The Age of Hospital Reform
Ignaz SemmelweisAsepsis is today very well understood. During the days before Lister, the reasons for why patients died of infection were not fully understood. The risk of death especially as a result of surgery was greatly increased by the lack of understanding of infection and what caused it.
Cleanliness although encouraged, i.e. the floor of the ward should be clean and the beds tidy, it was a sad fact that the surgeon was the more likely spreader of disease. He was more than likely to wash his hands after the operation than before it.
The clothes and aprons worn by surgeons during operations were, to quote a source, “stiff and stinking with Pus and blood” In those day's sawdust was used for soaking up the blood on the floor.
Asepsis, Clean practise and infection control with doctors and other staff, in wards and operating rooms was a world problem and was only really addressed by people such as Florence Nightingale, Joseph Lister and a Hungarian Doctor by the name of Ignaz Semmelweis.
This Hungarian obstetrician, discovered how to prevent puerperal fever from being transmitted to mothers, thus introducing antiseptic prophylaxis into medicine.
Born in Buda and educated at the universities of Pest and Vienna, Semmelweis became assistant professor in the maternity ward of the Vienna general hospital. 1
In the 1840s puerperal, or child bed fever, a bacterial infection of the female genital tract after childbirth, was taking the lives of up to 30% of the women giving birth in lying-in wards, whereas most women who gave birth at home remained relatively unaffected.
Semmelweis noticed that women who were examined by student doctors who had not washed their hands after leaving the Post Mortem room, had much higher mortality rates.
When a colleague who had received a scalpel cut died from infection, Semmelweis concluded that the puerperal fever was septic and contagious.
By ordering students to wash their hands with chlorinated lime before examining patients, he reduced the maternal mortality rate from 12.24% to 1.27% in two years.
Semmelweis nevertheless encountered strong opposition from hospital officials, and because of his political activity as well, he left Vienna in 1850 for the University of Pest, where he became professor of obstetrics at the university hospital.
In spite of his enforcing antiseptic practices and reducing the mortality rate from puerperal fever to 0.85%, Semmelweis findings and publications were resisted by hospital and medical authorities in Hungary and abroad. After suffering a breakdown, he went to a mental hospital in Vienna, where he died ironically of blood poisoning from an infection contracted during an operation he had performed earlier. 2
The basic principle of hygiene was summed up by this man. “Wash your Hands! As Hygiene is two thirds of health".
Florence Nightingale 1820-1910
"The Lady with The Lamp"
In history, very few notable women have influenced the society they lived in. Eve in Genesis was the first to radically influence the world as her giving in to temptation introduced man to death. There is Helen of Troy, this Spartan woman was said to have been responsible for a ten-year war.
You could also name Mary mother of Jesus or the great Queens such as Elizabeth I, Victoria or Catherine the Great of Russia.
Florence Nightingale was a woman that was to change the face of the hospital environment and patient care radically.
In the mid-19th century, women were to be seen and not heard, especially when their voice was political, or contradicted the established view.
The reformers of the 19th century was in most part men (how many influenced by women is unknown). A typical example was the slave trade reformer William Wilberforce who happened to be a close friend of Miss Nightingales father and mother, who was herself a very active supporter of the slavery abolition campaign.
In hospitals, the administration of most tasks was undertaken by men, mostly doctors, whose authority was never or rarely challenged. Nurses had been around for centuries, so did not result from the appearance of Florence Nightingale. In the 17th century they were being paid 4 shillings a week.
Florence Nightingale was born on 12th May 1820 of wealthy parents in the Villa La Columbia, Florence Italy.
As a young lady she was determined to be a nurse, against the wishes of her parents.
She was extremely well educated and had influential friends in high places. Lord Palmerstone, who was the Prime Minister during the Crimean War, was a close friend of the Nightingale family; his estate in Hampshire adjoined theirs.
The Crimean war broke out in March 1854, and initially all the country was behind the government’s decision to deploy the troops to battle.
