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8. Florence Nightingale a Hundred Years On

Florence Nightingale A Hundred Years On: Who She Was and What She Was Not

Lynn McDonald,Women’s History Review 19,5 (November 2010):721-740

Abstract

This article reviews Florence Nightingale’s work 100 years after her death, based on surviving writing compiled for The Collected Works of Florence Nightingale. Described are her founding of a new profession for women, based on patient care, her pioneering work in statistics and data analysis and her bold reform of the workhouse infirmaries. A section on historiography focuses on the negative impact of F.B. Smith’s attack on Nightingale in 1982 and Monica Baly’s progressively more negative interpretations from the 1970s to her death in 1998. Note is made of future research opportunities.

Introduction

Who was Nightingale and what did she accomplish? With the benefit of hindsight the achievements of Florence Nightingale (1820-1910) look even better on the centenary of her death (on 13 August 1910) than at any time during her life.1 2010 marks also the 150th anniversary of the foundation of the Nightingale School at St Thomas’ Hospital, London, and the publication of her most famous book, Notes on Nursing: What It Is and What It Is Not.

Nightingale was a legend in her time, the revered ‘lady with the lamp,’ the major founder of the modern profession of nursing, a statistical pioneer (the first woman member of the Royal Statistical Society and an honorary member of the American Statistical Association) and a renowned hospital reformer. She had a vision of a comprehensive health care system, and even the core principles of what would become the welfare state, with a system of agencies for the care of the aged, long-term infirm, disabled and children of destitute parents, and some measures for income security.

The very establishment of a profession for women, when they were excluded from all, lacked the vote and property rights, and very few were educated, was a formidable challenge. Women were then admitted into no recognized profession in Britain, or the public service, Parliament, the church, universities, or the army or navy. That a new profession to provide patient care should be established at all was a novel idea. There was in fact no such occupation in Britain when Nightingale first sought to become a nurse (in the 1840s), and very few women employed at what we would call nursing when her school opened in 1860. Her goal was no less than an independent, woman-led profession, with opportunities for promotion and commensurately higher salaries and responsibilities. The matron or superintendent would hire, promote, dismiss and discipline nurses, not a doctor, a measure probably aimed at least in part at sexual harassment.

Women called ‘nurses’ existed long before Nightingale’s time, but they were, apart from ‘nurses’ who were nursemaids, in effect hospital cleaners, untrained, ill paid and notorious for stealing their patients’ food and drink. The exceptions were women given informal instruction by a doctor, who then largely looked after his patients. (Nightingale herself during the Crimean War learned how to dress wounds from one such nurse, who had retired from St Thomas’ Hospital.) It was Nightingale’s idea that nurses should be providers of quality patient care, under the physician, when few women obtained even the equivalent of a secondary education, let alone a university degree.

Nightingale wanted both improved patient care, with attention to health promotion and disease prevention, and a worthwhile and challenging means of livelihood for women. Doctors at the time visited their patients at home, and patient care was then left either to an (untrained) woman in the family, or the ‘nurses’ and orderlies in hospital. Nightingale approved of the admission of women into the medical profession, but rightly saw that few women would gain entry into it. (By 1878 only nine women had been admitted to the medical register in Britain.2) Her school (opened in 1860) had by then provided careers for many and had begun to raise standards of care in hospitals all over Britain, and the start had been made to bring professional nursing elsewhere in the world. (Nursing in Roman Catholic religious orders developed quite differently, with little influence of Nightingale, and is not considered here.)

Now that nursing is a well-established profession it is hard to appreciate that when Nightingale took it on the ‘cardinal sin’ of unreformed nursing was exacting bribes for services. The drinking was such that junior medical doctors were detailed to see that the ‘nurses’ were carried into/out of the wards. The ‘nurses’ were not only badly paid, but their living and working conditions were abysmal. In 1854 Nightingale reported to her friend Elizabeth Herbert that the nurses at St Bartholomew’s Hospital in London still slept in ‘wooden cages’ on the landings outside the wards.3 Women ‘nurses’ in army hospitals in the early nineteenth century had the status of a private, reported to a sergeant, and were paid less than a laundress or cook.4

Nightingale has been charged with lowering the status of nurses, making them subordinate to doctors, as if they had earlier been regarded as equals. Said one such critic, who regretted that Nightingale still ‘haunts’ the nursing profession: ‘She unwittingly created the subservient role of nurses to doctors,’ and even ‘endangered the principles of good care,’ points made with no mention of the actual standard of care prior to Nightingale’s time, nor of salaries, benefits, working conditions and educational levels.5

Nightingale was a pioneering researcher.6 She honed her research skills post-Crimea by preparing a massive confidential report on what went wrong in that war, incorporating vast numbers of tables of illness and death from the War Office, and extracting correspondence from doctors in the field to headquarters to ascertain who reported what problem, and what was done about it, or more often not done in response.7 Nightingale wanted to convince people, from the prime minister and Cabinet down through informed opinion leaders, of the need for comprehensive reform in administrative procedures in the War Office. Or else the same death rates would occur again, she repeatedly asserted. Good data were essential to track the outbreak of diseases, and distinguish between ordinary numbers of sick and dead from a new epidemic.

Using both quantitative data and extracted reports, Nightingale made the case for thorough reform of bureaucratic procedures. Bad systems fundamentally were responsible for the high death rates. In her confidential report she also set out the failures of individuals, but in her own published evidence8 she kept to institutional reform and scarcely named a culprit.

Nightingale published nothing explicitly on research methodology, but her views are known through copious notes she took in working through L.A.J. Quetelet’s Physique sociale, an excellent source on how to analyze data.9 A ‘Nightingale method’ can be discerned from her own practice; it is still good advice for students and junior researchers:

  • Obtain the best information available on the topic, using official reports (especially statistics), books and articles; augment this material by interviewing experts.
  • If the available information is inadequate, collect your own data. Draw up a questionnaire; on the wording of questions consult appropriate experts who use the data; test the questionnaire before sending it out.
  • After writing up the results of the research, send a draft or printed proof to experts for review before publication (an informal means of peer review).

Nightingale herself devised institutional questionnaires both for her own studies and for government commissions and inquiries, but she never conducted a survey of individuals. Examples are questionnaires on army stations for the royal commission on India, mortality and morbidity in aboriginal residential schools and hospitals, maternal deaths post-childbirth in Britain and Europe, the organization of maternity hospitals and the staffing of a provincial spa hospital.

The purpose of Nightingale’s research was always application, and she was well aware that reports were not ‘self-executive.’ An implementation strategy had to be carefully devised in the early stages of the research. Next, as recommendations drawn from the research were put into practice, their actual effects had to be ascertained, through further research. Nightingale had learned from Quetelet that good intentions could have harmful consequences. One of his favourite examples, which she quoted frequently, was the fact that foundling hospitals, established with benevolent intentions, had high death rates. At Scutari she learned that the well-intentioned Barrack Hospital, which was large, on an apparently excellent site (high ground and seabreezes), with a full medical staff and for the first time nurses, had a defective sewer system which, with other sources of pollution, resulted in high death rates.

