Nightingale viewed the hospital as the best place for nature to run its course. Nourishment, hygiene, and patient comfort were the keys. “Recovery from sickness in the vast majority of cases depends [more] upon pure air and pure water, with suitable diet, than upon any medical treatment, however skillful,” she insisted. A meticulous record-keeper, Nightingale proved her point with a series of “mortality diagrams” showing the dramatic improvements in Crimea once she and her fellow nurses took charge of the day-to-day care. Deaths went down dramatically; epidemics eased; patients recovered. Disease—or much of it—disappeared.
Word of her work soon crossed the Atlantic, winning converts like Surgeon General William Hammond. Among his initiatives would be the construction of one-story Civil War “Pavilion hospitals” providing more light, better ventilation, and extra space between the beds. The most impressive of these, the enormous Satterlee Military Hospital in West Philadelphia, contained a maze of low-slung buildings with large windows and wood plank construction to let the fresh air in and the bad air out. At its height, following the Battle of Gettysburg, Satterlee held more than 3,500 patients, making it one of the largest hospitals in the world.
The sheer number of casualties also led Hammond and Army Secretary Simon Cameron to recruit female volunteers as military nurses, a bold step at the time. There were no training schools like the one Nightingale had created in London because nursing wasn’t yet a recognized profession in the United States. American doctors generally viewed women as too delicate and flighty for the serious demands of medical work. How would they react to the odor of a pus-filled wound or the sight of gushing blood? And what sort of woman would voluntarily tend to the most intimate needs of a male stranger, beyond a lonely spinster or a self-absorbed busybody with nothing better to do? As one doctor sneered, “Can you fancy half a dozen or a dozen old hags, for that is what they are, surrounding a bewildered hospital surgeon, each one clamoring for her little wants?”
The greatest fear, however, was that trained female nurses might challenge the doctor’s authority—or worse, try to become doctors themselves. The American Medical Association spoke directly to this problem when it described nursing as “an art and a science” in the hands of properly trained women, while also listing the deficiencies that prevented them from ever becoming good physicians: “uncertainty of rational judgment, capriciousness of sentiment, fickleness of purpose, and indecision of action.”
Treading lightly, army officials recruited the most competent (and least objectionable) nurses they could find: single women from religious orders, the best known being the Catholic Sisters of Charity. Having spent years working in orphanages, poorhouses, and hospitals like St. Vincent’s in New York City, the Sisters didn’t require on-the-job training. Indeed, the wounded soldiers at Satterlee took to calling them “Angel” and “Mother” for their remarkable skill and devotion. Even better, the Sisters presented no risks to the male medical staff. They were deferential to a fault; they saw nursing as a duty, not a profession; they had no desire to become doctors; and they were extremely good at what they did—so good that both sides, Union and Confederate, actively sought them out. The problem, quite simply, was that there weren’t enough Sisters to go around. As a result, much of the nursing in the early months of the war fell to runaway slaves, convalescing troops, even prisoners of war.
To plug this gap, Secretary Cameron chose Dorothea Dix, the noted social reformer, to create the Women’s Nursing Corps. On paper, at least, the qualifications were severe. Fixed in her ways and determined to avoid trouble, Dix vigorously applied the Victorian standards of the day. The proper nurse must be single, literate, and over thirty, she ordered, “plain almost to repulsion in dress and devoid of personal attractions.” That meant “no bows, no curls or jewelry, no hoop skirts”—nothing, in short, to excite the baser instincts of the wounded troops. Socializing was strictly forbidden. The nurse “must be in her room at taps, must not go to any place of amusement” or—worse yet—“allow a [man] in her room.” For reasons of prejudice—or perhaps jealousy at the powerful bond created between wounded soldiers and the Sisters of Charity—Dix instructed her charges “not to speak to those Catholic nurses.” She also rejected Catholic applicants “if a Protestant could be substituted.”
