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| committer | pgww <pgww@lists.pglaf.org> | 2025-09-01 11:22:01 -0700 |
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diff --git a/76791-h/76791-h.htm b/76791-h/76791-h.htm new file mode 100644 index 0000000..08b3d97 --- /dev/null +++ b/76791-h/76791-h.htm @@ -0,0 +1,3104 @@ +<!DOCTYPE html> +<html lang="en"> +<head> + <meta charset="UTF-8"> + <title> + Euthanasia: | Project Gutenberg + </title> + <link rel="icon" href="images/cover.jpg" type="image/x-cover"> + <style> + +body { + margin-left: 10%; + margin-right: 10%; +} + + h1,h2 { + text-align: center; /* all headings centered */ + clear: both; +} + +p { + margin-top: .51em; + text-align: justify; + margin-bottom: .49em; +} + +.p2 {margin-top: 2em;} + +.p6 {margin-top: 6em;} + +hr { + width: 33%; + margin-top: 2em; + margin-bottom: 2em; + margin-left: 33.5%; + margin-right: 33.5%; + clear: both; +} + +hr.tb {width: 45%; margin-left: 27.5%; margin-right: 27.5%;} +hr.chap {width: 65%; margin-left: 17.5%; margin-right: 17.5%;} +@media print { hr.chap {display: none; visibility: hidden;} } + + + +div.chapter {page-break-before: always;} +h2.nobreak {page-break-before: avoid;} + +ul.recipe{ list-style-type: none; } + + +table { + margin-left: auto; + margin-right: auto; +} +table.autotable { border-collapse: collapse; } +table.autotable td { padding: 0.25em; } + +.tdr {text-align: right; vertical-align: bottom;} +.tdc {text-align: center;} + +.pagenum { /* uncomment the next line for invisible page numbers */ + /* visibility: hidden; */ + position: absolute; + left: 92%; + font-size: small; + text-align: right; + font-style: normal; + font-weight: normal; + font-variant: normal; + text-indent: 0; + color: gray; +} /* page numbers */ + + + +.blockquot { + margin-left: 5%; + margin-right: 10%; +} + +.hanging{padding-left: 4em; text-indent: -2em;} + + +.center {text-align: center;} + + +.smcap {font-variant: small-caps;} + +.allsmcap {font-variant: small-caps; text-transform: lowercase;} + +.footnote {margin-left: 10%; margin-right: 10%; font-size: 0.9em;} + +.footnote .label {position: absolute; right: 84%; text-align: right;} + +.fnanchor { + vertical-align: super; + font-size: .8em; + text-decoration: + none; +} + +/* Poetry */ +/* uncomment the next line for centered poetry */ +.poetry-container {display: flex; justify-content: center;} +.poetry-container {text-align: center;} +.poetry {text-align: left; margin-left: 5%; margin-right: 5%;} +.poetry .stanza {margin: 1em auto;} +.poetry .verse {text-indent: -3em; padding-left: 3em;} + +/* Transcriber's notes */ +.transnote {background-color: #E6E6FA; + color: black; + font-size:small; + padding:0.5em; + margin-bottom:5em; + font-family:sans-serif, serif; +} + +/* local mods */ + +.smaller{font-size: 85%} + + +/* Poetry indents */ +.poetry .indent0 {text-indent: -3em;} +.poetry .indent18 {text-indent: 6em;} +.poetry .indent6 {text-indent: 0em;} +.poetry .indent24 {text-indent: 8em;} + + + </style> +</head> +<body> +<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, &c., &c., &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, &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> + diff --git a/76791-h/images/cover.jpg b/76791-h/images/cover.jpg Binary files differnew file mode 100644 index 0000000..0090b90 --- /dev/null +++ b/76791-h/images/cover.jpg |