Nightingale can be seen as an early practitioner of ‘evidence-based health care.’ She promoted the collection of uniform statistics by hospitals in 1860, to enable comparisons of outcomes between hospitals, and succeeded in having the first steps taken to that end.10

She tried to have questions on health status and housing added to the 1861 Census, so that there would be an accurate picture of illness and health for the whole nation; the question on housing reflects her view of its importance as a health determinant. Mortality data, which were by then regularly collected, were not enough, Nightingale thought, for much illness had serious consequences (lengthy illness, infirmity and unemployment) short of causing death. If she had been successful—her proposal was turned down—there would have been ‘a return of the whole sick and diseases in the United Kingdom for one spring day, which would give a good average idea of the sanitary state of all classes of the population.’11

Important as nursing was to Nightingale, it was always part of a broader approach to health care. Prevention of disease and health promotion were primary. When disease occurred, a natural, reparative process in her view, the simplest and safest treatment should be sought. Care at home, with a doctor and nurse visiting, were safer than a hospital stay, the preferred recourse only for acute surgical and medical cases. She was well aware of the high death rates of civil as well as military hospitals. She liked ‘safe’ doctors, those who resorted to surgery only as a last resort.

Even before she established her nursing school, with money raised in her honour during the Crimean War, she sought to reform hospitals. (The first edition of ‘Notes on Hospitals’ precedes the first edition of Notes on Nursing by two years.) Attention to site, drainage and ventilation was key to safer hospitals. Occupational health and safety for nurses and doctors was a concern from the beginning, for they, too, fell ill and died unnecessarily, in both civil and military hospitals.

Nightingale was adept at what would later be called public administration. Administrative arrangements had to work in practice to ensure safety. For example, procedures devised in the 1870s to prevent ‘blood poisoning,’ or septicemia, at St Thomas’ Hospital, had to be set out in rules clear to nurses and nursing students, who should be tested on them (the rules had been devised for surgeons and had not been properly understood).12

Perhaps the most significant of Nightingale’s achievements was her introduction of trained nursing into the dreaded workhouse infirmaries, albeit only a start—she had hoped to reform the whole lot. Two aspects of this challenge have to be understood: (1) that the workhouse infirmaries were the hospitals for the vast majority of the population, the ‘sick poor,’ who could not afford a fee-paying hospital; (2) that for Nightingale most of the inmates of workhouses should not be there at all. Her proposals for reform amount to a virtual dismantling of the Poor Law system, not just improved infirmaries.

People were housed in workhouses on account of destitution, which could be caused by any number of reasons, most of them beyond their control: sickness, long-term disability or infirmity, old age, mental illness or disability, and children of any of the above. Only roughly 10% of the inmates were willfully unemployed, the sturdy paupers who lived off the taxes of honest working people. Reform in the infirmaries was only part of her vision, bold as that was.

Nightingale sought no less than the same standard of nursing care for the sick poor as for the better off in the best-nursed civil hospitals in the suburbs. Moreover, she saw this as achievable. (In Canada this is called ‘one-tier’ health care and maintaining it is a constant challenge.) Quality care for all was the goal, for God was no respecter of persons. The pauper ceased to be a pauper when sick, Nightingale told the minister responsible for the Poor Law Board, but became a ‘brother’ to the best of us, and as a brother should be cared for.13 All of her work on nursing and broader social reforms devolve from her faith, which included what she termed a ‘call to service’ by God.

Nightingale never published her ‘ABCs of workhouse reform,’ but she set them out clearly enough, in a letter to leading sanitary reformer Edwin Chadwick:

  1. To insist on the great principle of separating the sick, insane, infirm and aged, incurable, imbecile, and above all the children from the usual pauper population of the metropolis. (How many of those called incurable are not incurable a life’s hospital experience has taught me. Old age, is, of course, incurable.)
  2. To advocate a single central administration.
  3. To place all these classes (especially those suffering from any disease, bodily or mental) under this distinct and responsible administration, amenable directly to Parliament.14

To the Conservative Cabinet minister who became head of the Poor Law Board in 1866, she argued that improved nursing in the workhouse infirmaries required changes right down to the foundation: ‘classification of workhouse inmates, separation of the sick, consolidation of sick wards into hospitals with a separate administration.’ All were ‘absolutely necessary to success.’15

Nightingale understood that the stigma of the workhouse would continue to interfere with real improvements in patient care, until and unless the infirmaries were taken out of the Poor Law system. The problem of stigma indeed still vexed the hospital system in the late 20th century. Without this crucial reform—the upgrading of the old workhouse infirmaries to the standard of regular hospitals—it is hard to imagine how the National Health Service could have been established in 1948. Nursing was improving in the regular hospitals, but no one had taken on the reform of the far worse workhouse infirmaries, which held five time as many patients.16

In this work Nightingale reveals herself as a committed liberal/Liberal reformer. She was appalled by the injustices produced by the capitalist system, especially the vast differences in income and wealth, which meant the relegation of the great majority to abject poverty. She abhorred the views of the laissez-faire liberals who rejected any welfare measures as likely to cause more harm than good. But, unlike the advocates for the far left, Karl Marx and fellow Communists, she believed that capitalism was reformable, including the workhouse system.

Nightingale stands in the political centre-left, an ardent and fundamental reformer—a critic of capitalism as much as the revolutionary socialists—and an opponent of the far right just as much as they were. She was far more ambitious in her conceptualization of possible reform than any of her contemporaries.

She did not succeed in dismantling the Poor Law system, but she did see many new caregiving institutions established, especially for the aged and for mental patients, in addition to reformed workhouse infirmaries. For a vision comparable in scope to Nightingale’s one has to look to the Minority Report on the Poor Law in 1909, forty-five years later, which measures would not be substantially realized until after World War II.

The Liberal president of the Poor Law Board, C.P. Villiers, with whom Nightingale first discussed her workhouse reform ideas, but who was replaced by Gathorne Hardy when the Liberal government fell, was staggered by the scope of change she envisaged. He had promised reform, innocently enough, but had no idea how far she wanted to go. He never had a bill drafted along the lines she had urged, which doubtless never would have got through Cabinet if he had. In the course of discussing reform he uttered a hilarious mismatched metaphor. He thanked Nightingale for ‘the peep behind the curtain’ she had given him, but ‘what the broth will be when it is ready one can hardly guess.’17 Other workhouse reformers of the time, such as Louisa Twining, were seeking more humane conditions for the inmates. Doctors sought better salaries and budgets for drugs (they had to provide any drugs they prescribed out of their own stipend). Medical publications pointed out the bad conditions and supported reforms, but these were much more limited in scope. No one had a vision close to hers in boldness.

Historiography on Nightingale

At the end of the Crimean War, a secretary at the British Embassy in Constantinople recounted an anecdote from a military dinner party at which Nightingale had been present. After the ladies had withdrawn, the ambassador proposed that everyone write down on a slip of paper the name of the person ‘most likely to descend to posterity with renown.’ Everyone chose her, a choice perhaps influenced by his own praise of her.18 That renown would seem to have been borne out for well more than a century after the war, but late in the twentieth century Nightingale would be nastily attacked by academics of various disciplines and by members of her own profession.

