Cicely Saunders and St Christopher's

Some revolutions in medicine begin in a laboratory, others on a battlefield. A few begin at a bedside, in a conversation between a nurse and a man who has two months to live, when the nurse is twenty-nine and the patient is forty and the question on the table is what to do with five hundred pounds.

THE WARD AT ARCHWAY

Cicely Mary Strode Saunders was born at Linden Lodge in Barnet in June 1918, the daughter of an estate agent, schooled at Roedean and St Anne's, Oxford. She came down in 1940 without a degree to train as a wartime nurse at the Nightingale School. A back injury drove her off the wards in 1944. She retrained as an almoner at the London School of Economics, and it was as an almoner, in February 1948 at the Archway Hospital in north London, that she met David Tasma. He was a Polish Jew out of the Warsaw ghetto, a waiter by trade, dying of inoperable cancer at forty, with no surviving family in England. She visited him for two months. They talked about what a home for the dying might look like, a place that was neither hospital nor workhouse, where the pain was treated and the person was not left alone. When he died he left her five hundred pounds. I'll be a window in your home, he said. She wrote the sentence down. She kept the sentence for nineteen years.

THE LONG APPROACH

The mid-century English ward had a settled grammar for the patient who would not recover. The screens went round the bed. The bed was wheeled to the side-room at the end of the corridor. The morphine, if morphine was offered, came on a four-hourly drip of the matron's discretion, given when the patient cried out and not before, so that the dose chased the pain and never caught it. Saunders had watched this and judged it. To change it she would need to be neither nurse nor almoner but doctor, and so at thirty-three, on the advice of the surgeon Norman Barrett who told her plainly that nobody would listen to her otherwise, she entered St Thomas's Hospital Medical School. She qualified in 1957. She went to St Joseph's Hospice in Hackney to study the dying. There, on Irish Sisters' wards crowded with East End cancer patients, she worked out a pharmacology: oral morphine on a regular clock, every four hours, given before the pain returned and not after; an antiemetic to settle the stomach the opiate disturbed; a small dose of cocaine or chlorpromazine for the anxiety the dying carry into the last weeks. The Brompton mixture, she called it, after the chest hospital where a version of it had first been compounded. She published the results. She lectured. She raised money. The King's Fund gave. The Wolfson Foundation gave. A thousand small Sydenham and Bromley parishes gave. By the spring of 1967 there was a four-storey building of brick and glass at 51-59 Lawrie Park Road, fifty-four beds, a chapel, a teaching wing, three hundred thousand pounds spent.

THE MORNING OF THE TWENTY-FOURTH OF JULY

Twenty past nine on a Monday morning, July sunlight through the south-facing entrance doors. The hall smelt of new paint and floor polish. Saunders stood in it with seven people: a matron, a senior sister, two staff nurses, two orderlies, and Mary Baines who would be the medical director. The first ambulances were due at ten. Seven patients from the Bromley and Sydenham referral lists had been accepted, four with carcinoma of the breast, two of the lung, one of the stomach. The drug cupboard was stocked. The nursing notes were ruled and dated. In the chapel along the east wall, the stained glass commissioned that spring from the Whitefriars Studio had been set into its frame the previous week, a tall plain window of clear and amber light. She had paid for it out of the Tasma money.

A SECOND OF TIME IN MEDICINE

She was forty-nine years old, one month short of her birthday, and what she was about to open was unlike anything in the country, unlike anything in the world. There was no academic hospice anywhere. There were Catholic homes for the dying, the Irish Sisters at Hackney, the Hostel of God at Clapham, places of immense kindness with no research arm and no teaching post and no register of drug effects, places medicine did not visit. There were hospitals, where dying was the wrong outcome, embarrassing, screened off. What she had built sat in the gap between them and proposed that the gap was the discipline. A clinical building. A pharmacology. A teaching syllabus. A research programme. A chaplaincy. A family room. The principle, plainly stated in her notebooks, that the patient was a person until the last breath and that pain was a clinical problem with a clinical answer, not a moral test for the sufferer to pass. It had taken her nineteen years to assemble the argument and the bricks. It would take ten minutes to open the doors. She looked down the hall to the chapel where the Tasma window held its small square of southern light, and thought of the Warsaw man's window in your home, and of the bed she had sat beside in 1948, and went to receive the first ambulance.

THE FIRST ADMISSIONS

Ten o'clock. The ambulances arrived in series. Seven patients were carried in on stretchers, settled into beds with the linen turned down, drug charts written up against the four-hour clock. By lunchtime each of them had been seen by Saunders, by Baines, by the senior sister, the questions asked that the hospital wards did not ask: where is the pain, what is the worst of it, who is at home, who knows. The morphine was given before the pain returned, not after. The vomiting was treated. The anxiety was treated. The visiting hours were abolished. The families came when they wished and stayed as long as they wished. By the end of the first week the wards were full. By 1970 there were the planned fifty-four beds. By 1985 there were seventy-three. The teaching wing took its first overseas fellows in 1969, Canadians, then Americans, then Australians, who went home and built hospices of their own.

THE WINDOW

On the wall of the chapel the Tasma window held the light it had been commissioned to hold. A man from Warsaw, who had lost everyone, whose grave was in a north London cemetery, who had spoken about a home where the dying would not be alone, was in the building as he had asked to be. Saunders kept his photograph on her desk for the rest of her working life. She wrote of him in her papers, in her lectures, in the foundation address: the founder of the modern hospice was not the doctor but the patient.

THE LONG RETURN

She was made OBE that same year, DBE in 1980, a member of the Order of Merit in 1989, one of the twenty-four living holders of the highest British civilian honour. The Templeton Prize came in 1981. She remained medical director at St Christopher's until 1985, then chairman of trustees. She married the Polish painter Marian Bohusz-Szyszko in 1980, when he was eighty and she sixty-one. She died at St Christopher's on the fourteenth of July 2005, eighty-seven years old, in a bed she had long since reserved for herself on the ward she had built. By the time of the 2025 international audit there were about thirty thousand hospice institutions in a hundred and twenty countries, with about eight million end-of-life admissions a year. The Brompton protocol of regular oral morphine, antiemetic and adjuvant, is the international standard of cancer pain relief.

Some revolutions in medicine begin in a laboratory, others on a battlefield. This one began at a bedside, and travelled outward through a stained-glass window on the east wall of a building in Sydenham that holds the southern light an hour before noon.