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Title: Euthanasia
or, Medical treatment in aid of an easy death
Author: William Munk
Release date: September 1, 2025 [eBook #76791]
Language: English
Original publication: London: Longmans, Green, and Co, 1887
Credits: deaurider and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)
*** START OF THE PROJECT GUTENBERG EBOOK EUTHANASIA ***
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.
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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.
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