The Nightingale Shore Murder (9 page)

By the time Florence started her training, men had effectively muscled in on the business of attendance at childbirth.

They had been interested in it for centuries: Leonardo da Vinci was drawing babies in the womb, based on knowledge gained through dissection, as early as 1500. The first printed book on midwifery (by a man) was published in 1513 and other major works appeared in the 17
^th
and 18
^th
centuries. It was during these centuries that the ‘man midwife' became commonplace.
Man-midwifery dissected,
published in 1793, actually argued against the trend. It depicted men midwives surrounded by instruments and medicines, while the woman midwife was shown in a domestic context, implying a more natural and gentle approach. Apart from different approaches to the birth itself, there were also strong factions which regarded a man's involvement at the birth as simply indecent. Morals and methods aside, though, there is no doubt that the men midwives contributed a great deal to the knowledge about childbirth and the procedures surrounding it. They were responsible for the invention and refinement of many familiar elements of modern childbirth: anaesthesia, forceps for difficult deliveries, and obstetric surgical procedures. And in Dublin, the hospital itself owed its existence to the passion and persistence of a man midwife.

The Rotunda Hospital (
Ospideal an Rotunda
), which Florence chose for her training, was another famous and venerable institution. It had been founded in 1745 by Bartholomew Mosse, a surgeon and man-midwife, as the ‘Dublin Lying-In Hospital'. Mosse was born in 1712, and served an apprenticeship to a Barber Surgeon in Dublin. From 1733 he practised as a surgeon and man-midwife. Midwives at this time had no special training, but could be licensed by Royal College of Surgeons in Dublin; following trips to Europe to develop his midwifery knowledge, Mosse obtained his licence from the College in 1740. The winter of 1739 to 1740 had seen a dreadful potato famine in Ireland, and the appalling conditions in which destitute mothers gave birth were the spur for Mosse to found a hospital to provide for these mothers in Dublin. He also wanted to train midwives and surgeons to care for mothers in the other counties of Ireland.

The first premises of the Dublin Lying-In Hospital were a former theatre, which opened as the hospital in 1745. As the number of women needing its services rapidly outstripped the facilities, Mosse raised funds for a new, purpose-built hospital through a combination of fundraising events – plays and performances of Handel Oratorios – and lotteries which he ran himself. For one of these he was charged with fraud and arrested in Anglesey. He escaped to mainland Wales and eventually back to Dublin, where he managed to explain away the misunderstanding over his handling of the lottery money. Mosse worked with the architect Richard Cassells on the design for the new hospital, insisting on small wards – which later helped to limit the spread of the often-fatal puerperal (childbirth) fever – as well as a tower on top of the building which, while having no practical purpose, became a famous symbol of the hospital. The Rotunda name came from one of amphitheatres included on the site as venues for fundraising activities.

The hospital was awarded a Royal Charter in 1756, which set up a system of Masters for the institution, each to serve a single seven year term, which has continued ever since. The new hospital opened the following year, making the building already 120 years old when Florence arrived, while the institution itself had more than 150 years of history. Mosse did not live to see his new hospital in action for long. He died in 1759 at the age of forty seven, in poverty, and was buried in an unmarked grave in Donnybrook Cemetery.

Florence's midwifery training followed a long period of development and some bold new experiments in the care of women giving birth. Chloroform had been used in the Rotunda for forceps deliveries from the mid-1800s. A home birth service had been established twenty years before Florence's arrival, incubators were being used for premature babies, and the first Caesarean section at the Rotunda was performed just 10 years earlier. More than one hundred sections were carried out during the Mastership that ran from 1889 to 1896. By 1896, the Master (the wonderfully-named Dancer Purefoy) was reporting the extensive use of gynaecological surgery, and the opening of the first Pathological Laboratory at the Rotunda.

But it was not all progress and success at the hospital. Puerperal fever came in epidemic waves, as it did at all maternity institutions, killing many of the mothers. And the doctors struggled to find ways to reduce the rate of infant mortality, which at times was as high as one baby in six, without a full understanding of infection control, and without antibiotics. All they could think of was increasing the ventilation of the wards. Florence must have seen many tragic losses and much grief during her midwifery training: experience that would stand her in good stead for future work in two war zones.

As soon as she was back from Dublin, Florence and Mabel enrolled at the Queen Victoria Jubilee Institute for Nurses in London, and started their district nurse training there in June 1897. They were about to become ‘Queen's Nurses'.

‘
Hospitals
,' Florence Nightingale wrote in 1876, ‘
are but an intermediate stage of civilisation. At present hospitals are the only place where the sick poor can be nursed, or, indeed, often the sick rich. But the ultimate object is to nurse all sick at home.'

Florence Shore's godmother is chiefly remembered for her influence on the nursing of wounded soldiers, and the organisation of hospital nursing. But she was also a prime mover in the founding of district nursing, and took a close interest in the development of nursing in the home throughout her life.

The idea of an organised system of nurses specially trained to care for people in their own homes originated with William Rathbone (the sixth of the name), a Liverpool merchant and philanthropist. When his wife was gravely ill following the birth of their fifth child in 1859, Rathbone engaged a nurse, Mrs Robinson, to care for her. Mrs Robinson was to have an enormous influence on her employer. She demonstrated ‘
the great comfort and advantage derived from trained nursing, even in a home where everything which unskilled affection could suggest was provided
,' as Rathbone later wrote in his own history of district nursing. After his wife died, Rathbone engaged Mrs Robinson for a further three months, to take her nursing skills into the homes of the ‘sick poor' in Liverpool.

