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EUTHANASIA. 
 
EUTHANASIA 
 
 OR, 
 
 MEDICAL TREATMENT IN AID 
 OF AN EASY DEATH. 
 
 BY 
 
 WILLIAxM MUNK, M.D., F.S.A. 
 
 FELLOW AKD LATE SENIOR CENSOR OF THE ROYAL COLLEGE OF 
 PHYSICIANS, &C., &C., &C. 
 
 LONDON : 
 
 LONGMANS, GREEN, AND CO, 
 
 AND NEW YORK: 15, EAST i6th STREET. 
 1887. 
 
 y4// rights reserved, 
 

 Mcci 
 
PREFACE. 
 
 IV/rUCH 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 
 EvOavaala Natural! ; et quid ad earn 
 conciliandam Medicina valeat " : — comprise 
 all I know that has been written specially 
 on these subjects in modern times. 
 
 Sir Henry Halford, who was con- 
 
VI , PREFACE. 
 
 fessedly a master in all that concerns 
 the management of the Dying, did much 
 by his example and counsel to com- 
 mend 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 else- 
 where. 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. 
 
 I'AGE 
 
 N SOME OF THE PHENOMENA OF DyING , I 
 
 II. 
 
 On THE Symptoms and Modes of Dying , 51 
 
 III. 
 
 On the General and Medical Management 
 
 of the Dying 5^ 
 
I. 
 
 SOME OF THE PHENOMENA 
 OF DYING. 
 
'^ Quod ad nos 
 Pertinetj et nescire malum est, agitamus." 
 
 Horace. 
 
SOME OF THE PHENOMENA 
 OF DYING. 
 
 /^NE 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.! And, although more than two 
 
 I " At nostrls temporibus, Medici quasi religio 
 est, aegrotis, postquam deplorati sint, assidere; ubi 
 meo judicio, si officio suo, atque adeo humanitati 
 ipsi deesse nolint,et artem ediscere et diligentiam 
 praestare deberent, qua animam agentes facilius 
 et mitius e vita demigrent — Hanc autem partem, 
 inquisitionem de Euthanasia exteriori (ad dif- 
 ferentiam ejus euthanasiae quae animae praepara- 
 
4 EUTHANASIA. 
 
 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 writ- 
 ings 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 
 
 tionem resplcit) appellamus ; eamque inter 
 desiderata reponimus." (Verulamus, De Aug- 
 mentis Scientiarum, lib. iv. cap. ij.) 
 
PHENOMENA OF DYING. 5 
 
 the Euthanasia,^ or of a calm and easy- 
 death, in so far as it respects the physician 
 is in need of special study ; and of a sys- 
 tematic treatment that has not hitherto been 
 accorded to it.- 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 
 
 1 " EvOavaala iiaturalis nobis dicitur facilis 
 et quam minimo cum cruciatu e vita exitus, qua 
 tenus moriendi facilitas e causis naturalibus 
 proxime pendet." '* Ad medicinam hujus 
 ev6avaala<; contemplatio pertinet ; est enim 
 naturaliSj non moralis, nisi qua tenus haec ad illam 
 momenti habet plurimum. Exteriorem idcirco 
 Verulamius appellavit." (Nicolai Paradysii, 
 Opuscula Academica, 8vo, Lugd. Batav, 1813. 
 Oratio de EvOavaala naturali et quid ad earn 
 conciliandam Medicina valeat, pp. 63 et 65.) 
 
 2 "A medicisvixinchoatum, nedum pertracta- 
 turn hue usque esset." (Paradysius, p. 63.) 
 
 / 
 
6 EUTHANASIA. 
 
 life easy and gentle, as it is to cure 'diseases 
 and restore health, i And this doctrine, so 
 accordant with the best principles of our 
 nature,^ is commended to us by that most 
 estimable and judicious of modern physi- 
 cians, Dr. Heberden ; 3 as it was also by 
 
 ^ "Etiam plane censeo ad officium medici per- 
 tinere, nontantum ut sanitatem restituat: verum 
 etiam ut dolores et cruciatus morborum mitiget : 
 neque id ipsum solummodo, cum ilia mitigatio 
 doloris, veluti symptomatis periculosi, ad conva- 
 lescentiam faciat et conducat : imo vero cum 
 abjecta prorsus omni sanitatis spe, excessum 
 tantum praebeat e vita magis lenem et placidum. 
 Siquidem non parva est felicitatis pars, ilia 
 Euthanasia." (De Augmentis Scientiarum.) 
 
 2 Sir Henry Halfoid, Essays and Orations 
 read and delivered at the Royal College of Physi- 
 cians. Third edition, i2mo, London, 1842. 
 
 p. 84. 
 
