From a public relations point of view, the Crimean War did not go well for Great Britain. The recent Limited Services Act permitted ordinary middle-class men to spend short periods on military duty, and gentlemen could now see for themselves the horrors of war. Moreover, photographers and reporters for the first time sent firsthand dispatches from the front. Members of the British public, with the new political power they had gained from the expanded franchise under the Reform Bill of 1832, read with dismay in the daily papers as “the best army that ever left these shores” succumbed to cannon fire, starvation, and disease, in a war fought in a faraway country, for obscure reasons.

In October 1854, a story in the Times of London reported that the British army was suffering terribly, not at the hands of the Russians, but from the indifference, incompetence, and bloody-mindedness of its own commanders, suppliers, and medical authorities. Every day, sick and wounded soldiers were shipped across the Black Sea from the Crimean front to the Scutari base hospital on a cliff overlooking the Bosphorus, opposite the imperial center of Constantinople. The doctors and orderlies there were overwhelmed. A few days after the appearance of the Times article, Secretary at War Sidney Herbert sent a contingent of thirty-nine nurses to Scutari, led by Florence Nightingale, a well-born woman of thirty-four. These women were also written up in the Times. Sending Florence Nightingale and her nurses was partly a propaganda move, a way for the War Office to be seen to be doing something. But in later life, Nightingale would achieve far more than anyone at the time could have expected.

Florence Nightingale is most famous as the founder of the modern nursing profession, but her work after the war as a public health reformer was at least as important, if not more so. Historians are gradually replacing the image of the slender young woman gliding among the hospital beds at Scutari, bringing care to dying men, with that of a plump, serious woman who, after she returned from the Crimea, spent years immersed in government blue books and hospital statistics. Less may be known about this later career, because her work as a reformer was mainly administrative and political. She wrote reports and letters, advised Parliament, the War Office, and the Colonial Office, and held meetings with politicians and civil servants, activities that are much harder to dramatize than nursing the wounded.

Recently there has been a revival in Florence Nightingale studies. Two new biographies have appeared in the past three years, along with an annotated collection of Nightingale’s correspondence with Mother Superior Mary Clare Moore, with whom she worked in the Crimea.1 Further biographies are underway, and Dr. Lynn McDonald of the University of Guelph, Canada, has been gathering all of Nightingale’s writings, including correspondence, from archives around the world. Her sixteen-volume abridged collection of Nightingale’s work will be published during the next five years. Since some of this material will be new to scholars, more biographies are sure to follow. The phenomenal medical advances of the twentieth century brought with them promises of universal good health and well-being. The growing interest in Nightingale may be partly the result of an emerging awareness that this hope has not been realized, and that the public health problems she struggled with are far from solved.

Nightingale was born in 1820. Her father had inherited a fortune from his uncle, a Derbyshire landowner and industrialist. While the Nightingales were not descended from the landed nobility—they had grown rich in Britain’s rapidly industrializing economy—they lived like aristocrats. They owned grand houses, engaged in social life, and pursued artistic and intellectual interests. Florence’s father dabbled in local politics, but devoted himself mainly to looking after his estates and educating Florence and her older sister, Parthenope. Florence was different from her sister. She preferred reading and studying to household affairs and party-going. She felt imprisoned by domestic trivia and writing polite notes to relatives. She couldn’t play the piano, at least not well, and she “craved for some regular occupation, for something worth doing instead of frittering away time on useless trifles.” She compared the limitations imposed on Victorian women to Chinese foot-binding.

