II
The state of the hospitals when Miss Nightingale arrived requires some description, which, however, need not be long. The treatment of the sick and wounded during the Crimean War was the subject of Departmental Inquiries, Select Committees, and Royal Commissions, which, when they had finished sitting upon the hospitals, began sitting upon each other. Enormous piles of Blue-books were accumulated, and in the course of my work I have disturbed much dust upon them. The conduct of every department and every individual concerned was the subject of charge, answer, and countercharge innumerable. Each generation deserves, no doubt, the records of mal-administration which it gets; but one generation need not be punished by having to examine in detail the records of another. Some of the details of the Crimean muddle will indeed necessarily be disinterred in the course of our story; but all that need here be collected from the heaps aforesaid are three general conclusions.
The reader must remember, in the first place, that, apart from controverted particulars, it was made abundantly manifest that there was gross neglect in the service of the sick and wounded. The conflict of testimony is readily intelligible. It was easy to give an account based upon the facts of one hospital or of one time which was not applicable to another. At Scutari, for instance, the General Hospital was from the first better ordered than the Barrack Hospital. Then, again, different witnesses had different standards of what was “good” in War Hospitals; to some, anything was good if it was no worse than the standard of the Peninsular War. Of Sir George Brown, who commanded the Light Division in the Crimea, it was said: “As he was thrown into a cart on some straw when shot through the legs in Spain, he thinks the same conveyances admirable now, and hates ambulances as the invention of the Evil One.”[87] Miss Nightingale had much indignant sarcasm for those who seemed content that the soldier in hospital should be placed in the condition of “former wars,” instead of perceiving that he “should be treated with that degree of decency and humanity which the improved feeling of the nineteenth century demands.” But the principal reason for the conflict of testimony was that the very facts of protest and inquiry put all the officials concerned upon the defensive. Any suggestion of default or defect was resented as a personal imputation. There is a curious illustration in the letter which the Head of the Army Medical Department wrote to his Principal Medical Officer in view of the Roebuck Committee. “I beg you to supply me, and that immediately”—with what? with the truth, the whole truth, and nothing but the truth? No—“with every kind of information which you may deem likely to enable me to establish a character for it [the Department], which the public appear desirous to prove that it does not possess.”[88] But though there was much conflict of evidence, the final verdict was decisive. What Greville wrote in his Journal—“the accounts published in the Times turn out to be true”—was established by official inquiry and admitted by Ministers. In consequence of the indictment in the Times, a Commission of Inquiry was dispatched to the East by the Secretary of State. The Commission arrived at Constantinople simultaneously with Miss Nightingale, and four months later it reported to the Duke of Newcastle.[89] I need not trouble the reader here with many particulars of its Report; for they were adopted and confirmed by a Select Committee of the House of Commons a few months later (the famous “Roebuck Committee”), which pronounced succinct sentence that “the state of the hospitals was disgraceful.” The ships which brought the sick and wounded from the Crimea were painfully ill-equipped. The voyage from Balaclava to Scutari usually took eight days and a half. During the first four months of the war, there died on a voyage, no longer than from Tynemouth to London, 74 out of every 1000 embarked. The landing arrangements added to the men's sufferings. To an unpractised eye the buildings used as hospitals at Scutari were imposing and convenient; and this fact accounts for some of the rose-coloured descriptions by which persons in high places were for a time misled. Even the Principal Medical Officer on the spot was naïvely content with whitewash as a preparation to fit the Barrack for use as a hospital. In fact, however, the buildings were pest-houses. Underneath the great structures “were sewers of the worst possible construction, loaded with filth, mere cesspools, in fact, through which the wind blew sewer air up the pipes of numerous open privies into the corridors and wards where the sick were lying.”[90] There was also frightful overcrowding. For many months the space for each patient was one-fourth of what it ought to have been. And there was no proper ventilation. “It is impossible,” Miss Nightingale told the Royal Commission of 1857, “to describe the state of the atmosphere of the Barrack Hospital at night. I have been well acquainted with the dwellings of the worst parts of most of the great cities in Europe, but have never been in any atmosphere which I could compare with it.” Lastly, hospital comforts, and even many hospital necessaries, were deficient.[91] The supply of bedsteads was inadequate. The commonest utensils, for decency as well as for comfort, were lacking. The sheets, said Miss Nightingale, “were of canvas, and so coarse that the wounded men begged to be left in their blankets. It was indeed impossible to put men in such a state of emaciation into those sheets. There was no bedroom furniture of any kind, and only empty beer or wine bottles for candlesticks.” Necessary surgical and medical appliances were often either wanting or not forthcoming. There was no machinery, until Miss Nightingale came, for providing any hospital delicacies. The result of this state of things upon patients arriving after a painful voyage in an extreme state of weakness and emaciation, from wounds, from frost-bite, from dysentery, may be imagined, and it is no wonder that cholera and typhus were rife. In February 1855 the mortality per cent of the cases treated was forty-two. No words are necessary to emphasize so terrible a figure.
