I am working on a new book at the moment, entitled To Comfort Always: A history of palliative medicine from the nineteenth century. In the opening chapter, I try to tease out some of the approaches to pain relief that were developing during the Victorian period in Britain. It is a fascinating trajectory. As the century advances, new formulations and methods for relieving pain come into practice. As a consequence the meaning of pain has to be re-examined. Over time it is disconnected from religious significance and becomes re-defined largely as a physical problem, one amenable to medical intervention. In parallel, the meaning of ‘euthanasia’ also changes from easeful death, to deliberate killing. And in the process the first shoots of modern palliative medicine begin to appear.
The death of pain?
Rosaleyne Rey in her sweeping 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. It was an era of break-throughs in the understanding of pain mechanisms as well as a flowering of clinical disciplines and therapeutic innovations. Such was the hubris of the time 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, Boston, USA led to a revolution in how pain could be both treated and conceptualised. It also brought a growing sense of hubris about what scientific medicine could achieve, more widely. As it became accepted as morally valid to obliterate pain in surgery, and then childbirth, so pain came to be seen more as a disease in itself and therefore a phenomenon with little ‘redemptive’ value.
Yet as Martha Stoddard Holmes 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 which could not be relieved: ‘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 …’
Pain and the ‘good death’
Lorna Jane Campbell in her well observed 2004 doctoral thesis from Edinburgh University, takes the view that from the mid-nineteenth century medicine was establishing how to integrate the use of new pain relieving drugs into the repertoire of practice. But at the same time this served to uphold notions of the ‘good death’, not least in a context where there was religious and theological opposition to the use of such measures, which were seen as un-natural and un-Godly. As the century advanced and these methods became more widespread and visible to families and publics, so they set in train calls for the further extension of their use – not only to relieve suffering in the context of a ‘natural death’ but also to deliberately end a life in order that suffering may be completely overcome, however ‘unnatural’ the death that resulted. this pointed the way to a changing meaning to ‘euthanasia’ – from a calm, easeful and idealised death to one brought about by deliberate medical intervention.
This transition involved considerable theological upheaval. As Lucy Bending has shown, 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.
As scholarship advances, more evidence is generated about nineteenth century doctors who were exercised by the importance of pain relief at the end of life. These 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.
Hugh Noble – medical student
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. With the refreshing open-ness of youth, and unintimidated by the status of earlier medical authorities and writers on care of the dying, Noble not only provides a wide commentary on the medical care of the dying patient, but addresses himself to the specific question of the relief of pain at the end of life. In keeping with other doctors of the time and wider public understanding, he uses the term ‘euthanasia’ to denote a peaceful and idealised 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 purposes 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. Half way through the thesis, he raises the 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’.
His response was that the sanctity of life placed such an action beyond the limits of medical practice and something which must therefore 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’. 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.
Freely available opiates
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 (Seymour and Clark 2005) . Medical practitioners could also be liberal in their use of such formulations in pursuit of ‘euthanasia’, still understood in the classical sense of a calm and easy death. But at the same time a science of pain relief was emerging and this would influence how death was perceived.
As Rey explains, this was the period in which ‘chemistry applied to medicine’ was taking off. After the initial work of the French chemist Charles Louis Desrosne, the isolation of the soporific principle in opium was achieved in 1806 in Paderborn, Germany, by Friedrich Sertürner, a native of Hanover. 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 became used more widely and this mode of administration was widely believed to be less addictive to the patient.
From the mid-nineteenth century therefore, the middle and upper classes dying of cancer and tuberculosis were often 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 commercial mixtures and formulations as well as 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 (Hodgson 2001), greater regulation of the use of opiates followed and a long running era was ushered in – still present today in some contexts – during which lack of access to opiates and pain relief became a deep rooted problem for medicine and health care. At the same time, medical attention to those dying of cancer was diluted by a shift of emphasis to the emergent possibilities of curing and containing the disease, offered by new developments in surgery, immunology and endocrinology.