 3 "Magnus ille verse philosophiae instaurator 
 Verulamus, queritur studium Euthanasiae medicis 
 haud satis cultum fuisse, Medici profecto munus 
 est asgrotis sanitatem reddere ; cum tamen ex 
 lege naturae erit tandem unicuique mortalium 
 aegrotatio nulla arte medicabilis, benevolae hujus 
 
PHENOMENA OF DYING. 7 
 
 the example and counsel of one of the 
 most popular and successful physicians of 
 the present century — the late Sir Henry 
 Halford.i 
 
 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 essenti- 
 ally results. On these diverse modes of 
 dying, and of death, modern science has 
 thrown much light ; and with the con- 
 solatory result of showing that the process 
 of dying, and the very act of death, is 
 but rarely and exceptionally attended by 
 those severe bodily suff'erings, which in 
 
 artis professoribus conveniret, mortem inevita- 
 bilcm, quantum fieri potest, terrore omni spo- 
 liare 5 et ubi non datum est praedam morti extor- 
 quere, 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,) 
 
 I Essays and Orations, ut supra passim. 
 
b EUTHANASIA. 
 
 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 argu- 
 ment, the general opinion of the painful- 
 ness of death ; and he was followed in the 
 last century with more eloquence, if with 
 less argument, by Buffon.i "There is 
 hardly any subject," writes an amiable 
 physician, " on which books afford us 
 more impressive topics, than the considera- 
 tion 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 
 
 I JohnFerriar, M.D., Medical Histories and 
 Reflections. 8vo, London, 1798. Vol. iii. 
 p. 196. 
 
PHENOMENA OF DYING. 9 
 
 process of death loses much of its horror on a 
 near viewT ^ 
 
 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 observa- 
 tion, 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 exhi- 
 bited signs of severe suffering. Sir 
 Benjamin Brodie, whose experience of 
 death from surgical disease was second to 
 none, states that, according to his observa- 
 tion, the mere act of dying is seldom, in 
 any sense of the word, a very painful 
 
 I John Ferriar, M.D., On the Treatment 
 of the Dying, ut supra ^ p. 191. 
 
lO EUTHANASIA. 
 
 process. I And another distinguished sur- 
 geon, Mr. Savory, writing on the same 
 subject, says, " Whatever may have been 
 the amount of previous suffering, we may 
 1 airly 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.^ 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." 3 
 
 1 The Works of Sir Benjamin Collins 
 Brodle. Arranged by Charles Hawkins. 
 3 Vols., 8vo, London, 1865. Vol. i. p. 184, 
 
 2 On Life and Death. 8vo. London, 
 1863, p. 175. 
 
 3 " Ipsae animae discessus a corpora fit, sine 
 dolore, et fit plerumque sine sensu, nonnunquam 
 etiam cum voluptatej'^ (Vopisci Fortunati 
 
PHENOMENA OF DYING. I I 
 
 But of far greater weight than the 
 observations and conclusions of medical 
 men, however eminent, towards the deter- 
 mination of such a question, is the evi- 
 dence 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 reanima- 
 tion under the influence of external treat- 
 ment. 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 conciousness has been 
 painless, or at most attended with a feeling 
 of oppression across the chest. The pro- 
 cess of recovery, however, is often one of 
 great bodily suffering. 
 
 Lastly, there are those specially interest- 
 ing cases of recovery from the apparent 
 
 Plempii. de Togatorum Valetudine tuenda 
 Commentatio. 410. Bruxellis, 1670. p. 26.) 
 
12 EUTHANASIA. 
 
 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.-^ 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 drown- 
 
 ^ Autobiographical Memoir of Sir John 
 Barrow, Bart. Svo, London, 1847, P- 39^* 
 
PHENOMENA OF DYING. I3 
 
 ing 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 plea- 
 surable 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. 
 
14 EUTHANASIA. 
 
 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 con- 
 sciousness 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 
 
PHENOMENA OF DYING. I5 
 
 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 de- 
 scribed above. One single but conflised 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 anyone 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 re- 
 
l6 EUTHANASIA. 
 
 covered from a similar state, a detail of their 
 feelings, which resembled his own as nearly 
 as was consistent with their different con- 
 stitutions and dispositions. Sir Benjamin 
 Brodie mentions an instance in a sailor ; ^ 
 De Quincey records a like instance in a 
 female, a near relative of his own ; ^ and 
 
 1 " 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 con- 
 ducted sailors in the ship^' (The Works of 
 Sir Benjamin Brodie, vol. i. p. 184.) 
 
 2 I was once told by a near relative of mine 
 — says De Quincey — that having in her child- 
 hood 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 for- 
 gotten incidents, arrayed before her as in a 
 mirror, not successively, but simultaneously -, 
 
Phenomena of dying. 17 
 
 I have myself heard of two similar cases, 
 but the details are not sufficiently precise to 
 justify their narration here. 
 
 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 de- 
 scribe her as in all respects a woman of remark- 
 able and interesting qualities. She enjoyed 
 throughout her long life serene and cloudless 
 health 5 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 characterisino- 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 
 
1 8 EUTHANASIA. 
 
