diff options
Diffstat (limited to '76791-0.txt')
| -rw-r--r-- | 76791-0.txt | 1748 |
1 files changed, 1748 insertions, 0 deletions
diff --git a/76791-0.txt b/76791-0.txt new file mode 100644 index 0000000..0b22575 --- /dev/null +++ b/76791-0.txt @@ -0,0 +1,1748 @@ + +*** START OF THE PROJECT GUTENBERG EBOOK 76791 *** + +Transcriber’s Note. + +Italic text is indicated with _underscores_, bold text with =equals=. +Small/mixed capitals have been replaced with ALL CAPITALS. + +Obvious typographical and punctuation errors have been corrected +silently. Inconsistent hyphenation has been normalised. + +Half-titles & reiterations of the chapter title have been discarded. + + + + + EUTHANASIA: + + OR, + + MEDICAL TREATMENT IN AID + OF AN EASY DEATH. + + BY + + WILLIAM MUNK, M.D., F.S.A. + + FELLOW AND LATE SENIOR CENSOR OF THE ROYAL COLLEGE OF + PHYSICIANS, &c., &c., &c. + + + LONDON: + + LONGMANS, GREEN, AND CO. + + AND NEW YORK: 15, EAST 16th STREET. + + 1887. + + _All rights reserved._ + + + + +PREFACE. + + +Much has been ably written on Death, and on the physiology of the +various modes of Dying, by Bichat, Alison, Wilson Philip, Symonds, and +others; while but little has been written on the medical management +of the Dying; or on the Euthanasia, to which such management should +contribute. A short but valuable essay of less than twenty pages, +“On the Treatment of the Dying”, by Dr. Ferriar, of Manchester, +in 1798: and a very elegant academical oration, of about the same +length, at my own alma mater, Leyden, in 1794, by Professor Paradys, +“Oratio de Εὐθανασία Naturali; et quid ad eam conciliandam Medicina +valeat”:--comprise all I know that has been written _specially_ on +these subjects in modern times. + +Sir Henry Halford, who was confessedly a master in all that concerns +the management of the Dying, did much by his example and counsel to +commend the subject to the attention of his medical brethren. But +the generation he personally influenced has passed away. His little +volume of “Essays and Orations” contains much on this subject that +is very valuable, and not to be found elsewhere. But his remarks are +unconnected; they occur incidentally in the course of his various +essays, and are now but little known. They were the result of an +experience so large, and so carefully thought out, that I have been +glad to adduce them, whenever I could, in support of, or in addition +to, what I have had myself to state, on the delicate and difficult +subjects considered in the following pages. + + 40, FINSBURY SQUARE. + _Sept. 24, 1887._ + + + + +CONTENTS. + + + I. + + ON SOME OF THE PHENOMENA OF DYING 1 + + II. + + ON THE SYMPTOMS AND MODES OF DYING 51 + + III. + + ON THE GENERAL AND MEDICAL MANAGEMENT + OF THE DYING 63 + + + + +I. + +SOME OF THE PHENOMENA OF DYING. + + + “Quod ad nos Pertinet, et nescire malum est, agitamus.” + + HORACE. + + + One of the wisest of our countrymen, Lord Verulam, saw reason to + censure the physicians of his own time for not making the Euthanasia a + part of their studies.[1] And, although more than two centuries have + since elapsed, it may be doubted whether as much attention is even + yet given to the subject as might be done, to the obvious benefit and + comfort of the dying. + + There is little to be found in medical writings on the management + of the dying, or on the treatment best adapted to the relief of the + sufferings incident to that condition. The subject is not specially + taught in any of our medical schools; and the young physician entering + on the active duties of his office has to learn for himself, as + best he may, what to do, and what not to do, in the most solemn and + delicate position in which he can be placed,--in attendance on the + dying, and administering the resources of the medical art, in aid + of an easy, gentle, and placid death. The whole subject of the + Euthanasia,[2] or of a calm and easy death, in so far as it respects + the physician is in need of special study; and of a systematic + treatment that has not hitherto been accorded to it.[3] In the + following pages I can but trace the outlines of this subject, leaving + to abler hands that fuller treatment which its interest and importance + claim for it. + + Lord Verulam held it to be as much the duty of the physician to smooth + the bed of death, and render the departure from this life easy and + gentle, as it is to cure diseases and restore health.[4] And this + doctrine, so accordant with the best principles of our nature,[5] + is commended to us by that most estimable and judicious of modern + physicians, Dr. Heberden;[6] as it was also by the example and + counsel of one of the most popular and successful physicians of the + present century--the late Sir Henry Halford.[7] + + The process by which death is brought about varies greatly in + different instances, and this according to the disease, or the organ + of the body, from which it essentially results. On these diverse modes + of dying, and of death, modern science has thrown much light; and + with the consolatory result of showing that the process of dying, and + the very act of death, is but rarely and exceptionally attended by + those severe bodily sufferings, which in popular belief are all but + inseparable from it, and are expressed and emphasized in the terms + “mortal agony” and “death struggle.” + + Montaigne was one of the first among modern writers to oppose, by + close argument, the general opinion of the painfulness of death; and + he was followed in the last century with more eloquence, if with + less argument, by Buffon.[8] “There is hardly any subject,” writes + an amiable physician, “on which books afford us more impressive + topics, than the consideration of death; and perhaps there is none + less studied in its intimate details.... It might be expected that a + scene through which we must all pass should excite a closer attention + especially as _the physical process of death loses much of its horror + on a near view_.”[9] + + Physicians, the clergy, and intelligent nurses--all, indeed, who + are practically conversant with the dying--testify to the truth of + this statement. Sir Henry Halford, towards the close of his medical + career, and after opportunities of observation, such as have fallen + to the lot of few physicians, expressed his surprise that of the + great number to whom it had been his professional duty to have + administered in the last hours of their lives, so few exhibited signs + of severe suffering. Sir Benjamin Brodie, whose experience of death + from surgical disease was second to none, states that, according to + his observation, the mere act of dying is seldom, in any sense of the + word, a very painful process.[10] And another distinguished surgeon, + Mr. Savory, writing on the same subject, says, “Whatever may have been + the amount of _previous_ suffering, we may fairly assume that, except + in extreme cases, the actual process of dying is not one of intense + agony, or indeed, for the most part, even of pain.”[11] Lastly, the + great anatomist, Dr. William Hunter, bore his own dying testimony + to the same effect. He retained his consciousness to the last, and + just before he died he whispered to his friend, Dr. Combe, “If I had + strength enough to hold a pen, I would write how easy and pleasant a + thing it is to die.”[12] + + But of far greater weight than the observations and conclusions of + medical men, however eminent, towards the determination of such a + question, is the evidence of those who have been restored from the + state of apparent death from drowning--a state which differs only from + actual death in the possibility of reanimation under the influence of + external treatment. And although the accounts given after recovery + from drowning vary much, there are a number of well-attested cases + which show, that in them at any rate, the loss of sensibility and + consciousness has been painless, or at most attended with a feeling + of oppression across the chest. The process of recovery, however, is + often one of great bodily suffering. + + Lastly, there are those specially interesting cases of recovery from + the apparent death of drowning, in which, although the mind has been + keenly alive and active throughout, there was an entire absence of + pain or other bodily suffering of any kind. The best authenticated + of these instructive and suggestive instances is that of Admiral + Beaufort, as described by himself in a letter to Dr. Wollaston.[13] + When a youngster on board one of H.M. ships in Portsmouth harbour, he + fell into the water, and, being unable to swim, was soon exhausted + by his struggles, and before relief reached him, he had sunk below + the surface. All hope had fled, all exertion ceased, and he felt that + he was drowning. “From the moment that all exertion had ceased,” + writes the admiral, “a calm feeling of the most perfect tranquillity + superseded the previous tumultuous sensations--it might be called + apathy, certainly not resignation, for drowning no longer appeared + to be an evil. I no longer thought of being rescued, _nor was I in + any bodily pain. On the contrary, my sensations were now of rather + a pleasurable cast, partaking of that dull, but contented sort of + feeling which precedes the sleep produced by fatigue._ Though the + senses were thus deadened, not so the mind; its activity seemed to + be invigorated in a ratio which defies all description--for thought + rose after thought with a rapidity of succession, that is not only + indescribable, but probably inconceivable, by any one who has not + himself been in a similar situation. The course of these thoughts I + can even now in a great measure retrace,--the event which had just + taken place, the awkwardness that had produced it, the bustle it must + have occasioned, the effect it would have on a most affectionate + father, and a thousand other circumstances minutely associated with + home were the first series of reflections that occurred. They then + took a wider range--our last cruise, a former voyage and shipwreck, + my school, the progress I had made there and the time I had misspent, + and even all my boyish pursuits and adventures. Thus travelling + backwards, every past incident of my life seemed to glance across my + recollection in retrograde succession; not, however, in mere outline + as here stated, but the picture filled up with every minute and + collateral feature; in short, the whole period of my existence seemed + to be placed before me in a kind of panoramic review, and each act + of it seemed to be accompanied by a consciousness of right or wrong, + or by some reflection on its cause or its consequences; indeed, many + trifling events which had been long forgotten, then crowded into my + imagination, and with the character of recent familiarity.” Certainly + two minutes did not elapse from the moment of suffocation to that of + being hauled up; and according to the account of the lookers on, he + was very quickly restored to animation. “My feelings,” continues + Admiral Beaufort, “while life was returning, were the very reverse in + every point of those which have been described above. One single but + confused idea--a miserable belief that I was drowning dwelt upon my + mind, instead of the multitude of clear and definite ideas which had + recently rushed through it--a helpless anxiety--a kind of continuous + nightmare seemed to press heavily on every sense, and to prevent the + formation of any one distinct thought, and it was with difficulty that + I became convinced that I was really alive. Again, _instead of being + absolutely free from all bodily pain, as in my drowning state_, I was + now tortured by pain all over me.” + + I have given this case at some length, because it seems to throw a + new light on the act of dying, and because analogous instances are + probably not uncommon. Admiral Beaufort tells us that he had heard + from two or three persons, who had recovered from a similar state, + a detail of their feelings, which resembled his own as nearly as was + consistent with their different constitutions and dispositions. Sir + Benjamin Brodie mentions an instance in a sailor;[14] De Quincey + records a like instance in a female, a near relative of his own;[15] + and I have myself heard of two similar cases, but the details are not + sufficiently precise to justify their narration here. + + In fact, all the best and all the most direct evidence that the + subject admits of, goes to show, that as a rule, the immediate act of + dying is in no sense a process of severe bodily suffering--or, indeed, + for the most part even of pain. + + The common belief that the act of dying is one of severe bodily + suffering is due probably in part to theoretical views of the nature + of the event itself;[16] but, principally, to the occurrence of + conditions, physiological or pathological, which precede or accompany + that act, and the nature and import of which are misinterpreted. + Doubtless also, it is due in no small degree to confounding the + actual stage of dying, with those urgent symptoms of disease that + precede and lead up to it, and which are often as severe or more so in + those who are to recover, as in those who are to die. As a rule, to + which there are doubtless exceptions, the urgent symptoms of disease + subside, when the act of dying really begins. “A pause in nature, + as it were, seems to take place, the disease has done its worst, + all strong action has ceased, the frame is fatigued by its efforts + to sustain itself, and a general tranquillity pervades the whole + system.”