Part 4

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.