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Problems

Level 3 Instruction Set Architecture

3. Information Representation
3.1 Unsigned Binary Representation
Binary Storage
Integers
Base Conversions
Range for Unsigned Integers
Unsigned Addition
The Carry Bit
3.2 Two’s Complement Binary Representation
Two’s Complement Range
Base Conversions
The Number Line
The Overflow Bit
The Negative and Zero Bits
3.3 Operations in Binary
Logical Operators
Register Transfer Language
Arithmetic Operators
Rotate Operators
3.4 Hexadecimal and Character Representations
Hexadecimal
Base Conversions
ASCII Characters
Unicode Characters
3.5 Floating-Point Representation
Binary Fractions
Excess Representations
The Hidden Bit
Special Values
The IEEE 754 Floating-Point Standard

8
3.6 Models
Chapter Summary
Exercises
Problems

4. Computer Architecture
4.1 Hardware
Central Processing Unit (CPU)
Main Memory
Input/Output Devices
Data and Control
Instruction Format
4.2 Direct Addressing
The Stop Instruction
The Load Word Instruction
The Store Word Instruction
The Add Instruction
The Subtract Instruction
The And and Or Instructions
The Invert and Negate Instructions
The Load Byte and Store Byte Instructions
The Input and Output Devices
Big Endian Versus Little Endian
4.3 von Neumann Machines
The von Neumann Execution Cycle
A Character Output Program
von Neumann Bugs
A Character Input Program
Converting Decimal to ASCII
A Self-Modifying Program
4.4 Programming at Level ISA3
Read-Only Memory
The Pep/9 Operating System
Using the Pep/9 System
Chapter Summary

9
Exercises
Problems

Level 5 Assembly

5. Assembly Language
5.1 Assemblers
Instruction Mnemonics
Pseudo-Operations
The .ASCII and .END Pseudo-ops
Assemblers
The .BLOCK Pseudo-op
The .WORD and .BYTE Pseudo-ops
Using the Pep/9 Assembler
Cross Assemblers
5.2 Immediate Addressing and the Trap Instructions
Immediate Addressing
The DECI, DECO, and BR Instructions
The STRO Instruction
Interpreting Bit Patterns: The HEXO Instruction
Disassemblers
5.3 Symbols
A Program with Symbols
A von Neumann Illustration
5.4 Translating from Level HOL6
The Printf() Function
Variables and Types
Global Variables and Assignment Statements
Type Compatibility
Pep/9 Symbol Tracer
The Shift and Rotate Instructions
Constants and .EQUATE
Placement of Instructions and Data
Chapter Summary

10
Exercises
Problems

6. Compiling to the Assembly Level

6.1 Stack Addressing and Local Variables
Stack-Relative Addressing
Accessing the Run-Time Stack
Local Variables
6.2 Branching Instructions and Flow of Control
Translating the If Statement
Optimizing Compilers
Translating the If/Else Statement
Translating the While Loop
Translating the Do Loop
Translating the For Loop
Spaghetti Code
Flow of Control in Early Languages
The Structured Programming Theorem
The Goto Controversy
6.3 Function Calls and Parameters
Translating a Function Call
Translating Call-by-Value Parameters with Global Variables
Translating Call-by-Value Parameters with Local Variables
Translating Non-void Function Calls
Translating Call-by-Reference Parameters with Global Variables
Translating Call-by-Reference Parameters with Local Variables
Translating Boolean Types
6.4 Indexed Addressing and Arrays
Translating Global Arrays
Translating Local Arrays
Translating Arrays Passed as Parameters
Translating the Switch Statement
6.5 Dynamic Memory Allocation
Translating Global Pointers
Translating Local Pointers

11
 Translating Structures
Translating Linked Data Structures
Chapter Summary
Exercises
Problems

7. Language Translation Principles

7.1 Languages, Grammars, and Parsing
Concatenation
Languages
Grammars
A Grammar for C Identifiers
A Grammar for Signed Integers
A Context-Sensitive Grammar
The Parsing Problem
A Grammar for Expressions
A C Subset Grammar
Context Sensitivity of C
7.2 Finite-State Machines
An FSM to Parse an Identifier
Simplified FSMs
Nondeterministic FSMs
Machines with Empty Transitions
Multiple Token Recognizers
Grammars Versus FSMs
7.3 Implementing Finite-State Machines
The Compilation Process
A Table-Lookup Parser
A Direct-Code Parser
An Input Buffer Class
A Multiple-Token Parser
7.4 Code Generation
A Language Translator
Parser Characteristics
Chapter Summary

12
Exercises
Problems

Level 4 Operating System

8. Process Management
8.1 Loaders
The Pep/9 Operating System
The Pep/9 Loader
Program Termination
8.2 Traps
The Trap Mechanism
The RETTR Instruction
The Trap Handlers
Trap Addressing Mode Assertion
Trap Operand Address Computation
The No-Operation Trap Handlers
The DECI Trap Handler
The DECO Trap Handler
The HEXO and STRO Trap Handlers and Operating System
Vectors
8.3 Concurrent Processes
Asynchronous Interrupts
Processes in the Operating System
Multiprocessing
A Concurrent Processing Program
Critical Sections
A First Attempt at Mutual Exclusion
A Second Attempt at Mutual Exclusions
Peterson’s Algorithm for Mutual Exclusion
Semaphores
Critical Sections with Semaphores
8.4 Deadlocks
Resource Allocation Graphs

13
 Deadlock Policy
Chapter Summary
Exercises
Problems

9. Storage Management
9.1 Memory Allocation
Uniprogramming
Fixed-Partition Multiprogramming
Logical Addresses
Variable-Partition Multiprogramming
Paging
9.2 Virtual Memory
Large Program Behavior
Virtual Memory
Demand Paging
Page Replacement
Page-Replacement Algorithms
9.3 File Management
Disk Drives
File Abstraction
Allocation Techniques
9.4 Error-Detecting and Error-Correcting Codes
Error-Detecting Codes
Code Requirements
Single-Error-Correcting Codes
9.5 RAID Storage Systems
RAID Level 0: Nonredundant Striped
RAID Level 1: Mirrored
RAID Levels 01 and 10: Striped and Mirrored
RAID Level 2: Memory-Style ECC
RAID Level 3: Bit-Interleaved Parity
RAID Level 4: Block-Interleaved Parity
RAID Level 5: Block-Interleaved Distributed Parity
Chapter Summary

14
Exercises

Level 1 Logic Gate

10. Combinational Circuits

10.1 Boolean Algebra and Logic Gates
Combinational Circuits
Truth Tables
Boolean Algebra
Boolean Algebra Theorems
Proving Complements
Logic Diagrams
Alternate Representations
10.2 Combinational Analysis
Boolean Expressions and Logic Diagrams
Truth Tables and Boolean Expressions
Two-Level Circuits
The Ubiquitous NAND
10.3 Combinational Design
Canonical Expressions
Three-Variable Karnaugh Maps
Four-Variable Karnaugh Maps
Dual Karnaugh Maps
Don’t-Care Conditions
10.4 Combinational Devices
Viewpoints
Multiplexer
Binary Decoder
Demultiplexer
Adder
Adder/Subtracter
Arithmetic Logic Unit
Abstraction at Level LG1
Chapter Summary

15
Exercises

11. Sequential Circuits

11.1 Latches and Clocked Flip-Flops
The SR Latch
The Clocked SR Flip-Flop
The Master–Slave SR Flip-Flop
The Basic Flip-Flops
The JK Flip-Flop
The D Flip-Flop
The T Flip-Flop
Excitation Tables
11.2 Sequential Analysis and Design
A Sequential Analysis Problem
Preset and Clear
Sequential Design
A Sequential Design Problem
11.3 Computer Subsystems
Registers
Buses
Memory Subsystems
Address Decoding
A Two-Port Register Bank
Chapter Summary
Exercises

Level 2 Microcode

12. Computer Organization

12.1 Constructing a Level-ISA3 Machine
The CPU Data Section
The von Neumann Cycle
The Store Byte Direct Instruction
Bus Protocols

16
 The Store Word Direct Instruction
The Add Immediate Instruction
The Load Word Indirect Instruction
The Arithmetic Shift Right Instruction
The CPU Control Section
12.2 Performance
The Data Bus Width and Memory Alignment
Memory Alignment
The Definition of an n-Bit Computer
Cache Memories
The System Performance Equation
RISC Versus CISC
12.3 The MIPS Machine
The Register Set
The Addressing Modes
The Instruction Set
MIPS Computer Organization
Pipelining
12.4 Conclusion
Simplifications in the Model
The Big Picture
Chapter Summary
Exercises
Problems

Appendix
Solutions to Selected Exercises
Index

17
Preface
The fifth edition of Computer Systems offers a clear, detailed, step-by-step
exposition of the central ideas in computer organization, assembly
language, and computer architecture. The book is based in large part on a
virtual computer, Pep/9, which is designed to teach the basic concepts of
the classic von Neumann machine. The strength of this approach is that the
central concepts of computer science are taught without getting entangled
in the many irrelevant details that often accompany such courses. This
approach also provides a foundation that encourages students to think
about the underlying themes of computer science. Breadth is achieved by
emphasizing computer science topics that are related to, but not usually
included in, the treatment of hardware and its associated software.