At age sixteen she experienced a revelation in which God called her to his service. She did not immediately know what she had been called to do, but eventually she became convinced that her destiny lay in hospital nursing. Her family hoped and assumed that she would outgrow this wish. At the time, only the poor were sent to hospitals. The rich were treated at home. Noblesse oblige was not unusual among women of her class and generation, many of whom paid occasional kindly visits to paupers and did other charitable work. But hospitals were off-limits to such women, and hospital nursing was considered disreputable, suitable for washerwomen and prostitutes. Nevertheless Florence persevered. She practiced nursing on dolls, sick animals, and eventually the poor who lived near her family’s Derbyshire estate. She fantasized about plague. When she was thirty-two her family finally relented and she spent a year working at an institution for sick governesses in Harley Street. By now she had many influential friends, including the secretary at war, Sidney Herbert, and the politician and philanthropist Richard Monckton Milnes. Herbert was aware of Nightingale’s competence and dedication, and he had advanced ideas about the role of women in society. So when he needed someone to help repair the disaster unfolding in the Crimean hospitals, she was an obvious choice.


Florence Nightingale: Avenging Angel by Hugh Small deals mainly with Nightingale’s experiences in the Crimea and in the year immediately after her return to England in August 1856, when she prepared a report on the health of the British army. During this period, Nightingale appears to have experienced a crisis, and in August 1857 she collapsed and rarely left her room for the next eleven years. Whether this crisis was due to physical or emotional causes is not clear, and may never be. But the episode is interesting because it also seems to mark a shift in Nightingale’s interests, from nursing to broader concerns about public health. Avenging Angel explores the mystery of Nightingale’s collapse and proposes a new explanation for it.

Other historians have addressed Nightingale’s sudden and prolonged confinement after the war. For example, Cecil Woodham-Smith, writing in a more Freudian age, saw the collapse as Nightingale’s escape from her smothering Victorian family, especially her sister and mother, who, having spent years trying to obstruct her career, were now dining out on her fame. More recently, D.A.B. Young, the former principal scientist at the Wellcome Foundation, suggested another explanation in a 1995 article in the British Medical Journal.2 Nightingale, he writes, might have had brucellosis, a bacterial infection, perhaps contracted from drinking goat’s milk in the Crimea. Brucellosis causes a recurring illness similar to malaria, with symptoms that include many of Nightingale’s complaints, including pain in the joints, loss of appetite, and fever. Brucellosis was not described by scientists until around the turn of the century, and even in the 1920s its symptoms were sometimes taken for malingering and neurasthenia.

During those long years spent mainly in bed, Nightingale nevertheless worked extremely hard on her program to reform public health. She wrote thousands of letters and reports, and both Woodham-Smith and Small imply that she worked into their graves some of the powerful men whose help she needed in order to accomplish her aims. To Small, it seems strange that anyone could work so hard and yet claim to be so indisposed. He believes that the real reason she collapsed had less to do with her physical health than with a nearly suicidal sense of guilt. She was haunted by the deaths of thousands of British soldiers in the Crimea; and Small believes that after the war she came to the horrifying realization that she herself may have been partly responsible for them.


During Nightingale’s first winter in Scutari, death was everywhere. According to Nightingale’s own testimony after the war, 4,077 soldiers died between November 1854 and March 1855, ten times more from such illnesses as typhus, typhoid, dysentery, and cholera than from battle wounds. In numerous letters from this period, Nightingale blames the officials in charge of supplies for not sending sufficient bedding, clothes, food, and other provisions, and she criticizes merciless commanders at the front for sending soldiers across to Scutari in such wretched condition. During that winter, as Nightingale struggled to procure needed supplies, she also tried to persuade the doctors at Scutari to accept the help of her nurses, and to keep the nurses themselves from drinking, flirting with the soldiers, and challenging her authority. In addition, she opened another ward in the hospital. But this, Small argues, only expanded the deathtrap.

In January 1855, the government of Lord Aberdeen fell, largely because of its mishandling of the war. Nightingale’s friend and protector Sidney Herbert lost his position in the War Office, and Lord Palmerston became the new prime minister. Within days, Palmerston arranged for a sanitary commission to inspect, and remedy, the conditions in the Crimean hospitals. Nightingale did not request this commission; nor did she seem to be aware of it until it arrived in March, four months after she did. The commissioners found that the sick and wounded at Scutari were wading through and drinking their own sewage, and that the wards were overcrowded, airless, and full of vermin. The Scutari water supply flowed through the carcass of a dead horse and absorbed the brimming contents of cesspits. The commissioners cleaned the latrines and cesspits, and arranged for the sewers to be flushed out; they reduced crowding, improved ventilation, and renovated rat-infested corners of the building.


