15 February 2011

Florence Nightingale: dedicated but no saint

William and Frances Nightingale, both from staunch Unitarian families, married in 1818 and left home on a long tour of  Europe. They had their two daughters (Parthenope and Florence) en route. Eventually the family returned to England in 1821 and settled down in William's inherited properties in Derbyshire where he owned and managed an active lead smelter. The main family home was Lea Hurst in Derbyshire, Florence's beloved childhood home.

Lea Hurst, Derbyshire

Unitarians believed that social evils were humanly created, not God inflicted, and therefore could be remedied by human efforts. In the early C19th, Unitarians were closely identified with the campaign for social and political reform. The scholarly William educated his two daughters well.

Florence became increasingly frustrated at the kind of life wealthy young women led. God was still calling her to His service, but He had not made it clear how she was to serve Him. Nursing was a possibility, but it was regarded as menial employment, needing neither study nor intelligence, suitable only for prostitutes and alcoholics (or perhaps Catholic nuns). In 1846 she met Earl Shaftesbury, famous politician and reformer, who showed Florence government reports called Blue Books. She became a self-taught authority on hospitals and sanitation, although with zero experience. She also met Sidney Herbert, Secretary of War, who became the most important contact she ever made.

Roll Call in Crimea, by Lady Butler, bought by Queen Victoria

After a Nile trip in 1850, Florence dabbled in nursing training in Alexandria. In Aug 1851 Florence gained some real experience as a trainee nurse in the Kaiserswerth Institution of Protestant Deaconesses in Dusseldorf, where she was a probationer. And between Aug 1853-Oct 1854, Florence went into residence in her first position, as the superintendent of a rundown Establishment for Invalid Gentlewomen, 1 Upper Harley St. That was the sum total of her medical training and experience!

In July 1853 Russia occupied territories in the Crimea that had previously been controlled by Turkey. Britain & France anguished over Russian expansion and tried to achieve a withdrawal. Turkey declared war on Russia and in Sep 1854, the Crimean War reluctantly began.

Through the first ever war correspondents, the British public learnt of the horrific condition of wounded soldiers. Secretary of War Sidney Herbert, her long time friend, agreed to allow Florence and 38 other lay women to nurse British soldiers in the war zone. She was Superintendent of the Female Nurses in Hospitals in the East.

The party arrived in Constantinople in Nov 1854. The Barrack Hospital in Scutari was old but they were assured by Sidney Herbert of abundant supplies and good facilities. The unfortunate nurses walk into horror; there was nothing there! The sick and wounded soldiers had no blankets, no clean water and totally inadequate food. In these conditions it was not surprising that war wounds only accounted for 1 death in 6 in army hospitals. Diseases like typhus, cholera and dysentery raged, accounting for the rest of the deaths. Furthermore the army doctors did not want nurses there, especially female nurses.

The fetid wards at Scutari. Lithograph by Robert Rigg, National Library Medicine.

In Feb 1855 the mortality rate at the hospital was 43%. Florence was given the task of properly organising the barracks hospital after Battle of Inkerman. At Scutari Barracks Hospital she was in sole control of 2,500 sick soldiers. The soldiers adored the gentle nurses, mopping their fevered brow. The introduction of female nurses to military hospitals was a huge success.

But the soldiers were packed into overcrowded, filthy corridors with poisonous blocked drains beneath. Many of the deaths were preventable, caused by fever caught IN hospital. The Lady with the Lamp image, gliding serenely through the corridors at Scutari, took on a horrible irony. The Russians weren’t killing British soldiers; British army hospitals were. Florence did nothing to improve conditions and got typhus herself.

To show the nation's gratitude for Nightingale, a public subscription was organised in Nov 1855 while she was still in Crimea. The money collected was to enable her to continue her reform of nurse education in the civilian hospitals of Britain. In Jul 1856, the war was over. Florence returned home in Aug 1856 and was surprised to find that the war had made her a national heroine to the troops and public.

The hero treatment triumphantly vindicated her claim that lay women could nurse soldiers without gross indecency taking place. This opened up new career opportunity for middle-class, Protestant women, AND it improved the quality of female nurses. She visited Queen Victoria and Albert to talk about the war, and found Queen a great supporter of women’s professional advancement.

