Of Death and Dying

Of Death and Dying
by John Ryle MD

To die is as natural as to be born. Of the latter process we are allowed no personal memory; of the former we have no chance to leave a record, and, if we had, the state of our consciousness during the hours or days preceding our demise would generally exclude all clear and useful observation. The death-bed clarities of fiction and the stage are seldom true presentments. Most of mankind, moreover, have small familiarity with the process of dying and the appearances of death in others, their experience being confined to phases of sad anxiety on behalf of a few who were near and dear to them and to the emotions of bereavement engendered by their loss. At the time they cannot be severely objective, and lack of medical training leaves them uncertain as to what the last state of feeling of the departed may have been. To doctors and nurses, to priests and soldiers alone is the opportunity given of a real familiarity with dying and with death, and of these only the first and the second can be accounted more or less trained observers and objectively interested. Writings on the subject even at their hands have not been frequent or informative.

As children are afraid of the dark and primitive races of the unknown, so the majority of men have walked in some measure of dread of death. Could we but teach them to be less fearful, what a service to humanity we might render. Religious doctrine and the superstitions born thereof, so far from helping most men and women to peace of mind in the prospect of mortality, have persistently aggravated fear, finding in the shadows of death a punishment for evil living instead of the peaceful, dreamless night that follows inevitably on life’s day; in­venting ideas of judgment, of purgatory and hell, without a shred or vestige of evidence in support of their inventions; concocting, as a bribe for better actions, a dubious comfort and reward for the elect by the offer of wings and haloes and harps. Not the wages of sin but the peace that passeth all understanding is the rationalists’ picture of the oblivion which follows toil and weariness, the decrepitudes of age, the pain of wounds, the weaknesses of fever and slow disease, the disillusion of failure; a peace, it seems to them, no less to be desired by those upon whom life has smiled kindly, a peace not to be rivalled or embellished by any second innings of hypothetical existence.

Everything that we see or feel and experience with our senses, all our emotions of love, joy and content, as well as all the grades and varieties of pain and woe, disappointment and alarm, depend on the physiological integrity of a nervous system so intricate and a viability and reactivity of tissues in a chemico-physical sense so delicate, elaborate and perfect that we cannot conceive of the dead and disintegrating body as experiencing these sensations and emotions at all. We know that no stimulus which evokes these natural reactions of the living can evoke them in the dead, who are as clay. Nor, as logical and scientific beings, can we believe that, with the cessation of all the motor and sensory activities of life through the dissolution of the structures which subserve life, any other motor or sentient part of us remains to move and feel in the way that we have been accustomed to move and feel. For us, whether there be a spirit separate from sensation, thought and motion or not, death, in so far as we understand sensation, thought and motion, must mean arrest of activity and an oblivion not different from that which obtained before we left the womb. And so we do not or should not fear death or what follows it. And in this belief we should surely train our children, ourselves and the whole educable world of men.

But if past generations feared death itself or the aftermath of death, perhaps a larger pro­portion of moderns, with the waning of superstition and conventional religious influence, and with the constant near reminders of death in violent forms which war and aerial onslaught bring, have become imbued rather with the fear of dying. Perhaps at all times the fear of dying, prompted by the appearances of the injured and the sick and those in articulo mortis, has competed strongly or been confused with or excelled the fear of death itself.

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It is well therefore that we should inquire whether dying is so much to be feared as men for the most part have assumed it to be. There are deaths from heart failure and accident and cerebral haemorrhage so instantaneous or swift, and others from various forms of coma so complete, that they can give no time or allow no faculty for apprehension or for any other uncomfortable sensation or emotion. Such deaths are universally acclaimed as merciful. There have been numerous escapes from death in mountain or motoring accidents or similar circumstance in which the victims of a serious crash or fall, avoided or checked as they say “by a miracle,” and resulting only in slight injury, have recorded that they felt no fear and had chiefly been conscious in retrospect of the quick reflex adjustments to save or to protect themselves. In sudden danger the protective reflex always tends to cancel fear. Some of our pilots who have been shot down and escaped by lucky crash or parachute may one day have something to tell us here. Two medical men, who served as pilots in the last war and before the days of parachutes, have written to tell me that in the course of serious crashes they felt no fear at all. But what of the less swift demise of acute illness, of pneumonia or heart disease, of exhausting wounds or haemorrhage? There are accounts by good observers, including medical men, who have been reclaimed from the seeming menace of death through causes such as these, and the story they tell is that when to the bedside watcher they appeared in their greatest distress, with heaving chest and blue lips or parched mouths and ex-sanguine pallor, their actual state of consciousness was like a dream or a state of partial anaesthesia and that they knew little or no suffering. A doctor recovering from a bad attack of heart failure described sensations during the most anxious period of his illness akin to a pleasant intoxication. Another old physician, swiftly taken in a heart attack of which he had had some small warnings, oblivious of those around him, counted himself out like a referee with the fallen champion of the boxing-ring. A third, who had a severe post-operative haemorrhage, referred to the “pleasant, dreamy, hazy existence” which it engendered. A fourth with pneumonia remembered nothing between being taken ill and coming to life a week or ten days later with an ardent desire for breakfast. A colleague of mine, whom I attended in a serious pneumonia and who was always able to answer questions ration­ ally at the time of the visits, had no recollection whatsoever of these visits afterwards. These gaps in memory must at least imply a con­siderable dimming of consciousness at the time of real or apparent suffering. Fever and shortness of breath can well imitate the twilight sleep of scopolamine and morphine, the effects and benefits of which we do not doubt. Most diseases accompanied by lack of oxygen or continued high fever may be considered to produce effects not unlike those experienced during the induction of an anaesthetic or under drug-narcosis. Many of the outwardly distressing or painful deaths are the sequel of shock, haemorrhage or fever or some combination of these, all of which are capable of dimming consciousness with a dreaminess or delirium as effective sometimes as the precious gifts of the hypodermic needle. In a convoy of wounded soldiers there are always those who are groaning with pain, but they are the minority and they are not always conscious in their groaning. There are others who have pain in plenty, but whose courage and a cigarette keep them in good heart. And there are the majority whose pain is of a less severe order. Of those in the category of the dying, however, I should doubt whether more than a small proportion are fully conscious of their suffering.

