Press reviews of Hugh Small's biography of Florence Nightingale
(published in 1998 under the title Florence Nightingale, Avenging Angel)

Click here for extracts from several reviews (the best bits!) or scroll down to see the full text of each of the reviews listed below:

New York Review of Books, Vol. XLVIII Number 4, 8 March 2001   
(see also the follow-up letter from the author in New York Review of Books, May 31, 2001
New York Times, 16 January 2000
Washington Times (DC), 26 December 1999
Publishers Weekly (US), 1 November 1999
Booklist (US), 1 November 1999
Library Journal (US), 19 September 1999
Review of the Arts, Literature, Philosophy, and the Humanities (US) - link to their site
Daily Telegraph (UK), 23 January 1999
Journal of the Crimean War Research Society (UK), January 1999
Contemporary Review (UK), January 1999
Catholic Herald (UK), 11 December 1998
Sunday Times (UK), 29 November 1998
The Scotsman (UK), 14 November 1998
Church of England Newspaper (UK), 13 November 1998
The Spectator (UK), 24 October 1998
Derby Evening Telegraph (UK), 18 September 1998
Evening Standard (London), 11 September 1998
Literary Review (UK), September 1998

Also see reviews in:
Isis (U. Chicago History of Science Society) Volume 92, No. 2, June 2001
The Historian (US) Vol. 63, Number 3, page 695 22 March 2001
Journal of Medical Biography, Volume 8 Number 1, February 2000
Journal of Women's History, Volume 12 Number 2, Summer 2000
Nursing History Review, Volume 9, 2001
English Historical Review, September 2000
Women: a cultural review, Vol. 13 Number 2, 2002
Victorian Studies, Summer 2001

New York Times 16 January, 2000
The Crimean War made Florence Nightingale (1820-1910) the world's most famous nurse. She didn't enjoy her fame for long. Twelve months after the war ended she collapsed and was bedridden for 10 years. In Florence Nightingale: Avenging Angel, Hugh Small argues passionately that she broke down because she felt responsible for the deaths of 14,000 men. At times he sacrifices clarity for rhetoric - Small's Nightingale is driven, tormented, messianic and interesting. In October 1854, the British government sent her to the army hospital in Scutari (now Uskudar, across the Bosporus from Istanbul) as head of a party of female nurses. As reported throughout the world, she held dying soldiers in her arms and wrote compassionate letters to their families. However, for months she seemed incapable of reducing the death rate in her hospital. Eventually deaths dropped dramatically. Analyzing the statistics after the war, Nightingale concluded that the drop coincided with the work of a doctor from the government's Sanitary Commission who cleaned toilets and sewers - elementary sanitary precautions she had ignored. Her life, she wrote in 1860, had been "a tissue of mistakes." To publicize the importance of sanitation, she presented her findings to the government, which buried them. Guilt-ridden, she collapsed. From her bed, she issued articles and letters urging environmental cleanups to prevent disease. She was harsh, unyielding and sarcastic with the medical establishment. But she was harshest with herself. "Blunders do more mischief than crimes," she wrote; Small believes she was referring to her own great blunder. Margaret Van Dagens

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Washington Times (DC), 26 December 1999
A lost Army over the Bosporus
"A passionate idolatry spread among the men; they kissed her shadow as it passed. 'Before she came,' said a soldier 'there was cussin' and swearin', but after that it was 'oly as a church.'"

The soldier was recalling a vision of Florence Nightingale lodged in the popular imagination, pacing miles around the sickbeds of the fallen during the Crimean War, improving all who came near. But as Lytton Strachey knew when he recorded this ethereal image of Nightingale in "Eminent Victorians", it was not the whole picture." Her real life began at the moment when in the popular imagination it had ended."

The most challenging part of Florence Nightingale's professional life took off once the war was over, this in spite of the fact that she spent much of it as an invalid. It was during this period that Nightingale would face the truth of her wartime service: that during the CrimeanWar, thousands of British soldiers lost their lives, not on the battlefield but under her watch at Scutari Barracks Hospital, an unventilated, crowded, gruesome place where "Hell yawned." In the years that followed, she would trade (to a point) her legendary persona for one committed to hospital reform, religious fervor, urban planning and more than occasional shows of a personality as cranky and domineering as it was saintly.