[17] + + Again, convulsions, which so often attend the process of dying, are + accepted in evidence of suffering, when in fact they are the reverse, + for they imply a loss of consciousness and sensibility, and therefore, + of the capacity to feel pain. They are automatic, and in all essential + respects like the convulsions of epilepsy, of which the subject is + wholly unconscious. The convulsive movements that sometimes attend + the last moments, and with which the person expires, constituting + the so-called “death struggle,” are doubtless of the same painless + character. + + Some few, however, do really suffer grievously in dying, and expire + in great bodily torture. This occurs in some diseases of the heart + and great vessels of the chest, in angina pectoris, and in ileus. But + especially in that most fearful of diseases, hydrophobia, in tetanus, + and in spasmodic cholera--in maladies characterized by spasm of the + external muscles, as distinguished from their convulsion, for spasm + implies no such unconsciousness as does convulsion, but the reverse. + Such cases are rare, but they are so terrible that they fix themselves + in the memory, exert an undue influence on the judgment, and, although + really exceptional in occurrence, and in the sufferings they entail, + come to be regarded as but extreme instances of what is assumed to be + the universal and inevitable lot of the dying. Happily for mankind it + is not so. + + So long as consciousness and intelligence continue, and they often + do so to the last, the influence of mind and of the emotions on the + bodily process of dying must be kept steadily in view. They are + well-nigh as potential in the dying man as they are in the healthy. + Hope is as soothing and fear as depressing in the one condition as in + the other. To the dying there is no greater solace and cordial than + hope--it is the most soothing and cheering of our feelings, and if, + when all hope of life and in the present has fled, the dying man can + dwell with hope and confidence upon his future, it will be well for + him. The retrospect of a well-spent life, “memoria bene actæ vitæ, + multorumque benefactorum recordatio” is a cordial of infinitely more + efficacy than all the resources of the medical art;[18] but a firm + belief in the mercy of God, and in the promises of salvation will do + more than anything in aid of an easy, calm, and collected death. To + those who are sceptical on this point, and such there are, I would + remark, that unless a man has himself felt the influence of religion + on his own mind, he is unable fully and accurately to understand its + influence on others. If I may trust my own experience I should say, + that in the aggressive _dis_believer, as in the mere passive agnostic, + doubt and anxiety as to his future is all but sure to obtrude itself + on his last conscious moments, disturb them, and render such an + euthanasia as we contemplate, impossible. + + “The less fear a reasonable man entertains of death,” says Zimmerman, + “the more placid is he in his last moments.” Happily such dread or + terror of death as disturbs the dying is rare. For the most part an + urgent fear of death, when it does exist, is observed not so much + at the moment when death is actually impending, as it is at that + earlier period when the individual realizes for the first time that + he is about to die. The shock at _that_ moment may be great, but it + is for the most part transient, and “the subsequent contemplation of + approaching death seems to be far less terrible.”[19] A torpor seems + indeed to steal softly over the whole being as death approaches, + and the earnestness to live abates, as the possession of life, from + whatever cause, is gradually withdrawn. Sir Henry Halford tells us + that of the great number to whom he had administered in the last + hours of their lives, he had felt surprised that so few have appeared + reluctant to go to “the undiscovered country from whose bourn no + traveller returns.”[20] + + No one, writes Mr. Savory, who has often stood at the bedside of the + dying, “can have failed to be struck by the fact of the comparative + or complete absence of dismay as death draws near. Often, no doubt, + the mind is otherwise too fully occupied, ... but even in the absence + of this and all distracting influences, and with a clear conviction + that the approaching change is near at hand,--the mind is calm and + collected, the thoughts serene, there is no quailing, no giving + way.”[21] + + The nature of the disease under which a person succumbs, would seem + to exert some influence in this respect. Sir Benjamin Brodie says, + “I have myself never known but two instances, in which, in the act + of dying there were manifest indications of the fear of death. + The individuals to whom I allude were unexpectedly destroyed by + hemorrhage, which from peculiar circumstances, it was impossible to + suppress. The depressing effects which the gradual loss of blood + produced on their corporeal system seemed to influence their minds, + and they died earnestly imploring the relief which art was unable to + afford.”[22] + + When the intimation that death is at hand has been postponed to the + latest possible moment, it comes upon the sufferer so late, that there + may not be time for him to get over the shock of the first impression, + and regain his serenity. Alarm associates itself with the act of + dissolution, which is imminent, or has already commenced, disturbs its + even, easy, tenor, and explains some at least of the harrowing scenes + that occasionally mark the death-bed. An earlier intimation[23] to the + dying person of the great change he is about to undergo is in all + respects desirable, and if the communication be made tenderly and with + prudence, nothing but good is likely to result from it. An important + question here presents itself. By whom should that communication be + made? + + “You will forgive me,” said Sir Henry Halford at one of the evening + meetings at the College of Physicians, “if I presume to state what + appears to me to be the conduct proper to be observed by a physician + in withholding, or making his patient acquainted with, his opinion + of the probable issue of a malady manifesting mortal symptoms. I own + I think it my first duty to protract his life by all practicable + means, and to interpose myself between him and everything which may + possibly aggravate his danger. And unless I shall have found him + averse from doing what was necessary in aid of my remedies, from a + want of a proper sense of his perilous situation, I forbear to step + out of the bounds of my province in order to offer any advice which + is not necessary to promote his cure. At the same time, I think it + indispensable to let his friends know the danger of his case the + instant I discover it. An arrangement of his worldly affairs, in which + the comfort or unhappiness of those who are to come after him is + involved, may be necessary; and a suggestion of his danger by which + the accomplishment of this object is to be obtained, naturally induces + a contemplation of his more important spiritual concerns, a careful + review of his past life, and such sincere sorrow and contrition for + what he has done amiss, as justifies our humble hope of his pardon + and acceptance hereafter. If friends can do their good offices at a + proper time, and under the suggestions of the physician, it is far + better that they should undertake them than the medical adviser. They + do so without destroying his hopes, for the patient will still believe + that he has an appeal to his physician, beyond their fears; whereas, + if the physician lay open his danger to him, however delicately he + may do this, he runs a risk of appearing to pronounce a sentence + of condemnation to death, against which there is no appeal, no + hope.... But friends may be absent, and nobody near the patient in + his extremity, of sufficient influence or pretension to inform him of + his dangerous condition. And surely it is lamentable to think that + any human being should leave the world unprepared to meet his Creator + and Judge, ‘with all his crimes broad blown.’ Rather than so, I have + departed from my strict professional duty, and have done that which I + would have done by myself, and have apprized my patient of the great + change he was about to undergo.” + + “In short, no rule, not to be infringed sometimes, can be laid down + on this subject. Every case requires its own considerations; but you + may be assured, that if good sense and good feeling be not wanting, + no difficulty can occur which you will not be able to surmount with + satisfaction to your patient, his friends, and yourselves.”[24] + + In some instances the patient himself is the first to discover, and + this from his own internal feelings, that he is about to die, and he + announces the fact calmly, and for the most part without alarm, to + those about him. + + Although a fear of death in itself, or for one’s own sake, is rare + and exceptional, the last moments of too many are made miserable by + solicitude for those they will leave behind, and their end is often + one of great _mental_ anguish. “Such have clung to life anxiously, + painfully, but they were not influenced so much by a love of life for + its own sake, as by the distressing prospect of leaving children, + dependent upon them, to the mercy of the world, deprived of their + parental care.”[25] + + * * * * * + + In some dying persons consciousness and the intellect remain perfect + to the last. The cases in which this is observed will be found to + agree in the fact that the brain is correspondently unimpaired; they + are for the most part chronic diseases of the chest and abdomen. If + the character of the dying person is naturally strong, the state of + his mind at the approach of death will generally be influenced by it. + Of those who retain consciousness and intellect, the majority die + thinking and acting in accordance with the influences that have been + exerted upon them in previous life, by education and example: and with + those which may be then brought to bear upon them, towards and at its + close. + + More often some delirium is present. The delirium of the dying is + often of a most interesting character, and according to Dr. Symonds + resembles dreaming more than any form of derangement. The ideas are + derived less from present perceptions than in insanity, and yet are + more suggested by external circumstances than in the delirium of + fever and phrenitis.