Magazine article History Today

New Light on the Lady with the Lamp: Susan-Mary Grant Looks at Florence Nightingale's Influence on Medical Care in the Crimea and the US Civil War

Magazine article History Today

New Light on the Lady with the Lamp: Susan-Mary Grant Looks at Florence Nightingale's Influence on Medical Care in the Crimea and the US Civil War

Article excerpt

`IT IS WITH FEELINGS OF surprise and anger,' announced The Times on October 12th, 1854, referring to the appalling conditions of the Crimean War, `that the public will learn that no sufficient medical preparations have been made for the proper care of the wounded. Not only are there insufficient surgeons ... not only are there no dressers and nurses,' but what, the paper asked rhetorically, `will be said when it is known that there is not even linen to make bandages for the wounded?' The Times continued its attack the following day with a critique of the `worn-out pensioners who were brought out as ambulance corps'. They were, the paper raged, `totally useless, and not only are surgeons not to be had, but there are no dressers or nurses to carry out the surgeon's directions and to attend on the sick during intervals between his visits.' The author of this diatribe was, not, as is commonly supposed, the famous war correspondent William Howard Russell, but The Times' Constantinople correspondent and future editor, Thomas Chenery. However, if the origin of these dispatches was quickly forgotten, their impact was not. Credited with inspiring, in part at least, Florence Nightingale's decision to take matters in hand as far as medical care in the Crimea was concerned, Chenery's revelations helped effect dramatic changes for soldiers fighting on both sides of the Atlantic in the mid-nineteenth century.

When the American Civil War broke out in April 1861, Nightingale was approached by the Federal Government for advice on organising medical care for troops in the field. By this time she was a well-known figure on both sides of the Atlantic. As early as December 1861, an article in the widely-read American periodical the Atlantic Monthly opened the debate over the appropriate treatment of the sick and wounded soldier. Here, the experience of the British at Scutari was recognised as indispensable. Nightingale's achievements, specifically, were regarded as crucial, in particular the stress she laid on `instant and silent obedience to medical and disciplinary orders.' In the journal's view, Nightingale's `practical hard work, personal reserve, and singular administrative power' had set new standards for the care of the wounded in wartime. `Through her, mainly,' it concluded:

   ... it is that every nation has already studied with some success the 
   all-important subject of Health in the Camp and in the Hospital. It now 
   lies in the way of American women to take up the office, and, we may trust, 
   to better the instruction. 

The last proved a false hope. Although Nightingale was cited frequently in articles on health care in the United States that appeared during the Civil War, learning from her experience and, more importantly, implementing her advice, proved no easy matter for the northern states during the Civil War. In July 1863, some two years into the war, one northern volunteer, Cornelia Hancock, was horrified at the conditions she witnessed in the aftermath of the battle of Gettysburg.

   ... The first day of my arrival, the sixth of July, and the third day after 
   the battle, was a time that taxed the ingenuity and fortitude of the living 
   as sorely as if we had been a party of shipwrecked mariners thrown upon a 
   desert island. 

`There was hardly a tent to be seen,' she wrote:

   Earth was the only available bed during those first hours after the battle. 
   A long table stood in this woods and around it gathered a number of 
   surgeons and attendants. This was the operating table, and for seven days 
   it literally ran blood. A wagon stood near rapidly filling with amputated 
   legs and arms; when wholly filled, this gruesome spectacle withdrew from 
   sight and returned as soon as possible for another load. 

Hancock came from a family of Quakers and, unlike Nightingale, never lacked familial backing, but she was almost felled at the first hurdle by Dorothea Dix, who had been appointed as superintendent of female nurses by the Union in June of 1861. Known as `Dragon Dix,' by many, she famously refused to employ any woman under thirty who was not plain in appearance. It was on those grounds that she tried to prevent the twenty-three-year-old Cornelia from boarding the train to Gettysburg in July 1863. `In those days', Hancock noted, `it was considered indecorous for angels of mercy to appear otherwise than gray-haired and spectacled'. Dix's objections having been noted, Hancock simply ignored her and went anyway.

An ability to circumvent opposition was not all that Nightingale and Hancock had in common, however. Both were educated women, and sought to use that education beyond the boundaries set for the nineteenth-century middle- and upper-class female. With exceptions, both found working with men easier, on the whole, than dealing with their own sex. Both, too, faced up to the practical and personal frustrations imposed by military life with characteristic determination and vigour. There were similaritities also in the respective conflicts that each woman found herself embroiled in.

