By Anne Perry

Random House Publishing Group

Nursing rating		Rating guide: excellent = 4 stars; good = 3 stars; fair = 2 stars, poor = 1 star
Artistic rating

"Tears don't remove bullets or splint broken limbs."

So says tough Victorian-era English nurse Hester Latterly, a veteran of Florence Nightingale's legendary wartime cadre in the Crimea. Latterly, frustrated in her efforts to reform the antiquated hospital systems she finds back home, pursues private nursing. She also becomes the sidekick of detective William Monk, the hero of some 15 mystery novels by Anne Perry. In this 1994 entry in the series, Latterly finds herself on trial for the murder of Mary Farraline, an elderly Scottish matriarch Latterly was hired to accompany on a train journey. The prosecution claims Latterly gave Farraline an overdose of heart medication so she could steal a valuable brooch from the wealthy widow. As Monk and lawyer Oliver Rathbone work desperately to save Latterly from the gallows, Perry introduces significant detail about the great transition in nursing in the Nightingale era--not least by having the formidable icon herself appear as a character witness at Latterly's trial.

"Sins of the Wolf" generally conveys that at least some nurses were intelligent women who saved lives using real skill. It makes clear that the work required great strength, and it shows nurses as aggressive reformers trying to shake up poor health systems. Parts of the book do tend to suggest that nursing itself was not intellectually challenging, and that nurses were especially impressive to the extent they acted as battlefield surgeons, which plays into the "you're so smart you could be a physician" mindset. Even so, the book presents mid-19th Century nursing as a progressive force in public health, and a focal point in the early struggle for professional equality for women.

William Monk is an abrasive, ruthless seeker of truth, a victim of amnesia who, at the time of this novel, has been reduced from his former police position to a somewhat hand-to-mouth existence as a private detective. Latterly has helped him in prior cases, at times going undercover, to prevent miscarriages of justice. The couple often engage in heated debate, and seem to really get under each other's skin. (Spoiler alert! Skip to next paragraph to avoid it!) Despite or because of this constant conflict, in a later novel the sparring investigative couple marry.

"Sins of the Wolf" is well-written and compelling, with some strong characters and dialogue, and persuasive insights into human nature. Perry offers convincing period detail, from the upper reaches of Edinburgh society to Latterly's neighbors in the prison where she awaits trial. Indeed, Perry has a keen sense of the era's disparities of wealth and power, especially where gender is concerned. The book features strong women pushing their patriarchal society toward a recognition that they can excel in professional settings. Latterly and Nightingale may be the main examples, but the prominent Scottish family Mary Farraline headed includes women who pursue outside-the-home projects that are extraordinary for their time. Farraline herself is a woman of considerable power, intellect, and wisdom.

It's true that Latterly and Monk may be a bit too pure in their ideals. A few of the more inventive plot twists strain credulity. There is some telling where showing would do. We get that Monk is clever and committed to justice, but also ruthless and arrogant, so characters need not say and think that over and over. And Perry tends to identify her main male characters by surname ("Monk"), but her female ones by given name ("Hester"). Even Nightingale is "Florence." This subtly undercuts the novel's gender themes.

Nursing appears as a profession in transition. Perry shows that the public has traditionally seen nursing as being populated by disreputable women. At one point, Latterly wonders if her Scottish lawyer, James Argyll, expected her to be "a drunkard, or a slut, or an ignorant woman who could find no better employment than emptying slops or winding bandages." However, the profession has become "almost respectable" because of the growing understanding of its vital, substantive role in the care of the sick, especially soldiers in extremis. Nightingale and her nurses are central to this transition. Indeed, the book suggests that Nightingale has become second in British esteem only to the Queen herself. Somewhat ironically, the book depicts virtually no clinical nursing. However, there are statements that it requires skill and mental strength, with some specific examples of what nurses do.

The novel depicts the nurses as advocates and reformers, though it only hints that those roles are central to the profession. Latterly tells Farraline of "the ideals which had burned so deeply in her when she first returned [from the Crimea], her passion to begin reforming the outdated hospital wards in England with their closed practices." Indeed, although Latterly appears to have advocated herself out of the hospital setting, she is a forceful advocate for herself, and, it appears, for others she and Monk have tried to save from injustice. Farraline at another point remarks that one of her daughters would have made a good nurse because she "is naturally intelligent and efficient, the most practical of my children; but more than that, she has the art of persuading people to do the right thing in such a way that they are convinced that it was their own idea." This does at least suggest that persuasion is part of the work of nursing.

Then there is Nightingale. The book portrays her (and actually refers to her) as a "force of nature" on the witness stand at Latterly's trial in Edinburgh. Latterly is represented by Argyll, advised by Rathbone, who cannot appear in Scottish courts. The courtroom is star-struck by Nightingale, though some of her testimony provokes outrage from the tradition-bound males in the courtroom, not least the all-male jury. Argyll suggests that before Nightingale's notoriety nurses were seen as women of "low degree" with "pretty rough habits" who could not find a "respectable domestic position." Nightingale does not disagree, noting that her family opposed her own entry into the field. But she asserts that she had been called by God.

