Born in Moscow in 1810, Pirogov began his medical studies at Moscow University at the age of just 14, and became a professor at the German University of Dorpat at the age of 25, before taking up the appointment of Professor of Surgery at the Academy of Military Medicine in St Petersburg. In 1847 he was with the Russian army in the Caucasus, where he pioneered the use of ether, becoming the first surgeon to employ anaesthesia in a field operation. Pirogov reported on the benefits of ether in several Russian-language publications between 1847 and 1852, though few doctors outside Russia were aware of his articles. Apart from the relief of pain and shock through anaesthesia, Pirogov emphasized that giving ether to the wounded on arrival at the hospital kept them calm and stopped them from collapsing so that the surgeon could make a better choice in selecting between those cases requiring urgent operation and those that could wait. It was this system of triage pioneered by Pirogov during the Crimean War that marked his greatest achievement.
Pirogov arrived in the Crimea in December 1854. He was outraged by the chaos and inhuman treatment of the sick and wounded. Thousands of injured soldiers had been evacuated to Perekop on open carts in freezing temperatures, many of them arriving frozen to death or with limbs so frostbitten that they had to be cut off. Others were abandoned in dirty barns or left by the roadside for lack of transport. There were chronic shortages of medical supplies, not least because of corruption. Doctors sold off medicines and gave their patients cheaper surrogates, exacting bribes for proper treatment. The hospitals struggled to cope with the enormous numbers of wounded. At the time of the allied landings, the Russians had hospital places for 2,000 soldiers in the Crimea, but after Alma they were overwhelmed by 6,000 wounded men, and twice that number after Inkerman.
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Conditions in the Sevastopol hospitals were truly appalling. Two weeks after the battle of the Alma, the surgeon from Chodasiewicz’s regiment visited the naval hospital:
He found the place full of wounded men who had never had their wounds dressed from the day of the Alma, except such dressings as they could make themselves by tearing up their own shirts. The moment he entered the room he was surrounded by a crowd of these miserable creatures, who had recognized him as a doctor, some of whom held out mutilated stumps of arms wrapped up in dirty rags, and crying out to him for assistance. The stench of the place was dreadful.
Most of the surgeons in these hospitals were poorly trained, more like ‘village craftsmen’ than doctors, in the estimation of one Russian officer. Practising a rough-and-ready surgery with dirty butcher’s knives, they had little understanding of the need for hygiene or the perils of infection. Pirogov discovered amputees who had been lying in their blood for weeks.
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As soon as he arrived in Sevastopol, Pirogov began to impose order on the hospitals, gradually implementing his system of triage. In his memoirs he recounts how he came to it. When he took charge of the main hospital in the Assembly of Nobles, the situation was chaotic. After a heavy bombardment, the wounded were brought in without any order, those who were dying mixed with those who needed urgent treatment and those with light wounds. At first, Pirogov dealt with the most seriously wounded as they came in, telling the nurses to transport them to the operating table directly; but even as he concentrated on one case, more and more seriously wounded men would arrive; he could not keep up. Too many people were dying needlessly before they could be treated, while he was operating on those patients too seriously wounded to be saved. ‘I came to see that this was senseless and decided to be more decisive and rational,’ he recalled. ‘Simple organization at the dressing station was far more important than medical activity in saving lives.’ His solution was a simple form of triage which he first put into practice during the bombardment of Sevastopol on 20 January. Brought into the Great Hall of the Assembly, the wounded were first sorted into groups to determine the order and priority of emergency treatment. There were three main groups: the seriously wounded who needed help and could be saved were operated on in a separate room as soon as possible; the lightly wounded were given a number and told to wait in the nearby barracks until the surgeons could treat them; and those who could not be saved were taken to a resting home, where they were cared for by medical attendants, nurses and priests until they died.
