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EUTHANASIA:
OR,
MEDICAL TREATMENT IN AID
OF AN EASY DEATH.
BY
WILLIAM MUNK, M.D., F.S.A.
FELLOW AND LATE SENIOR CENSOR OF THE ROYAL COLLEGE OF
PHYSICIANS, &c., &c., &c.
LONDON:
LONGMANS, GREEN, AND CO.
AND NEW YORK: 15, EAST 16th STREET.
1887.
_All rights reserved._
PREFACE.
Much has been ably written on Death, and on the physiology of the
various modes of Dying, by Bichat, Alison, Wilson Philip, Symonds, and
others; while but little has been written on the medical management
of the Dying; or on the Euthanasia, to which such management should
contribute. A short but valuable essay of less than twenty pages,
“On the Treatment of the Dying”, by Dr. Ferriar, of Manchester,
in 1798: and a very elegant academical oration, of about the same
length, at my own alma mater, Leyden, in 1794, by Professor Paradys,
“Oratio de Εὐθανασία Naturali; et quid ad eam conciliandam Medicina
valeat”:--comprise all I know that has been written _specially_ on
these subjects in modern times.
Sir Henry Halford, who was confessedly a master in all that concerns
the management of the Dying, did much by his example and counsel to
commend the subject to the attention of his medical brethren. But
the generation he personally influenced has passed away. His little
volume of “Essays and Orations” contains much on this subject that
is very valuable, and not to be found elsewhere. But his remarks are
unconnected; they occur incidentally in the course of his various
essays, and are now but little known. They were the result of an
experience so large, and so carefully thought out, that I have been
glad to adduce them, whenever I could, in support of, or in addition
to, what I have had myself to state, on the delicate and difficult
subjects considered in the following pages.
40, FINSBURY SQUARE.
_Sept. 24, 1887._
CONTENTS.
I.
ON SOME OF THE PHENOMENA OF DYING 1
II.
ON THE SYMPTOMS AND MODES OF DYING 51
III.
ON THE GENERAL AND MEDICAL MANAGEMENT
OF THE DYING 63
I.
SOME OF THE PHENOMENA OF DYING.
“Quod ad nos Pertinet, et nescire malum est, agitamus.”
HORACE.
One of the wisest of our countrymen, Lord Verulam, saw reason to
censure the physicians of his own time for not making the Euthanasia a
part of their studies.[1] And, although more than two centuries have
since elapsed, it may be doubted whether as much attention is even
yet given to the subject as might be done, to the obvious benefit and
comfort of the dying.
There is little to be found in medical writings on the management
of the dying, or on the treatment best adapted to the relief of the
sufferings incident to that condition. The subject is not specially
taught in any of our medical schools; and the young physician entering
on the active duties of his office has to learn for himself, as
best he may, what to do, and what not to do, in the most solemn and
delicate position in which he can be placed,--in attendance on the
dying, and administering the resources of the medical art, in aid
of an easy, gentle, and placid death. The whole subject of the
Euthanasia,[2] or of a calm and easy death, in so far as it respects
the physician is in need of special study; and of a systematic
treatment that has not hitherto been accorded to it.[3] In the
following pages I can but trace the outlines of this subject, leaving
to abler hands that fuller treatment which its interest and importance
claim for it.
Lord Verulam held it to be as much the duty of the physician to smooth
the bed of death, and render the departure from this life easy and
gentle, as it is to cure diseases and restore health.[4] And this
doctrine, so accordant with the best principles of our nature,[5]
is commended to us by that most estimable and judicious of modern
physicians, Dr. Heberden;[6] as it was also by the example and
counsel of one of the most popular and successful physicians of the
present century--the late Sir Henry Halford.[7]
The process by which death is brought about varies greatly in
different instances, and this according to the disease, or the organ
of the body, from which it essentially results. On these diverse modes
of dying, and of death, modern science has thrown much light; and
with the consolatory result of showing that the process of dying, and
the very act of death, is but rarely and exceptionally attended by
those severe bodily sufferings, which in popular belief are all but
inseparable from it, and are expressed and emphasized in the terms
“mortal agony” and “death struggle.”