An erratic trajectory
So it was that the relief of pain at the end of life was intermittent and erratic in its progression across the decades of the nineteenth century – making a simple narrative of ‘improvement’ both inaccurate and over-optimistic . As Campbell points out, it is important not to over-state the wider improvements to 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’.
Holmes quotes the English surgeon and physician William Dale, writing in The Lancet in 1871, who emphases 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 it 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 …’
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’ and stated 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’.[xxi]
The importance of William Munk
William Munk published his book Euthanasia: or, Medical Treatment in Aid of an Easy Death in 1887, when he was 71 years old and had spent more than 40 years in medical practice. Unlike Noble’s thesis, this was a work that had an immediate impact in medicine and in nursing – and on both sides of the Atlantic. In Munk’s Euthanasia and in contrast to earlier published works on the subject, we see something more extensive, more rigorous, more likely to be seen as a manual for medical care at the end of life, that might be taken up and championed by others – and thereby have some wider influence on medical practice.
William Munk was 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 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, is ‘worth all the materia medica’ but ‘it’s 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.
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’. According to Pat Jalland a leading historian of death and dying in the nineteenth century, Euthanasia ‘remained the authoritative text on medical care of the dying for the next thirty years’. Munk’s work certainly influenced the writer of an article which appeared in America three years later, entitled Some notes on how to nurse the dying, and attributed to ‘A Hospital Nurse’. It borrowed heavily from Munk and sought only to praise his contribution (Sumner 1890).
An earlier transatlantic review had appeared, in 1888, by the celebrated Canadian physician William Osler. Osler 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’.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 popularly 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. Yet if Euthanasia was influential within a narrow circle of reviewers and practitioners, its influence did not last significantly beyond Munk’s own generation. For example, a medical correspondent to The Times in 1914 on the subject of ‘the pains of death’ cites earlier works in support of his arguments, rather than Munk. By 1926 the American physician Arthur Macdonald was still calling for a scientific study of death which 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. And as late as 1935 the American physician Alfred Worcesterargued that the previous half-century had seen a deterioration in medical practice, rather than progress, in the art of caring for the dying. Munk’s work appears to have been unknown to Cicely Saunders when she embarked on her studies of pain and the care of the dying in the late 1950s.
The birth of palliative medicine?
Among his peers and immediate successors, then, we may tentatively infer that Munk was in the vanguard of what might be called a radical conservatism when it came to medical care of the dying. He brought together the best elements of past medical practice and summarised 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 the suffering of the dying. Yet Munk’s influence seems to have been rather narrowly circumscribed and later generations of doctors had to discover for themselves how best to care for the dying effectively and with humanity. It seems that the early twentieth century medical search for ‘root cause and ultimate cure’, in Patrick Wall’s phrase, inhibited a therapeutic approach to the symptoms of dying 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, recognising that ‘the immediate origins of misery and suffering need immediate attention while the search for long-term cure proceeds’.
Campbell makes clear that the Edinburgh medical student Hugh Noble raised in his MD thesis of 1854 some questions that remained key to the practice of medicine for the terminally ill for more than a century afterwards. If his work appears path-breaking 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 and even suggests that their ideas and influence diminished as time went on.It is tempting nonetheless to view William Munk, whose work of 1887 was so widely and positively received, as the grandfather of modern palliative medicine. Exactly a century after the publication of his classic work on care of the dying, the medical speciality was recognised in the United Kingdom and he was surely among the first of his profession to lay out so extensively the art and science of care at the end of life – in a form and manner which would influence others.
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Stoddard Holmes, M (2003) The grandest badge of his art: Three Victorian doctors, pain relief, and the art of medicine. In: ML Meldrum (ed) Opioids and Pain Relief: A Historical Perspective. Progress in pain research and management. Vol 25. Seattle: IASP Press.
Campbell, L J (2003) Principle and Practice: An analysis of nineteenth and twentieth century euthanasia debates (1854-1969). Unpublished PhD Thesis. University of Edinburgh, p18.
Bending, L (2000) The Representation of Bodily Pain in Late Nineteenth Century English Culture. Oxford: Oxford University Press
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