This was the time that the press was becoming more and more proactive, sending reporters on deployments, the Times Newspaper sent one such reporter to the war zone. The reports that were sent back by Irishman William Russell, the Times reporter, shocked the country as a whole, public opinion started to turn away from supporting the government, to one of horror, distress and sheer anger because of the lack of support being given to the troops, especially the wounded located at Scutari Hospital.
The cause of this war was a dispute between Russia and France over the Palestinian holy places. Challenging the claim of Russia to guardianship of the holy places, France in 1852 secured from Sultan Abd al-Majid certain privileges for the Latin churches. Russian counter demands were turned down by the powerful Ottoman government.
In July 1853, in sharp retort, Russia occupied the Ottoman vassal states of Moldavia and Walachia, and in October, after futile negotiations, the Ottomans declared war.
In 1854, Britain and France, having already dispatched fleets to the Black Sea, declared war on Russia; Sardinia followed suit in 1855.
In Sept. 1854, allied troops landed in the Crimea, with the object of capturing Sevastopol. The Russian fortress, defended by Totleben, resisted heroically until Sept., 1855.3
So, this was the first real intervention of the press in the affairs of the war office, this organisation was used to having complete control over its affairs and used to covering up the ghastly errors that were often caused by bad leadership or organisation.
It was after William Russell famously wrote in the Times in September 1854 appealing to women to volunteer to help the wounded. Russel wrote:"Are there no devoted women amongst us, able and willing to go forth to minister to the sick and suffering soldiers of the east in the hospitals in Scutari? Are none of the daughters of England, at this extreme hour of need, ready for such work of mercy? Must we fall far below the French in self-sacrifice and devoutness." 4
This article was the light that opened the eyes of all those back in Great Britain of the appalling nature of war and also the seemingly lack of concern by the Government about the plight of the wounded in faraway Crimea.
Sir Sidney Herbert, the Secretary of War, was forced to make a decision to try to improve conditions at Scutari Hospital.
He knew Florence as he was a family friend of the Nightingales and more importantly knew of Florence’s Nightingales expertise as a nurse and organiser.
So, he contacted her and requested that she go to the Crimea to help the sick and wounded of the war. She accepted without hesitation. The decision to send her was in November 1854.
Herbert was forced to resign in February 1855, because of the mess that the Government had got them self into over the Crimea but remained an active promoter of military reform until his early death.
Nightingale was given the title: "Superintendent of the female nurses", and was at first funded to enlist a group of 20 nurses. She preceded to Scutari hospital, which was just outside Constantinople, now a part of Turkey.
There was opposition to this deployment especially from the Military, as the deployment of women nurses had been tried before. These women however were untrained and were from the lower classes. Some were not interested in the needs of the injured or sick soldier. Most of them drank too much and caused more problems than they solved.
Her arrival at Scutari was the day before the battle of Inkerman.
The hospital facility at Scutari was overcrowded and was classed as a 3,758 bedded hospital. It was infested with vermin and was filthy, the mortality rate was high. Deaths were due to cholera, wound sepsis, dysentery and “Crimea fever”.
How Florence Nightingale and her team dealt with the situation at Scutari is legendary. It was said of her that: "Her gift was her power to dominate, which lifted her from out the ranks of those who are only 'able' to the highest reached by those who are great".5
Florence Nightingale's nurses were off duty at 8pm and male orderlies took over for the night. Only Florence Nightingale ventured onto the wards after 8pm. The picture of the lady with the lamp is familiar to most people around the world.
Nightingale and her nurses brought down the mortality rate to below 4% from its original 40% plus.
The lessons learned from the Crimean war went on to influence the military’s medical service, which from then on incorporated a nurse led service on the wards to look after post-op and medical patients. However, although the majority view of Nightingales role was that it was overstated, the results are what matter, Florence Nightingale had set in motion with the rest of the nurses, a system of patient care that obtained excellent results.
The reason why nurses in the three services were commissioned, is a legacy of the original Florence Nightingale nurses, these nurses were all members of the gentry and it seemed appropriate at the time to commission these "Lady" nurses so as they would not have to mix with the other ranks.
This tradition has in part carried on until now where nurses can apply for a nursing commission.
Florence Nightingale went on to write papers about the sanitary state of not only the British army’s medical facilities and hospitals but also those within what we now call the NHS.
