Nursing before Nightingale, 1815–1899 (review)

This densely researched work deals with London hospital nursing in the nineteenth century and takes issue with the bulk of nursing historiography, arguing that it exaggerates the importance of Florence Nightingale’s reforms; wrongly emphasizes social and religious aspects of changes in nursing, rather than clinical considerations; and ignores the contribution to the process of professionalization of the Anglican nursing sisterhoods, particularly that of St. John’s House.

The third charge is exaggerated; the first is unfounded. Since Celia Davies’s anthology, Rewriting Nursing History (1980), one writer after another, most notably Monica Baly, has demythologized Nightingale and foregrounded a more populous landscape of reform. But the name continues to sell books; hence, presumably, the confusing title of this one (Nightingale’s dates are 1820–1910).

The second charge is multistranded. The authors assert that by the mid-nineteenth century “new medicine” (pp. 27, 41, 61, and passim) required different and better nursing care. We are told, first, that new medicine promoted “supportive treatments” (p. 4), such as generous feeding and stimulants, over those involving depleting or lowering procedures, such as blisters and bleeding; the former necessitated more twenty-four-hour care. But evidence is contradictory: thus, “[t]he new medicine depended heavily for its success on timely patient assessment, regular feeding, prompt removal of blisters, checking that leech bites did not bleed too long” (p. 41). Charles Rosenberg’s maxim on “the inertia of traditional practice” (p. 35) is quoted without considering its implications. It is particularly inappropriate to suggest that British Army hospitals during the Crimean War demanded “clinical experience and familiarity with modern medical practice” (p. 95) of its nursing staff.

The authors also link improvements in nursing provision to the innovation of anesthesia. More and better-paid night and day nurses were hired by the London (1847), St. George’s (1849), University College Hospital (1851), and St. Thomas’s (1854), while the Middlesex “took action to reform its nursing in 1847” (pp. 55–57). No texts are quoted to buttress this linkage: the authors admit that from 1846 “anaesthesia was used selectively, and the number and length of operations did not increase significantly for several years” (pp. 55–56). Moreover, if Eliza Roberts of St. Thomas’s “had skills which few other nurses had in the 1850s, because by then the dressers had taken over so much of what the surgical sisters formerly did” (p. 114), this chronology of change needs rethinking.

No one would claim that poorly paid, overworked, abominably lodged nurses “before Nightingale” were providing all needful patient care, whether under a regime of “old” or “new” medicine. Numerous examples are assembled of dreadful behavior, which recall the axiom “work is the curse of the drinking class,” often as applicable to apothecaries and medical students as to nursing staff. But it cannot be inferred that all nurses failed at their tasks and had to be consigned to the dustbin of clinical history. The authors dismiss or ignore evidence on individuals contradicting their argument: “[T]hese sisters were so memorable because they were exceptions” (p. 45). Yet they accept that “before St John’s House took over the nursing at King’s College Hospital in 1856, experienced working-class nurses and head nurses taught the lady probationers” (p. 129). They largely ignore the wider context of domiciliary nursing; many competent women freelanced between homes and hospitals. Nor, surprisingly, do they relate changes in hospital management to the drive to professionalization culminating in the 1858 Medical Registration Act. Sisterhoods’ social authority, moral propriety, and esprit de corps were precious adjuncts to ambitions to raise the ambiguous social status of medical men and escape the indelicate aura of services to the body.

The chapters on St. John’s House sisters are valuable and original. Organization and medical training were prioritized, relations with their own working-class nurses were impeccable, their religious practice was less publicly visible than that of the nominally secular Nightingale corps. They left the London teaching hospitals...