Telling the Painful Truth"—Nurses and Physicians in the Nineteenth Century

Nursing History Review 16 (2008): 115–134. A Publication of the American Association for the His-

tory of Nursing. Copyright © 2008 Springer Publishing Company.

“Telling the Painful Truth”—Nurses and Physicians in the Nineteenth Century

Karen Nolte

Institute for the History of Medicine

Th e ability to cope with an end-of-life situation is a key qualifi cation in nurs-

ing care. All things considered, German nurses may be said to have seen their

fi rst exposure to a terminal patient as an initiation into the profession. When

a young woman was able to deal with death and with dying patients, she was

generally regarded as suitable for the nursing profession.1 Pivotal for this ter-

minal care that nurses had to render was the question of whether a seriously

ill patient should be told the truth about his or her imminent death and then,

how this “truth” was to be dealt with. Under the rubric “truth at the bedside”

(“truth telling” in the American debate), discussion is currently taking place

in German-language literature on the medical ethics of whether and to what

extent the physician should disclose his prognosis to a dying patient. In Ger-

many, even nowadays, the question of how to deal with truth telling is some-

thing that has to be negotiated between nurses and physicians and sometimes

gives rise to confl icts. From the legal point of view, diagnosis and prognosis as

well as their disclosure to the patient are exclusively reserved to the physician.

However, nurses are frequently confronted with questions from seriously ill

patients and their wish for comprehensive disclosure of their condition. Th us,

German nurses frequently feel quite powerless when, in their view, the patient

is not, or only insuffi ciently, informed about an incurable and fatal disease.2

Th is article retraces the historical roots of the medical and nursing ethi-

cal question of truth telling back to the nineteenth century. It focuses on the

perspective of the nurses trained at the fi rst German deaconess motherhouse

at Kaiserswerth and compares their way of dealing with dying patients, death,

and truth telling with the refl ections of physicians on this topic in the nine-

teenth century. Th e analyses in this article are based on everyday sources on

Protestant nursing care, because a large number of these historical records

exist, while hardly any records are available on daily work in Catholic nurs-

ing care.3 Consequently, the results presented in this article off er only limited

116 Karen Nolte

insight into the daily routine of nurses in dealing with dying patients and

truth telling and thus have to be understood as a fi rst approach to this topic.

First, physicians’ positions on truth telling in the nineteenth century are

presented and analyzed. After that, the specifi c manner in which Protestant

nurses, the Kaiserswerth deaconesses, dealt with the issue of disclosing the truth

to dying patients about their imminent death is examined, and possible lines

of confl ict concerning physicians’ medical-ethical views are determined. Beside

medical publications, this article is based on the large stock of deaconesses’ letters

written to the superintendents of the deaconess motherhouse at Kaiserswerth by

Christian nurses on a regular basis, in order to report about their work and their

experiences at hospitals and in community and private care.4

Physicians’ Positions on Truth Telling in the Nineteenth Century

During the fi rst half of the nineteenth century, physicians’ refl ections on the

issue of truth telling were closely linked to views on “dying well” (euthanasia

or, in its original German meaning, a “dignifi ed death”).5 In his work Ueber Euthanasie (On Euthanasia), the Goettingen professor Karl Heinrich Marx

(1840–77) made a distinction between “exterior” and “interior” euthanasia. By

means of exterior euthanasia the physician took care of the dying patient’s

physical health; by means of interior euthanasia he looked after the patient’s

spiritual well-being.6 Contemporary professional colleagues also regarded

interior euthanasia as their task, stressing that the physician was not allowed to

leave the dying patient even if he could not help him further from the medical

point of view. Th ey saw it as the physician’s duty to encourage the patient and

alleviate the dying process by means of regular visits.7 Th us it is explained in a

physician’s publication of 1806:

the moral human being is also [the] subject of his . . . last treatment; and the phy-sician is to be praised who associates himself emotionally with the suff ering heart of the dying patient, who knows how to support or to calm it according to the respective situation. Happy is the patient who has found a friend in his doctor!8

Physicians sometimes took on tasks at the deathbed that, from a contem-

porary point of view, would be regarded as more properly belonging to the

fi eld of nursing care. Th e Mainz physician Leo Lebrecht (1796–1834), for ex-

ample, advised his colleagues “to hold the dying patient’s hand or both hands

Telling the Painful Truth 117

lovingly, to fan his forehead, or to wash his forehead, temple, chest, hands and

feet with wine or fragrant waters. . . . Th us the physician does not appear as a

tormentor but as a reliever, who accompanies the dying patient in a friendly

manner and in the spirit of the Almighty.”9

Around 1800, physicians deliberated on the question of whether a patient’s

imminent death should be revealed or concealed from him in order not to

shorten his life by mortal fear. Some physicians stressed that even the claim of

being able to give a defi nite prognosis and thus to set a time of death was prob-

lematic. Th ey referred to the limits of medical science and of medical skill.10 In

the late 18th century, a physician described vividly the eff ects of a rashly given

terminal prognosis in the Allmanach für Ärzte und Nichtärzte (Almanac for Phy-

sicians and Nonphysicians): “Keeping in mind the rules of science, the careful

physician cannot judge about life and death without exposing himself to the

danger of making a mistake. . . . I saw pious souls who craved to be restored to

health . . . and noticed the swiftest changes in the face, the low spirits, the unmis-

takable fearfulness, the disorder of the pulse and the decline of vitality, and, as a

result, the rapid aggravation of the disease.”11 Th e “emotional upset” described

here was a concept best understood in the context of the teachings of the period,

which squarely belonged to the tradition of humoral pathology. According to

this concept, psychic and physical processes were inextricably linked with each

other, so that mortal fear could rapidly change the individual’s physical condi-

tion for the worse.12 Heinrich Bornholt explained as follows:

Th e soul, which by its imaginations and thoughts infl uences the body either in a useful or in a harmful way, depending on whether its thoughts are agreeable or disagreeable, has good or bad eff ects, especially on the sick body, when it is either en-couraged by reasonable and probable hope for recovery, or depressed and sad because of the fear for a bad outcome of the disease.13

In order not to weaken the condition of incurably ill patients with an

“emotional upset” and thus shorten their life expectancy, the majority of phy-

sicians in the early nineteenth century disapproved of disclosing to seriously

ill patients the fact of their probably imminent death.14 Th e vitalist Christoph

Wilhelm Hufeland (1762–1836), part of whose dietary concept was “peace

of mind,”15 to be achieved by balancing of the moods, in particular held the

radical view that the incurable nature of the patient’s disease and the fact

of his imminent death should under no circumstances be disclosed to him.