In Florence Nightingale, Avenging Angel, British writer Hugh Small goes one step further. Alleging that a cover up existed that included Nightingale, Queen Victoria and some of Britain's most powerful politicians, Mr. Small asserts that the goal was to keep the public from knowing how bad things were and that with more attention to basic hygiene much disease and death could have been prevented. Mr. Small holds "the 1ady of the lamp" accountable.

Early on he says, "Some of Nightingale's previous biographers imply vaguely that the death rate subsided when she took control of nursing in the army's hospitals. But Nightingale herself tells us that it soared, only beginning to decline four months later. The biographers have failed to ask a key question: when did Nightingale herself develop her theory that the men died because of poor hygiene? If Nightingale knew from the start why so many thousands of men were dying, why did it take four months to introduce what she later claimed was a simple remedy? And if she did not know then, when exactly did she find out, and what effect did that discovery have on her?"

One could argue that Mr. Small has all the subtlety of an Iran-Contra prosecutor. But his method is sure-footed. Beginning with the story of Florence Nightingale's life, he moves on to tell a captivating tale of the costs of the Crimean War, the soul-searching that followed it, the strains between monarchy and democratic government over the command of the army and what it took to enhance and secure the public health of 19th-Century Britain.

Florence Nightingale, was born in Italy on May 12, 1820, named for the city of her birth. Her father owned two large country houses in Derbyshire, and she was raised there along with her older sister Parthenope, so called for one of the sirens of Naples, an earlier stop on her parents extended continental honeymoon. Although she did not attend university, her father took a special interest in her education, especially in the area of mathematics.

Florence exhibited a strong mind early, but in short order she became disenchanted with her upper class world of parties and taking the waters. She had aspirations and she had gifts. When she was young, she took care of sick and injured pets, applying elaborate splints to the wounded paws of her dog. Sometime early on, she heard the voice of God telling her that she had a mission. When it became clear that her mission would be nursing, her family - particularly her mother who fainted at the mention of it - reacted as if nursing were not normal.

Nightingale would later write "It was if I had wanted to be a kitchen-maid ' " In 1849, she traveled abroad to study the European hospital system. One year later, she began training at the Institute of Saint Vincent de Paul in Alexandria, Egypt, then afterwards in Germany. In 1853, she became superintendent of the Hospital for Invalid Gentlewomen in London. Finally, in1854, pursuing a calling that would secure her eternal fame, she volunteered her services at the Scutari Barracks Hospital after the Crimean war broke out.

Mr. Small presents a fine chapter on the war, analyzing Britain's engagement in the conflict. Citing British author Asa Briggs, he notes that the Crimean war would probably never have happened if Lord Palmerston (a Nightingale family friend) had remained foreign secretary. Nevertheless, war began after the Russian navy destroyed the Turkish fleet at Sinope in the Black Sea and Russia invaded some Turkish provinces in the Balkans. Fearing Russian expansionism Britain and France attacked the naval base at Sebastopol in the Crimea in September 1854. The siege would last for a year.

The view from the Scutari Barracks Hospital over the Bosporus to the Golden Horn and the old city of Constantinople, known as Stamboul. (now Istanbul) was considered to be one of the best in Europe. But the view did little to mitigate the reality of the hospital's interior with its rotting wooden floors, its intractable stench and its crowding. Not long after, Sanitary Commissioners arrived from England along with the oddly named Inspector of Nuisances.

Nightingale had already begun to seek sanitary remedies for her soldiers' ills, taking the reins of the administrative requirements of her hospital. She ran a tight ship with strict rules, while simultaneously setting up the Nightingale Fund for the training of nurses. Her hard work caught the attention of Queen Victoria who sent her a diamond brooch for her efforts. Getting through the war was no small feat for Nightingale or for her nurses who were variously anonymous, rivalrous or fleeing. In spite of the chaos and despair around her, Nightingale was able to effect a record-keeping system involving mortality statistics that were both a credit to her intentions and a reminder of how she failed.

