Florence Nightingale and the "germ theory" of disease.
It has often been said that Florence Nightingale refused to accept the "germ theory", long after the discovery that diseases are spread by micro-organisms, or that alternatively she was "inconsistent" in her attitude to germs. After objectively examining the evidence, author Hugh Small in his book Florence Nightingale, Avenging Angel shows for the first time that these allegations against Florence Nightingale have no basis in fact.
Very little research is needed to establish the truth. Over and over again in her letters and writings, Nightingale lays down the law about sterilising equipment used in hospital, to kill germs. It is astonishing how so many commentators have managed to ignore this evidence. Florence Nightingale, Avenging Angel gives some examples of how historians have created the myth of her resistance to modern ideas (e.g. the myth of her opposition to sterilising milk, the myth that she mistakenly opposed the supposedly scientific views of John Simon). The explanation for this is that historians, usually out of subservience to the medical profession, have wanted to downplay her acerbic criticism of doctors who could not understand preventive medicine. Florence Nightingale, Avenging Angel shows how this lack of understanding is still leading to unnecessary deaths today (for example from respiratory disease in the Third World, and from cancer and Hospital Acquired Infection everywhere).
This page gives some additional insights into Florence Nightingale's attitude to germ theory. One common version of the myth holds that Nightingale "never" accepted the germ theory up to her death in 1910. Her critics seem to use the "never" to differentiate her from most of her highly distinguished medical contemporaries who were extremely slow to take on board the pioneering work of Pasteur, Lister and others in the 1860s. Thus Florence Nightingale "never believed that germs caused disease." - St. Thomas's Hospital, by E. M. McInnes, and again "never accepted the germ theory of disease" - Ever Yours, Florence Nightingale: Selected Letters by Vicinus and Nergaard (p. 2). Serious but popular books like this, by presenting no evidence to sustain these claims, create the impression that the issue is beyond dispute (even more than Lytton Strachey's dilettante essay, which even claimed that she believed there was no such thing as infection).
The most explicit and high-profile support that Nightingale gave to the germ theory was in an chapter written in the late 1870s for Quain's Medical Dictionary, first published in 1882. Nightingale specifically urges the use of antiseptic precautions (the use of chemicals against germs). "Always have chlorinated soda for nurses to wash their hands, especially after dressing or handling a suspicious case. It may destroy germs at the expense of the cuticle, but if it takes off the cuticle, it must be bad for the germs". When she came to hear about the aseptic methods (excluding germs rather than killing them with chemicals) which were making antiseptic methods obsolete she became a great enthusiast for asepsis. Ellen Ekblom, Head Surgical Sister at the Helsingfors Surgical Hospital in Finland, told Nightingale in 1896 of the aseptic methods used in that hospital, including the boiling of swabs in blotting paper which the nurse opened without touching the swab, heating catheters to 120 degrees, etc. Nightingale said "I wish I had known this when we wrote for Quain's". In Quain's she had recommended disinfecting catheters antiseptically, using carbolic acid.
Is 1896 a late date for conversion from antiseptic to aseptic ideas? Not if you take into account the "accepted ideas" of the medical profession. The date of first introduction of a practice is not a good guide to accepted ideas, because of the conservatism of most medical practitioners. Steam sterilisation of dressings was pioneered in Germany in 1886, and sterile rubber gloves for operations were first used in 1890. But author Hugh Small's father, when a young surgeon in the East End of London in 1933, assisted a senior colleague of the old school who still performed abdominal surgery the antiseptic way nearly half a century later, dousing his bare hands, swabs, and instruments in lysoform and often smoking a cigarette while he operated. Alan Small described the experience in his obituary of the old surgeon, A. J. Couzens, published in the British Medical Journal in 1960.
Nightingale's Quain's article contains an example of her criticism of doctors' misuse of germ theory: ".. the doctrine of 'disease germs', in the sense in which it may lead to considering 'infection' inevitable, must not be taught as a principle of sanitary nursing." She is referring back to her dispute with John Simon, Britain's Chief Medical Officer, who in 1858 had claimed that the high death rate from measles and scarlet fever was "inevitable". She attacked his official pronouncement publicly, and he later retracted his statement. She concluded that medically qualified individuals cannot be satisfactory public health managers unless they abandon their medical careers. Belief in the myth that she did not understand germs has caused governments to ignore this wise observation ever since.
Did she make contradictory statements about the existence of germs?
