Ministering Angels: A History of Nursing from The Crimea to The Blitz

1. In The Beginning

Women have nursed since the first mother gave birth to the first baby. Nursing has always been a woman’s duty, as much her responsibility as cooking, sewing and sweeping the floors: a domestic chore. Christianity made caring for the sick poor a work of charity, a penance, one of the most unpleasant jobs women (and men) could do to show their love of God. Even with the introduction of paid nurses – one of the consequences of the Protestant Reformation, particularly in England – things did not improve. The work was unpleasant, the hours killing, food and accommodation often poor, and wages low, and the sick poor got the sort of care they might have expected in such circumstances. Only in the last century did it begin to dawn on a few of the more enlightened doctors and social reformers that, with a little training, nurses might do more than care for a patient: they might help to cure. Woman’s oldest duty became her first profession.

While many ancient civilizations developed quite advanced systems of medicine and surgery and, particularly, of public hygiene and sanitation, women had only a small part to play in them. In the earliest days, medicine was inseparable from religion and superstition: medicine was magic, the priests were physicians and disease was the work of evil spirits. The functions of priest and doctor gradually separated but women’s work was generally confined to midwifery and nursing at home.

Christianity made a sacred duty of loving your neighbour and caring for the sick, the old and the afflicted. Deaconesses, ordained by the laying on of hands, achieved a particularly important position in the Eastern Church. They had the same role as consecrated virgins and widows, who undertook specific functions within the church and devoted their lives to charitable work, which included sick visiting. In the early centuries such women lived and worked freely in society, but gradually they formed themselves in to communities and hence their spheres of activity were limited and curtailed. Care of the sick was a particular responsibility of the bishops who, from the 4th century A.D., built separate hospitals for their care. One of the earliest and most magnificent was built by Basil, Bishop of Caesarea, in A.D. 370. The Basilias, like such later foundations as the Hôtel Dieu at Lyons (542) and the Hôtel Dieu, Paris (about 650), combined the functions of hospital, almshouse, orphanage and hostel, as it was not thought necessary to make a distinction between the various objects of charity. The first hospital in Rome was founded in 390 by Fabiola, a wealthy widow who was converted to Christianity, and in expiation of her former life and an unhappy second marriage, lavished her fortune on the sick and the poor.

In 817, the Council of Aix declared the care of the poor to be the chief duty of monastic communities. However, a gradual transfer of part of this responsibility had been taking place since St. Benedict (born 480) had declared in his monastic Rule, ‘Before all things and above all things care must be taken of the sick.’ The monastic life was particularly attractive to women as an alternative to marriage. The early nuns led free lives, most of them not even wearing distinctive dress. They were given the opportunity to develop their own interests, and many nunneries became centres of learning. The great double communities of monks and nuns were usually led by an abbess, often of the highest rank and ability. Hilda, Abbess of Whitby in the 7th century, was a kinswoman of the King of Northumbria. She trained many eminent monks and was a woman of national importance. The monasteries had wards for their own sick and many, particularly those belonging to the Benedictine rule, had separate buildings for travellers and the needy. Well-born ladies visited the hospitals to help care for the sick. The quality of medical care was low, but the spiritual tone was excellent.

By the 12th century, hospitals specifically for the sick were emerging as separate institutions. At the same time a number of religious orders were founded with the principal duty of nursing. In about 1050 a group of merchants from Amalfi, moved by the plight of the pilgrims pouring into Jerusalem , founded two hospitals in the Holy City. The one for men was under the protection of St. John the Almoner, the women’s, St. Mary Magdalene. After the capture of Jerusalem by the Crusaders in 1099, the Order of St. John, which had devotedly nursed the soldiers during the Crusades, was endowed with generous gifts and lands from all over Europe. Under the second Grand Master of the Order the members took the Augustinian Rule and added military duties to their nursing work. The Hospitallers were divided into three grades: the knights who bore arms and held the important positions, the priests, and the serving brothers who probably did most of the nursing. The Order was rich and glamorous and membership eagerly sought after. Their hospitals were well equipped and run with a military discipline which strongly influenced later hospital management. When Jerusalem fell to the Saracens in 1187 and Acre followed in 1291 the Knights lost all their possessions in Palestine and the few left alive escaped to Cyprus. They took and held Rhodes from 1310 to l522 and then the Holy Roman Emperor Charles V gave them Malta, where they remained until the island was captured by Napoleon Bonaparte in 1798. The female branch of the Order, however, apparently gave up nursing after fleeing from Jerusalem. The German Teutonic Knights were formed to serve the sick and poor and defend the holy places. Their first hospital was destroyed when Jerusalem fell in l187, but they re-formed and nursed wounded Christian soldiers during the siege of Acre in 1190. After Acre’s capture, they built a church and hospital there – but retreated to Venice and then Marienbad when the city fell finally into Moslem hands. Many hospitals in Germany were given to them.

