Osler’s “Study of the Act of Dying” (1900-1904): An Analysis of the Original Data Paul S....

Osler’s “Study of the Act of Dying” (1900-1904): An Analysis of the

Original Data

Paul S. Mueller, MD, MPH, FACP

Associate Professor of Medicine

Mayo Clinic Rochester

Disclosures

• I am a member of the Boston Scientific Patient Safety Advisory Board

• I am an associate editor for Journal Watch

• No off-label use of drugs or devices will be discussed

Objectives

• Explain why Osler did the study

• Explain why certain data were gathered

• Describe the results of the study

• Draw conclusions from the study

• Describe Osler’s post-study views of death

Sir William Osler12 Jul 1849 - 29 Dec 1919

• Born in Canada• Widely-adored physician

who practiced in Canada, the US, and the UK

• Highly influential author, educator, researcher, reformer, and civil servant

• Family man William Osler

Science and Immortality1904 Ingersoll Lecture at Harvard University

• Annual lecture on topic of immortality (still given today)

• Osler invited to give lecture multiple times by then Harvard President Eliot

• Osler eventually, yet reluctantly, agreed and gave lecture 18 May 1904

• Later published as a book

Science and ImmortalityExcerpt

“I have careful records of about five hundred death-beds...Ninety suffered bodily pain or distress of one sort or another, eleven showed mental apprehension, two positive terror, one expressed spiritual exaltation, one bitter remorse. The great majority gave no sign one way or the other; like their birth, their death was a sleep and a forgetting” (p.19).

Why re-examine Osler’s“Study of the Act of Dying”?

• A detailed manuscript describing the study and its results was never published, yet the brief quote from Science and Immortality continues to be cited

• Analysis would shed light on the attitudes toward death and the dying experience and during Osler’s era

• Few similar studies have been done

Methods of the current analysisResources:• Data collection

cards and a spreadsheet used by Osler and stored at McGill University

• JHH administrative records

• Osler’s papers

Methods:• Data abstracted

from cards and compared to data recorded on Osler’s spreadsheet

Features of Osler’s study

• Done at the Johns Hopkins Hospital (JHH) 1900-1904

• Observations of 486 dying patients recorded on data collection cards

• Data from cards transferred to a spreadsheet tallied by Osler

William Osler (1900)

Purpose of the study

Data collection

cardName blocked out

Thomas McCrae

Name blocked out

Purpose of the study

• Printed at bottom of data collection card

• “The object of this investigation is to ascertain the relative proportion of cases in which (1) the death is sudden; (2) accompanied by coma or unconsciousness; (3) by pain, dread, or apprehension.”

Tallies written by Osler and cited by him in Science and Immortality (“Ninety suffered bodily pain…eleven showed mental apprehension…”)

Osler’s spreadsheet

Results: Who completed and signed the data cards?429 (89%) cards were

signed:• 258 (60%) by nurses• 139 (32%) by

residents• 32 (7%) unidentified• None of the cards

were signed by Osler

149 unique individuals signed the cards:

• 97 (65%) nurses• 34 (23%) residents• 18 (12%)

unidentified

Osler and nurse Bessie Boley (1904)

Life on the JHH wards1898 Nursing Annual Report, Mary A. Nutting

“The head nurses are responsible for the general management of the wards…They are held responsible for every detail in connection with their wards, of which they do not and cannot do the actual work. They are an essential feature of a properly organized and equipped ward.”

M.A. Nutting

Results: Acquisition of cases

• First case 3 Jan 1900

• Last case 29 Mar 1904 (just 6 weeks before Osler gave the Ingersoll Lecture)

• >1-year gaps between card 400 (dated 18 Feb 1901) and card 401 (dated 26 Feb 1902) and between card 463 (dated 20 Jan 1903) and card 464 (dated 5 Feb 1904)

Results: Acquisition of cases

YEAR OSLER’S STUDY

ACTUAL DEATHS AT

JHH

ACQUISITION (%)

1900 232 308 75.3 1901 148 295 50.2 1902 81 304 26.6 1903 2 262 0.8 1904 23 280 8.2 Total 486 1449† 33.5%

†Mortality 6.6% (1449 deaths/21926 patients)

Results: Gender

• No place on the data card to record gender; however, gender-specific descriptors (eg, “he”) and names (eg, “Mary”) used for most patients

• Breakdown:– Male: 308 (63%)– Female: 169 (35%)– Unknown: 9 (2%)

Results: Nationality and religionNationality:• American: 360

(78%)• German: 44 (9%)• Unknown: 18 (4%)• Irish: 13 (3%)• Polish: 13 (3%)• Other 38 (7%)

Religion:• Protestant: 171

(35%)• Catholic: 69 (14%)• Jewish: 19 (4%)• “None”: 1• Unknown: 226

(47%)

Results: Age at death• Recorded for 477 (98%) patients (440

adults, 47 children)• Overall median (range) age at death:

39.0 (0.3-83) years• Gender: female 39.0 (0.8-75), male 40.0

(0.3-83)• Race: black 36.0 (0.3-82), nonblack 40.0

(0.8-83)