She died in 1910, but her legacy lives on. "I think one's feelings waste themselves in words; they ought all to be distilled into actions which bring results." 6
Nightingale taught her nurses the most important practical lesson that can be given, is to teach them what to observe - how to observe - what symptoms indicate improvement - what the reverse - which are of importance - which are of none - which are the evidence of neglect - and of what kind of neglect.
A final quote from this lady: "I have lived and slept in the same bed with English countesses and Prussian farm women... no woman has excited passions among women more than I have." 6
Mary StanleyMary Stanley was the daughter of the Bishop of Norwich, Edward Stanley and the sister of Arthur Stanley who was the Dean of Westminster.
She also grew up being a close friend of Florence Nightingale also Sidney and Elisabeth Herbert.
She was an ardent believer in the writings of Edward Bouverie Pusey, an Anglican reformer prior to her deployment, but was converted to the Roman Church during her service in Turkey in 1855.
Mary Stanley shared Florence Nightingale's interest in nursing, but, unlike Florence Nightingale, was an ardent advocate of the Kaiserswerth plan
with its emphasis on the instruction of nurses in the art of administering religious comfort to patients. Kaiserswerth is in Germany and is a hospital that even Florence Nightingale had on her list of places to visit, because of its reputation for excellence in nurse training.
"I was sick, and you visited me" -- and "Whoever receives one such child in my name receives me" Mat Chp 18+35-- these Gospel texts were the impulse for Theodor Fliedner, pastor of Kaiserwerth, and his wife, Friederike, to confront the dire needs of their time. She was encouraged by Cardinal Manning to lead a second party of Catholic nurses to the Crimea.
She and the other ladies were selected by Mrs Catherine Gladstone, Mrs Elizabeth Herbert and Lady Canning to be sent out to the Crimea's theatre of war after Nightingales initial deployment.
Florence Nightingale bitterly opposed this deployment and thus the feud between the two began soon after she and her other nurses arrived at Constantinople.
She was an uncompromising critic of Nightingale and the other ladies whom she felt were not physically and socially equipped for the work they endeavoured to do.(In effect what she was saying that they were snobs.)
Following is a portion of a letter written by Mary Stanley to the future Prime Ministers wife : "My Dear Mrs. Gladstone, I have had such a press of work I have never been able as I wished to write to you again. I have written at great length to Mrs. Herbert today as to the state of things here.
I am so afraid they may not understand it or be vexed with me. All I hope is that Mrs. H. will remember that I came out loving Florence [Nightingale] as much as she did and that I was long and loathe to believe she was not as great as I believed her to be.
If you knew what it was to me to hear everyone complaining of her and to feel that the blessing given by the nurses is so immense, and that so few comparatively enjoy it.
Miss Emily Anderson has been for a fortnight at the General Hospital, but she has sent in her resignation for she felt she could not work with Florence.
Miss Tebbutt has I believe written to you. She, I think, will wish to go home, she is so miserable.
The hardships are so useless, for it would be a half drop in the ocean that would make them comfortable and they feel that the work they are allowed to do is so very small compared with what might be done, or what they could do at home. The Irish nurses feel this especially.
My position here is a wretched one, for I do not know who to trust. It seems so heartless to act against the friend of many years, in concert with a new acquaintance of power and authority, but what can I do. My whole judgement is against Florence's view. For a long time, I hoped to be convinced she was right, but that hope is now over.” 7
It is a fact though that Florence Nightingale was a high-class snob and spoke down to medical officers and nurses of a lesser class or different nationality.
On Mary's return from the Crimea she continued with her charitable work, setting up savings clubs, an industrial laundry and creating employment for soldiers' wives in the production of army uniforms.
In 1861, during the "cotton famine" in Lancashire caused by the American Civil War, she assisted Elizabeth Gaskell to distribute aid to the unemployed cotton workers. She died in 1879 at the age of 66.
Mary SeacoleMary Seacole was born on the Island of Jamaica and christened Mary Jane Grant. She had a Creole Mother and a Scottish father, who was it believed to be an army officer.
She was taught herbal medicine and nursing from an early age.
