Florence Nightingale and the Foundations of Public Health Care, as seen through her Collected Works
by Lynn McDonald for Dalhousie Health Sciences
17 February 2000
For the first time it will be possible for interested scholars to consult, even to search electronically, the full range of Nightingale’s prodigious output of written work. Scholarly analysis of Nightingale’s work has been hampered up to now by the wide dispersal of sources: unpublished material is housed in roughly 100 archives and private collections in the UK, Europe, the United States, Canada, India, Australia, New Zealand and Japan. (There are, for example, more than ten collections in London alone, three each in Edinburgh, Oxford and Cambridge, at least ten in county record offices; in the United States there are three collections in Boston, and other collections spread between New York, Atlanta, Birmingham, Alabama, North Carolina, Iowa, Los Angeles etc.)
What will this new examination of Nightingale reveal? Readers will be able to judge for themselves, of course, for complete publication will permit people to focus in their own areas of specialization. Most notably the Collected Works will show that Nightingale was more than the founder of modern, secular nursing and a reformer of hospital construction, on both of which she is given full credit, but a major architect of the public health care system.
A volume, Public Health Care, will present Nightingale’s systemic approach to health care (with a major role for prevention, clean air and water, decent housing and good infant care), a range of institutions from hospitals to convalescent hospitals and long-term care facilities for persons with incurable diseases or disabilities. The material to be published in the Collected Works will show that Nightingale began to be interested in radical reform of public health care (notably the provision of professional nursing in workhouse infirmaries) even before the Crimean War.
The Nightingale method includes rigorous monitoring of all treatments as to their effectiveness, an early version of “evidence-based health care.” She promoted uniform hospital statistics so that results could be compared by country as well as by institution and type of treatment. She was one of the first people to examine data on occupational health and safety. She conducted the first study of the mortality of aboriginal children in residential schools in the dominions and colonies.
Nightingale did pioneering statistical work on maternal mortality in childbirth, when puerperal fever was a great killer of women. This analysis featured examination of death rates by social class and type of maternity institution (or home births), pointing out that childbirth was not a disease but a natural condition. It was attacked in an anonymous review in the British Medical Journal, the “authoress” guilty of “sublime simplicity” and being “purely sentimental, although she was credited with a “kind womanly heart.”
There is interesting, untapped material in the history of medicine. There will be a full chronology of symptoms and treatment of her own illness (probably brucellosis). This will permit a re-examination of the literature arguing psychoneurosis or emotional disturbance, malingering and even syphilis. There are three months of ward observations, prescriptions etc. from her stay at the hospital at the Kaiserswerth Deaconess Institution, near Düsseldorf, in 1851 (the hospital is now named after her). There is substantial material on the treatment of syphilis (Nightingale not only opposed the Contagious Diseases Acts but was in contact with doctors and nurses on the treatment of syphilis patients). There is a vast clinical correspondence from throughout her life, of referrals to doctors and admissions to hospitals, for other family members, friends, employees, former employees, villagers and numerous others, which will be an enormously valuable resource to historians of medicine. Nightingale’s views on women in medicine vs. nursing will be shown to be much more nuanced when the full range of her writing is consulted. Certainly the often-heard statement that she “opposed” women in medicine will be contradicted.
Nightingale’s vision of public health care included professional nursing for the “sick poor” as good as that available in the best suburban hospitals for fee-paying patients. This of course is an issue still today, quality care for all, or a two-tiered system of better, private, care for those with ability to pay. She succeeded both in setting up the first experiment to provide trained nurses in the Liverpool Workhouse Infirmary, and in extending it to metropolitan London and other industrial cities. In the case of the London workhouse infirmaries this required an Act of Parliament. The Collected Works will show how assiduous a “back room” political agitator Nightingale was, not only on this matter, but numerous others.
There has been very little publication to date on Nightingale’s forty years of work on public health care, broadly conceived, on India. The Collected Works will include newly-found Indian sources (Delhi and Poona) as well as the vast quantities of Indian material in collections, major and minor, in Britain and around the world. This material will show her early support for re-forestation and interest in the influence of environmental conditions on health. She routinely linked such social factors as land tenure and local government with health outcomes. Her influence on (active support for) the early stages of the nationalist movement will appear; Nightingale was the mentor of Gopal Krishna Gokhale, mentor to Gandhi (who read Nightingale while still in South Africa). Nightingale’s role in the birth of a “new nationality,” as she called it, is scarcely known.
Nightingale’s saintly reputation began to be questioned as early as Lytton Strachey’s iconoclastic essay on her in Eminent Victorians, 1918. There is a sizable revisionist literature naturally enough in the nursing profession and even an attempt in 1999 by some British nurses to have Nightingale removed as a model for the profession. The major source for denigration of Nightingale’s contribution generally has been an extensively end-noted book by an eminent Australian historian. The claims of Smith’s Florence Nightingale: Reputation and Power will be carefully examined in the Collected Works, where, in many cases, it will be shown that the documentation cited is irrelevant or incorrect.
Persons interested in Nightingale are invited to consult the website of the Collected Works project. Team members (as editors, consultants, verifiers etc.) are still needed, especially medical, nursing and military historians. We would be very grateful to hear from anyone knowing of original Nightingale letters or notes (in small hospital archives or private collections—major sources we already have). Website: https://cwfn.uoguelph.ca/
Lynn McDonald, PhD, is Professor of Sociology at the University of Guelph, Ontario, Canada. She is the author of two recent books on women theorists (including Nightingale): The Women Founders of the Social Sciences, 1994 and Women Theorists on Society and Politics, 1998. McDonald is a former president of the largest women’s organization in Canada, the National Action Committee on the Status of Women. She was a Member of Parliament 1982-88, when she introduced pioneering public health legislation, the Non-smokers’ Health Act.
Notes
1 Anonymous. British Medical Journal Nov. 11 1871:559.
2 Young DAB. Florence Nightingale’s Fever. British Medical Journal. 311 (23-30 Dec.) 1995:1697-1700; Dossey Barbara M. Florence Nightingale and her Crimean Fever and Invalidism. Journal of Holistic Nursing 16 (2) 1998:168-96.
3 Encyclopedia Britannica 15th ed 1989 8:706; Smith FB. Florence Nightingale: Reputation and Power. London: Croom Helm:92; Burton E. The Early Victorians at Home. London: Arrow 1974:198.
4 Pickering G. Creative Malady. London: Allen & Unwin 1974:165; Showalter E. “Florence Nightingale’s Feminist Complaint: Women, Religion, and Suggestions for Thought.” Journal of Women in Culture and Society 1981 6 (3):396.
5 Worman JA. Even Church Calendar was Cause for Argument. Episcopal Life Sept. 1991:12.
6 Strachey L. Eminent Victorians. New York: Weidenfeld & Nicholson illustrated ed. 1988 [1918].
7 Notably Baly M. Florence Nightingale and the Nursing Legacy. London: Whurr (2nd ed.) 1997; Summers A. Angels and Citizens: British Women as Military Nurses, 1854-1914. London: Routledge & Kegan Paul 1988.
8 Smith FB. Florence Nightingale: Reputation and Power. London Croom Helm:1982.