Until the war's end, the narrative of Mr. Small's book is a brisk, compelling read. But once the post-mortem begins, and the other Florence Nightingale emerges along with a cast of characters participating in the blame game, the book loses some steam. Although it is clear that Queen Victoria did not want the worst of the war's degradations made public, calling, it a cover up seems more of a modern construct, especially since the players as presented come in and out of focus, with allegiances too blurred to be either blameworthy or not. The cast includes such political and scientific heavyweights as Lord Panmure, Col. Alexander Tulloch, and John McNeill. Even when the noblest of these men seem to be advancing the best in public health initiatives, one still has to keep guessing which side of the Crown vs. Parliament debate over the army they occupy. Mr. Small concludes by noting that after Nightingale died at 90, she was treated to biographers who each created her in an image that played well with the prevailing biases. There is more to this book than its sensational appeal to our contemporary lust for corruption.  Carol Herman

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Publishers Weekly 1 November 1999
"Florence Nightingale is one of history's most famous invalids." So begins this abrasive exploration of Nightingale's career-making work in the Crimea and of why she may have "taken to her bed" for a decade after her return, becoming both an invalid and a recluse. Small proposes that Nightingale, who was sent to Constantinople to organize a nursing staff com-prising "ladies" (nurses were then commonly believed to be drunks and prostitutes, which they frequently were), may have in fact been responsible for thousands of deaths, since she failed to implement procedures to address the gross sanitation problems in the Scutari Barrack Hospital where she was headquartered. Small substantiates his claims with previously unreleased documents, notably letters between Nightingale and various members of the prime minister's Sanitary Commission, who were sent to investigate the mortality rate at Scutari. The revelations implicate Nightingale in a public health scandal sparked by battles between Queen Victoria and her prime minister, Lord Palmerston, over control of the army, which was perceived by all - including Nightingale - as a proving ground for social policy. Although Small purports to clear Nightingale's name, he compares her to Richard Nixon at the book's end, in a chapter titled "Reputation and Myth." Small's effort is interesting primarily for its insights into public health issues, however narrowly focused and dryly academic their presentation may be.

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Booklist (US), 1 November 1999
For this new interpretation of a durably fascinating woman, Small draws especially from letters not included in the official Nightingale papers and not used by other biographers. Nightingale took to her bed for many years after her famous Crimean War service. Small argues that the reason for her invalidism was not neurosis but overwhelming guilt when Nightingale realized that 14,000 British soldiers had died in the wartime hospitals because doctors and nurses failed to practice elementary sanitary procedures that she should have enforced. Small makes a strong case for his argument and for Nightingale's belief in the germ theory of infection, a "modern" notion with which other biographers have said she did not go along. Small also shows that Nightingale did not publish her confidential report to the Royal Commission that looked into the hospital deaths. Meanwhile, he clearly describes Nightingale's relationships with major politicians and appropriately places the whole story in the Victorian context. He adds valuably to the voluminous literature on a remarkable woman. William Beatty

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Library Journal (US) 19 September 1999
In 1854, Florence Nightingale sailed from England with 38 nurses, bound for the Scutari barracks in Constantinople and the Crimean War. Two years later, she returned a world figure: Queen Victoria sent her an inscribed brooch, and a public subscription raised over a million pounds to fund the training of hospital nurses. Then, at age 37, Nightingale collapsed and remained an invalid for ten years. Basing his study on extensive research into previously unpublished material, Small (a London-based management consultant) attributes Nightingale’s collapse to her discovery that her well publicized nursing efforts at Scutari had made no difference: "[She] had not been running a hospital. She had been running a death camp." The real culprits, he notes, were bad drains, overcrowding, and poor ventilation. Once past her distress, Nightingale moved to expose the government coverup. This book should reestablish Nightingale as a major figure in 19th-century health reform. Recommended for scholarly collections and larger general collections. David Keymer, Califomia State Univ., Stanislaus

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Daily Telegraph (UK), 23 January 1999
ALTHOUGH Florence Nightingale is revered in popular mythology as the ‘Lady with the Lamp’, bringing feminine compassion and elementary hygiene to the neglected casualties of the Crimean War, her most substantial achievements came after her return to England with the reform of the Army Medical Service and the founding of her School of Nursing.

Yet the reputation of this remarkable woman has always suffered from the charge that her personal life was the antithesis of the values she promoted in public. Her intentions may have been loving and humanitarian, her writings a masterpiece of lucidity and common sense, but her personal relationships were cold and her attitude to others tyrannical. The chronic invalidity which confined her to bed for 10 years has been interpreted as a sophisticated form of malingering, the better to manipulate those around her. ‘Her indeterminate illnesses,’ observed the historian F. B. Smith, ‘did not give her doctors much to work on.’

This cruel judgment has recently been revised in the light of strong circumstantial evidence that Miss Nightingale contracted brucellosis while in the Crimea, which, in its chronic form, both attacks the nerves and joints of the lower back, and gives rise to less specific symptoms - depression, loss of appetite, nervous tremors - that could only too readily be misinterpreted as psychosomatic.