Both the Crimean and the American Civil Wars began with an upsurge of popular enthusiasm. Queen Victoria described the Crimean conflict as `popular beyond belief,' and in 1861 men across America rushed to join their respective cause in a war that many believed would be both brief and glorious. In March 1854, a group of British gentlemen turned up at Gallipoli, seeing the war as a potential spectator sport, rather as at First Bull Run/Manassas in July 1861 civilians carrying picnics had to be moved out of the way of the Union and Confederate armies.

Both wars, too, fielded armies that were not what they seemed at first sight. Although The Times described the British forces sent to the Crimea in 1854 as the `finest army that ever left these shores,' most of the senior officers had either never seen active service or, at best, had served as junior officers under Wellington during the Pennisular War (1808-14). The American Civil War, described by Abraham Lincoln as `a people's contest', was just that: a war fought mainly by volunteer troops, most of whom, like their Crimean counterparts, were unfamiliar with the weaponry of the day and many of whom, especially in the latter stages of the war, had never even had the opportunity to practice manoeuvres on the parade ground before finding themselves facing the enemy.

As Anne Summers has argued, war in the nineteenth century became much more of a `civilian concern'. This was reflected not only in the conscript and volunteer composition of the armies themselves, but in the closer links maintained between the armies in the field and on the home front. War correspondents such as William Howard Russell helped establish such links via the dispatches he and others sent back from the Crimea and from the American Civil War, but there was more to it than media coverage alone.

During the Peninsular War, the Duke of Wellington famously described the men fighting under him as `the scum of the earth'. By the mid-nineteenth century, however, the view of the soldier was shifting. The mass volunteer armies, especially of the kind that fought in the American Civil War, could not be so summarily dismissed, in part because the causes for which they fought were regarded as of national importance. The soldier was no longer an individual who simply took the King's shilling for lack of alternative, but a symbol of a national cause and thus, potentially, a hero. Tennyson's famous observation on The Charge of the Light Brigade, `Theirs not to reason why,/Theirs but to do and die,' no longer applied by 1861. Support for the men in the field became more pressing in this new climate because non-combatants felt not only emotionally involved in the conflict but justified in becoming practically involved, too. This, essentially, was where women such as Nightingale and Hancock came in.

When Florence Nightingale arrived at Scutari in the Crimea in 1854 the situation was grim, as Thomas Chenery had described it. Nearly a thousand lives were lost to disease before the first shot had been fired. Cholera, dysentery and other enteric diseases were rife, landing some 20 per cent of the British expeditionary force in hospital between June and August of that year alone. An almost total lack of hygiene exacerbated matters. The soldiers, Nightingale noted, were able to wash only once in eighty days, resulting in `Fever, Cholera, Gangrene, Lice, Bugs, Fleas--& may be Erysipelas [a streptococcal infection causing inflammation],' all of which quickly spread by the sharing `of one sponge among many wounds'. There was no organisational structure in place to deal with the wounded and no ambulance corps to remove them to field or base hospitals. When the latter did arrive in July, they soon fell victim to either cholera or alcohol, or both. There was nothing waiting for Nightingale in the way of supplies--no food, or furniture, or cooking utensils. Barely a week after her arrival, she reported:

   1715 sick & wounded in this Hospital (among whom 120 Cholera patients and 
   650 severely wounded) ... when a message came to me to prepare for 510 
   wounded ... who were arriving from the dreadful affair of the 5th Nov'r at 
   Balaclava, where were 1763 wounded & 442 killed, besides 96 Officers 
   wounded & 38 killed. I always expected to end my days as Hospital Matron, 
   but I never expected to be Barrack Mistress. 

Many of those involved in nursing the wounded during the Civil War, including the formidable Dorothea Dix, had, of course, either direct experience of the Crimea, having served as voluntary nurses there, or were at least aware of the reforms in health care implemented by Nightingale. Dix herself was familiar with Nightingale's work, and had visited her hospitals. However, transporting Nightingale's reforms across the Atlantic proved difficult. While many volunteer nurses, and the American people in general, had taken note of Britain's struggle in the Crimea, the federal government and the army proved reluctant to learn the lessons of the past. There was an additional element in the American equation, too: contrabands--slaves who had escaped to federal lines in the course of the war--and, of course, African- American troops. If American officers and generals were rather less scathing than Wellington had been about white troops, they were dismissive about the needs of blacks, as Cornelia Hancock discovered when she went to work in a black field hospital. `If I were to describe this hospital', she wrote, `it would not be believed':

   North of Washington, in an open muddy mire, are gathered all the colored 
   people who have been made free by the progress of our Army. Sickness is 
   inevitable, and to meet it these rude hospitals, only rough wooden 
   barracks, are in use ... We average here one birth per day, and have no 
   baby clothes except as we wrap them in an old piece of muslin, that even 
   being scarce. 

