Ward life was regimented. The beds were iron with feather mattresses, a blanket and sheet underneath and three blankets and a counterpane on top. Alternate upper small windows were left open all the time with the ambient temperature kept at sixty degrees. An anti-toxic serum from immunized horses, newly developed by Prussian bacteriologist Emil von Behring, was given to those seriously ill with diphtheria. At first the serum was brought from Paris, but then the Royal College of Medicine stabled and kept ten horses and produced their own. The hospital boards of governors and some patients objected. They did not want biological affinity to monkeys or horses.
Edith Cavell was at the Fountains Hospital for seven months. The annual report of the Hospital for 1896 showed how heavy her workload must have been and how dangerously ill many of the patients were. Of the 3,640 patients treated, 1,335 recovered and were discharged, 1,665 went on to convalescent hospitals, 278 died, a quarter of them within forty-eight hours of admission, and 372 were in the hospital at the year’s end. Children were the main casualties. Those choking because of respiratory infection were given immediate tracheotomies. There were no antibiotics, no cure for acute inflammation.
Without informed cures, patient survival depended on good nursing: cold sponging to keep down fever, mustard poultices to alleviate inflammation, enemas of castor oil, repeated turning to prevent bedsores, rest, loving attention, invalid cooking with unlimited milk and eggs and ten ounces of beef tea daily, a calm environment and above all scrupulous hygiene.
Much of Edith Cavell’s work was menial: making beds, polishing and dusting, stoking fires, relaying messages, fetching and carrying, distributing meals, emptying bedpans. It was an induction into the procedures of a busy hospital and a test of her stamina and of whether this was the vocation she wanted to pursue. It was hard and dangerous work with chronically sick patients, demanding hours, strict rules and institutional living in an all-female environment with women for the most part younger than herself and from whom she had to take orders. The overriding imperative was that the patient came first. Any lateness or lapses on her part were recorded. The nurses’ living quarters were cramped and there was no privacy. In the time she was there, one assistant nurse died from pneumonia, three charge nurses, five assistant nurses and one ward maid caught scarlet fever, and four ward maids got diphtheria.
Edith Cavell’s application to be a probationer nurse at the London Hospital, April 17, 1896
Within a few months of being at the Fountains, Edith Cavell decided to take formal training and make nursing her career. On April 17, 1896 she applied to the London Hospital in Whitechapel in the East End—where her mother had lived as a child—to be a probationer nurse. The pay would be £12 in the first year, £20 in the second—less than at the Fountains. She said she was strong, had always had good health, had perfect sight and hearing and was single. Married women were not accepted unless widowed.
Miss Dickenson gave her a reference. On April 25 she wrote that she had “known Edith Cavill since December 1895.” Miss Cavill was “Orderly, Methodical & of kindly & gentle disposition, had an equable temper, a very pleasant manner, was well-educated, intelligent & capable, of good moral character and carried out her work satisfactorily.” She was, said Miss Dickenson, “a very suitable candidate for training as a hospital nurse.”
The Norfolk neighbor Annette Roberts of Brinton Hall again gave a character reference. She said she had known Edith for fifteen years and was glad of the opportunity to recommend her: she was energetic, adaptable, intelligent, decidedly capable, of high moral character and self-reliant yet willing to follow guidance. She had always had a high opinion of her.
After an interview with Eva Lückes, matron at the London, Edith Cavell was offered a place as a probationer nurse. She accepted it on July 18. She left the Fountains and went home to Swardeston to spend the summer with her mother. On September 3, 1896 she began, at the London Hospital, to train for what was to be her life’s chosen work.
10
THE PROBATIONER
Eva Lückes had been matron of the London Hospital for sixteen years. Aged forty—only ten years older than Edith Cavell—she was a friend and disciple of Florence Nightingale’s and dedicated to making the hospital a center of excellence for nursing care.
A large, purposeful woman—she looked like Queen Victoria, in group photographs with her nurses she presided at the center, conspicuous for her size and the dark of her uniform against their rows of starched white. The daughter of a wealthy banker and educated at Cheltenham Ladies’ College and a finishing school in France, she exuded the confidence of her class and ruled with the authoritative manner of a headmistress or an army commander.
The demands on the London Hospital were great. The East End was an area of squalid accommodation and bad sanitation, home to immigrants and the urban poor. It was also, because of the development of the docks and England’s trade by sea, the commercial center of the capital. The London was what was called a voluntary hospital, dependent on private funds and charitable donations. Such hospitals had medical schools and were patronized by royalty. They were staffed by the best physicians whose practices for private patients were in the smart West End and who two or three times a week went by carriage to do their hospital ward rounds and to operate. Treatment was for the most part free, but patients were assessed by doctors for admission and turned away if they could afford private care, or were destitute, mentally ill, or incurable.