She travelled to London in 1836 and met and married Edwin Horatio Seacole and godson of Admiral Lord Nelson.
Her husband died years later, and Mary returned to the Caribbean to assist her mother who was a herbalist and also ran a boarding house.
In 1854 after reading the Times, and it's plea for nurses, she returned to England and offered her services, and after being rejected by Nightingale (some suggest because of race reasons), she funded her own passage to the Crimea.
Mary Seacole arrived in the Crimea in February of 1855 and set up with the help of Thomas Day who was a friend of her late husband a hotel inbetween Balaclava and Sevastopol. She was interviewed by Florence Nightingale in Scutari, but Nightingale did not take her on as a nurse.
Mary Seacole was a very determined woman and decided to treat the sick and wounded where she could find them and in between seeing to the sick and wounded, she sold some of her herbal remedies to help finance her own cost of living.
She worked tirelessly tending the sick and wounded and obtained recognition for her work by the hundreds of troops she treated.
It is a sad fact that she hardly received any recognition during her time in the Crimea, except of course from the sick and injured who described her as a wonderful woman. She lifted their spirits.
Mary Seacole died in London on 14 May 1881 and was buried at her own request in St Mary’s Catholic cemetery at Kensal Green.
She was mourned as a British heroine, then promptly forgotten, surely in part because her colour and defiant self-possession forbade her from becoming a fashionable role model for Britain’s young ladies.
What the gentry at the time displayed was racism, but today we can fully highlight her contribution not only to nursing, but to the morale she bolstered in the sick and wounded troops at Crimea.
Salman Rushdie says:“See, here is Mary Seacole, who did as much in the Crimea as another magic-lamping lady, but being dark, could scare be seen for the flame of Florence's candle .” 8
William Russell wrote in the Preface of her autobiography and I will quote part of that:"She is no Anna Commena, who presents us a verbose history, but a plain truth-speaking woman, who has lived an adventurous life amid scenes which have never yet found a historian among the actors on the stage where they passed. I have witnessed her devotion and her courage; i have already borne testimony to her services to all who needed them. She is the first who has redeemed the name of "sutler" from the suspicion of worthlessness, mercenary baseness, and plunder; and I trust that England will not forget one who nursed the sick, who sought out her wounded to aid and succour them, and who performed the last offices for some of her illustrious dead."8
She said of herself: “I am a Creole and have good Scotch blood coursing through my veins. Many people have traced to my Scottish blood that energy and activity which are not always found in the Creole race, and which have carried me to so many various scenes: and perhaps they are right.
I have a few shades of deeper brown upon my skin which shows me related to those poor mortals you once held enslaved, and whose bodies America still owns.
Having this bond, and knowing what slavery is, having seen with my eyes and heard with my ears proof positive enough of its horrors, is it surprising that I should be somewhat impatient of the airs of superiority which many Americans have endeavoured to assume over me."
Clarissa Harlowe Barton 1821-1912The American comparable to Florence Nightingale was Clarissa Barton, or Clara, as she wished to be called.
She was born on Christmas Day 1821 and she is one of the most honoured women in American history for being a true pioneer as well as an outstanding humanitarian. As a pioneer, she began teaching school at a time when most teachers were men. She was among the first women to gain employment in the federal government.
When the Civil War broke out, she was one of the first volunteers to appear at the Washington Infirmary to care for wounded soldiers. Then, at age 60, she founded the American Red Cross in 1881 and led it for the next 23 years.
She risked her life when she was nearly 40 years old to bring supplies and support to soldiers in the field during the Civil War.
Her understanding of the needs of people in distress and the ways in which she could provide help to them guided her throughout her life.
She said, “I may be compelled to face danger, but never fear it, and while our soldiers can stand and fight, I can stand and feed and nurse them.”
By the force of her personal example, she opened paths to the new field of volunteer service. Her intense devotion to the aim of serving others resulted in enough achievements to fill several ordinary lifetimes. 9
"The world is put back by the death of everyone who has to sacrifice the development of his or her peculiar gifts to conventionality." 6
Sir John HallSir John Hall was Head of Medical Services during the Crimean War (1854-1856).
