An exploration of the word ‘palliative’ in the 19th century: searching the BMJ archives for clues
- 1Department of Palliative Medicine, Marie Curie Hospice Cardiff and Vale, Bridgeman Road, Penarth, UK
- 2Department of Oncology, Velindre Hospital NHS Trust, Cardiff, UK
- 3Cardiff University, Cardiff, UK
- Correspondence to Dr Mark Taubert, Department of Palliative Medicine, Marie Curie Hospice Cardiff and Vale, Penarth, CF64 3YR, UK;
Background Palliative care went through a significant evolution in the 20th century, but the 19th century has been seen my some scholars as the real turning point toward the more modern concept of hospices and palliative care.
Methods To investigate some examples of earlier uses of the word ‘palliative’, a literature search was conducted within the earliest available BMJ archive sections, the years 1840 to 1842. This provided a glimpse into how the word was used in the medical literature in Victorian times, mid-nineteenth century.
Results Search results brought up a number of case reports, and the word was employed to describe medicines (‘use of palliatives’) as well as passive, non-active treatment approaches, probably best described as a watch-and-wait strategy. Of note is that the first recorded use of the word in the archives is by a surgeon.
Conclusions Some doctors associated the word palliative with there not being any prospect for cure and only for the relief of symptoms and greater comfort of the patient. There were, however, early reflections on whether palliative treatments may in some cases increase the length of patients’ lives.
While palliative care is sometimes described as a new specialty, practising compassionate care for the terminally ill is of course not novel at all within healthcare settings, and has been going on since antiquity.
Modern palliative care has evolved rapidly, mainly in the 20th century, and was initially rooted firmly within oncological origins.3 Clark, who has published extensively on the history of palliative care, also sees strong parallels to the nineteenth century, a time when many new hospitals were being built and when both the medical establishment and the bereaved started seeing death as a medical failure.4 It was at this point, when dying patients were no longer welcome in hospitals, that charitable and philanthropic institutions outside conventional healthcare settings started emerging. In 1842, for instance, a young widow and bereaved mother called Jeanne Garnier, together with others in similar circumstances, formed l'Association des Dames du Calvaire in France, and went on to open a home for the dying.4 This was said to be characterised by a ‘respectful familiarity, an attitude of prayer and calm in the face of death’. Garnier is said to have been inspired when she met a woman covered extensively in wounds while visiting the backstreets of Lyon.5
These nineteenth century historical events, which would form a grounding for palliative care institutions in later years, prompted an interest and subsequent literature search, which was conducted in the online historical archives of the BMJ, which dates back to the year 1840 (see box 1). An Oxford English dictionary search for the etymological origin of the word was also undertaken (see box 2).
The BMJ online archive
In April 2009, the British Medical Journal made every article published since the journal's first issue in 1840 freely available online from its http://www.bmj.com/archive website. The ‘Provincial Medical and Surgical Journal’, as the BMJ was initially called, started rolling off the presses on the 3rd October 1840 and soon became popular with not only a national, but international readership of doctors. The archive includes some famous names and important articles which went on to change and challenge the world of medicine. In 1847, for instance, James Simpson used the journal to publicise his work on chloroform, paving the way for modern anaesthetic techniques. And in 1867, an article by Joseph Lister introduced the concept of antiseptic to promote wound healing. Other famous names from the archive include Arthur Conan Doyle and Florence Nightingale. Creating this complete and fully searchable archive took the British Medical Journal nearly a decade and involved scanning over 824000 pages of thin, friable paper.
Etymological background of the word palliative
The word palliative has its roots in the Latin noun pallium.
The word pallium, according to the Second Edition of the Oxford English dictionary (Volume XI: Ow-Poisant),6 dates back to antiquity, and is the name for the large, rectangular cloth or mantle worn by men, chiefly among the Greeks. Philosophers and ascetics would commonly wear this item of clothing, as well as others in the early Christian Church. In 1596 Spenser wrote in ‘State of Ireland’:
The Greekes..afterwards..chaunged the forme therof into their cloakes, called Pallia, as some of the Irish also do.
