activity twenty-five minutes after complete clinical cardiac cessation of activity.
In any attempt to resuscitate a person apparently dead the maintenance of the blood circulation is the chief end. If, however, the blood is not oxygenated the circulation will not go on automatically. Artificial respiration is used, and the active principle of the adrenal gland is injected to stimulate the heart. If the heart has stopped in diastole,—that is, when distended with blood,—this distention must be relieved by cardiac massage, commonly through an opening in the thoracic wall. Intratracheal insufflation of oxygen is also to be employed, as a rule.
In Essays in Pastoral Medicine[61] I mentioned several cases of resuscitation after what had appeared to be certain death. Two of these had been "dead" for forty-five minutes before they were revived temporarily. Wayne Babcock[62] reported a number of new cases of his own. One was a resuscitation which lasted for forty-three hours, and which was begun twenty-five minutes after respiration had ceased. The patient was a very fat negress who had collapsed after the use of scopolamine. A man whose arm had been torn off died from shock in the operating-room. After fifteen minutes of artificial respiration the circulation started again, and he was kept alive for six hours in this manner, but he died as soon as the artificial respiration was discontinued. An exactly similar case was kept alive for seven hours by artificial respiration. One of Babcock's cases was a woman of eighty-seven years of age, who apparently died on the table during an operation for strangulated hernia. After ten minutes of cardiac and respiratory cessation she was revived. She died four days later of peritonitis. A man fifty-six years of age undergoing the same operation ceased breathing and his heart stopped. He was completely revived and cured.
Father Juan Ferreres[63] holds that aborted and newly born children should be baptized, although they give no sign of life, if they show no clear evidence of putrefaction. This opinion is mine also, but the word maceration should be substituted as more exact. Eschbach[64] says: "Infantes recenter natos et in vitae discrimine positos, aut foetus abortivos plane formatos, cum vel levissimus in eis motus apprehenditur, absolute baptizari oportet: cum autem sine motu et sensu iidem videantur neque tamen adhuc corrupti aut putrefacti sint, sine mora baptizentur conditionate: Si vivis, ego te baptizo, etc." These quotations give the common opinion of moralists at present, and this opinion is fully safe. Eschbach, however, would have the fetus "plane formatus," which is erroneous and an echo of the old Aristotelian notion. If the fetus is visible at all, open the membranes and baptize it conditionally, even if it is not as big as a pea.
An infant born apparently dead may be resuscitated after a delay very much longer than would be possible in an older person, provided always the infant has not begun to breathe.
Ferreres mistakes cases of catalepsy which have recovered consciousness for cases of apparent somatic death. In these cataleptic conditions the blood circulation does not completely cease—if it did the nervous centres would be disintegrated. The case he reports on p. 26,[65] of the woman resuscitated by Rigaudeaux in 1748, was one of catalepsy, if it ever happened. The same is true of the case from Gaspar de los Reyes,[66] which probably had some foundation in a condition of catalepsy, but which more probably is a sheer invention by Reyes. It looks like an anecdote from a medieval Florentine novella.
Old writers speak of cessation of the pulse for long periods. Ballonius[67] mentions a person in whom there was no pulse for fourteen days before death; Ramazzini[68] describes a cessation of the pulse for four days before dissolution; Schenck[69] tells of a disappearance of the pulse for three days, with recovery. These all were apparently cataleptic cases, where the circulation was very feeble and the radial pulse was not palpable. Cheyne gives an account of a Colonel Townsend who had the power of apparently dying at will. He could so suspend the heart action that no pulse could be felt, and after a short while the circulation would become normal again. The longest period in which he remained in this condition was about thirty minutes. St. Augustine mentions a priest named Rutilutus who had a power like that of Colonel Townsend, and Caillé[70] reported a similar case.
The fakirs of India carry this power to great lengths. Braid,[71] on the authority of a Sir Claude Wade, says a fakir was buried unconscious at Lahore in 1837, and the grave was guarded day and night by sentinels from an English regiment. Six weeks after the burial the man was dug up and he presented all the appearance of a corpse. The legs and arms were shrunken and stiff, and the head reclined on the shoulder, as happens in corpses. There was no perceptible circulation anywhere, yet he revived.
Honigberger, a German physician in the service of Runjeet Singh, described[72] a fakir of the Punjaub who was put into a sealed vault for forty days, and the seal of Runjeet Singh was on the coffin. Grain was sown above the vault and it was well above the ground when the man was taken out of the vault and resuscitated. Sir Henry Lawrence testified to the truth of this story. The fakir's chin was shaved, Honigberger says, before the burial, and the beard did not grow while he was in the vault.
In keeping with these stories are many curious accounts of recovery after hanging. These are frequent in writings of the sixteenth and seventeenth centuries, when hanging was almost an every-day occurrence. These narratives are much more authentic than the anecdotes told of recovery after premature burial, which are as old as literature. Paul Zacchias[73] tells of a young man who died of the plague and was set out with the corpses for burial. He revived and was taken back to the pest-house. He "died" again and was again prepared for the grave, but he came to a second time. The stock story in these premature burial cases is that of the woman who is revived by a thief who cuts her finger in an effort to steal the rings buried with her.