[26] Such delirium is generally shown in quiet + talkativeness, which becomes later on a low muttering. In some the + mind is occupied on the events of childhood and early life, but + when the delirium is somewhat more active, the conceptions of the + dying man are generally derived from subjects, which, either in his + speculative pursuits or in the business of life, have principally + occupied his thoughts.[27] Lord Tenterden, as he approached his end, + became delirious and talked very incoherently. Afterwards he seemed to + recover his composure, and raising his head from his pillow, he was + heard to say in a slow and solemn tone, as when he used to conclude + his summing up, in cases of great importance, “And, now, Gentlemen + of the Jury, you will consider of your verdict.” These were his last + words; when he had uttered them, his head sunk down, and in a few + minutes he expired without a groan.[28] And the last words of Dr. + Armstrong were addressed to an imaginary patient, upon whom he was + impressing the necessity of attention to the state of the digestive + organs. + + Instances occur, and not very rarely, where the delirium ceases, and + the mind again for a time becomes clear and the sensations keen, to + be followed, however, ere long by a return of delirium, or it may + be of coma, or a rapid sinking of all the bodily powers and speedy + death. But along with this temporary clearing of the mental powers, + and in proof of its illusiveness, there are the usual signs of bodily + failure--a pinching of the features, coldness of the surface, cold + sweats, and a feeble rapid pulse. + + Active delirium and violence are but rarely associated with the act + of dying,--they are indeed scarcely compatible with it. They may pave + the way to it, but when the act of dying really begins, they cease and + give way to that low, rambling, muttering delirium, with which all + watchers by the death-bed are so familiar. + + It is especially at the stage of transition from the one to the other + of these states, that we meet with that return of intelligence--that + ‘lightening up before death’ which has impressed and surprised mankind + from the earliest ages. “We have all observed,” writes Sir Henry + Halford, “the mind clear up in an extraordinary manner in the last + hours of life, when terminated even in the ordinary course of nature; + but certainly still more remarkably when it has been cut short by + disease, which had affected, for a time the intellectual faculties. We + have seen it become capable of exercising a subtle judgment, when the + passions which had been accustomed to bias and embarrass its decisions + whilst they existed, are extinguished at the approach of death; and + when the inferences which wisdom had drawn from experience of the + former behaviour of men, were now made available to a correct estimate + of their future conduct, in the sense of Milton’s lines--” + + ‘When old experience does attain + To something like prophetic strain.’[29] + + “This is most frequently the case when the resistance of the + constitution against the influence of the disease has been long + protracted, or when the struggle, though short, has been very + violent.”[30] + + “A young gentleman of family, about twenty-five years of age, took + cold whilst under the influence of mercury. The disease increased + daily until it was accompanied at last, by so much fever and delirium, + as made it necessary to use, not only the most powerful medicines, + but also personal restraint. At length, after three days of incessant + exertion, during which he never slept for an instant, he ceased to + rave, and was calm and collected. His perception of external objects + became correct, and they no longer distressed him, and he asked + pressingly if it were possible that he could live? On being answered + tenderly, but not in a way calculated to deceive, that it was probable + he might not, he dictated some affectionate communications to his + friends abroad, recollected some claims upon his purse, ‘set his + house in order,’ and died the following night. The reason why so + unfavourable an opinion was entertained of his state, was, that the + apparent amendment was not preceded by sleep, and was not accompanied + by a slower pulse; two indispensable conditions--on which only a + notion of real improvement could be justified. But here was merely + a cessation of excitement occasioned by a diminution of power, and + by a mitigated influence of the action of the heart upon the brain.” + This case occurred in the practice of Sir Henry Halford.[31] Another + instance, the counterpart to that just described, which happened to + the same eminent physician, may not be out of place. + + A young gentlemen, who had also been using mercury very largely, + caught cold, and became seriously ill with fever. “His head appeared + to be affected on the fifth day, and on the seventh, when I was first + called into consultation with another physician, who had attended him + with great care and judgment from the commencement of his illness, we + found him in the highest possible state of excitement. He was stark + naked, standing upright in bed, his eyes flashing fire, exquisitely + alive to every movement about him, and so irascible as not to be + approached without increasing his irritation to a degree of fury.... + On the eleventh day of his disease, I was informed by my colleague, + when we met, and by the attendants, that he was become quite calm, + and seemed much better. It was remarked, indeed, that he had said + repeatedly, that he _should die_; that under this conviction he had + talked with great composure of his affairs; that he had mentioned + several debts which he had contracted, and made provision for their + payment,--that he had dictated messages to his mother, expressive of + his affection, and had talked much of a sister who had died the year + before, and whom, he said, he knew he was about to follow immediately. + To my questions, whether he had slept previously to this state of + quietude, and whether his pulse had come down, it was answered, No; + he had not slept, and his pulse was quicker than ever. Then it was + evident that this specious improvement was unreal, that the clearing + up of his mind was a mortal sign, ‘a lightening before death,’ and + that he would _die forthwith_. On entering his room he did not + notice us; his eyes were fixed on vacancy, he was occupied entirely + within himself, and all that we could gather from his words was some + indistinct mention of his sister. His hands were cold, and his pulse + immeasurably quick--he died that night.”[32] + + Some pass away in sleep. In natural healthy sleep respiration becomes + slower, the pulse weaker and less frequent, the circulation generally + feebler. The difference in these respects between the waking and the + sleeping states, is to the dying person often the difference between + life, and death. The circulation already reduced to the lowest ebb + compatible with life, is yet further reduced by sleep, and with this + reduction the patient dies. These are those who ‘sleep away.’ Similar + to, if not identical with them, are those to whom death comes so + easily that not a ruffle disturbs any portion of the frame, and the + most intelligent observer is unable to fix the moment when life has + fled, so easy is the parting of the last link, ‘when the body drops + to earth and the soul rises to eternity.’ It is probable that here, a + mere act of dozing becomes the act of dying. In these instances as in + old age, death is literally the last sleep, _uncharacterized_ by any + peculiarity. The general languor of the functions in the _last_ waking + interval, is attended with no peculiar suffering, and the last sleep + commences with the usual grateful feelings of repose.[33] + + The length of the interval between insensibility and the absolute + cessation of existence, varies greatly from a few seconds to several + hours or days. But consciousness is often retained much longer than + is generally supposed, and it is difficult to determine when the + external senses, and particularly that of hearing, are completely and + absolutely closed. + + The senses of smell, taste, and touch are generally the first to + fail us and disappear, while those of sight and hearing continue much + longer. + + Abnormal visual impressions are common when death is near at hand. In + many the sight fails,--there is complaint of commencing or of actual + darkness, and a desire is expressed for more light; while more rarely, + the dying one perceives a blaze of light, in the contemplation of + which, or immediately afterwards, he calmly expires. “It happens not + unfrequently,” writes Dr. Symonds in his admirable essay on Death,[34] + “that the spectra of the dying owe their origin to contemplations + of future existence, and consequently that the good man’s last + hours are cheered with beatific visions and communion with heavenly + visitors. Dreadfully contrasted with such visions are those which + haunt the dying fancies of others.”[35] The testimony of many of + those who have the largest experience, and have watched _continuously + and attentively_ at the dying bed, is in support of Dr. Symonds’ + statement. If some physicians are incredulous, and place little + reliance on testimony and inferences of this kind, I am inclined with + Dr. Conolly[36] to attribute it, to their being seldom engaged long + enough in watching by the bedside, where the senses and thoughts + naturally become concentrated on the events of the sick chamber + alone. My own observation in cases, where circumstances have made my + attendance on the dying close and protracted, goes to corroborate the + evidence there is on these points--points which are certainly not of + a nature to be made familiar to those, whose chief knowledge of the + dying is acquired in formal consultations, or in short daily visits to + the wards of hospitals. + + Hearing is, probably in most cases, the last of our senses to leave + us. “An elderly lady had a stroke of apoplexy; she lay motionless, and + in what is called a state of stupor, and no one doubted that she was + dying. But after the lapse of three or four days, there were signs + of amendment, and she ultimately recovered. After her recovery she + explained that she did not believe that she had been unconscious, + or even insensible, during any part of the attack. She knew her + situation, and heard much of what was said by those around her. + Especially she recollected observations intimating that she would very + soon be no more, but that at the same time she had felt satisfied that + she would recover; that she had no power of expressing what she felt, + but that nevertheless _her feelings, instead of being painful or in + any way distressing, had been agreeable rather than otherwise_. She + described them as very peculiar--as if she were constantly mounting + upwards, and as something very different from what she had ever before + experienced.”