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In his sketch ‘Sevastopol in December’, Tolstoy takes his readers into the Great Hall:
No sooner have you opened the door than you are assailed without warning by the sight and smell of about forty or fifty amputees and critically wounded, some of them on camp beds, but most of them lying on the floor … Now, if you have strong nerves, go through the doorway on the left: that is the room in which wounds are bandaged and operations performed. There you will see surgeons with pale, gloomy physiognomies, their arms soaked in blood up to the elbows, deep in concentration over a bed on which a wounded man is lying under the influence of chloroform, open-eyed as in a delirium, and uttering meaningless words which are occasionally simple and affecting. The surgeons are going about the repugnant but beneficial task of amputation. You will see the sharp, curved knife enter the white, healthy body; you will see the wounded man suddenly regain consciousness with a terrible, harrowing shrieked cursing; you will see the apothecary assistant fling the severed arm into a corner; you will see another wounded man who is lying on a stretcher in the same room and watching the operation on his companion, writhing and groaning less with physical pain than with the psychological agony of apprehension; you will see fearsome sights that will shake you to the roots of your being; you will see war not as a beautiful, orderly, and gleaming formation, with music and beaten drums, streaming banners and generals on prancing horses, but war in its authentic expression – as blood, suffering and death.
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The use of anaesthetics enabled Pirogov and his team of surgeons to work extremely quickly, completing over a hundred amputations in a seven-hour day by operating simultaneously on three tables (critics said he ran a ‘factory system’). He developed a new type of foot amputation at the ankle, leaving part of the heel bone to give added support to the leg bone, and generally, in his amputations, cut much lower than most other doctors to minimize the trauma and loss of blood, which he understood posed the greatest threat. Above all, Pirogov was aware of the dangers of infection (which he thought came from contaminated vapours) and made a point of separating post-operative patients with clean wounds from those whose wounds were discharging pus and showing signs of developing gangrene. Through all these pioneering measures, Pirogov achieved much higher rates of survival than the British or the French – up to 65 per cent for amputations of the arm. For thigh amputations, the most dangerous and common in the armies of the Crimean War, Pirogov had survival rates of around 25 per cent, whereas only one in ten survived the operation in British and French hospitals.
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The British were much less enthusiastic about the use of anaesthetic than the Russians or the French. Shortly before the British army left Varna for the Crimea, the principal medical officer, Dr John Hall, issued a memorandum in which he cautioned the army’s surgeons ‘against the use of chloroform in the severe shock of serious gunshot wounds … for however barbarous it may appear, the smart of the knife is a powerful stimulant; and it is much better to hear a man bawl lustily than to see him sink silently into the grave’. British medical opinion was divided on the new science of anaesthesia. Some feared the use of chloroform would weaken the patient’s ability to rally, and others thought it was impractical to use it in battefield surgery because of the shortage of qualified doctors to administer it. Such attitudes were closely linked to ideas about withstanding pain that were perhaps peculiar to the British sense of manliness (keeping ‘a stiff upper lip’). The notion that the British soldier was immune to pain was commonplace. As one doctor wrote from the Crimea:
The pluck of the soldier no one has yet truly described. They laugh at pain, and will scarcely submit to die. It is perfectly marvellous, this triumph of mind over body. If a limb were torn off or crushed at home, you would have them brought in fainting, and in a state of dreadful collapse. Here they come with a dangling arm or a riddled elbow, and it’s ‘Now doctor, be quick, if you please; I’m not done for so bad, but I can get away back and see!’ And many of these brave fellows, with a lump of towel wrung out in cold water, wrapped around their stumps, crawled to the rear of the fight, and, with shells bursting round them, and balls tearing up the sods at their feet, watched the progress of the battle. I tell you, as a solemn truth, that I took off the foot of an officer, Captain –, who insisted on being helped on his horse again, and declared that he could fight, now that his ‘foot was dressed.’