I believe that others have the same desire to serve their fellow men, and the conviction that nursing the sick is the finest way in which they can do it. There can be no higher calling, and none more urgently needed at such times than the relief of suffering, and where possible the restoration of life and restoration to health of men who have fought for their country.

Nightingale also testifies that Latterly was one of the best nurses in the Crimea because of her

[d]edication--and skill. There were too few surgeons and too many patients. ... Often a nurse had to act as she thought he would have done, or a man's life would be lost which she could have saved. ... Hester had both the courage and the knowledge to do so. There are many men alive in England now who would be buried in the Crimea were she a lesser woman.

Perry tells us that this stirs deep, mixed emotions in the courtroom:   reverence for Nightingale, bitter memories of the war, and "outrage at the challenge to centuries of masculine leadership."

The able prosecutor asks why, if Latterly is such an "excellent nurse" who has displayed "skills equal to those of many field surgeons" in emergencies, she holds no senior hospital position, but instead is found on an overnight train, giving simple medicine to a relatively healthy woman. Nightingale says that is because Latterly "is an outspoken woman, with more courage than tact, thank God." Latterly "does not care for hospital life, having to obey the orders of those who are on occasion less knowledgeable than herself but who are too arrogant to be told by someone they consider inferior."

The prosecutor can't let this go, arguing that Latterly seems self-indulgent and arrogant, a woman who believes herself above men who have been trained in "a profession perhaps she aspires to," but in which she has no training except practice in "extraordinary circumstances." It's pretty clear this attack is directed at Nightingale as well.

Nightingale proceeds to dismantle the prosecutor, essentially suggesting that he is a pampered slacker without the slightest clue how the world really works or what women are capable of:

Have you seen a man with his legs shot away? Do you know how quickly one must act to stop him hemorrhaging to death? Could you find the arteries in all that blood and save him? Would your nerve hold you, and your stomach? ... I am sure you are master of your profession. But how often do you work all day and all night for days on end? Have you lain on a canvas sheet on the earth, too cold to sleep, listening to the groans of those in agony, and hearing in your memory the rattle of the dying, and knowing tomorrow and tomorrow and tomorrow there will always be more, and all you can do will ease it only a little, a very little? ... And when you are ill, sir, vomiting and with a flux you cannot control, is there someone to hold a bowl for you, wash you clean, bring you a little fresh water, wash your sheets? I hope you are suitably grateful, sir--because, Dear God, there are so many for whom there is not, because there are too few of us willing to do it, or with the heart and the stomach for it! Yes, Hester Latterly is an extraordinary woman, molded by circumstances beyond most people to imagine. Yes, she is headstrong, sometimes arrogant, capable of making decisions that would quail many a heart less brave, less passionate, less moved by intolerable pity.

Nightingale concludes that such a woman would never have killed a patient for a "paltry piece of jewelry," and that if the prosecutor believes she would, he is "a lesser judge of mankind than you have a right to be and hold the position you do." Neither the prosecutor nor the equally hostile judge even tries to respond. (Nightingale then almost collapses coming off the witness-box, presumably because of her chronic ill-health, though Perry does not say so.)

Here is a portrait not just of the tough battlefield nurse, with skill and nerves of steel, but of the nurse as an epochal reformer and advocate, a 19th century woman so fearsome that she can reduce courtrooms of some of the era's powerful men to stunned silence. We see only this masterly courtroom performance, and there is nothing about Nightingale's apparent faults, though perhaps these were not widely understood at this point.

In any case, when Latterly herself testifies, she proves to be a worthy disciple of Nightingale when it comes to fighting the power. When the prosecutor suggests that he expects Latterly to use any art and argument she can devise to escape conviction, she shows him just how she finds the arteries in all that blood:

You make it sound, sir, as if we were two animals battling for mastery of each other, not rational humans seeking to find the truth and serve our best understanding of justice. Do you wish to know who killed Mrs. Farraline...or do you merely wish to hang someone, and I will do?

This may not serve Latterly's interests with the jury (her lawyers cringe), but it remains a timely critique of how the world's legal systems sometimes seem to operate when patient deaths provoke a public outcry (e.g. 1 and 2). And Perry gets extra credit for having her nurse characters subvert the "angel" image so aggressively, an image that haunts the nursing profession (and even the public's view of Nightingale) to this day.

The overall message the book sends about clinical nursing is more complex. Perhaps the most notable aspect of Nightingale's testimony and that of Dr. Alan Moncrieff (who also served with Latterly in the Crimea) is the focus on nurses' showing excellence by acting as battlefield surgeons. On the stand, Moncrieff admits that Latterly could be opinionated, dictatorial, and impatient with incompetence. But he praises her excellent "professional ability," her courage and hard work, the fact that she was "compassionate without sentimentality."