One of the earliest examples of the use of the word palliative in the English language, dates back to 1543, according to the Oxford English Dictionary, and can be traced to Bartholomew Traheron's translation of John Vigon's Chirurgerye (43 b/2):
We will speake of his cure aswel eradicatyure as palliatyue.
In 1841, Queen Victoria, age 23, was 4 years into her reign as the monarch of the United Kingdom of Great Britain and Ireland. The Industrial Revolution, acknowledged as the period between 1750 and 1850,7 changed manufacturing, agriculture, transportation and technology and was having a profound effect on the socio-economic conditions of the times. Urban population numbers were increasing rapidly as people moved from the countryside in order to find work. Preston, for instance, grew sixfold between 1801 and 1851; Bradford and Glasgow eightfold.8
Death rates were very high, and far worse in cities than in the countryside. Diseases like typhus, smallpox, tuberculosis and cholera were common. Overcrowding combined with poor sanitation and often extreme poverty led to many people being vulnerable. Sir Edwin Chadwick was energetic in establishing the links between poverty and disease, and a parliamentary enquiry resulted in the new Poor Laws of 1834. The notion of germs was not yet formalised or established. Antibiotics were not yet known (although theories would start emerging in the 1850s) and treatments were often botanical or herbal. Laudanum, an alcoholic tincture of opium, was commonly used as a sleeping remedy, pain medicine and tranquiliser. In Charles Dickens’ novel The Mystery of Edwin Drood, for example, it is used by the sinister character of uncle Jasper.
A historic archive literature search, using the word ‘palliative’ was conducted and provided a snapshot of the years 1840–1842. The archive was accessed via the website http://www.bmj.com/archive. The authors decided to review this particular period for two reasons: it constituted the first articles of a new publication of its time, during a defining time period in terms of medicine but also palliative care and its future. Second, the ease of access to the BMJ's online archives has made it easier to conduct word and literature searches. This was not a rigorous scientific or historical research exercise and was done for interest only, with only a few quotations being selected to give a fleeting impression of how the word palliative was used in the medical literature of the time.
The reviewers searched the Provincial Medical and Surgical Journal (see figure 1) and selected the dates between October 1840 and December 1842. The search term ‘palliative’ was used. Results were sorted in the date that they appeared, starting with the earliest. A subsequent search was conducted for the word hospice, and used the same time-frame between 1840 and 1842.
For the word palliative, a total of 18 articles (n=18) were found from the years 1841 and 1842 (the year 1840 did not produce any articles containing the search term, but the journal only started being available from October of that year). None of the articles had the word ‘palliative’ in the title. Some mentioned the word once (n=13), others twice (n=3) and two (n=2) articles mentioned it three times within the text of the individual papers. Two of the 18 articles used the noun ‘palliatives’ (plural) to describe treatment options and medication as a concept.
The word ‘hospice’ was also looked for, but only two articles (n=2) containing the word were found and both referred to hospices as places for abandoned children or ‘foundling’ refuges, and hence this search was not felt to be relevant to our article.
Examples of search results
For the results we have only chosen examples of the search for the word palliative. First in the search list and thus the
earliest paper came an article by Mr Bransby M Cooper, Esq., FRS, in the Provincial Medical and Surgical Journal on Saturday, 2 January 1841. The author is a surgeon, and the word palliative is qualified with the word ‘merely’.
Now the disease in these cases was of such an extent, that our only resources were to remove the limb by amputation, to excise
the morbid structures as I did, or to endeavour to support the patient during the process set up by nature to produce soft
ankylosis. Suppose I had amputated, the patients would have been mutilated for the remainder of their existence; and if we
had merely employed palliative measures, the process of separation and throwing off of the diseased tissues would have been
so slow, that instead of there now being considerable power restored to the limb, with the almost certain expectation of rapid
progression, all we should have been able to say would have been that the disease had advanced a little, and the general health
was beginning to suffer more evidently from the pain and discharge.9
A year later in the same journal, a certain Dr Graves employs the word with a more positive stance. A patient actually receives ‘palliative treatment’ and recovers, although we do not learn as to whether palliative means active or passive treatment measures.