The London Hospital, Whitechapel, where Edith Cavell trained as a general nurse
Eva Lückes c. 1900, Matron of the London Hospital from 1880 until her death in 1919
The London Hospital’s seven hundred beds were not enough to cope with demand. Staff nurses were also sent out from the hospital to give private care to paying patients in their homes. For many illnesses there was no reliable treatment: no insulin for diabetes, no knowledge of blood groups, or effective treatment for tuberculosis, no understanding of how to cure meningitis, septicaemia, pernicious anemia. Purging and bloodletting with leeches were standard, chloroform and ether were used as anesthetics and post-operative vomiting and confusion was routine.
The suffering of the ill was acute, and nursing care all-important. Following on from Florence Nightingale, Eva Lückes aspired to take nursing from its haphazard, unorganized, untaught, unclean and unrespected status and turn it into a noble profession for women. The day after her appointment as matron in 1879—at the age of twenty-four—she told the management committee at the London that the nursing staff were grossly inadequate in quality and numbers. Their sleeping quarters, she said, were “scattered in five directions,” they had no proper meals, no terms of employment. She insisted on the provision of decent living accommodation for her nurses, bathrooms for them, a training school.
She set about creating a syllabus of instruction in practical nursing and she persuaded the medical staff to give lectures on anatomy, surgery and physiology. By 1882 she had introduced examinations for probationers with the prompt of prizes and certificates of attainment. There was no centralized state registration. Each hospital awarded its own certificate and set its own standard. State registration, both Eva Lückes and Florence Nightingale believed, would standardize mediocrity.
Nor was there any state funding. Lack of money was a constant curtailment to plans. Windfalls were occasional. In 1884 the East London Railway wanted to extend the line from Whitechapel to Surrey Docks with a tunnel going under the hospital. As compensation for the disruption they paid the hospital £30,000, which was used as core funding for a nursing school and medical college. The Prince of Wales’s wife, Alexandra, opened both buildings in 1887.
In the same year as Edith Cavell started at the London as a probationer, Sydney Holland was elected its chairman. He said that despite Eva Lückes’s efforts “there was a blight over everything.”
There was only one operating theatre and only one table, a wooden affair like those in butchers’ shops. Aseptic surgery was just comi
ng in but the staff were still doubtful about it. When a surgeon went round he was followed by the beadle who carried a baize-covered tray containing instruments which were used and reused with complete disregard of the principles of asepsis. One tiny room sufficed for bacteriological work. There was no clinical laboratory. Röntgen had discovered his rays but a small shed in the garden was all the accommodation the London could spare for X-ray work. Most of the nurses lived a “Box and Cox life”5 and many lodged in the small houses in the district. There was only one Nurses Home. On the financial side the position was depressing. The subscriptions for 1895 had fallen to only £8,750. Nevertheless what I saw impressed me with the ambition to put things right. So I set to work and worked as I had never worked before in all my life.
Between them Sydney Holland—he became Viscount Knutsford—and Eva Lückes transformed the hospital. He was a tireless fundraiser and within a decade had persuaded rich financiers like the Rothschilds to pay for a new isolation ward, an outpatients’ unit, new operating theaters, a new nurses’ home and a block of new wards.
Probationer nurses at a “sickroom” cookery class, 1901
And so, on September 3, 1896, Edith Cavell began her nursing training at the start of a great movement for reform in the hospital’s practice and administration. She was one of an intake of ten. For the first six weeks she lived in at Tredegar House, the probationers’ school at 99 Bow Road, a short distance from the main hospital. The house, given to the London by Lord Tredegar, had opened the previous year and was the first preliminary training school in England. Its objective, Miss Lückes said, was “to soften the ordeal of the first beginning of hospital life for newcomers.”
Edith Cavell had had some experience of hospital life. Not many of the other newcomers knew what to expect. Among them Annie Hogg had worked in a drapery, Ella Robertshaw lived at home, Rebecca Startin had packed cartons for a living, Gertrude King was a widow, Marjorie Macfadyen was a masseuse, Gertrude Deighton and Emma Davie had both been teachers.
Probationers were issued with a uniform of mauve check cotton with removable lower sleeves and a white bibbed apron and white cap. They got up at 6:15 a.m., breakfasted at 7:00, then after prayers attended classes on bandaging, practical cooking, splint padding, ambulance work, and the chemistry of food, and lectures on physiology, hygiene and theoretical nursing. They had two hours off duty during the day and finished work at 8:30 in the evening. “Lights out” was at 10:30. One morning a week was given over to cleaning and housework. A “monitress,” appointed each day, checked there was no talking during class hours.
Miss Lückes kept large ledgers on the qualities, skills and shortcomings of all her nurses. It was a time of leather-bound, gold-embossed ledgers and account books with entries in scripted handwriting. Her manner was tough but personal. She was critical of her nurses and ambitious for them all to do well. She did not challenge the conventional view of “a woman’s place,” but in her lectures roused her probationers with vocational zeal and reminded them of their duty of subservience to the doctors and their caring role as women and Christians. Repeatedly she went to the first principles of nursing, to the underpinning concept of care. “You have chosen a profession,” she told them, “in which there is simply no limit to the good you can do.”
You must walk worthy of the vocation wherein you are called. The science of medicine and the art of nursing materially assist each other in their ultimate objects; the cure where that is possible and failing that the alleviation of suffering.
