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.