Lytton Strachey’s whimsical put-down of her work in 191819 had a considerable and long-lasting impact, although much worse was soon to come. Margaret Goldsmith’s Florence Nightingale: The Woman and the Legend,20 was extremely hostile. Cecil Woodham-Smith’s award winning biography represents the positive extreme. Published in 1950, it continues to be much cited, although it is also the source of numerous errors.21 The official biography by E.T. Cook, commissioned by the family, remains the most thorough and reliable.22

The major force in the vilification of Nightingale has been an Australian historian, F.B. Smith, whose Florence Nightingale: Reputation and Power, 1982,23 was quickly and uncritically accepted as an exposé of a legend, finally telling the truth (the word appears in reviews) of an overrated, nasty and vicious fraud. Some reviewers pointed out the sexism of many of his judgments,24 and/or the extremity or unfairness of many of his views.25

Despite these and other critical reviews, Smith acquired a substantial number of followers, including many leading academics: two editors of the Oxford Dictionary of National Biography (H.C.G. Matthew and Lawrence Goldman); and two at least of the advisors of the dictionary (Margaret Pelling, consultant editor and Anne-Marie Rafferty, associate editor, and dean of the Nightingale School of Nursing and Midwifery); such distinguished professors as Charles E. Rosenberg,26 Martha Vicinus27 and Mary Poovey;28 leading medical historians Charles Webster and John M. Eyler and nursing historians Robert Dingwall and Anne Summers, military historians Clive Ponting and Trevor Royle, and political historian Richard Shannon.

Rosenberg makes for a good example, since he published on Nightingale both before and after F.B. Smith’s 1982 denunciation. His 1979 chapter is courteous and reasoned, if not always accurate; he used no archival sources and missed the most relevant published sources. He described Nightingale’s views on etiology as ‘fundamentally holistic’ and ‘moral.’ But since she was ‘unwilling to accept the specificity of disease and the possible existence of specific causative agents,’ she saw the nurse’s role ‘as both multifaceted and indispensable.’29 He failed to notice that her views evolved, as did those of doctors—Nightingale’s first writing on nursing and health care date from the 1850s, before Louis Pasteur’s groundbreaking conceptualization of germs in the 1860s, and the great advances made in bacteriology in the 1870s and 1880s.

Rosenberg’s remarks in 1989, in the introduction to his edition of her Notes on Hospitals, are much nastier than his first take. Now she could not distinguish between the moral and material in hospitals, while ‘her certainty was strident and uncompromising.’ He even found fault with her ‘obsession with cleanliness and ventilation.’ Yet again he alluded wrongly to ‘her explicit rejection of germ theory,’ which he said moved her ‘further apart from the consensus of medical opinion during the last third of the nineteenth century.’ He faulted her also for her 1871 study of maternal deaths from puerperal fever post childbirth, Introductory Notes on Lying-in Institutions.30 In that book Nightingale clearly did not correctly identify the causal agent of the disease, although she did some extraordinarily interesting analysis and made recommendations for improving practice. One might add that the bacillus that causes puerperal fever was not identified until 1902. As for her moving away from medical opinion in the last third of the century, Rosenberg offered no evidence, and none is evident in her vast surviving correspondence with doctors. It is perhaps telling that the great Russian bacteriologist, Waldemar Mordecai Haffkine, Nobel laureate in 1908 for his work on plague and cholera, sought to meet her when he was visiting England in 1895.31 He sent her a copy of his report on cholera inoculation with his compliments.32

Nightingale in fact made the switch to germ theory in 1884 or 1885, although she continued to emphasis prevention by stringent measures of cleanliness, and ‘asepsis’ over ‘antisepsis.’ What convinced her was Robert Koch’s 1883 demonstration of the cholera bacillus as the cause of cholera. The next year Dr Sutherland bought a ‘beautiful Vienna microscope’ to see ‘Koch’s cholera bacillus,’ a discovery which he told her would save many lives.33 We do not know if he brought the microscope to Nightingale’s home for a demonstration, nor exactly when she changed her mind, but she did. A 1891 paper to the Poona Savajanik Sabha, which she had privately printed the same year, and which was republished in its journal in 1892, proposed that village schoolrooms be used for lectures, to be illustrated with ‘object lessons’ or slides, or, better still, a ‘magic lantern showing the noxious living organisms in foul air and water.’ She pointed out that such preparations shown at an international hygiene congress had produced a ‘strong impression,’ and surmised that they would also in Indian villages.34

Nightingale’s own school taught an elementary understanding of germ theory as early as 1873, which can be seen in the medical instructor’s published lectures to nurses.35 Her articles on nursing practice in Richard Quain’s Dictionary of Medicine, written in 1878, published in 1884, have numerous references to antiseptic practice, with precise instructions as to solutions, although without reference to germ theory. She regretted that she did not then know about ‘aseptic’ practice to prevent disease, as opposed to killing the germs afterwards.36

Nightingale’s 1897 ‘address’ to her nurses shows practically how she integrated the old and new views: ‘A great doctor, a friend of mine, says, “Call it germs, bacillus or dirt, the treatment is the same, that is, cleanliness.”‘37

By comparison, a nursing textbook jointly published in 1899 by nurse Isla Stewart and physician Herbert Edmund Cuff describes germs or microbes as ‘minute forms of vegetable life belonging to the order of fungi.’38 It gave aseptic surgery as the goal, while carbolic acid was said not to make up for the lack of thoroughness in cleaning. Somewhat more details are given about dressings and operating theatre procedures in this text than in Nightingale’s article in Quain’s Dictionary, but the similarities are more remarkable than the differences.

The growing negativism of Rosenberg’s interpretation can be traced to his falling for F.B. Smith’s Reputation and Power, which he frankly admitted in a book review. In the review he gleefully repeated Smith’s accusations that Nightingale was a ‘liar, a careerist, a bully, a callous manipulator of friends, and a barracuda-like enemy…in short, a power-hungry psychopath…never much of an administrator…and even less an original thinker.’ ‘Smith’s lively and even fascinating demolition of Miss Nightingale’s moral credentials convinces this reader at least; she may well deserve this portrait in psychopathology.’39

Similar comments now appear routinely in books on broader subjects, such as a Cambridge University overview of nineteenth-century medicine, where F.B. Smith’s Reputation and Power is described as ‘a trenchant analysis of her devious personality.’40

Richard Shannon, in his biography of W.E. Gladstone, argued that Sidney Herbert’s death ‘exposed’ Gladstone to the tenacious Nightingale, who tried to ‘manipulate’ him for her War Office reforms, hoping to ‘exploit’ an old friendship. The reader is not told that Gladstone pursued Nightingale assiduously, having met her at the Herberts pre-Crimea. He wrote her just prior to her leaving for the Crimean War (the letter is not extant41). Immediately after Herbert’s death he asked Nightingale for material on him, probably for his own tribute. Twice in later years he called on her without an appointment and she could not receive him—she both wrote him promptly and saw him later. Gladstone and Nightingale remained on cordial terms as fellow Liberals for years. She did not succeed in getting him to be as liberal on India as he was on Ireland—she did try—but their exchange shows warmth and respect both ways.42

Shannon’s review of F.B. Smith’s Florence Nightingale: Reputation and Power is one of the most sycophantic, sarcastically repeating some of the wildest and most inaccurate of his charges. A few quick examples: that her ‘first battlefield’ was the Harley Street institution, ‘which she briskly took over and reformed to extinction’; that she kept cholera ‘alive and well,’ was ‘bigoted and dogmatic,’ not the view of Nobel laureate Haffkine noted above; that her nursing was no more than ‘a form of applied housekeeping—a view she retained all her life.’43

