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Nineteenth-century doctors and care of the dying 

Nineteenth-century doctors and care of the dying
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Nineteenth-century doctors and care of the dying
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David Clark

DOI:
10.1093/med/9780199674282.003.0001
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date: 03 June 2020

Demographic change and the consequences for dying and death

By the late nineteenth century, the people of Europe and North America were living longer in societies of rapidly increasing size. A transformation of unprecedented proportions had brought widespread industrialization, urbanization, geographic mobility, the rise of scientific rationalities, political and ideological upheaval, and a growing questioning of religious values. The population of Europe had doubled during the course of the century, from 200 million to 400 million. Mortality rates were falling and the prospects of living into old age began to increase for many people. Nevertheless, with the benefits of longevity and the diminished threat of early death came particular consequences and repercussions. The predominant causes of death had started to shift—from sudden demise brought on by infection, disaster, and plague, to protracted dying associated with the emerging chronic diseases of the modern era, not least of which were cancer and tuberculosis. Whereas in Europe during the Middle Ages, the death that came too swiftly was something abhorrent and to be guarded against, now fears began to grow about lengthy dying and the suffering that it might entail.

The changing social world of the dying

Popular culture and Victorian fiction1 presented idealized images of a slow and controlled farewell to the world, with family members gathered around the dying person’s bedside and a sense of shared confidence in the imminent passage to a better world—the good death as a sign of coming salvation. However, by the later years of the century, concerns were emerging about the precise manner of dying, now coming to be seen not only as a social and cultural event, but also as a medical process. Strict rules existed for how to behave after a death occurred. Yet, there appeared to be less confidence in people’s dispositions towards the act of dying. The changing personnel around the deathbed, a new secrecy about the imminence of death, as well as the desire to quell the threat of pain and suffering—all revealed a growing anxiety about the dying process. That in turn opened up a space for medical intervention, which first took hold towards the end of the nineteenth century, but was to have implications for more than a hundred years thereafter, indeed right up to the time of this book’s writing in 2015.

For the French historian Phillipe Ariès, the nineteenth century was associated with the emergence of sentimental orientations to death that reflected major changes within the culture and structure of family life.2,3 He argued that as the meaning of family relationships deepened and became more nuanced, so parting with a dying relative—and the subsequent grief following that loss—became increasingly emotional and expressive. A growing emphasis fell on the personal pain of separation and on keeping the dead alive in memory, enhanced by new developments in photography that enabled carefully staged post-mortem images to be captured and preserved for posterity. It also meant elaborate rituals of mourning and funeral observance, along with the emergence of the cult of the grave as a family resting place. Undoubtedly it led to new representations of the deathbed itself. The wider Romantic movement contributed to notions of the ‘beautiful death’, to la mort de toi (‘thy death’), personified in the death of a loved one.

Ariès also describes how in the nineteenth century the rise of modern science brought challenges to religious authority, and specifically to the necessity of dying in the presence of the official representatives of formal religion. Medical men began to replace priests, clergy, and ministers at the bedsides of the dying. However, this created new dilemmas; for if the role of medicine was to focus on the technical preoccupations of attending to the relief of pain and the easing of physical distress, who was to address the fears of the dying, the distress of the bereaved, and the achievement of the ‘good death’? Using this point of reference, we might see this as the period in which dying was drained of meaning by science and medicine, forcing its retreat from public, religious, and family dimensions into the sequestered spaces of hospitals and, ultimately, homes for the terminally ill. For Ariès, the mid-nineteenth century was also the origin of ‘the lie’ wherein the gravity of the dying person’s situation was kept from them. Death was on the way to becoming something ‘shameful and forbidden’.

Later historians and sociologists have questioned Ariès’s linear conceptualizations. There are assertions that he relies on superficial readings of material relating mainly to the upper and middle-class elite, and that the experiences of working-class families and communities are misrepresented, or obscured in his grand narrative. He is also accused of romanticizing a bygone era and somehow caricaturing death in the twentieth century as anonymous, repressed, and pathological. From the perspective of Ariès’s critics, there was no golden age of grief that was subsequently ‘ruined’ by the scientific and medical discourses of modernity.4 As Julie-Marie Strange puts it, ‘the Victorian culture of death is a myth of our own making’.5 Perhaps it is better therefore to regard those living in the nineteenth century as no more and no less skilled than their forebears or successors in dealing with the experiences of dying, death, and bereavement.

The encounter with death is universal and as human beings we all know that we must die, but in every age and culture there are variations in how we experience our mortality—and our dying. There may be tendencies towards the framing of death as a uniquely personal experience for both the dying and the bereaved, and something requiring individualized adjustment. Other discourses put a strong emphasis on the place of death in society, its impact on social cohesion, and the legal, public, and policy consequences of dying and bereavement. In some contexts, discourses of religion may dominate; in others, the perspectives of science and humanism, even historical materialism, may hold greater sway. Using this approach, historians have argued for understanding death through the cultural values that shape how we describe it, rather than seeking to uncover any particular ‘truths’ about how we experience it. This is an important consideration for our focus here. There are incontrovertible ways in which our ability to care for dying people has improved and become more sophisticated in the period since the late nineteenth century. Nevertheless, we should beware the assumption that this means there can be wholesale improvement on the way death was managed in the past. The shift of dying from the social, community, and family realm to become the preserve of specialists, professional carers, and service providers of various types should not mask the fact that death remains a profoundly social experience. Reforming the social component is a far more challenging goal than, for example, improving the technologies of pain relief. When death becomes a matter of public debate, dissension is not far away. As we shall see in Chapter 7 of this book, death in the contemporary world has become a contested space, in which the interventions of palliative medicine are only one set of forces at play—and one not always welcomed unequivocally. As we delve into the historical record, it becomes clear that since at least the late nineteenth century, medicine has had a problematic relationship with death that is still far from resolved.

Experiences at the bedside: Representations of the dying patient and the grieving family

There is a certain amount of scholarship on nineteenth-century care of the dying in Europe and North America, beginning with research on the cultural aspects of death, dying, and bereavement, particularly the experiences of elite groups in society. This has led to encouraging signs of further interest in these topics that has taken us into the lives not just of lettered and literate affluent families, but also alongside the end-of-life experiences of people in poor communities, and those in both rural and urban environments.

In Britain, our understanding of the Victorian culture of dying and the place of doctors and families within it derives from a small number of historical studies, each with a specific focus. Outstanding among these is the work of Pat Jalland,6 who not only surveys the characteristics of medical practice for those at the end of life, but also takes us to the bedsides of the dying—at least in upper middle-class families7—to show how the rituals and practices associated with dying and death were shaped by wider Victorian values and beliefs. Jalland shows how the role of religion is key. It circumscribed the cultural terrain of dying, emphasizing the need for unwavering faith, a sense of humility, and a readiness to submit to the will of God. By these means, the good death could be achieved. If this meant bearing prolonged agonies of physical suffering, then this itself was a spiritual test that might result in everlasting life. Protracted dying was also an opportunity to rekindle a lost Christian faith or indeed to give one’s soul to Christ for the first time. Specifically, a powerful influence was brought to bear by the evangelical movement, which shaped Protestant dying around a script of atonement from sin, for which the final moments of life were a final opportunity to avoid everlasting torment. Such narratives found their way into widely distributed tracts, magazines, and memoirs. They were eagerly read and did much to influence popular beliefs about the appropriate manner of dying. As Jalland describes, these perceptions were echoed uncannily in the private correspondence, diaries, and deathbed memorials of middle and upper-class families in England, a finding made all the more powerful because these writings were often produced close to the time of the events and under the influence of intense emotion as death approached. The key difference that Jalland found between the two sets of texts—the public and the private—was that the latter were often remarkably frank about moral weaknesses, unpleasant symptoms, or ‘unworthy’ deathbed behaviour, elements usually expunged from the more widely published accounts.

