Beware Bad Smells

As a student at St Thomas’s Hospital, I used to walk the long ‘Nightingale’ wards – Florence Nightingale had not only founded its school of nursing but was influential in the design of the building – and learned to avoid prayer-time because the way out was obstructed by the line of ‘Nightingales’ kneeling at the door in order of seniority. And sometimes I watched patients having ECT in Scutari – the psychiatric clinic too was named in her honour.

Most of the heroes in the history of medicine (nearly all are men) have either discovered a remedy like penicillin or insulin, or developed a vaccine to protect against killer diseases like polio or smallpox, or introduced a bold new surgical procedure like heart transplantation. But Nightingale discovered nothing. Her forte was administration, and her main weapon was statistics. Did she even stalk the wards of the Barrack Hospital at Scutari at night? Yes – but with what to light her way? Mark Bostridge is no revisionist, but he does point out that the evidence from the 1850s has little or nothing to say about the lamp.

Nightingale’s path was enormously eased by her circumstances. Her family was wealthy. Her father educated her broadly and well: at 16 she was being taught chemistry, geography, physics, astronomy, mathematics, philosophy and history. She became fluent in French and Italian, was translating Homer and Plato in her teens, and at 19 was learning German. Her knowledge of geology was said by the president of the Geological Society to be bold and broad. Her Unitarian background cultivated an ethos of good works inspired by a belief in the individual’s moral obligation to society. Her father knew many leading figures of the day: Palmerston, Macaulay, Charles Darwin and Annabella Milbanke. In her twenties she came to know Christian von Bunsen, the Prussian ambassador in London, founder of a Protestant hospital in Rome and a German one in London, staffed by deaconesses from a Lutheran establishment at Kaiserswerth, near Düsseldorf.

Although Nightingale’s chosen vocation was wrong-headed in the eyes of her family – nursing was for working-class girls – she waited patiently until her opportunity came. Events provided it. In 1853, after a spell at Kaiserswerth, she was appointed superintendent of the Establishment for Gentlewomen during Illness, located for most of her time there in Upper Harley Street. It catered mainly for governesses in decline or at death’s door. After a year she gave notice – she wished to move on – but before giving up her job she took leave to nurse victims of the Broad Street Pump cholera outbreak in Soho. Between 31 August and 9 September, five hundred residents of the streets around Golden Square died.

Once the outbreak was over she returned to her parents’ home in Derbyshire. Mrs Gaskell was staying there at the time, writing North and South for serialisation in Charles Dickens’s Household Words. ‘She is like a saint,’ Gaskell wrote in a letter. ‘She must be a creature from another race so high & mighty & angelic, doing things by impulse – or some divine inspiration & not by effort & struggle of will … she seems as completely led by God as Joan of Arc.’ But in another letter she commented: ‘She will not go among the villagers now, because her heart and soul are absorbed by her hospital plans, and as she says, she can only attend to one thing at once.’

By this time the Crimean War was well underway. It had many modern features. ‘The British,’ Scientific American reported on 19 May 1855, ‘have displayed great inferiority in military management in the present war with Russia,’ but

it cannot be denied but that the national spirit for engineering enterprise has not failed to show itself in the most favourable light. Thus in the Crimea Uncle John has carried his railroads with him, and the locomotive is used there to wheel up shot, shell and other implements of war … from the camp in the Crimea, to the War Office in London, the Commander in Chief now reports direct the state of the siege every few minutes … a telegraph submarine cable, 301 miles long, is laid in the bed of the Black Sea, stretching from the monastery of St George, in the Crimea, to Kalerga, on the Bulgarian shore.

Information about the course of the war was brought to the British public with great speed by the Times’s Applegath rotary printing press, which could deliver ten thousand impressions an hour. It’s said that the telegraph’s power wasn’t appreciated by the military censors at first, and that by the time they came to understand what it could do, so much had been revealed about conditions in the Crimea that it was politically impossible to impose new controls. Nightingale’s decision to go there was prompted by a series of articles in the Times by its Constantinople correspondent, Thomas Chenery, describing the conditions at the Scutari military hospital. William Russell reported on the battles themselves, and the incompetence they revealed.

Everything about the war was a mess. Wherever one looked, the army appeared to be in a poorer state than it had been when it fought in the Peninsular War forty years earlier – when the treatise on military surgery that was officially recommended to medical officers going out to the Crimea was written. The Chief Medical Officer in the East, John Hall, had come from India in the summer of 1854, with a reputation for zeal based on his work in the Xhosa War of 1846. Yet at the Battle of the Alma on 20 September he replied to a request that each regiment should have its own operating table with the comment: ‘More stress has been laid on this want than is necessary. That surgeon must be poor in resource who cannot extemporise a table either out of a bank of earth, or his panniers if in the open field; and if in or near a house he surely could not be long without supplying himself with a substitute in the shape of a door or a window shutter which he could support on stones if nothing better presented.’