The important fact, however, is that in any case of death the exact moment in which the soul leaves the body is not knowable by any means we have at present, and where there is question of giving the sacraments the person apparently dead should have the benefit of the doubt. He is to receive conditional baptism, absolution, or extreme unction (preferably by the short method), in case these sacraments are required. For a whole hour after apparent death the probability that the soul has not departed is so strong that, in my opinion, a priest who does not give the necessary sacraments is virtually as guilty as if he neglected to administer them to a person evidently alive. Crile, one of the best medical authorities on this matter of somatic death, holds that the human respiratory system may survive anemia for from thirty to fifty minutes. How long after the hour a priest may administer the sacraments is not known, but a second hour, or even a third, are not unreasonable periods of time during which the sacraments may be administered conditionally. The sacraments are for man, and there is no irreverence if they are administered conditionally and the priest explains to the bystanders the reason he has for his action.
If a pregnant woman dies slowly, the fetus in her womb is likely to die owing to lack of oxygen; if she dies suddenly, the child may live for variable periods in various cases. Brotherton reported a case where a living child was taken from a woman twenty-three minutes after the death of the mother. Tarnier, the noted French obstetrician, told of a remarkable incident which happened in Paris during the rioting by the Commune after the war of 1870. The rioters fired on a maternity hospital, and a pregnant woman sitting on a bed in a ward was instantly killed by a bullet through her head. After a while she was discovered dead, and Tarnier was sent for to save the fetus, as its heart-sounds could be heard through the abdominal wall. When he began the operation the hospital was fired upon again, and it was necessary to carry the corpse to the cellar of the building. There Tarnier, an hour and three quarters at least after the death of the women, extracted a living child from the corpse. Hirst[74] tells of another case which was narrated to him by an American naval surgeon who saw it in the harbor of Rio Janeiro during the revolution at the beginning of the present republic of Brazil. A woman near term was killed instantly by a piece of shell. As soon as she fell to the ground a Brazilian surgeon, who was standing near by, cut open her abdomen with a penknife and drew out the child, but it was already dead.
Mack[75] was called to a pregnant woman, and he found she had died suddenly about five minutes before he arrived. He at once opened the uterus with a small lancet and extracted a child which was beyond the livid stage and had no heart-sound. He worked on the child for forty minutes, using the ordinary methods for reviving asphyxiated children, but got no sign of life. Then he injected a hypodermic syringeful of a 1:1000 epinephrin solution through the umbilical cord into the abdomen and continued the reviving motions. In ten minutes the child was crying vigorously, and it was a healthy baby afterward.
Gunn and Martin,[76] in experiments on rabbits poisoned by chloroform and apparently dead, found they could resuscitate about 70 per cent. of the animals if treatment was begun within ten minutes after the heart ceased beating. They started artificial respiration through a tube in the trachea, then injected epinephrin into the pericardium, and afterward massaged the heart through an opening in the abdomen. The rate of compression of the heart in this massage must be somewhat less than half that of the normal beat, and at short intervals the massage is to be stopped to allow the spontaneous beats to develop. Compression should be gradual and the relaxation abrupt. The massage is applied by one of these four methods, and they are arranged here in the order of their efficiency: (1) by direct compression of the heart through an opening in the thorax; (2) by compression above the diaphragm through an opening in the belly-wall; (3) by simple compression of the abdomen; (4) by simple compression of the thorax. Epinephrin, or pituitary extract, is used as an adjuvant intravenously to increase the cardiac movement after it has been started. The same methods will probably be effective in man, and have been used successfully.
When a woman is in articulo mortis with a living fetus in her womb, one should not wait for her death. If one waits, he will nearly always lose the child. The cervix should be dilated forcibly, the child turned and delivered. Even if this forcible delivery should happen to hasten somewhat the mother's death, the action would be morally licit. It would be a double-effect action; the two effects would proceed immediately and equally from the act, which is indifferent morally; one effect, the good one, is to save the child for baptism at least, and possibly permanently; the second, evil but reluctantly permitted, is the possible hastening of the maternal death. I should be willing even to slit the cervix, if necessary, provided the diagnosis were certain, with the possibility of tearing the uterus, in a case where the dilatation of the cervix would be too slow a method; but this supposition is scarcely practical.
Zsako[77] gives a method for determining the interval since death by muscular phenomena. Tapping with a percussion hammer on certain muscles of the body excites a reflex contraction up to from an hour and a half to two hours after death. The contraction may be elicited in the same manner on the living, but it is more evident on a cadaver owing to the absence of antagonistic tonus in the muscles. Some muscles may move for four hours after death. Tapping along the radius from the elbow downward, he says, a point is found where the stroke causes extension of the hand; tapping along the radius above the wrist makes the thumb bend; tapping on the spaces between the bones of the hand closes up the corresponding fingers; tapping on the back of the foot extends the toes, on the leg adducts the foot, on the tibia along the middle third extends the leg. When the lower third of the thigh is tapped across the muscles move, and if the back is struck between the scapula and the spine the shoulder blades move toward each other. If there is no response the person must be dead from two to four hours. I have had no experience with this method.
Satre[78] reported that many soldiers brought into the dressing-stations apparently dead from shock, head or spinal wounds, or gas asphyxiation, were revived after artificial respiration had been applied, sometimes for even six hours before results were obtained. Two tests were used to find out whether the patient was alive or not. In such cases ten c.c. of a 20 per cent. alkaline solution of fluorescine is injected subcutaneously, and if there is any circulation this dye will be carried to the eye and turn the conjunctiva green. The second test is to push a fine puncture-needle into the spleen or liver and thus remove a particle of the pulp. This pulp is put on blue litmus-paper and drawn free from blood. If the litmus-paper turns red the man is dead; if it remains blue he is alive. The reaction of the living pulp is alkaline, blue; this becomes acid, red, a half-hour after death; an hour after death the acid reaction is quite marked.