 In fact, all the best and all the most 
 direct evidence that the subject admits of, 
 
 shifted its ground amongst the incidents, nor had 
 any of the most trivial of the circumstances suf- 
 fered 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 com= 
 mencement. A process of struggle and deadly 
 suffocation was passed through half-consciously. 
 This process terminated in a sudden blow ap- 
 parently on or in the brain, after which there 
 was no pain or conflict : but in an instant suc- 
 ceeded a dazzling rush of light j 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 anaesthetics 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, 
 v/ere supremely happy and at rest : but that on 
 
PHENOMENA OF DYING. I9 
 
 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 pro- 
 bably in part to theoretical views of the 
 nature of the event itself ; ^ but, principally, 
 to the occurrence of conditions, physiologi- 
 cal or pathological, which precede or accom- 
 pany 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 
 
 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 strug- 
 gles " (The Agony of Dying, in Monthly 
 Paper of the Guild of St. Barnabas for Nurses. 
 Vol. iii. p. 81). 
 
 ^ J. A. Symonds, M.D., Art. Death, in the 
 Cyclopaedia of Anatomy and Physiology, 4 
 vols., royal 8vo, Lond. Vol. i. p. 800. 
 
20 EUTHANASIA. 
 
 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." ^ 
 
 Again, convulsions, which so often attend 
 the process of dying, are accepted in evi- 
 dence of suffering, when in fact they are 
 the reverse, for they imply a loss of con- 
 P sciousness and sensibility, and therefore, of 
 the capacity to feel pain. They are auto- 
 matic, and in all essential respects like the 
 convulsions of epilepsy, of which the sub- 
 ject is wholly unconscious. The convulsive 
 
 ^Halford, p. 18. 
 
PHENOMENA OF DYING. 21 
 
 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 charac- 
 terized 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 
 
22 EUTHANASIA. 
 
 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 feel- 
 ings, 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 retro- 
 spect of a well-spent life, *' memoria bene 
 actae vitae, multorumque benefactorum re- 
 cordatio" is a cordial of infinitely more 
 efficacy than all the resources of the medical 
 art ;i but a firm belief in the mercy of God, 
 
 I Halfordj p. 14. 
 
PHENOMENA OF DYING. 23 
 
 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 him- 
 self 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 /^/j-bellever, 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 
 
24 EUTHANASIA. 
 
 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 ap- 
 proaching death seems to be far less 
 terrible." i 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 what- 
 ever 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 re- 
 luctant to go to " the undiscovered country 
 from whose bourn no traveller returns." ^ 
 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 com- 
 parative or complete absence of dismay as 
 
 ^ Savory, ut supra ^ p. 178. '^ p. 74. 
 
PHENOMENA OF DYING. 25 
 
 death draws near. Often, no doubt, the 
 mind is otherwise too fully occupied, . . . 
 but even in the absence of this and all dis- 
 tracting influences, and with a clear con- 
 viction that the approaching change is near 
 at hand, — the mind is calm and collected, 
 the thoughts serene, there is no quailing, 
 no giving way." ^ 
 
 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 cir- 
 cumstances, it was impossible to suppress. 
 The depressing efi^ects which the gradual 
 loss of blood produced on their corporeal 
 
 ^ On Life and Death, 8vo, London, 1863, 
 p. 177. 
 
 3 
 
20 EUTHANASIA. 
 
 system seemed to influence their minds, and 
 they died earnestly imploring the relief 
 which art was unable to afford." ^ 
 
 V/hen the intimation that death is at 
 hand has been postponed to the latest pos- 
 sible moment, it comes upon the sufferer 
 so late, that there may not be time for him 
 to get over the shock of the first impres- 
 sion, and regain his serenity. Alarm asso- 
 ciates itself with the act of dissolution, 
 which is imminent, or has already com- 
 menced, disturbs its even, easy, tenor, and 
 explains some at least of the harrowing 
 scenes that occasionally mark the death- 
 bed. An earlier intimation ^ to the dying 
 
 1 Brodie ut supra^ p. 185. 
 
 2 " 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 
 
PHENOMENA OF DYING, 1"] 
 
 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 ac^ 
 quainted with, his opinion of the probable 
 issue of a malady manifesting mortal symp- 
 toms, I own I think it my first duty to 
 
 watched over these scenes, and regarded the pa- 
 tient 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, 
 i853>P. 3^2). 
 
28 EUTHANASIA. 
 
 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 
 provmce 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 
 
PHENOMENA OF DYING. 1(^ 
 
 hope of his pardon and acceptance here- 
 after. 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 phy- 
 sician 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 
 
30 EUTHANASIA. 
 
 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 dov/n on this sub- 
 ject. Every case requires its own con- 
 siderations ; 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 satisfac- 
 tion to your patient, his friends, and your- 
 selves." I 
 
 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 miser- 
 
 I Halford, p. 76. 
 
PHENOMENA OF DYING. 3 I 
 
 able 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." ^ 
 
 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 intel- 
 
 I Halford, p. 75. 
 
32 EUTHANASIA. 
 
 lect, 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 sug- 
 gested by external circumstances than in 
 the delirium of fever and phrenitis. ^ Such 
 delirium is generally shown in quiet talka- 
 tiveness, 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 
 
 I Cyclopaedia of Anatomy and Physiology, 
 art. Death, vol. i. p. 799. 
 