The above quotations show that she supported the germ theory, but is there any evidence that she was contradictory and opposed it on other occasions? Who started the story that she did not believe in germs, and on what evidence if any? The first to make this claim may have been Lytton Strachey, who wrote in his Eminent Victorians (1924) that Nightingale believed there was no such thing as "infection". Strachey appears to have got his material almost entirely from Cook's 1913 biography, but Cook as far as I can see does not claim that Nightingale opposed the germ theory or the idea of infection, apart from his mention of the Jervoise Clarke Jervoise pamphlet (see below). So where did Strachey dig this story up? The rapidity with which the idea spread unaccompanied by evidence seems to show that it has that mysterious quality of believability that characterises many urban myths. Once one author established it as conventional wisdom, there was a tendency by other authors to reinforce it by decorating it with lightweight "examples" that would not have been sufficient to establish it in the first place.
"Evidence" cited by those who claim that she did oppose germ theory
1. Her criticism of Simon and Greenhow (cited by F. B. Smith etc) - dealt with in Florence Nightingale: Avenging Angel ("FNAA")
2. Her corrections to Amy Hughes' book on District Nursing (cited by Monica Baly) - dealt with in FNAA
3. Her cancellation of the Francis Galton legacy ("endowing a microbe" - cited by F. B. Smith) - dealt with in FNAA
4. Her supposed endorsement of the Jervoise Clarke Jervoise pamphlet and its "remarks by Miss Nightingale" (cited by Sue Goldie)
Cook includes the following entry in his Bibliography:
(107) "Infection." By Sir J. Clarke Jervoise, Bart., with Remarks by Miss Nightingale. Second edition. London: Vacher & Sons, 1882. Pamphlet, in blue paper wrappers, pp. 63.
Miss Nightingale's "remarks" at pp. 62, 63, were on the first edition of the pamphlet (published anonymously in 1867) They are an attack on "the germ hypothesis".
Sue Goldie, in her Bio-Bibliography of Florence Nightingale says that this 1882 publication shows that Nightingale was in agreement with Sir J. Clarke Jervoise's position on germs, i.e. that they didn't exist. This would be odd indeed in the same year that her chapter in Quain's gave specific instructions for dealing with germs. A close examination of the pamphlet shows that it may not be a reliable record of Nightingale's comments, but even if she made the remarks exactly as claimed, the most that can be said is that in 1867 - the year in which she is said to have made these remarks - she found fault with a "germ hypothesis" that was current at that time.
"Remarks by Miss Nightingale on a pamphlet entitled 'Infection'
Anon
1867
This pamphlet is ably written. It reminds one very much of the arguments which in the middle ages might have been brought by an enlightened man against witchcraft, as a cause of disease.
The disease-germ-fetish, and the witchcraft-fetish, are the produce of the same mental condition; both of them considered simply as superstitions, or harmless theories; both of them spring from the same source, a desire to group together a number of detached phenomena, so as to make a kind of raft upon which weak minds can float. This view can easily be confirmed, by reading any of the trials for witchcraft, and comparing the facts and inductions, in the Cattle Plague Report, and in other medical treatises on so called Contagious Diseases. But when either the witchcraft hypothesis or the disease-germ hypothesis is made the basis of legislation on the assumption that any public good can follow from any Acts of Parliament, then the matter becomes very serious indeed; and the fact of such legislation being possible can only be considered as a striking proof how rapidly the (so called) scientific mind of England, is sinking into a condition of abject superstition.
This is not the only evil; commerce will inevitably suffer to a greater extent than heretofore from these absurdities unless a check is put on them.
It cannot be otherwise, because the germ hypothesis, if logically followed out, must stop all human intercourse whatever, on pain of risk of disease or death.
The germ hypothesis , moreover, is directly at variance in its results with ascertained sanitary experience, and to adopt it as a basis for legislation is, in strict logic, to declare that the Public Health Act, the Local Government Act, and all other Local Acts for improving the public health, have been founded on error.
This pamphlet is the first protest made publicly against this downward course.
The Author deserves great credit for his audacity, and one can only hope that it will open the eyes of other members of the House of Commons to the course on which they have entered."
