Part 3

“This is most frequently the case when the resistance of the constitution against the influence of the disease has been long protracted, or when the struggle, though short, has been very violent.”

“A young gentleman of family, about twenty-five years of age, took cold whilst under the influence of mercury. The disease increased daily until it was accompanied at last, by so much fever and delirium, as made it necessary to use, not only the most powerful medicines, but also personal restraint. At length, after three days of incessant exertion, during which he never slept for an instant, he ceased to rave, and was calm and collected. His perception of external objects became correct, and they no longer distressed him, and he asked pressingly if it were possible that he could live? On being answered tenderly, but not in a way calculated to deceive, that it was probable he might not, he dictated some affectionate communications to his friends abroad, recollected some claims upon his purse, ‘set his house in order,’ and died the following night. The reason why so unfavourable an opinion was entertained of his state, was, that the apparent amendment was not preceded by sleep, and was not accompanied by a slower pulse; two indispensable conditions--on which only a notion of real improvement could be justified. But here was merely a cessation of excitement occasioned by a diminution of power, and by a mitigated influence of the action of the heart upon the brain.” This case occurred in the practice of Sir Henry Halford. Another instance, the counterpart to that just described, which happened to the same eminent physician, may not be out of place.

A young gentlemen, who had also been using mercury very largely, caught cold, and became seriously ill with fever. “His head appeared to be affected on the fifth day, and on the seventh, when I was first called into consultation with another physician, who had attended him with great care and judgment from the commencement of his illness, we found him in the highest possible state of excitement. He was stark naked, standing upright in bed, his eyes flashing fire, exquisitely alive to every movement about him, and so irascible as not to be approached without increasing his irritation to a degree of fury.... On the eleventh day of his disease, I was informed by my colleague, when we met, and by the attendants, that he was become quite calm, and seemed much better. It was remarked, indeed, that he had said repeatedly, that he should die; that under this conviction he had talked with great composure of his affairs; that he had mentioned several debts which he had contracted, and made provision for their payment,--that he had dictated messages to his mother, expressive of his affection, and had talked much of a sister who had died the year before, and whom, he said, he knew he was about to follow immediately. To my questions, whether he had slept previously to this state of quietude, and whether his pulse had come down, it was answered, No; he had not slept, and his pulse was quicker than ever. Then it was evident that this specious improvement was unreal, that the clearing up of his mind was a mortal sign, ‘a lightening before death,’ and that he would die forthwith. On entering his room he did not notice us; his eyes were fixed on vacancy, he was occupied entirely within himself, and all that we could gather from his words was some indistinct mention of his sister. His hands were cold, and his pulse immeasurably quick--he died that night.”

Some pass away in sleep. In natural healthy sleep respiration becomes slower, the pulse weaker and less frequent, the circulation generally feebler. The difference in these respects between the waking and the sleeping states, is to the dying person often the difference between life, and death. The circulation already reduced to the lowest ebb compatible with life, is yet further reduced by sleep, and with this reduction the patient dies. These are those who ‘sleep away.’ Similar to, if not identical with them, are those to whom death comes so easily that not a ruffle disturbs any portion of the frame, and the most intelligent observer is unable to fix the moment when life has fled, so easy is the parting of the last link, ‘when the body drops to earth and the soul rises to eternity.’ It is probable that here, a mere act of dozing becomes the act of dying. In these instances as in old age, death is literally the last sleep, uncharacterized by any peculiarity. The general languor of the functions in the last waking interval, is attended with no peculiar suffering, and the last sleep commences with the usual grateful feelings of repose.

The length of the interval between insensibility and the absolute cessation of existence, varies greatly from a few seconds to several hours or days. But consciousness is often retained much longer than is generally supposed, and it is difficult to determine when the external senses, and particularly that of hearing, are completely and absolutely closed.

The senses of smell, taste, and touch are generally the first to fail us and disappear, while those of sight and hearing continue much longer.