After only a few weeks, however, she baulked at the task. Rathbone records:

This is hardly surprising. Liverpool was in the throes of a population explosion: from a population of 75,000 in 1800, the combination of famine in Ireland and the growing trade with America through Liverpool's port had brought thousands more people flocking to the city. By 1871, the city had more than 490,000 inhabitants, thousands of whom lived in windowless cellars, in spite of efforts to clear them after the Liverpool Sanitary Act. Thousands more lived in court houses: tall, narrow buildings with one room on each floor, built around a courtyard and back-to-back with other courts, restricting the flow of fresh air. Whole families shared single rooms in these houses, and sanitation was primitive, with only one or two toilets for the whole court. The one tap in the courtyard, serving everyone in the court house, was often only operational for part of each day. Infectious diseases such as typhus and cholera were commonplace, poverty led to all the ills of malnutrition, and there was virtually no organised health care available to people who could not pay for it, other than the workhouse hospitals.

Of these, Rathbone had considerable knowledge. He had already been involved in trying to improve standards at the Brownlow Hill workhouse infirmary: an institution of 1200 beds, overseen by two female officers, who, though not nurses themselves, supervised the nursing. They were assisted by pauper women ‘
who
', Rathbone observed, ‘
were as untrustworthy as they were unskilful'.

In spite of the huge number of beds, the hospital was over-subscribed, with three or four patients to a bed – not all of whom, in Rathbone's view, needed to be there:

After consultation with Florence Nightingale – with whom Rathbone collaborated and corresponded throughout his life – Miss Agnes Jones was brought in, with nurses from St Thomas's Hospital in London, to tackle the hospital's problems. She immediately began to reduce the numbers of patients, and attempted to introduce training for the pauper women. Both Rathbone and Florence Nightingale were devastated when Miss Jones died after just two years in post.

Mrs Robinson, meanwhile, was persuaded to stay on in spite of her misgivings, and continue her work with the sick poor in their own homes. She found, Rathbone reported with satisfaction,

So the model worked, and Rathbone wanted to extend the benefits of home nursing to more of the sick and needy in Liverpool. He was ahead of his time in his conviction that people were better cared for in their own homes. In his book, he sets out four good reasons for home rather than hospital care that perfectly match the arguments put forward for ‘care closer to home' today. His arguments started with the observation that many people had chronic conditions that could not be cured, so had to be dealt with at home. In addition, people preferred to be at home with their families; and hospitals lacked the capacity to cope with the level of demand, if everyone with any ailment needed to be taken in to hospital. Finally, he pointed out, hospital care was expensive, so it was more efficient to care for people at home.

But he ran into a problem in setting up a home nursing service. There were not enough properly trained nurses – such as those trained by the Florence Nightingale method at St Thomas's in London – to recruit into the service. Rathbone, after his experiences with trying to improve hospital care, was absolutely convinced that a dedicated training school for nurses was the key to good care.

Rathbone approached Florence Nightingale, who had supplied Agnes Jones and nurses for the Brownlow Hill infirmary, to see if she could spare more nurses for his district work. But all the Nightingale nurses were needed for hospital work, so Miss Nightingale suggested that he start his own training school. The Liverpool Training School and Home for Nurses was built in the grounds of the Infirmary, and paid for by William Rathbone. It was closely linked with the Infirmary, and aimed to provide ‘
thoroughly educated professional nurses for the Infirmary; district nurses for the poor; sick nurses for private families
'. The curriculum for district nurse training included technical class instruction in hygiene (ventilation and sanitation – students had to be able to draw a diagram of the sanitary and plumbing system of a house); nutrition and diets; fevers (diagnosis and disinfection); diseases of women; monthly nursing including the care of newborn infants; practical sick cookery; bandaging; and the use of medical and surgical appliances.

Meanwhile, on the practical side, Liverpool was divided into 18 districts, deliberately made coterminous with parishes or groups of parishes in order to foster the cooperation of the clergy; although the service was strictly non-denominational. A lady or committee of ladies was appointed to superintend the work of each district (but not, as they were not themselves nurses, to supervise the nurses). The lady superintendent's duties were to visit – in person or by deputy – all cases under treatment, to ensure that the nurses were ‘working faithfully and well'. She examined the nurse's register of patients and heard reports on patients; and arranged the supply, custody and distribution of medical appliances. The superintendents also kept memoranda of expenses incurred, and articles lent. Alongside district nursing, Liverpool had instituted that much less appreciated species, the health service manager.

As a city, Liverpool took great pride in its role in the invention of district nursing. At the 1909 Jubilee Congress, celebrating 50 years since William Rathbone's engagement of Mrs Robinson, the Lord Mayor of Liverpool said with evident satisfaction:

It was a friend of William Rathbone's, Charles Langton, who instituted another practical aspect of district nursing that would shape the working lives of Florence Shore and Mabel Rogers, along with thousands of other district nurses. He suggested that, rather than being isolated in lodgings or rooms of their own, district nurses should be accommodated together in a ‘district home', under the supervision of a professionally-qualified matron. This would allow them to support each other, and learn from each other's experiences. It also allowed the matron to ensure that they were engaged in proper nursing and not in ‘poor relief' – a major concern of Florence Nightingale's, who felt that acting as welfare agents ‘
demeaned the noble art of nursing
'. With training, nurses' homes and a service in place, the ‘Liverpool model' (or the Rathbone/Nightingale model) spread rapidly to other cities. In 1868, the East London Nursing Society was founded on a similar model, although without the district homes. The Metropolitan and National Nursing Association, initiated by the Council of the Order of St John of Jerusalem, and supported by the Duke of Westminster, was set up 1874; and most of the other major cities in England followed suit. Florence Nightingale was in no doubt of the success of this new model of nursing:

William Rathbone's own assessment of his scheme, in his history of district nursing, was simply that it was ‘
the story of a successful experiment'
.