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+*** START OF THE PROJECT GUTENBERG EBOOK 76791 ***
+
+Transcriber’s Note.
+
+Italic text is indicated with _underscores_, bold text with =equals=.
+Small/mixed capitals have been replaced with ALL CAPITALS.
+
+Obvious typographical and punctuation errors have been corrected
+silently. Inconsistent hyphenation has been normalised.
+
+Half-titles & reiterations of the chapter title have been discarded.
+
+
+
+
+                              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.
+
+ 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.
+
+
+
+
+ III.
+
+ THE GENERAL AND MEDICAL TREATMENT OF THE DYING.
+
+
+ Many of the sufferings of the death-bed are not naturally or
+ necessarily incident to the act of the dying; but are due to
+ surrounding circumstances that admit of alteration or removal. Thus,
+ restlessness and jactitation are often due to the weight of the bed
+ coverings, and are at once removed by lightening them;--difficulty
+ of breathing and gasping, increased by the heat and closeness of the
+ chamber, are removed by the admission of fresh and cooler air, by
+ change of posture and by pillows carefully adapted to the efficient
+ support of the trunk of the body.
+
+ There is nothing of greater importance in the treatment of the dying
+ than the right administration of nutriment. Errors in feeding are the
+ cause of much of the disquietude and of many of the sufferings that
+ attend the dying. The sinking and exhaustion that are in progress
+ throughout the system, are assumed by the attendants to demand a free
+ administration of food and stimulants, forgetting that the stomach
+ shares in the exhaustion, and has lost its tone, and in great part, if
+ not wholly, its power of digesting. Food is given too frequently, and
+ in quantities too large. The dying person is induced by the wearisome
+ importunity of his attendants to take food or stimulants, against
+ which nature and his stomach revolt. The evident dislike and loathing
+ with which he submits, the difficulty he has in swallowing it, and the
+ urging and retching which that act sometimes induces, ought to save
+ him from what is really under the circumstances an act of cruelty.
+ “Here,” to use the words of Sir Henry Holland, “we are called upon to
+ maintain the cause of the patient, for such it truly is, against the
+ mistaken importunities which often surround him, and which it requires
+ much firmness in the physician to put aside.”[51] The wishes of the
+ patient himself, when he has reached the stage of existence here
+ contemplated, may generally be taken as a correct indication in all
+ that relates to the administration of food and stimulants.
+
+ Food when unwisely given, accumulates in the stomach, distends and
+ distresses it, and impedes the respiration. Under such circumstances
+ the pit of the stomach will be found tumid and tense, dull upon
+ percussion, and intolerant of pressure. At length some of the contents
+ of the distended stomach regurgitate into the throat or mouth; or
+ there may be actual vomiting, and this to the evident relief of the
+ sufferer. Hiccup is often due solely to an overloaded and distended
+ stomach.
+
+ Much discretion is needed in fixing on the kind and quantity of food
+ to be given. Something will depend on the character of the disease
+ under which the patient is sinking; and something on the length of
+ time he is likely to survive. If the act of dying is likely to be
+ protracted, as it often is in cancer and some cases of consumption,
+ where death is brought about by slowly progressive exhaustion, the
+ food should be supporting and in somewhat larger quantity. I have
+ long doubted whether strong beef tea and meat extracts are as a rule
+ of much use, or are appropriate when the act of dying has really
+ commenced. Milk, cream, beaten eggs, and the farinacea are far better.
+ They are, too, the best vehicles for wine and spirits; and they have
+ less tendency than soups to become offensive in the stomach.
+
+ Alcohol in its fermented or distilled forms is of special use in
+ the treatment of the dying. Owing to its high diffusive power it
+ passes readily into the blood. It stimulates the failing heart, and
+ thus promotes the circulation through the lungs, which is one of
+ its most valuable properties in the dying. It may perhaps increase
+ the secretion of the gastric juice; it more probably stimulates
+ the peristaltic movements of the stomach, and by so much, aids the
+ digestive process, and supports the patient in the best and most
+ natural manner. Stimulants and nutriment should as a rule be given
+ together for they mutually influence each other.
+
+ The quantity of wine or spirit which is needed varies exceedingly,
+ and no definite rule can be laid down on this point. They should be
+ given in small quantities at a time and repeated at short intervals
+ before the effects upon the heart and pulse of the previous dose have
+ subsided.
+
+ Of wines, sherry is perhaps the most useful. Port, if preferred
+ by the patient, may be substituted, but I have not found it, as a
+ rule, to agree as well as sherry. Madeira from its slight acidity is
+ specially agreeable to the palate, and is besides the most sustaining
+ and cordial of wines. But tokay is often more acceptable than any
+ other wine, especially to those sinking from exhausting diseases, as
+ hemorrhage, profuse suppuration, and the like. It is best given with
+ cream. The stimulus of these wines is longer maintained than is that
+ of other forms of alcohol. Champagne is most refreshing and is often
+ eagerly taken; but its effects are evanescent and it needs repeating
+ at shorter intervals than other wines. A teaspoonful of brandy, or of
+ some liqueur may sometimes be advantageously added to it.
+
+ Sometimes brandy answers better than any wine, especially if the
+ stomach is irritable and there is nausea or vomiting. As a mere
+ stimulant it is best administered with yolk of egg and sugar, as
+ is Sir Henry Halford’s celebrated mixture--the Mistura Spiritus
+ Vini Gallici of the Pharmacopœia. If brandy is used for its special
+ tranquillizing influence on an irritable stomach, it may be given
+ neat, in drachm doses, or in double that quantity in a little simple,
+ or in one of the aërated, waters. The wish of the patient for any
+ particular form of stimulant is almost always a correct indication for
+ its use.
+
+ The dry and parched condition of the tongue and mouth so common in the
+ dying, and the inextinguishable thirst that attends some forms of it,
+ need constant attention. A spoonful of iced-water repeated frequently
+ will be a great comfort. So, too, is a small bit of ice allowed to
+ dissolve in the mouth--or lemonade--or weak black tea without milk,
+ and slightly acidulated with a slice of lemon.
+
+ In the case of nutriment and stimulants as of mere diluents, it is to
+ be understood--supposing there is nothing to forbid--that so long as
+ the lips close upon them, and an act of swallowing follows _promptly_,
+ they may be continued: but when liquids seem merely to trickle down
+ the throat, and after a time, only to excite a faint effort of
+ swallowing, they should no longer be persisted in. The sensibility
+ of the parts is so diminished that the patient is insensible to the
+ stimulus of the liquid, and we infer _a fortiori_ to the dry and
+ parched state of the mouth and fauces. If, after rubbing the lips
+ gently with the spoon, or with the spout of the feeding vessel, no
+ evident and distinct act of swallowing follows, it is useless, and
+ it may be cruel to persist; the liquid will but clog the mouth and
+ fauces, add to the impediment to breathing, and by so much, if any
+ consciousness remains, to the sufferings of the dying.
+
+       *       *       *       *       *
+
+ Next in value to stimulants in the treatment of the dying is opium.
+ It is a tradition that John Hunter used often to exclaim, “Thank God
+ for opium,”[52] and under no circumstances are we bound to be more
+ thankful for it then when ministering at the bedside of the dying.
+ Opium is here worth all the rest of the materia medica. Its object and
+ action must however be clearly understood. Opium is administered to
+ the dying, as an anodyne to relieve pain; or as a cardiac and cordial
+ to allay that sinking and anguish about the stomach and heart, which
+ is so frequent in the dying, and is often worse to bear than pain,
+ however severe. Opium should rarely be administered to the dying as a
+ mere hypnotic, or with a view to enforce sleep. To do so would be to
+ risk throwing the patient into a sleep from which he may not awake.
+ But opium often induces sleep indirectly, and in the kindest way, by
+ the relief of pain,[53] or sinking that had hitherto rendered sleep
+ impossible.
+
+ For the relief of pain in the dying wherever it may be situated,
+ we have our one trustworthy remedy in opium. Heberden writes, “In
+ impetu autem doloris, ubi ubi is fuerit, opium est unicum remedium.”
+ If judiciously and freely administered it is equal to _most_ of the
+ emergencies in the way of pain, that we are likely to meet with in the
+ dying,[54] whereas if timidly and inadequately used, the sufferer is
+ deprived of the relief which it alone is capable of affording.
+
+ The value of opium in allaying pain, great as that is, is however
+ second to its value in relieving the feeling of exhaustion and
+ sinking--of indescribable distress and anxiety--referred to the
+ stomach and heart, which so often attends some part of the act of
+ dying. To the practised eye, this condition is evidenced, as much
+ by the pinched features, pallid complexion, and _anxious expression
+ of face_, as by any verbal complaint of the sufferer. Here the
+ action of opium is that of a cordial in the fullest sense of the
+ word. “Of all cordials,” says Sydenham, “opium is the best that has
+ hitherto been discovered. I had nearly said,” adds he, “that it is
+ the only one.”[55] “Under the protection of an opiate,” writes Dr.
+ Heberden,[56] “the patient’s strength has been kept up, and even in
+ hopeless cases in which the dying person is harassed by unspeakable
+ inquietude, he may be lulled into some composure, and without dying
+ at all sooner may be enabled to die more easily.” I know of nothing
+ in our attendance on the dying more gratifying, than to witness the
+ improvement in face, feature, and expression, that marks the kindly
+ action of opium under these circumstances. In an hour or thereabouts,
+ after it has been taken, some colour returns to the face, the features
+ lose somewhat of their sharpness, a placid expression replaces the
+ look of anxiety, and the sufferer passes into an easy, gentle sleep,
+ from which he awakes refreshed and comforted, and helped as it would
+ seem, to die more easily, when his time arrives. Hufeland, writing at
+ the end of a long professional life, did not hesitate to declare that
+ opium “is not only capable of taking away the pangs of death, but it
+ imparts even courage and energy for dying.”[57]
+
+ Opium must be administered in such doses as will appease suffering and
+ disorder, and in this respect we are to be governed solely by the
+ effect and relief afforded. The dose for an adult should be rarely
+ less than a grain, but oftener more. “There exists,” writes Sir Henry
+ Holland, “distrust, both as to the frequency and extent of its use not
+ warranted by facts, and injurious in many ways to our success;”[58]
+ “its use is not to be measured timidly by tables of doses, but by
+ fulfilment of the purpose for which it is given. A repetition of small
+ quantities will often fail, which concentrated into a single dose
+ would safely effect all we require.”[59]
+
+ The effects of opium continue for about eight hours, and if its
+ action is to be maintained it should be repeated at intervals of
+ that duration or somewhat less. The dose is to be governed solely by
+ the relief afforded. Its effects are usually limited to relief of
+ the pain, or of the sense of sinking for which it has been given,
+ producing no other direct effect on the system in general. “It would
+ seem,” says Sir Henry Holland, “that the medicine, expending all its
+ specific power in quieting these disorders, loses at the time every
+ other influence on the body. Even the sleep peculiar to opium appears
+ in such instances to be wanting, or produced chiefly in effect of the
+ release from suffering.”[60]
+
+ Opium should always be given to the dying in its liquid forms--as the
+ tincture, or the liquid extract--or as morphia, of which I know of no
+ preparation of equal value to the solution of the bimeconate.
+
+ So long as the air passages are not obstructed by secretion, so long
+ as there is neither lividity nor even duskiness of face, opium, if
+ indicated, may be given in aid of the Euthanasia; but if they are
+ present, it is hazardous and might hasten death. Much care, too,
+ is needed in the employment of opium, in cases where the heart is
+ _greatly enfeebled_, and where the conditions, directly or indirectly
+ induced by opiates, especially that of sleep, may be just enough
+ to turn the balance against it. A contracted pupil is also a
+ contra-indication to opium; it implies a state of the brain, which
+ opium is likely to increase rather than relieve. And if food has
+ been injudiciously pressed upon the patient, so that the stomach is
+ distended with it, and the epigastrium is full and tense, opium given
+ by the mouth is rarely found to act kindly, if at all. If, under such
+ circumstances, the influence of opium is needed, we should resort to
+ the hypodermic injection of morphia.
+
+ Professor Paradys warns us of the confusion of the senses and of the
+ mind that sometimes follows the administration of opium to the dying,
+ and which to some persons is worse to bear than the sufferings for
+ which it has been prescribed.[61] But this, in my experience, has been
+ rare, and will be seldom observed if opium is restricted to the cases
+ where, as I have stated above, it is specially called for,--namely, in
+ relief of pain or of severe sinking. When, however, it does occur in
+ these circumstances, it is probably due, either to an idiosyncrasy on
+ the part of the patient, or to the inadequacy of the dose given, which
+ has been enough to confuse and stupify the senses, but not to control
+ the symptoms for which it was administered. “Si timide et nimis parce
+ datum fuerit,” writes Dr. Gregory,[62] “longe alium effectum habebit,
+ et iisdem ægrotis haud parum nocebit, quibus largius datum multum
+ profuisset.”
