Part 2

More often some delirium is present. The delirium of the dying is often of a most interesting character, and according to Dr. Symonds resembles dreaming more than any form of derangement. The ideas are derived less from present perceptions than in insanity, and yet are more suggested by external circumstances than in the delirium of fever and phrenitis.[26] Such delirium is generally shown in quiet talkativeness, which becomes later on a low muttering. In some the mind is occupied on the events of childhood and early life, but when the delirium is somewhat more active, the conceptions of the dying man are generally derived from subjects, which, either in his speculative pursuits or in the business of life, have principally occupied his thoughts.[27] Lord Tenterden, as he approached his end, became delirious and talked very incoherently. Afterwards he seemed to recover his composure, and raising his head from his pillow, he was heard to say in a slow and solemn tone, as when he used to conclude his summing up, in cases of great importance, “And, now, Gentlemen of the Jury, you will consider of your verdict.” These were his last words; when he had uttered them, his head sunk down, and in a few minutes he expired without a groan.[28] And the last words of Dr. Armstrong were addressed to an imaginary patient, upon whom he was impressing the necessity of attention to the state of the digestive organs.

Instances occur, and not very rarely, where the delirium ceases, and the mind again for a time becomes clear and the sensations keen, to be followed, however, ere long by a return of delirium, or it may be of coma, or a rapid sinking of all the bodily powers and speedy death. But along with this temporary clearing of the mental powers, and in proof of its illusiveness, there are the usual signs of bodily failure--a pinching of the features, coldness of the surface, cold sweats, and a feeble rapid pulse.

Active delirium and violence are but rarely associated with the act of dying,--they are indeed scarcely compatible with it. They may pave the way to it, but when the act of dying really begins, they cease and give way to that low, rambling, muttering delirium, with which all watchers by the death-bed are so familiar.

It is especially at the stage of transition from the one to the other of these states, that we meet with that return of intelligence--that ‘lightening up before death’ which has impressed and surprised mankind from the earliest ages. “We have all observed,” writes Sir Henry Halford, “the mind clear up in an extraordinary manner in the last hours of life, when terminated even in the ordinary course of nature; but certainly still more remarkably when it has been cut short by disease, which had affected, for a time the intellectual faculties. We have seen it become capable of exercising a subtle judgment, when the passions which had been accustomed to bias and embarrass its decisions whilst they existed, are extinguished at the approach of death; and when the inferences which wisdom had drawn from experience of the former behaviour of men, were now made available to a correct estimate of their future conduct, in the sense of Milton’s lines--”

‘When old experience does attain To something like prophetic strain.’[29]

“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.”[30]

“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.[31] 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.”[32]

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.[33]

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,[34] “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.”[35] 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[36] 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.”[37]

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.”[38]

“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.”[39]

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.”[40]

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.”[41]

FOOTNOTES:

[1] “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.)

[2] “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.)

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

[4] “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.)

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

[6] “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_.)

[7] Essays and Orations, _ut supra passim_.

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

[9] John Ferriar, M.D., On the Treatment of the Dying, _ut supra_, p. 191.

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

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

[12] “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.)

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

[14] “A sailor who had been snatched from the waves, after lying for some time insensible on the deck of the vessel, proclaimed on his recovery that he had been in Heaven, and complained bitterly of his being restored to life as a great hardship. The man had been regarded as a worthless fellow; but from the time of the accident having occurred, his moral character was altered, and he became one of the best conducted sailors in the ship.” (The Works of Sir Benjamin Brodie, vol. i. p. 184.)

