New light on the lady with the lamp

Florence Nightingale was honoured as a heroine and a pioneer of health reform. But a young surgeon who worked with her wasn't so impressed. By Paul Kelbie
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The romantic image of the Lady with the Lamp has helped to preserve the reputation of Florence Nightingale as one of Britain's greatest heroines. Until fairly recently she was the only female commoner to adorn the nation's banknotes, alongside such historical heavyweights as Newton, Wellington and Dickens and is probably the best-known Victorian woman next to the monarch herself.

But today, 150 years after she sailed to the Crimea and into the history books, establishing the basis for many modern medical procedures in the process, her reputation is in danger of being tarnished. It is not the word of some revisionist historian which casts doubt on the legend of the Nightingale but the newly discovered views of a young doctor who worked alongside her amid the horrors of war.

Dr David Greig was an ambitious surgeon when he joined the British, French and Turkish forces fighting the Russians to prevent the latter's expansion into the Balkans and eastern Mediterranean.

Between October 1854, when he joined the army just two days after the Battle of Balaclava, and 1856, when he left the military, Greig kept up a regular correspondence with his family in Dundee. His letters, which were found among a pile of old books in a Dundee house, detailed his experiences and the brutality of a war in which more British casualties were lost to sickness and disease than enemy action. As well as providing important historical information on military detail, Grieg's letters also reopen the controversy about the extent of Nightingale's role in transforming the treatment of patients.

For much of his time in the Crimea, Greig was stationed at the notorious Scutari hospital, where the conditions described by the war correspondent William Russell scandalised Britain and propelled Nightingale to international celebrity.

It was in response to the public outcry generated by the press reports that Sidney Herbert, the War Minister, appointed Nightingale to oversee the introduction of female nurses into military hospitals for the first time in more than 50 years.

Nightingale was born into a privileged background in 1820, and grew up in family homes in Hampshire and Derbyshire. She had to overcome her parents' objections to her career, but in 1851 she undertook three months' training and finally took up the position of superintendent of the Establishment for Gentlewomen during Illness at 1 Harley Street, London, in 1853.

It was through her work there that she became friends with Sidney Herbert and on 4 November 1854 she arrived at the Barrack Hospital in Scutari, a suburb on the Asian side of Constantinople, with a party of 38 nurses.

Amid what she described as "appalling horror - steeped up to our necks in blood", she and her team cleaned the hospital, arranged for vital medical supplies which had been withheld from the sick and wounded and won the respect of her patients in the face of obstructive behaviour by the Army Medical Corps and doctors.

Reports by Nightingale and her nurses describe the conditions they found: "There were no vessels for water or utensils of any kind; no soap, towels, or clothes, no hospital clothes; the men lying in their uniforms, stiff with gore and covered with filth to a degree and of a kind no one could write about; their persons covered with vermin ... We have not seen a drop of milk, and the bread is extremely sour. The butter is most filthy; it is in a state of decomposition; and the meat is more like moist leather than food."

Within months of her arrival the 35-year-old nurse had been credited with reducing the high death toll in the hospital. As a mark of the nation's gratitude, a public subscription was organised in November 1855 and the money enabled her to continue her reform of nursing in British hospitals when she returned.

It appears, however, that not everyone was impressed.

Although many of Greig's letters echo the press reports of the time about the horrors of Scutari, he is defensive about the role of the Army Medical Corps.

"In the front here, where we have 27,000 men under our supervision, we had only 22 cases of death during last month and as far as we have gone this month, it promises to be less still, in fact, no one could wish the British Army to be in a better condition," he wrote to his mother on 14 March 1856.

In another letter he describes wounded men arriving at the hospital naked, ragged or caked in mud "looking miserable and dragging their wearied limbs after them to die in peace", while at the same time revelling in the experience he is gaining as a surgeon.

It is clear that he has little time for Nightingale and her nurses. He pokes fun at the fact that she had a huge budget of £8,000 a year but her staff were no better than army orderlies.

"The nurses are all under her charge, sometimes we get a visit from her in the wards and if a nurse is required for a patient she sends one. She keeps strict watch over them and they work very well, but I think just the same could be done by the orderlies (soldiers who act as nurses), which we have always in our wards," he told his parents.

"I had a farce with Miss Nightingale today, she was visiting some of my patients who were very bad and was asking one poor fellow who had got his leg shot off and who was complaining of thirst, if he would like rice water or barley water. He thought for a little and then said he would prefer brandy and water if it was the same to her."

"It is clear from the letters that Greig didn't think much of Florence Nightingale," said Mr Hill of Big Bairn Books in Dundee, who found the lost correspondence. "I don't suppose she was as famous then as she is now but it is interesting to see the view of another medical person being given so frankly.

"Greig was a surgeon and I suppose he might have looked down his nose at her because she was just a nurse in his mind."

Or perhaps he was just a bit of a misogynist. When Nightingale first arrived in Scutari, diseases such as cholera and typhus were rife in the hospitals, which meant the patients were seven times more likely to die from disease than from their wounds. She placed great value on statistics, collecting data and organising a record-keeping system. She used this information as a tool to argue for improvements.

Her calculations showed that an improvement of the sanitary methods employed would result in a decrease in the number of deaths. By February 1855 the mortality rate had dropped from 60 per cent to 42.7 per cent.

Thanks to the establishment of a freshwater supply, as well as using private funds to buy fruit, vegetables and standard hospital equipment, the mortality rate in the spring had dropped further to 40.5 per cent.

However. revised research into her war records have cast doubt on just how effective she was. In the past four years, both a BBC documentary and a few historians have suggested that she was driven more by personal ambition than compassion. Despite her work at Scutari the death rate among the soldiers did not begin to fall immediately but actually rose and was higher than at any other hospital in the eastern theatre.

During her first winter at Scutari, 4,077 soldiers died, of which the vast majority succumbed to typhus, typhoid, cholera and dysentery. It wasn't until six months after she had been in charge that a sanitary commission sent by Lord Palmerston flushed out the defective sewers on which the hospital was built and improved the ventilation of the crowded wards. It was then that the death rate began to fall.

The historian Trevor Royle said: "Greig's comments on Florence Nightingale would seem to support the modern revisionist view that really what she did was just common sense and that her achievements were not that heroic." But he said he believed the letters provided a fascinating insight into events in the Crimea, and these had changed the way the British Army looked after its troops and the treatment of hospital patients throughout the world

Alex Attewell, director of the Florence Nightingale Museum, said he thought the letters illustrated some of the jealousy which the doctors felt towards Nightingale and her ability to get things done.

"There is a myth surrounding Florence Nightingale that portrays her as the lady with the lamp, mopping the brows of individual soldiers," he said. "But in reality her contribution was far, far greater than that.

"She was an administrator whose greatest achievements were getting the resources and the supplies that the hospitals needed but the doctors couldn't get because of red tape."

Mr Attewell said many of the nurses who worked with Nightingale were vastly more experienced than the doctors around them and any suggestion that they were no better than army orderlies was ridiculous.

When Nightingale returned to London after the war, she avoided the public spotlight but continued campaigning behind the scenes for changes to health policies. In 1860, she established the Nightingale Training School for nurses at St Thomas' Hospital and wrote her best-known work, Notes on Nursing, which laid down the principles of modern nursing.

Although, as with many health reformers of the time, many of her theories concerning infection were mistaken, they still led to improvements in hygiene.

She died, aged 90, in 1910.

In her own words

* "Women never have a half-hour in all their lives (excepting before or after anybody is up in the house) that they can call their own, without fear of offending or hurting someone." (1852)

* "What the horrors of war are, no one can imagine. They are not wounds and blood and fever or dysentery, cold and heat and famine. They are intoxication, drunken brutality, demoralisation and disorder on the part of the inferior ... jealousies, meanness, indifference, selfish brutality on the part of the superior." (1855)

* "No man, not even a doctor, ever gives any other definition of what a nurse should be than this - "devoted and obedient". This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman. "(1859)

* "It may seem a strange principle to enunciate as the very first requirement in a Hospital: that it should do the sick no harm." (1859)

* "The martyr sacrifices herself (himself in a few instances) entirely in vain. Or rather not in vain; for she (or he) makes the selfish more selfish, the lazy more lazy, the narrow narrower." (1867)