After all, “fear, especially of death, anxiety and terror [are] the most dan-

gerous poisons,” which “have a directly paralyzing eff ect on the vitality.”16

118 Karen Nolte

Johann Gottlieb Th ierfelder (1799–1867) carried this medical view on truth

telling to extremes by answering his own rhetorical question: “Is the physician

allowed to disclose to the patient the inevitability of his imminent death and

to shorten his life intentionally under certain circumstances?” He quite plainly

wondered: “Would this not mean to murder the patient?!—Still alive, his

grave is opened and he is pushed inside!”17 Other physicians adopted a more

nuanced position on truth telling. Generally, they advised their colleagues to

keep fatal prognoses to themselves. However, they did not want to keep the

truth from those seriously ill patients who expressly demanded comprehensive

disclosure in order to be able to take care of their personal aff airs.18 In 1840,

the Medicinischer Almanach (Medical Almanac) read as follows:

Th ings are diff erent when the sick person himself or his next of kin demand of the physician information about the actual degree of severity of the disease and about the outcome he expects. In this case, the physician generally has the duty to disclose his views without restraint, because in some cases, for example, when the patient has to put his aff airs in order . . . the failure of a clear answer may lead to the most disagree-able complications and irreversible disadvantages.19

Most physicians were of the opinion that close relatives should always receive

comprehensive information from the physician on the condition of the seri-

ously ill or dying patient.20

As early as the fi rst half of the nineteenth century, Christian terminal care

was unequivocally criticized by physicians. While they characterized clergy-

men and pastors as “messengers of death,” physicians represented themselves,

by contrast, as ambassadors of life and hope. Karl Heinrich Marx explained:

Just as the physician, in case of declining hope for recovery, has to refrain from intervening in his patient’s condition, he also has to keep away psychic intervention. As a priest of nature it is his task to take on the higher care for the inner human being as well. To hold him back from this exalted duty would mean to steal the most noble and salutary part of his offi ce. When the clergyman, who has never been there before, approaches the sickbed, he appears as a messenger of death. Th e heavenly solace he intends to give often only leads to apprehension, fear and severe emotional upsets.21

Karl Ludwig Klohss (born 1800) even went so far as to suggest that in-

stead of the priest, whom he saw as the “symbol . . . of the grief of death,” the

physician should take on spiritual care at the deathbed.22 “Even in those cases

that seemed totally hopeless not all the patient’s hope for life has vanished,”


and a clergyman could “paralyze and destroy this completely by his sheer pres-

ence.”23 Th e physician, on the other hand, was known to the dying person and

patient “as someone from whose hand he is accustomed to receive alleviation

of his affl iction, from whose mouth he is accustomed to hear solace and hope;

to him he is an always welcome, always longed-for and desired visitor, a person

dear and valued.”24 Furthermore, he could convey God’s word just as convinc-

ingly as a priest:

From his mouth as well the solaces of religion deliver their glorious powers to the suff ering patient and the words of edifi cation and elevation over all earthly things, as felt and believed by the physician himself, often have the same eff ect on the mind as if they were spoken by a clergyman himself.25

As one would expect, physicians sometimes took on the role of pastor, as

can be seen in the description by Hufeland of an 1807 case—a case concern-

ing a woman who was seriously ill with cancer of the abdomen. Th e physician,

in a manner of speaking, heard the dying woman’s confession:

Five days before her death I was alone with her for some time. Th en she confi ded in me about a deep sorrow, saying she could get no peace concerning this matter, which was the only reason for her present dangerous condition. Th is revelation was all the more pleasing to me because that very same day I was able to remedy her pressing problem completely and to calm her, and was thus enabled to hope for her recovery. However, the opposite happened.26

To what extent physicians had already become estranged from Christian

faith can be seen in the work “Über Religiosität der Ärzte” (On Physicians’

Religiousness) written by the Worms physician Georg Friedrich Christian

Greiner (1775–1858). Greiner asked his colleagues to readopt a Christian at-

titude. However, he made a distinction between the faith of physicians, char-

acterized by an “enlightened” understanding of life’s basics, and the Christian

“superstition” of the “uneducated” patient.27 Clergymen, on the other hand,

acquired medical knowledge in order to be able to recognize when seriously

ill patients were dying, there being no physician present. However, the phy-

sician Carl Capellmann (1841–98) stressed in his explanations of “pastoral

medicine” that diagnosis and treatment were not the “clergyman’s task”; it

should be suffi cient for him to recognize that a patient’s end was near. Th us,

Capellmann taught clergymen how to recognize the “signs of a serious, life-

threatening disease.”28

120 Karen Nolte

Furthermore, in literature put out by physicians toward the end of the

nineteenth century, a majority held that incurably ill patients should not

be told the truth about their condition. In the meantime, however, a change

in the medical paradigm had taken place. With medicine now elevated to a

natural science through the cellular pathology of Rudolf Virchow (1821–

1902) and the new discipline of bacteriology ushered in by Robert Koch

(1843–1910), the fi nal dissociation from humoral pathology—in both medi-

cal theory and practice—took place in the second half of the nineteenth cen-

tury. Diseases and the course they took were now almost exclusively ascribed

to somatic processes. Infl uenced by these developments, medicine no longer

saw a direct correlation between psychic crises and physical well-being. But

the opponents of comprehensive disclosure still used as an argument the dan-

ger of suicide by a patient confronted with his own mortality.29 Even in the

late nineteenth century, Robert Gersuny (1844–1924) pointed out, in his

recommendations for physicians, that taking away the seriously ill patient’s

hope for recovery put the physician in a dilemma, since no prognosis was in-

fallibly correct. Still, Albert Moll, whose handbook on medical ethics was

published in 1902, disassociated himself from the general attitude of his col-

leagues by stressing that the physician could not be allowed to withhold the

dreadful truth when the patient expressly asked him to disclose his progno-

sis.30 However, while many physicians in the nineteenth century adopted a

critical stance toward terminal care as practiced by religious bodies, it was

nevertheless a central focus of nursing care for the nurses from the deaconess

motherhouse at Kaiserswerth.