+
+       *       *       *       *       *
+
+ Ammonia is inferior as a stimulant to wine and brandy, which are
+ more palatable and preferable, while as an antispasmodic it is very
+ inferior to ether. But it is useful where the respiration flags
+ and the breathing is obstructed by secretion accumulating in the
+ bronchial tubes, and the complexion is becoming dusky and livid. Five
+ grains of the carbonate dissolved in camphor water is a good mode
+ of administering it. Small doses of oil of turpentine are sometimes
+ more effectual than ammonia. A drachm of the confection of turpentine
+ rubbed up in peppermint water, is perhaps the best form of giving it.
+
+       *       *       *       *       *
+
+ Next in value to opium in its power of alleviating the sufferings of
+ the dying is ether. It is specially indicated in gasping or spasmodic
+ difficulty of breathing, whether dependent on the lungs or heart;
+ and in flatulent distention of the stomach, attended with unavailing
+ efforts at eructation. These two conditions are often conjoined in the
+ dying, and then the indication for ether is the strongest. According
+ to my experience ether is most efficient when given in combination
+ with a few drops of sulphuric acid, as in the acid infusion of roses,
+ or better with mint water and sugar, as in the so-called “ether
+ punch.”[63] Opium or laudanum in somewhat smaller doses than those
+ recommended above, is often added, with great advantage to ether, when
+ there is need of a potent antispasmodic. In the paroxysms of severe
+ præcordial anguish and dyspnœa that characterize many deaths from
+ organic disease of the heart and great vessels of the chest, relief
+ must be sought in ether and opium, or from the inhalation of the
+ nitrite of amyl.
+
+       *       *       *       *       *
+
+ The fewer the drugs and the less of medicine we can do with in the
+ treatment of the dying, the better. Those above mentioned comprise
+ all I have had occasion for, and if judiciously used, they are equal
+ to the emergencies we are called upon to meet. I have no wish unduly
+ to limit the means at our command in aid of the Euthanasia; but when
+ the stage of existence contemplated in these pages has once been
+ reached, we dismiss all thought of cure, or of the prolongation of
+ life, and our efforts are limited to the relief of certain urgent
+ conditions, such as pain, exhaustion, dyspnœa, spasm, and the like;
+ for which the remedies mentioned above are to the full as efficient,
+ if not really more so, than any others as yet known. But no medicine
+ should be given without a distinct--I had almost written urgent--need
+ for it; and the physician should form a clear idea of the special
+ requirements of the case before him, and how, and by what means
+ they may be best accomplished. In very many cases there is no need
+ of medicines of any kind, and stimulants and light nourishment
+ _cautiously_ administered, meet every requirement. But often, and in
+ almost all cases, at a certain period of their course, the less even
+ of these that is given the better. “Medici plus interdum quiete, quam
+ movendo et agendo proficiunt,” writes Livy, and there are few dying
+ beds, where, just before the last, this precept does not find its
+ fitting application. “All that the dying person, then, requires is to
+ be left alone, and allowed to die in peace.”[64]
+
+  “Disturb him not--let him pass peaceably.”
+
+ “The physician,” writes Dr. Ferriar,[65] “will not torment his patient
+ with unavailing attempts to stimulate the dissolving system, from the
+ idle vanity of prolonging the flutter of the pulse for a few more
+ vibrations: if he cannot alleviate his situation, he will protect his
+ patient against every suffering which has not been attached to it by
+ nature.”
+
+ As the patient himself is wholly unable to explain what is needful in
+ his situation, the physician is bound to act for him in regulating the
+ economy of the bed-chamber. The temperature and ventilation of the
+ room--the amount of light to be admitted--the degree of quiet to be
+ maintained in it--must be determined according to the circumstances of
+ each particular case.
+
+ When the mode of dying is by the lung, and in the way of asphyxia, the
+ admission of fresh, cool air into the room seems to conduce to the
+ relief of dyspnœa, and greatly to the comfort of the sufferer.
+
+ The custom of excluding daylight as far as may be from the dying
+ chamber, and keeping it gloomy and dark, is in every respect a
+ mistake, and is to be opposed. If there is one thing about his
+ surroundings which more often than any other is complained of by the
+ dying, it is of failing sight--of a darkness gathering over him; and a
+ desire is expressed for more light.
+
+ Talking in an undertone and whispering in the presence of the dying is
+ to be peremptorily checked. What has to be said, and the less that is
+ the better, should be in a clear, distinct, ordinary tone, somewhat,
+ perhaps, below the ordinary.[66]
+
+ The dying chamber is no place for officious interference or obtrusive
+ curiosity.
+
+ The fewer that are admitted to it the better--the nurse, the minister
+ of religion, the medical attendant, and the immediate members of the
+ family, comprise those whose duty and feelings entitle them to be
+ present.
+
+ “While the senses remain perfect, the patient ought to direct his own
+ conduct, both in his devotional exercises, and in the last interchange
+ of affection with his friends.”[67] He will be wise if he does so
+ under the experienced guidance of his religious adviser. “The powers
+ of the mind, after being forcibly exerted on these objects, commonly
+ sink into complete debility, and respiration becoming weaker every
+ moment, the patient is rendered _apparently_ insensible to everything
+ around him. But the circumstances of the disease occasion much variety
+ in this progress.”[68]
+
+ Even when persons appear insensible, it is certain, as I have before
+ remarked, that frequently they are cognisant of what is passing about
+ them. “I have known them requested,” says Dr. Elliotson, “to give a
+ sign that they were still alive by moving a finger, or by interrupting
+ their breath when to move a finger was impossible: and they have
+ done so, although believed by many to have been long senseless.”[69]
+ In many cases there is a sort of lucid interval immediately before
+ dissolution. This may be perceived by the looks and gestures where the
+ patient is incapable of speaking.
+
+ When things come to the last and the act of dissolution is imminent,
+ all noise and bustle about the dying person should be prohibited, and
+ unless the patient should place himself in a posture evidently uneasy
+ he should be left undisturbed.[70] The dying are often impatient of
+ any kind of covering.[71] They throw off the bedclothes and lie with
+ the chest bare, the arms abroad, and the neck, arms, and legs as much
+ exposed as possible:--Ubi supinus æger jacet, porrectis manibus et
+ cruribus, writes Celsus--ubi brachia et crura nudat et inæqualiter
+ dispergit. “These actions,” writes Dr. Symonds,[72] “we believe to be
+ prompted by instinct, in order that neither covering nor even contact
+ with the rest of the body may prevent the operation of the air on the
+ skin. There are actions and re-actions between the air and the blood
+ in the skin similar to those which occur in the lungs, and these are
+ in aid of them.” Such automatic actions ought not to be interfered
+ with, unless the patient has got into a position evidently distressing
+ to himself, or except so far as decency requires when there is any
+ approach to unseemly exposure.
+
+ Exclamations of grief, and the crowding of the family round the bed,
+ only serve to harass the dying man, writes Ferriar, who adds, “The
+ common practice of plying him with liquors of different kinds, and of
+ forcing them into his mouth when he cannot swallow, should be totally
+ abstained from.” But to this error I have already referred.
+
+ It was a custom in the Middle Ages to strip the dying, drag them from
+ their beds, and lay them on ashes or on mattresses of straw or hair
+ upon the floor. It was then wholly or in part a penitential act, and
+ the influence of this custom has, perhaps, not yet wholly ceased.
+ “It is,” says Dr. Ferriar,[73] “a prevalent opinion among nurses and
+ servants that a person whose death is lingering cannot quit life
+ while he remains on a common bed, and that it is necessary to drag
+ the bed away and place him on the mattress. This piece of cruelty
+ is often practised when the attendants are left to themselves. A
+ still more hazardous practice has been very prevalent in France and
+ Germany, and I am afraid is not unknown in this country. When the
+ patient is supposed by the nurses to be nearly in a dying state, they
+ withdraw the pillows and bolster from beneath the head, sometimes with
+ such violence as to throw the head back and to add greatly to the
+ difficulty of respiration. As the avowed motive for this barbarity
+ is a desire to put the patient out of pain--that is, to put him to
+ death--it is incumbent on his friends to preserve him from the hands
+ of those executioners. Perhaps a more deplorable condition can
+ scarcely be conceived than that of being transferred from the soothing
+ care of relations and friends, to the officious folly or rugged
+ indifference of servants.” One would hope that such cruelty is a thing
+ of the past. My own experience forty years since as a dispensary
+ physician in the eastern parts of the metropolis, led me to conclude
+ that it was not _then_ and _there_ wholly unknown or unpractised. What
+ it may be in remote rural districts, where the class of old, ignorant
+ and prejudiced nurses still exist, I have no means of knowing. “This
+ is a state of suffering,” adds Dr. Ferriar, “to which we are all
+ exposed, and if it were unavoidable, I should be far from desiring
+ to unveil so afflicting a prospect. But the means of prevention are
+ so easy, that I cannot forbear to solicit the public attention to
+ them.”[74]
+
+ In the intelligent trained nurses of the present day, we have the
+ best security against such barbarity; and when they are absent, in the
+ presence in the dying chamber, of the relations or nearest friends
+ until all is over.
+
+ In cases of sudden death from disease of the heart, there is neither
+ occasion nor time for medical treatment of any sort. Death is
+ instantaneous and without warning. Where death beginning at the heart
+ takes place by way of syncope, fresh air and stimulants cautiously
+ given are the best resources. Wine or brandy, with egg or other
+ light nutriment, are appropriate. When death is taking place in the
+ slower way of exhaustion, a like treatment is to be pursued. In the
+ earlier stage, small quantities of soup, or beef tea may be given, but
+ when death is near they are best omitted. It is in these cases that
+ madeira and tokay answer so well. In all cases of dying by failure of
+ the heart’s action, the posture of the patient should be carefully
+ adjusted--the head should be low rather than raised, and it and
+ the shoulders supported on firm pillows. Any approach to the erect
+ or sitting posture is as a rule to be avoided. Its tendency is to
+ occasion fainting and death.
+
+ In death from the lungs or by asphyxia the struggle is often
+ protracted, and accompanied by all those marks of suffering which the
+ imagination associates with the closing scene of life. Doubtless in
+ the earlier stages of it, there is real suffering, but happily this is
+ rarely of long duration, for the circulation of venous blood ensues,
+ and deadens sensibility and pain. The respirations in this mode of
+ death become laborious and heaving, the expression of countenance
+ distressed and anxious. But soon the face becomes tumid and dusky,
+ the lips livid, and with the circulation of undecarbonized blood,
+ which these symptoms imply, the anxious expression of face subsides,
+ and there ensues a slowly increasing benumbing of sensation, and a
+ corresponding diminution of suffering. The breathing then becomes
+ irregular and laborious, and the heavings of the chest convulsive;
+ but these movements are automatic, and independent alike of sensation
+ and of the will. They soon pass into coma, stertor, rattle in the
+ windpipe, and death. Stertorous breathing is in great measure due to
+ affection of the brain or medulla, either primary or secondary. The
+ latter is the condition we are here contemplating. Stertor seems to
+ be due to a falling back of the base of the tongue into the pharynx,
+ and to the obstruction to respiration thence induced; and is increased
+ by the prone position on the back, into which such patients naturally
+ fall. It may be relieved by placing the person on one side, and
+ supporting him in that position by well-arranged pillows. The tongue
+ then drops to the side of the pharynx and mouth, and leaves room
+ for the ingoing air. Dr. Bowles, of Folkestone, to whom we owe the
+ knowledge of these facts, warns us, that care should be taken to keep
+ the neck rather straight, as, if the chin be brought too near the
+ sternum, the thyroid cartilage presses upwards and backwards, and
+ again pushes the base of the tongue, toward the back of the pharynx.
+ Nothing can be done, indeed nothing is needed, but regulation of the
+ posture, when coma is established. The head is to be supported on a
+ firm pillow, or bolster, and slightly raised, but not so much as to
+ increase the tendency to slide downwards in the bed. Whatever position
+ of the body is found to lessen the stertor, and ease the breathing
+ should be maintained.
+
+ In the earlier stages of the process above described--in the condition
+ which precedes and passes into coma--a carefully adjusted posture of
+ the patient, in which he is propped up at an angle of not less than
+ forty-five degrees, and often at one of much more, and due support
+ is given to the trunk of the body by pillows--will do more than
+ anything else in relief of embarrassed and laboured breathing. “The
+ object is to support with the pillows, the back _below_ the breathing
+ apparatus, to allow the shoulders room to fall back, and to support
+ the head, without throwing it forward.”[75] The suffering of dying
+ patients, says Miss Nightingale, is immensely increased by neglect
+ of these points. If secretions have accumulated in the air passages,
+ ammonia or turpentine may be administered. Should the breathing be
+ gasping and spasmodic, ether, with or without opium, should be tried.
+ When duskiness and lividity of the face have come on, we can do but
+ little--when deep coma and stertorous breathing, nothing--but adjust
+ the posture of the patient to the more pressing requirements of the
+ case.
+
+ When the heart or great vessels of the chest are the seat of the
+ disease, and the circulation through the lungs is becoming seriously
+ embarrassed by it, there are often paroxysms of great suffering. The
+ patient is agonized by a sense of instant suffocation, and sits in or
+ out of bed, with the head bent forward, resting on a table or other
+ support, and expecting dissolution every moment. Here ether and opium
+ is our best resource; or the nitrite of amyl, the cautious inhalation
+ of which has in some instances given marked relief.