[37] + + The case of Dr. Wollaston the physician and chemical philosopher is to + the same effect. “Some time before his life was finally extinguished + he was seen to be pale, as if there was scarcely any circulation + of blood going on--motionless, and to all appearance in a state of + complete insensibility. Being in this condition, his friends who were + watching round him, observed some motions of the hand which was not + affected by the paralysis. After some time it occurred to them, that + he wished to have a pencil and paper, and these having been supplied, + he contrived to write some figures in arithmetical progression, which + however imperfectly scrawled, were yet sufficiently legible. It was + supposed that he had overheard some remarks respecting the state in + which he was, and that his object was to show, that he preserved his + sensibility and consciousness. Something like this occurred some hours + afterwards, and immediately before he died, but the scrawl of these + last moments could not be deciphered.”[38] + + “I have been curious,” writes Sir Benjamin Brodie in commenting on + these cases, “to watch the state of dying persons in this respect, + and I am satisfied,” (and I may add, my own experience confirms Sir + Benjamin Brodie’s statement) “that, where an ordinary observer would + not for an instant doubt that the individual is in a state of complete + stupor, the mind is often active even at the very moment of death. A + friend of mine, who had been for many years the excellent chaplain of + a large hospital, informed me, that his still larger experience had + led him to the same conclusion.”[39] + + Instances such as these should teach the physician and all who are + about the dying, to be careful neither to say, nor do anything in the + presence of the patient, which they would wish him not to hear. Their + bearing on religious offices to the dying is obvious. + + * * * * * + + Sometimes, immediately preceding the very act of death, the eyelids + are raised, and a look of recognition of those around seems to be + permitted to the dying man. Less often there is an expression of agony + in the eye. “It is consolatory to know,” says Sir Charles Bell, “that + this does not indicate suffering, but increasing insensibility. The + pupils are turned upwards and inwards. This is especially observed + in those who are expiring from loss of blood. It is the strabismus + patheticus orantium of Boerhaave.”[40] + + The nature of the disease and the mode of death exert a marked + influence on the expression of face of the dying, and this is + often retained by the features after death. In some we observe the + impress of the previous suffering, as in peritonitis and in cases + of poisoning by irritants; in others the character is derived from + a peculiar affection of some part of the respiratory apparatus; or + from an affection of the facial muscles themselves, as in tetanus + and paralysis. But the condition of the mind is perhaps more often + concerned in the expression than even the physical circumstances of + the body. For, as some kind of intelligence is frequently retained, + and strong emotions are experienced till within a few moments of + dissolution, the features may be sealed by the hand of death in the + last look of rapture or of misery, of benignity or of anger. Every + poetical reader knows the picture of the traits of death (no less + true than beautiful) drawn by the author of “The Giaour.” But such + observations are not confined to poets. Haller could trace in the + dying countenance the smile which had been lighted by the hope of + a happier existence. “Adfulgentis fugienti animæ spei non raro in + moribundis signa vidi, qui serenissimo vultu non sine blando subrisu, + de vita excesserunt.”[41] + + + FOOTNOTES: + + [1] “At nostris temporibus, Medici quasi religio est, ægrotis, postquam +deplorati sint, assidere; ubi meo judicio, si officio suo, atque +adeo humanitati ipsi deesse nolint, et artem ediscere et diligentiam +præstare deberent, qua animam agentes facilius et mitius e vita +demigrent--Hanc autem partem, inquisitionem de _Euthanasia_ exteriori +(ad differentiam ejus euthanasiæ quæ animæ præparationem respicit) +appellamus; eamque inter desiderata reponimus.” (Verulamus, De +Augmentis Scientiarum, lib. iv. cap. ij.) + + [2] “Εὐθανασία naturalis nobis dicitur facilis et quam minimo cum +cruciatu e vita exitus, qua tenus moriendi facilitas e causis +naturalibus proxime pendet.... Ad medicinam hujus εὐθανασίας +contemplatio pertinet: est enim naturalis, non moralis, nisi qua tenus +hæc ad illam momenti habet plurimum. Exteriorem idcirco Verulamius +appellavit.” (Nicolai Paradysii, Opuscula Academica, 8vo, Lugd. Batav, +1813. Oratio de Εὐθανασία naturali et quid ad eam conciliandam Medicina +valeat, pp. 63 et 65.) + + [3] “A medicis vix inchoatum, nedum pertractatum huc usque esset.” +(Paradysius, p. 63.) + + [4] “Etiam plane censeo ad officium medici pertinere, non tantum ut +sanitatem restituat: verum etiam ut dolores et cruciatus morborum +mitiget: neque id ipsum solummodo, cum illa mitigatio doloris, veluti +symptomatis periculosi, ad convalescentiam faciat et conducat: imo vero +cum abjecta prorsus omni sanitatis spe, excessum tantum præbeat e vita +magis lenem et placidum. Siquidem non parva est felicitatis pars, illa +Euthanasia.” (De Augmentis Scientiarum.) + + [5] Sir Henry Halford, Essays and Orations read and delivered at the +Royal College of Physicians. Third edition, 12mo, London, 1842. p. 84. + + [6] “Magnus ille veræ philosophiæ instaurator Verulamus, queritur +studium Euthanasiæ medicis haud satis cultum fuisse. Medici profecto +munus est ægrotis sanitatem reddere; cum tamen ex lege naturæ erit +tandem unicuique mortalium ægrotatio nulla arte medicabilis, benevolæ +hujus artis professoribus conveniret, mortem inevitabilem, quantum +fieri potest, terrore omni spoliare; et ubi non datum est prædam morti +extorquere, sed vita necessario amittenda est, operam saltem dare, +ut cum minima crudelitatis specie amittatur.” (Heberdeni Gulielmi, +Commentaria de Morborum Historia et Curatione. Cap _De Ileo_.) + + [7] Essays and Orations, _ut supra passim_. + + [8] John Ferriar, M.D., Medical Histories and Reflections. 8vo, London, +1798. Vol. iii. p. 196. + + [9] John Ferriar, M.D., On the Treatment of the Dying, _ut supra_, p. +191. + + [10] The Works of Sir Benjamin Collins Brodie. Arranged by Charles +Hawkins. 3 Vols., 8vo, London, 1865. Vol. i. p. 184. + + [11] On Life and Death. 8vo. London, 1863, p. 175. + + [12] “Ipsæ animæ discessus a corpore fit, sine dolore, et fit plerumque +sine sensu, _nonnunquam etiam cum voluptate_.” (Vopisci Fortunati +Plempii. de Togatorum Valetudine tuenda Commentatio. 4to. Bruxellis, +1670. p. 26.) + + [13] Autobiographical Memoir of Sir John Barrow, Bart. 8vo, London, +1847, p. 398. + + [14] “A sailor who had been snatched from the waves, after lying for +some time insensible on the deck of the vessel, proclaimed on his +recovery that he had been in Heaven, and complained bitterly of his +being restored to life as a great hardship. The man had been regarded +as a worthless fellow; but from the time of the accident having +occurred, his moral character was altered, and he became one of the +best conducted sailors in the ship.” (The Works of Sir Benjamin Brodie, +vol. i. p. 184.) + + [15] I was once told by a near relative of mine--says De Quincey--that +having in her childhood fallen into a river, and being on the very +verge of death but for the assistance which reached her at the +last critical moment, she saw in a moment her whole life, clothed +in its forgotten incidents, arrayed before her as in a mirror, not +successively, but simultaneously; and she had a faculty developed as +suddenly for comprehending the whole and every part. The heroine of +this remarkable case, continues De Quincey, was a girl about nine +years old; and there can be little doubt that she looked down as +far within the _crater_ of death--that awful volcano--as any human +being ever _can_ have done that has lived to draw back and to report +her experience. Not less than ninety years did she survive this +memorable escape, and I may describe her as in all respects a woman +of remarkable and interesting qualities. She enjoyed throughout her +long life serene and cloudless health; had a masculine understanding; +reverenced truth not less than did the Evangelists; and led a life +of saintly devotion, such as might have glorified Hilarion or Paul! +I mention these traits as characterising her in a memorable extent, +that the reader may not suppose himself relying upon a dealer in +exaggerations, upon a credulous enthusiast, or upon a careless wielder +of language. Forty-five years had intervened between the first time +and the last time of her telling me this anecdote, and not one iota +had shifted its ground amongst the incidents, nor had any of the most +trivial of the circumstances suffered change. How long the child lay in +the water was probably never inquired earnestly until the answer had +become irrecoverable: for a servant to whose care the child was then +confided, had a natural interest in suppressing the whole case. From +the child’s own account it would seem that asphyxia must have announced +its commencement. A process of struggle and deadly suffocation was +passed through half-consciously. This process terminated in a sudden +blow apparently _on_ or _in_ the brain, after which there was no pain +or conflict: but in an instant succeeded a dazzling rush of light; +immediately after which came the solemn apocalypse of the entire past +life. (De Quincey’s Works, Edinb., 1862, Vol. I., Confessions of an +English Opium-Eater, p. 259.) Sir Dyce Duckworth reminds us that the +mental condition of some who have been put to sleep with anæsthetics +may throw some light on this matter. “Patients,” says he, “have told +us they dreamed they were transported from earth and carried off +into space, were supremely happy and at rest: but that on gradually +recovering consciousness, they seemed to light back again upon this +world, were most reluctant to leave the Elysium they had reached, and +to recommence their earthly toils and struggles.” (The Agony of Dying, +in Monthly Paper of the Guild of St. Barnabas for Nurses. Vol. iii. p. +81). + + [16] J. A. Symonds, M.D., Art. Death, in the Cyclopædia of Anatomy and +Physiology, 4 vols., royal 8vo, Lond. Vol. i. p. 800. + + [17] Halford, p. 18. + + [18] Halford, p. 14. + + [19] Savory, _ut supra_, p. 178. + + [20] p. 74. + + [21] On Life and Death, 8vo, London, 1863, p. 177. + + [22] Brodie _ut supra_, p. 185. + + [23] “I think there is reason for affirming that the risk of evil from +this cause is rated generally above the truth. In cases of imminent +danger, the mind is not always, or even commonly, to be interpreted +by the rule of health. Mental emotions are often altered in kind, +or greatly abated in degree. Death itself is beheld under different +views--a fact familiar to all who have watched over these scenes, and +regarded the patient apart from those who are grieving around his +death-bed. Suspicion of a painful truth often disturbs much more than +the truth plainly stated.” (Sir Henry Holland’s Medical Notes and +Reflections. Third edition, 8vo. Lond. 1853, p. 362). + + [24] Halford, p. 76. + + [25] Halford, p. 75. + + [26] Cyclopædia of Anatomy and Physiology, art. Death, vol. i. p. 799. + + [27] Symonds _ut supra_, p. 799. + + [28] Lord Campbell, Lives of the Chief Justices of England, vol. i. + + [29] On the Καῦσος of Aretæus, p. 96. + + [30] Halford, On the Cautious Estimation of Symptoms, p. 17. + + [31] Halford _ut supra_, p. 19. + + [32] On the Καῦσος of Aretæus, p. 91. + + [33] A. P. Wilson Philip, On Sleep and Death, 8vo, London, 1834, p. 165. + + [34] Cyclopædia of Anatomy and Physiology, vol. i. p. 799. + + [35] Dr. Symonds continues, “The previous habits and conduct of the +individual have sometimes been such as to incline spectators to +inquire, whether in the mode of his departure from existence, he +might not already be receiving retribution, just as, in other cases, +celestial dreams and colloquies have seemed fitting rewards for +blameless lives and religious meditation.” + + [36] Cyclopædia of Practical Medicine, art. Disease, vol. i. p. 629. + + [37] Brodie, _ut supra_, vol. i. p. 281. + + [38] Brodie _ut supra_, p. 182. + + [39] Brodie, p. 182. + + [40] The Anatomy and Philosophy of Expression. Fourth Edition, 1847, p. +185. + + [41] Symonds, _ut supra_, p. 803. + + + + + II. + + THE SYMPTOMS AND MODES OF DYING. + + + It is often difficult to determine when the act of dying really + begins. Practically, it should be dated from the moment when the + physician concludes from reliable signs, not only that the disease + under which the patient labours is incurable by nature or art, _but + that the vital powers are already so utterly reduced that they are + beyond the possibility of restoration_.