Summary of Contents
Computers operate at several levels of abstraction; programming at a high
level of abstraction is only part of the story. This book presents a unified
concept of computer systems based on the level structure of FIGURE
P.1 .
The book is divided into seven parts, corresponding to the seven levels
of Figure P.1:

Level App7 Applications

Level HOL6 High-order languages
Level ISA3 Instruction set architecture
Level Asmb5 Assembly
Level OS4 Operating system
Level LG1 Logic gate
Level Mc2 Microcode

18
The text generally presents the levels top-down, from the highest to the
lowest. Level ISA3 is discussed before Level Asmb5, and Level LG1 is
discussed before Level Mc2 for pedagogical reasons. In these two
instances, it is more natural to revert temporarily to a bottom-up approach
so that the building blocks of the lower level will be in hand for
construction of the higher level.

Level App7
Level App7 is a single chapter on application programs. It presents the
idea of levels of abstraction and binary information and establishes the
framework for the remainder of the book. A few concepts of relational
databases are presented as an example of a typical computer application.

Level HOL6

19
Level HOL6 consists of one chapter, which reviews the C programming
language. The chapter assumes that the student has experience in some
imperative language, such as Java or Python—not necessarily C. The
instructor can readily translate the C examples to other common Level
HOL6 languages if necessary.
This chapter emphasizes the C memory model, including global versus
local variables, functions with parameters, and dynamically allocated
variables. The topic of recursion is treated because it depends on the
mechanism of memory allocation on the run-time stack. A fairly detailed
explanation is given on the details of the memory allocation process for
function calls, as this mechanism is revisited at a lower level of abstraction
later in the book.

Level ISA3
Level ISA3 is the instruction set architecture level. Its two chapters
describe Pep/9, a virtual computer designed to illustrate computer
concepts. Pep/9 is a small complex instruction set computer (CISC); a von
Neumann machine. The central processing unit (CPU) contains an
accumulator, an index register, a program counter, a stack pointer, and an
instruction register. It has eight addressing modes: immediate, direct,
indirect, stack-relative, stack-relative deferred, indexed, stack-indexed, and
stack-deferred indexed. The Pep/9 operating system, in simulated read-
only memory (ROM), can load and execute programs in hexadecimal
format from students’ text files. Students run short programs on the Pep/9
simulator and learn that executing a store instruction to ROM does not
change the memory value.
Students learn the fundamentals of information representation and
computer organization at the bit level. Because a central theme of this
book is the relationship of the levels to one another, the Pep/9 chapters
show the relationship between the ASCII representation (Level ISA3) and
C variables of type char (Level HOL6). They also show the relationship
between two’s complement representation (Level ISA3) and C variables of
type int (Level HOL6).

Level Asmb5
Level Asmb5 is the assembly level. The text presents the concept of the
assembler as a translator between two levels—assembly and machine. It
introduces Level Asmb5 symbols and the symbol table.
The unified approach really comes into play here. Chapters 5 and 6
present the compiler as a translator from a high-order language to

20
assembly language. Previously, students learned a specific Level HOL6
language, C, and a specific von Neumann machine, Pep/9. These chapters
continue the theme of relationships between the levels by showing the
correspondence between (a) assignment statements at Level HOL6 and
load/store instructions at Level Asmb5, (b) loops and if statements at Level
HOL6 and branching instructions at Level Asmb5, (c) arrays at Level
HOL6 and indexed addressing at Level Asmb5, (d) procedure calls at
Level HOL6 and the run-time stack at Level Asmb5, (e) function and
procedure parameters at Level HOL6 and stack-relative addressing at
Level Asmb5, (f) switch statements at Level HOL6 and jump tables at
Level Asmb5, and (g) pointers at Level HOL6 and addresses at Level
Asmb5.
The beauty of the unified approach is that the text can implement the
examples from the C chapter at this lower level. For example, the run-time
stack illustrated in the recursive examples of Chapter 2 corresponds
directly to the hardware stack in Pep/9 main memory. Students gain an
understanding of the compilation process by translating manually between
the two levels.
This approach provides a natural setting for the discussion of central
issues in computer science. For example, the book presents structured
programming at Level HOL6 versus the possibility of unstructured
programming at Level Asmb5. It discusses the goto controversy and the
structured programming/efficiency tradeoff, giving concrete examples
from languages at the two levels.
Chapter 7, “Language Translation Principles,” introduces students to
computer science theory. Now that students know intuitively how to
translate from a high-level language to assembly language, we pose the
fundamental question underlying all of computing: What can be
automated? The theory naturally fits in here because students now know
what a compiler (an automated translator) must do. They learn about
parsing and finite-state machines—deterministic and nondeterministic—in
the context of recognizing C and Pep/9 assembly language tokens. This
chapter includes an automatic translator between two small languages,
which illustrates lexical analysis, parsing, and code generation. The lexical
analyzer is an implementation of a finite-state machine. What could be a
more natural setting for the theory?

Level OS4
Level OS4 consists of two chapters on operating systems. Chapter 8 is a
description of process management. Two sections, one on loaders and

21
Discovering Diverse Content Through
Random Scribd Documents
ensuing years, were the Birkenhead Hospital, the Chorlton Union
Infirmary, the Coventry Hospital, the Guildford (Surrey County)
Hospital, the Leeds Infirmary, the Malta (Incurables) Hospital, the
Putney Royal Hospital for Incurables, the North Staffordshire
Infirmary, and the Swansea Infirmary. Correspondence from foreign
countries, and a collection of tracts upon Hospital Construction
(1863) sent to her from France and Belgium, show that the
“reformation” was widespread. In India also her book was found
useful. “It arrived in the nick of time,” wrote Sir Charles Trevelyan,
the Governor of Madras (Aug. 10, 1859), “as you will see by the
accompanying note from Major Horsley, the engineer entrusted with
the preparation of the plan of the addition to our General Hospital.”

II

Like other reformers, Miss Nightingale encountered an occasional

defeat. One was at Manchester in a cause wherein she was enlisted
by a friend of Cobden, Mr. Joseph Adshead. He saw something of
Miss Nightingale during these years, and corresponded voluminously
with her. He is the subject of one of her clever and vivid character-
sketches—a sketch which throws interesting side-lights on her own
character too:—

(Miss Nightingale to Samuel Smith.) Burlington, Feb. 25, [1861]. Dear

Uncle Sam—Adshead of Manchester is dead—my best pupil.… How often I
have called him my “dear old Addle-head,” and now he is dead. He was a
man who could hardly write or speak the Queen's English; I believe he
raised himself, and was now a kind of manufacturer's agent in Manchester.
He was a man of very ordinary abilities and commonplace appearance—
vulgar, but never unbusiness-like, which is, I think, the worst kind of
vulgarity. Having made “a competency,” he did not give up business, but
devoted himself to good works for Manchester. And there is scarcely a
good thing in Manchester, of which he has not been the main-stay or the
 source—schools, infirmary, paving and draining, water-supply, etc., etc. At
60, he takes up an entirely new subject, Hospital Construction, fired by
my book, and determines to master it. This is what I think is peculiarly
Anglo-Saxon. He writes to me whether I will teach him (this is about 18
months ago), and composes some plans for a Convalescent Hospital out
of Manchester, to become their main Hospital if the wind is favourable. He
comes up to London to see me about these. The working plans passed
eight times thro' my hands and gave me more trouble than anything I
ever did. Because Adshead would not employ a proper builder, but would
do them himself—which is part of the same character, I believe. The plans
are now quite ready, but nothing more. He meant to beg in person all
over Lancashire, and had already some promises of large sums. He had
been asking for about a year, but never intermitted anything. I don't know
whether you remember that I had a three-months' correspondence with
him (and oh! the immense trouble he took) about the transplantation of
the Spitalfields and Coventry weavers to Manchester, Preston, Burnley,
etc.[311] … It never came to anything.… He was 61 when he died. This is
the character which I believe is quite peculiar to our race—a man, a
common tradesman, who—instead of “retiring from the world” to “make
his salvation,” or giving himself up to science or to his family in his old
age, or founding an Order, or building a housewill[425] patiently (at 60)
learn new dodges and new-fangled ideas in order to benefit his native
city.… How I do feel that it is the strength of our country and worth all the
R. Catholic “Orders” put together. I hate an “Order,” and am so glad I was
never “let in” to form one.…

Mr. Adshead had taken a prominent part in a movement to get the

Manchester Royal Infirmary condemned as insanitary, and to rebuild
it in better air outside the city boundaries. Miss Nightingale, though
she did not join publicly in the controversy, plied Mr. Adshead with
powder and shot. But they were defeated. Manchester decided to
patch and not to rebuild.