Montaigne was one of the first among modern writers to oppose, by
close argument, the general opinion of the painfulness of death; and
he was followed in the last century with more eloquence, if with
less argument, by Buffon.[8] “There is hardly any subject,” writes
an amiable physician, “on which books afford us more impressive
topics, than the consideration of death; and perhaps there is none
less studied in its intimate details.... It might be expected that a
scene through which we must all pass should excite a closer attention
especially as _the physical process of death loses much of its horror
on a near view_.”[9]
Physicians, the clergy, and intelligent nurses--all, indeed, who
are practically conversant with the dying--testify to the truth of
this statement. Sir Henry Halford, towards the close of his medical
career, and after opportunities of observation, such as have fallen
to the lot of few physicians, expressed his surprise that of the
great number to whom it had been his professional duty to have
administered in the last hours of their lives, so few exhibited signs
of severe suffering. Sir Benjamin Brodie, whose experience of death
from surgical disease was second to none, states that, according to
his observation, the mere act of dying is seldom, in any sense of the
word, a very painful process.[10] And another distinguished surgeon,
Mr. Savory, writing on the same subject, says, “Whatever may have been
the amount of _previous_ suffering, we may fairly assume that, except
in extreme cases, the actual process of dying is not one of intense
agony, or indeed, for the most part, even of pain.”[11] Lastly, the
great anatomist, Dr. William Hunter, bore his own dying testimony
to the same effect. He retained his consciousness to the last, and
just before he died he whispered to his friend, Dr. Combe, “If I had
strength enough to hold a pen, I would write how easy and pleasant a
thing it is to die.”[12]
But of far greater weight than the observations and conclusions of
medical men, however eminent, towards the determination of such a
question, is the evidence of those who have been restored from the
state of apparent death from drowning--a state which differs only from
actual death in the possibility of reanimation under the influence of
external treatment. And although the accounts given after recovery
from drowning vary much, there are a number of well-attested cases
which show, that in them at any rate, the loss of sensibility and
consciousness has been painless, or at most attended with a feeling
of oppression across the chest. The process of recovery, however, is
often one of great bodily suffering.
Lastly, there are those specially interesting cases of recovery from
the apparent death of drowning, in which, although the mind has been
keenly alive and active throughout, there was an entire absence of
pain or other bodily suffering of any kind. The best authenticated
of these instructive and suggestive instances is that of Admiral
Beaufort, as described by himself in a letter to Dr. Wollaston.[13]
When a youngster on board one of H.M. ships in Portsmouth harbour, he
fell into the water, and, being unable to swim, was soon exhausted
by his struggles, and before relief reached him, he had sunk below
the surface. All hope had fled, all exertion ceased, and he felt that
he was drowning. “From the moment that all exertion had ceased,”
writes the admiral, “a calm feeling of the most perfect tranquillity
superseded the previous tumultuous sensations--it might be called
apathy, certainly not resignation, for drowning no longer appeared
to be an evil. I no longer thought of being rescued, _nor was I in
any bodily pain. On the contrary, my sensations were now of rather
a pleasurable cast, partaking of that dull, but contented sort of
feeling which precedes the sleep produced by fatigue._ Though the
senses were thus deadened, not so the mind; its activity seemed to
be invigorated in a ratio which defies all description--for thought
rose after thought with a rapidity of succession, that is not only
indescribable, but probably inconceivable, by any one who has not
himself been in a similar situation. The course of these thoughts I
can even now in a great measure retrace,--the event which had just
taken place, the awkwardness that had produced it, the bustle it must
have occasioned, the effect it would have on a most affectionate
father, and a thousand other circumstances minutely associated with
home were the first series of reflections that occurred. They then
took a wider range--our last cruise, a former voyage and shipwreck,
my school, the progress I had made there and the time I had misspent,
and even all my boyish pursuits and adventures. Thus travelling
backwards, every past incident of my life seemed to glance across my
recollection in retrograde succession; not, however, in mere outline
as here stated, but the picture filled up with every minute and
collateral feature; in short, the whole period of my existence seemed
to be placed before me in a kind of panoramic review, and each act
of it seemed to be accompanied by a consciousness of right or wrong,
or by some reflection on its cause or its consequences; indeed, many
trifling events which had been long forgotten, then crowded into my
imagination, and with the character of recent familiarity.” Certainly
two minutes did not elapse from the moment of suffocation to that of
being hauled up; and according to the account of the lookers on, he
was very quickly restored to animation. “My feelings,” continues
Admiral Beaufort, “while life was returning, were the very reverse in
every point of those which have been described above. One single but
confused idea--a miserable belief that I was drowning dwelt upon my
mind, instead of the multitude of clear and definite ideas which had
recently rushed through it--a helpless anxiety--a kind of continuous
nightmare seemed to press heavily on every sense, and to prevent the
formation of any one distinct thought, and it was with difficulty that
I became convinced that I was really alive. Again, _instead of being
absolutely free from all bodily pain, as in my drowning state_, I was
now tortured by pain all over me.”