In fact Nightingale left her Harley St. hospital in 1854 in good shape, after a year and a half as superintendent, for the Crimean War. That she had been planning to leave it, to head the nursing at King’s College Hospital, was well understood by the ladies’ committee that had hired her. She remained on excellent terms with Lady Canning and Lady Cranworth, who were its leaders, as can be seen in a letter Lady Canning wrote her on behalf of the committee, before any of them had an inkling of her taking on the Crimean War nursing:

We well know that the great work you have always had at heart, namely to improve hospital nursing, cannot be carried in such an institution as this, and greatly as we shall feel a loss not to be replaced, we should do wrong in wishing you, for the benefit of our small institution, to forego for much longer an intention likely to lead to such important results.44

Further, Nightingale helped raise money for her old Harley St. hospital in 1901. It is still in existence, although with a different name, more than 150 years later.45

Nightingale’s nursing was never the mere ‘applied housekeeping’ Shannon called it (paraphrasing Smith that it was mere ‘common sense’ care, ‘adding nothing to the details of technical proficiency required’46), but the technical skills required increased as medical science and practice evolved. This is set out in detail the Nightingale School, where the limited requirements of 1860 are compared with the much more onerous tasks a nurse had to be able to perform two decades later.47

Martha Vicinus’s writing on Nightingale includes many unsubstantiated accusations, and one good edition of her letters, co-edited with Bea Nergaard, in 1990. There are chapters in two books, 1985 and 1986, plus an encyclopedia entry on Nightingale in 1988. The introductory material to the edition of letters is largely adequate. Still, there are snide remarks, for example, that Nightingale was vindictive, ungenerous and manipulative, and used her illness to force people into action.48 Vicinus and Nergaard were critical of Smith’s Reputation and Power, for his evaluating ‘all women reformers as meddling bullies.’ A good point, but they failed to note that he was simply wrong so much of the time. They also repeated his false statement about Nightingale being a lifelong opponent of germ theory.

Vicinus evidently considered Nightingale’s illness fake, referring to her ‘calculated decision to remain sick after returning from Crimea.’49 To the best of available knowledge, she came back from the war exhausted certainly, but up to a prodigious amount of work, including travel, briefing witnesses and active lobbying of Cabinet ministers. She fell ill again a year later, probably of brucellosis.50

Vicinus in her biographical sketch in 1985 referred to Nightingale’s ‘ambitiousness and her ruthlessness.51 Mary Poovey similarly referred to Nightingale’s ‘ruthlessness,’as unjustified.52 But what was she ruthless about? What were her ambitions? Nightingale sought no position and no money. Post-Crimea the only position she held was as director of the Nightingale Fund, an unpaid post, as were the two posts she held before and during the Crimean War. Indeed Nightingale’s nursing, India and other work cost her money and enormous effort, for she never had a grant or staff, and paid for books, documents, printing, etc., herself. Her ambition was to save lives, her enemy unnecessary mortality from disease. The terms ‘ruthless’ and ‘ambitious’ seem more suitable for dictators, warlords and serial killers than for a nurse on a relentless campaign for clean air and water, decent food and housing for the poor, education, jobs and safe childbirth for women.

Dingwall, Rafferty and Webster used similar language in referring to Nightingale’s ‘cruellest comments’ (they used her first name). Yet they gave no examples of any acts, cruel, crueller or cruellest, and none are evident in the massive available oeuvre. On the contrary, acts of kindness and consideration abound in the correspondence, as can be clearly seen in letters to her by recipients.

In a paper in 1996, or after many years of Smith’s book having its influence, Vicinus reported that feminist historians found Nightingale to be a ‘generally unattractive figure,’ indeed, anyone who relied on Smith or his followers would think so. These feminist historians granted Nightingale’s administrative expertise, which Smith did not, but faulted her ‘flagrant use of class privilege, consistent refusal to recognize the capacities of other women and recalcitrant unwillingness to accept antisepsis, the germ theory and virtually all other medical discoveries made in her lifetime.’53 The point about germ theory and antisepsis has already been documented—Vicinus was again wrong. As to not recognizing talented women, see the many women Nightingale encouraged and mentored, assisted with manuscripts and references for posts, and sent practical gifts (food, coffee, books, flowers) and moral support when their jobs were under threat. Luise Fuhrmann in Germany, for example, when she was belittled by Florence Lees Craven, used the books Nightingale had sent her, calling her her ‘good angel’ in difficulty: ‘when people saw the kind sweet words you have written in those books they began to think I could not be quite so bad and worthless as Mrs C. had tried to make out.’54

A similar charge frequent in the secondary literature, especially by women historians, is that Nightingale had a ‘low’ opinion of women and exploited them. Karen Armstrong was at least succinct in her completely unreferenced condemnation: that Nightingale, more than ‘all the Victorian viragos we have considered,…hated women…wanted the co-operation only of men,’ and was ‘a neurotic all her life.’55

Many who portray Nightingale as anti-woman refer to her 1861 letter to a friend, Mary Clarke Mohl, that women had ‘no sympathy.’ She was there replying to an argument Mohl had made in her book on Mme Récamier. Nightingale explained: ‘I have never found one woman who has altered her life by one iota for me or my opinions,’ and went on to name eight men who had.56 That was indeed the case in 1861, for not one of the women who nursed with her in the Crimean War continued to work with her afterwards. Her school opened in June 1860, and the first significant advances made by former pupils were not evident until 1865, when Agnes Jones became superintendent of nursing at the Liverpool Workhouse Infirmary. Nightingale increasingly had women who changed their lives to take on her challenges. She mentored many, as is clear in numerous letters to her from former pupils as they went on to matronships around the world. She also mentored women who sought her help who had not been trained in her school (such as Eva Lückes at the Royal London Hospital, Whitechapel and Ella Pirrie of workhouse infirmary in Belfast), as well as many American, European and Canadian nurses, and women in related fields such as Jane Senior, the first woman Poor Law inspector. But in 1861 none of this was evident.

Margaret Forster similarly cites the ‘sympathy’ letter, with no historical context. She also repeats the incorrect assertion (F.B. Smith’s influence again) that Nightingale refused to become a member of the first suffrage society. She foists a ‘nervous breakdown on Nightingale, and there is the usual sexist nomenclature, with ‘Fanny and Florence.’57

Statisticians and users of statistics, by contrast, have been and remain keen on Nightingale’s work, beginning with Karl Pearson, inventor of the correlation coefficient. Of the many more recent ones two examples will be cited, one American, I. Bernard Cohen58 (founder of the Department of the History of Science at Harvard University), and the British Richard Stone59 (Nobel laureate in economics).

A substantial biography published in 2009 may succeed in ending the grip F.B. Smith has had on Nightingale commentators.

Mark Bostridge’s 675-page Florence Nightingale: The Making of a Legend includes a spirited denunciation of F.B. Smith’s Reputation and Power, as ‘character assassination masquerading as a serious history.’60 The author not only gave considerable coverage to Nightingale’s public health and social reform work, he broke new ground in his research on her family relations. The biography, however, is marred by the frequent use of first names for women, in juxtaposition with references to men with surnames and honorifics. It is the first English biography to have made substantial use of the Collected Works of Florence Nightingale.61

Nursing Historians on Nightingale

Perhaps the best book on Nightingale by a nursing historian, certainly for its mere 169 pages, is Lucy R. Seymer’s assessment of the Nightingale School, published on the 100th anniversary of its opening.62 Seymer was apparently the first person to delve into the newly available Nightingale records on nursing deposited at the British Library. Few nursing historians have since.63 Monica E. Baly is one who did, although not as thoroughly as Seymer had, and she even castigated Seymer for failing to mention the intoxication of the resident medical officer at St Thomas’.64 Dingwall, Rafferty and Webster do not even cite Seymer’s excellent research, Few books on Nightingale’s nursing after Seymer’s use primary source material at all.

