Was she nice?

A reassessment of Florence Nightingale and her achievements requires consideration of her public work, her personal character and the relation between the two, and F.B. Smith has interesting things to say about all of this in his study of the Nightingale Papers and other documents. He recognises her impressive contributions, but not her unique place in the history of ideas related to medicine and public health in the last three centuries. His reading of her character would be more persuasive if she were occasionally given the benefit of a doubt. Was she, for instance, always impelled ‘to fight, to cheat, to bully and to boast’ as well as ‘to save lives’? And is it not the case that without the private character we could not have had the public work?

Florence Nightingale came to nursing at a time when standards of patient care were low and the nurse’s professional commitments not always limited to the side of the bed. Like Mr Cochrane in the London theatre at a later date, she made her profession suitable for young ladies and thus solved two problems, one for the profession and one for the young ladies. The professional problem was to attract recruits whose personal background guaranteed reasonable standards of hygiene and morality. The young ladies’ problem was to find employment at a time when marriage was regarded as the only alternative to an idle spinsterhood and primogeniture left many of them without an income. In practice, not enough ladies offered for training, and it was necessary to take ‘women’ from the respectable lower-middle and working classes, who were stronger than the ‘ladies’ and more willing to do unpleasant tasks.

Miss Nightingale’s contributions to nursing have perhaps been overemphasised in relation to her other interests and Smith puts them into perspective. On the negative side, ‘she neither invented modern nursing behaviour nor even the idea of nursing as a calling’; she had little interest in the care of some of the most neglected patients – for example, children and the mentally ill – and her intervention in midwifery training was disastrous; if she cannot justly be blamed for the low salaries of nurses, she did nothing to raise them; she was lukewarm in her support for the emancipation of women. Indeed, Florence Nightingale in some respects is an unsuitable figure to embody the aims of modern nursing, particularly in the United States, where her teaching that the nurse is subservient to the doctor is thought to be inconsistent with the aspirations of an independent profession. On the positive side, she introduced many sound features into nursing practice: her Notes on Nursing ‘is full of pithy good sense and vivid anecdotes about quiet, food, light and reassurance for patients and percipience in nurses’, and her Notes on Lying-In Institutions ‘provoked interest in the subject and accelerated the improvements in cleansing, rebuilding and antiseptic procedures that were beginning in wards about 1870’. Above all, ‘by bestowing her imprimatur upon secular nursing she gave it standing in Victorian Britain and throughout the world’: before she died her standards had been introduced into Scandinavia, Italy, Russia, the United States and throughout the Empire. ‘Rarely can such a beneficial revolution in the lives of so many people – patients and women – have been wrought on the basis of sheer reputation.’ The nurses trained by her methods made possible the modern hospital, and it takes nothing from her achievement to recognise that she was not alone in the enterprise. After this generous assessment it is something of a non-sequitur – and an indication of Smith’s attitude to his subject – to conclude that ‘Miss Nightingale served the cause of nursing less than it served her.’ It would be unfortunate if fine achievements were to be regarded as diminished to the extent that their creators had benefited from them.

It could be argued that her most enduring interest was sanitary reform, an issue with which she was concerned throughout her professional life. The notion that adverse environmental conditions were the cause of disease had been developing for more than a hundred years through the work of Mead, Pringle, Lind, Howard, Cook, Baker and others, and probably reached Miss Nightingale from Edwin Chadwick. It was confirmed by her experience during the first winter of the Crimean War, when more than one-third of the British soldiers were disabled by preventable illnesses. The same ideas were the basis of her famous collaboration with Sidney Herbert on sanitary reform in the Army, and, later, for her work with Sutherland, Farr and others on sanitary reconstruction in India. The measures she promoted were essentially those which led to the decline of waterborne and, later, food-borne diseases: clean water, sewage disposal, drainage and removal of refuse. Ventilation, about which Miss Nightingale was equally enthusiastic, was less effective in preventing airborne diseases, although Smith is mistaken in thinking that overcrowding did not contribute to the spread of tuberculosis. The crowding of people at home and at work in the industrial towns is the best explanation of the high level of mortality from the disease in the 19th century. The important influence on the infections which was underestimated by Miss Nightingale and the other pioneers of environmental medicine was malnutrition, but its effects were less obvious than those of the physical environment.

She has often been criticised because, like Chadwick himself, she denied the contagious nature of infectious disease: ‘There is no satisfactory evidence that syphilis is propagated only by contact with infected persons ... it rests exactly on the same evidence as does the presumed origin of smallpox solely from contagion.’ As Strachey explained, she believed in what she saw and beyond that she refused to go: ‘Years after the discoveries of Pasteur and Lister, she laughed at what she called the “germ-fetish”. There was no such thing “as infection”; she had never seen it and therefore it did not exist. But she had seen the good effects of fresh air; therefore there could be no doubt about them; and therefore it was essential that the bedrooms of patients should be well ventilated.’ She was wrong: but she was wrong in good company and the error had few serious consequences at the time when she was active in public affairs.