What was clear, however, were the constituent elements of Victorian evangelical death: place, practice, and temporality. Death should occur at home, preceded by carefully orchestrated farewells, devotions, and prayers. The dying person should be awake, lucid, and able to seek forgiveness for past transgressions. Pain should be borne with fortitude and welcomed as a final test of fitness for heaven. Death in this manner was becoming an intensely private affair, a reaction against the public dying before a crowd that had been known in Britain and France in the eighteenth century and which persisted into the late nineteenth century for royalty and famous statesmen. Nevertheless, the evangelical good death also had its didactic elements and could be used as a stimulus to the devout and a cautionary example to the unbeliever, presuming at least a limited audience. For if the good death was not achieved, then eternal damnation might follow, and that was a message to promulgate beyond the deathbed itself.

Jalland demonstrates clearly that these idealizations of the good death were significantly eroded in the period from 1870 to 1914, as evangelical fervour waned within society. With the declining influence of religion, concern for the soul was less demonstrated, and this led to an increasing preoccupation with matters of pain and other symptoms. The balance was slowly swinging away from a primary concern with the state of the soul in the final days of life, towards a greater emphasis on the body that was free from physical suffering. Linked to this was a new evaluation of sudden death—once feared because it denied a chance of preparation for the next world, now at least cautiously welcomed as it obviated any fear of impending demise and a life taken away. Jalland sees this as the key condition, merely a short step away, which led to the practice of deliberately withholding knowledge of their fate from dying people. Out of this crucible of change, she points the way to the modern twentieth-century death, which attenuated the role of faith and amplified the importance of pain and symptom relief, while at the same time diminishing the role of the clergy and, to some extent, the family, replacing them with an increasing emphasis on the sayings and doings of doctors.

Julie-Marie Strange has contributed a perspective on working-class grief and mourning8 in northern England over the period 1870–1914, precisely identified by Jalland as the time in which the foundations of the Victorian evangelical death began to shift. In acknowledging the paucity of historical research on this subject, Strange notes two points. First, the working classes left little correspondence or memoirs that might illuminate their experiences of dying and death, making this a challenging area for researchers. Second, she questions the assumption that grinding poverty, high mortality, and poor living conditions might have somehow created a sense of fatalism or resignation about death among poorer social groups, which perhaps made death less consequential for day-to-day life. Her focus is in a period when living standards were rising, attitudes to poverty were changing, mortality rates were declining, and access to medical care was increasing. Strange presents a rich picture of working-class attitudes and practices in the face of death. She shows how many accounts from the period reveal a sense of openness and pragmatism, in contrast to the growing veil of secrecy described by Jalland. However, when money was tight, it was common to prioritize subscriptions to the funeral club over payment for medical care. This was offset by a major investment of time and effort by family members and neighbours in informal networks of care for the sick and dying. Strange quotes Florence Bell’s moving account of care among impoverished ironworkers in Middlesbrough, in the industrial north east of England:

In one case, the husband, an ironworker, had been ill with rheumatic fever and pneumonia, the wife with consumption—both hopelessly ill; the husband died first, and the kindly neighbour … offered to take in the dying woman, who shrank from going to hospital. She took the invalid into her house and when the mother died, adopted the child.9

Strange found in her studies the pervasive influence of stories about attentive care and self-sacrifice. Families sought to hold onto their sick and dying members; they often equated hospitals with almshouses and places of stigma; and there was a belief that the care provided in such institutions would not match that available at home. However, at the same time, the protracted death, apparently idealized by wealthy families up until the 1870s, was feared as a further drain on limited resources. Illness brought unemployment, reduced income, and the need to expend more on the sick person, including medical bills. Death not only hurt the emotions, but also the family coffers. In such circumstances, the resilience and fortitude described by Strange is remarkable. Nor were there many options for the relief of pain and suffering, other than the use of alcohol, the companionship of close ones and, for those who could afford it, the prescription of morphine by the doctor. Strange observes that in contrast to the evangelical convictions of Jalland’s early Victorians, the working classes of the later period seemed to favour an all-forgiving god of mercy. They casually overlooked obligations to a god of judgement, and thus left the deathbed free from last-minute conversions and prayers for the forgiveness of sin.5

To these observations can be added the work of D. P. Helm,10 who sets out to understand the beliefs, motivations, and influences that shaped the care of the dying in the Victorian home, in an age immediately prior to the growth of hospitals and the subsequent shift of death from the home to the institutional setting. His focus is on data from three of England’s rural counties (Gloucestershire, Herefordshire, and Worcestershire), and his attention is with families of the ‘middling sort’—in other words, somewhere in-between those contexts described by Jalland and Strange. Helm shows how the key professional nexus in this regard was that of the clergy, nurses, and doctors, and he seeks to identify the currents of change that transformed care of the dying in the Victorian period. This study presents evidence from diaries, letters, novels, and the visual arts to suggest that family members’ central role in the decision-making process, and in providing care, allowed them to draw on shared emotional and psychological support and derive comfort from religious beliefs held in common. The wider community of friends, neighbours, extended family, and the many middle-class women who undertook to visit the sick as a Christian duty, all provided further support to carers.

Throughout the nineteenth century, Christianity still provided the framework within which most people in British society understood death. Christian end-of-life care was focused on spiritual preparation and gave the dying respect and a dignity conferred by their perceived proximity to God. For the carers, Helm argues, the emphasis on preparedness provided them with a comforting role—for example, in praying and reading from scripture with the dying, when otherwise they could feel impotent in the face of untreatable bodily suffering. Contrary to suggestions that Christians disapproved of pain relief, the evidence from Helm’s work suggests that analgesia was mostly welcomed once available, but when pain was encountered, Christian teachings about its purpose were drawn upon as a source of consolation and strength. Although doctors were becoming increasingly influential in end-of-life care through an increase in their professional status and an improving ability to provide effective pain management, Helm contends that they did not exercise the levels of authority and control over the domestic deathbed that they later came to assume in the hospital setting. These limitations on the doctor’s influence can be observed in the process of negotiation through which diagnoses were arrived at, frequently involving recourse to second opinions, and through the constraints imposed by the lack of effective treatments. Finally, Helm challenges the persistent preconception that the Victorians were morbidly obsessed with death, suggesting instead that the Victorian response to death should be seen as both pragmatic and rational, given the prevalence of death in society and the changing nature of religious and medical practice.

We also have evidence of nineteenth-century homecare of dying people in the German context, gleaned from research that focused on the work of deaconesses associated with the diaconal centre at Kaiserswerth, near Düsseldorf. In the training of these deaconesses of Kaiserswerth, the nursing of the soul—caring for the spirit of the sick person—was given equal importance to care of the physical body. After finishing their training in the motherhouse, the deaconesses were sent to hospitals and into parishes and private care in many German cities. Their letters, written back to the motherhouse, offer insight into their experiences of caregiving in domestic settings. Karen Nolte11 has provided an analysis of these experiences, which we can place alongside other depictions of nursing care of the terminally ill in Britain and America. This also gives insight into the forms of institutional care of the dying that were to develop from the late nineteenth century, and to which we turn in Chapter 2.