+
+ When death, commencing at the brain, destroys life through the lung,
+ and in the way of coma, as it usually does, the treatment is the same
+ as in the coma that occurs late in the series of events which mark
+ death by asphyxia. When, on the other hand, death, beginning at the
+ brain, destroys life through the heart and by way of exhaustion, the
+ treatment is the same as above described for those dying primarily
+ from the heart and in the way of asthenia.
+
+       *       *       *       *       *
+
+ When the face of the dying person is flushed, the head hot, and the
+ carotid arteries beating forcibly, the head is to be raised and
+ supported on firm pillows, and ice or a cold spirit lotion applied to
+ it.
+
+       *       *       *       *       *
+
+ In some delicate and highly sensitive persons, a kind of struggle is
+ sometimes excited when the respiration becomes very difficult.[76]
+ Dr. Ferriar says he has known this effort proceed so far, that the
+ patient a very few minutes before death, has started out of bed, and
+ stood erect for a moment. He ascribed it to apprehension and alarm,
+ and adds: “Those who resign themselves quietly to their feelings seem
+ to fare best.” This is probably true, but the sufferer needs whatever
+ relief art can supply; and ether and opium is the most likely to give
+ it.
+
+       *       *       *       *       *
+
+ Hiccup is somewhat alleviated by a sinapism to the epigastrium, and
+ a spoonful of aniseed water swallowed slowly. But if it is severe,
+ shaking the patient, and so adding greatly to his distress, we must
+ rely on opium given internally, and its application externally to the
+ pit of the stomach. If hiccup seems to be due, as it often is, to
+ an overloaded and distended stomach, and the influence of opium is
+ needed, the hypodermic injection of morphia is to be preferred.
+
+       *       *       *       *       *
+
+ Inquietude and restlessness, especially in the half-conscious dying
+ person, is often due to a distended bladder, and is at once quieted by
+ the catheter. In others, it is due to the weight of the bedclothes,
+ and is relieved by lightening them.
+
+       *       *       *       *       *
+
+ Coldness of the feet is best met by a foot warmer; and not by thick,
+ heavy bed clothing, which distresses the sufferer and gives rise to
+ inquietude and restlessness. “Weak patients,” says Miss Nightingale,
+ and the dying as much or more so than others, “are invariably
+ distressed by a great weight of bedclothes.” Light Whitney blankets
+ should alone be used for coverings under such circumstances. But I
+ am not sure that coldness of the extremities does always add to the
+ sufferings of the dying, or needs the consideration usually given to
+ it. The diminished circulation on which it depends is attended, for
+ the most part, in the dying by proportionate loss of sensibility; and
+ besides it is especially when the feet and legs are cold, sodden, and
+ dank, that we observe that impatience of any covering upon them--that
+ tossing about and exposure of them to the air--which I have before
+ described.
+
+       *       *       *       *       *
+
+ Death from old age--the natural termination of life, and the
+ simplest form of death that can occur, creeps on by slow and
+ almost imperceptible degrees. It is characterised by a gradual and
+ proportionate decay of all the functions and organs of the body, and
+ as a rule presents no symptoms that call for special treatment. It
+ is only where the normal course of decay is disturbed by supervening
+ disorder, or disease of an important organ, or by surrounding
+ circumstances, that suffering of any kind attends it. Good nursing,
+ and the due administration of light food and stimulants, comprise all
+ that is needed. The approaches to death are so gentle, and the act of
+ dying so easy, that nature herself provides a perfect euthanasia.
+
+
+  THE END.
+
+  UNWIN BROTHERS, PRINTERS, CHILWORTH AND LONDON.
+
+
+ FOOTNOTES:
+
+ [51] Medical Notes and Reflections. Third edition, 8vo, London, 1855,
+p. 379.
+
+ [52] Robert Willis, M.D., On Urinary Diseases, 8vo, London, 1838, p.
+100.
+
+ [53] “When there is a sudden cessation, or intermission, of acute pain,
+sleep frequently comes on instantaneously at every such interval of
+ease. The records of judicial torture furnish much striking evidence as
+to these effects.” (Sir Henry Holland’s Medical Notes and Reflections,
+p. 369.)
+
+ [54] I except hydrophobia, tetanus, &c., against which it is almost
+powerless.
+
+ [55] “Præstantissimum remedium cardiacum (unicum pene dixerim) quod in
+rerum natura hactenus est repertum.” Sydenham Thomæ Opera Omnia, edidit
+G. A. Greenhill, M.D., 8vo, London, 1844, p. 175.
+
+ [56] “Vires ægri somno recreatæ sunt, atque etiam ubi salus ejus
+prorsus desperata fuerit, et angor summus cruciaverit, opium utique
+sollicitudinem aliquantum levavit. Mors quidem neque serius, neque
+citius venit, sed tamen minore cum cruciatu.” (Heberden _De Ileo_.)
+
+ [57] Hufeland’s remarks on opium are so valuable that I give them at
+length. “Who would be a physician without opium in attendance on cancer
+or dropsy of the chest? How many sick has it not saved from despair?
+For one of the great properties of opium is, that it soothes not only
+corporal pains and complaints, but affords also to the mind a peculiar
+energy, elevation, and tranquility. The soothing virtue manifests
+itself in the most splendid manner in relieving death in severe cases,
+in effecting the euthanasia, which is a sacred duty and the highest
+triumph of the physician, when it is not in his power to retain the
+ties of life. Here, it is not only capable of taking away the pangs of
+death, but it imparts even courage and energy for dying; it promotes
+in a physical way even that disposition of mind which elevates it
+to heavenly regions. A man who had laboured for a long time under
+complaints of the chest and vomicas finally approached death. The most
+dreadful anguish of death with a constant danger of suffocation seized
+him, he got into real despair and his state was an insurmountable
+torment even for the persons around him. He now took half a grain of
+opium every hour. After three hours he became quiet, and after he had
+taken two grains he fell asleep, slept quietly for several hours, awoke
+quite cheerful, free from pain and anxiety, and at the same time so
+much strengthened and appeased in his mind, that he bade farewell with
+the greatest composure and satisfaction to his relatives, and after
+he had given them his blessing and many a good admonition fell again
+asleep and passed away while sleeping.” (The Three Cardinal Means of
+the Art of Healing, p. 46.)
+
+Somewhat to the same purport writes De Quincey. “Simultaneously with
+the conflict the pain of conflict has departed, and thenceforward
+the gentle process of collapsing life, no longer fretted by
+counter-movements slips away with holy peace into the noiseless deeps
+of the Infinite.” (Confessions of an English Opium-Eater, p. 149.)
+
+ [58] _Ut supra_, p. 516.
+
+ [59] Holland, _ut supra_, p. 518. To the same effect writes Dr. James
+Gregory of this remedy, “_Neque dubium est_, utcunque periculosus
+videatur usus talis medicamenti vix non venenati; _ægros plus fere
+incommodi et damni percepisse a nimis parva, quam a nimia ejus
+quantitate_. Medici igitur est, medicamentum adeo validum et sæpe
+perniciosum caute et prudenter adhibere, et in illis tantum morbis ad
+id confugere, qui aliquid istiusmodi plane requirunt; _ubi vero talis
+necessitas urget, oportet remedium libere et cum fiducia præscribere_;
+tunc enim non sperare modo potest, sed fere polliceri, se effectum
+illum salutarem, quem cupit, per suum medicamentum esse præstiturum.
+_Quod si timide et nimis parce datum fuerit_, longe alium effectum
+habebit, et iisdem ægrotis _haud parum nocebit, quibus largius datum
+multum profuisset_.” (Conspectus Medicinæ Theoreticæ, § MCCXXII.)
+
+ [60] _Ut supra_, p. 518.
+
+ [61] “Audivi plus semel ægros temporarium a narcoticis levamen enixe
+deprecantes, quod sensuum obscuratione nimis care querebantur emi.” (p.
+71.)
+
+ [62] “Conspectus Medicinæ Theoreticæ,” § MCCXXII.
+
+ [63]
+
+      ℞ Aq. Menthæ Viridis, f. ℥ v ss.
+      Sacchari, ℥ ss.
+      Acid. Sulphurici diluti ♏ XL.
+      Sp. Ætheris comp. f. ʒ ij.
+    Misce ft Mistura. Pars quarta pro dose.
+
+
+ [64] Elliotson, Human Physiology, p. 1043.
+
+ [65] _Ut supra_, p. 193.
+
+ [66] Miss Nightingale’s observations on whispered conversation in the
+room, or just outside the door, at p. 26 of her “Notes on Nursing,”
+have great value and a wide application. On these points in the
+management of the dying chamber Professor Paradys has the following:
+“Sed præterea adhiberi hoc loco moderatæ sensuum externorum impulsiones
+utiliter possunt, quæ vividiores phantasmatum impressiones obscurent:
+vitari itaque nimiæ tenebræ et silentia nimis alta debent, concedi
+contra modica lux, permitti notæ amicorum voces, immo excitari debent
+lenes, placidi, animum blande demulcentes affectus.” (p. 74.)
+
+ [67] Ferriar, p. 193.
+
+ [68] Ibid., p. 194.
+
+ [69] Human Physiology, p. 1043.
+
+ [70] Ferriar, p. 203.
+
+ [71]
+
+“Nihil adeo posses quoiquam leve tenueque membris Vortere in
+utilitatem.” (Lucretius vi. 1169.)
+
+“Nor would once endure The lightest vest thrown loosely o’er the
+limbs.” (Mason Good, p. 595.)
+
+ [72] “Cyclopædia of Anatomy and Physiology,” vol. i. p. 802.
+
+ [73] P. 200.
+
+ [74] P. 203.
+
+ [75] Miss Nightingale’s Notes on Nursing, p. 47.
+
+ [76] Ferriar, _ut supra_, p. 196.