In spite of her misunderstanding of the nature of infectious disease, Florence Nightingale assessed accurately the possibilities of preventive and therapeutic measures. She recognised that it is better to prevent than to cure, and if she were alive today she would no doubt have seen that with many diseases it is essential to prevent because we cannot cure. The lesson was even more obvious in the 19th century, when infections were the predominant cause of sickness and death, than it is in the 20th, when they have been replaced in some countries by non-communicable diseases. Smith summarises her position quite accurately: ‘Even in crude terms of lives preserved for money spent, her priorities, as against expenditure upon large hospitals and a highly skilled medical service, both in her own age and during the century since, were the right ones.’

Again there is a large blot on her record, her refusal to support vaccination against smallpox. Writing about vaccination in India, she said she didn’t ‘much care’ about it – ‘the greatest authorities in England believe that the diminution of smallpox has resulted more from sanitation than from vaccination.’ She was certainly correct in thinking that in England the decline of smallpox could not be attributed solely to vaccination, for the proportion of the population recently vaccinated was high for only a short period. Her opposition to the procedure was due both to her concept of the nature of infectious disease, and to her fear that its widespread use would divert attention from the sanitary measures which she believed were paramount.

Miss Nightingale has some claim to have been among the first to recognise the risks associated with medical treatment. At Scutari she had seen that hospital patients sometimes acquired a mortal infection, and she introduced her Notes on Hospitals with the well-known aphorism that the first requirement in a hospital is that it should do the sick no harm. This objective was not achieved during the 18th and early 19th centuries, when infectious and non-infectious cases were admitted to the same hospital and often to the same ward.

There are things to be learned in a hospital bed which cannot be learned at the side of it, and perhaps only a chronic invalid could have written so perceptively about the patient’s experience of disease: ‘Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion. Remember he is face to face with the enemy all the time, internally wrestling with him, having long imaginary conversations with him.’ ‘Do not cheer the sick by making light of their danger.’ ‘It is commonly supposed that a nurse is there to save physical exertion. She ought to be there to save [the patient] taking thought.’ In their insight into the stress associated with illness, these observations were far in advance of the thinking of their time.

The founding of the hospital system which for nearly a century provided most of the country’s beds was an unplanned consequence of the revision of the Poor Law. The 1834 Poor Law Amendment Act made admission to an institution a condition of public assistance, and the admission of the destitute led inevitably to admission of the sick. Patients selected on the grounds of their destitution varied greatly in their medical and other needs; they included the chronic sick, the infirm, the mentally retarded, the mentally ill, the venereally-infected and the acute sick. Florence Nightingale was indignant because these ill-assorted classes were to be found in the same institutions and often in the same wards, and she demanded the classification and disposal of patients according to their medical, nursing and social requirements. This rational approach to one of the most intractable problems of hospital organisation has not been fully achieved even today.

Smith says that Miss Nightingale was not an original thinker, because the ideas on which her work was based were already in the air or in use on a modest scale before she came to them. If this test were applied generally the same would have to be said about many of the great names in medicine and science – Withering, Jenner, Malthus, Darwin, Florey, to mention only a few. But it is questionable whether the test is valid: first, because we can rarely be certain that we have traced the origin of an idea – ‘it is always earlier than you think’; and, second, because the demonstration of latent possibilities in an idea is itself a significant and, in a different sense, an original contribution. Florence Nightingale’s judgment was almost unerringly accurate on many of the important issues of her time, and this achievement gives her a unique place in the history of ideas in medicine and public health.

If Smith’s assessment of Miss Nightingale’s character is accurate she would have scored badly on several of the tests for qualities – ‘reliability’, ‘calm’, ‘honesty’, ‘truthfulness’ – she demanded in her young nurses. But his most serious charge is that she was cruel to those to whom she was most indebted – her own family and some of her collaborators, particularly Sidney Herbert on whom she made heavy demands shortly before his death. In her defence it should be said that some of the criticism – for example, the suggestion that the history of hospital services in the Crimea was revised in her favour in order to please her – is based on documents which are inconclusive. But there are other examples in which the evidence only allows the interpretation which Smith has given, as in the case of her mean refusal to make her correspondence with Sidney Herbert available to his widow. Perhaps the most charitable conclusion which can be drawn on her behalf is that all progress requires a compromise between the ineffectual and the immoral, and Miss Nightingale was anything but ineffective.