PHENOMENA OF DVING; 33 
 
 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. ^ 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 con- 
 sider 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. ^ And the last 
 words of Dr. Armstrong were addressed to 
 an imaginary patient, upon whom he was 
 
 1 Symonds ut supra^ p. 799. 
 
 2 Lord Campbell, Lives of the Chief 
 Justices of England, vol. i. 
 
34 ' EUTHANASIA. 
 
 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 illusive- 
 ness, 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,— 
 ihey are indeed scarcely compatible with 
 it. They may pave the way to it, but 
 v/hen the act of dying really begins, they 
 cease and give way to that low, rambling, 
 muttering delirium, with which all watchers 
 by the deathbed are so familiar. 
 
PHENOMENA OF DYING, 2S 
 
 It is especially at the stage of transition 
 from the one to the other of these states, 
 that we meet with that return of intelli- 
 gence — that ' lightening up before death ' 
 which has impressed and surprised mankind 
 from the earliest ages. " We have all ob- 
 served," writes Sir Henry Halford, " the 
 mind clear up in an extraordinary manner 
 in the last hours of life, v/hen terminated 
 even in the ordinary course of nature ; but 
 certainly still more remarkably when it 
 has been cut short by disease, v/hich had 
 affected, for a time the intellectual faculties. 
 We have seen it become capable of exer- 
 cising a subtle judgment, when the passions 
 which had been accustomed to bias and em- 
 barrass 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 be- 
 haviour of men, v/ere nov/ made available 
 to a correct estimate of their future conduct, 
 in the sense of Milton's lines — 
 
36 EUTHANASIA. 
 
 ' When old experience does attain 
 To something like prophetic strain.' ^ 
 
 " 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." - 
 
 " A young gentleman of family, about 
 twenty-five years of age, took cold whilst 
 under the influence of mercury. The dis- 
 ease increased daily until it was accom- 
 panied 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 cor- 
 
 ^ On the Kav(To<i of Aretaeus, p. 96. 
 2 Halfordj On the Cautious Estimation of 
 Symptoms, p. 17, 
 
PHENOMENA OF DYING. 37 
 
 rect, 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 communi- 
 cations 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.^ Another instance, 
 
 I Halford ut supra ^ P* 19- 
 
38 EUTHANASIA. 
 
 the counterpart to that just described, 
 which happened to the same eminent phy- 
 sician, 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 phy- 
 sician, who had attended him with great 
 care and judgment from the commence- 
 ment 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 v/as 
 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 re- 
 
PHENOMENA OF DYING. 29 
 
 peatedly, that he should die -, that under this 
 conviction he had talked with great com- 
 posure 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 aff^ection, and had talked 
 much of a sister v/ho had died the year 
 before, and whom, he said, he knev/ 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 men- 
 
40 EUTHANASIA. 
 
 tlon of his sister. His hands were cold, 
 and his pulse immeasurably quick — he died 
 that night." ^ 
 
 Some pass away in sleep. In natural 
 healthy sleep respiration becomes slower, 
 the pulse weaker and less frequent, the 
 circulation generally feebler. The dif- 
 ference 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 flirther reduced by sleep, 
 and with this reduction the patient die^. 
 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 ob- 
 server is unable to fix the moment when 
 life has fled, so easy is the parting of 
 
 ^ On the KaOao? of Aretsus, p. 91. 
 
Phenomena of dying. 41 
 
 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 in- 
 stances 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. ^ 
 
 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. 
 
 I A. P. Wilson Philip, On Sleep and Death, 
 8vo, London, 1834, p. 165. 
 
42 EUTHANASIA. 
 
 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 com- 
 mon 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, ^ '^ 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 
 
 I Cyclopaedia of Anatomy and Physiology, 
 vol. i. p. 799. 
 
PHENOMENA OF DYING. 43 
 
 with such visions are those which haunt 
 the dying fancies of others.*' ^ The testi- 
 mony of many of those who have the 
 largest experience, and have watched con- 
 tinuously and attentively at the dying bed, 
 is in support of Dr. Symonds' statement. 
 \i some physicians are incredulous, and 
 place little reliance on testimony and 
 inferences of this kind, 1 am inclined 
 with Dr. Conolly- to attribute it, to 
 their being seldom engaged long enough 
 in watching by the bed-side, where the 
 senses and thoughts naturally become 
 
 ^ Dr. Symonds continues, " The previous 
 habits and conduct of the individual have some- 
 times been such as to incline spectators to 
 inquire, vi'hether in the mode of his departure 
 from existence, he might not already be re- 
 ceiving retribution, just as, in other cases, 
 celestial dreams and colloquies have seemed 
 fitting; rewards for blameless lives and relio-ious 
 meditation." 
 
 - Cyclopaedia of Practical Medicine, art. 
 Disease, vol. i. p. 629. 
 
44 EUTHANASIA. 
 
 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 con- 
 sultationSj 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 amend- 
 ment, 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 
 
PHENOMENA OF DYING. 45 
 
 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 never- 
 theless her feelings^ instead of being painful 
 or in any zvay distressing^ had been agree- 
 able 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." ^ 
 
 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 insensi- 
 
 I Brodie, ut supra ^ vol. i. p. 281. 
 