Results: Length of illness before death• Recorded for 428 (88%) patients

• Overall median (range) length of illness before death: 0.8 (0-81) months

• Gender: female 0.8 (0-81), 0.9 (0-48)

• Race: black 0.8 (0-26), nonblack 0.8 (0-81)

• Age: child 0.3 (0-24), adult 1.0 (0-81)

Results: Cause of death• At the start of the study, the data card had no place to

record diagnosis; place added later (first: #288 dated 6 Apr 1901)

• Overall, a diagnosis was recorded for 188 (39%) patients

From card #288

Results: Cause of deathAll (N=188):• Infection: 60 (32%)• CV: 33 (18%)• Surgical: 31 (17%)• Cancer: 21 (11%)• Nephritis: 16 (9%)• Trauma/burns: 13

(7%)• Other: 14 (7%)

Children only (N=17):• Infection: 9 (53%)• CV: 1 (6%)• Surgical: 2 (12%)• Cancer: 1 (6%)• Burns: 4 (24%)

Results: Cause of deathBy gender (adults only)

Men (N=110):

• Infection: 37 (34%)

• CV: 27 (25%)

• Surgical: 9 (8%)

• Cancer: 11 (10%)

• Nephritis: 11 (10%)

• Trauma/burns: 5 (9%)

• Other: 10 (9%)

Women (N=58):

• Infection: 14 (24%)

• CV: 5 (9%)

• Surgical: 19 (33%)

• Cancer: 9 (16%)

• Nephritis: 5 (9%)

• Trauma/burns: 3 (5%)

• Other: 3 (5%)

Results: “The act of dying”“If sudden”

• Recorded for 472 (97%) patients• Sudden: 340 (70%)• Observers specifically wrote “gradual” next to

“if sudden” for 46 patients and “quiet” next to “The act of dying” for 42

Results: “The act of dying”“Did respiration stop before pulse?”

• Recorded for 330 (68%) patients

• Respirations before pulse: 119 (24%)– Time available for 100 patients; median (range) 1

(0.1-10) minutes

• Pulse before respirations: 187 (38%)– Time available for 145 patients; median (range) 3

(0.1-240) minutes

• Same time: 24 (5%)

Results: “The act of dying”“Coma or unconsciousness”

• Recorded for 458 (94%) patients

• Coma affected 311 (64%) patients– Length of coma recorded for 296 patients– Median (range) length of coma 3 (0-168)

hours

• Alert: 147 (30%) patients

Results: “The act of dying”Number of unique patients experiencing discomforts

NUMBER OF DISCOMFORTS

REPORTED BY OSLER

OSLER’S SPREADSHEET*

DATA CARD ANALYSIS

ONE 104 125 157 TWO 0 7 29 THREE 0 0 0

TOTAL (PERCENT) 104 (21.0%) 132 (27.0%) 186† (38.0%)

*†41% higher than recorded on Osler’s spreadsheet†79% higher than reported in Science and Immortality

Results: “The act of dying”Number of discomforts experienced by patients

DISCOMFORT REPORTED BY OSLER

OSLER’S SPREADSHEET

DATA CARD ANALYSIS

PHYSICAL 90 129 158 MENTAL 13 9 56 SPIRITUAL 1 1 1 TOTAL 104 139* 215†

*Excludes 24 patients for whom “fear” column marked “yes”*34% higher than reported by Osler†107% higher than reported by Osler; p<0.05 v. spreadsheet

Results: “The act of dying”Specific discomforts experienced by patients

PHYSICAL MENTAL SPIRITUAL Pain 118 Fear 17 Spiritual distress 1

Dyspnea 33 Anxiety 16 Convulsions 5 Irrational 16 Weakness 1 Mental “yes” 6

Fever 1 Depression 1 158 56 1

Total number of discomforts: 215

Results: Discrepant discomfort data• Most discrepancies are not subtle

• 76 (16%) cards had data (84 discomforts) discrepant with Osler’s spreadsheet– Physical discomforts: 37 (pain 22, dyspnea 23)– Mental discomforts: 47 (fear 17, anxiety 15,

irrational 12)

Results: Discrepant discomfort dataPhysical (N=37)• Pain: 22 (for 4

patients, pain was marked as “yes” on Osler’s spreadsheet, but not on the cards)

• Dyspnea: 12• Convulsions: 3

Mental (N=47)• Fear: 17• Anxiety: 15• Irrational: 12• Mental “yes”: 2• Depression: 1

Specific spreadsheet-data card discrepanciesCard #47


Osler’s spreadsheet also marked “none” for each

“For about 10 minutes before death the patient was in a condition of acute mania. He fought with the orderlies, bit one and was restrained with difficulty.”