Thousands of Northern women volunteered for nursing duty during the Civil War. Some attracted wide attention: Clara Barton for her bravery on the front lines at Manassas and Antietam, where a bullet grazed the sleeve of her dress and killed the wounded soldier she was attending; Harriet Tubman, whose extraordinary nursing skills included the use of herbal remedies; and Louisa May Alcott, whose letters home, published as Hospital Sketches, showed off her literary gifts in the years before Little Women became a national sensation. In New York City, the ninety-one applicants chosen for duty in the Nursing Corps were sent to Bellevue or New York Hospital for a thirty-day training course in “making beds, cooking food properly for the sick, washing and dressing wounds, and ventilating and caring for a ward.” (A survey of their motives showed “philanthropy, patriotism, and Christian duty” heading the list.) Those who stuck it out—a fair number dropped away—spent the war in field hospitals, on military transports, or at places like Satterlee. Their experiences would lay the groundwork for professional nursing in the United States.
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“I had never been in a hospital before,” Elizabeth Hobson recalled of her first visit to Bellevue in 1872. “The sight of the patients and the loathsome smells sickened me so that I nearly fainted.” Having first inspected the laundry, which operated without soap, and then the kitchen, where a “huge negro” prepared greasy soup while “pauper women” huddled together peeling potatoes, Hobson reached her limit in the ladies’ surgical ward. The beds were “unspeakable,” she noted, and the single helper—“an Irishwoman of a low class”—slept in a washtub filled with trash. It seemed a hopeless place—“an Augean stable”—and it buckled her knees.
Hobson hadn’t gone alone. She was part of the “Local Visiting Committee to Bellevue Hospital,” a group of several dozen women of “wealth and high social position” determined to improve “the mental, moral, and physical [condition] of the patients.” What bound them together, besides “representing the very best class of our citizens,” was their volunteer work during the Civil War. Led by Louisa Lee Schuyler, a descendant of Alexander Hamilton, they hoped to keep that spirit alive by focusing on local issues such as “nursing the sick, protecting the children and caring for the aged whom they may find in the institutions of the City.”
The timing certainly was right. Stephen Smith’s Sanitary Conditions of the City had just alerted wealthy New Yorkers to the dangers of leaving festering social problems unaddressed, while Edward Dalton’s ambulance corps had shown that wartime medical advances could be put to civilian use. Meanwhile, the recent fall of Boss Tweed had spawned a cluster of reform efforts, including the curious inspection of Bellevue Hospital by Miss Schuyler and her well-heeled friends. “We are aware, owing to the many years of corruption and dishonesty in the administration of affairs in New York…that economy is one of [our] first duties,” the Visiting Committee noted. “We strive to…confine our demands to the real necessities.”
The most critical need they identified was nursing care, which ranged from primitive to none at all. Bellevue had long relied on inmates from the Tombs prison—vagrants and prostitutes known as “Ten Days Women” for the length of their sentences. When Bellevue separated from the almshouse in the 1840s, funds were provided to hire a handful of female “nurses” and male “orderlies,” but the pay was so low, the working conditions so wretched, that the new system seemed hardly different from the old. “The nurses, or rather those employed as such, were nearly without exception to the last degree incompetent,” wrote Dr. Robert Carlisle in his nineteenth-century Account of Bellevue Hospital. “They were ignorant, indifferent, dishonest.”
Determined to open the nation’s first professional nursing school, the Visiti
ng Committee went directly to the source. A liaison was dispatched to London to study the methods of Florence Nightingale, whose iconic “Letter of Advice to Bellevue” offered both a blueprint for the project and an endorsement of its goals. Applicants must be “moral” and “cultivated,” she wrote, and, above all, know their place. They were “there, and solely there, to carry out the orders of the medical and surgical staff, including, of course, the whole practice of cleanliness, fresh air, diet, etc.” As to the day-to-day operation of the school, Nightingale was equally blunt. A trained woman superintendent must be the sole manager and disciplinarian, with full authority over the students. “Otherwise,” she warned, “nursing is impossible.”
Opened in 1873, the Bellevue Training School for Nurses closely mirrored Nightingale’s views. The superintendent would select the entering class and supervise its training. Only single, literate, religious women need apply, a flyer stated, with a preference for the “daughters and widows of clergymen, professional men, and farmers throughout New England and the Northern states.” Most of the candidates were rejected on account of “bad breeding.” The first class had just six members, the second twenty.