+
+
+
+*** END OF THE PROJECT GUTENBERG EBOOK 76791 ***
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+<div style='text-align:center'>*** START OF THE PROJECT GUTENBERG EBOOK 76791 ***</div>
+<p><span class="pagenum" id="Page_iii">[iii]</span></p>
+
+
+
+<h1>EUTHANASIA:</h1>
+
+<p class="center smaller">OR,</p>
+
+<p class="center p2">MEDICAL TREATMENT IN AID
+OF AN EASY DEATH.</p>
+
+<p class="center smaller p6">BY</p>
+
+<p class="center">WILLIAM MUNK, M.D., F.S.A.</p>
+
+<p class="center smaller"> FELLOW AND LATE SENIOR CENSOR OF THE ROYAL COLLEGE OF
+PHYSICIANS, &amp;c., &amp;c., &amp;c.</p>
+
+
+<p class="center smaller p6">LONDON:</p>
+
+<p class="center">LONGMANS, GREEN, AND CO.</p>
+
+<p class="center smaller">AND NEW YORK: 15, EAST 16th STREET.</p>
+
+<p class="center">1887.</p>
+
+<p class="center p2"><i>All rights reserved.</i>
+</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_v">[v]</span></p>
+
+
+<h2 class="nobreak">PREFACE.</h2>
+</div>
+
+
+<p>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 <i>specially</i>
+on these subjects in modern times.</p>
+
+<p>Sir Henry Halford, who was confessedly<span class="pagenum" id="Page_vi">[vi]</span>
+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.</p>
+
+<p class="hanging">
+<span class="smcap">40, Finsbury Square.</span><br>
+<i>Sept. 24, 1887.</i><br>
+</p>
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_vii">[vii]</span></p>
+
+<h2 class="nobreak" id="CONTENTS">CONTENTS.</h2>
+</div>
+
+
+<table class="autotable">
+<tr>
+<td class="tdc">I.</td>
+<td class="tdr"></td>
+</tr>
+<tr>
+<td class="tdc">On Some of the Phenomena of Dying</td>
+<td class="tdr"><a href="#Page_1">1</a></td>
+</tr>
+<tr>
+<td class="tdc">II.</td>
+<td class="tdr"></td>
+</tr>
+<tr>
+<td class="tdc">On the Symptoms and Modes of Dying</td>
+<td class="tdr"><a href="#Page_51">51</a></td>
+</tr>
+<tr>
+<td class="tdc">III.</td>
+<td class="tdr"></td>
+</tr>
+<tr>
+<td class="tdc">On the General and Medical Management<br>of the Dying</td>
+<td class="tdr"><a href="#Page_63">63</a></td>
+</tr>
+
+</table>
+
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_1">[1]</span></p>
+
+<h2 class="nobreak" id="I">I.<br>SOME OF THE PHENOMENA
+OF DYING.</h2>
+</div>
+
+<p><span class="pagenum" id="Page_2">[2]</span></p>
+
+
+
+<div class="poetry-container">
+<div class="poetry">
+  <div class="stanza">
+    <div class="verse indent18">“Quod ad nos</div>
+    <div class="verse indent0">Pertinet, et nescire malum est, agitamus.”</div>
+    <div class="verse indent24"><span class="smcap">Horace.</span></div>
+  </div>
+</div>
+</div>
+
+
+
+
+
+
+<p><span class="pagenum" id="Page_3">[3]</span></p>
+
+
+<p>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.<a id="FNanchor_1" href="#Footnote_1" class="fnanchor">[1]</a> And, although more than two
+<span class="pagenum" id="Page_4">[4]</span>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.</p>
+
+<p>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<span class="pagenum" id="Page_5">[5]</span>
+the Euthanasia,<a id="FNanchor_2" href="#Footnote_2" class="fnanchor">[2]</a> 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.<a id="FNanchor_3" href="#Footnote_3" class="fnanchor">[3]</a> 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.</p>
+
+<p>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
+<span class="pagenum" id="Page_6">[6]</span>life easy and gentle, as it is to cure diseases
+and restore health.<a id="FNanchor_4" href="#Footnote_4" class="fnanchor">[4]</a> And this doctrine, so
+accordant with the best principles of our
+nature,<a id="FNanchor_5" href="#Footnote_5" class="fnanchor">[5]</a> is commended to us by that most
+estimable and judicious of modern physicians,
+Dr. Heberden;<a id="FNanchor_6" href="#Footnote_6" class="fnanchor">[6]</a> as it was also by
+<span class="pagenum" id="Page_7">[7]</span>the example and counsel of one of the
+most popular and successful physicians of
+the present century—the late Sir Henry
+Halford.<a id="FNanchor_7" href="#Footnote_7" class="fnanchor">[7]</a></p>
+
+<p>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
+<span class="pagenum" id="Page_8">[8]</span>popular belief are all but inseparable from
+it, and are expressed and emphasized in
+the terms “mortal agony” and “death
+struggle.”</p>
+
+<p>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.<a id="FNanchor_8" href="#Footnote_8" class="fnanchor">[8]</a> “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 <i>the physical
+<span class="pagenum" id="Page_9">[9]</span>process of death loses much of its horror on a
+near view</i>.”<a id="FNanchor_9" href="#Footnote_9" class="fnanchor">[9]</a></p>
+
+<p>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
+<span class="pagenum" id="Page_10">[10]</span>process.<a id="FNanchor_10" href="#Footnote_10" class="fnanchor">[10]</a> And another distinguished surgeon,
+Mr. Savory, writing on the same
+subject, says, “Whatever may have been
+the amount of <i>previous</i> 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.”<a id="FNanchor_11" href="#Footnote_11" class="fnanchor">[11]</a> 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.”<a id="FNanchor_12" href="#Footnote_12" class="fnanchor">[12]</a></p>
+
+<p><span class="pagenum" id="Page_11">[11]</span></p>
+
+<p>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.</p>
+
+<p>Lastly, there are those specially interesting
+cases of recovery from the apparent<span class="pagenum" id="Page_12">[12]</span>
+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.<a id="FNanchor_13" href="#Footnote_13" class="fnanchor">[13]</a> 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
+<span class="pagenum" id="Page_13">[13]</span>no longer appeared to be an evil. I
+no longer thought of being rescued, <i>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.</i> 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.<span class="pagenum" id="Page_14">[14]</span>
+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<span class="pagenum" id="Page_15">[15]</span>
+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, <i>instead of
+being absolutely free from all bodily pain, as
+in my drowning state</i>, I was now tortured
+by pain all over me.”</p>
+
+<p>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<span class="pagenum" id="Page_16">[16]</span>
+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;<a id="FNanchor_14" href="#Footnote_14" class="fnanchor">[14]</a>
+De Quincey records a like instance in a
+female, a near relative of his own;<a id="FNanchor_15" href="#Footnote_15" class="fnanchor">[15]</a>and<span class="pagenum" id="Page_17">[17]</span>
+I have myself heard of two similar cases,
+but the details are not sufficiently precise to
+justify their narration here.</p>
+<p><span class="pagenum" id="Page_18">[18]</span></p>
+<p>In fact, all the best and all the most
+direct evidence that the subject admits of,<span class="pagenum" id="Page_19">[19]</span>
+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.</p>
+
+<p>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;<a id="FNanchor_16" href="#Footnote_16" class="fnanchor">[16]</a> 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
+<span class="pagenum" id="Page_20">[20]</span>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.”<a id="FNanchor_17" href="#Footnote_17" class="fnanchor">[17]</a></p>
+
+<p>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
+<span class="pagenum" id="Page_21">[21]</span>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.</p>
+
+<p>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<span class="pagenum" id="Page_22">[22]</span>
+inevitable lot of the dying. Happily for
+mankind it is not so.</p>
+
+<p>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;<a id="FNanchor_18" href="#Footnote_18" class="fnanchor">[18]</a> but a firm belief in the mercy of God,
+<span class="pagenum" id="Page_23">[23]</span>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 <i>dis</i>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.</p>
+
+<p>“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<span class="pagenum" id="Page_24">[24]</span>
+earlier period when the individual realizes
+for the first time that he is about to die.
+The shock at <i>that</i> 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.”<a id="FNanchor_19" href="#Footnote_19" class="fnanchor">[19]</a> 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.”<a id="FNanchor_20" href="#Footnote_20" class="fnanchor">[20]</a></p>
+
+<p>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
+<span class="pagenum" id="Page_25">[25]</span>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.”<a id="FNanchor_21" href="#Footnote_21" class="fnanchor">[21]</a></p>
+
+<p>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
+<span class="pagenum" id="Page_26">[26]</span>system seemed to influence their minds, and
+they died earnestly imploring the relief
+which art was unable to afford.”<a id="FNanchor_22" href="#Footnote_22" class="fnanchor">[22]</a></p>
+
+<p>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<a id="FNanchor_23" href="#Footnote_23" class="fnanchor">[23]</a> to the dying
+<span class="pagenum" id="Page_27">[27]</span>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?</p>
+
+<p>“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<span class="pagenum" id="Page_28">[28]</span>
+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<span class="pagenum" id="Page_29">[29]</span>
+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<span class="pagenum" id="Page_30">[30]</span>
+done that which I would have done by
+myself, and have apprized my patient of
+the great change he was about to undergo.”</p>
+
+<p>“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.”<a id="FNanchor_24" href="#Footnote_24" class="fnanchor">[24]</a></p>
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_31">[31]</span>by solicitude for those they will leave
+behind, and their end is often one of great
+<i>mental</i> 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.”<a id="FNanchor_25" href="#Footnote_25" class="fnanchor">[25]</a></p>
+
+<hr class="tb">
+
+<p>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,
+<span class="pagenum" id="Page_32">[32]</span>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.</p>
+
+<p>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.<a id="FNanchor_26" href="#Footnote_26" class="fnanchor">[26]</a> 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
+<span class="pagenum" id="Page_33">[33]</span>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.<a id="FNanchor_27" href="#Footnote_27" class="fnanchor">[27]</a> 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.<a id="FNanchor_28" href="#Footnote_28" class="fnanchor">[28]</a> And the last
+words of Dr. Armstrong were addressed to
+an imaginary patient, upon whom he was
+<span class="pagenum" id="Page_34">[34]</span>impressing the necessity of attention to the
+state of the digestive organs.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_35">[35]</span></p>
+
+<p>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—”</p>
+
+<p><span class="pagenum" id="Page_36">[36]</span></p>
+
+<div class="poetry-container">
+<div class="poetry">
+  <div class="stanza">
+    <div class="verse indent0">‘When old experience does attain</div>
+    <div class="verse indent0">To something like prophetic strain.’<a id="FNanchor_29" href="#Footnote_29" class="fnanchor">[29]</a></div>
+  </div>
+</div>
+</div>
+
+<p>“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.”<a id="FNanchor_30" href="#Footnote_30" class="fnanchor">[30]</a></p>
+
+<p>“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,
+<span class="pagenum" id="Page_37">[37]</span>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.<a id="FNanchor_31" href="#Footnote_31" class="fnanchor">[31]</a> Another instance,
+<span class="pagenum" id="Page_38">[38]</span>the counterpart to that just described,
+which happened to the same eminent physician,
+may not be out of place.</p>
+
+<p>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,<span class="pagenum" id="Page_39">[39]</span>
+that he <i>should die</i>; 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 <i>die forthwith</i>. 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<span class="pagenum" id="Page_40">[40]</span>
+of his sister. His hands were cold,
+and his pulse immeasurably quick—he died
+that night.”<a id="FNanchor_32" href="#Footnote_32" class="fnanchor">[32]</a></p>
+
+<p>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
+<span class="pagenum" id="Page_41">[41]</span>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, <i>uncharacterized</i> by any
+peculiarity. The general languor of the
+functions in the <i>last</i> waking interval,
+is attended with no peculiar suffering, and
+the last sleep commences with the usual
+grateful feelings of repose.<a id="FNanchor_33" href="#Footnote_33" class="fnanchor">[33]</a></p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_42">[42]</span></p>
+
+<p>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.</p>
+
+<p>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,<a id="FNanchor_34" href="#Footnote_34" class="fnanchor">[34]</a> “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
+<span class="pagenum" id="Page_43">[43]</span>with such visions are those which haunt
+the dying fancies of others.”<a id="FNanchor_35" href="#Footnote_35" class="fnanchor">[35]</a> The testimony
+of many of those who have the
+largest experience, and have watched <i>continuously
+and attentively</i> 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<a id="FNanchor_36" href="#Footnote_36" class="fnanchor">[36]</a> to attribute it, to
+their being seldom engaged long enough
+in watching by the bedside, where the
+senses and thoughts naturally become
+<span class="pagenum" id="Page_44">[44]</span>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.</p>
+
+<p>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<span class="pagenum" id="Page_45">[45]</span>
+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
+<i>her feelings, instead of being painful
+or in any way distressing, had been agreeable
+rather than otherwise</i>. 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.”<a id="FNanchor_37" href="#Footnote_37" class="fnanchor">[37]</a></p>
+
+<p>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.
+<span class="pagenum" id="Page_46">[46]</span>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.”<a id="FNanchor_38" href="#Footnote_38" class="fnanchor">[38]</a></p>
+
+<p>“I have been curious,” writes Sir Benjamin
+Brodie in commenting on these cases,
+“to watch the state of dying persons in
+<span class="pagenum" id="Page_47">[47]</span>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.”<a id="FNanchor_39" href="#Footnote_39" class="fnanchor">[39]</a></p>
+
+<p>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.</p>
+
+<hr class="tb">
+
+<p>Sometimes, immediately preceding the
+very act of death, the eyelids are raised,
+and a look of recognition of those around
+<span class="pagenum" id="Page_48">[48]</span>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.”<a id="FNanchor_40" href="#Footnote_40" class="fnanchor">[40]</a></p>
+
+<p>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
+<span class="pagenum" id="Page_49">[49]</span>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.”<a id="FNanchor_41" href="#Footnote_41" class="fnanchor">[41]</a></p>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_51">[51]</span>
+</p><h2 class="nobreak" id="II">II.<br>THE SYMPTOMS AND MODES
+OF DYING.</h2>
+</div>
+
+
+
+<p><span class="pagenum" id="Page_53">[53]</span></p>
+
+
+<p>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,
+<i>but that the vital powers are already so utterly
+reduced that they are beyond the possibility of
+restoration</i>.<a id="FNanchor_42" href="#Footnote_42" class="fnanchor">[42]</a> And on these points the Father<span class="pagenum" id="Page_54">[54]</span>
+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 <i>facies Hippocratica</i>,<a id="FNanchor_43" href="#Footnote_43" class="fnanchor">[43]</a>
+<span class="pagenum" id="Page_55">[55]</span>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<a id="FNanchor_44" href="#Footnote_44" class="fnanchor">[44]</a> by which being is held together
+in the human frame.</p>
+
+<p>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, <i>unequal</i>, 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,<span class="pagenum" id="Page_56">[56]</span>
+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.</p>
+
+<p>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<span class="pagenum" id="Page_57">[57]</span>
+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.”<a id="FNanchor_45" href="#Footnote_45" class="fnanchor">[45]</a></p>
+
+<p>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.</p>
+
+<p>Death beginning at the heart is sometimes
+instantaneous. Suddenly and without
+warning of any kind, the heart ceases to
+<span class="pagenum" id="Page_58">[58]</span>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.”<a id="FNanchor_46" href="#Footnote_46" class="fnanchor">[46]</a> When death occurs from asthenia
+or failure of contractile power in the heart,
+“the pulse becomes very feeble and frequent,
+<span class="pagenum" id="Page_59">[59]</span>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.”<a id="FNanchor_47" href="#Footnote_47" class="fnanchor">[47]</a></p>
+
+<p>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.”<a id="FNanchor_48" href="#Footnote_48" class="fnanchor">[48]</a> 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
+<span class="pagenum" id="Page_60">[60]</span>common with other parts of the frame,
+first benumbs sensibility, and then abolishes
+it altogether. “Disturbance of respiration,”
+says Dr. Ferriar,<a id="FNanchor_49" href="#Footnote_49" class="fnanchor">[49]</a> “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.”</p>
+
+<p>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
+<span class="pagenum" id="Page_61">[61]</span>expand, the blood is no longer aërated,”<a id="FNanchor_50" href="#Footnote_50" class="fnanchor">[50]</a>
+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.</p>
+
+<p>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
+<span class="pagenum" id="Page_62">[62]</span>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.</p>
+
+
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_63">[63]</span></p>
+<h2 class="nobreak" id="III">III.<br>THE GENERAL AND MEDICAL
+TREATMENT OF THE DYING.</h2>
+</div>
+
+
+<p><span class="pagenum" id="Page_65">[65]</span></p>
+
+
+<p>Many of the sufferings of the death
+bed are not naturally or necessarily
+incident to the act of the dying; but are
+due to surrounding circumstances that
+admit of alteration or removal. Thus,
+restlessness and jactitation are often due
+to the weight of the bed coverings, and
+are at once removed by lightening them;—difficulty
+of breathing and gasping, increased
+by the heat and closeness of the
+chamber, are removed by the admission of
+fresh and cooler air, by change of posture
+and by pillows carefully adapted to the
+efficient support of the trunk of the body.</p>
+
+<p><span class="pagenum" id="Page_66">[66]</span></p>
+
+<p>There is nothing of greater importance
+in the treatment of the dying than the
+right administration of nutriment. Errors
+in feeding are the cause of much of the
+disquietude and of many of the sufferings
+that attend the dying. The sinking and
+exhaustion that are in progress throughout
+the system, are assumed by the attendants
+to demand a free administration of food
+and stimulants, forgetting that the stomach
+shares in the exhaustion, and has lost its
+tone, and in great part, if not wholly, its
+power of digesting. Food is given too
+frequently, and in quantities too large.