The views of the leading British nursing historian on Nightingale, Monica E. Baly (1914-98), changed over time as she gradually accepted F.B. Smith’s views in Reputation and Power. Baly had been an outstanding nursing leader when she took up nursing history on her retirement. Two of her books with major sections on Nightingale went into three editions, which straddle the publication of Smith’s 1982 book, her Florence Nightingale and the Nursing Legacy (1973, 1986 and 1997), and Nursing and Social Change (1973, 1980 and 1986). The change in coverage is remarkable, yet there is nothing to indicate that Baly did any further primary research after her doctoral thesis—certainly she cited no new primary sources. Rather she increasingly incorporated Smith’s hostile views. Her thesis, The Influence of the Nightingale Fund (1855 to 1914) on the Development of Nursing, is a fine piece of research. Accepted in 1984, it effectively predates Smith’s influence.

In the first edition of Nursing and Social Change, Baly credited Nightingale with ‘extraordinary administrative genius,’ while her ‘Herculean’ achievements, were solid facts. For fifty years she laboured ‘unremittingly’ with a ‘first-class intellect, a passion for statistics….and above all the imagination to see what needed to be done….her achievements shine like a beacon,’ whereupon Baly went on to flag other reforms Nightingale had effected in the army.65

By the third edition the same passage drops the remarks about the ‘Herculean’ achievements, and while the ‘unremitting labour’ gets a mention, the other positives have been dropped.66 A new section on the school at St Thomas’ Hospital is negative, asserting no less than that ‘the first ten years of the school were disastrous.’67 The final paragraph has lukewarm praise: ‘Under the Nightingale system undoubtedly nursing and hygiene improved.’68 Derogatory remarks are frequent in another Baly publication of about this time, ‘The Nightingale Nurses: The Myth and the Reality.’69 Yet Baly’s publications were never hatchet jobs and all have informative, well-written material as well.

Baly’s final capitulation to F.B. Smith can be seen in her entry on Nightingale in the Oxford Dictionary of National Biography, where Smith’s Reputation and Power is cited sixteen times. The entry shows a considerable departure from her earlier highly positive assessment of Nightingale’s work in nursing. It gives her credit for district nursing, but describes her nursing school as a failure,70 and fails to discuss its work in any detail. The bibliography omits the above-mentioned major book on the school, Seymer’s (1960) Florence Nightingale’s Nurses. Nightingale’s Harley St. establishment is mis-named.71

The one paragraph on workhouse nursing repeats Smith’s contention that Nightingale quit working on its reform after the death of Agnes Jones in 1868.72 Primary sources, however, show that Nightingale continued to give her time (and money) years thereafter. She actively mentored several workhouse infirmary matrons and came to see professional nursing established in a number of them, in time with full training schools. The Collected Works of Florence Nightingale contains more than 400 pages on this work, most of it from after Agnes Jones’s death.73 Baly gave workhouse nursing thorough attention and high praise in her earlier work.74

Far from her assisting ‘J.S. Mill, Charles Dickens and Louisa Twining,’ in the Association for Improving Workhouse Infirmaries, as Baly’s entry stated, Nightingale inspired them to take a stronger position on reform. She was disappointed with the half measures legislated by the Metropolitan Poor Law Act in 1867, which enabled improved nursing, but did not require it. But she did what she could, as reformers do, using whatever opportunities opened up. In fact many did, in Liverpool, Birmingham and Belfast as well as several in London, when progressive leaders approached her for advice, and suitably qualified nurses were willing to take on the challenge.

The ODNB entry has Nightingale in effect retiring more than ten years before she actually did. St Thomas’ is said to have appointed a matron in 1888 ‘without consulting her’ or her council.75 Baly made a similar point, but with the correct date (1889) in her ODNB entry on Alicia Lloyd-Still, a later matron at St Thomas’.76 Yet Nightingale’s notes of interviews with four candidates are available, as is her correspondence with Henry Bonham Carter on her choice, Louisa M. Gordon. The Nightingale Fund Council minute book notes both that the St Thomas’ treasurer initiated the consultation, and that Nightingale approved of the choice.77 Gordon, as the superintendent of her training school, reported to her regularly. Primary sources show that Nightingale remained active on nursing issues until the late 1890s.

In another reference in her Nightingale entry Baly again implies her premature retirement, but allows that Nightingale was ‘not, however, wholly inactive,’78 this for the period 1870-80. Yet this was a time of formidable achievement, when Nightingale saw through substantial reforms at her own school (vastly improving the academic content), extending nursing to hospitals elsewhere in Britain and other countries, and did an enormous amount of work on India and the Franco-Prussian War.

Baly’s entry includes a gross misrepresentation of Nightingale’s religious upbringing as ‘basically Unitarian,’79 in a section oddly grouping together ‘Religion and Attitude to Women,’ doing justice to neither topic. Baly also cited uncritically George Pickering’s ‘psychosomatic’ explanation of Nightingale’s illnesses. Pickering’s book interestingly included a chapter with a similar take on Charles Darwin, ignored in the ODNB entry on him.

Baly’s original entry in the ODNB was negative enough, but the editors both increased the negative comments and omitted positive ones. While asserting that they did not want her ‘to take the F.B. Smith approach,’ they suggested that there was no ‘need to be defensive about the ‘shortcomings’ of a woman such as Nightingale.’80 Were such requests made of the writers of the highly flattering entry on Charles Darwin? Baly had already condemned Nightingale’s nursing as a failure, described her methods as ‘ruthless,’ her addresses to nurses as ‘sentimental’ and yet again declared that she ‘continued to disregard the germ theory of infection.’81 Not one of Baly’s factual errors was picked up by the editorial advisors, but citations of F.B. Smith were increased. The editor removed Baly’s qualified endorsement of Smith, that he had started ‘with the premise that Florence Nightingale was motivated by the urge for power,’ and that he had ‘produced evidence to support it,’ again not noting that the evidence did not stand up to scrutiny. Unqualified praise replaced it: ‘Barry Smith’s striking study (1982) stripped away the iconic aspects of the Nightingale legend to examine the remarkable network of manipulation (mostly by letter) by which she sought to impose her will and achieve her objectives.’82

Non-academic nurses by the late twentieth century joined in the denunciation of Nightingale as well. One British nurses’ union, Unison, in 1999 called for her to be dropped as the model for the profession, and for ‘Nurses Week,’ then celebrated around her birthday, 12 May, be rescheduled.83 The Royal College of Nursing was more restrained than this union in its rejection of their profession’s major founder. It named its publishing house Scutari Press, in effect acknowledging Nightingale’s work there in the origins of professional nursing. The RCN History of Nursing Society, at a millennium conference in 2000, had one session on Nightingale. The conference report explained that it was early in the program, whereupon they moved on ‘to other significant, new and interesting matters which are of historical, professional and social interest and significance.’ Clearly, moving on from Nightingale was a good thing.84

On the centennial of Nightingale’s death in 2010, which also marks the 150th anniversary of the founding of the Nightingale School and the publication of Notes on Nursing: What It Is and What It Is Not, the Royal College of Nursing is funding a conference at which the influence of Nightingale’s nursing will be debated. That, however, might be taken as a reopening of interest at least, for nursing historians and nursing leaders largely stopped doing research on Nightingale after Smith’s Reputation and Power, either ignoring her completely or recycling his accusations. The contrast with the 150th anniversary of Charles Darwin’s Origin of Species in 2009, which was a real celebration of achievement, is remarkable.

