Part 3

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.

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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.

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