These "remarks" (from the BL copy of the pamphlet) are not signed by Nightingale. In fact, as you can see, they are signed "Anon" - presumably meaning that they are hearsay from an anonymous witness describing her alleged comments on the pamphlet and on germs. There is no doubt that Nightingale frequently made critical remarks on the doctors' abuse of their primitive germ theory which would have convinced a lot of die-hard oponents of germ theory that she was on their side. Jervoise's pamphlet attacks quarantine regulations and claims the Medical Officer of the Privy Council is ignorant and dictatorial, which Nightingale would have agreed with. However his pamphlet denies the possibility of infection, which Nightingale was prominent in admitting. Sceptics like Jervoise have no hesitation in scoffing that scientists had not been able to find leprosy germs even with a microscope capable of making "a child of three years old as big as Mont Blanc", but Nightingale is never known to have made such a bold claim..
The "remarks" as reported attack the "disease-germ-fetish" or "disease-germ-hypothesis" without making it exactly clear what Nightingale thought that fetish or hypothesis consisted of at the time (1867). By implication only, the remarks seem to be attacking the hypothesis enunciated in the Cattle Plague Report. One of the problems of analysing Nightingale's criticisms is that she was attacking a moving target: the "germ hypothesis" evolved rapidly under attack, forming its own new, resistant strains (the later "immune carrier" modification is a good example). In an earlier Note on Contagion in 1858 she had specified that she did not believe a then-current germ theory (soon afterwards shown to be false) that held that epidemics were caused by germs attaching themselves to objects. Clarke Jervoise did not include enough context in the "remarks" to say exactly what germ theory she was attacking in 1867. Whatever it was, it was a very early variety. Lister conducted his first operations with antiseptics only the year before.
Sir Jervoise Clarke Jervoise does not appear in Sue Goldie's Calendar of Letters of Florence Nightingale. I have not yet found any evidence that Nightingale knew him or communicated with him directly.
5. Her notes on a letter from Luise Fuhrmann (1889)
This is the first of two letters cited in the subject index of Sue Goldie's "Calendar" under "Germ Theory"
Fuhrmann wrote to someone in England and Nightingale has copied out the letter (BL Add MSS 45809 f94) and made some enigmatic jottings on the copy which show that she disagrees with the way some doctors employ the germ theory.
Miss Fuhrmann writes: "It seems that people in England have got the Certificate disease (or Register disease) for they attach a meaning to such a piece of paper which it has not got even in our bureaucratic country where one gives & gets certificates for anything & everything."
Nightingale has written below:
'FN: and who is to certify our certificates
[FN: The germs-disease is most dangerous and fatal - not to the Patient but to the Doctor. Bacteriology is likely to be a fatal (written above the last phrase: "prove a lethal") Epidemic]
and who is to train or guarantee our guarantors? Who to certificate our certifiers?
We are not Christinos - but we are not Burdettinos either'
6. The second letter under germ theory in Sue Goldie's calendar is is BL Add MSS 45767 to Douglas Galton (1893)
Nightingale is writing to Galton about an impending Buckinghamshire County Council Sanitary Commission meeting. Her relative F. Verney will chair the meeting and she wants Galton's advice on how to control the meeting. The agenda (not transcribed here) is included in the letter.
May 24 /93
How would you draw up a general rule to limit discussion on these subjects, so as to make the conference business-like but not professional
[FV says very truly: We must not allow it to become a field of debate for Doctors to argue out their technical or professional differences in a way incomprehensible to laymen]
This is really the main thing
[Did you notice that the Commission of Eminent men on Leprosy came to the conclusion that Leprosy is the direct consequence of a bacillus.
They do not say of
want of cleanliness
especially personal
foul food, especially putrid fish
&c &c
God forbid that the Bucks Sanitary Conference should come to the conclusion that
Typhoid Fever
Diptheria &c &c
of which they have had a great deal are the direct consequences of
Bacillus F
Bacillus D
Instead of
bad drainage
cess pools instead of dry earth closets
fouled water supply
&c &c
have you seen Dr. Poore's "Rural Hygiene" ... It appears to me admirable ... [Dr. Poore's book makes remarks on Water Closets] ... I should like to know what your conclusions are. ... I suppose you would not think Dr. Poore any help in giving hints about the management of Sanitary County Conference in a common sense way keeping out "germs". His book is totally free from "germs". Please say
In the above letter to Galton she says that public health authorities should not content themselves with identifying the strains of bacteria that produce Leprosy, Typhoid, and Diptheria but should instead emphasise the impact of bad sanitation in causing them. This is not the same as saying that germs do not play any role in these diseases. This viewpoint is logical and consistent with her statements - in her Quain's article 11 years earlier - that antiseptic precautions are necessary in hospital to stop the spread of disease through germs.