John Hall, soon to be created K.C.B. was a bitter, influential, hard and self-satisfied man who had felt himself entitled to a more important post than that of head of the medical staff of the Expeditionary Army.
Lord Raglan could neither like nor respect him, and soon after the army came to Balaclava he was sent back to Scutari to report on the base hospitals there.
Miss Nightingale had not yet arrived, and they were, as she subsequently discovered, "destitute and filthy". Dr Hall reported them as having been put "on a very creditable footing". Nothing, he said, was lacking. 10
He is not the surgeon you would like to meet today, in his letters, which record his correspondence during the 1840s and 1850s, he is quoted to saying: “I like my patients to feel the smart of the knife”.
True to type, Sir John was hostile to anaesthetics. He warned his medical officers against using chloroform, even in cases of severe gunshot wounds:
“However barbarous it may appear, the smart of the knife is a powerful stimulant; and it is better to hear a man bawl lustily, than to see him sink silently into the grave.” 11
Of particular note are his battles of control with Nightingale, who he referred to as the “petticoat imperium”. Writing to his superiors he defends the army medical services from her criticisms and pulls no punches in accusing her of arrogance and being an interfering busy body desperate for power.
He stated that her intervention deprived the army of perfectly good nurses who were working before her arrival.
On the other side Nightingale called his award of the K.C.B.,“Knight of the Crimean Burial grounds".
He did however have a great deal of respect for Mary Seacole who he viewed as a help and not a hindrance.
The fact of the matter was that Mary Seacole was a volunteer and was only allowed to enter the premises on his invite, so she had to be diplomatic as opposed to Nightingale who was not.
Sir John Hall died shortly after the war; he had a distinguished career starting his military life days after Wellington defeated Napoleon at Waterloo.
He ended up as Surgeon General at a time when there were a lot of changes and the introduction of anaesthesia and asepsis meant that all things surgical had to change, he sounded however like an old dog unwilling to learn new tricks.
"Miss Nightingale shows an ambitious struggling after power inimical to the true interests of the medical department."
Hall wrote of Florence Nightingale if not resisted, he wrote , “she will, with the influence she has at present at home, throw us completely into the shade in the future, as we are at present overlooked in all that is good and beneficial regarding our hospital arrangements, which are ascribed utterly to her presiding genius by great part of the press and her own itinerant eulogistic orators.”
Nicolai Ivanivich Pirogoff (1810-1881)His opposite on the Russian side during the Crimean war was Nicolai Ivanivich Pirogoff, quoted by some as one of the greatest figures in Russian Medical history.
In September 1854, when thousands of the wounded died in Sevastopol Pirogov forwarded a petition to send him to the theatre of the war. With a group of other medical doctors, Pirogov arrived at Sevastopol in winter 1854.
His work in Sevastopol saved many lives. During the siege of Sevastopol, he introduced the mass use of anaesthetic in surgical operations on the front line.
Pirogov organized medical aid and developed the basic principles of field surgery. The first to use plaster casts, he conceived the technique in 1851 while observing the work of a sculptor it became standard practise not only for the Russian Army, but all others. (This date is disputed as that would make him the official discoverer over Antonius Mathijssen who claimed that honour one year later.)
His experience in field surgery published in German in 1864 became a standard reference that would be used for many years thereafter. 12 He was to coin the phrase "War is traumatic epidemic".
His roles were similar in the way with Duchess Helena Pavlovna he introduced nurses to the war zone to look after the wounded. He said, “The first wealth is health.”
He still remembered today, in Russia, Bulgaria, Ukraine and Estonia many hospitals, medical universities, streets are named in honour of Nikolai Ivanivich Pirogov.
2 Antiseptic Principle Of The Practice Of Surgery, 1867 Joseph Lister
4 The Times Newspaper Sept 1854 William Russell
5 The Times Newspaper Sept 1855 William Russell
6 Florence Nightingale
7 https://pdfs.semanticscholar.org/dc82/acc8e12678118973179049a32bc9b117a709.pdf J.O Baylen
8 Wonderful Adventures of Mrs Seacole in Mary Lands