And she had exceptional initiative. I have on occasion thought it is unfortunate it is impossible to train women to practice medicine. More than one nurse, in cases when there was no surgeon, has performed successful operations to remove musket balls or pieces of shell, and even amputated limbs badly shattered on the field. Miss Latterly was one such. ... Surgery requires a steady hand, a good eye, a knowledge of anatomy, and a cool nerve. All of these qualities may be possessed by a woman as much as by a man. ... War is an extraordinary occupation... Both men and women rise to heights of gallantry, and of skill, that the calm, more ordered days of peace would never inspire.

Of course, such suggestions of gender parity shock the court, but note the assumption underlying these passages: nurses like Latterly are so smart and tough that they could be physicians. This suggests that nurses may be substantial people, and so perhaps their work is substantial, but it also strongly reinforces the idea that able women with the opportunity will probably become physicians, an idea that remains the prevailing one 150 years later. Consider the following diatribe from the trial judge, after Argyll asks Dr. Moncrieff if he knew Latterly in the Crimea in the pursuit of their "mutual profession":

You are misleading the jury. Dr. Moncrieff and Miss Latterly do not have a mutual profession...Dr. Moncrieff is a physician, a practitioner of the art of medicine. Miss Latterly is a nurse, a servant to such doctors in their care of the sick, to roll bandages, make beds, fetch and carry. She does not diagnose disease, she does not prescribe medicines, she does not perform operations of even the slightest nature. She does as she is told, no more. Do I make myself clear? ... Gentlemen?

At least half the jurors nod "sagely." Dr. Moncrieff's testimony about Latterly's surgical exploits rebuts these assumptions to a significant extent for women, and for nurses as people. But it does little for nursing. Moncrieff is not necessarily saying that nursing requires skill or initiative, but that some nurses are so good they could be physicians. Neither Nightingale nor Moncrieff actually says that Latterly saved lives working as a nurse. Were hygiene and monitoring factors in the soldiers' survival, or was surgery the only important thing? Nor does anyone directly rebut the judge's notion that nurses mechanically do physicians' bidding (though it is difficult to imagine the Nightingale we meet here playing that role). The public attitudes about women we see in this courtroom may seem laughable to a modern reader. But the judge's views of nursing remain commonly held, and they are on display each week on "House" and "Grey's Anatomy."  

Of course, nursing in the 1850's was not what it is today. We can't really fault the book for suggesting that "the chores of nursing were frequently tedious." But there is no comparable suggestion that the physician practices of the day also fell far short of modern standards. And consider Monk's idea that Rathbone try to change Latterly's unfavorable public image in advance of her trial by offering a vision of her in the Crimea, "passing all night along the rows of the wounded with a lamp in her hand, mopping brows, comforting the dying, praying...braving shot and shell to reach the wounded without thought for herself...then returning home to fight the medical establishment for better conditions here...and losing her post for her impertinence." When Rathbone asks if Monk sees Latterly that way, Monk snaps that he does not, as she is "an opinionated, self-willed woman doing precisely what she wants to do." But there is no direct suggestion that Monk's statement about Latterly's work is an incomplete description of nursing.

The closest the novel comes to presenting Latterly in a clinical context is the pivotal scene of Mary Farraline's care on the train, which goes disastrously wrong when she receives the overdose of a heart medication that turns out to be digitalis. Remarkably, Latterly appears to express no real interest in Farraline's condition or the nature of her medication until after her death. Instead, Latterly simply gets basic instructions from Farraline's maid on how much of the potion to give. After Farraline's death, Latterly says that she believes Farraline had a "heart ailment" but "was not told" any details. Even in the 1850's, would a nurse like Latterly have failed to ask what medication she was supposed to be giving her patient and why?

In fact, later in the book, Latterly has a striking exchange with Monk that touches on this same issue. As Latterly and Monk prepare to confront a suspect, Latterly asks what Monk plans to say. Monk snaps that he doesn't know yet, adding acidly that it "can't be prescribed and followed like a dose of medicine." Latterly: "Medicine is not prescribed and followed regardless. You watch the progress of the patient and do whatever you think best according to his response." Monk: "Don't be pedantic." This is nice, both as a statement about nursing and an example of one nurse's assertive banter. But it runs counter to Latterly's passivity about Mary Farraline's medicine and her overall condition. So which is it--uninformed order-following, or skilled, independent monitoring?

Even so, the book's overall vision of nursing is of a profession of real importance whose ranks were increasingly filled with intelligent, strong (arguably abrasive) women struggling to save lives and reform dysfunctional health systems despite entrenched resistance. Of course, a story set 150 years in the past may influence a modern reader's view of nursing only indirectly. But the two nurse characters who appear in "Sins of the Wolf" give a far better sense of the profession's true nature than most nurse characters who have appeared in popular fictional media in 2007. Seriously.

Review by Harry Jacobs Summers
Nursing Editor: Sandy Summers, MSN, MPH, RN
Reviewed September 27, 2007

The views expressed herein do not necessarily reflect those of the Board Members or Advisory Panel of The Truth About Nursing.