Nightingale had War Office support in her attempt to improve things. Commissariat deficiencies were one of the biggest problems and she attended to them in short order. She first entered the Barrack Hospital at Scutari on 4 November. By then the soldiers’ diet had been so deficient for so long that scurvy was beginning to appear. The medical department ordered 40,000 gallons of lime juice from the Admiralty. Twenty thousand gallons arrived in the Crimea in early December, but they weren’t distributed to the troops until early February. Such were the problems that Nightingale had to rectify.

To bypass blockages caused by red tape she bought supplies with her own money and with subscriptions sent from Britain and the colonies. She foraged in the official purveyor’s store as well. Although she made sure there was a medical officer’s written order for all the things she wanted, the rumour that these ‘cruises’, as she called them, led to the liberation of supplies without the filling in of forms did her reputation no harm. In January 1855 she wrote that she had become a kind of general dealer in ‘socks, shirts, knives and forks … cabbage and carrots … small toothcombs, precipitate for destroying lice … bedpans and stump pillows’. She crossed swords with the medical officer, who would have preferred her to confine herself to superintending the nurses. Even when it was said that the sick had been given port wine on the authority of the nurses alone, Hall stood no chance. ‘There is not an official who would not burn me like Joan of Arc if he could,’ Nightingale wrote, ‘but they know the War Office cannot turn me out because the country is with me.’

In 1855, the mortality rate at Scutari dropped to acceptable levels. Sebastopol fell on 8 September, but Nightingale’s canonisation had started long before. A big step was the publication in the Illustrated London News on 24 February of an engraving of the ‘Lady with the Lamp’. In early May she visited Balaclava and was received by cheering soldiers. On 13 May she collapsed and was laid low with fever. Her case was said to be as bad as any; recovery took weeks. What caused her illness? Bostridge is too enthusiastic in his acceptance of the case made in 1995 by D.A.B. Young that Nightingale’s illness and subsequent invalidism – from 1857 to 1880 she spent most of her waking hours propped up on a sofa – might have been caused by Brucella melitensis. In other words, she is supposed to have had Malta fever and then chronic brucellosis. But her symptoms are at best only compatible with that diagnosis. The organism is common in goats in the places she had been, and she may well have drunk their milk. However, the symptoms of both acute and chronic brucellosis are notoriously protean: we will never know the cause of her illness. There is, however, no doubt that like Darwin, who is said, but can’t be proved, to have had Chagas disease, Nightingale was a chronic invalid, and far more productive than her long lasting ill-health should have allowed.

Nightingale was not alone in bringing female nurses to the Crimea. The enemy had them too. The prime movers were the Russian surgeon Nikolai Ivanovich Pirogov and Grand Duchess Yelena Pavlovna, sister-in-law of the tsar. Pirogov was professor of surgery at the Academy of Military Medicine in St Petersburg, and one of the pioneers of ether anaesthesia. In 1847 he had experimented with its administration by rectum – but found that it caused too much irritation. In the Caucasus war that year he used anaesthetics routinely – the first military surgeon to do so. In September 1854 he wrote to Pavlovna suggesting that women be given the job of tending the wounded on the battlefield. On 6 November (the day after the Battle of Inkerman) she established a corps of nurses, the Khrestovozizhenska community. The first group arrived in the Crimea on 11 December and worked in the base hospitals, in the field, and under shellfire in the Sebastopol bastions. Seventeen of the 68 nurses who served in the peninsula died on duty. Pirogov stayed in Sebastopol for much of the siege and amputated many limbs. Pavlovna went on to found the Russian Red Cross and set up the St Petersburg Conservatory in her home, the Mikhailovsky Palace. Both figures have been celebrated as national heroes, and sometimes used to endorse institutional and government activities they probably wouldn’t have liked. A film portraying Pirogov as a socialist hero was released in 1947, more than sixty years after his death. The music was by Shostakovitch; but the script was by Yury Pavlovich German, whose best-known films portrayed heroic OGPU operatives tracking down criminals. The film won the Stalin Prize.