It should not be surprising that authors reporting original Nightingale material since the 1982 Reputation and Power have not been nurses or nursing historians but (in chronological order): Sue M. Goldie,85 secretary and research assistant; Michael D. Calabria,86 Egyptologist; Victor Skretkowicz,87 senior lecturer in English; Mary C. Sullivan,88 professor of English and Sister of Mercy; Lynn McDonald,89 professor of sociology;

Gérard Vallée,90 professor of religious studies; Jharna Gourlay,91 BBC producer.

Sexist language is a hazard for anyone who reads Nightingale material. Nightingale herself routinely used masculine words for both sexes, as was customary, but the complaint here is the use of first names and nicknames for her and other women, by contemporary and recent historians. Men, by contrast, are routinely accorded surnames with initials or first names and honorifics. No man in the Nightingale secondary literature to my knowledge has ever been referred to by a nickname, although many were so addressed at the time. Thus there is Sidney Herbert, or Lord Herbert, and his wife, Liz, although in correspondence they both got proper titles, or both got nicknames: he was ‘Sid,’ even the ‘Cid.’

Nightingale’s father is typically abbreviated W.E.N. (he is sometimes ‘William’), but that her mother routinely used initials too in family correspondence is ignored. Members of the family called him ‘Night’ or ‘Uncle Night.’ She is tediously ‘Fanny’ in the secondary literature, while she used ‘Frances’ outside the immediate family. Henry Bonham Carter and Nightingale wrote each other—they were first cousins—as ‘Flo’ and ‘Harry,’ but his nickname never appears, hers frequently, in the secondary literature. Benjamin Jowett’s surname and often the ‘Professor’ title appear—they were always Mr Jowett and Miss Nightingale to each other. Is it a coincidence that she is often demoted to being his pupil or the recipient of his spiritual advice? Anyone who reads the correspondence between them would see that they interacted as equals, each consulting the other on a wide range of subjects.92 Far from Jowett being her ‘spiritual advisor,’ they disagreed on central matters of faith, such as his belief in absorption after death, while Nightingale believed in an afterlife of great, individual, activity.

Future Research Opportunities

The silver lining in the cloud of so much inadequate work on Nightingale is that there remains much to do to elucidate who she really was from her actual writing: an abundance of worthy topics for books, theses and articles. The publication of The Collected Works of Florence Nightingale makes primary sources (drawn from more than 200 archives worldwide) easily accessible. Full records of transcriptions will be made available in some electronic form after the print publication is completed. In the meantime, scholars are given access to any available transcribed material, of which there is now a prodigious amount. The volumes are available to libraries as ebooks.

The intrepid nursing historian might look for the missing correspondence with nursing leaders. Nightingale kept their letters and Henry Bonham Carter made them available to scholars, but her letters to many early, important, nursing leaders are missing. Thus there are seven British Library volumes of letters of the first superintendent of the Nightingale School, Sarah E. Wardroper, to Nightingale, but only a very small number of Nightingale’s letters to her. (A list of missing correspondence is given in the Collected Works.93) Anyone who could find Nightingale’s correspondence to Elizabeth Vincent, the first superintendent of nursing at the St Marylebone Workhouse Infirmary, would have fine new material on this key development in the history of nursing (there is one British Library volume of letters to her).

There is material for research on Nightingale’s collaboration with a number of leading doctors, most notably with John Sutherland, whose entire work post-Crimea was linked with hers, and on whom there has yet to be a biography. Nightingale’s association with Sir John McNeill was shorter and quite different, but deeply meaningful. While Sutherland was Nightingale’s closest, nearly everyday collaborator, McNeill was more of a father figure (he lived in Edinburgh), perhaps the father who shared her deepest hopes and dreams in a way that her own did not. For both there are substantial archival materials, letters both ways. In the case of McNeill many are available in a ‘fair copy’ by his wife (he signed them).

William Farr’s biographer, John Eyler, gave a chapter to his work with Nightingale, but failed to capture the full warmth and closeness of their collaboration and friendship. He stated explicitly that Farr maintained ‘an unusual independence’ from Nightingale for someone in her inner circle, but none of her close collaborators were in any way dependent on her.94 The fact of the Farrs naming a daughter after her gets only an aside, that she was her ‘namesake.’95 The irony is missed of this namesake being the well-known actress Florence Farr, a ‘new woman,’ meaning sexually liberated. George Bernard Shaw wrote the role of the heroine of his great anti-war play, Arms and the Man, for Farr, who was the first actress to utter the delightful words on the stage: ‘You’re the chocolate cream soldier!’

Farr was effusive and whimsical in his letters to Nightingale. When her two papers on hospitals were read to a social science congress in Liverpool, he called them her ‘luminous hospital gospel.’ He liked her ‘dashing style of charge.’96 No doubt he did a lot for Nightingale’s mission of saving lives, so coolly described by Eyler. Working with her he did his best work, as noted above, on their famous coxcombs or rose charts. Eyler wrote an effusive review of F.B. Smith’s book.97

The reader may have noted that this retrospective is not balanced; there are no accusations of wrongdoing on Nightingale’s part, or even minor warts. This was deliberate. Given the vast extent of the hostile secondary literature—only the tip of the iceberg has been noted here—adding to it seemed a poor idea. Moreover, after years of reading her work (all that could be found) nothing of significance has appeared. When the research began for the Collected Works it was obvious that there were vast sources to track down—of course more and more appeared as the Internet made previously sequestered sources evident. The material itself proved to be richer than anticipated. Nightingale’s dedication could be moving, her wit often amusing. Even the tedious attention to detail had its point, for it showed a practised reformer who knew that people suffered and died as a result of small neglects. The positive take on Nightingale in this short article, as in the larger Collected Works, is the product of reading primary sources, the best way to discover who she was. Those who rely on the vast secondary sources will all too often see instead what she was not.

Biographical note:

Lynn McDonald is University Professor Emerita at the University of Guelph, Ontario, and director of the Collected Works of Florence Nightingale, of which the first 13 of the 16 planned volumes have been published. She is the author of 3 books on sociological theory that include women theorists: The Early Origins of the Social Sciences (McGill-Queen’s 1993), The Women Founders of the Social Sciences (McGill-Queen’s 1994) and an anthology, Women Theorists on Society and Politics (Wilfrid Laurier University Press 1998). Her short Florence Nightingale At First Hand (Continuum 2010) has recently appeared.

McDonald is a former member of Parliament and former president of the National Action Committee on the Status of Women, then Canada’s largest women’s organization. Correspondence to: Dept. of Sociology and Anthropology, University of Guelph, Guelph ON, N1G 2W1, Canada. Email: lynnmcd@uoguelph.ca

Endnotes

1 Citations of Nightingale, unless otherwise indicated, come from Lynn McDonald (Ed) (2001-) Collected Works of Florence Nightingale (Waterloo ONT: Wilfrid Laurier University Press). Volumes are identified by their short title and the volume and page number.