I have given this case at some length, because it seems to throw a
new light on the act of dying, and because analogous instances are
probably not uncommon. Admiral Beaufort tells us that he had heard
from two or three persons, who had recovered from a similar state,
a detail of their feelings, which resembled his own as nearly as was
consistent with their different constitutions and dispositions. Sir
Benjamin Brodie mentions an instance in a sailor;[14] De Quincey
records a like instance in a female, a near relative of his own;[15]
and I have myself heard of two similar cases, but the details are not
sufficiently precise to justify their narration here.
In fact, all the best and all the most direct evidence that the
subject admits of, goes to show, that as a rule, the immediate act of
dying is in no sense a process of severe bodily suffering--or, indeed,
for the most part even of pain.
The common belief that the act of dying is one of severe bodily
suffering is due probably in part to theoretical views of the nature
of the event itself;[16] but, principally, to the occurrence of
conditions, physiological or pathological, which precede or accompany
that act, and the nature and import of which are misinterpreted.
Doubtless also, it is due in no small degree to confounding the
actual stage of dying, with those urgent symptoms of disease that
precede and lead up to it, and which are often as severe or more so in
those who are to recover, as in those who are to die. As a rule, to
which there are doubtless exceptions, the urgent symptoms of disease
subside, when the act of dying really begins. “A pause in nature,
as it were, seems to take place, the disease has done its worst,
all strong action has ceased, the frame is fatigued by its efforts
to sustain itself, and a general tranquillity pervades the whole
system.”[17]
Again, convulsions, which so often attend the process of dying, are
accepted in evidence of suffering, when in fact they are the reverse,
for they imply a loss of consciousness and sensibility, and therefore,
of the capacity to feel pain. They are automatic, and in all essential
respects like the convulsions of epilepsy, of which the subject is
wholly unconscious. The convulsive movements that sometimes attend
the last moments, and with which the person expires, constituting
the so-called “death struggle,” are doubtless of the same painless
character.
Some few, however, do really suffer grievously in dying, and expire
in great bodily torture. This occurs in some diseases of the heart
and great vessels of the chest, in angina pectoris, and in ileus. But
especially in that most fearful of diseases, hydrophobia, in tetanus,
and in spasmodic cholera--in maladies characterized by spasm of the
external muscles, as distinguished from their convulsion, for spasm
implies no such unconsciousness as does convulsion, but the reverse.
Such cases are rare, but they are so terrible that they fix themselves
in the memory, exert an undue influence on the judgment, and, although
really exceptional in occurrence, and in the sufferings they entail,
come to be regarded as but extreme instances of what is assumed to be
the universal and inevitable lot of the dying. Happily for mankind it
is not so.
So long as consciousness and intelligence continue, and they often
do so to the last, the influence of mind and of the emotions on the
bodily process of dying must be kept steadily in view. They are
well-nigh as potential in the dying man as they are in the healthy.
