Nightingale: Lady and Legend

By Stephen J. Greenberg ~

Some people seem not quite real.  Not in the sense that they are imaginary, fictional beings; they existed, and they touched and changed their world and ours. But it is difficult to think of them as plain, walking-around human beings. Their attitudes and accomplishments just seem to be beyond any quotidian matters. George Washington was such a person. Abraham Lincoln was another. And Florence Nightingale, whose 200th birthday is on May 12th, 2020, certainly fits in this category as well.

Nightingale lived to be just past 90, dying in London on August 13, 1910. She was active until the very end, although she was famously an invalid for much of that long life. What is usually recalled (and celebrated) about her fits into five crucial years, from her departure to Scutari in modern day Turkey in 1854, and from there to the battlefront in Russia, to the publication of Notes on Nursing: What it is, and What it is not, in 1859. But her career, and her writing, were only just beginning when she returned to England from the Crimean War.

Portrait of Nightingale in “Notes on Nursing: What it Is, and What it is Not,” 1860 National Library of Medicine #68161130R

Title page of Notes on Nursing: What it Is, and What it is Not, 1860 National Library of Medicine #68161130R

Nightingale was born, it would seem, to lead an unconventional and extraordinary life. Her parents were well-to-do, educated, and social connected; connections that Florence would use to great effect throughout her career. Her parents were married, in England, in 1817, and promptly left for a combination honeymoon and Grand Tour of Europe. The tour, long a fixture in the upbringing of any Englishman of means, had been impossible during the decades of the Napoleonic Wars.  Free now to travel as they wished, William and Frances Nightingale stayed so long in Italy that not one but two of their children were born there: Frances Parthenope Nightingale, born in Naples in April of 1819 (“Parthenope” was the name of an early Greek town on the site that would become Naples), and Florence, born (where else?) in Florence in May of the following year. The family did not return to England until 1821.

The young Florence was educated by a series of governesses, as was thought proper for a young lady of the time.  As she grew older, she traveled on the continent and to Egypt with her father and, later, with other companions. She collected friends (and not a few suitors) along the way, most importantly Sidney Herbert, whom she met in Rome in 1847. As a Tory member of Parliament, Herbert had been Secretary of State for War in Sir Robert Peel’s cabinet of 1845–46, and would hold that same post, under Palmerston, during the Crimean War. Herbert would remain Florence Nightingale’s staunchest and most powerful ally in her attempts to reform the British Army’s appalling medical department in the midst of that war. (For details of the extended family, there is still nothing to surpass Gillian Gill’s Nightingales, published in 2004)

But Nightingale was little interested in moving amongst the rich and powerful, watching from the sidelines while others wrought changes in society.  She wanted to be an agent of that change, and would not let her parents, or her social standing and class “responsibilities” stand in her way. In 1850, already a spinster by the standards of her time, she found a tight focus for her efforts while visiting Pastor Theodore Fliedner’s training program for “deaconesses” in Kaiserwerth (Dusseldorf). It was the closest thing to professional training for nurses at the time. Nightingale studied with Fliedner (and his wife, Caroline) for four months, and wrote her first published work about the program, issued anonymously in 1851.

Nightingale had already been interested in the professional training of nurses for some years. Her own plans to study in a Salisbury hospital in 1845 had raised a storm of protest within her own family, and the plan was shelved. Her family was no more pleased by her time with the Fliedners, but eventually they agreed to support what she increasingly saw as her calling. The publication of her pamphlet, whose authorship was an open secret, helped as well. Florence Nightingale accepted the post of superintendent at the Institute for the Care of Sick Gentlewomen in London in 1853, with an annual allowance of £500 from her father (a reasonable but not enormous sum).  The stage was set for her most memorable half-decade. Supported by Herbert, she sailed for the war, with her hand-picked band of thirty-four nurses, late in 1854, and returned in July of 1856 as the “Lady with the Lamp.”

Much has been written about her time in Scutari and Balaclava, and there is no shortage on controversy over what (and when) she knew about disease, isolation, hygiene, and treatment. Cholera was the biggest, by no means the only, disease of soldiers in the war, and it was poorly understood.  John Snow had traced the linked between cholera and tainted wells in London in 1849, and the Italian researcher Filippo Pacini had seen the causative microorganism under his microscope in 1854, but it was not until 1884 that Robert Koch definitively described the cause and spread of the disease.