[42] And on these points + the Father of Physic is perhaps still our best guide. A sharp and + pinched nose, the eyes sunk in the orbits and hollow, the ears + pale, cold, shrunk, with their lobes inverted, and the face pallid, + livid, or black; these together make up the celebrated _facies + Hippocratica_,[43] and show that the work of dying has commenced, and + has already made some progress. They are signs of utter exhaustion + in the circulation and in the muscular system, and they point to a + loosening of all the bonds[44] by which being is held together in the + human frame. + + To these may be added the glazed half-closed eye; the dropped jaw and + open mouth; the blanched, cold, and flaccid lip; cold clammy sweats on + the head and neck; a hurried, shallow respiration on the one hand, or + slow, stertorous breathing with rattle in the throat upon the other; + a pulse irregular, _unequal_, weak, and immeasurably frequent; the + patient prostrate upon his back; and sliding down towards the foot + of the bed; his arms and legs extended, naked, and tossed about in + disorder; the hands waved languidly before the face, groping through + empty air, fumbling with the sheets, or picking at the bedclothes. + These latter symptoms come on for the most part later in the series; + they are the immediate precursors of death, and show that that event + is near at hand. + + More or fewer of these phenomena are to be seen in most dying + persons; but they vary in number and character, in the order of their + appearance, and in their combination, according to the nature of the + disease in the course of which they occur, and of the mode of dying + to which they severally tend. “Although,” says Sir Thomas Watson, + “all men must die, all do not die in the same manner. In one instance + the thread of existence is suddenly snapped, the passage from life + and apparent health perhaps to the condition of a corpse is made in + a moment: in another the process of dissolution is slow and tedious, + and we scarcely know the precise instant in which the solemn change + is complete. One man retains possession of his intellect up to his + latest breath; another lies unconscious and insensible to all outward + impressions for hours or days before the struggle is over.”[45] + + Whatever may be the remote causes of dissolution, the modes in which + death is actually brought about vary remarkably, according as it + begins in the heart, in the lungs, or in the brain. + + Death beginning at the heart is sometimes instantaneous. Suddenly + and without warning of any kind, the heart ceases to beat, the + individual turns pale, falls back or drops down and expires with one + gasp. But oftener, death takes place slowly, there is a more or less + lengthened period of exhaustion, and death occurs in the way either of + syncope, or of asthenia. The phenomena which attend dying by syncope + are described by Sir Thomas Watson as “paleness of the face and lips, + cold sweats, dimness of vision, dilated pupils, vertigo, a slow, + weak, irregular pulse, and speedy insensibility. With these symptoms + are frequently conjoined nausea and even vomiting, restlessness and + tossing of the limbs, transient delirium; the breathing is irregular, + sighing, and, at last, gasping; and convulsions generally occur, + and are once or twice repeated before the scene closes.”[46] When + death occurs from asthenia or failure of contractile power in the + heart, “the pulse becomes very feeble and frequent, and the muscular + debility extreme, but the senses are perfect, the hearing is sometimes + even painfully acute, and the intellect remains clear to the last.”[47] + + Death beginning at the lungs, from asphyxia or suffocation, is marked + by laborious heaving of the chest, strong but ineffectual contractions + of the respiratory muscles, distress about the breast; “the face + at first becomes flushed and turgid, then livid and purplish, the + veins of the head and neck swell, and the eyes seem to protrude from + their sockets. There is vertigo, then loss of consciousness, and + then convulsions.”[48] The livid face and laboured breathing are + accepted as evidence of severe bodily suffering, but they are only + partially so, for the circulation of undecarbonized blood on which + they severally depend, through the brain, in common with other + parts of the frame, first benumbs sensibility, and then abolishes + it altogether. “Disturbance of respiration,” says Dr. Ferriar,[49] + “is often the only apparent source of uneasiness to the dying, but + sensibility seems to be impaired in exact proportion to the decrease + of that function.” + + Death beginning at the brain destroys life indirectly--by its + influence on the lungs or on the heart, and so by the way of coma or + of asthenia. In death by coma there is “stupor more or less profound; + the sensibility to outward impressions is destroyed, sometimes + wholly and at once, much oftener gradually; the respiration becomes + slow, irregular, stertorous; all voluntary attention to the act of + breathing is lost, but the instinctive motions continue. At length + the chest ceases to expand, the blood is no longer aërated,”[50] and + thenceforward precisely the same internal changes occur as in death, + beginning at the lung. It is in this way that most fatal disorders + of the brain produce death. When death starting from the brain acts + through the heart, it occurs somewhat suddenly, and in the way of + shock, as in some of the worst cases of apoplexy--the “apoplexie + foudroyante,” for example--or more slowly, in the way of exhaustion or + asthenia, as in some cases of delirium tremens, or of phrensy--and as + happened in the two cases described at pages 36 and 38. + + The several modes of dying described above, are often combined in + the same person, complicating the process and confusing our views of + it; with the effect too, in some cases, of increasing the sufferings + of the dying, but in others of lessening them. Thus coma, from + implication of the brain supervening on diseases of the lung, first + lessens the perception of the distress and anguish which attend + them, and then extinguishes it. These mixed forms of death are seen + especially in fevers. + + + FOOTNOTES: + + [42] “At Medicus moriendi initium altius repetet, et jam ab eo inde +tempore ducet, quo signis minime dubiis cognoverit, morbum naturæ +artique non tantum insuperabilem esse, sed et sub eo vires sic perire +ut reparari nequeant.” (Paradys, Oratio de Εὐθανασία naturali, p. 67). + + [43] In the words of Lucretius, vi. 1, 190-- + +“Item, ad supremum denique tempus, Compressæ nares, nasi primoris +acumen Tenue, cavatei oculei, cava tempora; frigida pellis, Duraque, +inhorrebat tactum; frons tenta meabat: Nec nimio rigida post artus +morte jacebant.” + +Or, as rendered by an accomplished physician, Dr. Mason Good-- + +“Then, tow’rds the last, the nostrils close collaps’d; The nose +acute; eyes hollow; temples scoop’d; Frigid the skin, retracted; o’er +the mouth A ghastly grin; the shrivell’d forehead tense; The limbs +outstretch’d for instant death prepar’d.” + + [44] “Omnia tum vero vitai claustra lababant.” (Lucretius, vi. 1,151). + +“Then all the powers of life were loosen’d.” (Mason Good). + + [45] Lectures on the Principles and Practice of Physic. Fifth edition, +2 vols. 8vo, London, 1871, vol. i. p. 62. Sir Thomas Watson in his +admirable lecture on the Different Modes of Dying, has treated the +whole subject so graphically, that I shall follow him as closely as +possible in what I have to adduce on this part of my subject. + + [46] Watson, p. 66. + + [47] Watson, p. 68. + + [48] _Ibid._, p. 70. + + [49] On the Treatment of the Dying. Medical Histories and Reflections. +Vol. iii. p. 195. + + [50] Watson, p. 76. + + + + + III. + + THE GENERAL AND MEDICAL TREATMENT OF THE DYING. + + + Many of the sufferings of the death-bed are not naturally or + necessarily incident to the act of the dying; but are due to + surrounding circumstances that admit of alteration or removal. Thus, + restlessness and jactitation are often due to the weight of the bed + coverings, and are at once removed by lightening them;--difficulty + of breathing and gasping, increased by the heat and closeness of the + chamber, are removed by the admission of fresh and cooler air, by + change of posture and by pillows carefully adapted to the efficient + support of the trunk of the body. + + There is nothing of greater importance in the treatment of the dying + than the right administration of nutriment. Errors in feeding are the + cause of much of the disquietude and of many of the sufferings that + attend the dying. The sinking and exhaustion that are in progress + throughout the system, are assumed by the attendants to demand a free + administration of food and stimulants, forgetting that the stomach + shares in the exhaustion, and has lost its tone, and in great part, if + not wholly, its power of digesting. Food is given too frequently, and + in quantities too large. The dying person is induced by the wearisome + importunity of his attendants to take food or stimulants, against + which nature and his stomach revolt. The evident dislike and loathing + with which he submits, the difficulty he has in swallowing it, and the + urging and retching which that act sometimes induces, ought to save + him from what is really under the circumstances an act of cruelty. + “Here,” to use the words of Sir Henry Holland, “we are called upon to + maintain the cause of the patient, for such it truly is, against the + mistaken importunities which often surround him, and which it requires + much firmness in the physician to put aside.”