Small’s book is full of interesting details. Members of the commission carried out some of this work themselves, and Small quotes a report to the war minister by Mr. James Wilson, inspector of nuisances at Scutari Hospitals: “The water-closet attached to Lord William Paulet’s quarters being in an offensive state, I cleansed it myself, and applied peat charcoal.” Small comments, “There is something peculiarly Victorian about a functionary with a grandiose title actually cleaning out a general’s toilet with his own hands and proudly submitting a written report to the Cabinet describing the accomplishment.” The dedicated Crimean Sanitary Commission was a triumph. Almost immediately, the death rate fell more than tenfold and remained low for the rest of the war. It was now clear that sanitation made an enormous difference, something Nightingale herself seems not to have known previously.

After her return to England, Nightingale was determined that there should be an investigation into the calamities in the army hospitals during the war. A royal commission of inquiry into the health of the army was finally established in May 1857,3 a year later, but as early as the fall of 1856 Nightingale began work on her own report. She collaborated with William Farr, the statistician in the Office of the Registrar-General of Births, Deaths, and Marriages. Farr and Nightingale concluded that most soldiers were killed by poor sanitation, not by insufficient food and other supplies; they also concluded that the death toll at Nightingale’s hospital had been higher than at any other hospital in the Crimea, including those at the front, where presumably the wounded would have been in worse shape to start with. The sanitary arrangements at other hospitals may have been no better than they were at Nightingale’s, but hers was probably the filthiest and most crowded. Small believes Nightingale never forgave Sidney Herbert, or herself, for not making this obvious connection in time to save thousands of lives. She not only devoted many years of her life to sanitary reforms, she made sure Herbert did too.

Is Small correct? Was Nightingale’s emphasis on feeding and clothing the wounded soldiers, rather than on cleaning out their cesspits, a terrible blunder? Did she believe that despite her good intentions, she had really made things worse? Nightingale’s published letters suggest that during that terrible first winter in Scutari, she did not recognize that inadequate sanitation was an important cause of the high death rate there.4 However, according to McDonald, some of that deadly winter’s correspondence between Herbert and Nightingale has never been published, and Small seems not to have consulted the archives that contain it. These letters might reveal more about what Nightingale was thinking at the time, and when she discovered why so many men had died.

Whether Nightingale blamed herself for the sanitary disaster of the winter of 1854–1855 is not clear, but sanitation does seem to have been far from her mind at the time. None of Nightingale’s biographers adequately explains why she apparently failed to appreciate the importance of sewers, water, and ventilation until after the arrival of Palmerston’s sanitary commission. It is strange that she didn’t, since during the 1840s the government had launched a huge propaganda campaign to encourage local authorities to finance sewers and drains, to improve water supplies, and to remove filth and “nuisances.” This “sanitarian” campaign was highly controversial, and Nightingale would surely have been aware of it, since newspapers covered it and Lord Palmerston and Lord Shaftesbury, who supported the sanitarians, were family acquaintances.

The sanitarians of the 1840s and early 1850s were led by Edwin Chadwick, a civil servant and former secretary to Jeremy Bentham, who believed that sewers, drains, and water would be the salvation of Victorian society. This was a farsighted and sound idea, but Chadwick’s approach to the issue was callous and politically motivated, and this undermined both his own popularity and that of his campaign. Christopher Hamlin’s overlooked but fascinating Public Health and Social Justice in the Age of Chadwick: Britain, 1800– 1854 explores a period often considered the golden age of public health, and provides some perspective on the politics surrounding the sanitarian campaign. Not everyone was in favor of the sanitarians, and some of Nightingale’s friends were particularly skeptical about them. Despite her family connections, she might have been too, and this could explain her failure at Scutari, and what Small perceives to be her subsequent guilty feelings about it.