Mr. Herbert had not waited for the reports of Commission and Committee to reach the conclusion that things were wrong:—
“I have for some time,” he wrote on December 14, 1854, to the Commandant at Scutari, “been very anxious and very much dissatisfied as to the state of the hospital. I believe that every effort has been made by the medical men, and I hear that you have been indefatigable in the conduct of the immediate business of your department. But there has been evidently a want of co-operation between departments, and a fear of responsibility or timidity, arising from an entire misconception of the wishes of the Government. No expense has been spared at home, and immense stores are sent out, but they are not forthcoming. Some are at Varna, and for some inexplicable reason they are not brought down to Scutari. When stores are in the hospital, they are not issued without forms so cumbrous as to make the issue unavailing through delay. The Purveyor's staff is said to be insufficient. The Commissariat staff is said to be insufficient, your own staff is said to be insufficient,” etc.
By admission, then, and by official sentence, there were things amiss at Scutari which urgently called for amendment. This is the first general conclusion which has to be remembered in relation to Miss Nightingale's work.
To what individuals the disgrace of “a disgraceful state of things” attached, it is happily no concern of ours here to inquire. But as I have called Mr. Sidney Herbert as a witness to the fact of the disgrace, I must add my conviction that his own part in the business was wholly beneficent. Some research among the documents entitles me, perhaps, to express entire agreement with Mr. Kinglake's remark upon “what might have been if the Government, instead of appointing a Commission of enquiry on the 23rd of October, had then delegated Mr. Sidney Herbert to go out for a month to the Bosphorus, and there dictate immediate action.” At home, Mr. Herbert was a good man struggling in the toils. The fact is that, though there were some individuals palpably to blame, the real fault was everybody's or nobody's. It was the fault of a vicious system, or rather the vice was that there was no system at all, no co-ordination, but only division of responsibility. The remarks of Mr. Herbert, just quoted, point to the evil, and on every page of the Blue-books it is written large. There were at least eight authorities, working independently of each other, whose co-operation was yet necessary to get anything well done. There was the Secretary of State; there was the War Office (under the Secretary-at-War); there were the Horse Guards, the Ordnance, the Victualling Office, the Transport Office, the Army Medical Department, and the Treasury. The Director-General of the Medical Department in London told the Roebuck Committee that he was under five distinct masters—the Commander-in-Chief, the Secretary of State, the Secretary-at-War, the Master-General of Ordnance, and the Board of Ordnance. The Secretary of State said that he had issued no instructions as to the hospitals; he had left that to the Medical Board. But the Medical Director-General said that it would have been impertinent for him to take the first step.[92] If I were writing the history of the Crimean War, or of the Government Offices, other fundamental reasons for the disgraceful state of things in the hospitals—notably the miscalculated plan of military campaign—would have to be taken into account; but I am writing only the life of Miss Nightingale, and all that under this head the reader need be asked to bear in mind is this: That the root of the evils which had to be dealt with was division of responsibility, and reluctance to assume it.