[51] The wishes of the + patient himself, when he has reached the stage of existence here + contemplated, may generally be taken as a correct indication in all + that relates to the administration of food and stimulants. + + Food when unwisely given, accumulates in the stomach, distends and + distresses it, and impedes the respiration. Under such circumstances + the pit of the stomach will be found tumid and tense, dull upon + percussion, and intolerant of pressure. At length some of the contents + of the distended stomach regurgitate into the throat or mouth; or + there may be actual vomiting, and this to the evident relief of the + sufferer. Hiccup is often due solely to an overloaded and distended + stomach. + + Much discretion is needed in fixing on the kind and quantity of food + to be given. Something will depend on the character of the disease + under which the patient is sinking; and something on the length of + time he is likely to survive. If the act of dying is likely to be + protracted, as it often is in cancer and some cases of consumption, + where death is brought about by slowly progressive exhaustion, the + food should be supporting and in somewhat larger quantity. I have + long doubted whether strong beef tea and meat extracts are as a rule + of much use, or are appropriate when the act of dying has really + commenced. Milk, cream, beaten eggs, and the farinacea are far better. + They are, too, the best vehicles for wine and spirits; and they have + less tendency than soups to become offensive in the stomach. + + Alcohol in its fermented or distilled forms is of special use in + the treatment of the dying. Owing to its high diffusive power it + passes readily into the blood. It stimulates the failing heart, and + thus promotes the circulation through the lungs, which is one of + its most valuable properties in the dying. It may perhaps increase + the secretion of the gastric juice; it more probably stimulates + the peristaltic movements of the stomach, and by so much, aids the + digestive process, and supports the patient in the best and most + natural manner. Stimulants and nutriment should as a rule be given + together for they mutually influence each other. + + The quantity of wine or spirit which is needed varies exceedingly, + and no definite rule can be laid down on this point. They should be + given in small quantities at a time and repeated at short intervals + before the effects upon the heart and pulse of the previous dose have + subsided. + + Of wines, sherry is perhaps the most useful. Port, if preferred + by the patient, may be substituted, but I have not found it, as a + rule, to agree as well as sherry. Madeira from its slight acidity is + specially agreeable to the palate, and is besides the most sustaining + and cordial of wines. But tokay is often more acceptable than any + other wine, especially to those sinking from exhausting diseases, as + hemorrhage, profuse suppuration, and the like. It is best given with + cream. The stimulus of these wines is longer maintained than is that + of other forms of alcohol. Champagne is most refreshing and is often + eagerly taken; but its effects are evanescent and it needs repeating + at shorter intervals than other wines. A teaspoonful of brandy, or of + some liqueur may sometimes be advantageously added to it. + + Sometimes brandy answers better than any wine, especially if the + stomach is irritable and there is nausea or vomiting. As a mere + stimulant it is best administered with yolk of egg and sugar, as + is Sir Henry Halford’s celebrated mixture--the Mistura Spiritus + Vini Gallici of the Pharmacopœia. If brandy is used for its special + tranquillizing influence on an irritable stomach, it may be given + neat, in drachm doses, or in double that quantity in a little simple, + or in one of the aërated, waters. The wish of the patient for any + particular form of stimulant is almost always a correct indication for + its use. + + The dry and parched condition of the tongue and mouth so common in the + dying, and the inextinguishable thirst that attends some forms of it, + need constant attention. A spoonful of iced-water repeated frequently + will be a great comfort. So, too, is a small bit of ice allowed to + dissolve in the mouth--or lemonade--or weak black tea without milk, + and slightly acidulated with a slice of lemon. + + In the case of nutriment and stimulants as of mere diluents, it is to + be understood--supposing there is nothing to forbid--that so long as + the lips close upon them, and an act of swallowing follows _promptly_, + they may be continued: but when liquids seem merely to trickle down + the throat, and after a time, only to excite a faint effort of + swallowing, they should no longer be persisted in. The sensibility + of the parts is so diminished that the patient is insensible to the + stimulus of the liquid, and we infer _a fortiori_ to the dry and + parched state of the mouth and fauces. If, after rubbing the lips + gently with the spoon, or with the spout of the feeding vessel, no + evident and distinct act of swallowing follows, it is useless, and + it may be cruel to persist; the liquid will but clog the mouth and + fauces, add to the impediment to breathing, and by so much, if any + consciousness remains, to the sufferings of the dying. + + * * * * * + + Next in value to stimulants in the treatment of the dying is opium. + It is a tradition that John Hunter used often to exclaim, “Thank God + for opium,”[52] and under no circumstances are we bound to be more + thankful for it then when ministering at the bedside of the dying. + Opium is here worth all the rest of the materia medica. Its object and + action must however be clearly understood. Opium is administered to + the dying, as an anodyne to relieve pain; or as a cardiac and cordial + to allay that sinking and anguish about the stomach and heart, which + is so frequent in the dying, and is often worse to bear than pain, + however severe. Opium should rarely be administered to the dying as a + mere hypnotic, or with a view to enforce sleep. To do so would be to + risk throwing the patient into a sleep from which he may not awake. + But opium often induces sleep indirectly, and in the kindest way, by + the relief of pain,[53] or sinking that had hitherto rendered sleep + impossible. + + For the relief of pain in the dying wherever it may be situated, + we have our one trustworthy remedy in opium. Heberden writes, “In + impetu autem doloris, ubi ubi is fuerit, opium est unicum remedium.” + If judiciously and freely administered it is equal to _most_ of the + emergencies in the way of pain, that we are likely to meet with in the + dying,[54] whereas if timidly and inadequately used, the sufferer is + deprived of the relief which it alone is capable of affording. + + The value of opium in allaying pain, great as that is, is however + second to its value in relieving the feeling of exhaustion and + sinking--of indescribable distress and anxiety--referred to the + stomach and heart, which so often attends some part of the act of + dying. To the practised eye, this condition is evidenced, as much + by the pinched features, pallid complexion, and _anxious expression + of face_, as by any verbal complaint of the sufferer. Here the + action of opium is that of a cordial in the fullest sense of the + word. “Of all cordials,” says Sydenham, “opium is the best that has + hitherto been discovered. I had nearly said,” adds he, “that it is + the only one.”[55] “Under the protection of an opiate,” writes Dr. + Heberden,[56] “the patient’s strength has been kept up, and even in + hopeless cases in which the dying person is harassed by unspeakable + inquietude, he may be lulled into some composure, and without dying + at all sooner may be enabled to die more easily.” I know of nothing + in our attendance on the dying more gratifying, than to witness the + improvement in face, feature, and expression, that marks the kindly + action of opium under these circumstances. In an hour or thereabouts, + after it has been taken, some colour returns to the face, the features + lose somewhat of their sharpness, a placid expression replaces the + look of anxiety, and the sufferer passes into an easy, gentle sleep, + from which he awakes refreshed and comforted, and helped as it would + seem, to die more easily, when his time arrives. Hufeland, writing at + the end of a long professional life, did not hesitate to declare that + opium “is not only capable of taking away the pangs of death, but it + imparts even courage and energy for dying.”[57] + + Opium must be administered in such doses as will appease suffering and + disorder, and in this respect we are to be governed solely by the + effect and relief afforded. The dose for an adult should be rarely + less than a grain, but oftener more. “There exists,” writes Sir Henry + Holland, “distrust, both as to the frequency and extent of its use not + warranted by facts, and injurious in many ways to our success;”[58] + “its use is not to be measured timidly by tables of doses, but by + fulfilment of the purpose for which it is given. A repetition of small + quantities will often fail, which concentrated into a single dose + would safely effect all we require.”[59] + + The effects of opium continue for about eight hours, and if its + action is to be maintained it should be repeated at intervals of + that duration or somewhat less. The dose is to be governed solely by + the relief afforded. Its effects are usually limited to relief of + the pain, or of the sense of sinking for which it has been given, + producing no other direct effect on the system in general. “It would + seem,” says Sir Henry Holland, “that the medicine, expending all its + specific power in quieting these disorders, loses at the time every + other influence on the body. Even the sleep peculiar to opium appears + in such instances to be wanting, or produced chiefly in effect of the + release from suffering.”[60] + + Opium should always be given to the dying in its liquid forms--as the + tincture, or the liquid extract--or as morphia, of which I know of no + preparation of equal value to the solution of the bimeconate. + + So long as the air passages are not obstructed by secretion, so long + as there is neither lividity nor even duskiness of face, opium, if + indicated, may be given in aid of the Euthanasia; but if they are + present, it is hazardous and might hasten death. Much care, too, + is needed in the employment of opium, in cases where the heart is + _greatly enfeebled_, and where the conditions, directly or indirectly + induced by opiates, especially that of sleep, may be just enough + to turn the balance against it. A contracted pupil is also a + contra-indication to opium; it implies a state of the brain, which + opium is likely to increase rather than relieve. And if food has + been injudiciously pressed upon the patient, so that the stomach is + distended with it, and the epigastrium is full and tense, opium given + by the mouth is rarely found to act kindly, if at all. If, under such + circumstances, the influence of opium is needed, we should resort to + the hypodermic injection of morphia. + + Professor Paradys warns us of the confusion of the senses and of the + mind that sometimes follows the administration of opium to the dying, + and which to some persons is worse to bear than the sufferings for + which it has been prescribed.[61] But this, in my experience, has been + rare, and will be seldom observed if opium is restricted to the cases + where, as I have stated above, it is specially called for,--namely, in + relief of pain or of severe sinking. When, however, it does occur in + these circumstances, it is probably due, either to an idiosyncrasy on + the part of the patient, or to the inadequacy of the dose given, which + has been enough to confuse and stupify the senses, but not to control + the symptoms for which it was administered. “Si timide et nimis parce + datum fuerit,” writes Dr. Gregory,[62] “longe alium effectum habebit, + et iisdem ægrotis haud parum nocebit, quibus largius datum multum + profuisset.” + + * * * * * + + Ammonia is inferior as a stimulant to wine and brandy, which are + more palatable and preferable, while as an antispasmodic it is very + inferior to ether. But it is useful where the respiration flags + and the breathing is obstructed by secretion accumulating in the + bronchial tubes, and the complexion is becoming dusky and livid. Five + grains of the carbonate dissolved in camphor water is a good mode + of administering it. Small doses of oil of turpentine are sometimes + more effectual than ammonia. A drachm of the confection of turpentine + rubbed up in peppermint water, is perhaps the best form of giving it. + + * * * * * + + Next in value to opium in its power of alleviating the sufferings of + the dying is ether. It is specially indicated in gasping or spasmodic + difficulty of breathing, whether dependent on the lungs or heart; + and in flatulent distention of the stomach, attended with unavailing + efforts at eructation. These two conditions are often conjoined in the + dying, and then the indication for ether is the strongest. According + to my experience ether is most efficient when given in combination + with a few drops of sulphuric acid, as in the acid infusion of roses, + or better with mint water and sugar, as in the so-called “ether + punch.”