46 EUTHANASIA, 
 
 bility. 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 som^e figures 
 in arithmetical progression, which however 
 imperfectly scrawled, v/ere yet sufficiently 
 legible. It was supposed that he had over- 
 heard 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 im- 
 mediately before he died, but the scrawl 
 of these last moments could not be de- 
 ciphered." I 
 
 " I have been curious," writes Sir Ben- 
 jamin Brodie in commenting on these cases, 
 " to watch the state of dying persons in 
 
 I Brodie ut supra^ p. 182, 
 
PHENOMENA OF DYING. 47 
 
 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." ^ 
 
 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 
 
 I Brodie, p. 182. 
 
48 EUTHANASIA. 
 
 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 insensi- 
 bility. 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.'' ^ 
 
 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 
 
 I The Anatomy and Philosophy of Expres- 
 sion. Fourth Edition, ^84.7, p. 185. 
 
PHENOMENA OF DYING. 49 
 
 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 circum- 
 stances 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 be- 
 nignity 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 ob- 
 servations are not confined to poets. 
 Haller could trace in the dying coun- 
 tenance the smile which had been lighted 
 by the hope of a happier existence. " Ad- 
 fulgentis fugienti animae spei non raro in 
 moribundis signa vidi, qui serenissimo 
 vultu non sine blando subrisu, de vita 
 excesserunt." ^ 
 
 I Symonds, ut supra^ p. 803. 
 4 
 
II. 
 
 THE SYMPTOMS AND MODES 
 OF DYING, 
 
THE SYMPTOMS AND MODES 
 OF DYING. 
 
 TT 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, 
 hut that the vital powers are already so utterly 
 reduced that they are beyond the possibility of 
 restoration.^ And on these points the Father 
 
 I " At Medicus moriendi initium altius repetet, 
 et jam ab eo inde tempore ducet, quo signis 
 minime dubiis cognoverit, morbum naturae 
 
54 EUTHANASIA. 
 
 of Physic is perhaps still our best guide. 
 A sharp and pinched nose, the eyes sunk 
 in the orbits and hollow, the ears pale, cojd, 
 shrunk, v/ith their lobes inverted, and the 
 face pallid, livid, or black; these together 
 make up the cehhr ated facz'es Hippocratica,^ 
 
 artique non tantum insuperabilem esse, sed et 
 sub eo vires sic perire ut reparari nequeant." 
 (Paradys, Oratio de EvOavaala natural!, p. 67). 
 
 I In the words of Lucretius, vi. 1,190 — 
 
 "Item, ad supremum denique tempus, 
 Comprcssas nares, nasi primoris acumen 
 Tenue,cavatei oculei, cava tempora; frigida pellis, 
 Duraque, inhorrebat tactum^ frons tenta meabat: 
 Nee 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 pre- 
 
 par'd." 
 
SYMPTOMS AND MODES OF DYING. ^^ 
 
 and show that the work of dying has com- 
 menced, and has already made some pro- 
 gress. They are signs of utter exhaustion 
 in the circulation and in the muscular 
 system, and they point to a loosening of all 
 the bonds ^ 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, 
 
 I " Omnia turn vero vital claustra lababant." 
 (Lucretius, vi. 1,151). 
 
 "Then all the powers of life were loosen'd." 
 (Mason Good). 
 
56 EUTHANASIA. 
 
 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 combina- 
 tion, 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 per- 
 haps to the condition of a corpse is made 
 in a moment : in another the process of 
 dissolution is slow and tedious, and we 
 
SYMPTOMS AND MODES OF DYING. 57 
 
 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." I 
 
 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 some- 
 times instantaneous. Suddenly and without 
 warning of any kind, the heart ceases to 
 
 ^ Lectures on the Principles and Practice of 
 Physic. Fifth edition, 2 vols. 8vo, London, 
 1 87 1, vol. i. p. 62. Sir Thomas Watson in his 
 admirable lecture on the Different Modes of 
 Dying, has treated the whole subject so graphi- 
 cally, that I shall follow him as closely as possible 
 in what I have to adduce on this part of my 
 subject. 
 
58 EUTHANASIA. 
 
 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." I When death occurs from asthenia 
 or failure of contractile power in the heart, 
 " the pulse becomes very feeble and frequent, 
 
 I Watson, p. 66. 
 
SYMPTOMS AND MODES OF DYING. 59 
 
 and the muscular debility extreme, but the 
 senses are perfect, the hearing is sometimes 
 even painfully acute, and the intellect re- 
 mains clear to the last." ^ 
 
 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 purph'sh, 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." ^ 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 
 
 1 Watson, p. 68. 
 
 2 Ibid.^ p. 70. 
 
6o EUTHANASIA. 
 
 common with other parts of the frame, 
 first benumbs sensibiHty, and then abohshes 
 it altogether. ^^Disturbance of respiration," 
 says Dr, Ferriar, i " 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 sensibihty 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 con- 
 tinue. At length the chest ceases to 
 
 I On the Treatment of the Dying. Medical 
 Histories and Reflections. Vol* iii. p. 195. 
 