Sometimes, the mere presence of a nurse appeared to have had a soothing effect on the sick and their families. The Kaiserswerth sisters took care not only of the patients, but also of their family members. They cooked for husbands, children, and siblings, and provided personal and religious support for them. In administering pain relief, the nurses bore a great responsibility, which sometimes led to conflicts with the physician in charge. Some felt themselves better equipped than the attending physician to decide how much morphine a patient needed and at what time, while others seem to have administered morphine with considerable discretion. Nursing the soul became particularly significant once the doctors had no more to offer and the nurses could do little more with physical care. Nevertheless, even deeply held beliefs could be challenged by the severity of suffering. One particularly haunting report on the care of a woman with abdominal tumours appeared to trigger a crisis of faith, not only in the nurse, but also in the dying woman and her husband.

The Kaiserswerth nurses were expected to establish a professional distance between themselves and the patient’s family. They were urged not to eat with the family, not to accept personal gifts, and to wear the required deaconess habit at all times. They were also expected to leave the family as soon as their care was no longer needed. In the event of death, the nurse was permitted to stay through to the funeral, but she had to travel back to the motherhouse or to her next location immediately afterwards. Nolte observes that, at times, the way the deaconesses dealt with the deaths of their patients appeared rather technical and pragmatic—for example, in letters to the directors in Kaiserswerth, they gave estimates on how long it might take for a patient to die so that they could then leave. During their training period, the sisters were prepared for the care of the terminally ill in a ‘Course of Medicine’, which covered in detail the special physical care requirements of the dying. The sisters were expected to stay with the dying person continuously and alleviate the process by regularly washing and drying, turning, and repositioning the patient. However, spiritual care predominated and, as Nolte reports, the medicine course handbook stated the following:

The beautiful and sacred task of nursing not only in its seriousness, but also in its full meaning and importance is brought to bear at the bed of the dying. When the physician can help no longer, the love of the nurse is still working indefatigably, standing by the dying person with a caring hand and a gentle mind in the hour of strife and dissolution to bring him relief and consolation. She almost doubles her diligence and loyalty and her concern reaches even beyond the point when the decisive moment has passed.11

Emily Abel’s work on end-of-life care in nineteenth-century America gives further context, detail and definition to this type of narrative.12 Abel rejects the notion that doctors actively sought dominion over the dying process in these years, or that medicine eclipsed the role of families and religion at the deathbed. For Abel, the ability of medicine to control acute infectious disease was quickly offset by the rising tide of chronic conditions, within which the route to death could be protracted and unpredictable, and with unpleasant symptoms that were difficult to control. Patients were labelled ‘incurable’ (in the earlier period) or ‘terminal’ (somewhat later) and, by and large, ‘devalued and avoided’ by physicians and hospitals alike. Even though the American Medical Association (AMA) had drawn up a code as early as 1847 urging doctors not to abandon the incurably ill or those imminently dying, physicians were largely absent from the deathbed in this period. While medicine in the mid-nineteenth century made huge advances in the control of pain—using morphine and the newly invented hypodermic syringe—skills in relieving pain at the end of life lagged far behind those relating to pain relief after surgery. The AMA code also warned against making gloomy prognostications and this tended to foster a sense of false optimism, or even denial in doctors dealing with terminally ill patients. In this way, the stance of American medicine towards the dying could appear limited and detached. In 1873, America had only 120 hospitals, from which the dying were, in the main, actively excluded. Most people died at home, cared for by relatives who continued to view dying as a social and spiritual event that was largely the responsibility of the family. Nevertheless, death could also take place in the hospital, among strangers, and sometimes far from one’s roots and origins.

So in the ‘long’ nineteenth century, the prevalent culture of dying in Europe and North America moved from an idealized and protracted process oriented around spiritual considerations, to one where the primary concerns shifted more to the relief of physical suffering than to matters of religious observance. While the comfortable circumstances of the middle and upper classes may have favoured easy access to a new cadre of physicians willing to intervene at the deathbed, for poorer families the material realities of suffering continued to be managed by relatives and neighbours, with limited practical resources to alleviate pain and distress. Against this contextual background, it is now time to move our focus to some of the key medical innovators of the period, to examine how medicine began to develop a discourse of care for the terminally ill in the nineteenth century, and in so doing, defined a set of parameters for intervention and conduct at the bedsides of the dying.

Emerging medical perspectives on care of the dying

Julie Rugg has observed that by the late eighteenth century, the doctor was becoming a common presence for both upper and middle-class families around the time of death13 and this was a trend that continued as the nineteenth century advanced. As Lorna Jane Campbell notes, by the first half of the nineteenth century, attention was turning in earnest to the specific question of how best to care for the dying.14 At first, doctors had little to offer, either in the way of curative intervention, or systematic modes of symptom relief. Their role may have been limited to a combination of self-styled imperiousness and well-honed bedside manner, coupled with the judicious use of laudanum and opium that had become commonplace in ‘the anaesthetised age’ of the eighteenth century.15 As the nineteenth century progressed, however, medical men gained access to new technologies, and to the drugs that began to define the physician’s place at the deathbed. In time they became active in collating and disseminating their practice in this regard, achieving a growing audience for their endeavours. It is possible to identify a small number of medical authors, frequently at the end of their professional career (although not always), who made a particular contribution to the question of caring for those imminently dying. It is hard to assess whether their practices were representative of the prevailing norms. Their approach was essentially a distillation of practical wisdom gained from experience and from the writings of their antecedents, and we must assume that they were at the forefront (rather than the rear-guard) of thinking for their time—with many others having less complete or informed practices. We should therefore beware of forming from these texts a more general representation of medical care for dying people in this period.

As early as 1802, Richard Reece, following medical practice in Chepstow and Cardiff, produced his expansive eight-volume work for a wide readership entitled The Medical Guide, for the Use of Clergy, Heads of Families, and Seminaries and Junior Practitioners in Medicine; Comprising a Complete Dispensatory, and a Practical Treatise on the Distinguishing Symptoms, Causes, Prevention, Cure, and Palliation,16 a work that was still in print in its 17th edition in 1850, almost 30 years after his death. This is one of the earliest uses in medical writing of the term ‘palliation’, referring to the relief of symptoms and suffering. It is notable that Reece not only thought to include nonmedical persons in the readership of his book, but also gave prominence to care when cure was not possible. Yet, works of this kind were usually general texts that covered the entire spectrum of medical practice and were not in any sense specialist writing on the care of the dying. Those were much fewer in number.

Ninety years after Reece, in a lecture on the care of the dying first given to nurses at the Metropolitan Hospital in March 1892 that was then published two years later, Dr Oswald Browne remarked in his introduction on the paucity of literature available concerning his subject.17 To the following half a dozen works, he acknowledged his great debt:

  • Dr John Ferriar, Medical Histories and Reflections (1798)

  • Sir Henry Halford, Essays and Orations (1842)

  • Sir Benjamin Brodie, Essays (1865)

  • Sir William Savory, Lectures on Life and Death (1863)

  • Sir Dyce Duckworth, in the third volume of Misericordia (1885)

  • Dr William Munk, Euthanasia—or Medical Treatment in Aid of an Easy Death (1887)

Such a bibliography, covering almost a century of medical writing, may seem slender indeed, although as we shall see in what follows it was not entirely complete, and at least a small number of other doctors in the period found time to lecture and to write about their knowledge and experience of caring for the dying. (The list is also notable in excluding the contribution of Florence Nightingale.18) Nevertheless, it provides at best only partial evidence to support the idea that from the eighteenth century onwards, medical practitioners were actively seeking to colonize the process of dying. Rather, we find in the collection the distilled wisdom of prominent medical men, moved at some point to comment on the care that should be afforded to the dying in their final hours and days—without any obvious sense that care at the deathbed was presenting some new opportunity for medicine or a new challenge to be overcome. Where this sense of opportunity is articulated, it is found buried in academic theses that had little wider influence for many years.