In the case of St. Thomas's Hospital in London, which was

confronted from a different cause with the same choice, she was
successful. Hospital officials, when in difficulty, not infrequently
“went to Miss Nightingale.” This was the case with Mr. Whitfield, the
Resident Medical Officer of St. Thomas's (then on its ancient site in
the Borough), when the future of the Hospital was threatened by the
projected extension of the South-Eastern Railway from London
Bridge to Charing Cross. The Railway Company sought powers to
take some of the Hospital's land, and the opinion of the Governors
was likely to be divided on the policy to be pursued. Mr. Whitfield
was from the first in favour of the course which ultimately prevailed;
the Railway Company should be compelled to buy all the Hospital's
land or none, and in the former event the Hospital should be rebuilt
on a healthier site and on an improved plan. But there were others
who were disposed to take the line of least resistance, and to be
content with rebuilding on the old or an adjacent site so much as the
railway works made necessary. Mr. Whitfield opened the case to Miss
Nightingale in February 1859, and besought her aid; she entirely
agreed with him, and threw herself whole-heartedly into the matter.
Among the Governors of the Hospital was the Prince Consort, to
whom she sent a careful memorandum. The Prince went into the
case with his usual thoroughness, and ultimately concurred in Miss
Nightingale's views. He was scrupulous, as the correspondence
shows, to avoid any interference with the parliamentary side of the
case, but he let it be known, among his colleagues on the Board of
Governors, what his opinion was upon the best policy for the
Hospital to pursue, in the event of Parliament leaving it any option.
“Your intervention with Prince Albert,” wrote Mr. Whitfield presently
to Miss Nightingale, “has wrought wonders.” But there were still two
opinions. There was a strong party which attached more importance
to retaining the Hospital on its old site, “in the midst of the people
whom it served,” than to removing it to one which might be more
salubrious, but must be more distant. This is a controversy which
continually recurs. Miss Nightingale took immense pains in working
up the case for removal. She resorted, as usual, to a statistical
method. She analysed the place of origin of all the cases received;
tabulated the percentages in various radii; and showed that the
removal of the hospital to such and such distances would affect a far
smaller percentage of patients than was commonly supposed. Then
she made out sums in proportion, setting, on the one side, so much
inconvenience and conceivable danger in making a smaller number
of patients take a little longer time in reaching the Hospital; and, on
the other, the greater convenience and larger chance of recovery
which all the patients alike would have in better surroundings. At the
end of 1860 the critical moment arrived. The Railway Company had
served the Hospital with notice to decide within twenty-one days.
Mr. Whitfield wrote to Miss Nightingale in a state of considerable
flurry. He was by no means certain how the voting would go; every
vote and every influence were important; could she not whisper
once more in the Prince Consort's ear? She wrote to the Palace
forthwith; and the Prince communicated his views to the Court of
Governors on her side. And not only on her side. “You will find in the
Prince's letter,” she was told by one of those behind the scenes,
“your own arguments and sometimes even your own words
embodied.” Ultimately the Governors decided as Miss Nightingale
wished. The Railway Company was required to take all or none of
the Hospital's land. It took all and, as usually happens in railway
cases, the price was not suffered to err on the side of moderation.
St. Thomas's Hospital was removed to temporary buildings on the
old Surrey Gardens, and there remained till the present Hospital was
completed in 1871.
 A fair American visitor, taking tea upon the terrace of the Houses
of Parliament, and looking across the river to the sevenfold
splendours opposite, is said to have inquired, “Are those the
mansions of your aristocracy?” They are only instances of the reform
which Miss Nightingale introduced in Hospital construction, being the
“pavilions” of St. Thomas's. But Miss Nightingale was never
consulted, I feel sure, upon the architectural ornament of the
parapets. Her sense of humour would have made short work of the
urns which, as some one has suggested, seem waiting for the ashes
of the patients inside.

CHAPTER II

THE PASSIONATE STATISTICIAN

(1859–1861)
Full and minute statistical details are to the lawgiver, as the chart, the
compass, and the lead to the navigator.—Lord Brougham.

I remember hearing the first Lord Goschen make a speech in

Whitechapel many years ago, in which he avowed that for his part
he was “a passionate statistician.” “Go with me,” he said, “into the
study of statistics, and I will make you all enthusiasts in statistics.”
Mr. Punch parodied Marlowe thereupon, and invited his readers to
“all the pleasures prove That facts and figures can supply Unto the
Statist's ravished eye.” I do not know whether any large response to
the invitation was forthcoming from Lord Goschen's hearers or
Mr. Punch's readers; though, since the day when Lord Goschen
spoke, social reformers have more and more guided their schemes
by the chart and compass of statistics. If Miss Nightingale saw the
speech, it fell upon eyes long ago opened. A fondness for statistical
method, a belief in its almost illimitable efficacy, was one of her
marked characteristics.

Few books made a greater impression on Miss Nightingale than

those of Adolphe Quetelet, the Belgian astronomer, meteorologist,
and statistician; and she had few friends whom she valued more
highly than Dr. William Farr, the leading statistician of her day in this
country. From his meteorological studies, Quetelet deduced a law of
the flowering of plants. One of his cases was the lilac. The common
lilac flowers, according to Quetelet's law, when the sum of the
squares of the mean daily temperatures, counted from the end of
the frosts, equals 4264° centigrade. Miss Nightingale was greatly
interested in such calculations, and the lilac had a special place in
her year. Lady Verney's birthday was April 19, and a branch of
flowering lilac was Florence's regular birthday present to her sister.
Miss Nightingale used to talk of Quetelet's law with great delight,
and commended it to gardening friends for verification in their
Naturalist's Diaries. But this is a lighter example of Quetelet's
researches. What fascinated Miss Nightingale most was his Essai de
physique sociale (first published in 1835), in which he showed the
possibility of applying the statistical method to social dynamics, and
deduced from such method various conclusions with regard to the
physical and intellectual qualities of man. In regard to sanitation, we
have heard already of the reforms which Miss Nightingale was
instrumental in carrying out in Army Medical Statistics. She turned
next to the question of Hospital Statistics, where improvement
seemed desirable both for the surer advance of medical knowledge
and in the interests of good administration.
 Miss Nightingale had been painfully impressed during the Crimean
War with the statistical carelessness which prevailed in the military
hospitals. Even the number of deaths was not accurately recorded.
“At Scutari,” she said, “three separate registers were kept. First, the
Adjutant's daily Head-roll of soldiers' burials, on which it may be
presumed no one was entered who was not buried, although it is
possible that some may have been buried who were not entered.
Second, the Medical Officers' Return, in regard to which it is quite
certain that hundreds of men were buried who never appeared upon
it. Third, the return made in the Orderly Room, which is only
remarkable as giving a totally different account of the deaths from
either of the others.”[312] When Miss Nightingale came home, and
began examining Hospital Statistics in London, she found, not
indeed such glaring carelessness as this, but a complete lack of
scientific co-ordination. The statistics of hospitals were kept on no
uniform plan. Each hospital followed its own nomenclature and
classification of diseases. There had been no reduction on any
uniform model of the vast amount of observations which had been
made. “So far as relates,” she said, “either to medical or to sanitary
science, these observations in their present state bear exactly the
same relation as an indefinite number of astronomical observations
made without concert, and reduced to no common standard, would
bear to the progress of astronomy.”[313]

Miss Nightingale set herself to remedy this defect. With assistance

from friendly doctors on the medical side, and of Dr. Farr, of the
Registrar-General's Office, on the statistical, she prepared (1) a
standard list, under various Classes and Orders, of diseases, and (2)
model Hospital Statistical Forms. The general adoption of her Forms
would, as she wrote, “enable us to ascertain the relative mortality in
different hospitals, as well as of different diseases and injuries at the
same and at different ages, the relative frequency of different
diseases and injuries among the classes which enter hospitals in
different countries, and in different districts of the same countries.”
Then, again, the relation of the duration of cases to the general
utility of a hospital had never been shown. Miss Nightingale's
proposed forms “would enable the mortality in hospitals, and also
the mortality from particular diseases, injuries, and operations, to be
ascertained with accuracy; and these facts, together with the
duration of cases, would enable the value of particular methods of
treatment and of special operations to be brought to statistical proof.
The sanitary state of the hospital itself could likewise be
ascertained.”[314] Having formed her plan, Miss Nightingale
proceeded with her usual resourcefulness to action. She had her
Model Forms printed (1859), and she persuaded some of the London
hospitals to adopt them experimentally. Sir James Paget at St.
Bartholomew's was particularly helpful; St. Mary's, St. Thomas's, and
University College also agreed to use the Forms. She and Dr. Farr
studied the results, which were sufficient to show how large a field
for statistical analysis and inquiry would be opened by the general
adoption of her Forms.