SYMPTOMS AND MODES OF DYING. 6l 
 
 expand, the blood is no longer aerated/' i 
 and thenceforward precisely the same In- 
 ternal 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 con- 
 fusing 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 
 
 I Watson, p. 76. 
 
6% EUTHANASIA. 
 
 supervening on diseases of the lung, first 
 lessens the perception of the distress and 
 anguish which attend them, and then ex- 
 tinguishes it. These mixed forms of death 
 are seen especially in fevers. 
 
III. 
 
 THE GENERAL AND MEDICAL 
 TREATMENT OF THE DYING. 
 
THE GENERAL AND MEDICAL 
 TREATMENT OF THE DYING. 
 
 TV/TANY 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, in- 
 creased 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. 
 
66 EUTHANASIA. 
 
 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 cir- 
 
TREATMENT OF THE DYING. 67 
 
 cumstances 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. "^ 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 ad- 
 ministration 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 per- 
 cussion, and intolerant of pressure. At 
 length some of the contents of the dis- 
 tended stomach regurgitate Into the throat 
 
 I Medical Notes and Reflections. Third 
 edition, 8vo, London, 1855, p. 379. 
 
6^ EUTHANASIA. 
 
 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 farlnacea 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. 
 
TREATMENT OF THE DYING. 69 
 
 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 stimu- 
 lates 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 move- 
 ments 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 in- 
 fluence 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. 
 
^O EUTHANASIA. 
 
 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 re- 
 freshing and is often eagerly taken ; but its 
 effects are evanescent and it needs repeathig 
 at shorter intervals than other wines. A tea- 
 spoonful 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 
 
TREATMENT OF THE DYING. 71 
 
 with yolk of egg and sugar, as is Sir 
 Henry Halford's celebrated mixture — the 
 Mistura Spiritus Vini Gallici of the Phar- 
 macopoeia. 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 aerated, 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 fre- 
 quently 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 — - 
 
72 EUTHANASIA. 
 
 supposing there is nothing to forbid — 
 that so long as the Hps 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 
 ~Df swallowing, they should no longer be 
 persisted in. The sensibility of the parts 
 is so diminished that the patient is in- 
 sensible 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 breath- 
 ing, and by so much, if any consciousness 
 remains, to the sufferings of the dying. 
 
 Next in value to stimulants in the treat- 
 ment of the dying is opium. It is a 
 
TREATMENT OF THE DYING. 73 
 
 tradition that John Hunter used often to 
 exclaim, ^' Thank God for opium," ^ 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 allav 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 adminis- 
 tered 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,^ 
 
 ^ Robert Willis, M.D., On Urinary Diseases, 
 8vo, London, 1838, p. 100. 
 
 2 "When there is a sudden cessation, or inter- 
 
 5 
 
74 EUTHANASIA, 
 
 or sinking that had hitherto rendered sleep 
 impossible. 
 
 For the relief of pain in the dying where- 
 ever 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, ^ 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 isj is however second to its 
 
 mission, 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.) 
 ^ I except hydrophobia, tetanus, &c., against 
 which it is almost powerless. 
 
TREATMENT OF THE DYING. 75 
 
 value in relieving the feeling of exhaustion 
 and sinking — of indescribable distress and 
 anxiety — referred to the stomach and hearty 
 which so often attends some part of the act 
 of dying. To the practised eye, this con- 
 dition is evidenced, as much by the pinched 
 features, pallid complexion, and anxious 
 expression of face, as by any verbal com- 
 plaint 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." ^ 
 Under the protection of an opiate, writes 
 Dr. Heberden,2 the patient's strength has 
 
 ^ *' Praestantissimum remedium cardiacum 
 (unicum pene dixerim) quod in rerum natura 
 hactenus est repertum." Sydenham Thomae 
 Opera Omnia, edidit G. A. Greenhill, M.D., 
 8vo, London, 1844, p. 175, 
 
 2 " Vires aegri somno recreatas sunt, atque 
 etiam ubi salus ejus prorsus desperata fuerit, et 
 
76 EUTHANASIA. 
 
 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 attend- 
 ance 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 
 
 angor summus cruciaverit, opium utique sollici- 
 tudinem aliquantum levavit. Mors quidem 
 neque serius, neque citius venit, sed tamen 
 minore cum cruciatu." (Heberden De Ileo.) 
 
TREATMENT OF THE DYING. 77 
 
 time arrives. Hufeland, writing at the end 
 of a Jong 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." ^ 
 
 I 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 tran- 
 quility. 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 com- 
 plaints of the chest and vomicas finally approached 
 
78 EUTHANASIA. 
 
 Opium must be administered in such 
 doses as will appease suffering and disorder, 
 and in this respect we are to be governed 
 
 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 insur- 
 mountable 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 com- 
 posure and satisfaction to his relatives, and after 
 he had given them his blessing and many a good 
 admonition fell again asleep and passed avi'ay 
 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 thence- 
 forward 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.) 
 
TREATMENT OF THE DYING. 79 
 
 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 ; " i ^^ 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 quanti- 
 ties will often fail, which concentrated into 
 a single dose would safely effect all we 
 require." ^ 
 
 I TJt supra ^ p. 516. 
 