The Knights of St. Lazarus undertook military duties as well as the care of lepers in Jerusalem, and elsewhere.

The oldest purely nursing order of nuns were the Augustinian Sisters of the Hôtel Dieu in Paris. By the 13th century they were completely enclosed under the control of the clergy, and only allowed to leave the hospital for visiting nursing. In 1212 a decree by the Bishops in Council instructed hospitals in France to use as few nursing sisters as possible in order to economize on the expenditure of charitable gifts, so the hospital was understaffed, the Sisters untrained, ill-fed and dreadfully overworked. The standard of nursing was fairly low, though some visitors commented on the Sisters’ cheerful loving manner. Periods of overcrowding saw as many as five or six patients in one large bed.

For centuries the clerical and civil powers fought over the administration of the hospital. Investigations led to reforms, and then to decline. In the 14th century there were reports of insubordination, insolence and moral scandal. In the 17th century the Sisters were accused of disobeying orders, neglecting the sick in favour of religious meditation, and selling drugs. Visitors at the end of the 18th century reported overcrowding, bed bugs, filth and insanitary conditions. Throughout, the Sisters, with justification, pleaded overwork. With the French Revolution came suppression of the Augustinian Order, though conditions were improved and the Sisters were allowed to remain as lay nurses.

The increasing decadence of the monastic orders led to the growth of secular equivalents, many of whom devoted themselves to nursing. The most interesting of the women’s orders were the Beguines of Flanders, founded in 1180 as a protest against the more restrictive and artificial aspects of monastic life. They were vowed to chastity and obedience but could keep their own property and were free to leave the order and marry. The women lived together in threes and fours in small houses, grouped in a precinct, and nursed in hospitals and in the homes of the sick poor. The order spread to Germany, Switzerland and France and by 1300 it had about 200,000 members. Its independence made it unpopular with the Church, but the civil authorities and the people both gave it their support.

It was not until the 16th, 17th and 18th centuries that a further flowering of religious and secular nursing orders took place, many doing noble and self-sacrificing work. The members of one sisterhood, the Camellines, all died nursing in the last great plague of Barcelona, for instance. The most important of these later orders were the Sisters of Charity, founded by St. Vincent de Paul in 1630. St. Vincent was convinced that the work of visiting nurses was incompatible with enclosure and was determined that his Sisters should not become religious in the monastic sense. ‘My daughters,’ he said, ‘you are not nuns... for whoever says the word nun says cloister and the Sisters should go everywhere.’ He enlisted simple country girls with a basic education, clothed them in grey-blue rough gowns and handed them over to his associate Mlle. le Gras for practical nursing training. The girls were instructed to obey the doctors but also to watch and learn, so that they could be of use when no doctor was within call. They were to be willing and ready helpers, able to go anywhere and do any thing. In 1639 they took over the nursing of a hospital in Angers. In 1642 the first four Sisters took vows, which were to be renewed annually. In 1654, at Sedan, they undertook for the first time the military nursing for which they were to become well-known.

When St. Vincent and Mlle. le Gras both died in 1660 there were 350 Sisters in seventy establishments in France and Poland and the Order continued to grow rapidly. However, the early 19th century saw its decline. While nursing education broadened generally, its own narrowed. Sisters were not allowed to be present during child birth or at gynaecological examinations and they were forbidden to nurse venereal cases or take full charge of men patients. For these reasons, they were not suited to the demands of general hospital work.

The early hospitals in England, as in the rest of Europe, were religious foundations. In 936, Athelstan established a hospital in York, nursed by eight Sisters. Archbishop Lanfranc opened two hospitals in Canterbury in the 11th century. In 1101, Queen Mathilda founded St. Giles in the Fields for lepers, served by Poor Clares, and, in 1148, St. Katharine’s, where noblewomen undertook nursing duties, was founded. St. Bartholomew’s – nowadays known as Barts – was founded in 1123, the Holy Cross, Winchester, in 1132 and in 1215 St. Thomas’s, founded as the infirmary of the Priory of St. Mary Overie, became a separate hospital. Brothers and Sisters of the Augustinian Order nursed at Bart’s and St. Thomas’s.