In the 1830s and 1840s, escalating social unrest led some people in Britain to fear that the nation was on the verge of civil war. The great industrial towns were drawing impoverished laborers from the countryside, but lacked the means to accommodate so many new workers. The factories could not provide regular employment and, in any case, wages were extremely low. So workers, including children, were subjected to alternating periods of extreme overwork and utter destitution. Living conditions were miserable and epidemics were common. A laborer in Liverpool could expect to live, on average, to the age of fifteen; in Manchester, around half of all children died before they were five years old.5 Reform-minded allies of the Chartist movement demanded higher wages, shorter hours, safer working conditions, and other rights. As the spirit of revolution spread across the rest of Europe, in the north of England unemployed factory workers were forming armed gangs.

A target of much criticism was the 1834 New Poor Law, designed by Edwin Chadwick himself. The New Poor Law denied unemployed workers relief unless they entered squalid workhouses, which were like prisons, only worse. The Chartists and other reformers, and even some Poor Law physicians, bitterly complained about the dreadful conditions in Chadwick’s workhouses, and wrote about workers who preferred to starve rather than enter them. These reformers believed that the cause of so much death and illness among the poor was poverty itself, and they blamed the industrial economy. As one physician testified before a select committee in Parliament, “You purchase your advantage at the price of infanticide…. The profit thus gained is death to the child.”6

But Chadwick had other ideas about what was killing the poor. He was a defender of the free market and the new industrial economy that had enriched many of his friends, including his wife’s family. He maintained that his Poor Law and the workhouses were not cruel; they merely drove the workers harder. For Chadwick, poor health among urban laborers was caused solely by inadequate sanitation, which, if it were improved, would solve the health problems of the poor.

At the time, the causes of disease were not well understood. During the early years of the nineteenth century, a general consensus emerged around the idea of “miasma” as the cause of such epidemics as fevers and cholera. Miasma (Greek for “pollution”) referred to some form of toxic air, either from rotting sewage or from fetid human perspiration and other discharges. Miasma wasn’t a new idea, but in the minds of sanitarians like Chadwick, it soon eclipsed other theories about the cause of disease, such as “contagion,” or the idea that some people had “fragile constitutions.” The word “miasma” also had moral connotations, and Hamlin suggests that Chadwick and other sanitarians linked miasma to the social chaos among the angry masses. Poor sanitation degraded moral standards and created packs of unruly delinquents and troublemakers. Hamlin writes, “In attacking those ‘nuisances’ that were supposed to cause disease, might one equally attack the moral degradation that nurtured revolution?”

Chadwick himself did not discover that water and drains were important for health and well-being. Towns and estates had been installing sewers for hundreds of years. But he turned drains into a crusade. Hamlin argues that Chadwick’s millenarian enthusiasm for sewers was a direct response to criticism of the industrial economy in general and his New Poor Law in particular. He responded to his critics by arguing that factories were safe and wages adequate. Factory deaths were caused by careless workers, and poverty was caused by extravagance, a moral failing.

He also came to an extraordinary conclusion about the deaths in Ireland during the potato famine. Since there were not enough seed potatoes, sewage that would have been used as fertilizer accumulated and, he claimed, released deadly miasmas. If “miasma” was really a practical metaphor for the threatening discontent of the poor, Chadwick’s sewers symbolized the power of Victorian engineering to contain it. Like a perpetual motion machine, Chadwick’s system would whisk away dangerous filth and transform it into valuable fertilizer, which would in turn be transformed by rural farmers into food for the city dweller, who would then produce more sewage. As filth and miasmas were converted into fuel for the industrial economy, the rebelliousness and moral turpitude that accompanied them would disappear.

Chadwick was forced out of government in 1854, shortly before Nightingale left for the Crimea. He was much hated. Even sympathetic biographers have written that he was a fanatic and a bore.7 He attacked local governments that did not install sewers quickly enough or did not install them in the way he recommended. He accused careful engineers of dithering and demanded new taxes for his schemes, and he insulted physicians by placing public health in the hands of engineers and bureaucrats. He was also unpopular with many of Nightingale’s friends, including her former suitor Richard Monckton Milnes, and Sidney Herbert, her mentor in the War Office during the fatal four months in the Crimea. Chadwick may well have been unpopular with Nightingale too, but her published letters from before the war never mention him. Unless some reference to Chadwick turns up in the early letters being gathered by Lynn McDonald, we can only assume she was suspicious of Chadwick, as many of her contemporaries were.