In Florence Nightingale, Avenging Angel Hugh Small reveals there is considerably more to the enigma of her personality than even this theory allows. The military hospital in Scutari was an insanitary, ill-ventilated hellhole and, although Miss Nightingale and her nurses did their best, the wounded were in such a pitiful physical state that: ‘In the course of a few days all who had been entrusted to us had gone, and were succeeded by others who equally seemed doomed to die.’

These terrible experiences inspired Miss Nightingale, on her return, to agitate for a Royal Commission to inquire into the Medical Administration of the Army. This brought her for the first time into contact with the Victorian genius Dr William Farr, Superintendent of the Statistical Department of the Registrar-General’s Office.

Farr’s analysis of statistics from the war revealed the death rate at Scutari to have been three times higher than in the primitive regimental hospitals at the Front. He drew the obvious inference (bearing in mind that this was before the discovery of bacteria as the cause of infectious diseases) that ‘bad air’ in the hospital was a much more significant factor than the physical state of the wounded, and that nearly all the deaths in Scutari - almost 16,000 - could have been avoided with better hygiene. Hugh Small, in a masterly piece of historical detective work, convincingly demonstrates what all previous historians and biographers have overlooked - that Farr’s revelation is essential to the understanding of Miss Nightingale’s personality. Publicly lauded as a heroine, she now realised that her presence in Scutari had, by making it the focus of transport of the wounded back to Britain, contributed to the overcrowding that claimed so many lives. This is a compelling psychological portrait of a Very Eminent (and complex) Victorian. James Le Fanu.

 

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Journal of the Crimean War Research Society January 1999
On the face of it, Hugh Small’s Florence Nightingale, Avenging Angel is not exclusively about the Crimean War, but in fact it covers little else for after a brief chapter on her early life, the author turns to the war, and the long years afterwards as Miss Nightingale took to her bed as an invalid for the rest of her life. Mr Small argues persuasively that she was driven to this mental and physical collapse by remorse on finding from detailed study of the figures that the enormous number of British soldiers’ deaths - 14,000 - was due more to the conditions in the hospitals, especially her own at Scutari, than, as she had thought, the appalling conditions they had suffered in the trenches. Most of us believe that the majority of deaths were from inadequate food, overwork and lack of shelter? Not so, the book argues: the real culprit was poor sanitation in the base hospitals. In primitive regimental hospitals at the front, one in eight died during that first terrible winter. But in her hospital, three in eight succumbed. She had not been running a hospital so much as a death camp. How she herself came to this conclusion and the effect it had on her is a gripping story and I could not put this book down. It is an outstanding contribution to literature on our war, which should change widely held views, and must be read by every student of the war. Colin Robbins

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Contemporary Review (UK), January 1999
This new biography sets out to look again at the ‘myths’ surrounding Florence Nightingale in light of surviving material relating to her life and work. It must be regarded as belonging to the school of ‘debunking’ biography. The author reexamines her work at Scutari and argues that it was a failure, not a success. He shows that Florence Nightingale knew this and did not try to hide the truth. Others made the myths that surrounded her, not by herself. He pays close attention to her own unorthodox religious writings to recreate her views about herself and her work both in the 1850s’ and later. This book will fundamentally alter our views of ‘the Lady with the Lamp’ and perhaps restore them to a more even footing. Another’ popular statue in the nation’s shared memory has been toppled.

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Catholic Herald (UK), 11 December 1998
As formidable in her way as [Saint] Hildegard was Florence Nightingale. The sub-title of Hugh Small’s book Florence Nightingale, Avenging Angel is an ingenious pun on the modern use of the word "angel" to mean nurse, and the terrible wrath visited by Miss Nightingale on those who got in her way. Angel, perhaps, but no saint, despite repeated attempts by the Church of England to enrol her in its kalendar - their equivalent of canonisation. For all the great good of her example and legacy, she is not really the lady with the votive lamp. Here various mysteries of her life and character, especially in the long years after the Crimea, are explained. Brian Brindley

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Sunday Times (UK), 29 November 1998
Hugh Small has written the short and intriguing Florence Nightingale, Avenging Angel. Small's detailed examination of Nightingale's hospital work and the crisis that followed it sheds new light on her life and a surprising one on the way she was viewed at the time. Not quite the lady of the lamp we all thought. Miranda Seymour