+The dying person is induced by the
+wearisome importunity of his attendants
+to take food or stimulants, against which
+nature and his stomach revolt. The
+evident dislike and loathing with which he
+submits, the difficulty he has in swallowing
+it, and the urging and retching which
+that act sometimes induces, ought to save
+him from what is really under the circumstances<span class="pagenum" id="Page_67">[67]</span>
+an act of cruelty. “Here,” to
+use the words of Sir Henry Holland, “we
+are called upon to maintain the cause of
+the patient, for such it truly is, against the
+mistaken importunities which often surround
+him, and which it requires much firmness
+in the physician to put aside.”<a id="FNanchor_51" href="#Footnote_51" class="fnanchor">[51]</a> The wishes
+of the patient himself, when he has reached
+the stage of existence here contemplated,
+may generally be taken as a correct
+indication in all that relates to the administration
+of food and stimulants.</p>
+
+<p>Food when unwisely given, accumulates
+in the stomach, distends and distresses it,
+and impedes the respiration. Under such
+circumstances the pit of the stomach will
+be found tumid and tense, dull upon percussion,
+and intolerant of pressure. At
+length some of the contents of the distended
+stomach regurgitate into the throat
+<span class="pagenum" id="Page_68">[68]</span>or mouth; or there may be actual vomiting,
+and this to the evident relief of the
+sufferer. Hiccup is often due solely to an
+overloaded and distended stomach.</p>
+
+<p>Much discretion is needed in fixing on
+the kind and quantity of food to be given.
+Something will depend on the character of
+the disease under which the patient is
+sinking; and something on the length of
+time he is likely to survive. If the act of
+dying is likely to be protracted, as it often
+is in cancer and some cases of consumption,
+where death is brought about by slowly
+progressive exhaustion, the food should be
+supporting and in somewhat larger quantity.
+I have long doubted whether strong beef tea
+and meat extracts are as a rule of much
+use, or are appropriate when the act of dying
+has really commenced. Milk, cream, beaten
+eggs, and the farinacea are far better. They
+are, too, the best vehicles for wine and
+spirits; and they have less tendency than
+soups to become offensive in the stomach.</p>
+
+<p><span class="pagenum" id="Page_69">[69]</span></p>
+
+<p>Alcohol in its fermented or distilled forms
+is of special use in the treatment of the
+dying. Owing to its high diffusive power
+it passes readily into the blood. It stimulates
+the failing heart, and thus promotes
+the circulation through the lungs, which is
+one of its most valuable properties in
+the dying. It may perhaps increase the
+secretion of the gastric juice; it more
+probably stimulates the peristaltic movements
+of the stomach, and by so much,
+aids the digestive process, and supports the
+patient in the best and most natural manner.
+Stimulants and nutriment should as a rule
+be given together for they mutually influence
+each other.</p>
+
+<p>The quantity of wine or spirit which is
+needed varies exceedingly, and no definite
+rule can be laid down on this point. They
+should be given in small quantities at a
+time and repeated at short intervals before
+the effects upon the heart and pulse of the
+previous dose have subsided.</p>
+
+<p><span class="pagenum" id="Page_70">[70]</span></p>
+
+<p>Of wines, sherry is perhaps the most
+useful. Port, if preferred by the patient,
+may be substituted, but I have not found
+it, as a rule, to agree as well as sherry.
+Madeira from its slight acidity is specially
+agreeable to the palate, and is besides the
+most sustaining and cordial of wines. But
+tokay is often more acceptable than any
+other wine, especially to those sinking from
+exhausting diseases, as hemorrhage, profuse
+suppuration, and the like. It is best given
+with cream. The stimulus of these wines
+is longer maintained than is that of other
+forms of alcohol. Champagne is most refreshing
+and is often eagerly taken; but its
+effects are evanescent and it needs repeating
+at shorter intervals than other wines. A teaspoonful
+of brandy, or of some liqueur may
+sometimes be advantageously added to it.</p>
+
+<p>Sometimes brandy answers better than
+any wine, especially if the stomach is
+irritable and there is nausea or vomiting.
+As a mere stimulant it is best administered<span class="pagenum" id="Page_71">[71]</span>
+with yolk of egg and sugar, as is Sir
+Henry Halford’s celebrated mixture—the
+Mistura Spiritus Vini Gallici of the Pharmacopœia.
+If brandy is used for its special
+tranquillizing influence on an irritable
+stomach, it may be given neat, in drachm
+doses, or in double that quantity in a little
+simple, or in one of the aërated, waters.
+The wish of the patient for any particular
+form of stimulant is almost always a correct
+indication for its use.</p>
+
+<p>The dry and parched condition of the
+tongue and mouth so common in the dying,
+and the inextinguishable thirst that attends
+some forms of it, need constant attention.
+A spoonful of iced-water repeated frequently
+will be a great comfort. So, too,
+is a small bit of ice allowed to dissolve in
+the mouth—or lemonade—or weak black
+tea without milk, and slightly acidulated
+with a slice of lemon.</p>
+
+<p>In the case of nutriment and stimulants
+as of mere diluents, it is to be understood—supposing<span class="pagenum" id="Page_72">[72]</span>
+there is nothing to forbid—that
+so long as the lips close upon them,
+and an act of swallowing follows <i>promptly</i>,
+they may be continued: but when liquids
+seem merely to trickle down the throat,
+and after a time, only to excite a faint effort
+of swallowing, they should no longer be
+persisted in. The sensibility of the parts
+is so diminished that the patient is insensible
+to the stimulus of the liquid, and
+we infer <i>a fortiori</i> to the dry and parched
+state of the mouth and fauces. If, after
+rubbing the lips gently with the spoon, or
+with the spout of the feeding vessel, no
+evident and distinct act of swallowing
+follows, it is useless, and it may be cruel to
+persist; the liquid will but clog the mouth
+and fauces, add to the impediment to breathing,
+and by so much, if any consciousness
+remains, to the sufferings of the dying.</p>
+
+<hr class="tb">
+
+<p>Next in value to stimulants in the treatment
+of the dying is opium. It is a<span class="pagenum" id="Page_73">[73]</span>
+tradition that John Hunter used often to
+exclaim, “Thank God for opium,”<a id="FNanchor_52" href="#Footnote_52" class="fnanchor">[52]</a> and
+under no circumstances are we bound to be
+more thankful for it then when ministering
+at the bedside of the dying. Opium is
+here worth all the rest of the materia medica.
+Its object and action must however be
+clearly understood. Opium is administered
+to the dying, as an anodyne to relieve pain;
+or as a cardiac and cordial to allay that
+sinking and anguish about the stomach and
+heart, which is so frequent in the dying, and
+is often worse to bear than pain, however
+severe. Opium should rarely be administered
+to the dying as a mere hypnotic, or
+with a view to enforce sleep. To do so
+would be to risk throwing the patient into
+a sleep from which he may not awake. But
+opium often induces sleep indirectly, and
+in the kindest way, by the relief of pain,<a id="FNanchor_53" href="#Footnote_53" class="fnanchor">[53]</a>
+<span class="pagenum" id="Page_74">[74]</span>or sinking that had hitherto rendered sleep
+impossible.</p>
+
+<p>For the relief of pain in the dying wherever
+it may be situated, we have our one
+trustworthy remedy in opium. Heberden
+writes, “In impetu autem doloris, ubi ubi is
+fuerit, opium est unicum remedium.” If
+judiciously and freely administered it is
+equal to <i>most</i> of the emergencies in the
+way of pain, that we are likely to meet
+with in the dying,<a id="FNanchor_54" href="#Footnote_54" class="fnanchor">[54]</a> whereas if timidly and
+inadequately used, the sufferer is deprived
+of the relief which it alone is capable of
+affording.</p>
+
+<p>The value of opium in allaying pain,
+great as that is, is however second to its
+<span class="pagenum" id="Page_75">[75]</span>value in relieving the feeling of exhaustion
+and sinking—of indescribable distress and
+anxiety—referred to the stomach and heart,
+which so often attends some part of the act
+of dying. To the practised eye, this condition
+is evidenced, as much by the pinched
+features, pallid complexion, and <i>anxious
+expression of face</i>, as by any verbal complaint
+of the sufferer. Here the action of
+opium is that of a cordial in the fullest
+sense of the word. “Of all cordials,” says
+Sydenham, “opium is the best that has
+hitherto been discovered. I had nearly
+said,” adds he, “that it is the only one.”<a id="FNanchor_55" href="#Footnote_55" class="fnanchor">[55]</a>
+“Under the protection of an opiate,” writes
+Dr. Heberden,<a id="FNanchor_56" href="#Footnote_56" class="fnanchor">[56]</a> “the patient’s strength has
+<span class="pagenum" id="Page_76">[76]</span>been kept up, and even in hopeless cases
+in which the dying person is harassed by
+unspeakable inquietude, he may be lulled
+into some composure, and without dying at
+all sooner may be enabled to die more
+easily.” I know of nothing in our attendance
+on the dying more gratifying, than
+to witness the improvement in face, feature,
+and expression, that marks the kindly action
+of opium under these circumstances. In
+an hour or thereabouts, after it has been
+taken, some colour returns to the face, the
+features lose somewhat of their sharpness,
+a placid expression replaces the look of
+anxiety, and the sufferer passes into an
+easy, gentle sleep, from which he awakes
+refreshed and comforted, and helped as it
+would seem, to die more easily, when his<span class="pagenum" id="Page_77">[77]</span>
+time arrives. Hufeland, writing at the end
+of a long professional life, did not hesitate
+to declare that opium “is not only capable
+of taking away the pangs of death, but it
+imparts even courage and energy for
+dying.”<a id="FNanchor_57" href="#Footnote_57" class="fnanchor">[57]</a></p>
+<p><span class="pagenum" id="Page_78">[78]</span></p>
+<p>Opium must be administered in such
+doses as will appease suffering and disorder,
+and in this respect we are to be governed<span class="pagenum" id="Page_79">[79]</span>
+solely by the effect and relief afforded. The
+dose for an adult should be rarely less than
+a grain, but oftener more. “There exists,”
+writes Sir Henry Holland, “distrust, both
+as to the frequency and extent of its use
+not warranted by facts, and injurious in
+many ways to our success;”<a id="FNanchor_58" href="#Footnote_58" class="fnanchor">[58]</a> “its use is not
+to be measured timidly by tables of doses,
+but by fulfilment of the purpose for which
+it is given. A repetition of small quantities
+will often fail, which concentrated into
+a single dose would safely effect all we
+require.”<a id="FNanchor_59" href="#Footnote_59" class="fnanchor">[59]</a></p>
+
+<p><span class="pagenum" id="Page_80">[80]</span></p>
+
+<p>The effects of opium continue for about
+eight hours, and if its action is to be maintained
+it should be repeated at intervals
+of that duration or somewhat less. The
+dose is to be governed solely by the relief
+afforded. Its effects are usually limited to
+relief of the pain, or of the sense of
+sinking for which it has been given, producing
+no other direct effect on the system
+in general. “It would seem,” says Sir
+Henry Holland, “that the medicine, expending
+all its specific power in quieting
+these disorders, loses at the time every
+other influence on the body. Even the<span class="pagenum" id="Page_81">[81]</span>
+sleep peculiar to opium appears in such
+instances to be wanting, or produced
+chiefly in effect of the release from suffering.”<a id="FNanchor_60" href="#Footnote_60" class="fnanchor">[60]</a></p>
+
+<p>Opium should always be given to the
+dying in its liquid forms—as the tincture,
+or the liquid extract—or as morphia,
+of which I know of no preparation of
+equal value to the solution of the bimeconate.</p>
+
+<p>So long as the air passages are not obstructed
+by secretion, so long as there is
+neither lividity nor even duskiness of face,
+opium, if indicated, may be given in aid
+of the Euthanasia; but if they are present,
+it is hazardous and might hasten death.