By the time of the Reformation, the care of patients at St. Thomas’s had fallen to an extremely low standard. In 1536, the parishioners complained that a woman in child birth was turned away to die at the church door; that infant baptism was refused until the Master received half a noble; that religious services were not held; that the Master kept a concubine within the hospital; and that he was in the habit of selling church plate and claiming it had been stolen. But any care was better than none. England had no secular nursing orders and no public hospital system so, with the dissolution of the monasteries in the 1530s, the plight of the sick poor became desperate. St. Bartholomew’s, however, was reconstituted by Henry VIII in 1544, and in 1547 the mayor and aldermen of the City of London petitioned Edward VI for leave to take over St. Thomas’s, St. Bartholomew’s, Bethlehem and other lesser institutions.

Stripped of its religious elements of loving care and self-sacrificing duty, nursing was revealed as little more than domestic work. The matron was in charge of all the women in the hospital and was responsible for seeing ‘that the said washers and nurses of this howse be alwaies well occupied and not idle’, but it was not felt necessary that she should have any nursing experience and her duties were mainly concerned with housekeeping : ‘You shal also in every quarter of the yeare examine the inventorie which shal be delivered unto you, of the implements of the howse; as of beddes, bolsters, mattrasses, blanquets, coverlets, shets, pallads, shirts, hosen, and such other.’ Nurses were instructed: ‘Ye shall also faithfully and charitably serve and help the poor in all their griefs and diseases as well as by keeping them sweet and clean as in giving them their meats and drinks after the most honest and comfortable manner.’ Their duties were to keep the wards and the patients clean, to distribute food and drink, and to administer any medicines and special food ordered by the doctor.

The monastic term Sister was retained and applied to the nurse in charge of a ward. Sometimes Sisters were appointed from among the nurses or attendants, sometimes from the upper domestic classes outside. At St. Bartholomew’s, each Sister had sole charge of nine or ten patients and was expected to use her free time to spin. In 1550, twenty-one pairs of sheets were delivered to the matron, cut from cloth woven and spun by the Sisters. Earliest staffing lists also include a ‘foole’ or ‘innocent’, presumably employed to keep the Sisters amused. A cosy picture emerges of the earliest lay nurses serenely weaving, laughing at the antics of the fool, and stopping occasionally to comfort a patient, shoo the hens into the yard or consume a substantial meal. Unfortunately this happy picture is marred by the evidence of the surviving hospital records. At St. Thomas’s the matron was brought before the court three times from 1572 to 1580 for drunkenness. In 1559, the matron of St. Bartholomew’s was forbidden to sell ale in her house. In 1563, a St. Thomas’s Sister was reported by the matron as ‘she wolde not do her dutie in the office but ronne to the taverne.’ In 1650, a Sister at Bart’s was rebuked for entertaining men all night and letting them play cards in her ward; six years later three Sisters who had disturbed patients by fighting were dismissed. The nursing itself was probably quite adequate though, and the matron of St. Bartholomew’s, for example, distinguished herself during the plague of l665, when some of the physicians had fled, and was commended and rewarded by the governors.

With the secularization of nursing, however, ladies almost ceased to regard the sick poor in hospitals as worthy objects of Christian charity, though nursing, and even a little surgery, continued to be numbered among the domestic arts. Women collected recipes for medicines as eagerly as those for potting meat, and wealthier ladies accepted responsibility for the health of their households and their less fortunate neighbours as one of their domestic duties. The diary of Lady Hoby (1599-1605) contains many entries like the following: ‘After I praied, then I dined, then I walked and did see a sicke man,’ and, ‘I dressed the hand of one of the servants that was verie sore Cutte.’ Lady Mildmay (died 1620) recorded in her journal: ‘Also every day I spent some time in the Herball and books of phisicking, and in ministering to one or other by directions of the best phisitions of myne acquaintance.’

In the 18th century, wealthy British philanthropists set an example to the rest of the world by throwing themselves into an orgy of hospital building: the London opened in 1740; the Middlesex in 1745; the Westminster in 1719; St. George’s in 1728; and Guy’s in 1725. Outside London, Manchester Royal Infirmary opened in 1753; Liverpool Royal Infirmary in 1749; Leeds General Infirmary in l767; and Edinburgh Royal Infirmary in 1729. Towards the end of the century, public fever hospitals were set up, and, in a first glimmering of organized sanitation and preventative medicine, whitewash was applied to hospital walls. Iron bedsteads replaced bug-infested wooden ones. The forceful criticisms of John Howard, a prison reformer who also investigated hospitals, stung many hospital managements in to spring-cleaning. Yet, during this period, the status of nurses and the standard of nursing actually declined.

