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  • Writer's pictureDale DeBakcsy

The Many Wars of Florence Nightingale.

Though we think of her as the Lady With the Lamp, tirelessly patrolling the sick wards of the Crimean War offering solace and healing to soldiers who had been essentially left to die, Florence Nightingale's greatest contributions came from a period in her life when illness prevented her from leaving the four walls of her modest living space.  By then arguably the most famous woman in England next to Queen Victoria herself, she could have enjoyed a life of ease and acclaim, but opted instead to drive herself, and those around her, at a health-ruining pace to compile statistics, gather reports, and write up plans of action in a grand and constantly frustrated attempt to remake the laws for how humans treat their sick.


In fact, no emotion winds its way through the tale of Nightingale's life with anything like the same evil persistence as Frustration.  Frustration with herself, with her family, with her allies, with her enemies, with bureaucracy, with women generally and high born women particularly, with Prime Ministers and Viceroys - nobody was ever quite up to scratch in Florence Nightingale's precise yet merciless estimation, and anything short of total victory had to be reckoned as abject failure.  


The origin of Nightingale's iron streak is difficult to pinpoint, born more out of opposition to her upbringing than evolving therefrom.  Her father was an affable, scholarly gentleman whose ideal was to be left alone to ponder metaphysics, while her mother and sister focused upon making their home a hub of effervescent social activity.  Florence played the role of Elizabeth Bennet in this divided household, studying foreign languages, history, and philosophy with her father, but not taking herself so seriously that she snubbed opportunities for fun (in particular a good dance) that came her way.  


She could not stand, however, wasting time in the endless rounds of housecalls and rumor-mongering letters that were the expected mainstays of her station in life, and often hoped for some occupation beyond the rigidly organized leisure that obsessed her mother and sister.  Then, in February of 1937, she received what she believed to be a direct message from the Judaeo-Christian god, a verbal communication calling her to serve him.  For a decade and a half, that moment ruined her life, making her feel suicidal levels of shame for doing anything that didn't in some way measure up to a divine level of importance and merit.  Her notes from the time, scribbled on pieces of paper she had at hand, are those of a young woman berating herself as a failure, a broken vessel unable to satisfy the needs of her family or of her divine calling, useless to all, and perhaps better off dead.


Nightingale was prone to episodes of prolonged intense daydreaming that were the shameful agony of her existence.  In the middle of conversations, for long hours over the course of a day, she would snap into a world of intense fancy that she did not have the desire or will to leave, so uninspiring were the choices around her in reality.  Were she born today, she would probably consider the God's Command episode as psychologically an extension of her intense compulsion to daydream, but as it was the nineteenth century she considered it an actual physical intervention by a three thousand year old mythological character come to offer insistent if vague career advice, and that belief dominated her mental state for the coming difficult years.  



She felt she must find some cause to prove herself in, while her family felt that it was simply rank ingratitude to hunger after anything more than the very comfortable life they provided for her.  When, in 1845, she revealed to her family that she believed nursing was where her destiny lay, her mother and sister wailed, berating her for being so selfish as to destroy the family reputation with such a lowly choice of profession.  Any subsequent mention of a desire to even visit a nursing institution to see what went on there inspired renewed outbursts, and it was not until 1850, thirteen hard, self-flagellating years after her original divine calling, that she was able to take the first practical step in what was to be her life's work.  


That was the year she was able to finally visit the Kaiserwerth Institution and both observe and participate in the nursing practices there.  It was neither a terribly clean nor well-run institution, but the nurses there were of exemplary character and devotion, a decided contrast to the reputation that nurses had earned in Europe as being low class, promiscuous drunkards who as likely as not doubled as prostitutes in their spare time.  Nightingale's mission, as it emerged in the coming years, was to re-create British nursing with the high tone of Kaiserwerth, but married to the scientific insights, as gained through rigorous statistical analysis, of modern scientific practice.  


Between such scattered incidents of up-close observation and her systematic reading of the available nursing literature, Nightingale had gained a reputation in certain circles as somebody with a rare command of the practical needs of a medical institution, and in that capacity she was called in 1853 to serve as Superintendent for the gloriously named Institution for the Care of Sick Gentlewomen in Distressed Circumstances.  The Institution thought they were hiring a gifted fellow high-class socialite who would put time in here and there, as the spirit took her.  What they got was a dynamo of reform, who saw at an instant what must be done, and what must be procured to do it, and relentlessly prodded all concerned until it was accomplished.  


She was, it turned out to the surprise of all, a born administrator, with the ability to translate large-scale needs into the series of small-scale actions necessary to meet them.  This reputation, along with her considerable knowledge of the nursing profession, led to the offer from her friend Sidney Herbert, the Secretary at War, to lead a group of nurses to Scutari to see what might be done to improve the lot of those wounded in action while carrying out the variously misguided and undersupplied actions collectively known as the Crimean War.  