In Paternalism in Early Victorian England,8 David Roberts calls gentlemen like Herbert and Monckton Milnes “paternalists” because they believed the solution to the nation’s considerable social problems lay in old-fashioned patrician benevolence and charity, rather than legislation, such as Chadwick’s Poor Laws and his sanitarian Public Health Acts. Roberts argues that Herbert, Monckton Milnes, and many of their fellows among the upper classes were repelled by the changing politics of the Industrial Revolution and the growing sentiment in favor of equality, democracy, and rational government administered by technocrats rather than by benevolent rich people like themselves. Their ideas were at odds with those of middle-class civil servants like Farr and Chadwick, who were trying to shift power in government from the aristocracy to rational bureaucrats like themselves.

Nightingale’s many published letters from before the war do not tell us much about where she stood in the rapidly changing politics of her time. However, her emphasis in the Crimea not only on feeding and clothing the soldiers but also on encouraging them, and nurses as well, to avoid alcohol and to send their money home to their families suggest she may have had paternalistic ideas herself. Chadwick thought such patrician high-mindedness was useless, and it was he who persuaded Palmerston to send the sanitary commission to inspect Nightingale’s hospital. After the war, when Nightingale became a strong advocate of sanitation, she and Chadwick would become good friends, but by this time he was out of government, and would remain so for the rest of his life.

Before Nightingale went to the Crimea, there was still considerable debate about how best to help the poor. Nightingale and William Farr, the statistician who helped her with the Crimean death statistics after the war, seem to have realized that the events of that terrible winter in Scutari were like a laboratory experiment that might help decide which policies were most effective.9 The message contained in the numbers of soldier deaths before and after the arrival of the sanitary commission could not have been clearer. Sanitation, and not Nightingale’s efforts to procure food and warm clothing, reduced death rates among the soldiers. In 1857, Nightingale testified before a royal commission that the army was being destroyed by poor sanitation, and a year later, Parliament finally voted to finance the first comprehensive sewage system for London, which is still in use today.

Better sanitation saved many lives in Britain in the nineteenth century. But the condition of the British worker changed for the better in other ways. Nutrition improved, factories became safer, and workers gained important rights. Hamlin’s book and Small’s account of Nightingale’s dilemma during and after the Crimean War concern what may be the central problem of public health. What can be done about the inexorable connection between sickness, early death, and poverty? In mitigating the suffering of the poor, which approaches deserve the most support? Should the emphasis be on charity, as Herbert and his upper-class friends believed before the Crimean War? On modern technical solutions, as Chadwick and the sanitarians argued? On social change, as the Chartists, factory reformers, and the physicians who sympathized with them claimed?

Such questions are as relevant now as ever. Twenty percent of the world’s population lives on less than $1 per day, and the poor everywhere continue to suffer and die from cholera, tuberculosis, and other diseases that were common among Britain’s poor during the Industrial Revolution. Western democracies could certainly be more generous with foreign aid and charity, but will real progress in mitigating the suffering of the poor come only with technical advances, such as new vaccines for AIDS, malaria, and tuberculosis? How much impact will the latest information technologies have on the prevention of hunger and early deaths from disease? Perhaps more importantly, to what extent do the conditions of the global economy, particularly the terms of trade and investment, contribute to the suffering and early death of people in developing countries and among the poor in industrialized ones?10


Several years after the end of the Crimean War, Nightingale returned to her work on hospital nursing, but she spent the years immediately after the war writing about sanitation. Her book Notes on Hospitals (1859) is mainly about how to build a hospital, not how to work in one. Notes on Nursing: What It Is and What It Is Not (1860) is about care of the sick at home, particularly the cleaning of cesspits and the importance of ventilation. Perhaps significantly, especially in view of the title, she omits discussion of nursing in hospitals, except to advise patients to avoid them whenever possible. After the war, Nightingale became as critical of the well-born gentlemen in Parliament as she had once been of her idle mother and sister, and she came to believe that a truly rational government could perform miracles.