He writes on the 29 January 1842:
Mr H., a gentleman aged about 22, was attacked with pain in the side, cough, and fever, and, in a short time, with very copious
purulent expectoration. Soon after this the signs of extensive abscess made their appearance in the antero-superior and lateral
posterior of the lung. The patient was then considered to labour under tubercular caverns to a great extent. Shortly after
I saw him, when he presented the following symptoms: the whole antero-superior, lateral, and posterior upper part of the left
lung sounded extremely dull; perfectly distinct cavernous breathing, with large gurgling and pectoriloquy, were heard from
second rib downwards to the mamma, and the same phenomena were audible along the fold of the pectoral muscle, from the axilla
to seventh rib. The expectoration was copious, muco-puriform, but not fetid, and the pulse full, regular, and under 90. The
treatment adopted was palliative; the pulse soon became natural; all hectic fever ceased; the dullness of sound on percussion
gradually diminished, and the patient in the course of some months was perfectly restored to health, all the signs of caverns
having completely disappeared.10
A particularly striking feature here is the detailed description of the examination findings, which put those of 21st century case-notes to shame in their vivid description and seemingly sharp accuracy.
The word palliative is employed again in the same year in a book-review for the Dictionnaire de Médecine, ou Répertoire Général des Sciences Médicales considerées sous les Rapports Théorique et Pratique published in Paris. Clearly, any British physician or surgeon worth his salt was able to read French in those days, and the (British) reviewers give this book a glowing review. They go into some considerable detail reviewing a specific section entitled ‘Phthisis’, referring to tuberculosis. Phthisis, or ‘consumption’, has also been used to describe wasting away, weight loss and cachexia, which was and is strongly associated with tuberculosis since the time of Hippocrates. Only a few years prior to this period, in the 1830s, had physicians begun to use the term tuberculosis, due to the presence, postmortem, of tubercles on the lungs.
The word palliative is used in the following, concluding paragraph:
Monsieur Louis considers the curative treatment of phthisis as utterly hopeless. No case of confirmed phthisis has been ever
cured. Monsieur Andral coincides with him in this opinion. With regard to palliative measures, much may be done in alleviating
the symptoms, and in retarding, to a certain extent, the progress of the disease. This is all that can be hoped for in the
treatment of tubercular consumption. So little does M. Louis think of the necessity of dwelling on the remedial measures for
this disease, that his “Bibliography” occupies nearly the same number of pages, as his remarks on its treatment. We were struck
with the marked silence which the distinguished author observes throughout his treatise with regard to British writers. He
does not, with the exception of Dr. Carswell's researches, cite any English work or author on the subject.11
Leaving aside some apparent international rivalry in these sentences, the text declares that ‘much can be done in the alleviation of symptoms’. Are the authors referring to the use of laudanum, or perhaps just the absence of medical interventions, some of which were so gruesome as to probably hasten the onset of death? There is even a suggestion here that these palliative measures may increase life-expectancy.