[63] Opium or laudanum in somewhat smaller doses than those + recommended above, is often added, with great advantage to ether, when + there is need of a potent antispasmodic. In the paroxysms of severe + præcordial anguish and dyspnœa that characterize many deaths from + organic disease of the heart and great vessels of the chest, relief + must be sought in ether and opium, or from the inhalation of the + nitrite of amyl. + + * * * * * + + The fewer the drugs and the less of medicine we can do with in the + treatment of the dying, the better. Those above mentioned comprise + all I have had occasion for, and if judiciously used, they are equal + to the emergencies we are called upon to meet. I have no wish unduly + to limit the means at our command in aid of the Euthanasia; but when + the stage of existence contemplated in these pages has once been + reached, we dismiss all thought of cure, or of the prolongation of + life, and our efforts are limited to the relief of certain urgent + conditions, such as pain, exhaustion, dyspnœa, spasm, and the like; + for which the remedies mentioned above are to the full as efficient, + if not really more so, than any others as yet known. But no medicine + should be given without a distinct--I had almost written urgent--need + for it; and the physician should form a clear idea of the special + requirements of the case before him, and how, and by what means + they may be best accomplished. In very many cases there is no need + of medicines of any kind, and stimulants and light nourishment + _cautiously_ administered, meet every requirement. But often, and in + almost all cases, at a certain period of their course, the less even + of these that is given the better. “Medici plus interdum quiete, quam + movendo et agendo proficiunt,” writes Livy, and there are few dying + beds, where, just before the last, this precept does not find its + fitting application. “All that the dying person, then, requires is to + be left alone, and allowed to die in peace.”[64] + + “Disturb him not--let him pass peaceably.” + + “The physician,” writes Dr. Ferriar,[65] “will not torment his patient + with unavailing attempts to stimulate the dissolving system, from the + idle vanity of prolonging the flutter of the pulse for a few more + vibrations: if he cannot alleviate his situation, he will protect his + patient against every suffering which has not been attached to it by + nature.” + + As the patient himself is wholly unable to explain what is needful in + his situation, the physician is bound to act for him in regulating the + economy of the bed-chamber. The temperature and ventilation of the + room--the amount of light to be admitted--the degree of quiet to be + maintained in it--must be determined according to the circumstances of + each particular case. + + When the mode of dying is by the lung, and in the way of asphyxia, the + admission of fresh, cool air into the room seems to conduce to the + relief of dyspnœa, and greatly to the comfort of the sufferer. + + The custom of excluding daylight as far as may be from the dying + chamber, and keeping it gloomy and dark, is in every respect a + mistake, and is to be opposed. If there is one thing about his + surroundings which more often than any other is complained of by the + dying, it is of failing sight--of a darkness gathering over him; and a + desire is expressed for more light. + + Talking in an undertone and whispering in the presence of the dying is + to be peremptorily checked. What has to be said, and the less that is + the better, should be in a clear, distinct, ordinary tone, somewhat, + perhaps, below the ordinary.[66] + + The dying chamber is no place for officious interference or obtrusive + curiosity. + + The fewer that are admitted to it the better--the nurse, the minister + of religion, the medical attendant, and the immediate members of the + family, comprise those whose duty and feelings entitle them to be + present. + + “While the senses remain perfect, the patient ought to direct his own + conduct, both in his devotional exercises, and in the last interchange + of affection with his friends.”[67] He will be wise if he does so + under the experienced guidance of his religious adviser. “The powers + of the mind, after being forcibly exerted on these objects, commonly + sink into complete debility, and respiration becoming weaker every + moment, the patient is rendered _apparently_ insensible to everything + around him. But the circumstances of the disease occasion much variety + in this progress.”[68] + + Even when persons appear insensible, it is certain, as I have before + remarked, that frequently they are cognisant of what is passing about + them. “I have known them requested,” says Dr. Elliotson, “to give a + sign that they were still alive by moving a finger, or by interrupting + their breath when to move a finger was impossible: and they have + done so, although believed by many to have been long senseless.”[69] + In many cases there is a sort of lucid interval immediately before + dissolution. This may be perceived by the looks and gestures where the + patient is incapable of speaking. + + When things come to the last and the act of dissolution is imminent, + all noise and bustle about the dying person should be prohibited, and + unless the patient should place himself in a posture evidently uneasy + he should be left undisturbed.[70] The dying are often impatient of + any kind of covering.[71] They throw off the bedclothes and lie with + the chest bare, the arms abroad, and the neck, arms, and legs as much + exposed as possible:--Ubi supinus æger jacet, porrectis manibus et + cruribus, writes Celsus--ubi brachia et crura nudat et inæqualiter + dispergit. “These actions,” writes Dr. Symonds,[72] “we believe to be + prompted by instinct, in order that neither covering nor even contact + with the rest of the body may prevent the operation of the air on the + skin. There are actions and re-actions between the air and the blood + in the skin similar to those which occur in the lungs, and these are + in aid of them.” Such automatic actions ought not to be interfered + with, unless the patient has got into a position evidently distressing + to himself, or except so far as decency requires when there is any + approach to unseemly exposure. + + Exclamations of grief, and the crowding of the family round the bed, + only serve to harass the dying man, writes Ferriar, who adds, “The + common practice of plying him with liquors of different kinds, and of + forcing them into his mouth when he cannot swallow, should be totally + abstained from.” But to this error I have already referred. + + It was a custom in the Middle Ages to strip the dying, drag them from + their beds, and lay them on ashes or on mattresses of straw or hair + upon the floor. It was then wholly or in part a penitential act, and + the influence of this custom has, perhaps, not yet wholly ceased. + “It is,” says Dr. Ferriar,[73] “a prevalent opinion among nurses and + servants that a person whose death is lingering cannot quit life + while he remains on a common bed, and that it is necessary to drag + the bed away and place him on the mattress. This piece of cruelty + is often practised when the attendants are left to themselves. A + still more hazardous practice has been very prevalent in France and + Germany, and I am afraid is not unknown in this country. When the + patient is supposed by the nurses to be nearly in a dying state, they + withdraw the pillows and bolster from beneath the head, sometimes with + such violence as to throw the head back and to add greatly to the + difficulty of respiration. As the avowed motive for this barbarity + is a desire to put the patient out of pain--that is, to put him to + death--it is incumbent on his friends to preserve him from the hands + of those executioners. Perhaps a more deplorable condition can + scarcely be conceived than that of being transferred from the soothing + care of relations and friends, to the officious folly or rugged + indifference of servants.” One would hope that such cruelty is a thing + of the past. My own experience forty years since as a dispensary + physician in the eastern parts of the metropolis, led me to conclude + that it was not _then_ and _there_ wholly unknown or unpractised. What + it may be in remote rural districts, where the class of old, ignorant + and prejudiced nurses still exist, I have no means of knowing. “This + is a state of suffering,” adds Dr. Ferriar, “to which we are all + exposed, and if it were unavoidable, I should be far from desiring + to unveil so afflicting a prospect. But the means of prevention are + so easy, that I cannot forbear to solicit the public attention to + them.”[74] + + In the intelligent trained nurses of the present day, we have the + best security against such barbarity; and when they are absent, in the + presence in the dying chamber, of the relations or nearest friends + until all is over. + + In cases of sudden death from disease of the heart, there is neither + occasion nor time for medical treatment of any sort. Death is + instantaneous and without warning. Where death beginning at the heart + takes place by way of syncope, fresh air and stimulants cautiously + given are the best resources. Wine or brandy, with egg or other + light nutriment, are appropriate. When death is taking place in the + slower way of exhaustion, a like treatment is to be pursued. In the + earlier stage, small quantities of soup, or beef tea may be given, but + when death is near they are best omitted. It is in these cases that + madeira and tokay answer so well. In all cases of dying by failure of + the heart’s action, the posture of the patient should be carefully + adjusted--the head should be low rather than raised, and it and + the shoulders supported on firm pillows. Any approach to the erect + or sitting posture is as a rule to be avoided. Its tendency is to + occasion fainting and death. + + In death from the lungs or by asphyxia the struggle is often + protracted, and accompanied by all those marks of suffering which the + imagination associates with the closing scene of life. Doubtless in + the earlier stages of it, there is real suffering, but happily this is + rarely of long duration, for the circulation of venous blood ensues, + and deadens sensibility and pain. The respirations in this mode of + death become laborious and heaving, the expression of countenance + distressed and anxious. But soon the face becomes tumid and dusky, + the lips livid, and with the circulation of undecarbonized blood, + which these symptoms imply, the anxious expression of face subsides, + and there ensues a slowly increasing benumbing of sensation, and a + corresponding diminution of suffering. The breathing then becomes + irregular and laborious, and the heavings of the chest convulsive; + but these movements are automatic, and independent alike of sensation + and of the will. They soon pass into coma, stertor, rattle in the + windpipe, and death. Stertorous breathing is in great measure due to + affection of the brain or medulla, either primary or secondary. The + latter is the condition we are here contemplating. Stertor seems to + be due to a falling back of the base of the tongue into the pharynx, + and to the obstruction to respiration thence induced; and is increased + by the prone position on the back, into which such patients naturally + fall. It may be relieved by placing the person on one side, and + supporting him in that position by well-arranged pillows. The tongue + then drops to the side of the pharynx and mouth, and leaves room + for the ingoing air. Dr. Bowles, of Folkestone, to whom we owe the + knowledge of these facts, warns us, that care should be taken to keep + the neck rather straight, as, if the chin be brought too near the + sternum, the thyroid cartilage presses upwards and backwards, and + again pushes the base of the tongue, toward the back of the pharynx. + Nothing can be done, indeed nothing is needed, but regulation of the + posture, when coma is established. The head is to be supported on a + firm pillow, or bolster, and slightly raised, but not so much as to + increase the tendency to slide downwards in the bed. Whatever position + of the body is found to lessen the stertor, and ease the breathing + should be maintained. + + In the earlier stages of the process above described--in the condition + which precedes and passes into coma--a carefully adjusted posture of + the patient, in which he is propped up at an angle of not less than + forty-five degrees, and often at one of much more, and due support + is given to the trunk of the body by pillows--will do more than + anything else in relief of embarrassed and laboured breathing. “The + object is to support with the pillows, the back _below_ the breathing + apparatus, to allow the shoulders room to fall back, and to support + the head, without throwing it forward.”