Th e Letters of the Kaiserswerth Deaconesses

In 1836, the Protestant pastor Th eodor Fliedner (1800–1864) founded the

fi rst German deaconess motherhouse, at Kaiserswerth near Duesseldorf, with

the aim of systematically training daughters of middle-class families in nursing

care. Fliedner belonged to the Protestant pietist awakening movement, which

originated at the end of the eighteenth century. Th e personal conversion of

the individual (his “awakening”) was a central idea of this religious renewal

movement. Th e piety, thus awakened, was to fi nd its expression among one’s

fellows in the sphere of Christian social work.31 In this way, Fliedner not only

reacted in a practical manner in regard to the pressing “social issue” at the

beginning of the nineteenth century, but also saw in care for the poor and

sick the possibility of contributing to the re-Christianization of society. Th e


idea of the “inner mission” was based on the concern of the Protestant middle

classes that because of the proletariat’s affi liation to the social democratic and

socialist environment, the distance from Christian faith would not be easy

to bridge. Not only was Christian social work intended to relieve the social

distress of proletarian families, but it was also simultaneously intended to

undermine the socialist labor movement through this very activity.32 How-

ever, at fi rst the daughters of teachers, clergymen, and physicians could not

be persuaded to volunteer themselves for deaconess training—as Fliedner

had originally planned—because nursing did not enjoy much of a reputa-

tion as a profession. During the fi rst years after the establishment of the dea-

coness motherhouse at Kaiserswerth, young women hailing mainly from the

rural lower or middle class were the candidates for nursing care training.33 In

order to enable them to hold their own as unmarried women in the public

arena, Fliedner made sure that the young deaconesses were dressed appro-

priately, providing them with a dress made of dark blue fabric and a frilled

bonnet. Th e bonnet in question was generally taken as an indication that the

upper-middle-class woman wearing it was married.34 Th e deaconesses’ aspi-

ration toward middle-class status was further underlined by the expensive,

lavishly made Sunday dress.35 However, it was not only the dress but also the

education the young lower-class women obtained at the motherhouse that led

to social advancement for this fi rst generation of deaconesses. When Fliedner

did not succeed in fi nding a middle-class female to act as superintendent for

the deaconess motherhouse, his fi rst wife, Friederike Fliedner (1800–1842),

a woman willing to work with him and to subordinate herself to him uncon-

ditionally, took on the task. After Friederike Fliedner’s early death in 1842,

Th eodor Fliedner married Caroline Bertheau (1811–92), who belonged to

the Hamburg Awakening Movement. She succeeded his fi rst wife as super-

intendent. Th e Fliedners not only saw themselves as the deaconesses’ social

and professional superiors but also as standing in loco parentis to watch over

“their” deaconesses with love and strictness. In their letters to the Fliedners,

the deaconesses actually addressed them as “Dear mother” or “Dear father,”

respectively, and confi ded to them their large and small worries, their everyday

experiences, and their questions of faith.

Th e letters of the deaconesses and probationary nurses demonstrated

how they strove to fulfi ll the ideal image of the deaconess, and hence the ex-

pectations of the Fliedners.36 Th e rules imposed from outside were, together

with Christian middle-class virtues, to be internalized by means of Th eodor

Fliedner’s catechism of “questions of self-examination.”37 Some of the dea-

conesses’ letters were occasionally published in the in-house journal, “Der

Armen-und-Krankenfreund” (Friend of the Poor and Sick), and held up as

122 Karen Nolte

an example for other deaconesses. Th e kinds of thing the deaconesses chose to

write about were most certainly infl uenced by this fact as well. Accordingly,

the letters provide us, above all, with analytic tools for determining how the

deaconesses ideally and in reality saw themselves in their capacity as nurses

relating to their patients. Th e style of the letters betrays the writers’ attempts

to follow middle-class writing conventions. However, the poor education of

the lower-class deaconesses lets them down and their letters fail to attain the

level of refi nement desired—their quite long and carefully formulated letters

are sometimes strewn with orthographic and grammatical mistakes. However,

the personality of the individual letter writer vividly comes through in the

unconventional way of writing. Th e letters had a function additional to that of

reporting to the superintendents in detail and at regular intervals on the work

performed outside the motherhouse; they were also a medium for the young

deaconesses to convey to the “parents” at the motherhouse their everyday ex-

periences, confl icts, and burdens, the better to assimilate them. Th erefore,

discrepancies can be found in these “egodocuments,” characterized as they are

by a multitude of expectations, when in subordinate clauses or marginal notes

the writers unconsciously cross the boundaries established by self-censure.38

Spiritual Nursing Care and Christian Terminal Care

“Physical nursing care” was very important in the training of nurses at Kaiser-

swerth. At fi rst, Fliedner based his curriculum of practical nursing care on the

nursing-care textbooks authored by the physicians Johann Friedrich Dieff en-

bach (1792–1847)39 and Carl Emil Gedike (1797–1867),40 who in 1832 had

founded and who also administered the nursing school (Krankenwartschule) at the Berlin Charité Hospital. In these instructions, physicians obviously re-

garded terminal care as the task of both physicians and nurses. However, the

nurses’ task at the deathbed was already prescribed as a selfl ess “labor of love,”

which could neither be commanded nor recompensed.”41 Th e nurses were

enjoined to give up “superstition” and to follow physicians’ orders conscien-

tiously.42 Th e central tasks of “physical care” were the alleviation of pain, the

preparation of a comfortable deathbed, and the creation of a peaceful atmo-

sphere. However, care for and examination of the corpse—to ensure that the

deceased was indeed deceased and not buried alive and in error!—were also

part of the nurse’s duties.43

However, for the deaconesses of a more deeply spiritual orientation,

“spiritual nursing care” held a special signifi cance. Th eodor Fliedner himself


regarded terminal care as the very heart of the nursing care practiced by

deaconesses:

At the deathbed, the beautiful and holy task of nursing care appears in all its somberness, but also in its full signifi cance. What the physician can achieve has reached its limits, but the nurse’s love is still untiringly at work, moving her to stand by her patient and minister to him in the hour of his death throes with a caring hand and a gentle mind—to bring him alleviation and solace. She redoubles her eff orts and her loyalty, and even when the moment of truth has passed she goes on caring.44

In this conception, deaconesses were entitled to their own sphere of com-

petence, one that was independent of the physicians’ sphere of competence.

Th e deaconesses’ contribution exceeded that of the physicians, because the

nurses tended to the patients’ “salvation” in the moments before their death

and beyond. Th e deaconesses, who as a body sympathized with the neopietistic

awakening movement, were especially involved in the conversion of terminally

ill patients, in order to enable them to die “blessedly.”45 In their letters, they

made a reckoning of how many patients had died in toto in the course of the

year. Looking back on the year, they stressed individual experiences with dying

patients, describing these “case histories” in detail and assessing the particular

end-of-life episode with a clear attitude of superiority provided by their Chris-

tian perspective. Cases were given particular prominence when the death had

taken place in an exemplary manner, according to Christian rules, when the

dying patient had gamely resisted the deaconesses’ attempts at conversion, or

when he seemed to have been extremely “sinful.” Nurse Isabell Kummer con-

cluded in a letter: “On the whole, little desire for God’s word can be seen; such

ignorance of God’s word and Christian truth in general, especially in the parish

of Aachen, I have not experienced anywhere else before; we are often sad about

it.”46 In another letter she tells the story of a rich private patient, who “during

the last ten days of his life . . . suff ered indescribably: Although his physical con-

dition was extremely poor, it was nothing compared to his inner confl ict and

the incessant mortal fear in his soul! Th e unlucky man had no God, therefore

death still had a bad sting and kept all its bitterness for him; he turned and

tossed in mortal fear without, however, understanding anything about Him

who has overcome death and brings peace, about Whom we told him.”47 Th e

parish deaconesses Lisette Steiner and Louise Türmer report on their “joyous

experience” with a seventeen-year-old girl who died of a wasting disease:

She felt her end to be near and had great desire for the dear Lord, with the result that we could not sing enough songs for her or recite enough passages; she especially

124 Karen Nolte

loved the last two verses of Psalm 88: “When I will have to die . . .” Th ree days before her death, her mother arrived from afar and wanted to take her with her, but she was too weak for it; and when her mother cried, she said: Dear mother, do not cry, but turn to the Lord Jesus with me, then we will meet again in Heaven. And she found solace through the Lord’s mercy and the patient died in the full belief in the Lord.48

Deaconesses regarded full disclosure of the terminal patient’s condition

as an absolute prerequisite if the patient was to die “blessedly.” Th e Christian

nurses’ idealized view of a “blessed dying” can be inferred from the deacon-

esses’ reports in the “Armen-und-Krankenfreund” on the one hand, and from

the obituaries of Kaiserswerth deaconesses on the other. Th e scenes of dying

described there all follow the same dramatic pattern: at fi rst, the dying nurse is

afraid of death; then she calms down and recites core texts, songs, and prayers

learned at the motherhouse, and fi nally she dies with the “necessary knowledge

of salvation.”49 In the deaconesses’ letters to the motherhouse can be found

descriptions of their own life-threatening diseases and of serious diseases that

befell fellow deaconesses. Th ey represent the experience of having narrowly

escaped death as a religious touchstone, whereby they have been honored by

God. In 1875, nurse Lina wrote to the motherhouse: “[I have] a lot to praise

and to thank for . . .; because my God made me become so seriously ill, led me

to death’s door and let me recover again.”50 Matthias Benad terms these fre-

quently found descriptions “death piety” and regards this phenomenon as the

core of the deaconesses’ way of seeing themselves.51 What the Christian nurses

aimed to convey to their dying patients was that the experience of dying was

in the nature of a religious catharsis, an experience of being especially close

to God. In accordance with the special signifi cance accorded to terminal care

in the style of nursing care taught at Kaiserswerth, the letters of the deacon-

esses provide quite extensive descriptions of their work at the deathbed. Fur-

thermore, these passages were later frequently publicized—probably by the

deaconesses’ parents—refl ecting in this way the special interest in this fi eld of

nursing care.52

Everyday Work and Confl icts in Dealing with Dying Patients

Th e physicians’ refusal to disclose the patient’s condition is mentioned in

only a few of the deaconesses’ letters. However, the criticism of the physi-

cians expressed in these few examples is remarkable, because, according to

the Kaiserswerth offi cial regulations, the deaconesses were neither allowed


to contradict physicians nor to refuse to comply with their orders.53 Th us

it can be assumed that the deaconesses, who lived by strict rules, normally

obeyed physicians’ orders. In 1852, nurse Julie Creuzinger wrote about a

case in private care:

my dear patient is quite well at the moment; pain has diminished over the last few weeks, but the body is declining, although the mind is at times very cheerful and memory has grown sharper. Th e wound has been healing considerably for the last quarter of a year; her whole condition gives the appearance of being restored to health quite soon. Her dear parents are full of hope that she will recover, because the doctor makes them believe in recovery. He claims that the siblings and parents would otherwise not be able to bear the pain; I cannot talk to the doctor about it alone and I also think he would not be honest about her condition.54

Th e nurse predicts the child’s imminent death and is not only critical of the

physician for not enlightening the sick girl’s parents as to her grave condition

but also indicates that even with the nurse he fails to address the issue. How

Creuzinger resolves the dilemma created by her express criticism of the physi-

cian’s behavior and her duty to obey cannot be ascertained from her letter.

In the research literature, the second half of the nineteenth century is

called the “age of medical paternalism.”55 By the beginning of the twentieth

century, academic physicians had achieved, in comparison to members of

nonacademic medical professions, a monopoly position in the health care

market. As I have already demonstrated, physicians around 1900 were mostly

of the opinion that the hopelessness of terminal patients’ condition should

not be disclosed to them, in order to forestall suicide attempts on their part.

Instructions for deaconesses had not changed concerning the policy adopted

toward seriously ill and dying patients: it was still their express aim to con-

vert dying patients who were unbelievers to the Christian faith, thus lead-

ing them to a blessed death. In 1890, two district nurses—deaconesses of

Kaiserswerth—were looking after a family whose members were all critically

ill with typhoid fever. When, in order to spare their patients’ feelings, the

physician did not want them to receive the news of the death of the father and

the daughter, a confl ict arose between the nurses’ religious beliefs and the rule

of unquestioning obedience:

Since he was recovering, the head of the household was brought to a neighbor-ing house, because the other patients had to be isolated and there was not enough room. He remained quite well until Boxing Day, when he suddenly suff ered a stroke and died soon afterwards. Th e physician gave orders not to tell the patients anything

126 Karen Nolte

about it, because one of the daughters was seriously ill with typhoid fever and the other two were not doing much better. Th e seriously ill daughter died on the 13th of this month, and we hope to God that she died blessedly. Th en the physician again gave orders not to mention her demise to her mother and one of her sisters, but actu-ally to lie if the mother asked how her daughter was, and to tell her that she was well. However, we both announced that we could not do that and would fi nd ourselves forced to give up nursing them. Th en the son-in-law, H. Kersting, came and told the mother the truth. You can imagine her pain and sorrow, but, thank God, she is much better than we expected.56

Th e physician regarded it as necessary from the therapeutic point of view

to keep the death of the father and of one of the daughters from the rest of the

seriously ill family members. Th e deaconesses, however, failed to see the thera-

peutic necessity of it and complained that the physician had ordered them

to lie to the patients. As the deaconesses could neither lie nor disobey the

physician’s orders, they saw that the only way out of this dilemma was to

refuse to go on nursing the family. Although the confl ict was soon resolved

through the action of the son-in-law, the nurses wrote to their “parents” about

this confl ict with still noticeable indignation. Even if physicians’ orders were

opposed to their religious beliefs, the duty to obey the physician was obviously

the determining factor in the deaconesses’ behavior.