The case was now ready for a further move. Dr. Farr was one of
the General Secretaries of the International Statistical Congress
which was to meet in London in the summer of 1860. He and Miss
Nightingale drew up the programme for the Second Section of the
Congress (Sanitary Statistics), and her scheme for Uniform Hospital
Statistics was the principal subject of discussion. Her Model Forms
were printed, with an explanatory memorandum; the Section
discussed and approved them, and a resolution was passed that her
proposals should be communicated to all the Governments
represented at the Congress. She took a keen interest in all the
proceedings, and gave a series of breakfast-parties, presided over by
her cousin Hilary, to the delegates, some of whom were afterwards
admitted to the presence of their hostess upstairs. The foreign
delegates much appreciated this courtesy, as their spokesman said
at the closing meeting of the Congress; “all the world knows the
name of Miss Nightingale,” and it was an honour to be received by
“the illustrious invalid, the Providence of the English Army.” The
written instructions sent by “the Providence” to her cousin for the
entertainment of the guests show her care for little things and her
knowledge of the weaknesses of great men: “Take care that the
cream for breakfast is not turned.” “Put back Dr. X.'s big book where
he can see it when drinking his tea.” Miss Nightingale also induced
her friend Mrs. Herbert to invite the statisticians to an evening party.
The feast of statistics acted upon her as a tonic. “She has been more
than usually ill for the last four or five weeks,” wrote her cousin
Hilary (July 12); “now I cannot help thinking that her strength is
rallying a little; she is much interested in the Statistical Congress.”
Congresses, like wars, are sometimes “muddled through” by our
country, and Miss Nightingale was able here and there to smooth
ruffled plumes. A distinguished friend of hers, though his name had
been printed as one of the secretaries of a Section, had not received
so much as an intimation of the place of meeting; he was disgusted
at so unbusiness-like an omission, and was half inclined to sulk in his
tents. Miss Nightingale's letter on the subject is characteristic:—

(Miss Nightingale to Dr. T. Graham Balfour.) 30 Old Burlington St., July

12 [1860]. You are quite right in what you say. We are all of us in the
same boat. And, if it were not that England would not be the mercantile
nation she is, if she had not business habits somewhere, I should wonder
from my experience where they are. Certain of us, who were asked to do
 business for the Statistical Congress, had it all ready since December last
—and were not able to get it out of the Registrar-General's Office till this
week. Certain of us were asked to do business this morning, and to have
it ready by to-night, which, if not done, would arrest the proceedings of
the Congress, and, if done, must be the fruit of only five hours'
consideration, when five months might just as well have been granted for
it. I don't say that this is so bad as the treatment of you who are
Secretary. But still it is provoking to see a great International business
worked in this way.

What I want now is to put a good face upon it before the foreigners. Let
them not see our short-comings and disunions. Many countries, far behind
us in political business, are far before us in organization-power. If any one
has ever been behind the scenes, living in the interior, of the Maison Mère
of the “Sisters of Charity” at Paris, as I have—and seen their Counting
House and Office, all worked by women,—an Office which has twelve
thousand Officials (all women) scattered all over the known world—an
office to compare with which, in business habits, I have never seen any,
either Government or private, in England—they will think, like me, that it
is this mere business-power which keeps these enormous religious
“orders” going.

I hope that you will try to impress these foreign Delegates, then, with a
sense of our “enormous business-power” (in which I don't believe one
bit), and to keep the Congress going. Many thanks for all your papers. I
trust you will settle some sectional business with the Delegates here to-
morrow morning. And I trust I shall be able to see you, if not to-morrow
morning, soon.

Mind, I don't mean anything against your Office by this tirade. On the
contrary, I believe it is one of the few efficient ones now in existence.

Having received the imprimatur of an International Congress, Miss

Nightingale circulated her paper on Hospital Statistics widely among
medical men and hospital officials. Thereby she produced immediate
effect. She printed large quantities of her Model Forms, and supplied
them, on request, to hospitals in various parts of the country.
Through the good offices of M. Mohl, she also worked upon public
opinion in France. “Some months ago,” she wrote to Dr. Farr (Oct.
20, 1860), “I got inserted into the leading medical journals of Paris
an article on the proposed Hospital Registers; and you see they are
at work.” The London Hospitals took the matter up. Guy's printed a
statistical analysis of its cases from 1854 to 1861; St. Thomas's, of
its from 1857 to 1860; St. Bartholomew's, a table of its cases for
1860. With regard to the future, a meeting was held at Guy's
Hospital on June 21, 1861, and it was unanimously agreed—by
delegates from Guy's, St. Bartholomew's, St. Thomas's, the London,
St. George's, King's College, the Middlesex, and St. Mary's—that the
Metropolitan Hospitals should adopt one uniform system of
Registration of Patients; that each hospital should publish its
Statistics annually, and that Miss Nightingale's Model Forms should
as far as possible be adopted. She called further attention to her
scheme in a paper sent to the Social Science Congress at Dublin in
August 1861,[315] and incorporated it in a later edition of her Notes
on Hospitals. The statistics of the various hospitals which had
accepted her Forms were published in the Journal of the Statistical
Society for September 1862, but I do not find that the experiment
has been continued. So far from there being any uniform hospital
statistics, of the kind contemplated by Miss Nightingale, even in
London some of the hospitals do not keep, or at any rate do not
publish, any at all. The laboriousness, and therefore the costliness,
of the work of compilation, the difficulty of securing actual, as well
as apparent, uniformity, and a consequent doubt as to the value of
conclusions deduced from the figures are presumably among the
causes which have defeated Miss Nightingale's scheme. Some limited
portion of her object is perhaps attained by the statistical data which
the administration of King's Hospital Fund demands, but even here
there are possibilities of misleading comparison. There is probably
no department of human inquiry in which the art of cooking statistics
is unknown, and there are sceptics who have substituted “statistics”
for “expert witnesses” in the well-known saying about classes of
false statements. Miss Nightingale's scheme for Uniform Hospital
Statistics seems to require for its realization a more diffused passion
for statistics and a greater delicacy of statistical conscience than a
voluntary and competitive system of hospitals is likely to create.

At the time she was full of hope, and, having obtained a start with
medical statistics, she next pursued the subject in relation to surgical
operations. Sir James Paget had been in communication with her on
this point. “We want,” he had written (Feb. 18, 1861), “a much more
exact account and a more particular record of each case. Thus in
some returns we have about 40 per cent of the deaths ascribed to
‘exhaustion,’ in others, referring to the same [kind of] operations,
about 3 per cent or less; the truth being that in nearly all cases of
‘exhaustion’ there was some cause of death which more accurate
inquiry would have ascertained.” Miss Nightingale (May 1, 1861)
congratulated him on “St. Bartholomew's having the credit of the
first Statistical Report worth having,” but the table of operations was
still, she thought, most unsatisfactory. “It would be most desirable
that an uniform Table should be adopted in all Hospitals, including all
the elements of age, sex, accident, habit of body, nature of
operation, after-accidents, etc., etc. Could you come in to-morrow
between 2 and 4, and bring your list of the causes of death after
operations? It would be invaluable, coming from such an authority,
for constructing a Form.” She consulted other surgeons, civil and
military, and wrote a paper, with Model Forms, for the International
Statistical Congress held at Berlin in September 1863. These also
were included in a revised edition of Notes on Hospitals. The Royal
College of Surgeons referred the subject to a Committee, which,
however, reported adversely upon Miss Nightingale's Forms.