+Much care, too, is needed in the employment
+of opium, in cases where the heart is
+<i>greatly enfeebled</i>, and where the conditions,
+directly or indirectly induced by opiates,
+especially that of sleep, may be just enough
+<span class="pagenum" id="Page_82">[82]</span>to turn the balance against it. A contracted
+pupil is also a contra-indication to opium;
+it implies a state of the brain, which opium
+is likely to increase rather than relieve.
+And if food has been injudiciously pressed
+upon the patient, so that the stomach
+is distended with it, and the epigastrium
+is full and tense, opium given by the
+mouth is rarely found to act kindly, if at
+all. If, under such circumstances, the influence
+of opium is needed, we should resort
+to the hypodermic injection of morphia.</p>
+
+<p>Professor Paradys warns us of the confusion
+of the senses and of the mind that
+sometimes follows the administration of
+opium to the dying, and which to some
+persons is worse to bear than the sufferings
+for which it has been prescribed.<a id="FNanchor_61" href="#Footnote_61" class="fnanchor">[61]</a> But this,
+in my experience, has been rare, and will be
+<span class="pagenum" id="Page_83">[83]</span>seldom observed if opium is restricted to
+the cases where, as I have stated above, it
+is specially called for,—namely, in relief of
+pain or of severe sinking. When, however,
+it does occur in these circumstances, it is
+probably due, either to an idiosyncrasy on
+the part of the patient, or to the inadequacy
+of the dose given, which has been
+enough to confuse and stupify the senses,
+but not to control the symptoms for which
+it was administered. “Si timide et nimis
+parce datum fuerit,” writes Dr. Gregory,<a id="FNanchor_62" href="#Footnote_62" class="fnanchor">[62]</a>
+“longe alium effectum habebit, et iisdem
+ægrotis haud parum nocebit, quibus largius
+datum multum profuisset.”</p>
+
+<hr class="tb">
+
+<p>Ammonia is inferior as a stimulant to
+wine and brandy, which are more palatable
+and preferable, while as an antispasmodic it
+is very inferior to ether. But it is useful
+<span class="pagenum" id="Page_84">[84]</span>where the respiration flags and the breathing
+is obstructed by secretion accumulating in
+the bronchial tubes, and the complexion is
+becoming dusky and livid. Five grains of
+the carbonate dissolved in camphor water is
+a good mode of administering it. Small
+doses of oil of turpentine are sometimes
+more effectual than ammonia. A drachm
+of the confection of turpentine rubbed up
+in peppermint water, is perhaps the best
+form of giving it.</p>
+
+<hr class="tb">
+
+<p>Next in value to opium in its power of alleviating
+the sufferings of the dying is ether.
+It is specially indicated in gasping or spasmodic
+difficulty of breathing, whether
+dependent on the lungs or heart; and in
+flatulent distention of the stomach, attended
+with unavailing efforts at eructation. These
+two conditions are often conjoined in the
+dying, and then the indication for ether is
+the strongest. According to my experience
+ether is most efficient when given in combination<span class="pagenum" id="Page_85">[85]</span>
+with a few drops of sulphuric acid,
+as in the acid infusion of roses, or better
+with mint water and sugar, as in the so-called
+“ether punch.”<a id="FNanchor_63" href="#Footnote_63" class="fnanchor">[63]</a> Opium or laudanum
+in somewhat smaller doses than those recommended
+above, is often added, with
+great advantage to ether, when there is need
+of a potent antispasmodic. In the paroxysms
+of severe præcordial anguish and
+dyspnœa that characterize many deaths from
+organic disease of the heart and great vessels
+of the chest, relief must be sought in ether
+and opium, or from the inhalation of the
+nitrite of amyl.</p>
+
+<hr class="tb">
+
+<p>The fewer the drugs and the less of
+medicine we can do with in the treatment
+of the dying, the better. Those above<span class="pagenum" id="Page_86">[86]</span>
+mentioned comprise all I have had occasion
+for, and if judiciously used, they are equal
+to the emergencies we are called upon to
+meet. I have no wish unduly to limit
+the means at our command in aid of the
+Euthanasia; but when the stage of existence
+contemplated in these pages has once
+been reached, we dismiss all thought of
+cure, or of the prolongation of life, and
+our efforts are limited to the relief of
+certain urgent conditions, such as pain,
+exhaustion, dyspnœa, spasm, and the like;
+for which the remedies mentioned above
+are to the full as efficient, if not really
+more so, than any others as yet known.
+But no medicine should be given without
+a distinct—I had almost written urgent—need
+for it; and the physician should form
+a clear idea of the special requirements of
+the case before him, and how, and by what
+means they may be best accomplished. In
+very many cases there is no need of medicines
+of any kind, and stimulants and light<span class="pagenum" id="Page_87">[87]</span>
+nourishment <i>cautiously</i> administered, meet
+every requirement. But often, and in
+almost all cases, at a certain period of their
+course, the less even of these that is given
+the better. “Medici plus interdum quiete,
+quam movendo et agendo proficiunt,”
+writes Livy, and there are few dying beds,
+where, just before the last, this precept
+does not find its fitting application. “All
+that the dying person, then, requires is to
+be left alone, and allowed to die in peace.”<a id="FNanchor_64" href="#Footnote_64" class="fnanchor">[64]</a></p>
+
+<div class="blockquot">
+
+<p>“Disturb him not—let him pass peaceably.”</p>
+</div>
+
+<p>“The physician,” writes Dr. Ferriar,<a id="FNanchor_65" href="#Footnote_65" class="fnanchor">[65]</a>
+“will not torment his patient with unavailing
+attempts to stimulate the dissolving
+system, from the idle vanity of prolonging
+the flutter of the pulse for a few more
+vibrations: if he cannot alleviate his situation,
+he will protect his patient against
+<span class="pagenum" id="Page_88">[88]</span>every suffering which has not been attached
+to it by nature.”</p>
+
+<p>As the patient himself is wholly unable
+to explain what is needful in his situation,
+the physician is bound to act for him in
+regulating the economy of the bed-chamber.
+The temperature and ventilation
+of the room—the amount of light to
+be admitted—the degree of quiet to be
+maintained in it—must be determined
+according to the circumstances of each particular
+case.</p>
+
+<p>When the mode of dying is by the lung,
+and in the way of asphyxia, the admission
+of fresh, cool air into the room seems to
+conduce to the relief of dyspnœa, and
+greatly to the comfort of the sufferer.</p>
+
+<p>The custom of excluding daylight as far
+as may be from the dying chamber, and
+keeping it gloomy and dark, is in every
+respect a mistake, and is to be opposed. If
+there is one thing about his surroundings
+which more often than any other is complained<span class="pagenum" id="Page_89">[89]</span>
+of by the dying, it is of failing
+sight—of a darkness gathering over him;
+and a desire is expressed for more light.</p>
+
+<p>Talking in an undertone and whispering
+in the presence of the dying is to be peremptorily
+checked. What has to be said,
+and the less that is the better, should be in
+a clear, distinct, ordinary tone, somewhat,
+perhaps, below the ordinary.<a id="FNanchor_66" href="#Footnote_66" class="fnanchor">[66]</a></p>
+
+<p>The dying chamber is no place for
+officious interference or obtrusive curiosity.</p>
+
+<p><span class="pagenum" id="Page_90">[90]</span></p>
+
+<p>The fewer that are admitted to it the better—the
+nurse, the minister of religion, the
+medical attendant, and the immediate members
+of the family, comprise those whose
+duty and feelings entitle them to be
+present.</p>
+
+<p>“While the senses remain perfect, the
+patient ought to direct his own conduct,
+both in his devotional exercises, and in the
+last interchange of affection with his
+friends.”<a id="FNanchor_67" href="#Footnote_67" class="fnanchor">[67]</a> He will be wise if he does
+so under the experienced guidance of his
+religious adviser. “The powers of the
+mind, after being forcibly exerted on these
+objects, commonly sink into complete
+debility, and respiration becoming weaker
+every moment, the patient is rendered <i>apparently</i>
+insensible to everything around
+him. But the circumstances of the disease
+occasion much variety in this progress.”<a id="FNanchor_68" href="#Footnote_68" class="fnanchor">[68]</a></p>
+
+<p><span class="pagenum" id="Page_91">[91]</span></p>
+
+<p>Even when persons appear insensible, it is
+certain, as I have before remarked, that
+frequently they are cognisant of what is
+passing about them. “I have known them
+requested,” says Dr. Elliotson, “to give a
+sign that they were still alive by moving
+a finger, or by interrupting their breath
+when to move a finger was impossible: and
+they have done so, although believed by
+many to have been long senseless.”<a id="FNanchor_69" href="#Footnote_69" class="fnanchor">[69]</a> In
+many cases there is a sort of lucid interval
+immediately before dissolution. This
+may be perceived by the looks and
+gestures where the patient is incapable of
+speaking.</p>
+
+<p>When things come to the last and the
+act of dissolution is imminent, all noise and
+bustle about the dying person should be
+prohibited, and unless the patient should
+place himself in a posture evidently uneasy
+he should be left undisturbed.<a id="FNanchor_70" href="#Footnote_70" class="fnanchor">[70]</a> The
+<span class="pagenum" id="Page_92">[92]</span>dying are often impatient of any kind of
+covering.<a id="FNanchor_71" href="#Footnote_71" class="fnanchor">[71]</a> They throw off
+the bedclothes and lie with the chest bare,
+the arms abroad, and the neck, arms,
+and legs as much exposed as possible:—Ubi
+supinus æger jacet, porrectis manibus et
+cruribus, writes Celsus—ubi brachia et crura
+nudat et inæqualiter dispergit. “These
+actions,” writes Dr. Symonds,<a id="FNanchor_72" href="#Footnote_72" class="fnanchor">[72]</a> “we believe
+to be prompted by instinct, in order that
+neither covering nor even contact with the
+rest of the body may prevent the operation
+of the air on the skin. There are actions
+<span class="pagenum" id="Page_93">[93]</span>and re-actions between the air and the blood
+in the skin similar to those which occur in
+the lungs, and these are in aid of them.”
+Such automatic actions ought not to be
+interfered with, unless the patient has got
+into a position evidently distressing to himself,
+or except so far as decency requires
+when there is any approach to unseemly
+exposure.</p>
+
+<p>Exclamations of grief, and the crowding
+of the family round the bed, only serve to
+harass the dying man, writes Ferriar, who
+adds, “The common practice of plying him
+with liquors of different kinds, and of forcing
+them into his mouth when he cannot swallow,
+should be totally abstained from.”
+But to this error I have already referred.</p>
+
+<p>It was a custom in the Middle Ages to strip
+the dying, drag them from their beds, and
+lay them on ashes or on mattresses of straw
+or hair upon the floor. It was then wholly
+or in part a penitential act, and the influence
+of this custom has, perhaps, not yet wholly<span class="pagenum" id="Page_94">[94]</span>
+ceased. “It is,” says Dr. Ferriar,<a id="FNanchor_73" href="#Footnote_73" class="fnanchor">[73]</a> “a
+prevalent opinion among nurses and servants
+that a person whose death is lingering
+cannot quit life while he remains on a common
+bed, and that it is necessary to drag the
+bed away and place him on the mattress.
+This piece of cruelty is often practised when
+the attendants are left to themselves. A
+still more hazardous practice has been very
+prevalent in France and Germany, and I
+am afraid is not unknown in this country.
+When the patient is supposed by the nurses
+to be nearly in a dying state, they withdraw
+the pillows and bolster from beneath the
+head, sometimes with such violence as to
+throw the head back and to add greatly
+to the difficulty of respiration. As the
+avowed motive for this barbarity is a desire
+to put the patient out of pain—that is,
+to put him to death—it is incumbent on
+his friends to preserve him from the hands
+<span class="pagenum" id="Page_95">[95]</span>of those executioners. Perhaps a more
+deplorable condition can scarcely be conceived
+than that of being transferred from
+the soothing care of relations and friends, to
+the officious folly or rugged indifference of
+servants.” One would hope that such
+cruelty is a thing of the past. My own
+experience forty years since as a dispensary
+physician in the eastern parts of the metropolis,
+led me to conclude that it was not
+<i>then</i> and <i>there</i> wholly unknown or unpractised.