 ^ Holland, ut supra ^ p. 518. To the same 
 effect writes Dr. James Gregory of this remedy, 
 " Neque duhiuni est, utcunque periculosus 
 videatur usus talis medicamenti vix non venenati ; 
 CBgros plus fere incommocll et clamn'i percep'isse a 
 nimis parva^ qua?n a nltnia ejus quantitate, 
 Medici igiiur est, medicamentum adeo validum 
 et saepe perniciosum caute et prudenter adhibere, 
 et in illis tantum morbis ad id confugere, qui 
 aliquid istiusmodi plane requirunt ; ubi vero talis 
 
8o EUTHANASIA. 
 
 The ejffects of opium continue for about 
 eight hoursj and if its action is to be main- 
 tained 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, pro- 
 ducing no other direct effect on the system 
 in general. " It would seem/' says Sir 
 Henry Holland, ^^ that the medicine, ex- 
 pending all its specific power in quieting 
 these disorders, loses at the time every 
 other influence on the body. Even the 
 
 nrcessitas urget, oportet remedium lib ere et cum 
 fiducia prcescribere ; tunc enim non sperare modo 
 potest, sed fere polliceri, se effectum ilium 
 salutarem, quern cupit, per suum medicamentum 
 esse praestlturum. ^uod si timide et nimis parce 
 datu?n fuerit^ longe alium effectum habebit, et 
 iisdem aegrotis baud paru?n nocehit^ quibus largius 
 datum multu?n profuisset,''^ (Conspectus Medi- 
 cinae Theoreticse, § mccxxii.) 
 
TREATMENT OF THE DYING. 8 1 
 
 sleep peculiar to opium appears in such 
 instances to be wanting, or produced 
 chiefly in effect of the release from suffer- 
 ing." I 
 
 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 bime- 
 conate. 
 
 So long as the air passages are not ob- 
 structed 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 employ- 
 ment of opium, in cases where the heart is 
 greatly enfeebled^ and where the conditious, 
 directly or indirectly induced by opiates, 
 especially that of sleep, may be just enough 
 
 * Ut supra, p. 518. 
 
 5* 
 
82 EUTHANASIA. 
 
 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 in- 
 fluence of opium is needed, we should resort 
 to the hypodermic injection of morphia. 
 
 Professor Paradys warns us of the con- 
 fusion 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.^ But this, 
 in my experience, has been rare, and will be 
 
 I " Audivi plus semel segros temporarium a 
 narcoticis levamen enixe deprecantes, quod 
 sensuum obscuratione nimis care querebantur 
 emi." (p. 71.) 
 
TREATMENT OF THE DYING, 83 
 
 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 inade- 
 quacy 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, ^ 
 " longe alium effectum habebit, et iisdem 
 aegrotis 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 
 
 I ^' Conspectus Medicinse Theoreticas," 
 
 § MCCXXII. 
 
84 EUTHANASIA. 
 
 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 al- 
 leviating the sufferings of the dying is ether. 
 It is specially indicated in gasping or spas- 
 modic 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 com- 
 
TREATMENT OF THE DYING. S^ 
 
 bination 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." ^ Opium or laudanum 
 in somewhat smaller doses than those re- 
 commended above, is often added, with 
 great advantage to ether, when there is need 
 of a potent antispasmodic. In the par- 
 oxysms of severe praecordial anguish and 
 dyspnoea 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 
 
 I ^ Aq. Menthae Viridis, f . ^ v fs. 
 
 Sacchari, J fs. 
 
 Acid. Sulphuric! diluti nx XL. 
 
 Sp. ^theris comp. f. 3 ij. 
 Misce ft Mistura. Pars quarta pro dose. 
 
^6 EUTHANASIA. 
 
 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 exist- 
 ence contemplated in these pages has once 
 been reached, we dismiss all thought of 
 cure, or of the prolongation of life, and 
 our eiforts are limited to the relief of 
 certain urgent conditions, such as pain, 
 exhaustion, dyspncea, 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 medi- 
 cines of any kind, and stimulants and light 
 
TREATMENT OF THE DYING. 87 
 
 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."i 
 
 " Disturb him not — let him pass peaceably." 
 
 " The physician,'* writes Dr. Ferriar,^ 
 *^ will not torment his patient with unavail- 
 ing 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 situa- 
 tion, he will protect his patient against 
 
 I Elliotson, Human Physiology, p. 1043. 
 2 XJt supra^ p. 193. 
 
88 EUTHANASIA. 
 
 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 ventila- 
 tion 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 par- 
 ticular 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 dyspnoea, and 
 greatly to the comfort of the sufferer. 
 
 The custom of exckiding 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 com- 
 
TREATMENT OF THE DYING. 89 
 
 plained of by the dying, it is of failing 
 sight — of a darkness gathering over him ; 
 and a desire is expressed for more Ught. 
 
 Talking in an undertone and whispering 
 in the presence of the dying is to be per- 
 emptorily 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. ^ 
 
 The dying - chamber is no place for 
 officious Interference or obtrusive curiosity. 
 