Abnormal visual impressions are common when death is near at hand. In many the sight fails,--there is complaint of commencing or of actual darkness, and a desire is expressed for more light; while more rarely, the dying one perceives a blaze of light, in the contemplation of which, or immediately afterwards, he calmly expires. “It happens not unfrequently,” writes Dr. Symonds in his admirable essay on Death, “that the spectra of the dying owe their origin to contemplations of future existence, and consequently that the good man’s last hours are cheered with beatific visions and communion with heavenly visitors. Dreadfully contrasted with such visions are those which haunt the dying fancies of others.” The testimony of many of those who have the largest experience, and have watched continuously and attentively at the dying bed, is in support of Dr. Symonds’ statement. If some physicians are incredulous, and place little reliance on testimony and inferences of this kind, I am inclined with Dr. Conolly to attribute it, to their being seldom engaged long enough in watching by the bedside, where the senses and thoughts naturally become concentrated on the events of the sick chamber alone. My own observation in cases, where circumstances have made my attendance on the dying close and protracted, goes to corroborate the evidence there is on these points--points which are certainly not of a nature to be made familiar to those, whose chief knowledge of the dying is acquired in formal consultations, or in short daily visits to the wards of hospitals.

Hearing is, probably in most cases, the last of our senses to leave us. “An elderly lady had a stroke of apoplexy; she lay motionless, and in what is called a state of stupor, and no one doubted that she was dying. But after the lapse of three or four days, there were signs of amendment, and she ultimately recovered. After her recovery she explained that she did not believe that she had been unconscious, or even insensible, during any part of the attack. She knew her situation, and heard much of what was said by those around her. Especially she recollected observations intimating that she would very soon be no more, but that at the same time she had felt satisfied that she would recover; that she had no power of expressing what she felt, but that nevertheless her feelings, instead of being painful or in any way distressing, had been agreeable rather than otherwise. She described them as very peculiar--as if she were constantly mounting upwards, and as something very different from what she had ever before experienced.”

The case of Dr. Wollaston the physician and chemical philosopher is to the same effect. “Some time before his life was finally extinguished he was seen to be pale, as if there was scarcely any circulation of blood going on--motionless, and to all appearance in a state of complete insensibility. Being in this condition, his friends who were watching round him, observed some motions of the hand which was not affected by the paralysis. After some time it occurred to them, that he wished to have a pencil and paper, and these having been supplied, he contrived to write some figures in arithmetical progression, which however imperfectly scrawled, were yet sufficiently legible. It was supposed that he had overheard some remarks respecting the state in which he was, and that his object was to show, that he preserved his sensibility and consciousness. Something like this occurred some hours afterwards, and immediately before he died, but the scrawl of these last moments could not be deciphered.”

“I have been curious,” writes Sir Benjamin Brodie in commenting on these cases, “to watch the state of dying persons in this respect, and I am satisfied,” (and I may add, my own experience confirms Sir Benjamin Brodie’s statement) “that, where an ordinary observer would not for an instant doubt that the individual is in a state of complete stupor, the mind is often active even at the very moment of death. A friend of mine, who had been for many years the excellent chaplain of a large hospital, informed me, that his still larger experience had led him to the same conclusion.”

Instances such as these should teach the physician and all who are about the dying, to be careful neither to say, nor do anything in the presence of the patient, which they would wish him not to hear. Their bearing on religious offices to the dying is obvious.

* * * * *

Sometimes, immediately preceding the very act of death, the eyelids are raised, and a look of recognition of those around seems to be permitted to the dying man. Less often there is an expression of agony in the eye. “It is consolatory to know,” says Sir Charles Bell, “that this does not indicate suffering, but increasing insensibility. The pupils are turned upwards and inwards. This is especially observed in those who are expiring from loss of blood. It is the strabismus patheticus orantium of Boerhaave.”