[15] I was once told by a near relative of mine--says De Quincey--that having in her childhood fallen into a river, and being on the very verge of death but for the assistance which reached her at the last critical moment, she saw in a moment her whole life, clothed in its forgotten incidents, arrayed before her as in a mirror, not successively, but simultaneously; and she had a faculty developed as suddenly for comprehending the whole and every part. The heroine of this remarkable case, continues De Quincey, was a girl about nine years old; and there can be little doubt that she looked down as far within the _crater_ of death--that awful volcano--as any human being ever _can_ have done that has lived to draw back and to report her experience. Not less than ninety years did she survive this memorable escape, and I may describe her as in all respects a woman of remarkable and interesting qualities. She enjoyed throughout her long life serene and cloudless health; had a masculine understanding; reverenced truth not less than did the Evangelists; and led a life of saintly devotion, such as might have glorified Hilarion or Paul! I mention these traits as characterising her in a memorable extent, that the reader may not suppose himself relying upon a dealer in exaggerations, upon a credulous enthusiast, or upon a careless wielder of language. Forty-five years had intervened between the first time and the last time of her telling me this anecdote, and not one iota had shifted its ground amongst the incidents, nor had any of the most trivial of the circumstances suffered change. How long the child lay in the water was probably never inquired earnestly until the answer had become irrecoverable: for a servant to whose care the child was then confided, had a natural interest in suppressing the whole case. From the child’s own account it would seem that asphyxia must have announced its commencement. A process of struggle and deadly suffocation was passed through half-consciously. This process terminated in a sudden blow apparently _on_ or _in_ the brain, after which there was no pain or conflict: but in an instant succeeded a dazzling rush of light; immediately after which came the solemn apocalypse of the entire past life. (De Quincey’s Works, Edinb., 1862, Vol. I., Confessions of an English Opium-Eater, p. 259.) Sir Dyce Duckworth reminds us that the mental condition of some who have been put to sleep with anæsthetics may throw some light on this matter. “Patients,” says he, “have told us they dreamed they were transported from earth and carried off into space, were supremely happy and at rest: but that on gradually recovering consciousness, they seemed to light back again upon this world, were most reluctant to leave the Elysium they had reached, and to recommence their earthly toils and struggles.” (The Agony of Dying, in Monthly Paper of the Guild of St. Barnabas for Nurses. Vol. iii. p. 81).

[16] J. A. Symonds, M.D., Art. Death, in the Cyclopædia of Anatomy and Physiology, 4 vols., royal 8vo, Lond. Vol. i. p. 800.

[17] Halford, p. 18.

[18] Halford, p. 14.

[19] Savory, _ut supra_, p. 178.

[20] p. 74.

[21] On Life and Death, 8vo, London, 1863, p. 177.

[22] Brodie _ut supra_, p. 185.

[23] “I think there is reason for affirming that the risk of evil from this cause is rated generally above the truth. In cases of imminent danger, the mind is not always, or even commonly, to be interpreted by the rule of health. Mental emotions are often altered in kind, or greatly abated in degree. Death itself is beheld under different views--a fact familiar to all who have watched over these scenes, and regarded the patient apart from those who are grieving around his death-bed. Suspicion of a painful truth often disturbs much more than the truth plainly stated.” (Sir Henry Holland’s Medical Notes and Reflections. Third edition, 8vo. Lond. 1853, p. 362).

[24] Halford, p. 76.

[25] Halford, p. 75.

[26] Cyclopædia of Anatomy and Physiology, art. Death, vol. i. p. 799.

[27] Symonds _ut supra_, p. 799.

[28] Lord Campbell, Lives of the Chief Justices of England, vol. i.

[29] On the Καῦσος of Aretæus, p. 96.

[30] Halford, On the Cautious Estimation of Symptoms, p. 17.

[31] Halford _ut supra_, p. 19.

[32] On the Καῦσος of Aretæus, p. 91.

[33] A. P. Wilson Philip, On Sleep and Death, 8vo, London, 1834, p. 165.

[34] Cyclopædia of Anatomy and Physiology, vol. i. p. 799.

[35] Dr. Symonds continues, “The previous habits and conduct of the individual have sometimes been such as to incline spectators to inquire, whether in the mode of his departure from existence, he might not already be receiving retribution, just as, in other cases, celestial dreams and colloquies have seemed fitting rewards for blameless lives and religious meditation.”

[36] Cyclopædia of Practical Medicine, art. Disease, vol. i. p. 629.

[37] Brodie, _ut supra_, vol. i. p. 281.

[38] Brodie _ut supra_, p. 182.

[39] Brodie, p. 182.

[40] The Anatomy and Philosophy of Expression. Fourth Edition, 1847, p. 185.

[41] Symonds, _ut supra_, p. 803.

II.

THE SYMPTOMS AND MODES OF DYING.