She agreed, and on November 5, 1854, she and her nurses set foot in the infamous Barrack Hospital of Scutari, where they were met with open hostility by the doctors in attendance, who determined that they would not be put to use in lessening the suffering of the men strewn throughout the rooms and corridors, there to die in soiled and infested garments by the hundreds and thousands.  Three roads lay open to Nightingale - to read the room and leave, to force her way past the doctors and put her nurses to work over their will and desires, or to sit at Scutari and wait until they came to her.  Many of the nurses under her, motivated by the clear suffering of the men, wanted her to take the second option, but Nightingale knew instinctively that any attempt to force themselves upon the doctors' domain would breed nothing but resentment that would make eventual collaboration impossible.  


She decided to wait, employing her nurses in whatever tasks had not explicitly been forbidden them by the doctors, and determining the true state of the hospital's arcane provisioning system.  Sooner or later, she felt, the doctors would have to come to her, and the hospital's functioning would be helped by the spirit of cooperation, instead of hindered by one of resentment.  Eventually, of course, they did seek her out, when the sheer scale of the human disaster in the Crimea overwhelmed the capacity of the Barrack Hospital to even remotely handle.  Huge vats of diarrheal feces lay open in the halls as the only means of relief since the rudimentary lavatory system had long since clogged and ceased to function.  Vermin ran rampant through the corridors.  The walls sweated moisture and grew mold.  Food was insufficient and irregular.  Fresh clothing and bedding were available in the storehouses, but because of the British requisition system, none of it had been distributed in the hospital, so men died in the urine-and-feces stained clothes they had left the warfront in weeks before.  



Into this maelstrom of unnecessary death and disease strode Florence Nightingale.  Her efforts were hampered on all sides - by the Catholic nuns among her nurses who refused to recognize her authority, by the requisitions officers who declined to distribute warehouses' worth of goods for fear of overstepping their minutely defined authority, and by administrators who sought to hide their misconduct by smearing her name back home.  And yet, by dint of an unbreakable will that surprised even herself, she succeeded in pushing through reforms.  Out of her own funds she purchased goods and distributed them on her own authority to the wounded.  The lavatories were flushed and cleaned.  New diets were created for the various needs of her patients, and a system erected to see to its equitable distribution.  A new hospital wing was built, again on her authority, that saved untold lives in the surges of wounded and ill soldiers that followed.  Windows were opened, floors were scrubbed, clothes and sheets were changed and cleaned.  


Having set reform at the Barrack Hospital in Scutari on its way, Nightingale's next task was to put the other military hospitals connected to the Crimean conflict in order.  These were the hospitals where the nurses who had chaffed under her approach to nursing had fled, in particular the rebellious Catholic contingent under Mother Bridgeman.  The hospitals under the care of these rogue nurses were in a sad state, desperately needing organization, but Nightingale's original commission was as Superintendent of the Female Nursing Establishment of the English General Hospitals in Turkey, a fact which administrators used to argue that she had no authority over nurses in Crimean hospitals that did not happen to be in Turkey.  


As she was fighting to gain the authority to do the things that desperately needed to be done in the face of a system which desperately wanted its towering deficiencies to remain hidden, Florence Nightingale fell deathly ill with a case of Crimean fever, and for two weeks her death was believed to be immanent.  She survived, but her attempts to institute meaningful reform in the non-Turkish military hospitals foundered on bureaucratic inertia and religious rebellion until her position as General Superintendent of the nurses of all military hospitals was confirmed in 1856, thereby giving her at last the clear authority she needed to bring the other Crimean hospitals in line with her Scutari reforms.  


That cable, however, reached her in March, just one month before the end of the war, and four months before the departure of the last patient from the Scutari hospital.  She was given authority, in other words, at almost the exact moment when the only thing to do with that authority was to oversee the dismantling of the system it was meant to have created.  Nightingale returned home in late July of 1856, a hero in a conflict desperately lacking them.  She was so unreservedly beloved that she could have bent her public adulation to the task of accomplishing medical reform by leading a broad-based popular movement but again she stuck to her belief that the way to achieve reform was to work within the system.  And so began the second, and I would say even more heroic, stage of Nightingale's public career.  


