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."
[60] _A Study with the Electrocardiograph of the Mode of Death of
the Human Heart. Journal of Experimental Medicine_, 1912, xvi,
291.
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.
[61] New York, 1906, p. 164.
[62] _Proceedings of the American Therapeutic Society_, 1912.
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.
[63] _La Muerte Real y Apparente_, 4th ed., p. 21. Madrid, 1911.
[64] _Quaestiones Physiologicae-Theologicae_, disp. 3, p. 2, c.
3, a. 3.
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_.
[65] P. 30 in the English translation.
[66] P. 35; p. 39, English translation.
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.
[67] _Opera Medica Omnia._ Geneva, 1762.
[68] _Epistolae_, 1692.
[69] _Observationum Medicarum_, etc. Frankfort, 1600.
[70] _New Orleans Medical and Surgical Journal_, xvi.
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.
[71] _Treatise on Human Hibernation_, 1850.
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.
[72] _Medical Times and Gazette_, vol. i. London, 1870.
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.
[73] _Quaestiones Medico-Legales_, 1701.
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.
[74] _A Textbook of Obstetrics_, 7th ed., p. 643. Philadelphia,
1912.
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.
[75] _Journal of the American Medical Association_, August 28,
1915.
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.
[76] _Journal of Pharmacology and Experimental Therapeutics._
Baltimore, July, 1915.
* * * * *
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.
[77] _Münchener medizinische Wochenschrift_, January 18, 1916.
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.
[78] _Presse Médicale_, Paris, xxiv, 66.