+What it may be in remote rural
+districts, where the class of old, ignorant and
+prejudiced nurses still exist, I have no
+means of knowing. “This is a state of
+suffering,” adds Dr. Ferriar, “to which we
+are all exposed, and if it were unavoidable,
+I should be far from desiring to unveil so
+afflicting a prospect. But the means of
+prevention are so easy, that I cannot forbear
+to solicit the public attention to them.”<a id="FNanchor_74" href="#Footnote_74" class="fnanchor">[74]</a></p>
+
+<p><span class="pagenum" id="Page_96">[96]</span></p>
+
+<p>In the intelligent trained nurses of the
+present day, we have the best security
+against such barbarity; and when they are
+absent, in the presence in the dying chamber,
+of the relations or nearest friends until all
+is over.</p>
+
+<p>In cases of sudden death from disease of
+the heart, there is neither occasion nor time
+for medical treatment of any sort. Death
+is instantaneous and without warning.
+Where death beginning at the heart takes
+place by way of syncope, fresh air and
+stimulants cautiously given are the best
+resources. Wine or brandy, with egg or
+other light nutriment, are appropriate.
+When death is taking place in the slower
+way of exhaustion, a like treatment is to
+be pursued. In the earlier stage, small
+quantities of soup, or beef tea may be
+given, but when death is near they are
+best omitted. It is in these cases that
+madeira and tokay answer so well. In all
+cases of dying by failure of the heart’s<span class="pagenum" id="Page_97">[97]</span>
+action, the posture of the patient should be
+carefully adjusted—the head should be low
+rather than raised, and it and the shoulders
+supported on firm pillows. Any approach
+to the erect or sitting posture is as a rule
+to be avoided. Its tendency is to occasion
+fainting and death.</p>
+
+<p>In death from the lungs or by asphyxia
+the struggle is often protracted, and accompanied
+by all those marks of suffering
+which the imagination associates with the
+closing scene of life. Doubtless in the
+earlier stages of it, there is real suffering,
+but happily this is rarely of long duration,
+for the circulation of venous blood ensues,
+and deadens sensibility and pain. The
+respirations in this mode of death become
+laborious and heaving, the expression of
+countenance distressed and anxious. But
+soon the face becomes tumid and dusky,
+the lips livid, and with the circulation of
+undecarbonized blood, which these symptoms
+imply, the anxious expression of face subsides,<span class="pagenum" id="Page_98">[98]</span>
+and there ensues a slowly increasing
+benumbing of sensation, and a corresponding
+diminution of suffering. The breathing
+then becomes irregular and laborious, and
+the heavings of the chest convulsive; but
+these movements are automatic, and independent
+alike of sensation and of the
+will. They soon pass into coma, stertor,
+rattle in the windpipe, and death. Stertorous
+breathing is in great measure due to
+affection of the brain or medulla, either
+primary or secondary. The latter is the
+condition we are here contemplating.
+Stertor seems to be due to a falling back of
+the base of the tongue into the pharynx,
+and to the obstruction to respiration thence
+induced; and is increased by the prone position
+on the back, into which such patients
+naturally fall. It may be relieved by placing
+the person on one side, and supporting him
+in that position by well-arranged pillows.
+The tongue then drops to the side of the
+pharynx and mouth, and leaves room for<span class="pagenum" id="Page_99">[99]</span>
+the ingoing air. Dr. Bowles, of Folkestone,
+to whom we owe the knowledge of these
+facts, warns us, that care should be taken to
+keep the neck rather straight, as, if the
+chin be brought too near the sternum, the
+thyroid cartilage presses upwards and backwards,
+and again pushes the base of the
+tongue, toward the back of the pharynx.
+Nothing can be done, indeed nothing is
+needed, but regulation of the posture, when
+coma is established. The head is to be
+supported on a firm pillow, or bolster, and
+slightly raised, but not so much as to increase
+the tendency to slide downwards in
+the bed. Whatever position of the body
+is found to lessen the stertor, and ease the
+breathing should be maintained.</p>
+
+<p>In the earlier stages of the process above
+described—in the condition which precedes
+and passes into coma—a carefully adjusted
+posture of the patient, in which he is
+propped up at an angle of not less than
+forty-five degrees, and often at one of<span class="pagenum" id="Page_100">[100]</span>
+much more, and due support is given to
+the trunk of the body by pillows—will do
+more than anything else in relief of embarrassed
+and laboured breathing. “The
+object is to support with the pillows, the
+back <i>below</i> the breathing apparatus, to allow
+the shoulders room to fall back, and to
+support the head, without throwing it forward.”<a id="FNanchor_75" href="#Footnote_75" class="fnanchor">[75]</a>
+The suffering of dying patients,
+says Miss Nightingale, is immensely increased
+by neglect of these points. If
+secretions have accumulated in the air passages,
+ammonia or turpentine may be
+administered. Should the breathing be
+gasping and spasmodic, ether, with or
+without opium, should be tried. When
+duskiness and lividity of the face have
+come on, we can do but little—when deep
+coma and stertorous breathing, nothing—but
+adjust the posture of the patient to
+<span class="pagenum" id="Page_101">[101]</span>the more pressing requirements of the
+case.</p>
+
+<p>When the heart or great vessels of the
+chest are the seat of the disease, and the
+circulation through the lungs is becoming
+seriously embarrassed by it, there are often
+paroxysms of great suffering. The patient
+is agonized by a sense of instant suffocation,
+and sits in or out of bed, with the head bent
+forward, resting on a table or other support,
+and expecting dissolution every moment.
+Here ether and opium is our best resource;
+or the nitrite of amyl, the cautious inhalation
+of which has in some instances given
+marked relief.</p>
+
+<p>When death, commencing at the brain,
+destroys life through the lung, and in the
+way of coma, as it usually does, the treatment
+is the same as in the coma that occurs
+late in the series of events which mark death
+by asphyxia. When, on the other hand,
+death, beginning at the brain, destroys life
+through the heart and by way of exhaustion,<span class="pagenum" id="Page_102">[102]</span>
+the treatment is the same as above
+described for those dying primarily from
+the heart and in the way of asthenia.</p>
+
+<hr class="tb">
+
+<p>When the face of the dying person is
+flushed, the head hot, and the carotid
+arteries beating forcibly, the head is to be
+raised and supported on firm pillows, and
+ice or a cold spirit lotion applied to it.</p>
+
+<hr class="tb">
+
+<p>In some delicate and highly sensitive
+persons, a kind of struggle is sometimes
+excited when the respiration becomes very
+difficult.<a id="FNanchor_76" href="#Footnote_76" class="fnanchor">[76]</a> Dr. Ferriar says he has known
+this effort proceed so far, that the patient
+a very few minutes before death, has started
+out of bed, and stood erect for a moment.
+He ascribed it to apprehension and alarm,
+and adds: “Those who resign themselves
+quietly to their feelings seem to fare best.”
+This is probably true, but the sufferer
+<span class="pagenum" id="Page_103">[103]</span>needs whatever relief art can supply; and
+ether and opium is the most likely to give
+it.</p>
+
+<hr class="tb">
+
+<p>Hiccup is somewhat alleviated by a
+sinapism to the epigastrium, and a spoonful
+of aniseed water swallowed slowly.
+But if it is severe, shaking the patient,
+and so adding greatly to his distress,
+we must rely on opium given internally,
+and its application externally to the
+pit of the stomach. If hiccup seems to be
+due, as it often is, to an overloaded and
+distended stomach, and the influence of
+opium is needed, the hypodermic injection
+of morphia is to be preferred.</p>
+
+<hr class="tb">
+
+<p>Inquietude and restlessness, especially in
+the half-conscious dying person, is often
+due to a distended bladder, and is at once
+quieted by the catheter. In others, it is
+due to the weight of the bedclothes, and
+is relieved by lightening them.</p>
+
+<p><span class="pagenum" id="Page_104">[104]</span></p>
+
+<hr class="tb">
+
+<p>Coldness of the feet is best met by a foot
+warmer; and not by thick, heavy bed clothing,
+which distresses the sufferer and gives
+rise to inquietude and restlessness. “Weak
+patients,” says Miss Nightingale, and the
+dying as much or more so than others,
+“are invariably distressed by a great weight
+of bedclothes.” Light Whitney blankets
+should alone be used for coverings under
+such circumstances. But I am not sure
+that coldness of the extremities does always
+add to the sufferings of the dying, or needs
+the consideration usually given to it. The
+diminished circulation on which it depends
+is attended, for the most part, in the dying
+by proportionate loss of sensibility; and
+besides it is especially when the feet and
+legs are cold, sodden, and dank, that we
+observe that impatience of any covering
+upon them—that tossing about and exposure
+of them to the air—which I have
+before described.</p>
+
+<p><span class="pagenum" id="Page_105">[105]</span></p>
+
+<hr class="tb">
+
+<p>Death from old age—the natural termination
+of life, and the simplest form of
+death that can occur, creeps on by slow and
+almost imperceptible degrees. It is characterised
+by a gradual and proportionate
+decay of all the functions and organs of
+the body, and as a rule presents no symptoms
+that call for special treatment. It is
+only where the normal course of decay is
+disturbed by supervening disorder, or
+disease of an important organ, or by surrounding
+circumstances, that suffering of
+any kind attends it. Good nursing, and
+the due administration of light food and
+stimulants, comprise all that is needed. The
+approaches to death are so gentle, and the
+act of dying so easy, that nature herself
+provides a perfect euthanasia.</p>
+
+
+<p class="center">THE END.</p>
+
+<p class="p6 smaller center">UNWIN BROTHERS, PRINTERS, CHILWORTH AND LONDON.
+</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<h2 class="nobreak" id="FOOTNOTES">FOOTNOTES:</h2>
+</div>
+
+
+<div class="footnote">
+
+<p><a id="Footnote_1" href="#FNanchor_1" class="label">[1]</a> “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 <i>Euthanasia</i> exteriori (ad differentiam
+ejus euthanasiæ quæ animæ præparationem
+respicit) appellamus; eamque inter
+desiderata reponimus.” (Verulamus, De Augmentis
+Scientiarum, lib. iv. cap. ij.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_2" href="#FNanchor_2" class="label">[2]</a> “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.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_3" href="#FNanchor_3" class="label">[3]</a> “A medicis vix inchoatum, nedum pertractatum
+huc usque esset.” (Paradysius, p. 63.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_4" href="#FNanchor_4" class="label">[4]</a> “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.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_5" href="#FNanchor_5" class="label">[5]</a> Sir Henry Halford, Essays and Orations
+read and delivered at the Royal College of Physicians.
+Third edition, 12mo, London, 1842.
+p. 84.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_6" href="#FNanchor_6" class="label">[6]</a> “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
+<i>De Ileo</i>.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_7" href="#FNanchor_7" class="label">[7]</a> Essays and Orations, <i>ut supra passim</i>.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_8" href="#FNanchor_8" class="label">[8]</a> John Ferriar, M.D., Medical Histories and
+Reflections. 8vo, London, 1798. Vol. iii.
+p. 196.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_9" href="#FNanchor_9" class="label">[9]</a> John Ferriar, M.D., On the Treatment
+of the Dying, <i>ut supra</i>, p. 191.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_10" href="#FNanchor_10" class="label">[10]</a> The Works of Sir Benjamin Collins
+Brodie. Arranged by Charles Hawkins.
+3 Vols., 8vo, London, 1865. Vol. i. p. 184.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_11" href="#FNanchor_11" class="label">[11]</a> On Life and Death. 8vo. London,
+1863, p. 175.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_12" href="#FNanchor_12" class="label">[12]</a> “Ipsæ animæ discessus a corpore fit, sine
+dolore, et fit plerumque sine sensu, <i>nonnunquam
+etiam cum voluptate</i>.” (Vopisci Fortunati
+Plempii. de Togatorum Valetudine tuenda
+Commentatio. 4to. Bruxellis, 1670. p. 26.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_13" href="#FNanchor_13" class="label">[13]</a> Autobiographical Memoir of Sir John
+Barrow, Bart. 8vo, London, 1847, p. 398.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_14" href="#FNanchor_14" class="label">[14]</a> “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.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_15" href="#FNanchor_15" class="label">[15]</a> 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 <i>crater</i> of death—that awful
+volcano—as any human being ever <i>can</i> 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
+<i>on</i> or <i>in</i> 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).</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_16" href="#FNanchor_16" class="label">[16]</a> J. A. Symonds, M.D., Art. Death, in the
+Cyclopædia of Anatomy and Physiology, 4
+vols., royal 8vo, Lond. Vol. i. p. 800.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_17" href="#FNanchor_17" class="label">[17]</a> Halford, p. 18.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_18" href="#FNanchor_18" class="label">[18]</a> Halford, p. 14.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_19" href="#FNanchor_19" class="label">[19]</a> Savory, <i>ut supra</i>, p. 178.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_20" href="#FNanchor_20" class="label">[20]</a> p. 74.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_21" href="#FNanchor_21" class="label">[21]</a> On Life and Death, 8vo, London, 1863,
+p. 177.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_22" href="#FNanchor_22" class="label">[22]</a> Brodie <i>ut supra</i>, p. 185.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_23" href="#FNanchor_23" class="label">[23]</a> “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).</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_24" href="#FNanchor_24" class="label">[24]</a> Halford, p. 76.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_25" href="#FNanchor_25" class="label">[25]</a> Halford, p. 75.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_26" href="#FNanchor_26" class="label">[26]</a> Cyclopædia of Anatomy and Physiology,
+art. Death, vol. i. p. 799.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_27" href="#FNanchor_27" class="label">[27]</a> Symonds <i>ut supra</i>, p. 799.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_28" href="#FNanchor_28" class="label">[28]</a> Lord Campbell, Lives of the Chief
+Justices of England, vol. i.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_29" href="#FNanchor_29" class="label">[29]</a> On the Καῦσος of Aretæus, p. 96.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_30" href="#FNanchor_30" class="label">[30]</a> Halford, On the Cautious Estimation of
+Symptoms, p. 17.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_31" href="#FNanchor_31" class="label">[31]</a> Halford <i>ut supra</i>, p. 19.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_32" href="#FNanchor_32" class="label">[32]</a> On the Καῦσος of Aretæus, p. 91.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_33" href="#FNanchor_33" class="label">[33]</a> A. P. Wilson Philip, On Sleep and Death,
+8vo, London, 1834, p. 165.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_34" href="#FNanchor_34" class="label">[34]</a> Cyclopædia of Anatomy and Physiology,
+vol. i. p. 799.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_35" href="#FNanchor_35" class="label">[35]</a> 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.”</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_36" href="#FNanchor_36" class="label">[36]</a> Cyclopædia of Practical Medicine, art.