II

Before the International Congress at London in 1860 separated,

Miss Nightingale addressed a letter to Lord Shaftesbury (President of
the Second Section), which was read to the whole Congress, and
adopted by it as a resolution. The point of it was to impress upon
Governments the importance of publishing more numerous abstracts
of the large amount of statistical information in their possession. She
gave various instances in which useful lessons might thus be
enforced upon the public mind, and cited Guizot's words: “Valuable
reports, replete with facts and suggestions drawn up by committees,
inspectors, directors, and prefects, remain unknown to the public.
Government ought to take care to make itself acquainted with, and
promote the diffusion of all good methods, to watch all endeavours,
to encourage every improvement. With our habits and institutions,
there is but one instrument endowed with energy and power
sufficient to secure this salutary influence—that instrument is the
press.” With Miss Nightingale statistics were a passion and not
merely a hobby. They did, indeed, please her, as congenial to the
nature of her mind. Her correspondence with Dr. Balfour and Dr. Farr
shows how she revelled in them. “I have a New Year's Gift for you,”
wrote Dr. Farr (Jan. 1860); “it is in the shape of Tables, as you will
conjecture.” “I am exceedingly anxious,” she replied, “as you may
suppose, to see your charming Gift, especially those Returns
showing the deaths, admissions, diseases,” etc., etc. But she loved
statistics, not for their own sake, but for their practical uses. It was
by the statistical method that she had driven home the lessons of
the Crimean hospitals. It was the study of statistics that had opened
her eyes to the preventable mortality among the Army at home, and
that had thus enabled her to work for the health of the British
soldier. She was already engaged on similar studies in relation to
India. She was in very serious, and even in bitter, earnest a
“passionate statistician.” And the passion, as will appear in a later
chapter,[316] was even a religious passion.

Miss Nightingale made a valiant attempt to extend the scope of

the Census of 1861 in the interest of collecting statistical data for
sanitary improvements. There were two directions in which she
desired to extend the questions. One was to enumerate the numbers
of sick and infirm on the Census day. For sanitary purposes it would
be extremely useful to determine the proportion of sick in the
different parts of the country. To those who said that it could not be
done, because the people would not give the information, the
answer was that it had been done in Ireland. The other point was to
obtain full information about house accommodation; facts which, as
would now be considered obvious, have a vital bearing on the
sanitary and social conditions of the people. This point also had been
covered in the Irish Census. Dr. Farr entirely agreed with Miss
Nightingale, but he could not persuade Sir George Lewis, the Home
Secretary, to include these provisions in the Census Bill (1860). Miss
Nightingale thereupon drew up a memorandum on the subject, and,
through Mr. Lowe (Vice-President of the Council), submitted it to the
Home Secretary. Mr. Lowe may have agreed with her, but he failed
to persuade his colleague. “Whenever I have power,” wrote Mr. Lowe
(May 9), “you can always command me, but official omnipotence is
circumscribed in the narrow limits of its own department.” Sir George
Lewis replied that “both of Miss Nightingale's points had been duly
considered before the Census Bill was introduced. It was thought
that the question of health or sickness was too indeterminate.” “With
regard to an enumeration of houses, it was thought that this is not a
proper subject to be included in a Census of population.” A very
official answer! But Sir George added that he did not see how the
result of such enumeration could be “peculiarly instructive”—an
avowal which he also made in the House of Commons. The cleverest
of men are sometimes dense; and this remark of Sir George Lewis,
added to his subsequent conduct of the War Office, earned for him,
in Miss Nightingale's familiar correspondence, the sobriquet of “The
Muff.” In communicating the result of her first attempt to Dr. Farr,
she said, “If you think that anything more can be done, pray say so.
I'm your man.” But she had not waited to be spurred on. She had
already bethought herself of a second string in the House of Lords.
Lord Shaftesbury, to whom she had appealed, promised to do all he
could. Lord Grey did the same, and asked her to send Dr. Farr to
coach him. She began to “thank God we have a House of Lords”:—

(Miss Nightingale to Robert Lowe.) Old Burlington St., May 10 [1860]. I

cannot forbear thanking you for your letter and for your exertions in our
favour. Sir George Lewis's letter, being interpreted, means:
“Mr. Waddington does not choose to take the trouble.” It is a letter such
as I have scores of in my possession, from Airey, Filder, and alas! from
Lord Raglan, from Sir John Hall (the doctor) and from Andrew Smith. It is
a true “Horse Guards” letter.

They are the very same arguments that Lord John used against the
feasibility of registering the “cause of death” in '37—which has now been
the law of the land for 23 years. He was beaten in the Lords. And we are
now going to fight Sir George Lewis in the Lords. And we hope to beat
him too. It is mere child's play to tell us that what every man of the
millions who belong to Friendly Societies does every day of his life, as to
registering himself sick or well, cannot be done in the Census. It is mere
childishness to tell us that it is not important to know what houses the
people live in. The French Census does it. The Irish Census tells us of the
 great diminution of mud cabins between '41 and '51. The connection
between the health and the dwellings of the population is one of the most
important that exists. The “diseases” can be obtained approximately also.
In all the more important—such as smallpox, fevers, measles, heart-
disease, etc.—all those which affect the national health, there will be very
little error. (About ladies' nervous diseases there will be a great deal.)
Where there is error in these things, the error is uniform, as is proved by
the Friendly Societies; and corrects itself.…

The passionate statisticians were, however, hopelessly out-voted

in the House of Commons. Mr. Caird moved in her sense on the
subject of fuller detail about house-accommodation, and in sending
her the printed notice of his amendment, said that “his position
would be greatly strengthened with the House if he could obtain
Miss Nightingale's permission to quote her name in favour of the
usefulness of such an inquiry.” I do not know whether she gave
permission; the debate is reported very briefly in Hansard. But in
any case Mr. Caird's amendment was promptly negatived. As for the
House of Lords, Miss Nightingale's reliance upon a better love of
statistics in that assembly was cruelly falsified. The Census Bill came
up late in the session, and I do not find that either Lord Grey or Lord
Shaftesbury said a word upon the subject. The only critical
contribution made to the debate proceeded from Lord Ellenborough,
who, so far from wanting the Census Bill to include provision for
more statistical data, proposed to exclude most of those that were
already in. He could not for the life of him see what was the use of
asking people so many questions.[317] Here, then, Miss Nightingale
was in advance of the time; in one case, by a generation, in the
other, by two generations. Recent Censuses have included more
particulars of the housing of the people, though still not so many as
she wanted. Official statistics of the local distribution of sickness will
presently be obtained, I suppose, in a different way, through the
machinery of the National Health Insurance Act.

Deprived by the recalcitrance of the Home Secretary and

Parliament of a fuller feast of statistics at home, Miss Nightingale
turned to the Colonies and Dependencies. The Secretary for the
Colonies gave her facilities for collecting much curious and
instructive information; and the Secretary for India accepted her aid
in collecting and tabulating facts and figures which were the
foundation of some of the most notable and beneficent of her
labours. But, though she was already (1860–1) engaged in these
inquiries, they belong in the main to a later period; and we must
now turn to another side of Miss Nightingale's work for the
improvement of the National Health.

CHAPTER III

THE FOUNDER OF MODERN NURSING

(1860)
Where is the woman who shall be the Clara or the Teresa of Protestant
England, labouring for the certain benefit of her sex with their ardour, but
without their delusion?—Southey's Colloquies (1829).

The nineteenth century produced three famous persons in this

country who contributed more than any of their contemporaries to
the relief of human suffering in disease: Simpson, the introducer of
chloroform; Lister, the inventor of antiseptic surgery; and Florence
Nightingale, the founder of modern nursing. The second of the great
discoveries completed the beneficent work of the first. The third
development—the creation of nursing as a trained profession—has
co-operated powerfully with the other two, and would have been
beneficent even if the use of anæsthetics and antiseptics had not
been discovered. The contribution of Florence Nightingale to the
healing art was less original than that of either Simpson or Lister;
but perhaps, from its wider range, it has saved as many lives, and
relieved as much, if not so acute, suffering as either of the other
two.