The third conclusion of the official inquiries, which I want to emphasize, is contained in a passage in the Roebuck Committee's Report, which prefaced a reference to Miss Nightingale's mission: “Your Committee in conclusion cannot but remark that the first real improvements in the lamentable condition of the hospitals at Scutari are to be attributed to private suggestions, private exertions, and private benevolence.”
So, then, we see that there were disgraceful evils at Scutari needing amendment, and that in order to amend them what was needed was bold initiative. This it was that Miss Nightingale supplied. The popular voice thought of her only or mainly as the gentle nurse. That, too, she was; and to her self-devotion in applying a woman's insight to a new sphere, a portion of her fame must ever be ascribed. But when men who knew all the facts spoke of her “commanding genius,”[93] it was rather of her work as an administrator that they were thinking. “They could scarcely realize without personally seeing it,” Mr. Stafford told the House of Commons, “the heartfelt gratitude of the soldiers, or the amount of misery which had been relieved” by Miss Nightingale and her nurses; and, he added, “it was impossible to do justice, not only to the kindness of heart, but to the clever judgment, the ready intelligence, and the experience displayed by the distinguished lady to whom this difficult mission had been entrusted.” These were the qualities which enabled her to reform, or to be the inspirer and instigator of reforms in, the British system of military hospitals. She began her work, where it lay immediately to her hand, in the Barrack Hospital at Scutari. She did the work in three ways. She applied an expert's touch and a woman's insight to a hospital hitherto managed exclusively by men. She boldly assumed responsibility, and did things herself which she could find no one else ready to do. And, thirdly, she was instant and persistent in suggestion, exhortation, reproaches, addressed to the authorities at home. It will not be possible to keep these three branches of our subject entirely distinct; but in the main they will form the topics successively of the next three chapters.
CHAPTER IV
THE EXPERT'S TOUCH
Write that, when pride of human skill
Fell prostrate with the weight of care,
And men pray'd out for some strong will,
Some reason 'mid the wild despair,—
The loving heart of Woman rose
To guide the hand and clear the eye,
Gave hope amid the sternest woes,
And saved what man had left to die.
R. M. M.: “A Monument for Scutari,”
Times, Sept. 10, 1855.
Miss Nightingale arrived at Scutari, as we have seen, on November 4, and was immediately in the midst of heavy work in nursing. The Battle of Balaclava was fought on October 25; and on the day after her arrival, the Battle of Inkerman.
“Miss N. is decidedly well received,” reported Mr. Bracebridge to Mr. Herbert (Nov. 8). A few days later, the Commander of the Forces, in a letter dated “Before Sevastopol, Nov. 13th, 1854,” bade her a hearty welcome, tendering to her a “grateful acknowledgment for thus charitably devoting yourself to those who have suffered in the service of their country, regardless of the painful scenes you may have to witness.” With some of the military officers she had difficulties; from the Commander she received nothing but courtesy, sympathy, and support.
“Miss Nightingale cannot but here recall,” she wrote after the war, “with deep gratitude and respect, the letters of support and encouragement which she received from the late Lord Raglan, who invariably acknowledged all that was attempted,[182] for the good of his men, with the deepest feeling, as well as with the high courtesy and true manliness of his character. No tinge of petty jealousy against those entrusted with any commission, public or private, connected with the Army under his command, ever alloyed his generous benevolence.”[94]
The behaviour of some (but not all) of the military officers, and of the men who caught their manners from the officers, was at first different. There was sometimes ill-disguised jealousy, and consequent sulkiness. Outwardly, there was politeness; but difficulties were put into the way of “the Bird,” as some of them called her behind her back, and she was left to shift for herself, when a little help might have eased the burden. “It is the Bird's duty,” they would say. Miss Nightingale, however, kept perfect command of her temper. “She was always calm and self-possessed,” says one of the Roman Catholic Sisters; “she was a perfect lady through everything—never overbearing. I never heard her raise her voice.”