One such example, which we shall discuss in the next section, was the thesis of Hugh Noble, who was writing about the care of the dying in Edinburgh in the 1850s. There was also the thesis entitled De Euthanasia Medica19 of Dr Carl Friedrich Heinrich Marx (1796–1887) (Figure 1.1), presented in Latin in 1826 at the University of Goettingen, which at that time was part of the Kingdom of Hanover. His work had some influence on German physicians, but did not reach a wider audience until 1952 when it was translated into English and published by Dr Walter Cane of Nassau County, New York.20 Marx writes elegantly and comprehensively about the desired disposition of medicine to those who are dying and begins by asking what can be done to make the passing from life ‘gentle and bearable’. He defines this as a science that controls the oppressing features of illness, relieves pain, and renders the supreme and inescapable hour a most peaceful one. He suggests that up until that time, the subject had not been thoroughly studied, and he is modest in the claims he makes for his own contribution. Nevertheless, he is also critical of those physicians who, when they find their treatments wanting, begin to lose interest in their patient, believing they are dealing with a disease, and not a human being. The nobler path, he asserts, is taken by some physicians, whom Marx observes in this wonderfully rousing passage:

With no shining ray of hope remaining, consider it their more lofty duty to lay to peaceful rest a life they can no longer save. Accordingly they will extend their energy and their affection, they will follow each successive turn of events, they will apply palliatives wherever they can, and with an all-caring heart they will put themselves in readiness for the great event, so that the last breath of passing may be light and not dreadful to those left behind.


Figure 1.1 CFH Marx (1796–1887)
Marx’s thesis of 1826, presented at the University of Goettingen, explored the role of the doctor in producing ‘euthanasia’—a peaceful death. It was not until the end of the nineteenth century that ‘euthanasia’ came to denote the deliberate ending of life or hastening of death by medical means. The carefully documented clinical observations of Marx were maintained in the writings of other nineteenth-century doctors, who succeeded in setting out some of the principles that were later to embody the practice of what came to be known as palliative medicine.

Figure 1.1 CFH Marx (1796–1887)

Marx’s thesis of 1826, presented at the University of Goettingen, explored the role of the doctor in producing ‘euthanasia’—a peaceful death. It was not until the end of the nineteenth century that ‘euthanasia’ came to denote the deliberate ending of life or hastening of death by medical means. The carefully documented clinical observations of Marx were maintained in the writings of other nineteenth-century doctors, who succeeded in setting out some of the principles that were later to embody the practice of what came to be known as palliative medicine.

Reproduced from Wellcome Images, http://catalogue.wellcomelibrary.org/record=b1181192, Image ID: L0025130, Copyright © 2016 Welcome Library, London.

He then lays out three principles to guide such an orientation. First, there is foresight: the watchful attendance of nurses and others, whom with skill take every opportunity to ensure the patient’s comfort and the correct organization of the sickroom. Second, is the avoidance of suffering: this means eschewing dubious therapeutic and surgical measures, and focusing on eliminating or curbing pain, torment, and restlessness though sedative and analgesic medications. Third, is the pursuit of higher comfort: this should not be left only to the priest, but should capitalize on the known face of the physician, who endeavours to relieve agitation, bring confidence to the despairing, assure the doubtful, and assuage fear.

In all this, Marx is clear that ‘euthanasia’ is not about the physician bringing forward the moment of death, a practice he condemns: ‘ … least of all should he be permitted, prompted either by other people’s requests or by his own sense of mercy, to end the patient’s pitiful condition by purposely and deliberately hastening death’. In this context, Marx can still praise the use of narcotics, which ‘if properly and cautiously administered, are the most salubrious medicines for the whole human race and particularly appropriate for euthanasia’. At the same time, practitioners must use them with care and be alert to untoward side effects, aware of how they can differ in every individual, and sensitive to their power to produce stupor at high doses. He singles out opium as the ‘solace of phthisics’ or the ‘blessed anchor’ for cholera.

According to Cane, Marx’s thesis was later praised by Dr Heinrich Rohlfs (as a ‘medical classic’ in his work Geschicte der deutschen Medizin, published in 1880). Marx’s short treatise contains many key elements in the nineteenth-century medical pursuit of euthanasia. That term would later in the century change its meaning significantly and, in so doing, serve to obscure the goals of care that Marx and others sought to identify for medicine when all therapeutic endeavour had become ineffective. As we shall see in subsequent chapters, his blueprint for euthanasia bears remarkable resemblance to later endeavours that came to be known as palliative care. It was not about actively seeking to end the life of the patient.

A paper by Mark Taubert and colleagues21 investigated the occurrence of the word palliative within articles appearing in the Provincial Medical and Surgical Journal (later the British Medical Journal) in the first three years from its inception in 1840 (a dozen years before William Noble was submitting his thesis at Edinburgh). They found a smattering of references, some pejorative (‘mere palliatives’), others implying a more purposive orientation to palliative treatments. Some concerned cases of cancer and some tuberculosis. None seemed to have been concerned with patients actively dying, but they do indicate that nineteenth-century doctors were distinguishing between clinical interventions that might have a curative intent, and those where the purpose might be to give comfort, alleviate suffering, and lift morale.

The final work on Browne’s list for his 1892 lecture, Munk’s Euthanasia: Or, Medical Treatment in Aid of an Easy Death, was already gaining significant attention among medical and nursing readers. For in Munk’s 1887 work22 we see something much more extensive, more rigorous, and more like a manual for end-of-life medical care that might be taken up and championed by others, and thereby have some wider influence on medical practice.

William Munk was born in 1816 and qualified in medicine in 1837, having attended medical schools in London and Holland.23 He established a successful general practice in London, where he worked for over 60 years and became well known in the profession. He was not only a leading authority on smallpox, but also in his role as Harveian Librarian to the Royal College of Physicians, he single-handedly produced the Roll of the Royal College of Physicians of London 1518–1700.24 Though a prolific medical biographer, he yielded a smaller output of clinical writings. In the present context, it is his Euthanasia book,22 published when he was 71 years old and had spent more than 40 years in medical practice, for which he is most notable. This was a work that had an immediate impact in medicine and in nursing—on both sides of the Atlantic. For this reason, it is important to look at Munk in some detail.

Munk’s reason for writing Euthanasia is not clear. It is against the tide of his other major publications, which were almost exclusively biographical.25,26 As we shall see in Chapter 2, there was a cluster of people in the years immediately preceding the publication of Euthanasia whose religiously inspired commitment to caring for the dying resulted in the establishment of special homes for that purpose in London and elsewhere.27 Yet Munk gives no indication that he is aware of, or engaged with, any of these people or their activities. The title of his work immediately gains the attention of the modern reader. But, as we have seen, at the time of Munk’s writing, euthanasia still referred chiefly to the notion of a calm and peaceful death, the good death brought about with the assistance of the physician. It was not until the beginning of the twentieth century that the modern sense of euthanasia, understood as a deliberate medical intervention to end life, was fully articulated. Such it was described by Robert Saunby in his 1902 work on medical ethics as ‘the doctrine that it is permissible for a medical practitioner to give a patient suffering from a mortal disease a poisonous dose of opium or other narcotic drug in order to terminate his sufferings’.28 Munk, by contrast, uses the word euthanasia in its classical sense, to describe the goal of the physician in helping the sufferer to a more comfortable death. He is clear that care should be taken to avoid even the accidental premature death of the dying patient by the incautious administration of opium.22 This sense of euthanasia had become widely understood in Victorian Britain and was also used to refer to the glorious deaths encountered through global exploration or other feats of heroism, and which did not involve the medical practitioner.