To find out more about some of the treatments used at this time, two articles using the plural noun ‘palliatives’ were looked
at in more detail. The first is the case report of a 17-year-old girl with a painful affliction of the cervix. The doctor
Soon after I began to attend her she had hysterical retention of urine, requiring the use of the catheter every eight or twelve
hours during some weeks. The remedies which I tried were: a more nourishing diet; the carbonate of iron; Fowler's arsenical
solution; quinine; a warm hip-bath gradually reduced to a cool one; fetid pill with zinc, and valerian tea with tincture of
castor; the hydriodate of potash. Then mere palliatives: decoction of pareira brava root containing soda and the tinctures
of henbane and tobacco; opium in the rectum; foetid injections; balsam of copaiba with turpentine injections; the application
of lunar caustic and of extract of belladonna to the neck of the uterus, etc.-all to no purpose. She was sent to the Nottingham
Hospital, and she returned without having obtained relief. She and her parents begged I would try some fresh remedies, though
I was not then the parish surgeon. I considered the removal of the painful part of the uterus the only resource; to which
they all readily assented, declaring that death would be preferable to such a constant state of suffering.12
Of note is the fact that Dr Allison has quite an arsenal of treatments at his disposal, some of which sounded quite holistic in today's terms (a warm hip-bath and a nourishing diet). The reader is left wondering whether Allison went on to perform the surgery he describes, and what the outcome may have been. He describes a real moral dilemma in his last sentences, which is that of using palliative surgery as an option with the realistic risk of death as an outcome, and this in his and the family's opinion being preferable to the current status quo. The use of rectal morphine is described, and further mention is made of opium in the next article.
This turns out to be another case report, one of a woman with cancer of the uterus, who appears to be in the advanced stages
of her illness and is suffering considerable pain. The doctor is glum about her prospects:
In the present case nothing could be done but to prescribe palliatives, and principally opium, to assuage the pain. The patient
was not a fit object of this charity, her disease being beyond hope of cure; and she has gone to reside for the remainder
of her life, which must be short, and I fear will be a period of intense suffering, with her daughter in the country.13
This is yet another stark reminder of the feeling of helplessness within the medical community of the time, infused with statements like ‘nothing could be done’, ‘beyond hope’ and ‘intense suffering’.
This article is by no means a comprehensive literature search and one of the shortcomings is that only one journal of the time was searched, mainly due to the free and easy accessibility of the scanned documents.
Searching the archives online was easy and straightforward. Articles have been scanned, but are easy to read and readers can even do word searches within the text proper of the papers, using the ‘Find’ option. Most of the articles of the time were case reports and letters. They give an indication of the resources available, the doctor–patient relationships and the diseases. The most common disease association in those articles containing the word palliative was tuberculosis, but some articles did cover cancer. Doctors usually associated the word palliative with there not being any prospect for cure and ‘only’ for the relief of symptoms and greater comfort of the patient.
There are, however, early reflections here on whether palliative treatments may actually increase the length of patients’ lives. This is striking given the historical context and in particular when we reflect on our understanding of palliative interventions today, and how we are only starting to appreciate their impacts on length and quality of life. But also, palliative approaches in the nineteenth century appear to have been used when doctors felt there was no hope and that ‘conventional’ active treatments of the time would not work. These conventional treatments included risky medicines and procedures (like blood-letting), which may well have shortened the lives of patients. For instance, during the nineteenth century cholera epidemic, death rates were considerably lower in the London Homeopathic Hospital than they were in the Middlesex Hospital; at the time, nobody could treat cholera, and therefore, inert treatments may have been preferable to the more conventional practices in that they caused less additional harm.14 ,15
More than one-and-a-half centuries later, we find that the meaning of the word palliative and what it entails has changed considerably and that we are starting to move further away from the concept of synonymising palliative care with the phrase ‘there is nothing more we can do.’4 ,16
A 2010 study in the New England Journal of Medicine puts the historical nineteenth century papers into further perspective. It finds that lung cancer patients receiving palliative care survive for longer than those who do not.17 One is left pondering what future researchers looking back at our current practice may make of our palliative exploits and what the word may mean and entail in years to come.
The authors thank the helpful and friendly staff at Velindre Hospital Medical Library and Cardiff Central Library.
Contributors MT had the idea and wrote the article. EM, HF and RF helped with finding and researching historically relevant material.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
- Received 22 May 2012.
- Revision received 8 October 2012.
- Accepted 9 October 2012.
- Published Online First 14 November 2012
- Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions