Historians of nursing in Britain have long been fighting for a place in the history of medicine. For example, of the 718 pages of text in Roy Porter’s best-selling The Greatest Benefit to Mankind, only five are concerned with nursing, and these, inevitably, with Florence Nightingale and 19th-century hospital reform. Although nurses appear more frequently in Charles Webster’s magisterial two-volume history of the British National Health Service since the Second World War, there is no sustained discussion of their role, even though they were the largest section of the trained labour force in the National Health Service. There are some excellent general histories of nursing, with seminal overviews of the development of the profession by Brian Abel-Smith, Christopher Maggs and Monica Baly complemented by the more sociological approach of authors such as Celia Davies and Anne Marie Rafferty. These are indispensable in charting the development of the nursing profession in 20th-century Britain, but the nature of the professional struggle is necessarily at the centre of their work. This contrasts with medical history, which traditionally concentrated on advances in medical knowledge, while nursing history rarely discussed the technical aspects of nursing.
In many medical histories, the nurse’s functions are usually clearly limited within the Nightingale legacy. The nurse is important as the guarantor of hygiene, the dispenser of comfort, and the centre of calm in the often chaotic world of the hospital. Her actual duties are rather vaguely described, and the boundaries between the roles of doctor and nurse are not clearly defined. This is, as Celia Davies and others have pointed out, because these boundaries were always shifting. Many medical techniques, originally the province of doctors, and presented as evidence of medical skill, were passed over to nurses as the scope of medical expertise widened. Using a stethoscope, checking blood pressure, giving intravenous injections, operating a defibrillator – all regarded as highly skilled medical tasks when they were introduced – have passed into the domain of the nurse, or even further along the chain to paramedics; with the inevitable result that they are redefined as less skilled. The extent of a nurse’s power to diagnose and prescribe varies from country to country, and is often hotly contested. In a state-run medical system like the British, there is always pressure to transfer tasks to nurses, since they are so much cheaper than doctors. As Davina Allen has written, ‘Attempts to fix the nursing role too rigidly are doomed to fail; the content of nursing practice … is forever changing, both historically and in daily practice, and will continue to do so.’(1) She also noted that in the modern British hospital there were pragmatic reasons for nurses taking over medical functions, since it sometimes took so long to get a doctor on to the ward that nurses ended up doing the job themselves.
Historians and nurses now tend to use the phrase ‘nursing work’ to define what nurses do, rather than ‘nursing’, with its gendered assumption of a link between nursing and feminine domestic instincts. In the mid 19th century, Florence Nightingale’s admirers believed that she had transposed the female instincts for cleanliness and nurture into the hospitals. By the mid 20th century, in a neat inversion, doctors and politicians were attempting to combat the nursing shortage in the National Health Service by arguing that a girl trained in basic nursing skills would be better prepared for marriage and motherhood. ‘Nursing work’ moves the subject firmly out of the home and into the workplace, though as the book reviewed here clearly shows, the perceived link between the nursing and domestic ideals did not break down, even as the technical expertise of nurses was more widely acknowledged.
As a historian who is also a nurse, Christine Hallett is well qualified to take up the challenge of writing about nursing work, and what it entailed under the unforeseen strains of total war. She makes her approach clear at the beginning, arguing that although there have been many books about nurses, ‘yet, remarkably, these have said very little about the work those nurses actually did’ (p. xi). The First World War is a central subject in many fine histories of medicine, for, like the Napoleonic wars, it stimulated medical research and led to the development of new surgical techniques. Nurses certainly featured in histories of the Great War, but less for their importance to the medical endeavour, than for the revelation of women’s endurance under extreme pressure. The books that leave the most lasting impression of wartime nurses are not histories, but the unforgettable literary accounts by Ernest Hemingway and Vera Brittain. Yet, as Hallett points out, it was nurses who were chiefly responsible for the continuing care of wounded men, and for implementing the new types of wound treatment when the doctors’ initial work was done. Hallett emphasizes nurses’ work in holding together both shattered bodies and shattered minds, hence the book’s title. ‘Containing trauma’ deals with the techniques for maintaining stability while healing took place.
The book is organized around different aspects of the theme of ‘containment’. Containment of physical trauma includes the grosser conditions encountered close to the front: haemorrhage, sepsis, physiological shock, the effects of toxic gas, and, because nursing work did not end when the patient was beyond hope, coping with the dying. Under the heading ‘relief and restoration’, Hallett describes longer-term treatments, such as the aftermath of surgery, handling pain, and rehabilitation. These two sections are focused mainly on the Western Front, and are followed by a chapter on nursing in more far-flung places, particularly in the Middle East and on hospital ships in the Mediterranean. Although the nurses’ living and working conditions were hardly ideal in many of the western hospitals, they were even more basic and badly supplied in these areas, and Hallett is concerned not only with the nurses’ work, but how they coped with the constant threats to their own health and efficiency. The next section deals with mental and emotional issues, including shell-shock, and the final chapter with ‘self-containment’, the nurses’ relationship with their patients, and their own mental and physical condition.
Hallett’s main sources are a very wide range of personal accounts from the nurses themselves – letters, diaries and published memoirs. She has tracked these down in a number of Commonwealth archives as well as in Britain, and so her story also draws on the experiences of Australian, New Zealand and Canadian nurses. She recognises that each type of source has its own pitfalls. Letters had to be written with the censor in mind. Memoirs might be unreliable or written for a particular audience. Hallett contends, I think rightly, that these objections are less significant when the subject is the everyday work of nurses. Descriptions of events and relationships in personal accounts may be distorted for various reasons, but the routine work of the nurse, and the techniques she employed, are less likely to be forgotten or elided. In novels written by nurses, the characters and events may be fictitious, but the descriptions of nursing work are usually rooted in experience. These accounts therefore offer cumulative, rather than individual, evidence of nursing work.
This book is engrossing and extremely readable in spite of its appalling subject matter. The tone is set in the first section with the reception of wounded from the front line into the casualty clearing stations. Here the medical team tried to revive patients suffering from physical shock so severe that death might occur before surgery could begin. In these conditions, the usual boundaries between medical and nursing broke down far more rapidly than in peacetime conditions. The medical staff struggled to cope with emergency surgery, and so the trained nursing staff took on duties that would not normally fall to them, such as triage, administration of saline drips and intravenous injections, and the dispensing of stimulant and narcotic drugs. Legally, only doctors could prescribe these, but, as Hallett notes, ‘in the tense, urgent atmosphere of a CCS, details of frequency and dosage were often left to [the nurses’] discretion’ (p. 32). It is interesting that a number of these techniques were returned firmly to the medical province after the war, though they moved over to nurses again in later decades.
In the conditions of the Western Front, where wounds were contaminated with mud from agricultural land, the medical staff were confronted with sepsis that was no longer common in aseptic British hospitals, together with other life-threatening infections such as tetanus and ‘gas gangrene’. The nursing staff were responsible for implementing many of the new research developments aimed at combating infection. They administered the new tetanus injections (a laborious process), and the complex Carrel Dakin treatment, constantly irrigating wounds with a weak solution of sodium hypochlorite. Nurses had to care for the apparatus as well as the patient. The Carrel Dakin method involved a mass of rubber and glass tubes, all of which had to be kept sterile. Trained nurses passed on to the volunteers (VADs) the time-consuming hospital techniques of their own training, with particular emphasis on clean hands. They had also to cope with the effects of new wartime technology, using oxygen cylinders for soldiers with lungs full of mustard gas, and sodium bicarbonate lotion for their blinded eyes. Having cared for the wounded in the often primitive conditions of the clearing stations, nurses were then detailed to accompany them during their journeys to base hospitals in overcrowded hospital trains.
A number of personal accounts by wartime nurses were written by VADs like Vera Brittain. They had minimal training, though many, as a result of their war work, acquired considerable nursing skill. Some, highly literate feminists, wrote accounts of their experiences that were intended to emphasize the essential role of women in the war. While drawing on these accounts, Hallett gives more emphasis to the professional nurses who had to manage chaotic situations, while organizing teams of volunteers and orderlies. Under war conditions, even the more basic duties of nursing required exceptional administrative skills, as in the account by one nurse of taking 480 sick and wounded on a hospital train, with a junior nurse, one doctor and two orderlies. Seeing that all were fed properly was ‘a stupendous business’ (p. 108). VADs could cook and clean, but the overall organization of these tasks required managerial skills.
Hallett’s account of nursing in the distant theatres of war is an interesting contrast to the more familiar story of the war in France. In Salonika and the Middle East, nurses worked and lived in tents, with poor supply lines for food, and difficulty in finding clean water. Nurses and patients coped with heat, flies, dust, snow, mud, enteric diseases and malaria, while those on board the hospital ships off Gallipoli came within firing range to collect the wounded. Hallett puts all this into perspective, while still concentrating on the work done by nurses in these extreme conditions. Their own diaries and letters tended to emphasize the ‘travel’ aspects of foreign places, but Hallett extracts much information on the types of treatment offered and the nature of nursing work in adverse conditions.
In her chapter on ‘emotional containment’, Hallett ventures into more difficult territory. Nurses had to deal with psychological as well as physical suffering. ‘Shell shock’ and the trauma of war have continued to fascinate, with Pat Barker’s highly regarded fiction following the story first told by Siegfried Sassoon and Robert Graves. There were severe cases that required specialized treatment in Britain, but many wounded soldiers suffered various degrees of trauma that could be ameliorated in comfortable and orderly surroundings. Hallett argues convincingly that nurses have largely disappeared from the familiar accounts of psychological trauma, yet they were responsible for providing the environment that assisted recovery. This was the more traditional role of the nurse: restoring cleanliness, peace and order. For men who had been removed from their families, sometimes for years, Hallett argues that nurses represented ‘home and normality’. The relationship between patient and nurse, she contends, had to be asexual, with the nurse trying to avoid ‘both cold, clinical professionalism and romantic attachment’ (p. 178). Nurses also had to provide spiritual comfort for the dying, and remain with them to the end. Hallett is aware of the irony, as emphasized in Joanna Bourke’s Dismembering the Male: Men’s Bodies, Britain and the Great War(2), that the medical duty of repairing bodies and minds had a primary aim of returning men to face mortal danger. Nevertheless, she concentrates on the ‘artistry’ of the nurse, who had to achieve self-containment in order to perform her work: ‘Nurses protected the psyches of their patients by being available to those who were suffering. This sounds simple, but was in reality, incredibly difficult to achieve: being with a severely mutilated and psychologically distressed patient and showing neither horror nor fear took some practice’ (p. 158). Experienced nurses were perhaps better able to meet this challenge, but they could help the VADs to meet it also.
This is a fine and moving book. I have two reservations, which do not detract from its value as a historical account. Firstly, Hallett sometimes relaxes her critical approach to her source material. Some of the most interesting accounts are from personal letters, yet these must have been greatly affected, less by the censor, than by the tailoring of news to a particular recipient. If one is looking for sexual attachments in wartime nurses, they are hardly likely to appear in letters to parents. Hallett did not entirely convince me that nurses and officers formed no romantic ties. Traditional footnoting of letters always used to include the recipient as well as sender, and would be particularly desirable in a work like this. Secondly, were there no bad nurses in World War I? Following hints from the diaries of Irene Rathbone and Enid Bagnold, Hallett briefly comments that some nurses’ outlook ‘probably bordered on the callous’ (p. 159). Since the nurse-patient relationship was a mutual one, would soldier’s accounts throw further light on this subject? These are quibbles. Christine Hallett’s book helps to restore nurses to their rightful place in the front line in coping with the wreckage of war.