Munk’s opening chapter covers four main aspects of dying. The first is to assert that the moment of death is not as dreadful or painful in reality as is often supposed. This was one of the contemporary arguments against deliberate killing. Here as elsewhere, we see Munk drawing on the influence and arguments of earlier medical writers on his subject—specifically Sir Henry Halford, who had gained a significant reputation for his solicitous care of dying members of the upper classes in the late eighteenth and early nineteenth centuries,15 but also the more recent influences of Sir Benjamin Brodie and Sir William Savory. He acknowledges that the process of dying may be painful, but maintains the distinction between the moment of death and the ‘urgent symptoms of disease that precede and lead up to it’. There are some exceptions to this, where death is caused by disease of the heart and great vessels, as well as in cases of ileus, hydrophobia, tetanus, and cholera, in which ‘some few do really suffer grievously in dying and expire in great bodily torture’.

The mental aspects of dying, the second phenomenon noted by Munk, echo the physical dimensions. That is, the moment of death is usually accompanied by calm, particularly if the physician, or the patient’s friends, have helped to maintain an attitude of hope. The great shock of discovering that death is imminent usually gives way to a state of tranquillity, providing there has been sufficient time for the patient to adjust. Where the realization of death’s imminence comes too close to the event itself, Munk notes, recovery from the shock is less likely, and this ‘explains some at least of the harrowing scenes that occasionally mark the deathbed’. It is for this reason, he argues, that the dying person should be fully informed about their condition: ‘An earlier intimation to the dying person of the great change he is about to undergo is in all respects desirable.’

The third phenomenon Munk considers is the state of the intellect at the actual moment of death. This may vary from alert to delirious, but regardless of what state has been dominant during the process of dying, the transition to the moment of death is marked by a ‘return of intelligence, that “lightening up before death” which has impressed and surprised mankind from the earliest ages’.

The content of Munk’s first chapter is derived from his considerable experience as a practising physician, and his assertions are supported by reference to previous authors, with whom he appears to always agree. A much shorter chapter follows, ‘The Symptoms and Modes of Dying’, in which Munk presents the variety and individuality of ways of dying, according to the nature and the site of the disease. A footnote informs the reader that he has not relied so much on his own experience in this part of the book, because ‘Sir Thomas Watson, in his admirable lecture on the Different Modes of Dying,29 has treated the whole subject so graphically that I shall follow him as closely as possible in what I have to adduce on this part of my subject’. Munk was a great admirer of Sir Thomas Watson30 and saw him as the most important doctor in the land.

Munk’s third chapter, ‘The General and Medical Treatment of the Dying’, opens with the proposition that much suffering is not ‘naturally or necessarily incident to the act of dying’, but is due to surrounding circumstances that can be changed or managed. These include the provision of appropriate bedding, physical position in the bed, fresh air in the room, and so on. In these observations and recommendations, Munk reveals the influence of Florence Nightingale’s approach to nursing. Nightingale’s Notes on Nursing (1859)18 is cited three times: (1) regarding the desirable posture for a dying patient in bed; (2) the benefits of light bedclothes; and (3) the necessity to avoid whispered conversations in the sick room. The most important of the nursing considerations, according to Munk’s account, is the provision of appropriate nourishment. He devotes seven pages to this, claiming that there is nothing of more importance in the management of the dying. The best kind of food depends on the nature of the disease and the likely prognosis. Where death results from ‘slowly progressive exhaustion’, as with cancer and some cases of consumption, then food should be more nourishing and given in relatively greater quantity. Sceptical of the value of beef tea and other meat extracts, favouring instead milk, cream, beaten eggs, and cereal, Munk also asserts that wine and spirits are of special use in the treatment of the dying. Alcohol passes readily into the blood, stimulating the heart and lungs, and promoting the circulation. It increases gastric secretion, stimulates peristalsis, and aids digestion. Ideally, alcohol and food should be given together, as they mutually influence one another. Champagne is the best choice, but it needs to be given more frequently than other wines or spirits. In all cases, the wishes of the patient are the most reliable guide to what should be given. Munk’s approach to the use of opium is discussed in the next section of this chapter, entitled ‘The question of pain relief’.

Munk’s book closes with prescriptions for the regulation of the dying chamber, specific recommendations for managing death from disease associated with the heart, lungs, and brain, and symptomatic management of hiccup, restlessness, respiratory struggle, and various other phenomena. The final paragraph describes death from old age, which Munk claims is ‘so gentle … that nature herself provides a perfect euthanasia’.

The majority of physicians in England and the United States in the 1870s and 1880s were opposed to the deliberate killing of a dying patient, which they saw as morally wrong, dangerous to individuals, and to society.31 Munk, for his part, gives no indication that he is aware of any wider debate on the matter and does not engage with arguments for, or against this practice. His insistence on using the traditional and literal meaning of the word euthanasia, at a time when other meanings were beginning to be attached to it, may have been intended as a quiet, but forceful, statement of his position. As Nick Kemp suggests, perhaps overstating the case, ‘one of the principal reasons why nineteenth-century physicians were not engaged in discussion about the physician-assisted suicide variety of ‘euthanasia’ was because they were directing their attention to issues of palliative care which would secure ‘euthanasia’ in the classical sense’.32 (See the final section of this chapter, ‘End of the century’, for a discussion on the tendency of both practitioners and historians to make use of twentieth-century concepts—in particular the concept of palliative care—when seeking to explain nineteenth-century practices.)

In 1888, the year after its publication, The Lancet printed a glowing review of Euthanasia, calling it a ‘treatise by a thoughtful and experienced physician’ and supporting fully both Munk’s aim in bringing the subject to the notice of the medical profession and his execution of important instruction in the medical management of the dying. ‘We have not a fault to find with this treatise’, the review concludes. ‘It fulfils its purpose and we commend it to our readers’.33 According to Jalland, Euthanasia ‘remained the authoritative text on medical care of the dying for the next thirty years’.6 Munk’s work certainly influenced the writer of an article that appeared in an American journal three years later, entitled ‘Some notes on how to nurse the dying’. It borrowed heavily from Munk and sought only to praise his contribution.

When I first took charge of wards there was nothing I so much dreaded as attending death-beds and nursing the dying … I in vain enquired for any book to help me and, with the exception of a few sentences in various medical works, found nothing; until a short time ago I read a most interesting and suggestive book called ‘Euthanasia’ by Dr. Munk … and I thought that perhaps a few hints and some account of this book might be interesting to some of my fellow nurses … Where all is so excellent it is most difficult to make selections. I can only recommend the perusal of Dr Munk’s book to those nurses who find the efficient nursing of the dying one of their most anxious and difficult duties …34

An earlier transatlantic review had appeared in 1888 by the celebrated Canadian physician William Osler. He is more muted in his praise for the book, simply approving its ‘general and scientific interest’ along with its ‘many valuable suggestions to practitioners and sound advice as to the medical management of the dying’.35 Osler’s main purpose in writing seems to be to show how Munk’s opinions accord with his own, particularly on the subject of death not being the torment it is commonly supposed to be.

Munk’s text was authoritative, according to Jalland, because it drew widely on the practice and teaching of the previous generation of doctors and showed an essential continuity with their experience.6 Yet, if Euthanasia was influential within a narrow circle of reviewers and practitioners, its influence did not last significantly beyond Munk’s own generation. In 1914 a medical correspondent to The Times cites, on the subject of ‘the pains of death’, earlier works by Savory and Brodie in support of his arguments, rather than Munk.36 By 1926, the American physician Arthur Macdonald was still calling for a scientific study of death that would enhance the sum of knowledge and enable ‘a general picture of the dying time, based upon a sufficient number of observations and with instruments of precision where possible’ so that fear of death would be diminished and pain eliminated.37 Moreover, as late as 1935, the American physician Alfred Worcester38 argued that the previous half-century had seen a deterioration in medical practice, rather than progress, in the art of caring for the dying, with no mention of Munk.

