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.

More or fewer of these phenomena are to be seen in most dying persons; but they vary in number and character, in the order of their appearance, and in their combination, according to the nature of the disease in the course of which they occur, and of the mode of dying to which they severally tend. “Although,” says Sir Thomas Watson, “all men must die, all do not die in the same manner. In one instance the thread of existence is suddenly snapped, the passage from life and apparent health perhaps to the condition of a corpse is made in a moment: in another the process of dissolution is slow and tedious, and we scarcely know the precise instant in which the solemn change is complete. One man retains possession of his intellect up to his latest breath; another lies unconscious and insensible to all outward impressions for hours or days before the struggle is over.”[45]

Whatever may be the remote causes of dissolution, the modes in which death is actually brought about vary remarkably, according as it begins in the heart, in the lungs, or in the brain.

Death beginning at the heart is sometimes instantaneous. Suddenly and without warning of any kind, the heart ceases to beat, the individual turns pale, falls back or drops down and expires with one gasp. But oftener, death takes place slowly, there is a more or less lengthened period of exhaustion, and death occurs in the way either of syncope, or of asthenia. The phenomena which attend dying by syncope are described by Sir Thomas Watson as “paleness of the face and lips, cold sweats, dimness of vision, dilated pupils, vertigo, a slow, weak, irregular pulse, and speedy insensibility. With these symptoms are frequently conjoined nausea and even vomiting, restlessness and tossing of the limbs, transient delirium; the breathing is irregular, sighing, and, at last, gasping; and convulsions generally occur, and are once or twice repeated before the scene closes.”[46] When death occurs from asthenia or failure of contractile power in the heart, “the pulse becomes very feeble and frequent, and the muscular debility extreme, but the senses are perfect, the hearing is sometimes even painfully acute, and the intellect remains clear to the last.”[47]

Death beginning at the lungs, from asphyxia or suffocation, is marked by laborious heaving of the chest, strong but ineffectual contractions of the respiratory muscles, distress about the breast; “the face at first becomes flushed and turgid, then livid and purplish, the veins of the head and neck swell, and the eyes seem to protrude from their sockets. There is vertigo, then loss of consciousness, and then convulsions.”[48] The livid face and laboured breathing are accepted as evidence of severe bodily suffering, but they are only partially so, for the circulation of undecarbonized blood on which they severally depend, through the brain, in common with other parts of the frame, first benumbs sensibility, and then abolishes it altogether. “Disturbance of respiration,” says Dr. Ferriar,[49] “is often the only apparent source of uneasiness to the dying, but sensibility seems to be impaired in exact proportion to the decrease of that function.”

Death beginning at the brain destroys life indirectly--by its influence on the lungs or on the heart, and so by the way of coma or of asthenia. In death by coma there is “stupor more or less profound; the sensibility to outward impressions is destroyed, sometimes wholly and at once, much oftener gradually; the respiration becomes slow, irregular, stertorous; all voluntary attention to the act of breathing is lost, but the instinctive motions continue. At length the chest ceases to expand, the blood is no longer aërated,”[50] and thenceforward precisely the same internal changes occur as in death, beginning at the lung. It is in this way that most fatal disorders of the brain produce death. When death starting from the brain acts through the heart, it occurs somewhat suddenly, and in the way of shock, as in some of the worst cases of apoplexy--the “apoplexie foudroyante,” for example--or more slowly, in the way of exhaustion or asthenia, as in some cases of delirium tremens, or of phrensy--and as happened in the two cases described at pages 36 and 38.

The several modes of dying described above, are often combined in the same person, complicating the process and confusing our views of it; with the effect too, in some cases, of increasing the sufferings of the dying, but in others of lessening them. Thus coma, from implication of the brain supervening on diseases of the lung, first lessens the perception of the distress and anguish which attend them, and then extinguishes it. These mixed forms of death are seen especially in fevers.

FOOTNOTES:

[42] “At Medicus moriendi initium altius repetet, et jam ab eo inde tempore ducet, quo signis minime dubiis cognoverit, morbum naturæ artique non tantum insuperabilem esse, sed et sub eo vires sic perire ut reparari nequeant.” (Paradys, Oratio de Εὐθανασία naturali, p. 67).

[43] In the words of Lucretius, vi. 1, 190--

“Item, ad supremum denique tempus, Compressæ nares, nasi primoris acumen Tenue, cavatei oculei, cava tempora; frigida pellis, Duraque, inhorrebat tactum; frons tenta meabat: Nec nimio rigida post artus morte jacebant.”

Or, as rendered by an accomplished physician, Dr. Mason Good--

“Then, tow’rds the last, the nostrils close collaps’d; The nose acute; eyes hollow; temples scoop’d; Frigid the skin, retracted; o’er the mouth A ghastly grin; the shrivell’d forehead tense; The limbs outstretch’d for instant death prepar’d.”

[44] “Omnia tum vero vitai claustra lababant.” (Lucretius, vi. 1,151).

“Then all the powers of life were loosen’d.” (Mason Good).

[45] Lectures on the Principles and Practice of Physic. Fifth edition, 2 vols. 8vo, London, 1871, vol. i. p. 62. Sir Thomas Watson in his admirable lecture on the Different Modes of Dying, has treated the whole subject so graphically, that I shall follow him as closely as possible in what I have to adduce on this part of my subject.

[46] Watson, p. 66.

[47] Watson, p. 68.

[48] _Ibid._, p. 70.

[49] On the Treatment of the Dying. Medical Histories and Reflections. Vol. iii. p. 195.

[50] Watson, p. 76.