The profession of nursing is at once very old and very new; and
the place of Miss Nightingale in the history of it has not always been
rightly understood. Nursing—and even nursing by educated women
—is very old. “She herself nursed the unhappy, emaciated victims of
hunger and disease. How often have I seen her wash wounds whose
fetid odour prevented every one else from even looking at them! She
fed the sick with her own hands, and revived the dying with small
and frequent portions of nourishment. I know that many wealthy
persons cannot overcome the repugnance caused by such works of
charity. I do not judge them; but, if I had a hundred tongues and a
clarion voice, I could not enumerate the number of patients for
whom she provided solace and care.” This passage, which is not
unlike some of the panegyrics showered upon Florence Nightingale's
work during the Crimean War, was written, nearly fifteen centuries
earlier, by St. Jerome in describing the work of Fabiola, a lady of
patrician rank, who in 390 A.D. built a hospital at Rome, where she
devoted herself to the care of the sick. Female nursing is as old as
Christianity, and for centuries the religious Orders had sent cultivated
women into the hospitals. The very name of “Sister,” now applied to
a rank in the nursing profession in general, recalls its historical origin
in religious enthusiasm. Nor was there anything novel in the mere
fact, though there was much that was novel in the method, of Miss
Nightingale's service as a war-nurse. It was novel in the case of the
British Army, but in that of other countries Sisters had already
accompanied armies to the field. And, again, it was not an original
conception on Miss Nightingale's part that nurses should be trained
for their work. Her master, Theodor Fliedner, had shown the way in
Germany; and in our own country Mrs. Fry's Institute of Nursing was
established in 1840, and the St. John's House in 1848, Miss
Nightingale's, at St. Thomas's, not till 1860.

Nevertheless, though not the founder of nursing, Florence

Nightingale was the founder of modern nursing. It is not always
realized how modern is the institution of nursing, on any large scale
as a distinct and trained calling. I have indicated above the three
lines of influence—religion, war, and science—along which the
development of sick-nursing has proceeded. Miss Nightingale came
at the psychological moment to give it a vast impetus upon each of
those lines. Religion was tending to become less abstract, and more
closely allied to the service of man. Miss Nightingale was the St.
Clara or the St. Teresa of the new order, for whom Southey had
called. She was prepared, by her experience, by the character of her
mind, by the drift of her philosophical speculations, not to imitate old
forms, but to create a new order, an order of nurses who should,
indeed, be devoted to their calling, but should be organized on a
secular basis. The deeply religious bent of Miss Nightingale's
character, the single-mindedness of her purpose, and her constant
appeal to high ideals, enabled her to give to (or at any rate to
require from) the Seculars of the new order something of the
devotion possessed by the religious Regulars. The Crimean War, in
which Miss Nightingale was one of the central figures, gave further
force to a movement for increasing the number and improving the
qualification of nurses. It enlisted sentiment in the cause. The
American Civil War (in which, as we shall hear presently, Miss
Nightingale's example played a great part) extended the movement
to the United States, and the Red Cross organization may also be
considered as an outcome of her work in the Crimea. The progress
of science was tending in a like direction. Medicine and surgery were
on the eve of receiving great developments. Sanitary science was
already making advance. At the time when Florence Nightingale was
in training at Kaiserswerth, Joseph Lister was a medical student at
University College. Cohn, the founder of bacteriology, was only eight
years her junior. Parkes, one of the founders of modern hygiene,
was almost exactly her contemporary. It was inevitable that nursing
also should be developed in a scientific spirit, and no one was better
qualified than Miss Nightingale to take the lead in such a movement.
Her experience in the East had filled her with a passionate conviction
of the importance of sanitary science. She was the centre of a circle
of earnest and devoted men who were devoting themselves to it.
She was personally acquainted with many of the leading physicians
and surgeons of the day. And there was yet a fourth line upon which
Miss Nightingale might seem to be predestined for this special work.
What is called the “woman's movement” was beginning. “There is an
old legend,” wrote Miss Nightingale, at the beginning of her
pamphlet on Kaiserswerth, “that the nineteenth century is to be the
‘century of women.’” At the time when she wrote (1851), the
century, she added, had not yet been theirs. But there was a spirit
stirring the waters. Other notable women were at work, claiming for
their sex a place in the sun of the world's work. Miss Nightingale was
not wholly sympathetic to what she called “woman's missionariness.”
But the circumstances of her own life, as the First Part of this
Memoir has shown, made her intensely interested in claiming that a
woman should not be debarred from entering a walk of life to which
she is fitted simply because she is a woman; and of such walks of
life, nursing is obviously one. Controversy is perennial between those
who ascribe the course of political or social history mainly to great
men, and those who ascribe it rather to streams of tendency. It is
less open to controversy to say that the great men who leave the
more permanent mark upon history are those whose genius
conforms to the spirit of their time, but who are yet a little in
advance of their age. Among such “great men” the founder of
modern nursing is to be reckoned.

II

In what precise respect, it may be asked, did Florence Nightingale

“found” modern nursing? The answer to this question may, I think,
be disentangled without much difficulty from a good deal of
conflicting statement. I have referred already, in connection with the
fettering scruples of Miss Nightingale's parents,[318] to a conflict of
evidence upon the morals of hospitals and hospital nurses in the
middle of the nineteenth century. Her own opinion at that time (and
she did not express it without much inquiry and observation) is given
in the pamphlet, above mentioned, where she says that hospitals
were “a school, it may almost be said, for immorality and impropriety
—inevitable where women of bad character are admitted as nurses,
to become worse by their contact with male patients and young
surgeons.… We see the nurses drinking, we see the neglect at night
owing to their falling asleep.”[319] Such statements were indignantly
denied by other authorities, equally well qualified to form a correct
judgment. Controversy broke out upon the subject a few years later
in connection with the Nightingale Memorial Fund. A correspondent
of the Times, who signed himself “One who has walked a good
many Hospitals,” gave in 1857[320] the same kind of account that
Miss Nightingale had given in 1851. He was answered, and his
statements were hotly denied.[321] Obviously there were hospitals
and hospitals, and still more there were nurses and nurses, and no
general indictment was just on the point of morals. Upon the
question of drinking among nurses, both in hospitals and in private
service, there is less room for doubt. Dickens was a caricaturist, but
he was an effective caricaturist; and no caricature is effective in its
day unless it bears considerable resemblance to the truth. In his
preface he spoke of Mrs. Gamp as a fair representation, at the time
Martin Chuzzlewit was published, of the hired attendant on the poor;
and he might have added, says his biographer, that the rich were no
better off, for the original of Mrs. Gamp “was in reality a person
hired by a most distinguished friend of his own a lady, to take
charge of an invalid very dear to her.”[322] This one can the more
readily understand in the light of a remark by Lady Palmerston
quoted above.[323] “‘Mrs. Gamp,’ said Mrs. Harris, ‘if ever there was
a sober creetur to be got at eighteen pence a day for working
people, and three and six for gentlefolks, you are that inwallable
person.’” Great ladies clearly thought that such persons existed only,
and could only be expected to exist, in the world of imagination and
of Mrs. Harris. In 1854, Miss Mary Stanley, or a friend of hers, sent
out a circular, very possibly with the knowledge of Miss Nightingale,
to various persons connected with hospitals and infirmaries, of which
the object was to suggest that nurses should be instructed, on the
Kaiserswerth plan, in the art of administering religious comfort to
patients. The replies which were subsequently printed[324] throw
much light upon the position of nurses at the time. “If I can but
obtain a sober set,” wrote a doctor in the North, “it is as much as I
can hope for.” “I enquired for Dr. X.,” said another reply, “about the
character of the nurses, and he says they always engage them
without any character, as no respectable person would undertake so
disagreeable an office. He says the duties they have to perform are
most unpleasant, and that it is little wonder that many of them
drink, as they require something to keep up the stimulus.” The
ordinary wages were £14 to £16 a year. It should be remembered,
further, that hospital nurses had, as a rule, in the middle of the last
century no uniform dress, and cooked their own food (which they
bought for themselves), eating their meals in the ward kitchens or
scullery: “If the sister happened to be partial to red herrings for
breakfast, or onion-stew for dinner, or toasted cheese for supper, the
consequent state of the ward may be imagined. The assistant nurses
had to do all the scrubbing and cleaning of the wards, and to cook
for the other nurses and themselves.”[325] A side-light is thrown on
the slovenliness of the arrangements by the account of what
happened at King's College Hospital when the nursing was taken
over in 1856 by trained nurses from St. John's House under Miss
Mary Jones. “By the end of the day the new-comers, who had
arrived in clean and dainty uniforms, were like a set of sweeps or
char-women, in such an appalling state of disorder had they found
their wards.”[326] There were some excellent nurses under the old
régime (apart from those trained at St. John's House), as Sir James
Paget testified[327]; though it may be noted that even amongst his
model Sisters, one was “not seldom rather tipsy.” But “the greater
part of them,” he says, “were rough, dull, unobservant, untaught.”
The stoutest defender of the old system, the most stubborn
opponent of Miss Nightingale's reforms, gives unconsciously equal
support to Sir James Paget's statement that “in the department of
nursing there is the greatest and happiest contrast of all.” Mr. South
was of opinion that all was for the best, before Miss Nightingale
began to interfere, in the best of all possible nursing worlds. But his
conception of the ideal nurse is this: “As regards the nurses or ward-
maids, these are in much the same position as housemaids, and
require little teaching beyond that of poultice-making.”[328]

