Reappraising Florence NightingaleBMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a2889 (Published 16 December 2008) Cite this as: BMJ 2008;337:a2889
Revisionism has hardly touched Florence Nightingale, and she remains one of the great icons of the Victorian age. Despite some hostile comment, in particular from F B Smith,1 the popular image of her remains that of the angel of Scutari and the genius behind much medical reform and the development of nursing. However, an examination of primary sources shows that much of this reputation is based on the myths created by the popular press at the time of the Crimean war and subsequently by Cook’s biography of her.2 This was commissioned by Nightingale’s family after her death and can therefore hardly be regarded as unbiased. The Nightingale myth was given a considerable boost by Woodham-Smith’s book,3 written in the aftermath of the second world war, a time when Britain desperately needed heroic figures. Indeed, such was the acclaim with which this book was greeted that Nightingale’s reputation was largely unimpeachable for the next few decades.
One reason this situation remained unchallenged is that historians generally have not undertaken the breadth of primary research necessary to objectively re-evaluate Nightingale’s work, her achievements, and her role in the movement for medical reform in the 19th century. This is particularly true in regard to military medicine, and it may fairly be argued that Nightingale, far from guiding the reform and development of military medicine, actually impeded its progress as a result of her class based hostility to military doctors.
It is often forgotten, or overlooked, that Nightingale was born into a wealthy and well connected family. Indeed, at a time when influence was often determined by social standing, the Nightingales could exercise considerable influence. Lord Palmerston, who was prime minister during much of the Crimean war, was a close friend of the Nightingale family, his estate in Hampshire adjoining theirs. Such contacts were easily extended, and in her 20s Nightingale formed a close friendship with Sidney Herbert, who later became secretary at war and her most important political patron.
As a member of the gentry class Nightingale was well versed in the philosophy of noblesse oblige—hence her sincere and deep felt care for common soldiers entering her hospitals in Scutari. But undoubtedly she also was a snob, displaying considerable resentment towards people, Crimean doctors in particular, who had dared to rise above their station. At the time, almost three quarters of military doctors were Scottish or Irish; many came from fairly modest or poor backgrounds, and they were often despised by the aristocratic or upper class English line officers.4 It was therefore easy for the likes of Lord Raglan, the commander in chief in the Crimea, to blame the medical officers for problems caused by his own staff when under attack by politicians in London. Such class consciousness and social prejudice was fairly widespread, as illustrated by the post-war statement by Palmerston that the greatest deficiencies in the Crimea had been caused “where there were persons belonging to other classes of the community—in the Medical Department, the Commissariat Department, the Transport Service, which have not been filled by the aristocracy or gentry.”5
Nightingale seemed to have no hesitation in participating in the attacks on army doctors working in the Crimea and the army medical department in general. Indeed, she became noted for her exaggerated statements and vituperative asides in relation to the senior medical staff.6 She had a particular dislike of Andrew Smith, a doctor who rose from a lowly background (his father was a shepherd) to the position of director general of the army medical department, and John Hall, the principal medical officer in the Crimea. The former she referred to as “that old smoke-dried Dr Andrew Smith,”6 and when Hall was awarded a knighthood for his work in the Crimea, she scathingly remarked that in his case the letters KCB stood for “Knight of the Crimean Burial-grounds.”7 She also promoted the damaging assertion that Hall had no adequate medical qualification, when in fact he was an FRCS, by examination, and had an MD from St Andrews.6 Hall regarded her as a spy for the politicians in London, and it is true that she sent Sidney Herbert lengthy observations on the Scutari doctors, wielding to advantage the power that political patronage had accorded her. The full extent of her vilification of those to whom she took a dislike or the extent to which she promoted the cause of her favourites can never be known since she destroyed many of her papers and letters relating to the period.
The fame and influence Nightingale gained from the Crimean war would never have happened without the actions of the press. British troops did suffer hardships in the Crimea, but the extent of the problems of army maladministration and of the suffering of the troops during the first year of the war was greatly exaggerated, and often distorted, by a press seeking to extend its power and influence and increase readership. No previous war had been so extensively covered by the press, or in such a way, with sensationalist and scandalous stories fanning the flames of mass hysteria in Britain. It was this that provided the stimulus to action, and to obfuscation, both by a government that sought to placate its critics and assuage the public outcry and by individual politicians anxious to protect their reputations and careers. Herbert’s recruitment of Nightingale and her nurses was merely one aspect of consequent government action. However, this highly visible exercise provided more benefit in terms of public relations than it did practical help. Nightingale took only 38 nurses to Scutari, where there were initially around 3200 patients.8 Each nurse thus had charge of 84 patients, making it inconceivable that more than a few patients could receive adequate attention. Within a few months the number of patients had risen to over 5000, but the number of nurses remained unchanged.
What Nightingale achieved at the hospitals at Scutari has been subject to some debate, and there is much evidence to suggest that she did more harm than good. However, the self serving press created the angel myth that has dominated the popular view of her, and Nightingale may justly be heralded as the first media created celebrity, with all the accompanying trappings, including a devoted fan club as evidenced by the large number of fawning letters written to her at Scutari. Sentiments such as those expressed in a letter by “CR,” who confessed to be “one among the many who truly admires, thinks, dreams, and prays for your welfare,”9 cannot have failed to inflate her own ego and form the basis for her remark in 1856 that “the War Office cannot turn me out because the country is with me.”10
Exposing the myths
From such a base it was but a short step to Nightingale setting herself up as an authority on, and major protagonist in, the reform of military medicine. The myths about her achievements have been repeated so often that they have attained the status of fact, but they are easily exploded by reference to archival material, particularly the reports of the various parliamentary committees and Royal Commissions of the time.
Many of the reforms in military medicine attributed to Nightingale’s influence had been long standing proposals, or had been mooted previously by others. One highly significant development was the establishment of the Medical Staff Corps in June 1855 as a direct response to the problems caused by the orderlies in the Scutari hospitals. Although the idea for this has been attributed to Nightingale in a letter to Sidney Herbert in January 1855, it had, in fact, been proposed earlier by Smith and agreed by the War Office the previous month.10 Nightingale regarded the establishment of a medical statistical branch as one of her most important proposals adopted by the Royal Commission in 1857.10 But again Smith had proposed to the War Office in December 1855 that a board for medical statistics be established formally within his office, a function that it was already performing.11 Nightingale has also been credited with the idea of the need for an army medical school, but this is something that had been first proposed over 50 years previously,6 although she did have some influence on the running of the school once it was established. It is also of note that, contrary to popular belief, British military hospitals had employed female nurses at the beginning of the 19th century, long before Nightingale went to Scutari.12
While such myths are easily exposed, the limits of Nightingale’s influence at this time may be gauged more directly from her recorded failures, notably her attempts to stop the building of the new army hospital at Netley, near Southampton. The scheme had been instigated by Andrew Smith and was approved in January 1856 despite opposition from Nightingale and her supporters, who argued that the site was unsafe on sanitary grounds.10 In 1858, while Netley was in the process of construction, the Nightingale faction attempted to have it “finished as a barrack,”13 but this again proved futile, and Netley became a highly successful hospital, eventually closing in 1958. With the death of Herbert in 1861 Nightingale’s influence with the War Office waned, and henceforth she would focus her attention on sanitary reform.
Cite this as: BMJ 2008;337:a2889
Published courtesy of the Wellcome Trust. An earlier version was published in Wellcome History 2008;37:2-4. Contact firstname.lastname@example.org for a free subscription to the journal.
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.