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The Scotsman (UK), 14 November 1998
"Good intentions are supposed to be enough", wrote Florence Nightingale late in life. "Yet blunders, organised blunders, do more mischief than crimes". By that time she had become agonisingly aware that Crimea's real killing fields, had not been at the front but in the halls of her own hospital at Scutari. Even healthy visitors to its precincts, it seems, had often entered never again to leave. Thanks to the unsanitary conditions and overcrowding which prevailed there, the healing touch of the Lady with the Lamp and her nurses was more properly a kiss of death. Though always creditably level-headed about her own extravagant mythology, Nightingale had still gone home afterwards with a warm, glowing sense of a job well done. Only afterwards had cumulative statistics, and the emergent "germ theory", come to point up the fact that some 14,000 had died unnecessarily. The discovery that the government wanted her complicity in suppressing these figures drove her over the edge into breakdown. A management consultant by profession, Small comes at his subject from a novel and startlingly illuminating perspective. Far from debunking this great Victorian icon, however, his portrait liberates a formidable woman from dreamy angelhood, underlining her tragic heroism instead. **** Michael Kerrigan

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Church of England Newspaper 13 November 1998
Her father taught her that Anglicans go in for creeds, Unitarians for deeds. Yet his father-in-law, the Unitarian MP William Smith, was a close associate in the abolition of the slave trade of William Wilberforce, an Anglican evangelical. Wilberforce tried to win Smith for Christ.

When Florence put her father’s teaching into practice he was horrified: nursing was not for ‘ladies", only for nuns or for ignorant sluts like Mrs Gamp. Florence overcame family and class prejudice and made nursing an honourable profession.

As this finely illustrated book shows, the Nightingales moved in government. circles and when the Crimean War led to public uproar over the high death rate in the military base hospital at Scutari opposite Constantinople, the Cabinet sent Florence out as superintendent. The death rate continued to rise until a sanitary commission made some recommendations that Nightingale carried out, without spotting their significance.

Hugh Small describes the fearsome scenes of suffering, the military and medical incompetence, the courage of the wounded and sick soldiers, which formed the background of Nightingale’s own selfless service and made her a national heroine as ‘the Lady with a Lamp’,

But this is not intended as a new biography. It corrects one aspect of Nightingale’s life. Mr Small is a professional statistician and became interested in her use of statistics as she prepared her evidence for the Royal Commission after the war.

She was much influenced by the pioneer statistician Dr Farr, who proved, to her horror and sense of guilt, that most of the 16,000 young men, no less, who died in her hospital were killed, not by wounds or illness contracted at the front, but by her own refusal to realise that the insanitary condition of herhospital had made it a death trap.

When the government refused to publish her self-incrimiriating report she had a physical.and nervous collapse. Recovered, she spent the rest of her life promoting sanitary reform in the Army and the nation. She even likened herself to Christ as a pioneer. John Pollock

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The Spectator (UK), 24 October 1998
Thou wast not born for death, immortal bird!
History has not been kind to Florence Nightingale. Ever since Lytton Strachey caricatured her in Eminent Victorians, she has been attacked (mainly by men) as bossy and manipulative. Feminists have deconstructed her breakdowns and sexuality and woven candyfloss theory around her years in bed. Hugh Small's new book probes the one area we thought was safe: her Crimean war record at Scutari Hospital.

When Florence Nightingale arrived at Scutari she was 34; she had no training (her youth had been spent in enforced idleness, busily not marrying Monckton Milnes and bemoaning her unproductive lot) and her only experience of hospital administration was a year running a nursing home for governesses in Harley Street. She owed her appointment to her friends in high places, especially Sidney Herbert, secretary-at-war, whose wife supported Florence's campaign to show that women should be allowed to nurse men. That was really why she wanted the job-to prove the fitness of her sex; and what she lacked in knowledge she made up for with a shrill selfconfidence that was truly outrageous.

At Scutari Barracks Hospital she was in sole control of 2,500 sick soldiers, whom she found packed into stinking, overcrowded, filthy corridors with poisonous blocked drains beneath. Somehow, the men kept on dying. Convinced that they died because they were already at death's door when they arrived, Nightingale watched unperturbed, calmly accepting God's will. No one noticed that the death rate at Scutari was higher than in other hospitals. No one cleaned it up. She didn't know it, but she was running a death camp. During the ghastly winter of 1854Ä5 as many as 5,000 men died under Nightingale's care. Three in eight of her patients never came out alive. And many of these deaths were preventable, caused by fever caught in hospital. The image of the Lady with the Lamp gliding silent and serene through the corridors at Scutari, dying men kissing her shadow as she passed, takes on a horrible irony. She was the Angel of Death.

