Before we begin, some terminological clarification might be useful. The Oxford English Dictionary defines compassion as ‘sympathetic pity and concern for the sufferings or misfortunes of others’ . More particularly, compassionate healthcare advocate Dr. Robin Youngson defines it as the ‘humane quality of understanding suffering and wanting to do something about it’ . The term has a long history and was in use in the early nineteenth century. The Dictionary of the English Language (1828) defined compassion as ‘Pity; commiseration’ and compassionate as ‘Inclined to pity; merciful; exercising compassion’ . In a more specific context, the Edinburgh surgeon John Bell wrote in 1801 that, in cases involving a ‘tedious, lingering disease, the surgeon must be every thing to his patient; watchful, friendly, compassionate, cheerful’ . In all these cases compassion evokes a feeling, one of pity and sympathy. But in Youngson’s definition there is a specific emphasis on action. As he writes, ‘It’s a motivation, not just a feeling’. The pre-modern usage has a less instrumentalist connotation and was part of a wider constellation of terms relating to the intersubjective experience, the most important and commonly used of which was sympathy.
It is important to note that, in the context of the early nineteenth century, terms such as sympathy and compassion were part of a pervasive culture of sensibility. Sensibility is a complex concept about which much has been written. However, in brief it can be seen as an intellectual and cultural phenomenon which served to ease social relations through a highly-attuned sensitivity to the feelings of others. In the works of David Hume and Adam Smith, the capacity of the individual to ‘feel’ through their senses was elaborated into a system of moral philosophy. For our purposes it is notable that one of Smith’s early examples in his Theory of Moral Sentiments (1759) concerned the ‘chirurgical operation’ the sight of which was liable to make people ‘faint and grow sick’, the ‘bodily pain … occasioned by the tearing of flesh’ exciting in them ‘a most excessive sensibility’ . As this quotation suggests, sympathy could exert a profound physical and physiological influence. Just as contemporaries believed that one part of the body might experience pain or develop disease in sympathy with the disordered actions of another, so too did they believe an individual might be physically overwhelmed, even rendered mortally sick, by an act of imagination.
There were criticisms of this culture of sensibility, with some suggesting that it might be misdirected, exaggerated or even faked . But it remained remarkably resilient and by the early nineteenth century had evolved into what we might term ‘Romantic sensibility’ with its veneration of honest, heartfelt feeling and its particular emphasis upon the sympathetic treatment of women and children. Indeed, while it is generally thought to have declined from the 1830s onwards, one can see clear traces of its influence in Victorian sentimentality. The leading early nineteenth-century surgeon, Sir Astley Cooper, was said by his nephew and biographer, to be unable to ‘supress a tear’ when he saw a hungry child in the street and when he read to him the famous scene in the workhouse from Oliver Twist (1837–9) ‘he was quite overcome, and, crying like a child, would not suffer me to continue my description of the distressing tale’ .
It should not be thought, however, that compassion and sympathy in this period were only about feeling and not about agency. To be sure, medical practitioners sometimes talked about feeling things to which their office would not allow them to give full expression. In 1813, for example, the Scottish surgeon Henry Oswald confided to his diary about the distress of dealing with a seriously ill young woman whose despairing father ‘groaned in Spirit and writhed with anguish’:
These are the scenes which medical men are obliged to behold in apparent coolness whatever may be their inward pain. Perhaps by seeing them so frequently they make less impression on them than others but people are not aware of the anxiety we suffer when a patient is suffering severely and approaching to death, and when every effort of art is in vain. Then we must suppress all feeling, appear composed and endeavour to comfort if we do not wish to produce mischief by adding to the alarm which others experience.
Oswald wrote of the ‘embarrassing uncertainty of the medical art’ in such cases . So too did John Bell, who evoked ‘that silent humiliation in the presence of misery, which so well becomes one, who feels that he cannot alleviate the pangs, nor avert the changes, of the scene before him’ . Nonetheless, as well as evoking pity, sympathy with suffering was also supposed to encourage benevolence and kindness. Indeed, compassion and sympathy can be said to have been at the heart of the early nineteenth-century surgical encounter.
Returning to Bell’s earlier comment about the surgeon being ‘every thing’ to his patient, the reason he gives for this is that ‘the patient lives upon his good looks; it is when his surgeon becomes careless, or seems to forsake him, that he falls into despair’ . As this quotation suggests, in the late eighteenth and early nineteenth centuries, it was generally believed that the health of a patient was dependent to a very significant degree on their emotional wellbeing. In an era before complications such as post-operative infection were adequately understood and when the interior operations of the body were largely inaccessible, surgeons often struggled to find reasons why an apparently successful operation or a seemingly mild illness could lead to death. More than this, early nineteenth-century medical orthodoxy perceived little separation between mind and body and, as we have seen, set great store by the operations of sympathy and imagination. As Sir Astley Cooper wrote, ‘The mind has great influence over the actions of the body and it often happens after operations that the least discouraging expression will produce fatal effects’. In evidence of this, he cited the case of a Mrs. Shipley who had been operated upon by Cooper’s mentor, Henry Cline, for a cancerous breast. ‘She said she was sure she should die’, Cooper wrote, and ‘immediately after the operation she became almost lifeless and in three hours she died’. As if to prove the inevitability of her demise, he observed that she had made arrangements to hand over her role as mistress of the household, stating: ‘All her keys were found marked that there might be no confusion occasioned by her death’ .