In the aftermath of the Crimean war, it became obvious that a top military hospital was needed in Britain. The Royal Victoria Military Hospital at Netley became the biggest military hospital ever built. Stretching .5k on Southampton Water, the huge red brick complex was built in 1856-63 (and later demolished). It received wounded soldiers from across the British Empire and had an army nursing school.

Nothing could stop the critics focusing on the Crimean debacle. Yet the embarrassed government dithered and the army refused to allow investigations. So Nightingale published her Notes on Matters affecting the Health and Efficiency and Hospital Administration of the British Army and pushed her political contacts for a Royal Commission. Finally in 1857 the government had no choice.

Scottish Dr John Sutherland visited Crimea in 1855 at the request of Palmerston, heading up the Sanity Commission. He was later appointed to a series of posts that gave him responsibility for military hospitals in Britain and India, and became Florence’s closest ally.

Florence Nightgale recovering from Crimea-guilt and from disease

Nightingale had all her hospital notes from Crimea, but she didn’t know how to analyse them. So her first task was to have the government statistician, William Farr, teach her professional statistics. Nightingale quickly learned how to use graphs, charts and tables, based on her hospital notes. She was thus an innovator in the collection, tabulation, interpretation and graphical display of descriptive statistics. Florence became the first woman elected to Fellow of the Statistical Society in 1860.

Soon the data clarified what had happened i.e terrible hygiene at Scutari in 1854-5 had killed more men than any battle! After a mental break down Florence took to bed, where she remained for the rest of her life. She never again made a public appearance, attended a public function or issued a public statement. But it didn’t stop her from working. A new, finer Florence was born from Crimea-guilt, and the campaigns she ran from her sick bed were critical in the development of good public health. The evidence she gave to the 1857 Sanitary Commission, resulted in the formation of the Army Medical College.

Nightingale's scientific analysis of the Crimean data, 1856

After 1858 Florence was recognised as the leading expert on military and civilian sanitation in India. Newly assigned viceroys to India visited her home for briefings, before travelling. Nightingale published two reforming books in 1859, Notes on Hospital and Notes on Nursing. They were very popular, and were expanded in 1860-1 with a special section on infant care. This was civilian health care!

With the support of wealthy friends and after publicity from The London Times, Florence raised £59,000 to improve the quality of nursing. In 1860 she used this money to found the Nightingale Training School and Home for Nurses at St Thomas' Hospital, supervised from her London flat. The first students began in June 1860 and the school, the first professional training school for nurses, went on to be a success!

Once trained, her nurses were sent to staff hospitals in Britain and abroad, and to establish nurse training schools on the Nightingale model. In 1860 her best known work, Notes on Nursing, was republished. Her principles of nursing: careful observation and sensitivity to the patient's needs, were translated into 11 foreign languages.

But good nurses needed good hospital buildings and she, of course, had clear ideas on how hospitals should be designed. In the late 1850s she published a number of articles on the Sites and Construction of Hospitals and in the 1860s advised on specific building projects. She had a major influence on the subsequent design of both civil and military hospitals. This was amazing. For someone who had had almost zero nursing training, little experience running a ward and an utterly disastrous experience in Crimea, Nightingale was now building success on success. She had become so famous that by the time the Royal Hampshire County Hospital was built early 1860s, the architects felt obliged to consult Florence on the building’s design.

Florence Nightingale and her graduating nurses at Claydon House.

Her ultimate goal was to revise all public health care in the UK. Nightingale was clearly not a modest woman, nor a woman easily fazed by seriously huge tasks. In 1864-7, and still bed ridden, she worked on setting up home nursing system, and designing an obstetric hospital, barracks for married soldiers and hospitals for the insane & poor. Importantly she helped to stop the practice of putting all sick and poor people together: men, women, children, insane and sane.

Rural hygiene was a concern, so Florence also became involved in the development of community nursing in Liverpool. This led to the wide spread establishment of both the District Nursing Service and the Health Visitors. Many Nightingale-trained nurses became pioneers in these fields.

Deaths in childbirth were continuing. So a training school for midwives was founded at King's College Hospital London in 1861. By having small birthing wards and clean conditions, deaths from puerperal fever dramatically dropped in her facilities. She published the results in Notes on Lying-In Hospitals, 1871.