 I Miss Nightingale's observations on whis- 
 pered 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 praeterea adhiberi hoc loco moderatae sen- 
 suum externorum impulsiones utiliter possunt, 
 quae vividiores phantasmatum impressiones ob- 
 scurent : vitari itaque nimiae tenebrae et silentia 
 nimis alta debent, concedi contra modica lux, 
 permitti notae amicorum voces, immo excitari 
 debent lenes, placidi, animum blande demulcentes 
 affectus." (p. 74.) 
 
90 EUTHANASIA. 
 
 The fewer that are admitted to it the better 
 — the nurse, the minister of religion, the 
 medical attendant, and the immediate mem- 
 bers 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/' ^ 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 ap- 
 parently insensible to everything around 
 him. But the circumstances of the disease 
 occasion much variety in this progress.'' ^ 
 
 ^ Ferriar, p. 193. 
 2 Ibid., p. 194. 
 
TREATMENT OF THE DYING. 9I 
 
 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.'* ^ In 
 many cases there is a sort of lucid inter- 
 val 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. ^ The 
 
 ^ Human Physiology, p. 1043. ^ Fefriar,p. 203. 
 
92 EUTHANASIA. 
 
 dying are often impatient of any kind of 
 any kind of covering, i They throw off 
 the bed-clothes and He with the chest bare, 
 the arms abroad, and the neck, arms, 
 and legs as much exposed as possible : — Ubi 
 supinus aeger jacet, porrectis manibus et 
 cruribus, writes Celsus — ubi brachia et crura 
 nudat et insequaliter dispergit. *^ These 
 actions," writes Dr. Symonds,^ " 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 
 
 I " 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.) 
 
 2 " Cyclopaedia of Anatomy and Physiology," 
 vol. i. p. 802. 
 
TREATMENT OF THE DYING. 93 
 
 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 him- 
 self, 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 swal- 
 low, 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 mattrasses of straw 
 or hair upon the floor. It was then wholly 
 or in part a penitential rxt, and the influence 
 of this custom has, perhaps, not yet wholly 
 
94 EUTHANASIA. 
 
 ceased. " It is/* says Dr. Ferrlar,i *^ a 
 prevalent opinion among nurses and ser- 
 vants that a person whose death is Hngering 
 cannot quit life while he remains on a com- 
 mon bed, and that it is necessary to drag the 
 bed away and place him on the mattrass. 
 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 
 
 I P. 200. 
 
TREATMENT OF THE DYING. 95 
 
 of those executioners. Perhaps a more 
 deplorable condition can scarcely be con- 
 ceived 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 metro- 
 polis, led me to conclude that it was not 
 then and there wholly unknown or unprac- 
 tised. 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.''^ 
 
 I P. 203. 
 
96 EUTHANASIA. 
 
 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 
 
TREATMENT OF THE DYING. 97 
 
 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 
 1?o be avoided. Its tendency is to occasion 
 fainting and death. 
 
 In death from the lungs or by asphyxia 
 the struggle is often protracted, and ac- 
 companied 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 sub- 
 
 6 
 
EUTHANASIA. 
 
 sides, 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 in- 
 dependent alike of sensation and of the 
 will. They soon pass into coma, stertor, 
 rattle in the windpipe, and death. Ster- 
 torous 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 posi- 
 tion 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 
 
TREATMENT OF THE DYING, 99 
 
 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 back- 
 wards, 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 in- 
 crease 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 
 
ICO EUTHANASIA. 
 
 much more, and due support is given to 
 the trunk of the body by pillows — will do 
 more than anything else in relief of em- 
 barrassed 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 for- 
 ward." I The suffering of dying patients, 
 says Miss Nightingale, is immensely in- 
 creased by neglect of these points. If 
 secretions have accumulated in the air pas- 
 sages, 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 
 
 I Miss Nightingale's Notes on Nursing, 
 p. 47- 
 
TREATMENT OF THE DYING. lOl 
 
 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 inhala- 
 lation 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 treat- 
 ment 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 exhaus- 
 
 6* 
 
I02 EUTHANASIA. 
 
 tion, 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. I 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 
 
 I ferriar, ut st^pra, p. 196. 
 
TREATMENT OF THE DYING. IO3 
 
 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 spoon- 
 ful 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 inter- 
 nally, 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 
 i§ relieved by lightening them. 
 
I04 EUTHANASIA. 
 
 Coldness of the feet is best met by a foot 
 warmer ; and not by thick, heavy bed cloth- 
 ing, 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 ex- 
 posure of them to the air — which I have 
 before described. 
 
TREATMENT OF THE DYING. I05 
 
 Death from old age — the natural ter- 
 mination of llfe^ and the simplest form of 
 death that can occur, creeps on by slow and 
 almost imperceptible degrees. It is cha- 
 racterised by a gradual and proportionate 
 decay of all the functions and organs of 
 the body, and as a rule presents no symp- 
 toms 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 sur- 
 rounding 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. 
 
 XINWIN BROTHERS, PRINTERS, CHILWORTH AND LONDON. 
 
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