What conclusions can be drawn from the study results?• Nurses played a major role in the study;

Osler had little direct involvement• Data collected suggest nearly constant

bedside presence of observers who completed the data cards

• Dying patients were young• Median length of illness before death

was brief; shorter for children

What conclusions can be drawn from the study results?• Most common cause of death infectious

diseases; causes differed by gender

• A majority experienced coma before death; median duration of coma brief

• More patients (38%) experienced discomforts (mostly physical) than reported by Osler (21%) in Science and Immortality

What prompted Osler to do a study of dying?Personal interest

• 1872: to investigate causes of death among the “highest objects” of the physician

• Entries in his pocket “day books”

• Plans for lectures and essays (eg, “On the Hour of Death”)

• Numerous volumes on death, dying and related topics in his personal library

What prompted Osler to do a study of dying?Popular opinion and fears

Death viewed as the “King of Terror.” Why?• Decline of religious faith• Reduced death rates, especially due to

infectious diseases; death primarily affects elders with chronic diseases

• Rise of science, and hospitals; death medicalized and moved from home to hospital

• Death becomes “foreign” to most

What prompted Osler to do a study of dying?Osler openly disputed the popular opinion

• Osler, like many physicians of his era, refuted the popular opinion that death was accompanied by suffering:– 1888 article: death a “sleep and forgetting”– 1893 lecture: death “accompanied with pleasure

rather than with pain”

• Nevertheless, empirical data about death were sparse; Osler was a naturalist

Why were certain data gathered?• Popular concerns about “apparent

death,” the nature of the exact moment of death and about discomforts associated with the dying process

• Physician interest in modes of death:– Sudden versus gradual– Cardiac versus respiratory– Presence or absence of coma

Why were the results reported by Osler inaccurate?Possible reasons:

• Osler did not carefully examine data cards (he did not sign any of them)

• Confusing layout of data cards

• Osler did not complete the spreadsheet

• Osler inaccurately tallied the spreadsheet

• Haste

Confusing layout of data cardsCard #41

Confusing layout of data cardsCard #164

Inaccurate tallying of spreadsheet by Osler

__ ___ __ __Actual figures: 24 131 9 1

None of these 24 included in the “mental” column

Possible role of haste• Short interval between last case (29 Mar

1904) and lecture (18 May 1904)• Hectic time for Osler:

– Very busy with consultative practice and scholarly activities

– Great Baltimore Fire of February 1904 nearly consumed Osler’s home

– Observations of others and comments by Osler

The Great Baltimore FireFebruary 1904

View from Calvert and Baltimore Streets

Observations of others and comments by Osler

Possible role of haste:• Cushing1: lecture written “in

a single morning”• Cushing biography notes2:

lecture “written in some haste...misquoted sources”

• Osler letter to Miss Jewett2: “a rash production”

1Ann Med Hist (Summer, 1919)2Cushing folders at McGill UniversityHarvey Cushing

McCrae on Science and ImmortalityLetter to Cushing (8 Jul 1920)

“There is one point there in which I know you are in error; namely in saying that the address ‘Science and Immortality’ was written in a morning. Up till that time he had never spent as much time on an address and had written it several times.”

Thomas McCrae

Cushing on Science and ImmortalityThe Life of William Osler (Oxford, 1925)

“With all this pressure upon him the date of the Ingersoll Lecture was approaching, and though he had been making notes and giving thought to it during the preceding months there had been scant time for the sort of preparation the subject…He, indeed, had agonized over it perhaps more than any of his previous drafts and it was rewritten and redrafted many times.” (p. 638)

Parts of Science and Immortality were written years before the lecture• Osler traveled to Minneapolis during

1898

• Document in Cushing folders at McGill:– “Written chiefly in the train from Minneapolis to

Boston copied Sept. 24th and 25th.”– “Fragment written by W.O. (Script) on 1 West

Franklin Street notepaper.”– Contains basic elements of Science and

Immortality (but no mention of the dying study)

Osler’s reporting of the study resultsProbable sequence of events

• Osler wrote elements of Science and Immortality years before it was given

• Final touches were likely added in haste:– Hectic period for Osler – Study statistics must have been added just prior to

the lecture– Spreadsheet and spreadsheet tally (the statistics

cited in lecture) were inaccurate– Observations of colleagues and Osler suggest haste

What were Osler’s views of death after the study?• Remained interested in the topic and

did not waver in his opinion as expressed in Science and Immortality– Added volumes on death and dying to his library– 1911 letter to Spectator: protests painful

characterization of death in essay (Death) written by Nobel Prize (literature) recipient Maeterlinck

– 1919: wrote book review of Aspects of Death by F. Parkes Weber for Ann Med History

Osler’s death at age 70 years29 Dec 1919

• Acute complication of chronic bronchitis

• Experienced painful bouts of coughing:– “Shunt the whole pharmacopoeia, except opium…

What a comfort it has been!”

• Osler calmly accepted death:– “The experience has been encouraging--

discomfort of course, but no actual pain & except for the worry about leaving dear ones, singularly free of mental distress…”

Conclusions

• A substantial number of dying patients in Osler’s study experienced discomforts

• Osler was prompted to do the study because of popular fears and a lack of empirical data regarding death

• The historical context of the study is rich

• Lessons for today

Acknowledgements

• Osler Library of the History of Medicine at McGill University

• Alan M. Chesney Archives at the Johns Hopkins University

• The Chest Foundation

• Mayo Foundation

[email protected]

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