In these circumstances it was imperative that the surgeon do his best to regulate the emotional state of his patient and keep them from sinking into ‘low spirits’. In principle, this did not extend to dishonesty. A surgeon was not supposed to mislead a patient about their condition by giving them false hope or sparing them news of unfortunate or dangerous developments. Nonetheless, patients occasionally suspected that this was the case. One of Sir Astley Cooper’s female patients, who he was treating for a growth in the breast, wrote to him in 1832:
Could you, Sir think of any thing to afford me relief I should for ever feel extremely thankful, for I must acknowledge that I still feel apprehension of a cancer, and when most troubled with pain am fearful you did not tell me exactly what it really was, therefore dear Sir your candid answer will be very very acceptable to me and greatly ease my mind .
Evidently such fears were not unfounded, for in 1822, Mr. Rosenware, a surgeon of Wadebridge in Cornwall, wrote, relative to his patient, ‘As Miss Best is extremely anxious and agitated on the subject I have endeavoured as much as possible to keep the real nature of the complaint from her until imperious [sic] changes in it should oblige me to be more explicit, and I still think that the most cautious manner of proposing an operation would be necessary; I have as yet only ventured to hint at it’ .
Neither were surgeons to be obsequious or false in their manner. Typically, for a society deeply troubled by the idea of insincerity, Benjamin Brodie derided what he called those ‘courtier like manners, those continued attempts to suit the inclination and flatter the self-love of others, by means of which mean persons endeavour to make up for their own Ignorance and want of skill, and which disgrace the dignity of our profession’ . Rather, the job of the surgeon was to manage his patient through an earnest ‘gentleness of manner’. This was important enough in the consultative relationships that composed much of the surgeon’s workload, but it was especially vital when it came to the prospect of operative surgery. Surgery is a troubling enough prospect in the modern day but, in the absence of anaesthesia and modern forms of infection control, it was infinitely more so in this period. As Cooper suggested, ‘Patients having a natural dislike to operations, feel still more uneasy if they discover any thing in their practitioner’s behaviour that makes them apprehend rough treatment’ . ‘Violence’ of manner was ‘in all cases bad’ and was ‘in some attended by fatal consequences’. As a demonstration of this, he referred to the case of a surgeon who, on examining a patient for a compound dislocation of the ankle joint declared ‘Carthage must fall. Thereby implying that amputation must be performed’. ‘Indeed’, Cooper concluded, ‘from the rough manner in which he treated his patient there seemed no other chance for the poor fellow’s recovery. In this case gentleness might have prevented such an unpleasant circumstance’ .
Thirty years later, Frederic Skey made a similar point, suggesting that, in the case of a patient about to undergo an operation, it was rare that ‘sympathy does not tell beneficially upon his mind... A peculiar kindness, and in the example of a female or a child, even of tenderness of manner, begets a confidence, which, without betraying weakness or uncertainty, fortifies the patient’s mind and reconciles it to the effort’ .
The first thing that was necessary in operative surgery was to judge whether the patient was capable of bearing the procedure. As with Henry Cline’s patient and her keys, those patients who were despairing or convinced of their own death should, it was suggested, be spared an operation, whereas the specific fear of the pain produced by the operation itself might be managed. Overall, surgeons of the period argued that one should never operate too rashly. Rather, they should weigh up all the options and, in the words of Cooper, ‘make the case your own, and ask if you yourself would submit to it’ . When performing the operation, too, gentleness of conduct was a prerequisite. It is often said that early nineteenth-century surgeons were noted for their quickness and, in the case of individuals such as Robert Liston, this was indeed remarked upon. But many surgeons distrusted speed as a marker of skill and saw in it the spectre of self-promotion. Again, as Cooper remarked, ‘when performing an operation you are to consider that gentleness is essential to success, and indicates humanity, whereas violence on the contrary is shocking, and tends not a little to the want of success in operations in general. Never regard quickness in operating, tho’ weak minds often have that more in view than the safety of the patient’ .
The patient was, then, to be the sole focus of the surgeon’s endeavours and everything possible was to be done to ensure their emotional wellbeing. This even extended to the use and display of surgical instruments. For example, the leading London surgeon John Abernethy cautioned against the use of certain words in theatre. ‘Give me the knife Sir’, he imagined a surgeon declaring during a trephination; ‘good God, what must the patients feeling be, blind folded and hearing give me the knife Sir – Had you not better say give me the Bistoury, a name which not being familiar to the patient would not alarm him’ . In another case, the same surgeon entered the operating theatre which had been arranged by a young doctor ‘anxious to have everything duly prepared’. On inspection, Abernethy initially declared all to be well but then paused, before throwing a napkin over the instruments and saying ‘it is bad enough for the poor patient to have to undergo an operation without being obliged to see those terrible instrument.’ .
It should be noted that surgeons did not just seek to accommodate their patients’ feelings, they also spoke of their own and the challenges they faced in inflicting pain on their fellow creatures. Occasionally a surgeon might shed a tear during or after a procedure but, for the most part, the rhetoric of surgeons emphasised, in line with Oswald’s earlier comments, a degree of emotional restraint. As Everard Home claimed:
An excess of sensibility is of no use & takes away the power of giving relief. A mother, when the house is on fire will carry her infant through the flames or she may hold her infant to have an operation performed with great firmness & resolution, & afterwards when it is over faint away. During an operation, while he is acting for the relief of another, [the surgeon] is putting a restraint on his own feelings. He does not feel the momentous distress he occasions. As there is nothing in Surgery which can soften an unfeeling man so there is nothing to diminish his benevolence or humanity. Every act which he performs is to relieve distress, to remove temporal evils & to preserve life .