Hope is as soothing and fear as depressing in the one condition as in
the other. To the dying there is no greater solace and cordial than
hope--it is the most soothing and cheering of our feelings, and if,
when all hope of life and in the present has fled, the dying man can
dwell with hope and confidence upon his future, it will be well for
him. The retrospect of a well-spent life, “memoria bene actæ vitæ,
multorumque benefactorum recordatio” is a cordial of infinitely more
efficacy than all the resources of the medical art;[18] but a firm
belief in the mercy of God, and in the promises of salvation will do
more than anything in aid of an easy, calm, and collected death. To
those who are sceptical on this point, and such there are, I would
remark, that unless a man has himself felt the influence of religion
on his own mind, he is unable fully and accurately to understand its
influence on others. If I may trust my own experience I should say,
that in the aggressive _dis_believer, as in the mere passive agnostic,
doubt and anxiety as to his future is all but sure to obtrude itself
on his last conscious moments, disturb them, and render such an
euthanasia as we contemplate, impossible.
“The less fear a reasonable man entertains of death,” says Zimmerman,
“the more placid is he in his last moments.” Happily such dread or
terror of death as disturbs the dying is rare. For the most part an
urgent fear of death, when it does exist, is observed not so much
at the moment when death is actually impending, as it is at that
earlier period when the individual realizes for the first time that
he is about to die. The shock at _that_ moment may be great, but it
is for the most part transient, and “the subsequent contemplation of
approaching death seems to be far less terrible.”[19] A torpor seems
indeed to steal softly over the whole being as death approaches,
and the earnestness to live abates, as the possession of life, from
whatever cause, is gradually withdrawn. Sir Henry Halford tells us
that of the great number to whom he had administered in the last
hours of their lives, he had felt surprised that so few have appeared
reluctant to go to “the undiscovered country from whose bourn no
traveller returns.”[20]
No one, writes Mr. Savory, who has often stood at the bedside of the
dying, “can have failed to be struck by the fact of the comparative
or complete absence of dismay as death draws near. Often, no doubt,
the mind is otherwise too fully occupied, ... but even in the absence
of this and all distracting influences, and with a clear conviction
that the approaching change is near at hand,--the mind is calm and
collected, the thoughts serene, there is no quailing, no giving
way.”[21]
The nature of the disease under which a person succumbs, would seem
to exert some influence in this respect. Sir Benjamin Brodie says,
“I have myself never known but two instances, in which, in the act
of dying there were manifest indications of the fear of death.
The individuals to whom I allude were unexpectedly destroyed by
hemorrhage, which from peculiar circumstances, it was impossible to
suppress. The depressing effects which the gradual loss of blood
produced on their corporeal system seemed to influence their minds,
and they died earnestly imploring the relief which art was unable to
afford.”[22]
When the intimation that death is at hand has been postponed to the
latest possible moment, it comes upon the sufferer so late, that there
may not be time for him to get over the shock of the first impression,
and regain his serenity. Alarm associates itself with the act of
dissolution, which is imminent, or has already commenced, disturbs its
even, easy, tenor, and explains some at least of the harrowing scenes
that occasionally mark the death-bed. An earlier intimation[23] to the
dying person of the great change he is about to undergo is in all
respects desirable, and if the communication be made tenderly and with
prudence, nothing but good is likely to result from it. An important
question here presents itself. By whom should that communication be
made?