From all this, facts emerge which will clearly explain wherein Miss
Nightingale's work as the founder of modern nursing consisted. She
was not entirely alone, nor was she in point of time the first, in the
field; and there were exceptional cases to which the following
statements do not apply. But she was able to do on a larger scale,
and on a scale and in a form which attracted general imitation, what
others had attempted. And speaking generally, we may say that
before Miss Nightingale appeared on the scene, nursing was, and
was regarded as, a menial occupation which did not attract women
of character; that it was ill-paid and little respected; that no high
standard of efficiency was expected; and that no training was
organized: the women picked up their knowledge in the wards. They
were, as the correspondent of the Times said, “meek, pious, saucy,
careless, drunken, or unchaste, according to circumstances or
temperament, mostly attentive, and rarely unkind”; but, with very
few exceptions, they were untrained. “A poor woman is left a widow
with two or three children. What is she to do? She would starve on
needlework; she is unfit for domestic service; she knows nobody to
give her charring, and has no money to buy a mangle. So she gets a
recommendation from a clergyman, and is engaged as a Hospital
Nurse.” The change which has come about since Miss Nightingale's
work took effect is strikingly illustrated in the Census. In 1861 there
were 27,618 nurses “in hospitals, or nurses not apparently domestic
servants,” and they were enumerated, in the tables of Occupations
of the People, under the head of “Domestic.” In 1901 there were
64,214 nurses, and they were enumerated under the head of
“Medicine.” Miss Nightingale was the founder of modern nursing
because she made public opinion perceive, and act upon the
perception, that nursing was an art, and must be raised to the status
of a trained profession. That was the essence of the matter. Other
things, such as the opening of nursing to higher social strata, the
better payment of nurses, etc., though important and interesting,
were only results.

III

The means by which Miss Nightingale achieved this great work

were three. She brought to bear upon it the force, successively, of
her Example, her Precept, and her Practice. The first two of these
aspects of her work will be considered in the remainder of the
present chapter; the third is the subject of the next chapter.

No woman, I suppose, who was not canonized or who had not

worn (or been deprived of) a crown, has ever excited among her sex
so much passionate and affectionate admiration, and set to so many
an example, as Florence Nightingale. I have tried in an earlier
chapter, entitled “The Popular Heroine,” to describe the effect which
her work in the Crimean War produced upon the minds of her
contemporaries. To get first-hand impressions, the younger readers
of to-day must go to their grandmothers or great-aunts. It is they
who can help us best to some imagination of the thrill which the
stories of her nursing in the Crimea excited throughout the land, of
the intensity of sympathetic admiration which went out towards her,
of the impulse towards a fuller and worthier life which proceeded
from her example. But old letters are of some assistance too. From a
packet of family letters here is one, from an aunt to a niece: “April
15, 1857. I fear from a line in one of the newspapers that Florence
Nightingale's life is approaching an end. I have been deeply
impressed by her life these last few days, which in respect of mine
forms but a fragment in regard of time, and what she has
accomplished! A high mission has been given her which has cost her
her life to fulfil.”[329] In how many other minds, young and old alike,
must Florence Nightingale's example have stirred similar thoughts! A
lady who had attained high distinction as a Nightingale nurse was
asked after Miss Nightingale's death to record her recollections: “My
first thoughts of Miss Nightingale date back to that winter of frozen
rivers, when children, catching up the rumours of the street, ran
about shouting Sebastopol's taken; or danced, listening around the
old weaver's wife who had come to the door of her cottage to catch
the last light, and read aloud to her husband what ‘Lord Raiglan’ was
doing and saying; or later, in the hour before bed-time, sat at their
father's feet while he told of the frozen trenches, of the ‘dreary
corridors of pain,’ and of that ‘ministering angel,’ whose devotion
was lightening a nation's distress; or perhaps later still in sleep,
dreamed children's dreams of creeping amid sleeping Russians,
stealing the golden crown from the Czar's head, and escaping with it
to Florence Nightingale! Such experiences left indelibly impressed on
the minds of the children of my generation the gentle and heroic
figure of Miss Nightingale.” Often, no doubt, the impulse was
fleeting, and the broken purpose wasted in air. And often, too, the
impulse was vague, and resulted in no definite action; yet not on
that account, perhaps, to be cast aside as valueless. “I have a belief
of my own,” says one of George Eliot's characters, “and it comforts
me—That by desiring what is perfectly good, even when we don't
quite know what it is, and cannot do what we would, we are part of
the divine power against evil.” But often the force of Florence
Nightingale's example was direct and practical. Among those whom
it influenced in this way was Luise, the Grand Duchess of Baden,
who in 1859 founded a Ladies' Society in Baden for the training of
nurses. She had never seen Miss Nightingale, but a letter filled the
Grand Duchess with enthusiastic gratitude. “I felt,” she wrote (Sept.
1861), “that both joy and strength had come to me from your dear
letter. I may try indeed to thank you for it, but I shall never succeed
in expressing how deeply and how highly I felt your kindness. If
there is any progress in the work I have so much at heart, it is
greatly to your encouraging support I owe it.” Those who saw Miss
Nightingale, and who were sympathetic, felt thrilled in her presence.
“She is so far more delightful in herself,” wrote Clara Novello, “than
in one's imagination.” To nurses already engaged in work, Miss
Nightingale's personal influence was an inspiration. Miss Mary Jones,
of King's College Hospital, addressed her as “My beloved Friend and
Mistress.” “I value your nosegay too much to part with any one
flower even.” “I look on a visit to you as my one indulgence and
greatest pleasure.” But those who never saw Miss Nightingale, nor
even heard from her, felt the force of her example. In what was
publicly known of her career, there was, as it were, a call and a
challenge to women. Here was a woman, of high ability and of social
standing, who had forsaken all to be a nurse. She sought to raise
nursing to the rank of a High Art. She had already in some measure
done it by her example.

IV
 In every walk of life, however, there are those who seek the palm
without the dust. Miss Nightingale had seen already in the Crimea
many women who had followed her example, indeed, in desiring to
nurse the sick, but into whose heads it had never entered that
nursing required special gifts and careful training. Example had to be
supplemented by precept. Miss Nightingale's precepts upon the Art
of Nursing were first given to the world in 1859–60. Her Notes on
Nursing—the best known, and in some ways the best, of her books
—was published in December 1859. It was instantly recognized by
the leaders in medical and sanitary science as a work of first-rate
importance; as one of those rare books to which, within their range,
the term epoch-making may rightly be applied. “I am ashamed to
find,” wrote Sir James Paget, “how much I have learnt from the
Notes, more, I think, than from any other book of the same size that
I have ever read.” “I am delighted with them,” wrote Sir James Clark.
“They will do more to call attention to Household Hygiene than
anything that has ever been written.” “This,” wrote Harriet
Martineau, “is a work of genius if ever I saw one; and it will operate
accordingly. It is so real and so intense, that it will, I doubt not,
create an Order of Nurses before it has finished its work.” This was a
true prediction. Miss Nightingale was the founder of a New Model,
and the Notes on Nursing was its gospel.