Of British deaths in hospital in the Crimea, 16,334 came from disease and 1724 from wounds. Just under 13,500 died from intestinal afflictions: 3651 from diarrhoea, 2543 from dysentery, 4513 from cholera and 2790 from ‘common continued fever’ (many of these were probably typhoid and paratyphoid). Diarrhoea, however, is a symptom, not a diagnosis. Which microbes caused it one can’t say, but it is certain they would have been transmitted by the faecal-oral route. Only dysentery is commonly spread by person-to-person contact; drinking water contaminated with human faeces accounts for the others. The number of diarrhoea and dysentery cases and deaths was highest in the period from November 1854 to January 1855. Did Nightingale’s activities end this massive outbreak? The microbiological answer is no. There is no doubt that she eased the lot of the sick and wounded. She improved soldiers’ diet, and the washing of clothes may have made typhus less common by removing lice. But there was no clean water. In later years she blamed the ‘want of ventilation, want of draining, want of cleanliness … frightful overcrowding’ – but not the drinking water. Nor did her efforts have much effect on deaths after surgery. Primary amputations (of which there were 1027) had a mortality of 28 per cent, and secondary ones (150) a mortality of 51.2 per cent. The best that can be said is that a 47 per cent mortality rate for leg amputations showed a 10 per cent improvement over the Peninsular War.

From her sofa Nightingale spent the next twenty-five years driving reforms in nursing, hospital design and military health. Her correspondence was vast and much of it survives. The Collected Works, edited by Lynn McDonald, has reached volume ten; six more are planned. Volumes on society and politics, theology, public health care, women, health in India, and social change in India have appeared already, and illustrate the breadth of her interests. The volumes on the Crimea, War Office reform, professional nursing, and hospital reform are still to come. Nightingale was consulted on all these subjects. If she wasn’t, she made it her business to make her views known. Not every battle was won – many ended in a draw. St Thomas’s Hospital is a good example. The wide spacing of its pavilions fell short of her ventilation standards by only a small margin, but their location on the Embankment was a defeat. She believed that its urban setting, and effluvia and dampness from the Thames, would breed disease. Far better would have been the leafy suburbs of Camberwell, Norwood or Lewisham.

Nightingale’s Notes on Nursing: What It Is and What It Is Not remains the most important book on the subject ever written. The first edition – or rather the first edition as revised by Nightingale – was in print for 34 years; reprinted in 1924, it has remained in print ever since. Nightingale’s philosophy is clear:

Is it not living in a continual mistake to look upon diseases, as we do now, as separate entities, which must exist, like cats and dogs, instead of looking upon them as conditions, like a clean and dirty condition … I have seen with my eyes and smelt with my nose smallpox growing up in first specimens, either in close rooms or in overcrowded wards, where it could not by any possibility have been ‘caught’, but must have begun.

Evidently, she was not only a miasmatist who ‘knew’ that disease came from bad smells, vitiated air and putrefaction, but also a believer in spontaneous generation. Miasmatism was the dominant public health paradigm throughout most of Nightingale’s working life, so it would be anachronistic to criticise her for holding to it. Fierce battles between bacteriologists and miasmatists were still going on when cholera attacked Europe for the last time, in Hamburg in 1892.

Bostridge concludes his book with an account of 20th-century Nightingale iconography. In his penultimate paragraph he describes a memorial service in Westminster Abbey in 2005, at the end of which a lighted lamp was placed on the high altar. ‘She would have scorned the perpetuation of the myth associated with her name,’ Bostridge observes, but goes on to write that ‘many of Florence Nightingale’s greatest concerns remain ours too … Most worrying to much of the population of the United Kingdom is our reported failure to keep hospitals clean and free from infection.’

He is right that the myth remains powerful, but doesn’t see that its influence is far from benign. It continues to drag miasmatism in its wake. This antique, intuitive, apparently commonsensical but deeply flawed set of beliefs is clearly alive and well in the minds of those who advise prime ministers that hospital ‘deep cleans’ are the way forward. ‘Cleanliness’ is attractive to policy-makers, but a visibly clean hospital is not necessarily a safe one – microbes cannot be detected by the naked eye. Neither is a dirty hospital always dangerous. It all depends on the microbes and how they are transmitted. A classic experiment was carried out by the US army in Cuba in 1900. The general view at the time was that yellow fever was spread by fomites – in this instance, infected clothing and bedding. But Walter Reed had evidence that it was transmitted by mosquitoes. To convince the doubters he constructed an ‘Infected Clothing and Bedding Building’. Sheets, pillowcases and blankets deliberately contaminated with the vomit, urine and faeces of yellow fever patients were shaken to distribute their contents into the air and used to make up beds in which three US army volunteers slept for 21 nights. Two more volunteers slept in yellow fever patients’ garments for 21 nights, and another two did the same using pillows covered with towels soiled with blood from a patient. None of the volunteers got sick.