These years and decades lack the tragic-romantic imagery of her Crimean work, but in terms of persistent and largely thankless self-sacrifice, there are few things in the annals of all history to match her efforts of the 1850s, 60s, and 70s.  Her physical health had been ruined by her time in the Crimea so that, as the years wore on, she was reduced entirely to a life lived between the walls of her various living spaces, sitting in bed with nothing but her ceaselessly scratching pen and steady flow of selected visitors to connect her with the outside world.  She became enamored of the raw power of statistical analysis to present arguments concisely and forcefully, and much of her life was engaged in collecting, from hospitals the world over, as much raw data as they could provide, and then pain-stakingly condensing that data into visual statistical representations the use of which she pioneered, and which were the ancestors of the charts and graphs we are exposed to in every news cycle as a matter of course today.  



She made herself the century's indispensable expert on hospital design and medical practice, whose encyclopedic command of how each reform translated, in verifiable numerical terms, into lowered mortality and illness rates, won over even the most skeptical of administrators sent to interview her.  She was asked to serve on a Royal Commission investigating the health of the Army, a task to which she applied all her organizational genius and apparently boundless inner energy.  Her problem, was, of course, her gender, which meant that, though she was the central hub of information and reform policy, she needed to rely on others to attempt to implement that policy in government, others whose efforts could never attain the heights of her expectations.  


And yet, the astounding fact is that, in spite of expending so much effort time and again in amassing data and writing lengthy proposals of reform which, time and again, disappeared down the gullet of British bureaucracy, never to be seen again, she kept trying.  When a scandal broke about the health system in India, she made it her business to send out detailed questionnaires to every medical hospital in the Raj as the first step in a massive effort to determine the relevant health statistics of the situation, making herself, a person who had never set foot in India, the world expert on Indian medical practices and their shortcomings.  She proposed a radical overhaul not only of how the British ran their hospitals in India, but of how the country was administered as a whole, encouraging the development of irrigation as a first step in improving the overall health of the land, the good effects of which would ripple through to the state of the hospitals.  Prospective viceroys came to her dwelling to sit by her bed and receive their education about the land they were due to administer, and yet, in spite of all the oaths to do better, each regime largely failed to implement the most basic of her ideas, to the detriment of millions.


Faced with frustration and vexation in her attempts to get the overall health system of the Empire to reform its worst practices, Nightingale met with better success in her secondary mission, the elevation of the nursing profession.  In 1860 she established the Nightingale Training School (still in operation) at St. Thomas's Hospital as an experiment in producing nurses of the caliber she had so desperately needed, but so rarely possessed, in the Crimea.  Prospective nurses at the school were not only to be trained using the most modern methods, but minutely observed to ensure that their character would bring credit to the nursing profession.  They were even instructed to keep a diary which was regularly submitted to Nightingale and the school authorities for review in order to ascertain the purity of their minds and instincts.  


The institution was a success, but Nightingale would forever lament, to anybody who might care to listen, the lack of qualified applicants, a fact which lay at the heart of her rather pessimistic evaluation of women as a gender.  She bemoaned the fact that her school had so many requests for qualified nurses coming in from all corners of the country, but so few people to send out to those assignments because so few qualified individuals had applied to the school.  Growing up surrounded by women who floated in seas of free time that could be profitably spent in service of others, it baffled Nightingale that so few would take the opportunity represented by her school to do some real good.  Nevertheless, the success of her students in overseeing their own hospital nursing staffs, combined with the mythic status of her time as the Lady With the Lamp, resulted in a definite shift in the perception of nurses over the course of the late nineteenth century which drove the professionalization of the career, all be it in directions Nightingale did not always support.



In the last decade of her life, following years of frustration in which she had to tend to her family's failing health while relinquishing the active reform that sustained her, she slipped at last into a more equitable appreciation of what she had accomplished in her time.  Instead of declaring that she had failed in everything she had ever attempted because she had not obtained total victory on every point, she came to see the value of the partial steps that had been taken, and the worth of the momentum she had begun.  Her last few years saw her sink into increasing blindness but also a peaceful seeming senility, much as her mother had at her life's end, not understanding entirely where she was or what was being said to her, but enjoying the pleasures of the day as they arrived until finally, on August 13, 1910, Florence Nightingale fell asleep, never to awake.  


FURTHER READING:  


Many people's first in-depth experience of Florence Nightingale's life probably came in the form of Lytton Strachey's devastating portrait in Eminent Victorians (1918) which, while admiring her good traits, primarily delighted in her less heroic ones, such as her various metaphysical obsessions.  And sure, it's a fun read because Lytton Strachey is one of history's most gifted biographical stylists, but if you want something of more balance, I'd go for Cecil Woodham-Smith's 1951 biography, which contains maybe my favorite first line of any Women in Science book.  Of course, you might want something written this century in which case Mark Bostridge's 2008 book is probably what you're looking for.  This particular piece can be found as one of the 120 medical portraits you can find in my A History of Women in Medicine and Medical Research, available now from Amazon or Pen & Sword Books!




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