The nature of the disease and the mode of death exert a marked influence on the expression of face of the dying, and this is often retained by the features after death. In some we observe the impress of the previous suffering, as in peritonitis and in cases of poisoning by irritants; in others the character is derived from a peculiar affection of some part of the respiratory apparatus; or from an affection of the facial muscles themselves, as in tetanus and paralysis. But the condition of the mind is perhaps more often concerned in the expression than even the physical circumstances of the body. For, as some kind of intelligence is frequently retained, and strong emotions are experienced till within a few moments of dissolution, the features may be sealed by the hand of death in the last look of rapture or of misery, of benignity or of anger. Every poetical reader knows the picture of the traits of death (no less true than beautiful) drawn by the author of “The Giaour.” But such observations are not confined to poets. Haller could trace in the dying countenance the smile which had been lighted by the hope of a happier existence. “Adfulgentis fugienti animæ spei non raro in moribundis signa vidi, qui serenissimo vultu non sine blando subrisu, de vita excesserunt.”

FOOTNOTES:

“At nostris temporibus, Medici quasi religio est, ægrotis, postquam deplorati sint, assidere; ubi meo judicio, si officio suo, atque adeo humanitati ipsi deesse nolint, et artem ediscere et diligentiam præstare deberent, qua animam agentes facilius et mitius e vita demigrent--Hanc autem partem, inquisitionem de Euthanasia exteriori (ad differentiam ejus euthanasiæ quæ animæ præparationem respicit) appellamus; eamque inter desiderata reponimus.” (Verulamus, De Augmentis Scientiarum, lib. iv. cap. ij.)

“Εὐθανασία naturalis nobis dicitur facilis et quam minimo cum cruciatu e vita exitus, qua tenus moriendi facilitas e causis naturalibus proxime pendet.... Ad medicinam hujus εὐθανασίας contemplatio pertinet: est enim naturalis, non moralis, nisi qua tenus hæc ad illam momenti habet plurimum. Exteriorem idcirco Verulamius appellavit.” (Nicolai Paradysii, Opuscula Academica, 8vo, Lugd. Batav, 1813. Oratio de Εὐθανασία naturali et quid ad eam conciliandam Medicina valeat, pp. 63 et 65.)

“A medicis vix inchoatum, nedum pertractatum huc usque esset.” (Paradysius, p. 63.)

“Etiam plane censeo ad officium medici pertinere, non tantum ut sanitatem restituat: verum etiam ut dolores et cruciatus morborum mitiget: neque id ipsum solummodo, cum illa mitigatio doloris, veluti symptomatis periculosi, ad convalescentiam faciat et conducat: imo vero cum abjecta prorsus omni sanitatis spe, excessum tantum præbeat e vita magis lenem et placidum. Siquidem non parva est felicitatis pars, illa Euthanasia.” (De Augmentis Scientiarum.)

Sir Henry Halford, Essays and Orations read and delivered at the Royal College of Physicians. Third edition, 12mo, London, 1842. p. 84.

“Magnus ille veræ philosophiæ instaurator Verulamus, queritur studium Euthanasiæ medicis haud satis cultum fuisse. Medici profecto munus est ægrotis sanitatem reddere; cum tamen ex lege naturæ erit tandem unicuique mortalium ægrotatio nulla arte medicabilis, benevolæ hujus artis professoribus conveniret, mortem inevitabilem, quantum fieri potest, terrore omni spoliare; et ubi non datum est prædam morti extorquere, sed vita necessario amittenda est, operam saltem dare, ut cum minima crudelitatis specie amittatur.” (Heberdeni Gulielmi, Commentaria de Morborum Historia et Curatione. Cap De Ileo.)

Essays and Orations, ut supra passim.

John Ferriar, M.D., Medical Histories and Reflections. 8vo, London, 1798. Vol. iii. p. 196.

John Ferriar, M.D., On the Treatment of the Dying, ut supra, p. 191.

The Works of Sir Benjamin Collins Brodie. Arranged by Charles Hawkins. 3 Vols., 8vo, London, 1865. Vol. i. p. 184.

On Life and Death. 8vo. London, 1863, p. 175.

“Ipsæ animæ discessus a corpore fit, sine dolore, et fit plerumque sine sensu, nonnunquam etiam cum voluptate.” (Vopisci Fortunati Plempii. de Togatorum Valetudine tuenda Commentatio. 4to. Bruxellis, 1670. p. 26.)

Autobiographical Memoir of Sir John Barrow, Bart. 8vo, London, 1847, p. 398.