The anticipations of her friends that the Notes would be popular

were abundantly fulfilled. Here was a book by Florence Nightingale
on the very subject to which her fame was attached. The effect
produced upon many minds by Notes upon Nursing was the greater
because it came, as it were, as a kind of resurrection of the popular
heroine. The years which had passed since Miss Nightingale's return
from the Crimea were, as we now know, years of ceaseless activity;
years during which she had done some of her greatest work. But it
must be remembered that all this was entirely unknown to most
people at the time. The common belief was that Miss Nightingale
had retired into private life upon her return from the Crimea; but
now after a long interval she came before the public again. And,
though, as in all that she wrote for the public eye, there was a
conspicuous absence of self-advertisement, there was enough in the
book to connect many of its pages with scenes and episodes of the
Crimean War. An enthusiastic review in a paper not generally given
to enthusiasm pointed out the connection: “Hundreds of brave men
attested with their dying breath how nobly Miss Nightingale's self-
imposed task was fulfilled, and this little book would be almost
enough to explain her success. Its tone seems to tell of the solemn
scenes from which experience in such matters has to be gained. Its
language is grave, earnest, and impetuous, like that of a person who
has lived among sad realities, and has been face to face with almost
every form of human suffering.”[330] Nor was it only the general
tone of the book that was suggestive of the heroine of the Crimean
War. Here and there little touches of personal experience were
introduced, in which every one could read the occasion between the
lines. When the author talked of her “sadly large experience of
death-beds,” the reader thought of the Lady with the Lamp at
Scutari; and when in her chapter on “Variety” she recalled “the acute
suffering produced from the patient (in a hut) not being able to see
out of window,” the reader's mind went back to the pictures of Miss
Nightingale at Balaclava. “I shall never forget,” she wrote, “the
rapture of fever patients over a bunch of bright-coloured flowers.”
She was thinking again of the Crimea. The wild flowers there are
many and brilliant; and the nurses used to gather them in the early
morning walk which each took in turn.[331]
 The book was not cheap at first; the price was 5s. But 15,000
copies were sold in a month, and a cheaper edition at 2s. quickly
followed. It was read, sooner or later, by all sorts and conditions of
people; in palaces, in cottages, in factories. Queen Victoria “thanked
Miss Nightingale very much for the book,” and sent in return a print
of herself and the Prince Consort. From the Grand Duchess of Baden
the book called forth an overflowing tribute. “I will not attempt to
describe to you,” she wrote (Oct. 9, 1860), “with how much interest
and admiration I read these pages, so beautiful in their simplicity, so
admirable in their true Christian spirit. Rarely has a book made so
deep an impression on me. I cannot refrain from expressing the real
admiration I feel for the noble English lady who has devoted so
much of her life to suffering mankind, and who has given to all her
sisters an example never to be forgotten.” With further expressions
of personal admiration, the Grand Duchess added a very just
characterization of the book: “The gentle feelings of the woman are
joined to experience, reflexion, and science.” Miss Nightingale was
urged to prepare a popular sevenpenny edition, and this appeared
early in 1861 with the title Notes on Nursing for the Labouring
Classes, and with a new chapter called “Minding Baby.” “And now,
girls,” this chapter begins, “I have a word for you. You and I have all
had a great deal to do with ‘minding baby,’ though ‘baby’ was not
our own baby.[332] And we would all of us do a great deal for baby,
which we would not do for ourselves.” “Did I tell you,” wrote Miss
Nightingale to Madame Mohl (May 7, 1861), “what prompted my
little chapter on Minding Baby? A Peckham schoolmaster asked me,
saying he could always make the school-girls mind my book by
telling them it was ‘for baby's sake.’ And several opened their
parents' windows at night (greatly to the indignation of the parents,
I am thinking), and removed dung-hills before the doors in
consequence.” In its cheap form, the book had a very large
circulation. Mr. Chadwick interested himself in getting it
recommended for school-reading. Benevolent persons distributed it
gratuitously in villages and cities. Edition after edition was rapidly
called for. Among Miss Nightingale's papers I find letters from
correspondents reporting cases in which office clerks and factory
hands, after reading the book, voted the windows open.

The book was read, not only by all sorts and conditions of people
at home, but also in many countries and in many tongues abroad. It
had instantly been reprinted in America. It was translated into
German, into French (with a preface by Miss Nightingale's old
acquaintance, M. Guizot),[333] and into most of the other European
languages. If the book be out of print, it ought to be included in one
of the cheaper series of the day. It can never be out of date, and no
one who has read it has ever found it dull.

Miss Nightingale was essentially a “man of action,” not a writer.

Yet her writings are very characteristic of her work, and none is
more pleasantly so than Notes on Nursing. Not the whole of her
nature “breaks through language and escapes” into it, but this little
book alone would be enough to explain to an understanding reader
several characteristics of her mind and work. It is an incomparable
treatise on the art of nursing; but, as Sir James Paget indicated, it is
more than that: it is an alphabet of Household Hygiene. Miss
Nightingale's treatment of the subject reveals at the outset her
philosophical grasp. “Shall we begin,” she says, “by taking it as a
general principle that all disease, at some period or other of its
course, is more or less a reparative process, not necessarily
accompanied with suffering: an effort of nature to remedy a process
of poisoning or decay, which has taken place weeks, months,
sometimes years beforehand, unnoticed, the termination of the
disease being then, while the antecedent process was going on,
determined? If we are asked, Is such or such a disease a reparative
process? Can such an illness be unaccompanied by suffering? Will
any care prevent such a patient from suffering this or that?—I
humbly say, I do not know. But when you have done away with all
that pain and suffering, which in patients are the symptoms, not of
their disease, but of the absence of one or all of the essentials to the
success of Nature's reparative processes, we shall then know what
are the symptoms of, and the sufferings inseparable from, the
disease.” This is, surely, sound philosophy; not overthrown by any
later discoveries about germs and microbes. It is the philosophy of
eliminating the known as a preliminary to investigating the unknown.
It leads Miss Nightingale to insist on the importance, as she calls it,
of “nursing the well” before they become the sick; or in other words,
to the principles of domestic hygiene—ventilation, warming, drains,
light, cleanliness. In all this her book had more originality than the
younger readers of to-day will realize without some effort of
retrospective imagination. The homes of the poor were in her day
those that were not very much caricatured by Dickens and
Cruickshank. The schools of the poor, which have taught some of the
principles of hygiene directly, and have had a yet wider influence
indirectly by setting an example of airy rooms and cleanliness, were
still in the future. Working people in those days could, moreover,
hardly be reached by writings. It was the popular fame of Florence
Nightingale that won for her Notes on Nursing an audience from “the
Labouring Classes.” Nor is it only among those classes that great
changes in current ideas and practice about domestic hygiene have
been effected. At the time when Miss Nightingale wrote, stuffiness
characterized the most genteel interiors. She was a pioneer in
establishing the principles of modern hygiene; and perhaps even to-
day there is still room for a wider acceptance of her doctrine that
“nursing the well” is even more important than nursing the sick—
preventive hygiene, than curative medicine.

A characteristic of Miss Nightingale's mind, and of her methods in

action is, as has been noticed already, her combination of general
grasp with minute attention to detail, and this is particularly
remarkable in her Notes on Nursing. In the chapter dealing with
nursing, in the more common acceptance of the term, one is struck
on almost every page with this rare combination of gifts. Nothing is
too minute for her touch, but everything is referred to a general
principle. Her philosophy of “Noises,” with the detailed injunctions
which she bases upon it, is alone enough to entitle her to the eternal
gratitude of invalids.

The book is no less remarkable for delicacy of observation and

fineness of sympathy. “Apprehension, uncertainty, waiting,
expectation, fear of surprise, do a patient more harm than any
exertion. Remember, he is face to face with his enemy all the time,
internally wrestling with him, having long imaginary conversations
with him. You are thinking of something else. Rid him of his
adversary quickly is a first rule with the sick.” “People who think
outside their heads, who tell everything that led them towards this
conclusion and away from that, ought never to be with the sick.” “A
sick person intensely enjoys hearing of any material good, any
positive or practical success of the right. Do, instead of advising him
with advice he has heard at least fifty times before, tell him of one
benevolent act which has really succeeded practically—it is like a
day's health to him. You have no idea what the craving of the sick,
with undiminished power of thinking but little power of doing, is to
hear of good practical action, when they can no longer partake in it.”
The whole chapter, entitled “Chattering Hopes and Advices,” from
which this last extract is taken, is full of wit and wisdom. It could
only have been written as the expression of an understanding mind
and a sympathetic heart; just as the following chapter, “Observation
of the Sick,” with its directions in the finer technique of nursing,
could only have come from one of long and varied experience in the
practice of it.

Another of Miss Nightingale's characteristics—her taste for

epigrammatic and often pungent expression—is conspicuous in
Notes on Nursing. “Feverishness is generally supposed to be a
symptom of fever; in nine cases out of ten, it is a symptom of
bedding.” “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.” “Some
‘obedient’ nurses know no medium between ‘Now no fire,’ ‘Now fire,’
as if they were volunteer riflemen.” “It seems a commonly received
idea among men, and even among women themselves, that it
requires nothing but a disappointment in love, or incapacity in other
things, to turn a woman into a good nurse. This reminds one of the
parish where a stupid old man was set to be schoolmaster because
he was ‘past keeping the pigs.’” There is lively humour, too, in many
of the personal descriptions. Miss Nightingale quotes Lord
Melbourne's saying: “I would rather have men about me when I am
ill; I think it requires very strong health to put up with women.”[334]
“I am quite of his opinion,” she adds, and she gives some little word-
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