[75] The suffering of dying + patients, says Miss Nightingale, is immensely increased by neglect + of these points. If secretions have accumulated in the air passages, + ammonia or turpentine may be administered. Should the breathing be + gasping and spasmodic, ether, with or without opium, should be tried. + When duskiness and lividity of the face have come on, we can do but + little--when deep coma and stertorous breathing, nothing--but adjust + the posture of the patient to the more pressing requirements of the + case. + + When the heart or great vessels of the chest are the seat of the + disease, and the circulation through the lungs is becoming seriously + embarrassed by it, there are often paroxysms of great suffering. The + patient is agonized by a sense of instant suffocation, and sits in or + out of bed, with the head bent forward, resting on a table or other + support, and expecting dissolution every moment. Here ether and opium + is our best resource; or the nitrite of amyl, the cautious inhalation + of which has in some instances given marked relief. + + When death, commencing at the brain, destroys life through the lung, + and in the way of coma, as it usually does, the treatment is the same + as in the coma that occurs late in the series of events which mark + death by asphyxia. When, on the other hand, death, beginning at the + brain, destroys life through the heart and by way of exhaustion, the + treatment is the same as above described for those dying primarily + from the heart and in the way of asthenia. + + * * * * * + + When the face of the dying person is flushed, the head hot, and the + carotid arteries beating forcibly, the head is to be raised and + supported on firm pillows, and ice or a cold spirit lotion applied to + it. + + * * * * * + + In some delicate and highly sensitive persons, a kind of struggle is + sometimes excited when the respiration becomes very difficult.[76] + Dr. Ferriar says he has known this effort proceed so far, that the + patient a very few minutes before death, has started out of bed, and + stood erect for a moment. He ascribed it to apprehension and alarm, + and adds: “Those who resign themselves quietly to their feelings seem + to fare best.” This is probably true, but the sufferer needs whatever + relief art can supply; and ether and opium is the most likely to give + it. + + * * * * * + + Hiccup is somewhat alleviated by a sinapism to the epigastrium, and + a spoonful of aniseed water swallowed slowly. But if it is severe, + shaking the patient, and so adding greatly to his distress, we must + rely on opium given internally, and its application externally to the + pit of the stomach. If hiccup seems to be due, as it often is, to + an overloaded and distended stomach, and the influence of opium is + needed, the hypodermic injection of morphia is to be preferred. + + * * * * * + + Inquietude and restlessness, especially in the half-conscious dying + person, is often due to a distended bladder, and is at once quieted by + the catheter. In others, it is due to the weight of the bedclothes, + and is relieved by lightening them. + + * * * * * + + Coldness of the feet is best met by a foot warmer; and not by thick, + heavy bed clothing, which distresses the sufferer and gives rise to + inquietude and restlessness. “Weak patients,” says Miss Nightingale, + and the dying as much or more so than others, “are invariably + distressed by a great weight of bedclothes.” Light Whitney blankets + should alone be used for coverings under such circumstances. But I + am not sure that coldness of the extremities does always add to the + sufferings of the dying, or needs the consideration usually given to + it. The diminished circulation on which it depends is attended, for + the most part, in the dying by proportionate loss of sensibility; and + besides it is especially when the feet and legs are cold, sodden, and + dank, that we observe that impatience of any covering upon them--that + tossing about and exposure of them to the air--which I have before + described. + + * * * * * + + Death from old age--the natural termination of life, and the + simplest form of death that can occur, creeps on by slow and + almost imperceptible degrees. It is characterised by a gradual and + proportionate decay of all the functions and organs of the body, and + as a rule presents no symptoms that call for special treatment. It + is only where the normal course of decay is disturbed by supervening + disorder, or disease of an important organ, or by surrounding + circumstances, that suffering of any kind attends it. Good nursing, + and the due administration of light food and stimulants, comprise all + that is needed. The approaches to death are so gentle, and the act of + dying so easy, that nature herself provides a perfect euthanasia. + + + THE END. + + UNWIN BROTHERS, PRINTERS, CHILWORTH AND LONDON. + + + FOOTNOTES: + + [51] Medical Notes and Reflections. Third edition, 8vo, London, 1855, +p. 379. + + [52] Robert Willis, M.D., On Urinary Diseases, 8vo, London, 1838, p. +100. + + [53] “When there is a sudden cessation, or intermission, of acute pain, +sleep frequently comes on instantaneously at every such interval of +ease. The records of judicial torture furnish much striking evidence as +to these effects.” (Sir Henry Holland’s Medical Notes and Reflections, +p. 369.) + + [54] I except hydrophobia, tetanus, &c., against which it is almost +powerless. + + [55] “Præstantissimum remedium cardiacum (unicum pene dixerim) quod in +rerum natura hactenus est repertum.” Sydenham Thomæ Opera Omnia, edidit +G. A. Greenhill, M.D., 8vo, London, 1844, p. 175. + + [56] “Vires ægri somno recreatæ sunt, atque etiam ubi salus ejus +prorsus desperata fuerit, et angor summus cruciaverit, opium utique +sollicitudinem aliquantum levavit. Mors quidem neque serius, neque +citius venit, sed tamen minore cum cruciatu.” (Heberden _De Ileo_.) + + [57] Hufeland’s remarks on opium are so valuable that I give them at +length. “Who would be a physician without opium in attendance on cancer +or dropsy of the chest? How many sick has it not saved from despair? +For one of the great properties of opium is, that it soothes not only +corporal pains and complaints, but affords also to the mind a peculiar +energy, elevation, and tranquility. The soothing virtue manifests +itself in the most splendid manner in relieving death in severe cases, +in effecting the euthanasia, which is a sacred duty and the highest +triumph of the physician, when it is not in his power to retain the +ties of life. Here, it is not only capable of taking away the pangs of +death, but it imparts even courage and energy for dying; it promotes +in a physical way even that disposition of mind which elevates it +to heavenly regions. A man who had laboured for a long time under +complaints of the chest and vomicas finally approached death. The most +dreadful anguish of death with a constant danger of suffocation seized +him, he got into real despair and his state was an insurmountable +torment even for the persons around him. He now took half a grain of +opium every hour. After three hours he became quiet, and after he had +taken two grains he fell asleep, slept quietly for several hours, awoke +quite cheerful, free from pain and anxiety, and at the same time so +much strengthened and appeased in his mind, that he bade farewell with +the greatest composure and satisfaction to his relatives, and after +he had given them his blessing and many a good admonition fell again +asleep and passed away while sleeping.” (The Three Cardinal Means of +the Art of Healing, p. 46.) + +Somewhat to the same purport writes De Quincey. “Simultaneously with +the conflict the pain of conflict has departed, and thenceforward +the gentle process of collapsing life, no longer fretted by +counter-movements slips away with holy peace into the noiseless deeps +of the Infinite.” (Confessions of an English Opium-Eater, p. 149.) + + [58] _Ut supra_, p. 516. + + [59] Holland, _ut supra_, p. 518. To the same effect writes Dr. James +Gregory of this remedy, “_Neque dubium est_, utcunque periculosus +videatur usus talis medicamenti vix non venenati; _ægros plus fere +incommodi et damni percepisse a nimis parva, quam a nimia ejus +quantitate_. Medici igitur est, medicamentum adeo validum et sæpe +perniciosum caute et prudenter adhibere, et in illis tantum morbis ad +id confugere, qui aliquid istiusmodi plane requirunt; _ubi vero talis +necessitas urget, oportet remedium libere et cum fiducia præscribere_; +tunc enim non sperare modo potest, sed fere polliceri, se effectum +illum salutarem, quem cupit, per suum medicamentum esse præstiturum. +_Quod si timide et nimis parce datum fuerit_, longe alium effectum +habebit, et iisdem ægrotis _haud parum nocebit, quibus largius datum +multum profuisset_.” (Conspectus Medicinæ Theoreticæ, § MCCXXII.) + + [60] _Ut supra_, p. 518. + + [61] “Audivi plus semel ægros temporarium a narcoticis levamen enixe +deprecantes, quod sensuum obscuratione nimis care querebantur emi.” (p. +71.) + + [62] “Conspectus Medicinæ Theoreticæ,” § MCCXXII. + + [63] + + ℞ Aq. Menthæ Viridis, f. ℥ v ss. + Sacchari, ℥ ss. + Acid. Sulphurici diluti ♏ XL. + Sp. Ætheris comp. f. ʒ ij. + Misce ft Mistura. Pars quarta pro dose. + + + [64] Elliotson, Human Physiology, p. 1043. + + [65] _Ut supra_, p. 193. + + [66] Miss Nightingale’s observations on whispered conversation in the +room, or just outside the door, at p. 26 of her “Notes on Nursing,” +have great value and a wide application. On these points in the +management of the dying chamber Professor Paradys has the following: +“Sed præterea adhiberi hoc loco moderatæ sensuum externorum impulsiones +utiliter possunt, quæ vividiores phantasmatum impressiones obscurent: +vitari itaque nimiæ tenebræ et silentia nimis alta debent, concedi +contra modica lux, permitti notæ amicorum voces, immo excitari debent +lenes, placidi, animum blande demulcentes affectus.” (p. 74.) + + [67] Ferriar, p. 193. + + [68] Ibid., p. 194. + + [69] Human Physiology, p. 1043. + + [70] Ferriar, p. 203. + + [71] + +“Nihil adeo posses quoiquam leve tenueque membris Vortere in +utilitatem.” (Lucretius vi. 1169.) + +“Nor would once endure The lightest vest thrown loosely o’er the +limbs.” (Mason Good, p. 595.) + + [72] “Cyclopædia of Anatomy and Physiology,” vol. i. p. 802. + + [73] P. 200. + + [74] P. 203. + + [75] Miss Nightingale’s Notes on Nursing, p. 47. + + [76] Ferriar, _ut supra_, p. 196. + + + +*** END OF THE PROJECT GUTENBERG EBOOK 76791 *** |