Monday, January 3, 2011

Florence Nightingale (1820-1910)

“We want to rouse the interest of the public: for behind the Cabinet in England always stands the House of Commons & behind the House of Commons always stands the British public. And these are they we want to interest: and these can only be interested by narratives of real lives.”

Although Florence Nightingale is a well-known historical figure, the details of her life are probably familiar to very few. Yet she appears to me not just as one of the most impressive disabled people of the Victorian era, but as one of the most extraordinary women of all time. Known mainly as a benevolent nurse, she deserves recognition as a brilliant health reformer and thinker on public health.

Born in 1820 to a prosperous Derbyshire family, before she could begin the pioneering work to which she believed God had called her, she had first to fight against the prevailing cultural norm that a respectable lady should not have a public career. A woman of her class was expected to devote herself to her family, to frivolous occupations, and to some decorous do-gooding in her local neighbourhood. In particular, nursing was seen as totally unsuitable for a lady, because nurses were considered feckless loose women, who were prone to alcoholism. Florence Nightingale's conflict with her family, in particular with her demanding older sister Parthenope, overshadowed the first half of her life. Moreover, despite being courted by several eligible men - among them Richard Monckton Milnes and Benjamin Jowett, who went on to be Master of Balliol College, Oxford, Nightingale made the active to choice to remain free and single, rather than becoming a submissive wife and mother. Around 1850, she wrote a polemical autobiographical essay about the predicament of middle class Victorian women, Cassandra. When it was finally published in 1928, it was hailed as a proto-feminist classic and inspired both Virginia Woolf and Vera Brittain.

By 1854, having broken free of bourgeois expectations about family loyalty, and with the benefit of a period of training and studying in European hospitals such as Kaiserswerth in Germany, Florence Nightingale was ready to make her contribution to history. The sentimental myth of "The Lady with the Lamp" highlights her work as a nurse in the Crimean war of 1853-1856. Having fought for recognition of the potential benefits of trained female nurses, in 1854 she led a team of forty nurses to care for the injured soldiers in the hospital at Scutari, near Istanbul.

Yet despite the image, Florence Nightingale's talents were to find greatest expression as an administrator, statistician and health reformer, rather than as a carer herself. On her return from the Crimea, shocked by the disastrous logistical inefficiencies and health tragedies she had witnessed, she campaigned tirelessly to improve the medical services available to the British army. She then broadened her interest to other areas of health and social improvement. A convert to the importance of good sanitation, hygiene and ventilation, she first advocated for the improved design of hospitals. Taking advantage of the Nightingale Fund, which had been raised by private subscription after she became an iconic public figure in Britain after her Crimean service, she planned and promoted a training school for nurses at St Thomas' Hospital. Her short book Notes on Nursing outlined her philosophy of nursing and was hugely influential. Later, she turned her attention to the appalling situation of destitute people in British workhouse infirmaries, campaigning for trained nurses to be available for their care. After the great Indian famine of 1877, she became very concerned with promoting health and improving irrigation in the subcontinent, writing in one influential article: "We do not care for the people of India. This is a heavy indictment: but how else account for the facts about to be given? Do we even care enough to know about their daily lives of lingering deaths from causes which we could so well remove?"

As evidenced by her diverse interests and achievements, Florence Nightingale was a highly driven individual. On 7 February 1837, she had received what she believed was a personal calling from God. Her family were Unitarians, but early in life she had rejected organized religion and developed her own eclectic and sophisticated theological approach, combining science and reason with faith. She has been compared to mystics such as Joan of Arc, in the way that she combined contemplation with action. For her, religion was about contributing to the realization of God's law through work.

Alongside her passion, Nightingale enjoyed several other advantages. She had a private income, which enabled her to work independently; her extraordinary public profile allowed her to use the threat of popular opinion to promote her causes; she worked closely with politicians such as Sidney Herbert and with researchers such as John Sutherland and William Farr; and she used her formidable intellect to gather evidence and advocate for reform. In particular, her talent for mathematics saw her at the forefront of the new science of statistics.

Why does Nightingale deserve to be included in a roll-call of distinguished disabled people? Because she has been described as "history's most famous invalid". While in the Crimea, she experienced an acute episode of fever. After her return to England, a gaunt and weary figure, she had recurrent bouts of illness during her lifetime, starting with a collapse in autumn 1857. From 1861, she became bed-bound, for six years. At several points she was believed to be close to death. As a result, she became reclusive, conducting all her research and policy work from her bedroom at the Burlington Hotel, or later from her home at 35, South Street, London. She had always shunned publicity, now she avoided most human contact, relying on endless correspondence to pursue her work: 14,000 of her letters survive. She always worked behind the scenes, and her religious faith led her to shun recognition for her achievements. Not only her physical appearance, but also her personality changed, as she exploited the friends, relatives and allies who supported her work of health reform and endlessly reproached them for their supposed failures and betrayals. She has been accused of malingering, using her illness for her own obsessive ends, and of being a neurotic.

However, recent analysis provides a physical explanation for Nightingale's behaviour (Young, 1995). The fever she contracted in the Crimea has been identified as chronic brucellosis, a disease resulting from a bacterial infection. In the absence of appropriate treatment with antibiotics the condition can persist for years. The symptoms include depression, insomnia, rheumatism, neuralgia and spondylitis, "one of the most incapacitating and painful maladies that can affect man". Poor health combined with a punishing schedule of public health activities meant that frequently Nightingale's friends and allies feared that she was likely to kill herself through overwork. Thankfully, after the age of 60, Nightingale's depression lifted and her personality resumed its previous benevolence, and she was able again to take walks and enjoy visits. She lived on quietly until the age of ninety, although for the last five years of her life she was unaware of her surroundings.

From the start, coverage of Florence Nightingale has veered between the two extremes of "sentimental angel" or "dictatorial reformer". Mark Bostridge's excellent biography (2008) gives a rich and balanced picture of a highly complex and passionate woman, who was intellectually the equal of any man of her time, and who made a major contribution to public health, despite her own debilitating chronic illness.

Further reading

Bostridge M, Florence Nightingale, Penguin, London, 2008.

Young DAB, Florence Nightingale's fever, British Medical Journal 1995, 311: 1697


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