On the other hand, deaconesses seemed to have a good deal of latitude and

scope when physicians did not give specifi c directives for dealing with dying

patients. Many letters make it clear that they sometimes took the liberty of

launching into their spiritual terminal care even without a clear prognosis by

the physician. In 1862, nurse Johanne Niendecker described how an unbeliever

suff ering from dropsy had challenged her to tell him about his imminent end:

We had an especially terrible case. A typesetter came to our town, miserably dressed and suff ering from dropsy. At fi rst all went well, but when he became more and more miserable, we told him that he would probably die. Th is was terrible for him; he clung to life with all his might. It shook us badly to see how he kept on im-ploring the doctors to do whatever they could to help him. “I do not want to die!” he exclaimed. Th en he said, if he could only live for two more years. Finally, on the Sunday before his death, he begged me urgently to administer him some painkillers. Th en I could not refrain from telling him that I did not believe he had many more days to live and advised him to turn seriously to Jesus, in order to become blessed. He was sitting in an armchair, and the water kept leaking from his legs. Th en, he jumped up and ran out of the room as fast as his miserable condition allowed; it was terrible. . . . Th en, his fi nal hour approached; he was unconscious; it was night and I was alone with him, standing in the middle of the room; it was so eerie. If we had no Redeemer in situations like these, what would we do?57


From this and other letters by the deaconesses it can be seen how insistently

the Christian nurses pursued the conversion of dying patients who were unbe-

lievers. Th ey regarded it as a severe defeat if they did not succeed in converting

seriously ill patients to God before their death. Th us, they frequently overrode

the patients’ express wish not to talk about their imminent end. Th ey exerted

much psychological pressure in this, as is revealed in the following paragraph

from a report about an encounter with a seriously “chest sick” man in commu-

nity care: “Th e patient said: I am still far from dying. We told him that the Lord

could come like a thief in the night and asked him if he would stand the test

before Christ’s tribunal? He could not answer this.”58 Th e two nurses intention-

ally frightened the patient with talk of his imminent death, in order to make

him profess Christianity. But this was also the reason why a goodly number of

physicians wanted to keep clergymen away from the deathbed, their assumption

being that mortal fear would shorten the life of a seriously ill patient.

While terminal care for a devout Christian was frequently described by

the nurses as an “elevating” experience, the deathbed ordeal of unbelievers was

very “eerie” for them. Out of fear, they would sometimes not visit the bedside

of such patients unless accompanied by a second deaconess. In 1853, nurse

Dorothea Haube wrote this about an unmarried woman who was seriously ill:

She did not want to see me, because I had been obliged to tell her the truth several times before—not only that she did not have much longer to live, but other matters as well. Once she had said to another woman that it was easy for me to talk like that, but the dear Lord I had told her about was absent, and he who wanted to rely on him would be deceived, and talk like that. In short: I did not know what to do with her.59

Day after day, Haube visited the unbelieving patient with a “heavy heart.”

When the patient was close to death, Haube took another nurse with her,

because she found it “so eerie” to be alone with the dying woman. Johanne

Niendecker also describes her uneasy feelings concerning a patient suff ering

from dropsy, who could not be converted at all: “His fi nal hour approached;

he was unconscious; it was night and I was alone with him, but I stood in the

middle of the room; it was so eerie. If there was no Redeemer in such cases,

what would we do?”60

Occasionally, when dying patients themselves felt the end to be near, nei-

ther disclosure by the physician nor hints by the deaconesses were necessary:

Mrs. Arns was a cheerful lady of 75, only chest sick and suff ering from dropsy. . . . Last Saturday, she suddenly expectorated blood. From then on, her condition rapidly

128 Karen Nolte

turned critical; she was losing her appetite, which until then had been quite good; her strength was declining visibly. Th e patient felt her end approaching, but whenever she talked about it to her relatives they talked her out of it. Th is was quite diffi cult for me. Her daughter, Dr Füllrath, and a daughter-in-law assisted in nursing during the diffi cult last days, because two persons were needed to lift her. So I was never alone with the patient, although I was not afraid of giving her the necessary comfort. She was not allowed to see a clergyman. She was very restless and impatient, but she realized it was a sin; and on the last day, although completely conscious, she was calm and patient like a lamb, which gave me great pleasure because I had prayed to God for it. She had realized that she was a great sinner and I hope that the dear God has received her mercifully.61

In this case, the dying woman wanted to talk about her death but it was

the relatives who were afraid to face it. Th e relatives also refused to summon

a clergyman to the deathbed. Th erefore, nurse Sophie Stock took on herself

the task of pastor. Although, in the Kaiserswerth offi cial regulations, spiritual

nursing care was distinguished from pastoral care, Fliedner gave his deacon-

esses the authority to interpret God’s word—a competency usually assigned

to theologians alone.62 In this and other letters—especially those from com-

munity and private care situations—it can be seen that the boundary lines

between spiritual nursing care and pastoral care, and thus between the deacon-

esses’ and pastors’ fi elds of activity, were fl uid.63

Conclusion

As late as at the beginning of the nineteenth century, physicians conceived

of “interior euthanasia”—terminal care focusing on the seriously ill patient’s

spiritual condition—as a medical task, thus removing it from the sphere of

clergymen and pastors. Th e deaconesses’ letters, however, reveal that with the

professionalization of nursing care from the 1840s on, “interior euthanasia”

was increasingly viewed as a central area of nursing care and practiced accord-

ingly. In the twentieth-century textbooks for nursing care—mostly written by

physicians—the intense human devotion called for in terminal care is por-

trayed as the task of nurses.64 Confl icts between physicians and deaconesses

obviously arose only when physicians gave truth-telling directions that were

opposed to the nurses’ religious beliefs. Quite a number of letters, however,

show that deaconesses, in the course of their spiritual nursing care, talked

to the patients about their imminent death and took the liberty of doing so

without the truth being disclosed to the patient by a physician beforehand.


On the basis of his narrative interviews of nurses, Andreas Heller refers to a

similar practice found in the 1940s and 1950s. A nurse interviewed by him

explained how she had called a priest for a dying patient who had not yet been

told the truth by the physician, because she was under the impression that the

patient would soon die. Th is example also shows that, on the one hand, the

nurses were not allowed to disclose to seriously ill patients their imminent

death, but that, on the other hand, they were nevertheless supposed to take

care of the patient’s spiritual and religious well-being. Th us, this latter demand

on the caregivers sometimes justifi ed a way of acting independently of physi-

cians’ orders.65

Agnes Karll’s (1868–1927) letters to her mother66 make plain that in the

wake of the professionalization of nursing care, the meaning of truth telling

underwent a change. Karll, one of the founders of Germany’s professional

nurses’ association, was critical of the fact that a family doctor did not want

to tell the dying patient the truth about her imminent death. However, in

this case the focus was not on care for the patient’s spiritual salvation in the

religious sense. In fact, Karll regretted that the patient did not want to face

death and was so rebellious against the unavoidable that dying at peace with

herself became impossible.67 During the fi rst half of the twentieth century,

terminal care was still central for nurses, who in the meantime were no longer

denominationally tied.68 For secular nurses as well, the seriously ill patient’s

active refl ection on death was important, because it enabled him to fi nish his

life in a proper manner, take care of his personal aff airs, and fi nally die at peace