That project on maternal health care appeared to be the end of her active career which had spanned only 20 yrs: from Kaiserwerth 1851 to utter failure in Scutari to hospital designs and nursing training 1871 when she was 51, but what an action-packed 20 years that had been. Her reforms, which WERE profound, came after the Crimea debacle. They struck at the roots of public health, dealing with hospitals, care of soldiers, infant care & psychiatric centres, culminating in the founding of District Nursing. And her writings analysing health care all remain. She wrote on Indian issues for 40+ years.

Nightingale helped to turn nursing into a respectable profession for capable, middle class, Protestant women. Arguably her training school was one of her greatest contributions to medicine. Although she was sometimes ahead of her time, she was sufficiently part in her culture to have very Victorian views and behaviours.

Battling medical obstinacy would make anyone seek allies, as the primary method of achieving reform, even Florence Nightingale. The trouble was that no-one lived up to her hopes; everyone eventually let her down. Even the cleverest people were not as focused or analytical or committed as she was. Nurses who married, and therefore HAD to leave nursing, were traitors to Nightingale and to the profession. Politicians who took up other issues were unreliable. She must have been a tough person to live with.

The end came in Aug 1910 when she died at 90.

23 comments:

Xenophon said...

Great text about Florence Nightingale. With all this patriotic/heroic stuff it's often forgotten that sickness caused much more deaths than battles.

Hermes said...

Not one of my heroes much prefer Mary Seacole. Florence often regarded herself as a male and had ambivalent attitudes to women. Not sure her success was really so great or all her own work.

Hels said...

Xenophon,

agreed. The details of germ theory weren't finalised until the 1860s by people like Ignaz Semmelweis, John Snow, Louis Pasteur, Robert Koch, Joseph Lister and others. This was too late for the Crimean War of the 1850s.

But it strikes me as willful ignorance not to recognise the catastrophic effects of poor ventilation, poor food, fetid beds and clothes, overcrowding and a putrid sewer in the centre of the hospital ward.

If a soldier was shot in the Crimean War, he would have done better being left to lie in the open field, rather than being taken to the Barrack Hospital in Scutari.

Hels said...

Hermes

her success was great alright, but it did not start until _after_ she had returned from the Crimea to Britain. The stuff about sainted lady with the lamp, silently passing through the Crimean wards filled with wounded 18 year boys and saving their lives, was always total nonsense.

Nightingale's post-war depression back in Britain didn't start _until_ she realised what a disservice the hospital had done to the young soldiers. She eventually understood her own stats and took to her bed. Permanently.

Joseph said...

There is a small Florence Nightingale museum in the Barracks Hospital in Scutari. The tower has her private room, a bit of furniture, relics from the war, clothes and photos.

The best way to get there was via a ferry across the Bosporus Strait to Uskudar on the other side.

ChrisJ said...

I'm always amazed at just how much she could accomplish before sepsis was fully understood.

When women were "encouraged" to give birth in hospitals, the death rate soared from puerperal fever. The doctors wanted to control the birthing process, but didn't make the connection for several years -willful ignorance and the need to control!

Hels said...

Joseph
thank you. I also should have mentioned The Florence Nightingale Museum which can be visited at St Thomas' Hospital, London.

Hels said...

Chris
you are a woman after my own heart.

By the 1790s puerperal fever was suggested as the cause of much maternal mortality. By the 1840s well-read doctors KNEW that puerperal fever could easily be carried from woman to woman by the medical staff. Avoiding autopsies and thorough hand washing by the medical staff could have greatly cut down on the spread of puerperal fever in labouring women.

It is horrible that deaths in childbirth were continuing after the 1840s. Yet a training school for midwives was not founded at King's College Hospital London until 1861! Certainly deaths from puerperal fever dramatically dropped in her facilities.

But why did it take so long before all medical staff took normal cleanliness precautions? Did they not care about their patients? Did they care about normal patients but found labouring women immoral, because of the connection with sex?

Hermes said...

Another fascinating discussion. Can I throw in the name of Ignaz Semmelweis, nearly forgotten now, but who tried to change things.

Hels said...

Hermes

absolutely agreed. In my answer to Xenophon, I put Semmelweis in the first position.

Semmelweis was treated pretty badly by his fellow doctors who presumably feared he was criticising them for spreading puerperal fever. Noone likes a whistle blower, especially powerful people like male doctors.