2 Louisa Garrett Anderson (1939) Elizabeth Garrett-Anderson 1836-1917 (London: Faber & Faber 1939), p. 286.

3 Letter reproduced in McDonald, Extending Nursing 13:60.

4 Fred Smith (1929) A Short History of the Royal Army Medical Corps (Aldershot: Gale & Polden), pp. 11-14.

5 Joan Iveson (11 May 1983) A Legend in the breaking, Nursing Mirror, pp. 26-27.

6 It would be an exaggeration to credit her with the invention of the prototype pie chart, or ‘rose’ or area chart, which she used in her own report and which appeared also in the official royal commission report. Britain’s leading medical statistician, William Farr, deserves that credit, which she made clear, but it seems unlikely that he would ever have achieved such a vivid result without her collaboration. Certainly his earlier reports show nothing so lively or persuasive.

7 Nightingale (1858) Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army (London: Harrison). Some 200 pages of this document are available online, excerpted for Measuring Hospital Care Outcomes (1999) (Oakbrook Terrace ILL: Joint Commission on the Accreditation of Healthcare Organizations), pp. 17-218; key material is reproduced in McDonald, Crimean War.

8 Nightingale (1858) Answers to Written Questions Addressed to Miss Nightingale by the Commissioners, Report of the Commissioners appointed to Inquire into the Regulations affecting the Sanitary Condition of the Army and the Treatment of the Sick and Wounded (London: HMSO) 361-94, reproduced in McDonald, Crimean War.

9 McDonald, Society and Politics 5:11-74.

10 McDonald, Society and Politics 5:74-92. See Jocelyn M. Keith (1998) Florence Nightingale: Statistician and Consultant Epidemiologist, International Nursing Review 35(5), pp. 147-50.

11 Letter to William Farr 21 April 1860, in McDonald, Society and Politics 5:96.

12 See letter 7 June 1878 to Henry Bonham Carter in McDonald, Nightingale School 12:344.

13 Letter to C.P. Villiers [30 December 1864], in McDonald, Public Health Care 6:329.

14 Letter 9 July 1866, reproduced in McDonald, Public Health Care 6:346-49.

15 Letter to Gathorne Hardy 25 July 1866, reproduced in McDonald, Extending Nursing 13:591-93.

16 The five to one proportion is given by Brian Abel-Smith (1964) The Hospitals 1800-1948: A Study in Social Administration in England and Wales (London: Heinemann), p. 46.

17 Letter 10 January [1867] in McDonald, Public Health Care 6:397.

18 James Henry Skene (1883) With Lord Stratford in the Crimean War (London: Richard Bentley & Son), p. 39.

19 Lytton Strachey (1918) Florence Nightingale, Eminent Victorians (London: Folio Society 1967). On the early historiography see Lynn McDonald (December 6 2001) Florence Nightingale Revealed in her own Writings, Times Literary Supplement pp. 14-15; Lynn McDonald, Appendix B: The Rise and Fall of Florence Nightingale’s Reputation, in Life and Family 1:843-47 and McDonald, Appendix B: Secondary Sources on Nightingale and Women, in Women, 8:1039-53; McDonald, The Revisionist Literature on Nightingale, in Extending Nursing 12:31-36.

20 Margaret Goldsmith (1937) Florence Nightingale: The Woman and the Legend (London: Hodder & Stoughton).

21 See W.H. Greenleaf (December 1959) Biography and the ‘Amateur’ Historian: Mrs Woodham-Smith’s ‘Florence Nightingale.’ Victorian Studies, pp. 190-202.

22 E.T. Cook (1913) The Life of Florence Nightingale. 2 vols. (London: Macmillan).

23 F.B. Smith (1982) Florence Nightingale: Reputation and Power (London: Croom Helm).

24 Among many examples, see Anne Summers in her review (autumn 1982) Florence Nightingale: Reputation and Power. History Workshop Journal, pp. 153-55.

25 Notably a review by Eileen & David Spring (1983) The Real Florence Nightingale?: An Essay Review, Bulletin of the History of Medicine 57(2) pp. 285-90.

26 Ernest E. Monrad Professor in the History of Science, Harvard University.

27 Eliza M. Mosher Distinguished University Professor of English, Women’s Studies and History, University of Michigan.

28 Samuel Rudin University Professor of the Humanities, Institute for the History of the Production of Knowledge, New York University.

29 Charles E. Rosenberg (1979) Florence Nightingale on Contagion: The Hospital as Moral Universe, in C.E. Rosenberg (Ed) Healing and History: Essays for George Rosen (New York: Science History), p. 126.

30 Charles E. Rosenberg (1989) Introduction, Florence Nightingale on Hospital Reform (New York: Garland) unpaged.

31 Henry Acland was the intermediary, but there is nothing to show that any meeting took place (Acland letter to Nightingale 29 December 1895, Bodleian Library f231).

32 W.M. Haffkine (1895) Anti-Cholera Inoculation. Report to the Government of India (Calcutta: Thacker, Spink), Wellcome Library Rare Books.

33 E.T. Cook (1913) The Life of Florence Nightingale (London: Macmillan), 2:344. The correspondence between Sutherland and Nightingale in this period is not extant, so that we have to rely on Cook’s account.

34 Florence Nightingale (July 1892) Sanitation in India, Quarterly Journal of the Poona Sarvajanik Sabha, 15 (1), pp. 13-17, reproduced in Social Change in India 11:362-65. See also Florence Nightingale (December 1896) Health Missioners for Rural India, India: A Record and Review of Indian Affairs, 7 (12), pp. 359-60, reproduced in 11:388-92. For further see McDonald, Social Change in India 11:862-65 and Nightingale School 12:10-21.

35 John Croft (1873) Lecture 19, Disinfectants and Antiseptics, Notes of Lectures at St Thomas’ Hospital (London: St Thomas/Blades, East & Blades).

36 See McDonald, Nightingale School 12:714.

37 Reproduced in McDonald, Nightingale School 12:872.

38 Isla Stewart & Herbert Edmund Cuff (1899) Practical Nursing (Edinburgh: William Blackwood), p. 233.

39 Charles E. Rosenberg (1983) review of F.B. Smith, Florence Nightingale: Reputation and Power, in Medical History, 27, p. 93.

40 W.F. Bynum (1994) Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press), p. 246.

41 Entry 19 October 1854 in M.R.D. Fast & H.C.G. Matthew (Eds) (2004) The Gladstone Diaries (Oxford: Clarendon Press) 4:655.

42 The correspondence is published in McDonald, Society and Politics 5:427-76.

43 Richard Shannon (28 May 1982) An Icon and her Intrigues, review of F.B. Smith, Florence Nightingale: Reputation and Power. Times Literary Supplement, pp. 571-73.

44 Letter 8 August 1854, Claydon House Bundle 105.

45 It was the Florence Nightingale Hospital for Gentlewomen 1892-1953, then dropped the ‘for Gentlewomen’; in 2010 it moved to 11-17 Lisson Grove; letter by Edith Glandie 18 November 1901 thanking Nightingale for donation to the ‘Ladies’ Home, Harley St.’ Florence Nightingale Museum 0545.