with himself.69

Until the present day, this ideal of dying dominates the approach taken

with dying patients. In 1969, the physician Elisabeth Kübler-Ross devel-

oped a fi ve-phase model for the dying process, which was to begin with

disclosure. Th is model also incorporated the ideal of dying in “spiritual

peace.” Kübler-Ross regarded anger and rebellion against death as typical of

the second stage of dying70—against which background, dying in strife and

anger against death appears as regressive. Th is model of terminal care in the

various stages of dying, which is in a way a secular form of spiritual care, also

required the disclosure of the prognosis to the dying patient. With regard

to terminal-care nursing, recent refl ections on nursing ethics place more

stress on the process of truth telling. Only after disclosure by the physician

does the patient gradually start to “understand and recognize a medically

correct diagnosis.”71 In the meantime, the experience of human sympathy

for the suff ering and dying of the patient has mainly become the task of

nurses, while, from the nurse’s point of view, physicians are responsible for

the medical care of the dying patient.72

130 Karen Nolte

Karen Nolte, PhD

Institute for the History of Medicine, University of Wuerzburg

Oberer Neubergweg 10a

D-97074 Wuerzburg, Germany City, Germany

Notes

1. See Andreas Heller, “ ‘Da ist die Schwester nicht weggegangen von dem Bett . . .,’ Berufsgeschichtliche Aspekte der Pfl ege von Sterbenden im Krankenhaus in der ersten Hälfte des 20. Jahrhunderts,’ in Zur Sozialgeschichte der Pfl ege in Österreich. Krankenschwest-ern erzählen über die Zeit von 1920 bis 1950, ed. Elisabeth Seidl and Hilde Steppe (Vi-enna: Maudrich, 1996), 192–211, especially 201. See also Ilse Walter, “Initiation in eine Schwesternschaft?” in Sozialgeschichte der Pfl ege, ed. Seidl and Steppe, 136–55.

2. See Andreas Heller, “Sterbebegleitung und Bedingungen des Sterbens,” in Kul-tur des Sterbens. Bedingungen des für das Lebensende gestalten, ed. Andreas Heller (Freiburg: Lambertus, 1994), 57–61. Ingrid Hoff mann, “Wahrheit am Krankenbett. Zur ethischen Problematik der Pfl egeberufe,” Deutsche Krankenpfl egezeitschrift 46 (1993), Beiheft Pfl ege-forschung: 2–27, especially 4, 23–25.

3. Unfortunately the intense search for egodocuments and everyday sources in the archives of the German Catholic nursing orders, in the archive of Caritas, and in bishopric and diocese archives has not yet been successful.

4. Th ese “Letters By Nurses” are stored at the archive of the Fliedner Cultural Foundation at Kaiserswerth (FSAK).

5. On the history of the “good death,” see. Udo Benzenhöfer, Der gute Tod. Eu-thanasie und Sterbehilfe in Geschichte und Gegenwart (Munich: Beck 1999); on the cultural history of Th e Art of Dying, see Th e Art of Dying. Die Kunst des Sterbens einst und heute, ed. Arthur E. Imhof (Vienna: Böhlau, 1991).

6. See Karl Heinrich Marx, Ueber Euthanasie (Berlin, 1827). 7. See Christoph Wilhelm Hufeland, Enchiridion medicum oder Anleitung zur

medizinischen Praxis (Berlin: Jonas, 1836), 717–18; “Vom Verhalten der Ärzte gegen un-heilbare Kranke und Sterbende,” Allgemeine medizinische Annalen des neunzehnten Jahr-hunderts, 538–46; Leo Lebrecht, Der Arzt im Verhältnis zur Natur, zur Menschheit und zur Kunst. (Mainz: Florian Kupferberg, 1821), 102–7, Ludwig Choulant, Der junge Arzt am Krankenbette. (Leipzig: Carl Cnobloch, 1823), 43–45; Karl Ludwig Klohss, Die Euthana-sie. Die Kunst den Tod zu erleichtern (Berlin: G. Reimer, 1835).

8. “Vom Verhalten der Ärzte,” 541. 9. Lebrecht, Der Arzt, 107. Karl Heinrich Marx, however, wanted to leave this task

at the deathbed to the care of well-trained attendants. Marx, Ueber Euthanasie, 6–9.10. See Heinrich Bornholt, Characteristik eines wahren Arztes. (Frankfurt am

Main: Gebhard und Körber, 1797), 35; “Ist es Pfl icht des Arztes, dem Kranken oder den Anverwandten den bevorstehenden Tod zu verkündigen?” Allmanach für Ärzte und Nich-tärzte (1793), 222–242.

11. “Ist es Pfl icht des Arztes,” 222–42, 229.


12. On concepts of the body in the late 18th Century, see also Michael Stolberg, Homo patiens. Krankheits- und Körpererfahrung in der Frühen Neuzeit. (Cologne: Böhlau, 2003).

13. Bornholt, Characteristik, 30–31.14. See “Ist es Pfl icht des Arztes”; Bornholt, Characteristik, 35; “Vom Verhalten der

Ärzte”; Hufeland, Enchiridion medicum, 716–18; see also Ulrich Brand, “Ärztliche Ethik im 19. Jahrhundert. Der Wandel ethischer Inhalte im medizinischen Schrifttum. Ein Be-itrag zum Verständnis der Arzt-Patient-Beziehung” (med. diss., Freiburg, 1977), 145–49.

15. See Christoph Wilhelm Hufeland: Die Kunst das menschliche Leben zu verlän-gern, (Vienna: Haas, 1797).

16. Hufeland, Enchiridion medicum, 717–18. Karl Ludwig Klohss also fi rmly re-jected the disclosure of “the unvarnished truth” about his condition to the patient. Klohss, Die Euthanasie, 79.

17. Johann Gottlieb Th ierfelder, “Darf der Arzt dem Kranken die vorhandene un-vermeidliche Gefahr des nahen Todes ankündigen, und unter gewissen Umständen das Leben absichtlich verkürzen?” Medicinischer Argos (1843): 148–62, especially 158.

18. See John Gregory, Vorlesungen über die Pfl ichten und Eigenschaften des Arztes (Leipzig: Caspar Fritsch 1778), 42–43; Georg Friedrich Christian Greiner, “Über die Wahrhaftigkeit des Arztes,’ Allgemeine medizinische Annalen des neunzehnten Jahrhunderts (1810): 273–78; C.A.W. Richter, “Einige Winke für das Savoir faire,” Medizinischer Alma-nach 5 (1840): 80–151; Ludwig Choulant, Der junge Arzt, 43–46.

19. Quoted in Richter, “Einige Winke,” 121–22.20. See Gregory, Vorlesungen Pfl ichten des Arztes, 43; “Ist es Pfl icht des Arztes,” 232;

Hufeland, Enchiridion medicum, 718; Th ierfelder, “Darf der Arzt,” 152.21. Marx, Ueber Euthanasie, 13–14.22. See Klohss, Die Euthanasie, 148–50.23. Ibid., 149.24. Ibid.25. Ibid.26. Christoph Wilhelm Hufeland, “Gebärmutterblutsturz, Krebs der Geschlechts-

organe und Wassersucht des Ovariums,” Journal der practischen Arzneykunde und Wundar-zneykunst 25, no. 1 (1807): 113.

