Whether consciousness of bodily sensations continues till the very commencement of the death-struggle, or agony,* as it is termed, is an enquiry often put to the medical attendant either by patients themselves, or by their anx ious relatives. The ideas entertained by per sons unaccustomed to physiological study re specting the pains of dying, have arisen partly from their theoretical views of the nature of the event itself, and partly from their obser vation of its preceding or accompanying phe nomena. When they imagined death to be a kind of forcible severing of the spirit from the body,—a separation so opposed to the incli nation of the former that some have fancied it longing to return to the body, 'or when they regarded the throes of death as efforts of the confined inmate to escape from its tenement ; or when laying aside their imaginings, they witnessed a heaving respiration, cold dew on the face, and convulsive agitations of the whole frame, affections so often known to accompany in tense bodily suffering,—it is not wonderful that the process of dying should have been considered one of distress and anguish. But the practitioner ought to be able to console the friends of the dying by the assurance that whatever may have been the previous torture, it must be all over when once those changes begin in which death essentially consists. He must explain to them how upon the failure of the circulation, the function of the brain must cease by necessity ; that if the cessation of the former be gradual, that of the latter may and. often does precede it ; that if the mortal pro cess begins in the lungs, unconsciousness pre cedes the arrest of the circulation ; and if in the brain, that an injury of this organ sufficient to affect the lungs and the heart fatally is sure to annihilate its own sensibility. The muscu lar spasms, the slow, gasping, or gurgling breathing, the collapsed or distorted features, though in some cases accompanied by feeling, are altogether independent of it. Convulsion is not, as superficial observers often interpret it, the sign of pain, or the result of an in stinctive effort of nature to get rid of the cause of pain,—it is an affection of the moti fic not of the sensific part of the nervous sys tern.'i' The pangs of the disease may last till within a short period of death, but it is a great error to attribute them to the process which brings them to an end. Such cases however are rare ; it is far more common for the sensibility to be blunted, or for the cause of pain to subside before the phenomena of dying commence. A person poisoned by an irritant is said to die in great agony ; a very incorrect expression, since death in such cases is ushered in by coma and by convulsions un attended with pain. Temporary syncope and asphyxia, the nearest approaches to actual death, have nothing formidable in sensation if we may judge from the reports of those who htive experienced them ; so far from it indeed, tbat some have described feelings of extreme pleasure, connected with each of these con ditions.f The relaxation and incapacity of the muscular system, though for the most part ex treme, has in some.cases been much less than might have been expected ; and even chronic maladies, attended during their course with great emaciation and debility, have suddenly terminated when the patients were in the act of walking, or of performing some other exertion disproportionate to the rest of the functions. The condition of certain muscles in the last stage of existence will be alluded to when we come to speak of the general aspect and pos ture of the dying.
The voice is generally weak and low as death approaches, but sometimes has a shriller pitch than natural; sometimes it is husky and thick, and not unfrequently it dwindles to a mere whisper. These changes are caused prin cipally by the debility which the vocal share with all thc other muscles in the system. In terruptions of the voice are obviously often due to the state of the respiration. It must not be omitted that in some instances the voice has remained firrn to the last.
Of the signs of death derived from the organic functions, the first in importance are those belonging to the circulation. The mode in which the action of the heart declines is extremely various, but has for the most part some connexion with the nature of the dis order. In maladies of considerable duration,
and in which for a long time all the func tions have suffered in a greater or less degree, the cessation of the heart's motion is nearly always aradual. The number of pulsations may, wahin a brief period of decease, greatly exceed the natural rate, but their energy is impaired, and the quantity of blood expelled at each systole is very small. In many acute affections the 'failure is evidenced some times by increased frequency and diminished vigour of the contractions, and sometimes by their irregularity and frequency, the force being but little altered. In such cases the cause of dis turbance is, without doubt, in some interruption of the nervous connexions of the organ. In other cases, the heart, before finally ceasing to beat, contracts with great violence, and then rapidly and suddenly comes to a stop. We have frequently noticed this kind of action in diseases of the brain, and have had reason to think that the syncope was brought on by the state of the respiration ; the latter effect, how ever, beina itself due in no slight measure to the irregurar action of the heart.
The increased frequency of the pulsations in a debilitated state of the heart indicates a greater susceptibility to the stimulus of the blood, at the same time that the resulting contractions are less efficient. The period of repose be tween the diastole and the sys'iole is briefer than in the normal action, besides that less time is occupied by the systole itself, in conse quence perhaps of the very slight shortening of the fibres. In a vigorous heart the reverse of this takes place; the irritability is not such as to prevent a considerable pause after the dias tole, and the fibres undergo a much greater degree of shortening. Why the irritability of a part should increase to a certain extent with increasing debility, is a problem yet to be solved. But we have reason to think that it is chiefly in acute diseases that the great rapidity of the heart's action is presented, and that in chronic affections there is a. more gradual ex haustion of -irritability. Inequality of arte rial action when amounting to a great degree, is one of ;he most threatening symptoms that can be witnessed. We allude particularly to that extraordinary pulsation. of the carotids which is sometimes observable, when the ra dial artery can scarcely be distinguished. It is perhaps one of the strongest presumptions that arteries possess a vital contractility, which may be disturbed in them as in other parts of the system.
The state of the respiration in a moribund person is extremely various ; sometimes hur ried and panting till within a few moments of decease; sometimes ceasing gradually, in har mony with the languishing circulation ; but sometimes slow, laborious, and stertorous, and, as Haller expresses it, " dum anxietas equidem cooit moliri, vetat debilitas." In addition to bthose causes of struggling respira tion which belong to the nervous centres and to the circulation in the lungs, the function is often dreadfully embarrassed by the accumu lation of fluids, mucous, serous or purulent, in the bronchim. The quantity of these secre tions is often increased by a state of the bron chial membrane, analogous to what we shall notice presently in the skin, designated by Laennec 44 the catarrh of the dying;" but the mere accumulation of the natural quantity from defect of those muscular actions which usually remove it, whether in the fibres of Iteisseissen, or in the general respiratory appa ratus, is amply sufficient to cause exquisite distress. Mediate or immediate auscultation detects a loud guggling throughout the chest-, which is sometimes audible even at a little distance, and the vibrations of which may be felt by the hand. This sound must not be confounded with the true 44 death-rattle," Whieh is produced not by struggles between air and liquid in the bronchial ramifications, but by the ejection of air from the lungs through the fluid in the trachea. It is often followed by a flow of spumous liquid through the mouth and nostrils.