Munk brought together the best elements of past medical practice and summarized them for his contemporaries and immediate successors. At the same time, he focused on the most modern technologies and the best of caring practices that could be used to relieve suffering. Yet Munk’s influence seems to have been narrowly circumscribed and later generations of doctors had to discover for themselves how best to care for the dying effectively, and with humanity. The early twentieth-century search for ‘root cause and ultimate cure’, in Patrick Wall’s words, inhibited a therapeutic approach to the symptoms of dying. This was until the mid-century palliative care pioneers in the emerging hospice movement began to draw attention again to the need to give comfort in the absence of cure, recognizing that ‘the immediate origins of misery and suffering need immediate attention while the search for long-term cure proceeds’.39

If Munk was the first to attempt a comprehensive documentation and codification of the issues in the medical care of the dying, Sir William Osler reported the first clinical study of the manner in which patients die in his 1906 lecture Science and Immortality—‘Observations of 500 dying patients’.40 Following postgraduate training in Europe, Osler returned to McGill University’s faculty as a professor in 1874. He was appointed chair of clinical medicine at the University of Pennsylvania in Philadelphia in 1884. When he left Philadelphia in 1889, it was to take up the position as first physician-in-chief of the new Johns Hopkins Hospital in Baltimore, Maryland. Shortly afterwards, in 1893, Osler was instrumental in the creation of the Johns Hopkins University School of Medicine, and he became one of the school’s first professors in medicine. In 1905, he was appointed to the Regius Chair of Medicine at Oxford, a position he held until his death in 1919. He pioneered the practice of bedside teaching, making rounds with a handful of students, demonstrating what one student referred to as his method of the incomparably thorough physical examination. Osler fundamentally changed medical teaching in North America, and his influence spread to medical schools across the globe.41

Shigeaki Hinohara42 has explained in some detail Osler’s concern for the dying and the bereaved, and how Osler displayed a level of personal interest and concern for his dying patients and their family members from his earliest years in the profession. In general, Osler considered death from disease as unnatural and likely to be accompanied by pain and suffering, but he regarded death from old age as almost always the easiest of deaths, accompanied as much by pleasure as pain. Across a lifetime of writing and lecturing, Osler declaimed often on issues of dying and death. In a piece delivered in 1897, he condemned nurses for intruding at the bedside of the dying, offending the wishes of patients who may desire to be alone and usurping the role of family members.43 More controversially, in his valedictory address at Johns Hopkins Hospital, he endorsed Anthony Trollope’s account in the novel The Fixed Period whereby men at the age of 60, after a year of contemplation, are dispatched peacefully with a dose of chloroform.44 In general, Osler is known for his view that death is less discomforting and painful than generally assumed, and he demonstrated this in his analysis of the deaths of 486 patients at Johns Hopkins Hospital during the period of 1900–1904. A nurse interviewed the patient in his or her last moments of life and items were recorded by a chief nurse on a questionnaire, which was then countersigned by the patient’s doctor. Osler reported the following:

I have careful records of about five hundred death-beds, studied particularly with reference to the modes of death and the sensations of dying. The latter alone concerns us here. Ninety suffered bodily pain or distress of one form or another, eleven showed mental apprehension, two positive terror, one expressed spiritual exaltation, one bitter remorse. The majority gave no sign one way or the other; like their birth, was a sleep and a forgetting.45

Osler was also greatly interested in his own mortality and when his health deteriorated significantly in 1919, exacerbated by the losses of his two sons, the second in Flanders, he engaged actively with his own process of dying. He spent his last days in active goodbyes, in visits from loved ones, and maintained his intellectual endeavours to the last.46

Essentially, Osler took the view that the dying patient’s comfort was paramount and that aggressive and useless medical interventions should not be allowed to interfere in the last days of life, when a sense of closure was essential. Yet, he could not fully endorse Munk’s view that the deliberate ending of life, even in the interests of relieving suffering, should always be avoided. As we shall see in the conclusion to this chapter, he straddled a period and a debate that was critical in redefining the meaning of euthanasia.

The question of pain relief

Rosaleyne Rey, in her comprehensive history of pain, sets out an expansive view of the achievements of the nineteenth century in both the understanding of pain and in its management and relief.47

In the 19th century, there were an increased number of break-throughs in the understanding of pain mechanism as well as a flowering of clinical disciplines and therapeutic innovations. These were such that the century was truly one of great discoveries in which the terrae incognitae were revealed in a decisive way allowing men to better understand and sometimes better relieve pain.

It was, of course, across these decades that the so-called ‘death of pain’ began to be envisaged. The successful public demonstration of surgical anaesthesia with ether in 1846 in Massachusetts General Hospital in Boston led to a revolution in how pain could be both treated and conceptualized. It also brought a growing sense of hubris about what scientific medicine could achieve. It now became accepted as morally valid to obliterate pain in surgery, and then in childbirth, and so pain came to be seen more as a disease in itself—a phenomenon with little redemptive value. Yet, as Martha Stoddard Holmes48 suggests in her essay on Victorian doctors and pain relief, the triumph over one kind of pain may have created for doctors a sense of conflict, or even shame in relation to pain that could not be relieved, so much so that:

… after 1846, the landscape in which doctors imagined and treated pain was a terrain where the pain of the dying was increasingly out of place, at odds with medicine imagined as a field of technological cures and miracles … Unlike a discrete surgical event, moreover, the pain of chronic or terminal illness had to be addressed over and over again.

Campbell takes the view that, beginning in the mid-nineteenth century, medicine was establishing how to integrate the use of the new pain-relieving drugs into the repertoire of practice, but was at the same time seeking to uphold notions of the ‘good death’. This was a particular challenge in a context where there was religious and theological opposition to the use of these drugs, which were seen as unnatural and un-godly. However, as the century advanced and these methods became more widespread and visible to families and the public, they set in motion calls for the further extension of their use. This was not only to relieve suffering in the context of a ‘natural death’, but also to deliberately end a life so that suffering might be overcome, however ‘unnatural’ the death that resulted.14 This transition involved considerable theological upheaval. As Lucy Bending has described, in the 1840s, debates about the understanding of pain were closely linked to beliefs about eternal damnation, but by the 1860s, the principle point of distinction was between those who found theological meaning and divine purpose in suffering, and those who did not.49

During the nineteenth century in Britain and North America, opium and opiates were freely and legally available across society for enjoyment or for domestic use in treating minor ailments.50 Barbara Hodgson51 presents a fascinating illustrated history of the use of morphine and laudanum in daily life, showing how they were present in mixtures sold to the public for coughs, colds, diarrhoea, infant teething, and a multitude of other problems. Medical practitioners could also be liberal in their use of such formulations in pursuit of euthanasia, understood in that classical sense of a calm and easy death. However, a science of pain relief was also emerging. As Rey explains, this was the period in which ‘chemistry applied to medicine’ was taking off.47

After the initial work of the French chemist Charles Louis Desrosne, Friedrich Sertürner, a native of Hanover, achieved the isolation of the soporific principle in opium in 1806 in Paderborn, Germany. He originally named the substance ‘morphium’, after the Greek god of dreams Morpheus and for its tendency to cause sleep. The drug was first marketed to the general public by Sertürner and Company in 1817 as an analgesic, and also as a treatment for opium and alcohol addiction. Commercial production began in Darmstadt, Germany, in 1827 by the pharmacy that became the pharmaceutical company Merck, with morphine sales being a large part of its early growth. After the invention of the hypodermic needle in 1857 by the English physician Alexander Wood, morphine use became more widespread and this mode of administration was widely believed to be less addictive to the patient.