Progressives like Austin Flint and Stephen Smith strongly supported the school. But others thought it a fool’s errand, almost certain to fail. “I do not believe in the success of a training school for nurses,” a Bellevue surgeon declared. “Our patients are such a difficult class to deal with, and the service is so hard, that the conscientious, intelligent women you are looking for will lose heart and hope long before the two years are over.”
But the Visiting Committee pressed ahead, raising $24,000 to provide living quarters for the students and salaries for the staff—the biggest donor being Mrs. William Henry Osborn, whose husband ran the Illinois Central Railroad. Following strict “Nightingale procedure,” the training stressed “deportment, patience, industry and obedience.” A Bellevue intern described the students as “slavishly afraid” of their supervisors. “They had military discipline,” he said. “They didn’t go out [with men] except surreptitiously.” And they worked twelve-hour shifts, seven days a week, for little more than room and board. Should a patient pose a medical question, the proper answer—the only answer—was: “I don’t know—ask your doctor.”
Still, resentments grew as the Training School assumed a larger presence in the wards. A confrontation was inevitable, and it erupted in 1874 over the Visiting Committee’s demand that student nurses be posted on the Bellevue maternity floors. The rationale was the rising death rate among mothers who had just given birth. Everyone knew the cause to be puerperal fever. The larger issue was what, if anything, could be done to prevent it.
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Puerperal (or childbed) fever, a bacterial infection of the female reproductive tract, had plagued Bellevue for years. In 1851, eighteen of the 207 women who delivered babies there had contracted the fever, and twelve had died. “Every effort has been made to arrest its progress by isolating the patients, purifying the wards, and changing the attendants,” a doctor noted—but nothing had worked. The fever seemed to float on the miasma clouds that permeated every nook and cranny of the hospital.
In Europe, meanwhile, a breakthrough seemed at hand. In 1847, a young physician named Ignaz Semmelweis noticed a pattern to puerperal fever at his hospital in Vienna. The maternity ward run by the midwives had far fewer cases than the maternity ward run by the obstetricians. Semmelweis had no concept of Germ Theory; that would come later with the discoveries of Louis Pasteur, Robert Koch, and Joseph Lister. What Semmelweis did observe, however, was that the obstetricians, unlike the midwives, regularly conducted cadaver dissections in the hospital’s dead house, and few of them bothered to wash their hands before entering the maternity wards to deliver babies. This must be the cause of puerperal fever, he thought. Doctors were transferring deadly “particles” from the morgue to the birthing rooms.
In fact, these “particles” came from numerous sources—not simply cadavers—but Semmelweis was on to something. He urged his colleagues to soak their hands in a chlorine solution before each delivery, a procedure that did, indeed, reduce contamination among those who tried it. The problem was that Semmelweis proposed no scientific mechanism to explain his claims to those he indelicately accused of killing their own patients. “His genius [had] led him to a discovery for which the world was not yet prepared,” wrote one biographer. “He violated the most basic of the principles that underlie the hunting-rules of those who would track down Nature’s secrets: an idea must never be presented before its time.”
Deaths from puerperal fever had climbed steadily at Bellevue in the post–Civil War years, from seventeen in 1865 to thirty-three by 1872. The patient logs describe a slow, agonizing demise, about two weeks in duration. “Case XXXII…aged 25, single, delivered a boy…following a labor of 27 and a half hours.” Her symptoms began that evening with a rapid pulse and a temperature of 105. Day by day, her condition worsened: “sweating profusely…excited and nervous and often wanders…vomited a dark green liquid…tongue dry and covered with a brown coat…face flushed and burning hot.” Her nourishment included “brandy and milk…a pint of beer and as much beef-tea” as she could hold down. The treatment relied on quinine, morphine, and “tincture of veratrum viride,” a toxic plant extract used to slow a rapid heartbeat. The last notation read: “Respiration 26, pulse imperceptible at the wrist, temperature 107. Died 4:15 p.m.”