+Disease, vol. i. p. 629.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_37" href="#FNanchor_37" class="label">[37]</a> Brodie, <i>ut supra</i>, vol. i. p. 281.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_38" href="#FNanchor_38" class="label">[38]</a> Brodie <i>ut supra</i>, p. 182.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_39" href="#FNanchor_39" class="label">[39]</a> Brodie, p. 182.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_40" href="#FNanchor_40" class="label">[40]</a> The Anatomy and Philosophy of Expression.
+Fourth Edition, 1847, p. 185.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_41" href="#FNanchor_41" class="label">[41]</a> Symonds, <i>ut supra</i>, p. 803.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_42" href="#FNanchor_42" class="label">[42]</a> “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).</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_43" href="#FNanchor_43" class="label">[43]</a> In the words of Lucretius, vi. 1, 190—</p>
+
+<div class="poetry-container">
+<div class="poetry">
+  <div class="stanza">
+    <div class="verse indent6">“Item, ad supremum denique tempus,</div>
+    <div class="verse indent0">Compressæ nares, nasi primoris acumen</div>
+    <div class="verse indent0">Tenue, cavatei oculei, cava tempora; frigida pellis,</div>
+    <div class="verse indent0">Duraque, inhorrebat tactum; frons tenta meabat:</div>
+    <div class="verse indent0">Nec nimio rigida post artus morte jacebant.”</div>
+  </div>
+</div>
+</div>
+
+<p>Or, as rendered by an accomplished physician,
+Dr. Mason Good—</p>
+
+<div class="poetry-container">
+<div class="poetry">
+  <div class="stanza">
+    <div class="verse indent0">“Then, tow’rds the last, the nostrils close collaps’d;</div>
+    <div class="verse indent0">The nose acute; eyes hollow; temples scoop’d;</div>
+    <div class="verse indent0">Frigid the skin, retracted; o’er the mouth</div>
+    <div class="verse indent0">A ghastly grin; the shrivell’d forehead tense;</div>
+    <div class="verse indent0">The limbs outstretch’d for instant death prepar’d.”</div>
+  </div>
+</div>
+</div>
+
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_44" href="#FNanchor_44" class="label">[44]</a> “Omnia tum vero vitai claustra lababant.”
+<br>(Lucretius, vi. 1,151).</p>
+
+<p>“Then all the powers of life were loosen’d.”
+<br>(Mason Good).</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_45" href="#FNanchor_45" class="label">[45]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_46" href="#FNanchor_46" class="label">[46]</a> Watson, p. 66.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_47" href="#FNanchor_47" class="label">[47]</a> Watson, p. 68.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_48" href="#FNanchor_48" class="label">[48]</a> <i>Ibid.</i>, p. 70.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_49" href="#FNanchor_49" class="label">[49]</a> On the Treatment of the Dying. Medical
+Histories and Reflections. Vol. iii. p. 195.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_50" href="#FNanchor_50" class="label">[50]</a> Watson, p. 76.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_51" href="#FNanchor_51" class="label">[51]</a> Medical Notes and Reflections. Third
+edition, 8vo, London, 1855, p. 379.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_52" href="#FNanchor_52" class="label">[52]</a> Robert Willis, M.D., On Urinary Diseases,
+8vo, London, 1838, p. 100.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_53" href="#FNanchor_53" class="label">[53]</a> “When there is a sudden cessation, or intermission,
+of acute pain, sleep frequently comes on
+instantaneously at every such interval of ease.
+The records of judicial torture furnish much
+striking evidence as to these effects.” (Sir Henry
+Holland’s Medical Notes and Reflections, p. 369.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_54" href="#FNanchor_54" class="label">[54]</a> I except hydrophobia, tetanus, &amp;c., against
+which it is almost powerless.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_55" href="#FNanchor_55" class="label">[55]</a> “Præstantissimum remedium cardiacum
+(unicum pene dixerim) quod in rerum natura
+hactenus est repertum.” Sydenham Thomæ
+Opera Omnia, edidit G. A. Greenhill, M.D.,
+8vo, London, 1844, p. 175.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_56" href="#FNanchor_56" class="label">[56]</a> “Vires ægri somno recreatæ sunt, atque
+etiam ubi salus ejus prorsus desperata fuerit, et
+angor summus cruciaverit, opium utique sollicitudinem
+aliquantum levavit. Mors quidem
+neque serius, neque citius venit, sed tamen
+minore cum cruciatu.” (Heberden <i>De Ileo</i>.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_57" href="#FNanchor_57" class="label">[57]</a> Hufeland’s remarks on opium are so valuable
+that I give them at length. “Who would be a
+physician without opium in attendance on cancer
+or dropsy of the chest? How many sick has it
+not saved from despair? For one of the great
+properties of opium is, that it soothes not only
+corporal pains and complaints, but affords also
+to the mind a peculiar energy, elevation, and tranquility.
+The soothing virtue manifests itself in
+the most splendid manner in relieving death in
+severe cases, in effecting the euthanasia, which
+is a sacred duty and the highest triumph of the
+physician, when it is not in his power to retain
+the ties of life. Here, it is not only capable of
+taking away the pangs of death, but it imparts
+even courage and energy for dying; it promotes
+in a physical way even that disposition of mind
+which elevates it to heavenly regions. A man
+who had laboured for a long time under complaints
+of the chest and vomicas finally approached
+death. The most dreadful anguish of death with
+a constant danger of suffocation seized him, he
+got into real despair and his state was an insurmountable
+torment even for the persons around
+him. He now took half a grain of opium every
+hour. After three hours he became quiet, and
+after he had taken two grains he fell asleep, slept
+quietly for several hours, awoke quite cheerful,
+free from pain and anxiety, and at the same time
+so much strengthened and appeased in his mind,
+that he bade farewell with the greatest composure
+and satisfaction to his relatives, and after
+he had given them his blessing and many a good
+admonition fell again asleep and passed away
+while sleeping.” (The Three Cardinal Means
+of the Art of Healing, p. 46.)</p>
+
+<p>Somewhat to the same purport writes De
+Quincey. “Simultaneously with the conflict
+the pain of conflict has departed, and thenceforward
+the gentle process of collapsing life, no
+longer fretted by counter-movements slips away
+with holy peace into the noiseless deeps of the
+Infinite.” (Confessions of an English Opium-Eater,
+p. 149.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_58" href="#FNanchor_58" class="label">[58]</a> <i>Ut supra</i>, p. 516.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_59" href="#FNanchor_59" class="label">[59]</a> Holland, <i>ut supra</i>, p. 518. To the same
+effect writes Dr. James Gregory of this remedy,
+“<i>Neque dubium est</i>, utcunque periculosus
+videatur usus talis medicamenti vix non venenati;
+<i>ægros plus fere incommodi et damni percepisse a
+nimis parva, quam a nimia ejus quantitate</i>.
+Medici igitur est, medicamentum adeo validum
+et sæpe perniciosum caute et prudenter adhibere,
+et in illis tantum morbis ad id confugere, qui
+aliquid istiusmodi plane requirunt; <i>ubi vero talis
+necessitas urget, oportet remedium libere et cum
+fiducia præscribere</i>; tunc enim non sperare modo
+potest, sed fere polliceri, se effectum illum
+salutarem, quem cupit, per suum medicamentum
+esse præstiturum. <i>Quod si timide et nimis parce
+datum fuerit</i>, longe alium effectum habebit, et
+iisdem ægrotis <i>haud parum nocebit, quibus largius
+datum multum profuisset</i>.” (Conspectus Medicinæ
+Theoreticæ, § <span class="allsmcap">MCCXXII</span>.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_60" href="#FNanchor_60" class="label">[60]</a> <i>Ut supra</i>, p. 518.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_61" href="#FNanchor_61" class="label">[61]</a> “Audivi plus semel ægros temporarium a
+narcoticis levamen enixe deprecantes, quod
+sensuum obscuratione nimis care querebantur
+emi.” (p. 71.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_62" href="#FNanchor_62" class="label">[62]</a> “Conspectus Medicinæ Theoreticæ,”
+§ <span class="allsmcap">MCCXXII</span>.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_63" href="#FNanchor_63" class="label">[63]</a></p>
+
+<ul class="recipe">
+<li>℞ Aq. Menthæ Viridis, f. ℥ v ss.</li>
+<li>Sacchari, ℥ ss.</li>
+<li>Acid. Sulphurici diluti ♏︎ <span class="allsmcap">XL</span>.</li>
+<li>Sp. Ætheris comp. f. ʒ ij.</li>
+</ul>
+<p>
+Misce ft Mistura. Pars quarta pro dose.<br>
+</p>
+
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_64" href="#FNanchor_64" class="label">[64]</a> Elliotson, Human Physiology, p. 1043.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_65" href="#FNanchor_65" class="label">[65]</a> <i>Ut supra</i>, p. 193.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_66" href="#FNanchor_66" class="label">[66]</a> Miss Nightingale’s observations on whispered
+conversation in the room, or just outside
+the door, at p. 26 of her “Notes on Nursing,”
+have great value and a wide application. On
+these points in the management of the dying
+chamber Professor Paradys has the following:
+“Sed præterea adhiberi hoc loco moderatæ sensuum
+externorum impulsiones utiliter possunt,
+quæ vividiores phantasmatum impressiones obscurent:
+vitari itaque nimiæ tenebræ et silentia
+nimis alta debent, concedi contra modica lux,
+permitti notæ amicorum voces, immo excitari
+debent lenes, placidi, animum blande demulcentes
+affectus.” (p. 74.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_67" href="#FNanchor_67" class="label">[67]</a> Ferriar, p. 193.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_68" href="#FNanchor_68" class="label">[68]</a> Ibid., p. 194.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_69" href="#FNanchor_69" class="label">[69]</a> Human Physiology, p. 1043.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_70" href="#FNanchor_70" class="label">[70]</a> Ferriar, p. 203.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_71" href="#FNanchor_71" class="label">[71]</a></p>
+
+<div class="poetry-container">
+<div class="poetry">
+  <div class="stanza">
+    <div class="verse indent0">“Nihil adeo posses quoiquam leve tenueque membris</div>
+    <div class="verse indent0">Vortere in utilitatem.”</div>
+    <div class="verse indent18">(Lucretius vi. 1169.)</div>
+  </div>
+</div>
+</div>
+
+<div class="poetry-container">
+<div class="poetry">
+  <div class="stanza">
+    <div class="verse indent18">“Nor would once endure</div>
+    <div class="verse indent0">The lightest vest thrown loosely o’er the limbs.”</div>
+    <div class="verse indent18">(Mason Good, p. 595.)</div>
+  </div>
+</div>
+</div>
+
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_72" href="#FNanchor_72" class="label">[72]</a> “Cyclopædia of Anatomy and Physiology,”
+vol. i. p. 802.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_73" href="#FNanchor_73" class="label">[73]</a> P. 200.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_74" href="#FNanchor_74" class="label">[74]</a> P. 203.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_75" href="#FNanchor_75" class="label">[75]</a> Miss Nightingale’s Notes on Nursing,
+p. 47.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_76" href="#FNanchor_76" class="label">[76]</a> Ferriar, <i>ut supra</i>, p. 196.</p>
+
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+</div>
+
+<div class="transnote">
+
+<p class="center">Transcribers notes.</p>
+
+
+<p>Obvious typographical and punctuation errors have been corrected
+silently.  Inconsistent hyphenation has been normalised.</p>
+
+<p>Half-titles & reiterations of the chapter title have been discarded.</p>
+</div>
+
+<div style='text-align:center'>*** END OF THE PROJECT GUTENBERG EBOOK 76791 ***</div>
+</body>
+</html>
+
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+Project Gutenberg (https://www.gutenberg.org) public repository for eBook #76791
+(https://www.gutenberg.org/ebooks/76791)