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Like the French, Pirogov attached great importance to the role of nurses in his hospitals. Nurses helped to sort the wounded and brought comfort to the men. They dispensed medicines, brought them tea or wine, wrote letters to their families, and gave spiritual support to the dying. The affection of the nurses won the hearts of many men, who often likened them to their mothers. ‘It is astonishing’, wrote Pirogov to his wife, ‘how the presence of a woman, nicely dressed, among the helpers in a hospital alleviates the distress of the men and relieves their suffering.’ Pirogov encouraged the initiatives of Russian noblewomen to recruit teams of nurses for the Crimea. The Grand Duchess Elena Pavlovna, the Tsar’s German-born sister-in-law,
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founded the Community of the Holy Cross shortly after news of the defeat at Inkerman. Its first group of thirty-four nurses followed Pirogov to the Crimea, arriving in Simferopol on 1 December after a long and difficult journey over a thousand kilometres of dirt roads from St Petersburg. Most of them were the daughters, wives or widows of military men, with some from families of merchants, priests and state officials of the minor nobility, though they themselves of course had no experience of the harsh conditions of a battle zone and many of them soon fell ill with typhus and the other epidemics that raged among the men. Pirogov divided the nurses into three groups: those who were to attend to the wounded and help in operations; those who dispensed medicines; and those in charge of the general housekeeping in the hospital. For Alexandra Stakhovich, who was assigned to the operating room, the first amputation was a personal trial, but she got through it, as she wrote to tell her family:
I was at two operations by Pirogov; we amputated an arm in one, and a leg in another; and by the grace of God I did not pass out, because in the first, where we cut off his arm, I had to hold the poor man’s back and then dress his wound. Of my boldness I am writing only so that you are reassured that I am not afraid of anything. If only you knew how gratifying it can be to help these suffering men – you cannot imagine how much the doctors appreciate our presence here.
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In the Crimea itself, women from various communities had organized themselves into teams of nurses and made their way to the dressing stations and field hospitals of the battlefields around Sevastopol. Among them was Dasha Sevastopolskaia, the girl who had cared for the wounded at the Alma, who worked with Pirogov in the operating theatre at the Assembly of Nobles. Another was Elizaveta Khlopotina, the wife of a battery commander wounded in the head at the Alma, who had followed her husband into battle and worked as a nurse in the dressing station at Kacha. Pirogov was full of admiration for the courage of these women, and battled hard against the objections of the military establishment, which was opposed to a female presence among the troops, for more teams of nurses to be organized. The influence of the Grand Duchess eventually told, and the Tsar agreed to recognize the work of the Community of the Holy Cross. Much of its early medical work in the Crimea was financed by the Grand Duchess, who had purchased medical supplies, including precious quinine, through family contacts in England and stored them in the basement of her home in the Mikhailovsky Palace in St Petersburg. But once it had the blessing of the Tsar, donations poured in from the Russian aristocracy, merchants, state officials and the Church. In January two more contingents of nurses organized by the Community arrived in Sevastopol, the second of them led by Ekaterina Bakunina, the daughter of the governor of St Petersburg and a cousin of the revolutionary anarchist Mikhail Bakunin (at that time imprisoned in the Peter and Paul Fortress in the Russian capital). Like many of the Russian upper class, she had spent her childhood summers in the Crimea, and was horrified by the invasion of her favourite holiday resort. ‘I could not imagine that this beautiful little corner of our great empire could be turned into a brutal theatre of war.’
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Florence Nightingale had a similar administrative drive to the Grand Duchess. Born into a family of successful industrialists in Derbyshire, she was better educated than most of the men in the British government, among whom her family had a number of connections, though because of her sex she was forced to limit her activities to the field of philanthropy. Inspired by her Christian faith, she entered nursing at the age of 25, much against the will of her family, working first as a social reformer among the poor and then in a Lutheran religious community at Kaiserswerth-am-Rhein near Düsseldorf in Germany, where she observed Pastor Theodor Fliedner and his deaconnesses care for the sick. Graduating from Kaiserswerth in 1851, Nightingale brought back its principles of nursing to the hospital in Harley Street, where she took over as superintendent in August 1853. It was these principles – basic cleanliness and good housekeeping on the wards – that Nightingale would take to the Crimea. There was nothing new in her ideas. The British medical officers in the Crimea were well aware of the benefits of hygiene and good order in the hospital. Their main problem in turning these commonsense ideals into active policies was a lack of manpower and resources – a problem Nightingale would only partly overcome.