Especially when your patients are weak and helpless and irritable you need to be gentle and considerate towards them; they are so completely in your power and they may so easily be made to suffer more than they need to by your having a sharp way of speaking, a rough touch, or a grumbling manner of attending to them. Unless you have been very ill yourself you have no notion how weak patients depend for their own courage on their nurse’s strength. The best guide is simply to judge whether you would like to have such offices as you may have to perform for your patients rendered in the same manner that you are adopting towards them.
Truthfulness, obedience, and punctuality, are indispensable qualities. Each of you who wins our certificate of training will have it in your power to make us proud of your connection with us in the future or very sadly the reverse.
Selfishness is pre-eminently a defect which disqualifies a woman from the nursing profession. You must strenuously cultivate a self-controlled manner. A nurse who screams, who flies aimlessly about in all directions … Self-control must be gained if you are to be thoroughly efficient. A want of self-control is selfish, showing you do not put your patient first.
For Edith Cavell such instruction resonated with what she felt and all she had been brought up to believe. Eva Lückes’s exhortations were for her the practical manifestation of the love prescribed in Thomas à Kempis’s writings in The Imitation of Christ. From her father Edith Cavell had learned the demands and expectations of Christian faith. From Eva Lückes she was to learn that the implementation of charity required goals, high standards, vigilance and management.
After six weeks’ induction, probationers moved to the main hospital. Edith Cavell had a room in the nurses’ home. There was the same brutal timekeeping. Up at 6:00, breakfast at 6:30, on duty at 7:00. It was a twelve-hour day with half an hour off for lunch, and two hours off during the day when and if pressure of work allowed. On night duty the hours were 9 p.m. until 8:00 in the morning. She had a fortnight’s holiday a year.
She worked for an allotted time in all the wards of the hospital. She was moved from a men’s surgical to a women’s medical ward, from a gynecological to a children’s ward, from admissions to the operating theater. The objective was to gain experience in all aspects of hospital care. She worked to instruction from the staff nurse and she was overseen by the ward sisters, each of whom had a sitting room and bedroom on the ward where she was in charge. The sisters sent their reports on Edith Cavell to Eva Lückes: her dates of duty, whether she was on days or nights, the range of problems she had faced, an assessment of her performance.
Much of the work of the probationer nurses was skivvying. Untrained “scrubbers” were paid to do arduous work like washing the floors and laying and stoking the large open fires, but the probationers dusted the iron bedsteads, polished the brass plaques above the ward beds and the copper tea urns, sorted laundry, gave patients their meals, emptied bedpans, made shrouds for the dead. At 6:00 in the evening they attended lectures. “Be careful not to get into the habit of leaning up against the tables and chairs and the patients’ beds under any circumstances,” their matron taught them. “It always gives an impression of slovenliness. Of course you will never think of sitting down or of remaining seated while you are speaking or being spoken to by any of the medical staff whether a senior or junior member of it, including the dressers and students. It looks unbusinesslike and unprofessional.” She instructed them in how to warm and oil bedpans, clean splints, give ice baths for typhoid (“brandy is frequently administered to the patient while in the bath”), apply and remove leeches (“a little salt sprinkled on them will cause them speedily to relinquish their hold”). She taught them how to prepare patients for operations (“for amputations or where there is a probability of much bleeding a tray with sawdust should be placed under the operation table ready for use”), how to rouse patients to consciousness after anesthetic (“water and a towel must be flapped about the patient’s face”), how to insert a catheter, clear blocked tracheotomy tubes with a feather, give hypodermic injections (“brandy and other stimulants are sometimes injected hypodermically but this is almost always done by the doctor”). She impressed on them that they must ventilate the wards: “You have to fight against the proverbial horror of fresh air peculiar to the class of people from which most of your patients come.”
Every detail of care was covered: “Scarlet blankets form the best sort of coverlets. It is popularly supposed they help to keep away the fleas.�
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There was in the hospital a nurses’ library and a museum of specimens and instruments. Physicians gave lectures in pathology and medicine. Frederick Treves, a surgeon, taught anatomy and surgery. It was he who rescued Joseph Merrick, known as “the elephant man” and who was probably suffering from a disease called neurofibromatosis, from the indignity of being a sideshow exhibit viewed for 2d., and gave him shelter at the London Hospital. Treves described Eva Lückes as “one of the ablest and most remarkable women of the age, an organiser with unequaled genius.” He said she transformed the hospital. “There breathed through the harsh and dismal building a woman’s influence like a breath of Spring. By some magic force the nurses became obedient, efficient and proud of their work.”
Sir Frederick Treves (1853–1923) surgeon and teacher at the London Hospital
Edith Cavell wrote her notes in a black book in the neat forward-sloping handwriting taught her by her father. She wrote of tracheotomies for children with typhoid fever: “if the tube is coughed out the child must be laid across the nurse’s knee with the head thrown back and the wound held open until the tube can be replaced”; of how to stem their bleeding from cut tonsils or from circumcision; of the use of cocaine, morphine and champagne to alleviate pain; of how to give bread and charcoal poultices.
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