27. Georg Friedrich Christian Greiner, “Über Religiosität der Ärzte,” Allgemeine medizinische Annalen des neunzehnten Jahrhunderts (1810): 556–64. On physicians’ reli-giousness, see. also Angelo Antonio Scotti, Die Religion und Arzneykunde in ihren wech-selseitigen Beziehungen dargestellt (Vienna: Carl Gerold, 1824).

28. See Carl Capellmann, Pastoral-Medicin, 10th edition (fi rst edition 1877), (Aachen: Rudolph Barth 1895), 203–10. On pastoral medicine, see also Ernst Joseph Gus-tav de Valenti, Medicina Clerica ode: Handbuch der Pastoral-Medizin für Seelsorger, Päda-gogen und Aerzte nebst Diätetik für Geistliche (Leipzig: Köhler 1831); Heinrich Pompey, Die Bedeutung der Medizin für die kirchliche Seelsorge im Selbstverständnis der sogenannten Pastoralmedizin (Freiburg: Herder, 1968).

29. See Robert Gersuny, Arzt und Patient. Winke für Beide (Berlin: Enke, 1884), 26–27; Julius Pagel, Medicinische Deontologie. Ein kleiner Katechismus für angehende Prak-tiker (Berlin: Oscar Coblentz, 1897), 141; Ernst Schweninger, Der Arzt (Frankfurt am Main: Rütten und Loening, 1906), 76–79. Albert Moll, especially, reports on the argument often used by colleagues that “truth telling” may result in the patient’s suicide: see Moll,

132 Karen Nolte

Ärztliche Ethik. Die Pfl ichten des Arztes in allen Beziehungen seiner Th ätigkeit (Stuttgart: Enke, 1902), 123–24.

30. Moll, Ärztliche Ethik, 121.31. See Arnd Götzelmann, “Die Soziale Frage,” in Der Pietismus im neunzehnten

und zwanzigsten Jahrhundert, ed. Ulrich Gäbler (Göttingen: Vandenhoeck & Rupprecht), 272–307.

32. On the history of the Kaiserswerth deaconry, see Ruth Felgentreff , Das Dia-koniewerk Kaiserswerth 1836–1998. Von der Diakonissenanstalt zum Diakoniewerk—ein Überblick (Kaiserswerth: Eigenverlag 1998); Silke Köser, Denn eine Diakonisse darf kein Alltagsmensch sein. Kollektive Identitäten Kaiserswerther Diakonissen 1836–1914 (Leipzig: Evangelische Verlagsanstalt, 2006); Jochen-Christoph Kaiser, “Innere Mission und Diakonie,” in Die Macht der Nächstenliebe. Einhundertfünfzig Jahre Innere Mission und Diakonie 1848–1998, ed. Ursula Röper and Carola Jüllig (Berlin: Jovis 1998): Lisel-otte Katscher, “Die Krankenpfl ege,” in Macht der Nächstenliebe, ed. Röper and Jüllig, 152–61.

33. On the social background of the Kaiserswerth deaconesses, see Jutta Schmidt, Beruf: Schwester. Mutterhausdiakonie im 19. Jahrhundert (Frankfurt am Main: Campus, 1995), 161–216; Felgentreff , Diakoniewerk Kaiserswerth, 22–23. At the beginning, the training was quite short: It lasted just for two months and was only gradually extended.

34. See. Felgentreff , Diakonie Kaiserswerth, 25.35. Silke Köser especially stresses the identity-creating dimension of the uniform for

the Kaiserswerth deaconesses: Köser, Kollektive Identitäten, 251–79.36. On the “construction of the deaconess,” see Köser, Kollektive Identitäten.37. Th e “questions of self-examination” are printed in the appendix of the Kaisers-

werth offi cial regulations: see Haus-Ordnung und Dienst-Anweisung für die Diakonissen in der Diakonissen-Anstalt zu Kaiserswerth, Kaiserswerth 1852, 87–94, Sign.: 1852: Gr. Fl. IV i 3 2, FSAK. On the origin and the practice of the “questions of self-examination,” see Köser, Kollektive Identitäten, 217–19.

38. Dutch historian Jacques Presser used the term “egodocuments” to describe a range of autobiographical materials, including diaries, memoirs, and wills, to signal the distance of this genre from earlier notions of what constituted autobiography. See Rodolf M. Dekker, ed., Egodocuments and History: Autobiographical Writing in Its Social Context since the Middle Ages (Rotterdam: Verloren Publishers, 2002). On the German debate on egodocuments, see Winfried Schulze, ed., Ego-Dokumente. Annäherung an den Menschen in der Geschichte (Berlin: Akademie-Verlag, 1996); Benigna Krusenstjern: “Was sind Selb-stzeugnisse? Begriff skritische und quellenkundliche Überlegungen anhand von Beispielen aus dem 17. Jahrhundert,” Historische Anthropologie 2 (1994): 462–71.

39. Johann Friedrich Dieff enbach, Anleitung zur Krankenwartung (Berlin: August Hirschwald, 1832).

40. Carl Emil Gedike, Handbuch der Krankenwartung. Zum Gebrauch für die Krank-enwart-Schule der K. Berliner Charité-Heilanstalt sowie zum Selbstunterricht (Berlin: August Hirschwald, 1854).

41. Ibid., 109–15.42. See Dieff enbach, Anleitung zur Krankenwartung, 175. Time and again, old cus-

toms, regarded as “false compassion,” like taking away the dying patient’s pillow or turning him on his stomach and thus suff ocating him, are mentioned. See also Gedike, Handbuch der Krankenwartung, 110. On these popular practices of euthanasia, see Michael Stolberg,


“Active Euthanasia in Pre-Modern Society, 1500–1800: Learned Debates and Popular Practices,” Social History of Medicine (Spring 2007).

43. See Gedike, Handbuch der Krankenwartung, 109–15, and Dieff enbach, Anlei-tung zur Krankenwartung,, 174–81.

44. Th eodor Fliedner, “Der Medizinische Kurs,” 1845, quoted in Anna Sticker, Die Entstehung der neuzeitlichen Krankenpfl ege. Deutsche Quellenstücke aus der ersten Hälfte des 19. Jahrhunderts (Stuttgart: Kohlhammer, 1960), 278.