Still, much of Nightingale’s writing deals with questions of religious faith. Of the projected sixteen volumes of McDonald’s Collected Works of Florence Nightingale, four will deal with religion. The most comprehensive of the new biographies, and the one most concerned with Nightingale’s spiritual life, is Florence Nightingale: Mystic, Visionary, Healer by Barbara Dossey, a New Mexico expert on holistic nursing. Her book is beautifully illustrated and clearly written, but contains little new information. It also advances a puzzling inter-pretation of Nightingale’s life and ideas. For Dossey, Nightingale’s public health work was a holistic exten-sion of nursing, something Nightingale could appreciate because of her own visionary, almost supernatural gifts. Nightingale was indeed deeply religious, and for a while even became interested in the occult, but her God was very pragmatic, a Supreme Administrator rather like herself when she was sending her reports to the offices of government.

Nightingale struggled to reconcile the realities of the unnecessary death and misery she saw around her with the Victorian conviction that there was order in God’s world. Both McDonald and Small write about how Nightingale came to believe that statistics were messages from God, advising human beings how to improve their condition. She made many contributions to what was then a young science, including new systems for keeping hospital statistics. A few years after the war, she met one of her childhood heroes, Alphonse Quetelet, the famous Belgian statistician who developed methods for conducting social research. Basing his calculations on the average daily temperature since the last frost, he taught Nightingale how to predict when a flower would bloom. For years, Florence sent her older sister lilacs that had been calculated to bloom on her birthday.

Nightingale was not a diehard sanitarian like Chadwick. She believed that statistics would not only prove the need for better sanitation; they would also guide public policy toward the improvement of human welfare in general. She realized that health depended not simply on medical care and cleanliness but also on the broader social system under which people lived. After the war, she criticized the Poor Laws, and she also wrote about poverty, crime, labor, the social causes of madness, and what we would now call human rights. Henri Dunant, the founder of the Red Cross, said that the idea that the war wounded should be considered “neutral” and treated the same no matter which side they were on was Nightingale’s. She also advised the drafters of the Geneva Convention.

After returning from the Crimea, she became interested in India. Still writing from her bedroom, she designed improved irrigation and drainage schemes and advised the government to provide generous long-term loans to finance them. She argued that taxes were too hard on poor Indian farmers, and she supported repeal of the infamous salt tax; she also supported famine relief, and sanitation, for Indians as well as British colonists. She was in favor of Indian self-rule, and encouraged research into the effects of colonial policy on the physical and economic well-being of Indian people.11

Nightingale believed that the causes of social problems lay in political and religious institutions. “Man’s will is determined by the acting causes of his ‘social system.’ Alter these and his will is altered.” It was God who established the laws of this “social system,” and it was the duty of policymakers to determine what these divine laws were, using the methods of social research, which were essentially God’s instructions for rational administration. She wanted, she said, to “grow a new moral world out of the discovery of what the laws [of society] are,” not by “confessions and bewailing our ‘desperate wickedness….’ The causes influencing the social system are to be recognized and modified. From the past we may predict the future.”12 There is indeed something mystical about this way of thinking. But there is also something very practical about it, in that Nightingale’s God seemed to be so concerned with the details of government policy.

If only, she thought, His servants would pay attention. Nightingale considered it a sin against the Holy Ghost for politicians to ignore the lessons of the past in making their decisions, and she complained that they passed laws “without knowing [what they] were doing.” When Nightingale returned from the Crimea, or soon after, she felt she had to confront the fact that God’s inspiration was not to be found in the noble lords and gentlemen in government who, however well-intentioned, made so many mistakes in the war. God would be found in the truths that science would discover.

This Issue

March 8, 2001