The London Hospital opened with a man and wife to act as caretakers and look after the patients. A nurse was not appointed until a year or two later when it was decided that ‘Squire be contracted with by the Chairman of the Committee as Nurse for the Women’s wards at the rate of £14 a year.’ A night nurse was appointed at £9, but when both nurses became resident in 1743, their salaries were reduced to £6 and £4 respectively. The nurses slept off the wards and the watches (night nurses) in the attic. Day duty began at 6 am in summer and 7 am in winter and lasted until supper at 10pm. Nurses had to be in bed by 11 pm, had no holidays, no days off and no pension. In 1756, the list of their duties included the following: ‘To make the beds of the officers and servants, to clean the rooms, passages and stairs and the Court and Committee rooms.’ Records of most hospitals of the time report, with dreary regularity, nurses rebuked or dismissed for drinking, insolence, lack of discipline, absenteeism, thieving, or soliciting payment from the patients. One visitor recorded seeing an in-coming patient stopped at the door by a loud–mouthed virago – the Sister – who demanded her fee before he could enter.

The nurses seldom wore uniform, usually cooked their own food and ate it in the ward kitchens or sculleries. Their hours were long, their accommodation inadequate and insanitary, and night nurses often had to sleep in lobbies next to the racket of the wards. Most of the actual nursing was done by medical students. It was almost impossible to get respectable women to work in such conditions. One doctor reported, ‘We always take them without a character because no respectable woman would take such work.’ Another wrote, ‘I know that a respectable woman was declined the other day, as being too good for the situation. The only conditions that are made are... that they are not confirmed drunkards... In general they are not educated at all.’ The London Hospital decided to appoint only women who could read and write, but was forced to compromise when insufficient numbers of suitable candidates presented themselves. Instead, the hospital ordered ‘that only those nurses who could read and write were to administer medicine.’ In 1844 the Board of Leeds Infirmary rejected a proposal that ‘no nurse be engaged in the domestic duties of the House’. Guy’s finally relieved nurses of scrubbing floors as late as 1857, but ordered that, as a consequence, each nurse was to care for twice as many patients . Standards were not uniformly bad. Edinburgh Royal Infirmary maintained a reasonable level of nursing care and operated an excellent set of nursing regulations. Although formally untrained , some Sisters who worked for years on the same ward under the same physician picked up a useful amount of practical skill. In 1885, Sir James Paget spoke in their defence: ‘It is true that even fifty years ago there were some excellent nurses, especially among the Sisters on the medical wards, where everything was more gentle and orderly than in the surgical. They had none of the modern art: they could not have kept a chart or skilfully taken a temperature, but they had an admirable sagacity and a sort of rough practical knowledge which were nearly as good as an acquired skill.’ A correspondent to The Times in 1857 wrote with more understanding of the nurses’ position than was then usual, ‘Hospital nurses have been much abused – they have their faults, but most of them are due to the want of proper treatment. Lectured by committees, preached at by chaplains, scowled on by treasurers and stewards, scolded by matrons, sworn at by surgeons, bullied by dressers, grumbled at and abused by patients, insulted if old and ill-favoured, talked flippantly to if middle-aged and good humoured, tempted and seduced if young and well-looking – they are what any woman might be under the same circumstances.’

Efforts to improve the quality of nursing were generally limited to pious hopes, stern injunctions and envious glances across the English Channel to the religious orders who at least gave loving care ( though by then most of the nursing in the major public institutions was done by lay attendants, as much practical nursing was banned to the Sisters on the grounds of impropriety). It did not seem to have occurred to hospital managers and doctors that they got what they paid for and that respectable, even educated, women might be drawn to nursing by higher salaries and improved conditions. Unable to visualize good nursing outside the confines of a sisterhood, all they could do was to vainly ask, ‘Where are our Sisters of Charity?’

The conditions in the great voluntary hospitals affected only a minority of the sick. The rich employed private nurses at home, though as most of these were of the Mrs. Gamp stamp vividly described by Charles Dickens, the quality of care was no better than in hospital. The remainder of the population stayed at home for as long as their family and friends could cope with them. Most who were forced to seek institutional care ended up in the workhouse infirmaries, either because there was no voluntary hospital in their area or because the voluntary hospitals would not accept them. When the great union workhouses were built following the Poor Law Amendment Act of 1834, they undertook to provide medical attention and in-patient facilities to all who were both destitute and in need of them. But, such was the deterrent effect of the grim buildings, the penal restrictions and the comfortless diet and accommodation, that the able-bodied preferred almost any fate