Essentially, little had changed between the Crimea and the Civil War. In 1861, disease was still the main enemy to be faced, and epidemics of typhoid, malaria, measles, diphtheria, scarlet fever and dysentery were far more effective than any human enemy at putting entire regiments out of action. Two thirds of the 600,000 who died during the Civil War succumbed to disease, in part because army medical care was basic, virtually primitive, and no better organised than it had been for British troops in the Crimea. The medical profession as a whole had not yet got to grips with new developments such as anaesthesia, and chloroform, even when available, was not always used, even for amputations. As in the Crimea, the importance of basic hygiene was not understood, and gangrene, chronic sickness and the ministrations of ignorant medical personnel frequently finished off men who had survived the battlefield itself. As late as July 1864, close to the end of the Civil War, Cornelia Hancock observed how, there `were not surgeons near enough who were willing to stay in the sun and attend to the men', and this on top of a persistent lack of food and supplies, a situation that prevailed for the duration of the conflict. As she put it:

   I do think military matters are enough to aggravate a saint. We no sooner 
   get a good physician than an order comes to remove, promote, demote or 
   something. Everything seems to be done to aggravate the wounded. They do 
   not get any butter; there is certainly a want of generalship somewhere for 
   there is surely enough butter in the United States to feed these brave 

Had it not been for the United States Sanitary Commission, a civilian volunteer organisation established at the start of the war in the North, the suffering of Civil War soldiers would have been far worse. Organised by men such as Frederick Law Olmsted--more famous for designing New York's Central Park--Henry Whitney Bellows and Samuel Gridley Howe, who had been active in reform movements before the Civil War, the Sanitary Commission was the largest and the most effective non-governmental agency during the Civil War. It raised funds for medical supplies, provided reports on conditions in the field, ran hospitals, hospital ships and soldiers' homes, helped soldiers claim back-pay and pensions, mobilised hundreds of individuals to support its efforts both on the home front and in the field, held fund-raising Sanitary Fairs in many of the major northern cites throughout the war, and constantly pressured the War Department to improve facilities for the medical, and general, care of Union troops. Yet it did not meet with instant or universal approval. Abraham Lincoln referred to it as a `fifth wheel', while the Secretary of War, Edwin Stanton, did not take kindly to the Commission's apparent attempts to take over the running of the Medical Bureau, nor to its swift seizure of the moral high ground as far as medical care was concerned. Nevertheless, many Union troops had cause to be grateful to the Sanitary Commission in the course of the war, and northern volunteers such as Cornelia Hancock recognised its value. `Uncle Sam is very rich, but very slow,' she wrote, `and if it was not for the Sanitary [Commission], much suffering would ensue.' It was, in her view, `a God appointed institution.' She described how it functioned:

   The mode the Sanitary operates is this--they bring a large stock of food on 
   barges which lay at City Point. Then in every Corps they put a large tent 
   and stores are sent to it; then every lady who has charge of a cooking tent 
   makes a requisition for what she needs and sends it to this Sanitary tent 
   ... Then besides this, in every section there is an agent who visits the 
   tents, supplies the men with clothing, tobacco, pipes etc. 

She contrasted the Sanitary Commission's approach with that of another volunteer body, the Christian Commission, which was, in her view, neither so well-organised nor as effective. `They generally pitch a large tent and cook their own food and distribute it thru their own agents, which is done in a desultory and fitful manner which disturbs the good order of the hospital,' she observed, and as a consequence `frequently Surgeons forbid their coming into the wards.'

The Sanitary Commission was a gigantic triumph of organisational and administrative skill. At the time of the Civil War, only the Federal Government itself and the railroad companies operated systems of similar complexity. In this, the Sanitary Commission can be seen as directly descended from Florence Nightingale's efforts in the Crimea. There, she had found herself trapped in the middle of an arcane system that ensured that the three departments responsible for the health of the fighting man--the Commissariat, the Purveyor's Department and the Medical Department--worked against each other and to the obvious benefit of none. The `difficulties & delays of mediating between conflicting orders in the various departments,' were responsible, she concluded, for 'most of the signal failures' she encountered. The Sanitary Commission faced many of the same problems. A few months after the war began, the Commission reported:

   It was an every-day occurrence for the agents of the Commission to find the 
   volunteer in a camp hospital very sick; his only sustenance fresh bread and 
   salt pork; his only drink, green coffee. He lies on the damp ground, with 
   no covering but a blanket, which cannot properly be called a blanket. He 
   wants kind and constant attention, and delicate food ... But the regimental 
   surgeon, who may or may not be properly called a surgeon, is too much 
   absorbed in learning the intricate history of official requisitions, and in 
   waiting for a personal interview with the government man on the other side 
   of town, who can supply an ambulance, to see him often. 