Nightingale was never interested nursing alone; she always saw trained nurses as a part (albeit a very important part) of a comprehensive and integrated system to provide health care to those who needed it most, whether it be “sick gentlewomen” in London, or soldiers dying of cholera outside of Sebastopol. While Notes on Nursing is her most famous and most often reprinted work (the National Library of Medicine’s History of Medicine Division holds no fewer than twelve editions in English published before 1924), and while it is still required reading in many nursing schools, Nightingale also wrote extensively on the administration and even the designs of hospitals. She authored reports on the subject for the House of Commons, most famously Notes on Matters affecting the Health, Efficiency, and Hospital Administration of the British Army, which was duly submitted to that body in 1858 by Sidney Herbert. It is over 800 pages long. In A Contribution to the Sanitary History of the British Army During the Late War with Russia : Illustrated with Tables and Diagrams, her astounding graphs and charts, comparing disease deaths with battlefield deaths, by month, over time, are stunning examples of data visualization in Victorian England.

Plan of the Hospital Lariboisiere, paris. Nightingale approved of the hospital’s pavilion design but criticized some features (e.g., privies in the middle). Nightingale, “Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and War,” 1858 National Library of Medicine #9302861

“Diagram of the Causes of Mortality in the Army in the East,” in “A Contribution to the Sanitary History of the British Army during the Late War with Russia,” 1859. “Contribution” was a brief but powerful indictment of unnecessary, because preventable, deaths among British soldiers in the Crimea. Nightingale’s bold use of color in the summary chart was far ahead of its time. National Library of Medicine #330362

As an aside, it should be noted that the publication of Notes on Nursing was not without its own drama.  The London publisher was dubious about its commercial prospects, and requested a subsidy from the family to defray his costs. The money was forthcoming. Only a few weeks later, in another London printshop just a brisk walk away across the Vauxhall Bridge, this story would be repeated with another wealthy family being asked to subsidize another book with little perceived commercial value.  Neither Notes on Nursing, nor this other book, Charles Darwin’s On the Origin of Species, has ever been out of print since their first editions in 1859.

Nightingale is not a simple figure to fathom; so much is obscured by her legendary image. She was controversial in her time, and there is no shortage of revisionist history marking the bicentennial of her birth. She certainly avoids any simple labels like “feminist” or “humanitarian.” The Victorian novelist Elizabeth Gaskell is said to have remarked that Nightingale preferred dealing with abstract notions of “humanity” than with actual people, although that is hard to square with Nightingale’s work with the poor in London. As for feminism and women’s rights, the evidence is more complex. She certainly wanted freedom of action for herself, unbound by the societal conventions and gender limitations that are the stuff of Jane Austen novels. It is the great good fortune of Nightingale’s life that she was (eventually, and with great effort) able to secure that freedom for herself.  There is abundant evidence, however, that Nightingale did not see all or even most women as being the equal of men. Her preference for nursing as a celibate professional was a problem, not least for her family, for whom celibacy smacked of Popery. Nightingale’s lack of esteem for her own gender may also help to explain her sometimes tense relationship with Elizabeth Blackwell, the British-born but American-trained first woman doctor. The two were exact contemporaries: Nightingale less than a year older, and both died in 1910. Blackwell lacked Nightingale’s financial cushion, and therefore was forced to pursue a different kind of independence. Nightingale was willing to be Blackwell’s nurse, but that wasn’t what Blackwell had in mind for women. This year’s slogan for National Nurses Week: “Compassion. Expertise. Trust,” would make perfect sense to Nightingale.

But in the larger picture, this is irrelevant to the Nightingale story, be it actual or mythic.  Florence Nightingale took a lowly, not entirely respectable job, and recreated it as a profession for the educated and dedicated practitioner. She described what she had seen in her broad travels and experience in a way that informed a more enlightened public health policy and mechanism for those who were willing to listen. If the modern world, on the occasion of her 200th birthday, has some difficulty seeing the real person behind the legend, it is not because the real person, and her lasting accomplishments, aren’t there. It is just up to us to look a little harder.

The National Library of Medicine’s holdings of Nightingale materials are (unsurprisingly) extensive, with over seventy printed titles and editions. In addition, the Library holds a group of Nightingale letters written between 1845 and 1878, all of which may be read as part of the Florence Nightingale Digitization Project, and a copy of an oral history interview conducted by M. Adelaide Nutting (herself a giant in the history of nursing) in 1890. A transcript is available at https://findingaids.nlm.nih.gov/repositories/4/archival_objects/25738.

Stephen J. Greenberg, PhD, is Head of Rare Books and Early Manuscripts for the History of Medicine Division at the National Library of Medicine.