46 Smith, Reputation and Power, p. 178.

47 In her Quain’s articles, reproduced in McDonald, Nightingale School, especially 12:741-45.

48 Martha Vicinus & Bea Nergaard (Eds) (1990) Ever Yours, Florence Nightingale: Selected Letters (Cambridge Mass: Harvard University Press), p. 10.

49 Martha Vicinus (1996) ‘Tactful organising and executive power’: Biographies of Florence Nightingale for Girls, in Michael Shortland & Richard Yeo (Eds) Telling Lives in Science (Cambridge University Press), p. 200.

50 D.A.B. Young (23-30 December 1995) Florence Nightingale’s Fever, British Medical Journal, 311, pp. 1697-1700.

51 Vicinus (1985) Independent Women: Work and Community for Single Women 1850-1900 (Chicago: University of Chicago Press), p. 21.

52 Mary Poovey (Ed) (1993) Florence Nightingale: Cassandra and Other Selections from Suggestions for Thought (New York: New York University Press) p. xxvii.

53 Vicinus, ‘Tactful organising and executive power,’ p. 211.

54 Letter 24 December 1882, Add Mss 45806 f24.

55 Karen Armstrong (1986) The Gospel According to Woman: Christianity’s Creation of the Sex War in the West (London: Elm Tree), p. 147.

56 Letter reproduced in McDonald, Women 8:563-66.

57 Margaret Forster (1984) Florence Nightingale 1829-1910, in Significant Sisters: The Grassroots of Active Feminism 1839-1939 (London: Penguin), p. 94.

58 I. Bernard Cohen (March 1984) Florence Nightingale, Scientific American 246, pp. 128-33 and 136-37; and (2006) The Triumph of Numbers: How Counting Shaped Modern Life (W.W. Norton) pp. 158-77.

59 Richard Stone (1997) Florence Nightingale and Hospital Reform, in Some British Empiricists in the Social Sciences 1650-1900 (Cambridge: Cambridge University Press/Raffaele Mattioli Foundation), pp. 303-37.

60 Mark Bostridge (2008) Florence Nightingale: The Making of a Legend (London: Farrer, Straus, Giroux), p. 542.

61 An earlier Swedish biography which did: Asa Moberg Boije (2007) Hon var ingen Florence Nightingale: människan bakom myten [She was no Florence Nightingale: the Woman behind the Myth] (Stockholm: Natur och Kultur).

62 Lucy R. Seymer (1960) Florence Nightingale’s Nurses: The Nightingale Training School 1860-1960 (London: Pitman Medical).

63 Examples of nursing historians who have used primary sources are (in chronological order): Lois A. Monteiro (Ed) (1974) Letters of Florence Nightingale in the History of Nursing Archive, Special Collections, Boston University Libraries (Boston: Boston University Mugar Memorial Library Nursing Archive); Vern Bullough, Bonnie Bullough and Marietta P. Stanton (Eds) (1990) Florence Nightingale and her Era (New York: Garland); Barbara M. Dossey (1999) Florence Nightingale: Mystic, Visionary and Healer (Philadelphia: Springhouse).

64 Baly, Myth and Reality, p. 34.

65 Baly (1973) Nursing and Social Change (London: Heinemann) 1st ed, p. 64.

66 Baly (1995) Nursing and Social Change (London: Routledge) 3rd ed., p 111.

67 Ibid., p. 119.

68 Ibid., p. 122.

69 Monica E. Baly (1985) The Nightingale Nurses: The Myth and the Reality, in Christopher Maggs (Ed) Nursing History: The State of the Art (London: Croom Helm), pp. 33-45.

70 Monica E. Baly & H.C.G. Matthew (2004) Nightingale, Florence (1820-1910), Oxford Dictionary of National Biography (Oxford: Oxford University Press) 40:904-12. Some of the erroneous material has been removed in the online edition.

71 Ibid., 40:905, where Baly has it ‘The Institute for Sick Governesses in Distressed Circumstances,’ while its title was the mere ‘Establishment for Gentlewomen during Illness.’

72 Smith, Reputation and Power, p. 173.

73 McDonald, Public Health Care 6:223-506 and Extending Nursing 13:377-705.

74 Baly (1986) Florence Nightingale and the Nursing Legacy (London: Croom Helm), 2nd ed, Chapter 5, Poor Law Nursing.

75 Ibid., 40:909.

76 Baly (2004) Still, Dame Alicia Frances Jane Lloyd- (1869-1944) 52:780.

77 Correspondence with Gordon is in British Library Add Mss 47737 and Wellcome Library for the History and Understanding of Medicine Ms 5476; the correspondence with Henry Bonham Carter is in Add Mss 47722; Nightingale Fund Council minute of meeting 5 May 1890, London Metropolitan Archives A/NFC-2/1.

78 Baly, ODNB, 40:909.

79 Ibid., 40:910.

80 Letter by Michael Bevan, Research Editor Medicine, 3 September 1998, Royal College of Nursing Archives, Edinburgh. These archives hold the correspondence between Baly and the editors, and her original article.

81 Ibid., 40:910.

82 Baly 40:911.

83 Robin Young (27 April 1999) Nurses ditch dated ‘lady of the lamp,’ The Times; David Brindle (27 April 1999), Nurses snuff Nightingale image, The Guardian; BBC Online News (27 April 1999), Nurses ditch Florence Nightingale image,; Jane Kelly (28 April 1999) Nurses abandon Florence: Feminist, Rebel and the Ideal Role Model, Daily Mail, p. 25.

84 Anon. (summer 2000) Significant Steps Forward for History of Nursing, International History of Nursing Journal, 5 (3), p. 66.

85 Sue M. Goldie (Comp) (1983) A Calendar of the Letters of Florence Nightingale, and (Ed) (1987) ‘I have Done my Duty’: Florence Nightingale in the Crimean War 1854-1856 (Manchester: Manchester University Press).

86 Michael D. Calabria (Ed) (1987) Florence Nightingale in Egypt and Greece: Her Diary and ‘Visions’ (Albany: State University of New York Press).

87 Victor Skretkowicz (Ed) (1996) Notes on Nursing (London: Baillière Tindall).

88 Mary C. Sullivan The Friendship of Florence Nightingale and Mary Clare Moore (Philadelphia: University of Pennsylvania Press).

89 Lynn McDonald (Ed) (2001-) 13 volumes of the 16 Collected Works of Florence Nightingale.

90 Gérard Vallée (Ed) (2003-7) 3 volumes of The Collected Works of Florence Nightingale.

91 Jharna Gourlay (2003) Florence Nightingale and the Health of the Raj (Aldershot Hants: Ashgate).

92 See McDonald, Theology 3:521-623 and Vincent Quinn & John Prest (Eds) Dear Miss Nightingale: A Selection of Benjamin Jowett’s Letters to Florence Nightingale 1860-1893 (Oxford: Clarendon 1987).

93 McDonald, Nightingale School 12:42-43.

94 John M. Eyler, Victorian Social Medicine: The Ideas and Methods of William Farr (Baltimore: Johns Hopkins University Press 1979), 160.

95 Ibid., p. 189.

96 Letters 16 October 1858 and 9 January 1859, ADD MSS 43398 ff83 and 102.

97 John M. Eyler (April 1983) American Historical Review, 88(2), p. 397.

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