Although the relief of suffering was the intended outcome, in effect, Nightingale's main task was, like that of the Sanitary Commission, organisational and administrative rather than purely benevolent. Many of the letters she sent back from Scutari to the Secretary at War, Sidney Herbert, detailed her proposals for alternative bureaucratic structures that would, in her view, facilitate the running of the hospitals, the procurement of supplies and, ultimately, the care of the wounded. Her main goal was, in part, the promotion of nursing as a profession, but it was, more significantly, the promoting of professionalism itself with regard to medical care in the armed forces and beyond.

Many of the improvements made in medical care during the American Civil War clearly derived from the work done by Florence Nightingale, both in the Crimea and after. Several leading figures of the time, including Dix, Olmsted and William A. Hammond, the Surgeon-General of the United States during the Civil War, acknowledged this, in their own attempts at reform, and in their emphasis on hygiene and hospital administration.

Florence Nightingale's significance in this regard has been rather downplayed, for two reasons. First, as `The Lady with the Lamp,' her reputation has tended to focus solely on her work in the Crimea and this has overshadowed the importance of the reform initiatives she pursued after 1856. Her reputation, indeed, has proved something of a liability by effectively removing her from the broader context of her own life and times. Writings about Nightingale tend to fall into one of two camps: the hagiographical or the critical. They either emphasise the great step forward achieved by women and by the nursing profession as a result of her activities in the Crimea or focus on the limitations of her reforms. Second, as an unusual woman in a man's world, Nightingale remains restricted to the female sphere as much by modern writers as by her contemporaries. She is frequently seen as the British `counterpart' to US Civil War nurses such as Dix and Clara Barton.

In many ways, Nightingale had more in common with Frederick Law Olmsted and other men involved in the United States Sanitary Commission than she did with women like Dorothea Dix. Olmsted was frequently driven to distraction by the latter, to the point where he argued that `female nurses ... are under the present Military Regulations, not practicable.' Yet he was no misogynist, and indeed scorned any comparison between Dix and Nightingale. The former was too emotional, he believed, to achieve the necessary reforms that would, in the end, result in improved care for the wounded. Where Nightingale and Olmsted differed from many civilian volunteers was in their modern, scientific approach to the problem of medical care. They believed in the importance of information, statistics, and systematic record-keeping. Only via such means, they concluded, could the needs of the soldiers be addressed.

Greater civilian involvement in warfare, together with changes in the scientific, economic, medical and social fields of the nineteenth century prompted the development of different social and organisational structures. If Nightingale's recommendations in this regard were neither understood nor implemented as effectively as they might have been, the fault lay not in nineteenth-century opposition to active women, as such, but to the confusion of a period facing war and widespread change simultaneously. Both the Crimea and the American Civil War revealed the suffering that disorganisation could cause; both also produced pioneers in the development of new systems.

The methods advocated and adopted by Florence Nightingale in the Crimea and by the Sanitary Commission during the Civil War pointed the way toward a more rational future. In outlook and approach they were simultaneously bureaucratic and benevolent. Both placed their faith in hard statistical data to provide answers to their questions, and in rigorous discipline to implement their reforms. Both, too, faced considerable opposition from the establishment, yet they succeeded in showing just how much civilian effort could achieve at a time of national crisis. Above all, both reflected the changing relationship between war and society in the nineteenth century. After the Crimean and American Civil Wars, it was no longer possible to regard war itself as the sole responsibility of armies: for good or ill, warfare had become a national responsibility.


Robert H. Bremner, The Public Good: Philanthropy and Welfare in the Civil War Era (Alfred A. Knopf, 1980); Sue M. Goldie (ed.), `I have done my duty': Florence Nightingale in the Crimean War (Manchester University Press, 1987); Henrietta Stratton Jaquette (ed.), Letters of a Civil War Nurse, Cornelia Hancock, 1863-1865 (University of Nebraska Press, 1998); Witold Rybczynski, A Clearing in the Distance: Frederick Law Olmsted and America in the Nineteenth Century (Touchstone, 2000); Anne Summers, Angels and Citizens: British Women as Military Nurses, 1854-1914 (Routledge & Kegan Paul, 1988); Martha Vicinus and Bea Nergaard (eds.), Ever Yours, Florence Nightingale: Selected Letters (Virago, 1989); Cecil Woodham-Smith, Florence Nightingale, 1820-1910 (Constable, 1950).

Web: (United States Sanitary Commission); (excellent site with original documents from the Crimean War).

Susan-Mary Grant is Reader in American History at the University of Newcastle-upon-Tyne. She is the author of North Over South: Northern Nationalism and American Identity In the Antebellum Era (University of Kansas Press, 2000)

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