Enzie Shahmiri * Portrait Artist said...

I think in a world dominated by men, this woman accomplished a great deal.
Fascinating to learn about her.

Hels said...

Enzie,
Florence accomplished two lifetimes worth full of successes, but in the face of enormous male opposition. Naturally :(

She would have been defeated, if it wasn't for her own total persistence and the heroic support of Sidney Herbert Secretary at War; the Royal Victoria Hospital Netley; politician and relative Richard Monckton Milnes 1st Baron Houghton; government statistician William Farr and others.

Hels said...

I had imagined that it was very difficult to get "decent" women to go to Crimea to nurse; that the only women who volunteered readily were Catholic nuns (used to caring for the sick) and prostitutes (desperate for money and for accessibility to young soldiers).

But the National Archives in Kew have letters of application from many other women who were keen to nurse in Crimea: soldiers wives, lady volunteers and private nurse-housekeepers. Apparently there were more women wanting to go than there were spaces available.

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Hels said...

Hey Max
thanks for popping in.

The Florence Nightingale story has always been fantastic.. it is just a shame that the legends normally end in Crimea.

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Hels said...

Readers might be interested in an article called 15 Florence Nightingale Facts Every Nurse Should Know. I don't agree with every single detail, but it is very interesting that there was a connection between a] this nurse with the British army in the Crimean War and b] American hospitals in their Civil War.

http://www.nursingschools.net/blog/2011/05/15-florence-nightingale-facts-every-nurse-should-know/comment-page-1/#comment-16654

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Stashworth said...

The Lady with the Lamp idea is not all untrue, but to a great extent exaggerated, and it is true that there were many failures in the Crimea. However, I feel that the accomplishments made are to easily downplayed in this article, and many accomplishments are left out. I think more can be said for the woman who Henry Dunant, the founder of the Red Cross and Geneva Convention, said deserved more credit than he did. Instead of direct nursing, the majority of her time in the Crimea was spent as an administrator, seeking to reform the systems that provided the troops with medical supplies, housing and food. She was sent with full authority by the secretary of war, but due to mistrust and bureaucratic red tape improvement and some poor wording in her job description by Secretary of War, any improvement in conditions she made were incredibly difficult to achieve and were often overturned shortly afterward. Some things she accomplished in the Crimea: the provisioning of clean bedding and clothing; complete and frequent cleaning of the hospital facilities; succeeded getting the government to send an investigative committee to the Crimea to inspect the conditions, which resulted in the cleaning of the sewers and water supply of the hospital; initiating and overseeing the refurbishing of a fire damaged hospital wing when more room was needed; succeeded in having the British govt to increase the daily pay of a sick soldier to that of active duty soldiers; provided secure methods for the troops to send funds back to family members; provided separate areas for surgery, when they were previously done amongst the other sick; used her own funding to provided trained cooks. One of the non-medical but profound changes that happened was in the change in how the upper military viewed the common foot soldier. Crimea was not her first experience in nursing or administration nor her last, she was consulted by the govt until her death, she helped found numerous schools among many things helped instigate research that showed that women had higher mortality and infant mortality in hospitals than at home. Due to this research she coordinated with a university (King's I believe...) and started a school for midwives. She often butted heads with women not because she thought herself a man, but because in her opinion the majority of women interested in nursing either did not care for the disciplined study aspect or they considered the soothing and attending to the spiritual wellbeing of patients to be more important that practical medical help.

Hels said...

Stashworth,

thank you for that detailed and thoughtful response. I agree with everything you said from the time she returned home from Crimea and started the second part of her career.

But I cannot find any evidence of soldiers' physical health being improved by being in Nightingale's ward _during_ the war. Yes she eventually succeeded in getting the government to establish an investigative committee to the Crimea to inspect the conditions. But during the war itself, they had no idea that they were killing more soldiers than the bullets killed. Thankfully her relentless pushing in time led to much healthier wards.

Florence said...

I am named after this lady, Florence Nightingale. Now I know, having a name of FLORENCE is having a great responsibility to my fellowmen, to those in need especially the sick... Hope to follow her good deeds!

Hels said...

Florence

I wish you well in your life goal :) You will have to become skilled at statistics, have a fine eye for hospital design, understand professional nursing education, develop successful public health campaigns, publish widely and be committed to top quality community health services :)