Upon most of the medical men on the spot she made a good impression at once, because she proved herself to be efficient and helpful. She applied the expert's touch. But there were doctors and doctors. Some welcomed her and her staff, and made as much use of them as possible. Others resented their presence, and threw obstacles in their way. There was one ward in which the junior medical officers had been advised by their superior to have as little to do with Miss Nightingale as possible. She showed exemplary patience under this kind of opposition, and gradually won her way into the confidence of most of the doctors.[95] “Miss Nightingale told us,” says one of her staff, “only to attend to patients in the wards of those surgeons who wished for our services, and she charged us never to do anything for the patients without the leave of the doctors.”[96] “The number of nurses admitted into each division of a hospital depended,” Miss Nightingale herself explained, “upon the medical officer of that division, who sometimes accepted them, sometimes refused them, sometimes accepted them after they had been refused; while the duties they were permitted to perform varied according to the will of each individual medical officer.”[97] That this ill-defined state of things called constantly for tact and diplomacy on the part of the Lady Superintendent, and often for severe self-restraint, will readily be perceived.
On the first arrival of Miss Nightingale and her staff, the wounded were pouring in fast, and the nurses were told off to the worst surgical cases:—
“Comfort yourselves,” wrote Mr. Bracebridge to her parents (Nov. 20), “that what the good Flo has done and is doing is priceless, and is felt to be so by the medical men—the cleanliness of the wounds, which were horribly dirty, the general order and arrangement. There has not been half the jealousy I expected from them towards her.”
“As to Miss Nightingale and her companions,” wrote Mr. Osborne to Mr. Herbert (Nov. 15), “nothing can be said too strong in their praise; she works them wonderfully, and they are so useful that I have no hesitation in saying some 20 more of the same sort would be a very great blessing to the establishment. Her nerve is equal to her good sense; she, with one of the nurses and myself, gave efficient aid at an amputation of the thigh yesterday. She was just as cool as if she had had to do it herself.”[98]
A letter from Miss Nightingale herself to her friend of Harley Street, Dr. Bowman, the ophthalmic surgeon, gives a lively account of some of her difficulties, and a vivid picture of the horrors amid which her work was done (Nov. 14):—
“I came out, Ma'am, prepared to submit to everything, to be put upon in every way. But there are some things, Ma'am, one can't submit to. There is the Caps, Ma'am, that suits one face, and some that suits another. And if I'd known, Ma'am, about the Caps, great as was my desire to come out to nurse at Scutari, I wouldn't have come, Ma'am.”—Speech of Mrs. Lawfield.—Time must be at a discount with the man who can adjust the balance of such an important question as the above, and I for one have none: as you will easily suppose when I tell you that on Thursday last we had 1715 sick and wounded in this Hospital (among whom 120 Cholera Patients), and 650 severely wounded in the other Building called the General Hospital, of which we also have charge, when a message came to me to prepare for 510 wounded[184] on our side of the Hospital who were arriving from the dreadful affair of the 5th November from Balaklava, in which battle were 1763 wounded and 442 killed, besides 96 officers wounded and 38 killed. I always expected to end my Days as Hospital Matron, but I never expected to be Barrack Mistress. We had but half an hour's notice before they began landing the wounded. Between one and 9 o'clock we had the mattresses stuffed, sewn up, laid down—alas! only upon matting on the floor—the men washed and put to bed, and all their wounds dressed. I wish I had time. I would write you a letter dear to a surgeon's heart. I am as good as a Medical Times! But oh! you Gentlemen of England who sit at Home in all the well-earned satisfaction of your successful cases, can have little Idea from reading the newspapers of the Horror and Misery (in a Military Hospital) of operating upon these dying, exhausted men. A London Hospital is a Garden of Flowers to it.