For the blessed help of morphine we can never be too grateful. But have we medical men, I often wonder, spent enough time in reassuring the relatives of the moribund, not only about the effectiveness of our methods of giving ease, but also about the wonderful compensatory relief which nature allows for many a mortal hurt or illness? Touring a hospital ward to see some of the victims of a bombing raid with manifold and various injuries, I noted that nearly all were in sleep or something like it, and that those probably destined to die were certainly neither in terror nor great pain. No, the harder sufferings fall to those who recover slowly or are incurable but live long. Of those who face an early death from illness or wounds the greater number do not know it. Sir William Osler, one of the wisest and most experienced of physicians, wrote :

I have careful records of about five hundred death-beds, studied particularly with reference to the modes of death and the sensations of the dying. The latter alone concerns us here. Ninety suffered bodily pain or distress of one sort or another, eleven showed mental apprehension, two positive terror, one expressed spiritual exaltation, one bitter remorse. The great majority gave no sign one way or another : like their birth, their death was a sleep and a forgetting. (From the Ingersoll lecture on Science and Immortality given at Harvard University in 1904)

Dr. Parkes Weber, in his Aspects of Death, quotes the supporting opinions of such eminent men, among others, as Sir Benjamin Brodie, Sir William Gull, Sir James Goodhart, Professor Nothnagel and Sir Frederick Treves.

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It is interesting to inquire whether there be a physical awareness or sense of dying apart from the occasional intelligent acceptance that the hour draws near. There is in fact a sense of dying, a feeling of impending dissolution, the angor animi or meditatio mortis of medical writers, which is sometimes hinted at or de­scribed by patients with evident anxiety or horror. It is not, however, very common and it is nearly always a false witness. Sufferers from angina pectoris experience it in a small proportion of cases. It is far commoner in so-called vasomotor angina or Gower’s syndrome, a purely nervous disorder affecting the heart and circulation, which accompanies certain states of physical and emotional ill-health. It may also complicate serum-shock and bad attacks of vertigo. Some of its attendant physical effects remind us of the paralysis or “freezing” of the rabbit in the presence of the snake or stoat. I have never encountered a symptom akin to it in those who were in fact about to die. It seems therefore that the physical processes of dying tend to eliminate not only the terrors concerning it which have been harboured in times of health, but also much of the mental and physical distress which has in imagination given special cause for the apprehension; that dying may sometimes, in truth, be a terrible or a painful experience, but that consciousness is more often mercifully clouded by the chemico-physical disturbances with which nature counters haemorrhage, shock, the bacterial infections, the lethal wound and the failing heart; and that in some instances dying may even be a pleasant process.

If then death itself is not to be feared because it implies nothingness or oblivion, if dying is only rarely a painful or terrifying experience, except in anticipation and imagination and in respect of our sorrow at leaving or being left by those whom we love, what is there remaining for purely personal dread? Admitted the circumstances of illness and the idea of beautiful bodies shattered are hurtful things to all sensitive minds, but should we not whenever possible draw comfort from the actualities of medical experience and thereby lessen the aesthetic hurt.

Let us now assure ourselves that for the victims dying is not so terrible a thing as we have been led to believe. It is often the witnesses who suffer the greater mental pain. Their suffering is largely, however, a matter of untutored sympathy, of imagining what others must be feeling and what they themselves may be called upon to endure. Acceptance of the assurances here outlined does not at all imply callousness. Apart from what has been related we have the accounts in the daily Press of the courage and even cheerfulness of men, women and children who have fallen victim to the bomb or fallen debris, and of soldiers, sailors and airmen continuing to man their guns and planes when mortally wounded. These too should remind us that under such conditions body and feeling and will are not always so crippled by pain or fear as they might be presumed to be. To believe this detracts not at all from the incredible courage of man, which must always quicken our wonder and our sympathy. Sympathy in active and generous forms we cannot and should not withhold, but a purely subjective sympathy and unnecessary self-flagellation with imagined suffering are not only unhappy but useless things, and must serve to inhibit good endeavour and the preparation for it. In times like the present, furthermore, the fear of death and injury can be a spark to panic and so help the enemy.

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Those are most alive to-day who are most confidently and whole-heartedly employed in military and humane activities, since action crowds out fear. And is it not better to die living than to live in the rehearsal of death? Those only may be considered dead and dying who nurture their angor animi or meditatio mortis, who shun healthy action for morbid thinking, or who hold that “the struggle nought availeth,” that the fight for life and for a better mode of life and for the ultimate cessation of killing as a means of international policy is something not in their province or worth their while.

Those, on the other hand, whose lives are compounded of action and a faith in mutual aid need know no death, and if a bomb, a bullet or the bacteria of disease should take them unawares they will find, in all probability, that the phase of passing is something quite different from all imagined experience, from all that ignorance, fiction and superstition have made it. In their leave-taking from the green earth and from their friends they may or they may not, with the numbing of their senses, feel a fleeting wistfulness, but they will know no terror and no shame.