Theories abounded as to its spread, the most popular still blaming dangerous “miasma clouds.” “All admit that the saturation of the air with the exhalations of surgical and puerperal patients is eminently toxic,” wrote Bellevue’s Fordyce Barker, past president of the New York Academy of Medicine and personal physician to Ulysses S. Grant. Others added commentaries of their own—none more peculiar than the observation of Bellevue’s chief obstetrician, William T. Lusk, that his birthing wards were filled with guilt-ridden “unwed mothers” who wanted to die. “Few people realize the appalling mental condition of some of these poor outcasts,” he declared. “Without money, or friends, or sympathy…it is difficult to keep under control the suicidal propensities of the more desperate.”
There was a better explanation, of course. With a new medical college at Bellevue, as well as a larger morgue for dissection, the chance of bacterial transmission had dramatically increased. Dozens of students and instructors now moved freely between the dead house and the maternity wards, ignorant of the dangers involved. (Fordyce Barker’s widely read Bellevue lectures on puerperal fever, published in 1874 and running to 512 pages, make no mention of Semmelweis.) Further, these wards sat directly above the general operating rooms, where fatal infections—due, in part, to the role of anesthesia in permitting more invasive procedures—were also on the rise. While puerperal fever had invaded hospitals everywhere, Bellevue seemed ideally suited to its spread.
In 1874, Schuyler and her Visiting Committee issued a scathing report calling for Bellevue to be torn down and replaced by a series of low-slung, Pavilion-style structures. Citing the work of Florence Nightingale and William Hammond, they charged that Bellevue’s “defective ventilation [and] construction” had created a death trap, “its walls saturated with the poisonous emanations of disease.” No patient was safe from these “fatal influences,” Schuyler claimed. Pyaemia, erysipelas, gangrene, puerperal fever—all thrived within this teeming, decrepit, filth-ridden disgrace.
The logic may have been faulty but the problem was disturbingly real. An in-house survey of fifty-five amputations performed at Bellevue in 1869 showed more than half the patients (twenty-seven) dying within a month of their surgeries. The survey didn’t note the cause of death in all cases, but when it did, blood poisoning was mentioned almost every time. (“Died on the 14th day from pyaemia,” read a typical entry.) And a follow-up of fifty-eight amputations at Bellevue in 1872–73—“not including fingers and toes”—counted “30 recoveries” and “28 deaths,” with pyaemia (11), exhaustion (8), and s
hock (4) topping the list. Small wonder that a black-lettered sign in one of the wards read: “PREPARE TO MEET YOUR GOD.”
Bellevue was hardly unique. All urban hospitals in these years recorded horrifying fatality rates from infections following surgery. “Everything swam in pus,” recalled an intern at Boston City Hospital. “We [had] so much…gangrene that all operations were suspended for several weeks because to cut a man meant to kill him.” The difference was one of scale. Bellevue was massive: more patients meant more surgical procedures, and more surgical procedures meant more deaths from infection.
While razing the hospital struck most who worked there as extreme, it did have the support of two high-profile Bellevue faculty members: Frank Hamilton and William Hammond. Hamilton had long warned of deadly miasma clouds, which he blamed for virtually all of surgery’s current ills. “The best place to treat a sick or wounded man is always, other things being equal, where he can get the most and the purest air,” he wrote in his popular Treatise on Military Surgery. Hammond, the driving force behind Satterlee and other Pavilion-style hospitals, had moved to Bellevue following his controversial dismissal as surgeon general, and quickly found trouble again. A snippet from one of the Bellevue faculty meetings explained why: “Dr. Hammond [has] been disloyal to the college…in remarking to persons not members of the faculty that the Hospital was infested and should be destroyed.” The well-regarded Hamilton easily survived the crisis; the more disagreeable Hammond did not.
In the end, a compromise was reached. Bellevue would remain standing, but student nurses would take over the patient care in the birthing wards, despite angry protests from the physicians in charge. But even this did no good. By 1874, the mortality rate among new mothers at Bellevue was one in three—and climbing rapidly. Desperate for answers, Elizabeth Hobson consulted several physicians familiar with the disease, who told her that the controversial theories of Ignaz Semmelweis—a name she, and most Americans, hadn’t heard before—appeared to be gaining ground. Many European hospitals were now requiring his chlorine solution; some had banned physicians who performed autopsies from delivering babies, and a few had even constructed separate maternity buildings, with excellent results.
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