In the last page of his book Smith claims to have exposed the fallacy ‘that doers of good deeds must necessarily be good in themselves’: but the tone of his writing and the severity of his criticism suggest that he thinks it is realistic to ask that they should be. Perhaps we should accept that men and women seek to advance themselves – if they did not the human species would not exist – and concentrate instead on their ‘other ends’ and the means to which they resort in furthering them. Florence Nightingale’s ‘other ends’ were almost without exception laudable – broadly, the prevention of disease and the humane care of the sick. Some of her methods were less creditable: but she was a woman operating in a man’s world and who is to say that if she had been more scrupulous she would have been equally effective? In any case a character must be taken as a whole, and if we respect her achievements it is futile to condemn her because she was not a nicer person. We may point the finger but we should refrain from wagging it.

Florence Nightingale knew many things – Edward Jenner one big thing: that a mild cowpox infection affords protection against smallpox. This observation was the origin of the vaccination procedure which has led to the international control of smallpox, the first, and so far the only, disease which can be said to have been eradicated from the human population. As smallpox is thought to have been acquired originally by man from cattle, and as there are closely-related viral infections that affect other animals – they include monkeypox, camelpox, goatpox and buffalopox – it would be optimistic to believe that the disease has gone for ever. But if it does reappear, the effectiveness of the procedure which Jenner developed gives good grounds for thinking that it can be controlled.

The new biography by Paul Saunders is based on a careful examination of original documents and an intimate knowledge of Cheltenham, where Jenner spent the most important years of his professional life. It covers the period in which vaccination established itself, from Jenner’s first successful experiment in 1796 until his death in 1823. The experiment was performed by injecting material from a cowpox pustule into the arm of an eight-year-old boy, and a few weeks later Jenner wrote to a friend: ‘Listen to the most delightful part of my story. The boy has since been inoculated for the smallpox, which, as I ventured to predict, produced no effect.’ It is an experiment which today no one would dare to repeat, but it must be remembered that inoculation was practised widely in the 18th century after its introduction to England from the Middle East. Indeed, for many years Jenner had to argue that vaccination was equally effective and much safer than inoculation, which was, in effect, an attempt to provide protection against smallpox by transmitting the disease itself.

By the severe test applied by Smith to the achievements of Florence Nightingale, Jenner was not an original thinker. For some time before his experiment it had been known that cowpox infection protects against smallpox, and Saunders suggests that it is likely that farmers in the West Country had already experimented with cowpox serum. Moreover Jenner was fortunate, as those investigating the relation between smoking and disease in the present century have been fortunate, because the results were so striking that, once suspected, they could hardly be missed. Anyone could vaccinate successfully: in Jenner’s absence his manservant often practised in his place, and it was said that ‘the housewife scratched with her needle, the cobbler with his awl and even the shepherd boys each other with their pocket knives.’ The vaccine prepared by Jenner was distributed around the world and appeared to retain its effectiveness when kept for many months under conditions which must have been far from ideal. The success of the procedure even survived misunderstanding of the duration of its effectiveness: Jenner claimed that ‘perfect vaccination is permanent in its influence’, but international regulations recently required revaccination at three-year intervals and an experienced clinician today would be uncomfortable if exposed to smallpox without a recent vaccination. But Saunders’s chronicle of the vaccination campaign leaves no doubt that it would be quite wrong to attribute Jenner’s reputation to either good luck or the exploitation of a well-recognised observation. Jenner alone perceived the significance of the immunity conferred by cowpox infection, and he devoted his life to researching and developing his vaccination. It is regrettable that we do not have a clearer picture of his experiments, but this is due to the deficiency of the records rather than any omission on the part of his biographer.

Because of the nature and significance of his work Jenner has been claimed as the founder of several medical sciences. But the gifts and interests required to launch a science are sometimes very different from those needed for its subsequent development; it would not have occurred to Mendel that his simple observations on garden peas were the beginning of a subject which would provide scope for mathematicians, and Jenner might have been surprised if he had known that he was to be regarded as the originator of disciplines such as immunology and virology. His true scientific identity was that of a practising physician with a strong, even obsessive commitment to clinical trials, and if he were alive today one could more easily imagine him at the centre of one of the current controversies about the aetiology of disease – for example, the relation of saturated fats to coronary heart disease – than as a laboratory recluse.

A comparison between the gifts and achievements of Edward Jenner and Florence Nightingale illustrates the futility of attempting to dissociate the personal character from the public work. Well-fitted for the pursuit of his single objective, Jenner would have been quite lost had he been confronted by the multiple problems on which Florence Nightingale became engaged, having neither the taste nor the gifts required for success in the corridors of power. She, by contrast, was marvellously equipped for the power game but had a restless intelligence which would never have been satisfied with a lifelong commitment to one idea.