We have had such a Sea in the Bosphorus, and the Turks, the very men for whom we are fighting, carry in our Wounded so cruelly, that they arrive in a state of Agony. One amputated Stump died 2 hours after we received him, one compound Fracture just as we were getting him into Bed—in all, twenty-four cases died on the day of landing. The Dysentery Cases have died at the rate of one in two. Then the day of operations which follows.…
We are very lucky in our Medical Heads. Two of them are brutes, and four are angels—for this is a work which makes either angels or devils of men and of women too. As for the assistants, they are all Cubs, and will, while a man is breathing his last breath under the knife, lament the “annoyance of being called up from their dinners by such a fresh influx of wounded”! But unlicked Cubs grow up into good old Bears, tho' I don't know how; for certain it is the old Bears are good. We have now four miles of Beds, and not eighteen inches apart.
We have our Quarters in one Tower of the Barrack, and all this fresh influx has been laid down between us and the Main Guard, in two Corridors, with a line of Beds down each side, just room for one person to pass between, and four wards. Yet in the midst of this appalling Horror (we are steeped up to our necks in blood) there is good, and I can truly say, like St. Peter, “It is good for us to be here”—though I doubt whether if St. Peter had been here, he would have said so. As I went my night-rounds among the newly wounded that first night, there was not one murmur, not one groan, the strictest discipline—the most absolute silence and quiet prevailed—only the steps of the Sentry—and I heard one man say, “I was dreaming of my friends at Home,” and another said, “I was thinking of them.” These[185] poor fellows bear pain and mutilation with an unshrinking heroism which is really superhuman, and die, or are cut up without a complaint.
The wounded are now lying up to our very door, and we are landing 540 more from the Andes. I take rank in the Army as Brigadier General, because 40 British females, whom I have with me, are more difficult to manage than 4000 men. Let no lady come out here who is not used to fatigue and privation.… Every ten minutes an Orderly runs, and we have to go and cram lint into the wound till a Surgeon can be sent for, and stop the Bleeding as well as we can. In all our corridor, I think we have not an average of three Limbs per man. And there are two Ships more “loading” at the Crimea with wounded—(this is our Phraseology). Then come the operations, and a melancholy, not an encouraging List is this. They are all performed in the wards—no time to move them; one poor fellow exhausted with hæmorrhage, has his leg amputated as a last hope, and dies ten minutes after the Surgeon has left him. Almost before the breath has left his body it is sewn up in its blanket, and carried away and buried the same day. We have no room for Corpses in the Wards. The Surgeons pass on to the next, an excision of the shoulder-joint, beautifully performed and going on well. Ball lodged just in the head of the joint and fracture starred all round. The next poor fellow has two Stumps for arms, and the next has lost an arm and a leg. As for the Balls they go in where they like and come out where they like and do as much harm as they can in passing. That is the only rule they have.…
I am getting a Screen now for the amputations, for when one poor fellow, who is to be amputated to-morrow sees his comrade to-day die under the knife, it makes impression and diminishes his chance. But, anyway, among these exhausted Frames, the mortality of the operations is frightful. We have Erysipelas, fever and gangrene, and the Russian wounded are the worst.
We are getting on nicely though in many ways. They were so glad to see us. The Senior Chaplain is a sensible man, which is a remarkable Providence.… If you ever see Mr. Whitfield, the House Apothecary of St. Thomas', will you tell him that the nurse he sent me, Mrs. Roberts, is worth her weight in gold.… Mrs. Drake is a Treasure. The four others are not fit to take care of themselves, but they may do better by and bye if I can convince them of the absolute necessity of discipline. We hear there was another engagement on the 8th and more wounded, who are coming down to us. This is only the beginning of things.
The Senior Chaplain had the sense, among other things, to appreciate Miss Nightingale. “The Chaplain says,” wrote Mr. Nightingale to a friend (Dec. 12), “‘Miss Nightingale is an admirable person; none of us can sufficiently admire her. A perfect lady, she wins and rules every one, the most rugged official melts before her gentle voice, and all seem glad to do her bidding.’”