From the mid-nineteenth century onwards, those of the middle and upper classes dying of cancer and tuberculosis were likely to receive copious quantities of opiates to relieve pain and suffering at the end of life. Others, if they could afford to buy them over the counter, would have had access to laudanum or tinctures of opium. This picture of the fairly abundant medical and public use of morphine began to change as the twentieth century approached. Moral concerns about such drugs and their various mixtures began to surface, and greater regulation of the use of opiates followed (such the 1914 Harrison Narcotic Act in the United States).52 A long-running era of drug restriction was ushered in, during which a lack of access to opiates and pain relief became a problem for medicine and healthcare. At the same time, medical attention to those dying of cancer was diluted by a shift in emphasis to the emergent possibilities of curing and containing the disease, offered by new developments in surgery, immunology, and endocrinology.53 Therefore, the relief of pain at the end of life was intermittent and erratic in its progression across the decades of the nineteenth and early twentieth centuries, making a simple narrative of ‘improvement’ both inaccurate and over-optimistic. As Campbell also points out, it is important not to overstate the wider progress in pain relief that came about in the nineteenth century: ‘It would be an over-simplification to read this period as a heroic moment in history, in which the adoption of certain types of techniques was related solely to a triumph over pain.’14

As scholarly research advances, more evidence is generated concerning nineteenth-century doctors who were inspired by the importance of pain relief at the end of life. These accounts ranged from eminent physicians and surgeons with royal patronage and senior hospital doctors not afraid to express their views in strong terms, to country practitioners, and even those still undergoing medical education. A hidden treasure of these writings has been analysed by Campbell, who devotes an extended discussion to the thesis of the Edinburgh medical student Hugh Noble, a work submitted for the degree of MD in 1854, before the author apparently slipped into medical obscurity. Its title was simply Euthanasia.54 With the refreshing openness of youth, and unintimidated by the status of earlier medical authorities on care of the dying such as Sir Henry Halford55 and Christoph Wilhelm Hufeland,56,57 Noble not only provides a wide commentary on the medical care of the dying patient, but addresses himself to the specific issue of pain relief at the end of life. Like Munk, Noble uses the term euthanasia to denote a peaceful and idealized death. But as Campbell shows, he also nudges his thinking towards a consideration of what the new approaches to pain relief might mean for medicine, if challenged to use them for the purpose of bringing about deliberate and final relief of suffering. Noble considers the question of when to treat the dying patient, how much to take his or her wishes into consideration, and how much information to proffer or withhold. Halfway through the thesis, he raises this fundamental question:

In regard to the active measures which may be adopted with the incurable or moribund, it may be asked how far the practitioner may be justified in interfering with the purposes of modifying or changing the mode of death.14

His response was that the sanctity of life placed such an action beyond the limits of medical practice and therefore rendered it something that must be condemned. He went on to observe that when the hope of recovery had passed, the physician often turned away from the patient, forgetting that ‘more may be done—that the time has come for restudying the case from a different point with a new object in view’.14 If the physician was forbidden from actively ending the life of a patient, this did not mean that he must aggressively seek to prolong it.

Stoddard Holmes, also considering this new objective, quotes the English surgeon and physician William Dale, writing in The Lancet in 1871, who emphasizes the twin principles of telling the patient of his or her fate, and then using active means to relieve their pain.

Opium is … our chief medicine for relieving pain and procuring sleep—our right hand in practice … suffering humanity owes much to its virtues, and the physician could ill spare it in his battle with disease and pain … On the near approach of death, where much pain is endured, after having, as in duty bound, made the patient sensible of his condition, I see no reason why he may not be kept constantly under the influence of opium …58

Writing in 1874, John Kent Spender, a surgeon and physician based in Bath and also described by Holmes, saw pain relief by the doctor as ‘the grandest badge of his art’. He writes that one of the ‘chief blessings of Opium is to help us in granting the boon of a comparatively painless death … we may, without extinguishing consciousness, take away the sharp edge of suffering, and make the departure from this world less full of terror’.59

William Munk had been clear to state that an important aspect of managing the process of dying is the correct use of opium for the relief of physical pain and for the ‘feeling of exhaustion and sinking, the indescribable distress and anxiety’ that can accompany dying. Although placed second in importance to the administration of stimulants, Munk gives even more space to precise and detailed recommendations about how to use opium to best effect. Opium in this context, writes Munk,22 is ‘worth all the materia medica’, but ‘its object and action must be clearly understood’. It is given both to relieve pain and to ‘allay that sinking and anguish about the stomach and heart, which is so frequent in the dying, and is often worse to bear than pain, however severe’. It should be given freely and judiciously, not timidly and inadequately, or it will not achieve its purpose.

A similarly bold approach was taken by Herbert Snow, who worked at the London Cancer Hospital (later the Royal Marsden) as a surgeon from 1877 to his retirement in 1906. Like a handful of his contemporaries, Snow was interested in the administration of strong opiates for the relief of pain and ‘exhaustion’ in advanced cancer. An advocate of early surgical intervention for malignant disease, he also believed that cancer, in many instances, had a neurotic origin and he sought to treat it by inducing an ‘opium habit’ in his patients. By the 1890s, he was arguing that the conjunction of both morphine and cocaine could not only relieve the symptoms of advanced cancer, but could indeed slow the progression of the underlying disease. His 1896 paper, published in the British Medical Journal and entitled ‘Opium and cocaine in the treatment of cancerous disease’ argued that the two drugs had the power of ‘inhibiting tissue metabolism’ as well as ‘sustaining the bodily powers under excessive and protracted strain’.60 He presented a number of case histories in support of his argument, stating that morphine was effective in relieving pain, while cocaine had value in ‘sustaining vitality’. Less than a year later, however, in a letter to the same journal, Snow complained that ‘for reasons of hospital finance I have been reluctantly compelled to abandon this costly medicine [cocaine] for the majority of my hospital patients’.61

Snow may have been confused about some of the effects of his prescribing methods, but his importance from a modern perspective was in highlighting the role of opiates for symptom management in advanced cancer. It appears that his ideas about combining morphine and cocaine crossed the road (Cale Street) from the Cancer Hospital to the Brompton Hospital. There, the therapeutic goal of his successors was significantly different. For Snow, the chief virtue of the combination was its apparent effect on the progression of cancerous disease, and he seems to have reserved the use of the opium pipe as the chief method for ‘palliation’ and symptom relief in advanced cancer. When the combination was first reported at the Brompton in the early twentieth century, its use was recommended for the relief of physical suffering and pain associated with tuberculosis. As we shall see in later chapters, the Brompton Cocktail, as it came to be known, had a special place in the history of twentieth-century hospice and palliative care. Its origins go back to Snow, and he in turn was part of a wider community of nineteenth-century doctors who were eager to capitalize on the pain-relieving properties of the opiates, especially to relieve pain in those imminently dying. As we are starting to see, the purposes of such drugs were beginning to vary in the minds of physicians. And so it was that debates about access to pain relief and the principles of its administration would echo long through the decades as new possibilities emerged and, in time, a wider philosophy of modern hospice and palliative care took hold.

End of the century

In August 1899, only a few months away from the end of the nineteenth century, an article appeared in the Fortnightly Review by Joseph Jacobs,62 an Australian living in Britain at that time and well known for his extensive work in the field of folklore.63 He set out a provocative account of the nature of death in contemporary society, arguing that it had lost its terror, that the church had become more oriented to the present life rather than the life to come, and that the fear of death was being replaced by the joy of existence. He attributed this to public health improvements, increasing longevity, and to the fact that when death comes with more warnings, ‘We are more willing to go, less eager to stay’.63 This tendency, he argued, could be exacerbated by medical science, which protracts life at the cost of extra suffering, making death not only a relief to the sufferer, but also to those who remain. Jacobs asserted that ‘on all sides death is losing its terrors. We are dying more frequently when our life’s work is done, and it seems more natural to die’.