45. On the conversion of patients at the hospital by Kaiserswerth deaconesses, see also Walter Klein, “ ‘Sie sehen mir alle mit freundlichen Gesichtern entgegen.’ Die Bezie-hung zwischen Patienten und Krankenschwestern im Saarbrücker Bürgerhospital in der Mitte des 19. Jahrhunderts,” Medizin, Gesellschaft und Geschichte 21 (2002): 63–90. 78. See also Karen Nolte, “Vom Umgang mit Tod und Sterben in der klinischen und häusli-chen Krankenpfl ege des 19. Jahrhunderts,” in Pfl ege—Räume. Macht und Alltag, ed. Sabine Braunschweig, 165–74 (Zürich: Chronos 2006).

46. Letter from Isabell Kummer, January 25, 1877, Aachen Luisenhospital, 1872–81, Sign.: 1094, FASK.

47. Ibid.48. Letter from Lisette Steiner and Louise Türmer, September 30, 1846, Cleves par-

ish care, 1844–54, Sign.: 1337, FSAK.49. See Köser, Kollektive Identitäten, 363–71.50. Letter from nurse Lina Sauerland, February 2, 1875, Aachen Luisenhospital,

Sign.: 1094, FASK.51. See Matthias Benad, “ ‘Und wenn du mich mit Lauge wüschest . . .’ Rein werden

zum seligen Sterben,” Weg zum Menschen 49 (1997), Heft 2: 78–89; and Matthias Benad, “ ‘Komme ich um, so komme ich um. . . .’ Sterbelust und Arbeitslast in der Betheler Dia-konissenfrömmigkeit,” Jahrbuch für Westfälische Kirchengeschichte 97 (2002): 195–213.

52. See letter from Isabell Kummer, January 25, 1877, Aachen Luisenhospital, 1872–81, Sign.: 1094, FSAK. Here, the superintendents have marked a passage in which nurse Isabell tells the story of a man who died painfully from cancer of the stomach. He had died in an especially restless state because of feelings of guilt at having committed a crime. He had been to jail for three years for having embezzled 35.000 thaler from the Rheinische Bahn. Th e nurse ended her report with the words: “Th at people’s sin is their ruin we have experienced once more here! I wish we would fi ght it more earnestly!” See also Isabell Kummer’s letter of February 8, 1877, also from the Aachen Luisenhospital. Here is marked the story of a rich man from Romania, an unbeliever, who could not be converted. See also Isabell Kummer’s letter of January 24, 1879: Isabell’s description of a rich salesman who did not make use of the chance of turning to God, despite the deaconesses’ serious attempts to convert him, is marked by a thick blue line in the margin of the text. In other letters as well, such markings can be found: see letters from nurses, Cleve parish care, 1844–54, Sign. 1337; letters by nurses from Bonn, 1854–64, Sign.: 1151; letters by nurses from Wuppertal Elberfeld, 1844–50, Sign.: 1778, FSAK; letters by nurses from Wuppertal Elberfeld, 1851–65, Sign.: 1779; letters by nurses from the Aachen Luisenhospital, 1872–81, Sign.: 1094, and others (all FSAK).

53. According to paragraph 3 of the house regulations (1837) of the deaconess motherhouse at Kaiserswerth, physicians’ orders were to be obeyed “punctually and with-out contradiction.” See Köser, Kollektive Identitäten, 198–99.

54. Letter from nurse Julie Creuzinger, March 3, 1852, Gemeindepfl ege in Cleve parish care, Sign.: 1337, FSAK.

134 Karen Nolte

55. See Claudia Huerkamp, Der Aufstieg der Ärzte. Vom gelehrten Stand zum profes-sionellen Experten: Das Beispiel Preußen (Göttingen: Vandenhoeck & Rupprecht, 1985).

56. Letter from nurse M. Großmann, January 17, 1890, Privatpfl ege [private care], Sign.: Bestand 2–1 Diakonissenanstalt, 201, FSAK.

57. Letter from nurse Johanne Niendecker, January 9, 1862, Krankenhaus hospital in Wuppertal-Elberfeld, Sign.: 1779, FSAK).

58. Letter from nurse Lisette Steiner, September 24, 1847, Gemeindepfl ege in Cleve, Sign.: 1337, FSAK).

59. Letter from nurse Dorothea Haube, February 11, 1853, Gemeindepfl ege in Cleve, 1845–54, Sign.: 1337, FSAK.

60. Letter from nurse Julia Niendecker, January 9, 1862, Wuppertal-Elberfeld, 1851–65, Sign.: 1779, FSAK.

61. Letter from nurse Sophie Stock, January 20, 1899, Privatpfl ege, Sign.: Bestand 2–1 Diakonissenanstalt, 201, FSAK.

62. See Th eodor Fliedner, “Instruktion für die erste Seelenpfl ege des Kranken,” in Die Entstehung der neuzeitlichen Krankenpfl ege. Deutsche Quellenstücke aus der ersten Hälfte des 19. Jahrhunderts, ed. Anna Sticker (Stuttgart: Kohlhammer, 1960), 280–81.

63. In his house regulations of 1837, Fliedner put the deaconesses fi rmly in their place by stressing that they should “interfere neither in the offi ce of the physician nor [in the offi ce] of the pastor.” See Köser, Kollektive Identitäten, 198.

64. See., among others, Rudolf Salzwedel, Handbuch der Krankenpfl ege. Zum Ge-brauch für die Krankenwartschule des Kgl. Charité- Krankenhauses sowie zum Selbstunterricht,8. Aufl ., 415–16 (Berlin: August Hirschwald 1904); “Medizinalabteilung des Ministeriums für geistliche, Unterrichts- und Medizinal-Angelegenheiten,” in Krankenpfl egelehrbuch (Berlin: August Hirschwald 1909), 286–88. See also Moll, Ärztliche Ethik, 129.

65. A nurse tells how she had called the priest for a dying patient before the physi-cian disclosed to him the truth about his imminent death. See Heller, “Da ist die Schwester nicht,” 197.

66. See Anna Sticker, ed., “Briefe von Agnes Karll an ihre Mutter 1888–1912,” in Agnes Karll. Die Reformerin der deutschen Krankenpfl ege, ed. Anna Sticker (Wuppertal: Aus-saat, 1977).

67. See Sticker, ed., Agnes Karll, Die Reformerin, 84–86.68. See Heller, “Da ist die Schwester nicht.”69. In an 1888 textbook on nursing care, only the regulation of “secular” matters at

the deathbed is mentioned—for example, it is stressed that the human being should have “fi nished with his aff airs on earth” before “facing the gates of death.” See Paul Sick, Die Krankenpfl ege in ihrer Begründung auf Gesundheitslehre mit besonderer Berücksichtigung der weiblichen Krankenpfl ege (Stuttgart: Steinkopf 1884), 434.

70. See Elisabeth Kübler-Ross, On Death and Dying (New York: Macmillan, 1969).71. See Hoff mann, “Wahrheit am Krankenbett,” 3.72. Ibid.

Documents

Telling the Painful Truth"—Nurses and Physicians in the Nineteenth Century