Florence Nightingale had that “excellent thing in woman”: Lady Lovelace, in the poem already quoted, spoke of her friend's “soft, silvery voice”; but it could command, as well as charm, unless indeed it were the charm that commanded. “She scolds sergeants and orderlies all day long,” wrote Mr. Bracebridge to her parents (Nov. 20); “you would be astonished to see how fierce she is grown.” That was written, of course, in fun; but there was always a note of calm authority in her voice. A Crimean veteran recalled her passing his bed with some doctors, who were saying, “It can't be done,” and her replying quietly, “It must be done.” “I seem to hear her saying it,” writes one who knew her well; “there seemed to be no appeal from her quiet conclusive manner.”
With regard to the nurses, Miss Nightingale, as may be gathered from the letter to Dr. Bowman, found them rather a difficult team to drive, and this fact should be remembered in considering an episode presently to be related (II.). She had to send one nurse back to England at once, filling the vacancy by a German Sister from the Kaiserswerth colony at Constantinople. Of the six nurses supplied by St. John's House, “four, alas! returned shortly from Scutari, not being prepared to accept the discipline and privations of the life out there.”[99] We need not be too impatient with Mrs. Lawfield (who turned out an excellent nurse) for her objection to the cap. The uniform, devised on the spur of the moment, seems to have been very much less becoming than that of the “Staff Nurse, New Style,” with her “gown of silver gray, bright steel chain, and chignon's elegant array.”[100] The Nightingale nurses in the East wore “grey tweed wrappers, worsted jackets, with caps and short woollen cloaks, and a frightful scarf of brown holland, embroidered in red with the words, ‘Scutari Hospital.’”[101] Such is the description of the costume worn by the seculars which is given by one of the Roman Catholic Sisters, not without some pity as she thought of her own religious habit. But the short cloak should not be so contemptuously dismissed. “The red uniform cape worn by the ladies of the Queen Alexandra's Imperial Military Nursing Service is modelled on that originally introduced by Florence Nightingale for the nurses whom she took with her to Scutari. This cape may therefore be regarded as a memorial to the great founder of military nursing.”[102] As for the “frightful scarf” some such distinctive badge was a very necessary precaution amid the rough-and-tumble of a military depot and its camp-followers. A raw new-comer was seen to approach one of the nurses in the street. “You leave her alone,” said his mate, “don't you see she's one of Miss Nightingale's women?” Their cloth was respected throughout the camps; but Miss Nightingale had to dismiss two or three for levity of conduct. On arriving at Scutari, she had placed ten in the General Hospital and twenty-eight in the Barrack Hospital, and in neither did she find it easy to maintain discipline. From time to time she transferred nurses, sending the best to other hospitals, keeping the less trustworthy under her own eye; and sending some home, who were unwilling to stay or found incompetent, as other recruits arrived. Of the thirty-eight in the first party, she considered that not more than sixteen were really efficient, whilst five or six were in a class of excellence by themselves.
The difficulties—including the great Dress Question—which Miss Nightingale had with her staff, appear clearly enough in the “Rules and Regulations for the Nurses attached to the Military Hospitals in the East,” which Miss Nightingale presently sent home to Mr. Herbert, who had them printed, and handed to every candidate for appointment as nurse. “As it has been stated,” says the preamble, “that the nurses who have gone to the hospitals in the East, have in some instances complained of being subject to hardships and to rules for which they were not previously prepared, and of having to do work differing from what they expected, it has been thought desirable to state distinctly the regulations relative to the outfit, clothing, duties, and position of nurses in military hospitals.” The nurses, it is then set forth, “are required to appear at all times in the regulation dress with the badge, and never to wear flowers in their bonnet-caps, or ribbons, other than such as are provided for them, or are sanctioned by the superintendent.” Another rule defines the precise quantities of spirituous liquor which a nurse will be allowed; a third states that “no nurse will be allowed to walk out except with the housekeeper, or with a party of at least three nurses together, and never without leave previously obtained.” The whole code shows the necessity which Miss Nightingale had found for enforcing strict discipline.[103] And even with these new regulations to back her, she still found discipline hard to enforce. Her official letters to the War Office complain of unsuitable recruits being sent out to her, and of the greater number of them as being “wholly undisciplined.”