The Crimean war made Florence Nightingale a national heroine, triumphantly vindicating her claim that women could nurse soldiers without gross indecency taking place. Back in England, the Royal Commissions of Inquiry set to work. Only when William Farr, the government statistician, taught Florence to analyse the figures (and she was no mean mathematician) did she realise the terrible truth. Bad hygiene at Scutari in 1854-5 had killed more men than any battle. When hygiene was improved on the recommendation of inspectors the following year, the deaths dropped. To her credit, she was overcome with remorse. She tried desperately to publish the truth, but was silenced by an establishment cover-up. After a breakdown (characteristically brisk and brief) Nightingale took to her bed, where she mostly remained for the rest of her life, suffering, it seems, from repressed guilt. Hugh Small believes that a new, finer Nightingale was born in that terrible realisation, and that the campaigns she skilfully orchestrated from her sickbed were critical in the development of public health.

Hugh Small's book is really more polemic than biography: readers who idly wonder whether Nightingale died a virgin, dream on - you won't find the answer here. But his gripping story of Nightingale's nemesis and redemption goes a long way to rehabilitate her. She was worse than we ever thought; but she was greater too.  Jane Ridley.

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Derby Evening Telegraph (UK), 18 September 1998
The untold story of Florence Nightingale
Two years after her return from nursing troops, the angel of mercy in the Crimea, Derbyshire heroine Florence Nightingale collapsed and was bed-ridden for the next 11 years and was an invalid for the rest of her long life.

The mystery of what caused this divide in her life is researched by psychologist Hugh Small in Florence Nightingale Avenging Angel that probes into areas other biographies have glossed over.

The reason why at the age of 37 on that day in August 1857 "a large part of her died" was that she had now realised in utter shame that she was largely responsible for the deaths of 18,000 soldiers in her hospital at Scutari.

She had been fighting a campaign, involving top politicians and Queen Victoria herself, to blame the Army for the fatal illnesses of the troops because of their poor food that made them weak and already dying before they reached the hospital.

Now she had suddenly become convinced that it was the insanitary conditions in the overcrowded hospital over which she presided that had made it a death camp. Not bad food but bad air.

Miss Nightingale was a great writer of letters - 12,000 are in the archives - but there is a gap before her collapse as the terrible truth was coming home to her, she caused many letters of that time to be destroyed but Mr Small has used some that escaped.

The book does not deal at length with her early life in Derbyshire, except to record that, having reached 30, the only time she felt satisfied was on her six-week summer stays at Lea Hurst when she visited the poor and sick and taught their children in the village schools. "At Lea Hurst .. I had found my business in this world. 1 wanted no other heaven," she wrote.

Instead she found the hell of Scutari and the burden of blame for the rest of her life. Geoff Hammerton

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Evening Standard (London), 11 September 1998
Lady with the Lamp's guilt over soldiers' sordid deaths
FLORENCE NIGHTINGALE, famed as the Lady with the Lamp who gave comfort to dying soldiers during the Crimean War, unwittingly contributed to their deaths, according to a startling new account. Her collapse, at the age of 37, which left her bedridden for 10 years, was caused by a nervous breakdown over her guilt and distress at realising that the filthy conditions at the hospital at Scutari were to blame, claims author Hugh Small.

Mr Small dispels many other theories about the cause of Nightingale's mysterious illness. His research suggests it was a result of her confronting the truth about the care the men received, and then having that information suppressed, which destroyed her.

Nightingale, an independent-minded woman from a wealthy family, gave up a comfortable job in Harley Street to work at the hospital near Sebastopol in 1854. In the first six months, 12,000 soldiers came into the wards, but conditions were no better than a slum in inner London. According to Mr Small, "the men were packed like sardines in an unventilated building on top of defective sewers". For this reason, their death rates were double those of the smaller regimental hospitals in the winter of 1854-55. As the war progressed, the patients arrived with increasingly awful symptoms. Many were starved and frost-bitten, others had lost hands and feet, and long-neglected wounds were infested with maggots. Half the patients who went to Scutari never came out.

