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.