Florence Nightingale on Public Health Care (review)

The bulk of this sixth of sixteen volumes of Florence Nightingale's oeuvre consists of the text of her famous Notes on Nursing (the 1861 "Labouring Classes" edition, with changes from previous and subsequent editions indicated) and an enormous collection of letters on workhouse infirmaries (mostly from the 1860s, and chiefly with regard to the short career of Agnes Jones in Liverpool and attempts to consolidate care in greater London). Included are miscellaneous unpublished documents on "Nature, Disease, Germs, and Contagion," "Rural Health," and "Medical Care of Employees, Former Employees and Tenants." As well as letters by Nightingale, there are also materials by associates such as John Sutherland and William Rathbone, most of them addressed to her. Also included are an 1863 Social Sciences Association paper titled "Sanitary Statistics of Native Colonial Schools and Hospitals," and two papers from the early 1890s: "Sick Nursing and Health-Nursing," and "Rural Hygiene."

There are gems in this huge volume that will help us rethink Nightingale. She emerges as a more critical statistician than is often recognized; her conceptions of disease and etiology appear more ambiguous than they are sometimes presented; and one gets a clearer sense of her concept of "administration," which, more than any other element of nursing practice or training, appears here as the keystone of nursing reform, and the aspect in which it most seriously intersected with the reform of public medical services. We also see, on such issues as Poor Law medical services and metropolitan consolidation, a mix of sharpness and naiveté. She does not appreciate why Poor Law medical provision is so intractable and contentious an issue, or why metropolitan rationalization is so delicate. On one occasion we even see this mistress of certainty baffled, at the mercy of sanitarian engineers who find her home to be a sewer-gas death trap, remediable only by costly and contradictory doses of replumbing: "I lie awake thinking what I ought to do," she writes to Douglas Galton (p. 561).

The volume is not easy to use. Within sections, items are organized topically and chronologically, but some cannot be dated, nor can contexts always be identified. While the editor provides brief section and subsection introductions and identifies some of those involved in Nightingale's life, this background is rarely deep enough to make sense of the complicated situations into which the reader is suddenly thrust. In part this reflects how little we still know about Victorian public medicine, but more editorial attention to central issues such as the agendas of Henry Rumsey and John Simon, or the work of the Royal Sanitary Commission, or the long-standing issues about appropriate treatment for the sick poor would be essential for a reader not well read in these obscure subjects. In one case Nightingale's own error is repeated in an identification: though Ernest Hart worked for the Lancet early in his career, he was never its editor (he was famous as the BMJ editor). Moreover, readers will need to realize that while a topical organization of the series is defensible, Nightingale did not always respect boundaries: in the documents published here her topics include religion, India, and nursing practice; doubtless parts of other volumes treat public health. Some Nightingale letters referenced in section introductions are not included in the text; a short analytical catalog of all materials published in this series would help readers to more easily locate particular documents and better follow particular themes and issues.

This volume will be of use to those tracing Nightingale's involvement with and/or views on particular public issues. It is less useful for understanding developments in public health, or in nursing, or even Nightingale's own intellectual trajectory. An exception is the fascinating final section, which addresses a question that biographers often fail to tackle: How did Nightingale, expert on household health and artisan of human well-being (p. 142), cope with the servants and tenants of...