Such a position runs into problems at the level of medical practice. A starting point for the present work will be the contention that since the late nineteenth century there has been a diminishing importance given to the matter of life or existence after death. Instead, the focus for professional and social interest has become the process of dying itself. How we die now matters more than the consequences of our dying. It was this notion that the nineteenth-century doctors recognized. Those among them who showed an interest in the care of the dying set out to create an approach that could be taught to others and which might merit the interest of fellow professionals through lectures, journal articles, and medical textbooks. Even so, the goals of medicine at the end of life were often problematic to lay observers and commentators. In 1911, the year in which he won the Nobel Prize for literature, Maurice Maeterlinck, the Belgian playwright and essayist, also writing in the Fortnightly Review, claimed that ‘all doctors consider it their first duty to protract as long as possible even the most excruciating convulsions of the most hopeless agony’.64 This he attributed to medicine’s compulsion to prolong life at all costs. Yet, he also conceded, ‘they are slowly consenting, when there is no hope left, if not to deaden, at least to lull the last agonies’, although he continued to criticize those who ‘like misers, measure out drop by drop the clemency and peace which they grudge and which they ought to lavish’. Maeterlinck’s ideas on the subject were further elaborated in a short book published the same year, simply entitled Death.65 We know that William Osler took a close interest in these writings, as he had with the work of Munk. In a letter to the Spectator in 1911, Osler objected to Maeterlinck’s hysterical scaremongering about the pains of death and the prolonged suffering associated with the deathbed. He reiterated the findings of his empirical study of the dying, while rejecting Maeterlinck’s call for doctors to intervene to end life when suffering is intractable, and death is imminent.35

Stoddard Holmes and Helm both question the Foucauldian66 notion that in the period described here the patient’s narrative of suffering disappeared from medical discourse, in favour of the cataloguing and inscribing of signs and symptoms. Each sees plenty of evidence that nineteenth-century doctors sought ways to find meaning in pain, along with their patients and families, and they also strived to relieve suffering, even when death became inevitable. A similar view is found implicitly in the work of Jalland. What emerges from a review of the historiography and of some of the medical writings is that whether provincially based in family practice or working in the metropolitan hospital, there were nineteenth-century physicians and surgeons who gave their extended time and attention to the needs of dying patients and their families. These practitioners grappled with important questions: whether patients should know of their imminent demise; how to accompany them on the journey to death; how to relieve pain and suffering; and ways to give comfort to distressed and grieving relatives. The developing interest in these areas, however, seems to have found only a limited audience; pockets of enthusiasm here and there among like-minded practitioners, but not a critical mass capable of fostering transformational change. Instead, the gaze of medicine looked away—to the benefits that science and new knowledge might make in the control of disease, to the potential for new specialisms, and to the growing influence of the medical schools.

Also important, as notions of the evangelical ‘good death’ waned and there was increased attention given to dying in the absence of pain and suffering, was the emergence of the first publications to use euthanasia in a new sense—as medicalized killing or physician-assisted death. Kemp traces the origins of the modern euthanasia debate to the early 1870s and sees it essentially as a philosophical discussion, in which the profession of medicine played no part. It was sparked by the publication of a paper given to the Birmingham Philosophical Society by a schoolteacher named Samuel Williams that gave strong support to the idea of voluntary euthanasia.67 It appears that despite the appearance of numerous articles and editorials in the medical press after 1873, medical practitioners did not take a prominent part in these discussions. Kemp argues that while such discussions did take place in the United States68 from a fairly early stage, in Britain ‘the concept of mercy-killing failed, quite manifestly, to make any impact with the medical profession until shortly before the turn of the twentieth century’.32

A common theme among writers on the care of the dying and the use of pain relief in the nineteenth century is how the rich discourse of care and practice developing at that time became forgotten by the early twentieth-century medical professionals. It was not until the groundbreaking work of later pioneers of hospice and palliative care got underway in the mid-twentieth century that these antecedents were recovered. There may well be some truth in this. Certainly, it is a view held among professionals in the field as well as historians. It is a position taken by the pain specialist Patrick Wall69 in an editorial in 1986 and echoed by Cicely Saunders in her foreword to the first edition of the Oxford Textbook of Palliative Medicine, which appeared in 1993.70 Perhaps this is an understandable viewpoint among clinicians eager to uncover a deeper heritage to their current goals and ambitions. It is a more surprising tendency among historians, such as Jalland and Strange, who appear keen to interpret nineteenth-century cultures and patterns of dying and care through a late-twentieth-century ‘palliative care’ lens. Strange, for example, speaks of ‘models of palliative care in the late Victorian and Edwardian period’5 while, disarmingly, Jalland states that ‘the nineteenth century medical authorities were remarkably close to modern experts in their view on the use of opiates for the dying’, a very curious remark, given it was not until the 1950s that clinicians began to understand that morphine could work orally.6 There were undoubtedly attentive doctors and nurses in the nineteenth century who were solicitous about the needs of dying patients and their families. This is not in dispute. But to describe their practice as palliative care is misleading for, as we shall see, this was essentially a concept of the later twentieth century, when the term became widely adopted and came to take on specific meanings and definitions. That said, some of the phrases of Marx, Noble, and Munk would not look out of place in the early writings of Cicely Saunders, though we have no evidence that she read any of them.

Campbell makes it clear that the questions the Edinburgh medical student Hugh Noble raised in his MD thesis in 1854 remained key to the practice of medicine for the terminally ill for more than a century afterwards. If his work appears groundbreaking in some respects, its influence was negligible. It was not published for a wider readership and Noble himself was not heard of again. Stoddard Holmes takes the view that the other Victorian doctors writing about pain were also rather peripheral to mainstream medicine, even suggesting that their ideas and influence diminished as time went on.48 It is tempting, therefore, to view William Munk, whose work of 1887 was so widely and positively received, as the grandfather of modern palliative medicine. Exactly 100 years after the publication of his classic work on care of the dying, the specialty of palliative medicine was recognized in the United Kingdom. Munk was surely among the first of his profession to lay out so extensively the art and science of end-of-life care—in a form and manner that would influence others, and which was extensively praised at the time.

As David Cannadine notes, the ‘denial of death’, so often attributed to the period after 1945, was probably underway even before 1914. In addition to citing Jacobs’s 1899 article,63 he points out that the English of this period were less acquainted with death than any generation since the Industrial Revolution, that the death rate had fallen markedly, that ostentatious mourning had been in decline for 30 years, and that dying was increasingly associated with old age. In the same period, death on the battlefield—at the time thought unlikely—was seen as glorious, noble, and romantic.71 The Great War would change everything. Death and destruction on an industrial scale eclipsed the suffering of the domestic and hospital deathbed. However, it also promoted a cult of the dead that prevailed in the interwar years when Britain and other European countries went into a prolonged phase of public mourning and bereavement. The societal focus at this time was on collective loss and establishing memorials. This may well have served to sequestrate dying itself, which did indeed become a societal taboo and a matter about which it was difficult to speak. The interpretation goes a long way in explaining medicine’s loss of traction in the same interwar period with regard to improvements in care for the dying. But as we shall see in Chapter 2, there were a few small institutions, founded in the late nineteenth century and focused explicitly on the care of the terminally ill, which continued into the next millennium, and in so doing kept alight a flame of interest in medical care when death was imminent. It is to these homes and hospices that we will now turn our attention.

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