Florence Nightingale did what she could to improve hygiene. With her 38 nurses, she tried to wash, de-louse and give the men clean clothes. She attempted to disinfect the floors, but the wooden planks were so rotten it was impossible. According to Mr Small, an unpublished letter written by her shows that it was not until 1857, when the war had ended, that she realised the conditions within the hospitals themselves had caused such a huge number of deaths. Until then, she had blamed the Army for incompetent and heartless treatment of soldiers by allowing malnutrition and exposure. After all, more than 16,000 men had died of sickness compared with fewer than 2.600 in battle and 1,800 of wounds.

Nightingale tried to publish her statistics showing that conditions at Scutari were much to blame: mortality from stomach and bowel diseases, such as dysentery, was 25 per cent higher on her wards than in front-line hospitals in the Crimea. To compound her guilt, it was she who had, insisted to the Commander-in-Chief Lord Raglan that sick soldiers were sent to Scutari instead of staying at hospitals at the front. In May 1857 in a letter to Sir John McNeill, leader of the Supplies Commission and a friend of Lord Palmerston, she wrote that "disease was chiefly generated within the building itself". The nurse, however, found herself caught up in a row between the British government and Queen Victoria and her generals. The Royal Commission into the Health of the Army was reluctant to publish revelations which would trigger off a new round of recriminations between politicians and officials. "Nightingale wanted the country to know why so many young men had died," Mr Small said. Three weeks after giving her evidence to the Royal Commission, she collapsed. Mr Small believes the row over the deaths explains much of Nightingale's odd, neurotic behaviour. "She felt she had betrayed the country three times - firstly by failing to improve the conditions, secondly by blaming the Army, and thirdly by being involved in the subsequent cover-up.' What did emerge, however, was a greater understanding of communicable disease. Nightingale went on to do much to improve sanitation, including teaching women how to sterilise milk for babies. Her views were prescient. She wrote in 1858: "1 look to the abolition of all hospitals and workhouse infirmaries. But it is no use to talk about the year 2000". In the approach to the millennium, nearly one in 25 Britons will die of a hospital-acquired infection.  If Nightingale could see this, why are we still fighting the battle 140 years on? Jo Revill

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Literary Review (UK), September 1998
An Ingenious Theory That She was Racked by Guilt
IT IS YEARS since anyone has thought of Florence Nightingale as the Lady with the Lamp. Revisionist voices have long talked about her atrocious management skills, her suffocating relationship with her mother, her desperate need to dominate cabinet ministers from her invalid’s couch. But no one before Hugh Small has ever had her down as a mass murderer.

Small’s thesis is that the field hospital at Scutari was a kind of killing field. Soldiers went in with a 50-50 chance of survival, and came out in coffins, thanks to the appalling sanitary conditions, which produced an impromptu germ warfare. Men were dropping like flies not because of bullet wounds or lost limbs but because of the infections they picked up in hospital. Chronic overcrowding and the kind of squalor which outdid anything social investigators were finding in the cities at home meant that a good proportion of the British army vomited and shat itself to death under Miss Nightingale’s misguided care.

Small says that Nightingale refused to see the truth, even though it was under her eyes and, more particularly, her nose. It was not until twelve months after she got back home that she let the statistical evidence sink in, finally accepting the terrible truth that she had been responsible for helping thousands of men to their deaths. Her strategy was to collapse into invalidism and work like mad to ensure that it never happened again. Coached by the statistician William Farr and using the biddable Sidney Herbert as her proxy in the corridors of power, Nightingale tried to boss Britain into cleaning up its act. Everything that came after, even the celebrated Nightingale Training School for nurses, was of secondary importance as Nightingale strove to atone for what she had come to see as her terrible crime.

Small’s thesis is genuinely new, and rewrites the psychofeminist claim that Nightingale collapsed in a heap back in Britain because she couldn’t bear being near her dominating mother and elder sister. Small stays in the realm of psycho-biography, but gives it a stiffer spine, marrying Nightingale’s slump to a set of tormenting statistics.

In the right hands, this could have been a clever little book along the lines of Dava Sobel’s Longitude. It is part detective story, part biography, and wholly relevant to current debates about preventive medicine. A third of the size of a regular biography, it inserts itself in the gaps which bigger, older studies of Nightingale have left behind, and explores the reasons for their reticence. In the process, the book becomes not just a study of one life, or one historical problem, but a commentary on the difficulties of writing about both. Kathryn Hughes

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