“You will forgive me,” said Sir Henry Halford at one of the evening
meetings at the College of Physicians, “if I presume to state what
appears to me to be the conduct proper to be observed by a physician
in withholding, or making his patient acquainted with, his opinion
of the probable issue of a malady manifesting mortal symptoms. I own
I think it my first duty to protract his life by all practicable
means, and to interpose myself between him and everything which may
possibly aggravate his danger. And unless I shall have found him
averse from doing what was necessary in aid of my remedies, from a
want of a proper sense of his perilous situation, I forbear to step
out of the bounds of my province in order to offer any advice which
is not necessary to promote his cure. At the same time, I think it
indispensable to let his friends know the danger of his case the
instant I discover it. An arrangement of his worldly affairs, in which
the comfort or unhappiness of those who are to come after him is
involved, may be necessary; and a suggestion of his danger by which
the accomplishment of this object is to be obtained, naturally induces
a contemplation of his more important spiritual concerns, a careful
review of his past life, and such sincere sorrow and contrition for
what he has done amiss, as justifies our humble hope of his pardon
and acceptance hereafter. If friends can do their good offices at a
proper time, and under the suggestions of the physician, it is far
better that they should undertake them than the medical adviser. They
do so without destroying his hopes, for the patient will still believe
that he has an appeal to his physician, beyond their fears; whereas,
if the physician lay open his danger to him, however delicately he
may do this, he runs a risk of appearing to pronounce a sentence
of condemnation to death, against which there is no appeal, no
hope.... But friends may be absent, and nobody near the patient in
his extremity, of sufficient influence or pretension to inform him of
his dangerous condition. And surely it is lamentable to think that
any human being should leave the world unprepared to meet his Creator
and Judge, ‘with all his crimes broad blown.’ Rather than so, I have
departed from my strict professional duty, and have done that which I
would have done by myself, and have apprized my patient of the great
change he was about to undergo.”
“In short, no rule, not to be infringed sometimes, can be laid down
on this subject. Every case requires its own considerations; but you
may be assured, that if good sense and good feeling be not wanting,
no difficulty can occur which you will not be able to surmount with
satisfaction to your patient, his friends, and yourselves.”[24]
In some instances the patient himself is the first to discover, and
this from his own internal feelings, that he is about to die, and he
announces the fact calmly, and for the most part without alarm, to
those about him.
Although a fear of death in itself, or for one’s own sake, is rare
and exceptional, the last moments of too many are made miserable by
solicitude for those they will leave behind, and their end is often
one of great _mental_ anguish. “Such have clung to life anxiously,
painfully, but they were not influenced so much by a love of life for
its own sake, as by the distressing prospect of leaving children,
dependent upon them, to the mercy of the world, deprived of their
parental care.”[25]
* * * * *
In some dying persons consciousness and the intellect remain perfect
to the last. The cases in which this is observed will be found to
agree in the fact that the brain is correspondently unimpaired; they
are for the most part chronic diseases of the chest and abdomen. If
the character of the dying person is naturally strong, the state of
his mind at the approach of death will generally be influenced by it.
Of those who retain consciousness and intellect, the majority die
thinking and acting in accordance with the influences that have been
exerted upon them in previous life, by education and example: and with
those which may be then brought to bear upon them, towards and at its
close.
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.
It is often difficult to determine when the act of dying really
begins. Practically, it should be dated from the moment when the
physician concludes from reliable signs, not only that the disease
under which the patient labours is incurable by nature or art, _but
that the vital powers are already so utterly reduced that they are
beyond the possibility of restoration_.[42] And on these points
the Father of Physic is perhaps still our best guide. A sharp and
pinched nose, the eyes sunk in the orbits and hollow, the ears
pale, cold, shrunk, with their lobes inverted, and the face pallid,
livid, or black; these together make up the celebrated _facies
Hippocratica_,[43] and show that the work of dying has commenced, and
has already made some progress. They are signs of utter exhaustion
in the circulation and in the muscular system, and they point to a
loosening of all the bonds[44] by which being is held together in the
human frame.
To these may be added the glazed half-closed eye; the dropped jaw and
open mouth; the blanched, cold, and flaccid lip; cold clammy sweats on
the head and neck; a hurried, shallow respiration on the one hand, or
slow, stertorous breathing with rattle in the throat upon the other;
a pulse irregular, _unequal_, weak, and immeasurably frequent; the
patient prostrate upon his back; and sliding down towards the foot
of the bed; his arms and legs extended, naked, and tossed about in
disorder; the hands waved languidly before the face, groping through
empty air, fumbling with the sheets, or picking at the bedclothes.
These latter symptoms come on for the most part later in the series;
they are the immediate precursors of death, and show that that event
is near at hand.