Read through the internet archive: https://archive.org/details/b20387118/
the book starts with a letter.
The book is highly quantitative. You might expect a treatise from a nurse of her era to be mostly anecdote - but she has the British Army’s data in hand, and she has a keen analytical sense to make good use of it. There are pages and pages of tabulated data. Hardly a page goes by that doesn’t have a figure or a ratio used to buttress a point.
There’s a great part where A Guy talks about how maybe women pick on the cleanliness of a hospital, but it’s really quite clean and the men are all very busy, you see, and boy does Florence bring receipts.
[ testimony from Dr. Smith ]
“Then the state of things which has been described, absence of washing and so on … — I must say that there was not an absence of washing … the number of articles washed was very large … I had no reason, from any communications that I had received, to believe that there was that state of filth in the hospital that it would be readily noticed.
I was perfectly aware that females can see many things, in which there might be a deficiency of cleanliness and comfort, that men do not see, and even that men have ot time to see; because the medical officers were overwhelmed with work — there might be a spot upon a sheet that a male officer would not notice, and a woman would at once.”
In order now to form an idea of what Dr. Smith considers as a "very large number of articles washed” is, of course, necessary to compare them with the number of men washed for.
The number of sick treated, although manifestly incorrect, is taken from Dr. Smith’s return, where it accompanies number of articles washed, in the same return, apparently for the purpose of comparison, and the result is as follows, viz., that, in the month of January, when 20,000 men were treated in hospital at Scutari,
11,600 shirts,
10,600 sheets,
9,200 blankets.
considered to be a “very large number of articles washed” for them, or 1 shirt to each 2 men, and less than 1 sheet and 1 blanket to each 2 men.
(p. 99 [txt] - p.264 of scan)
Then not only does she bring receipts, she brings boilers - from her own resources -
“With the view of meeting to some extent the want proper washing. Miss Nightingale established a wash-house which was provided with boilers, part from the engineer office, partly from her own resources”
I love a lady with boilers.
She mentions that without proper clothes washing facilities soldiers would recieve a poorly washed garment from someone else.
This doesn’t sound too scary nowadays but it’s useful to remember that something as simple as a body louse would carry serious disease - very much a cause of the “Fevers” which are so prominent nowadays, still present in some low-income countries.
I’m assuming “Dr. Smith” is Heywood Smith.
Uncannily similar to what happened with Mary Shelly, it sounds like a few specific authors - much after her time, late in the 20th century - took it upon themselves to quite pervasively distort her ideals in their writings.
I love reading examples of the practical effectiveness of methodical inquisition and intervention.
Florence preempts the public response to pandemic measures:
Whether the contagion or the seclusion and sanitary cordons commonly used to prevent it are most "to be dreaded” enlightened sanitary opinion will now decide. The most sensible measure adopted, however, seeing that "Sir J. Pringle,in enumerating the causes of mortality in the army, has represented Hospitals themselves as one of the chief of them,‘’was dividing the sick among a large number of small Hospitals instead of congregating them together in large buildings, which the Medical Department did not appear to be able to preserve in proper sanitary condition. The result of these various measures is stated to have been that typhus, and hospital gangrene soon disappeared, and in four months’ time the army was effective and fit for the field, with the exception of the Guards and a few other regiments.
The book is full of these kinds of success stories.
At that date the deaths on cases treated were no less than 315 per 1 ,000, or nearly one in three, and, when the sanitary works were almost completed, the deaths fell to 22 per 1,000 on cases treated.
The first part of the book is a human-factors analysis of the management of war - information flow, decisionmaking.
The absolute values are remarkable. Huge forces are stated at having 40% of the men not well enough to fight.
Like many contemporary authors, Florence talks about “bad air”. But, at least in the parts that I read, she seems to have fairly rigidly identified that the true cause of “bad air” is contagion from other sick individuals. She doesn’t succumb to the full follies of miasma theory; it’s clear that her shrewd observation has bent the theories of the time towards the cause we now know.
In the pandemic, we saw CFD analyses of flow patterns throughout hospital wards - a kind of modern spin on miasma. When she posits ideas of “pure air”, she frequently is referring to this kind of design.
She does mention sewer gases around 87. But, the snippets are, I think, highly defensible. In cases where she falls prey to miasma, it is often not on her own experience, but in quoting others:
It was stated to us that a change of wind had been observed to be attended by an accession of fever cases from among the sick, and that existing fever cases put on a more aggravated form. We found that the winds to which these results were attributed blew in the direction of the open mouths of the sewers.
There seem to be few instances where she is concerned with sewer gas in the abstract; almost invariably when this is brought up the intervention is to minimize fluid, fomites or spray.
Experience has shown that all porous substances, such as the lister of walls and ceilings, and even woodwork, absorb the emanations proceeding from the bodies and breath of the sick. After a time, the plaster becomes saturated with organic matter, and is a fresh source of impurity to the air of the ward. It hence follows that unless the walls and ceilings of Hospitals be constructed of absolutely non-absorbent materials, it is necessary, at short intervals, to use some {plication capable of neutralizing or destroying the absorbed organic matter. Of all known materials, quicklime wash is 1’ > best and cheapest for this purpose. Its effect in freshening the air in crowded wards and rooms is immediate, and it is one of the most efficacious agents for mitigating the virulence (i epidemic disease.
Comparing to a modern standard, maybe the main difference between this paragraph and the evidence-based practice is that the walls and ceilings are emphasized.
Routine cleaning of inpatient areas occurs while the patient is admitted, focuses on the patient zones and aims to remove organic material and reduce microbial contamination to provide a visually clean environment.
https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html
" On several occasions, both in the Barrack and other Hospitals, we saw the excreta of patients in utensils under the bei instead of having been at once removed."
Immediately attend to body fluid spills
Clean spills of blood or body fluids immediately, using the techniques in 4.5 Spills of blood or body fluids.
Another thrust of the book is the emergence of the modern “If it isn’t written down, it wasn’t done” mindset; having high expectations in documentation and inventory. Florence demands that storerooms be fully inventory-tracked, that medicines not disappear. She gives an example where a measure of a “bottle of medicine” could depend on on how big the soldier’s cup happened to be.
She also pays attention to patient compliance. She advocates for sheets with dosages and administration times (what might today be called a MAR sheet?).
With pharmaceuticals being in their infancy, I would imagine that this would have greater effect later as medicines developed. Still, it seems she had access to a few genuinely potent things like Quinine, Laudanum.
Compare with a modern author:
We chart dressing changes, vital signs, medication administration, patient teaching—a whole range of nursing care— because we know that documentation is vital
This want of fuel has been productive Diiuch disease, because the rations were used in an uncooked state, than which nothing is more conducive to affections of the stomach and bowels.
Clinical Medicine, including the practice of various methods of investigating the history of disease, of examining the patient, and recording his Medical history, practising Auscultation and Percussion, &c., to determine the diseased state, — the application of the microscope, — notation of progressive phases of disease on the admission-card and in the case-book.
Reading more broadly:
https://connect.springerpub.com/content/book/978-0-8261-5559-7/part/part01/chapter/ch01
Anesthetics were new and experimental. Nightingale promoted their use during the Crimean War, although the principal medical officer, her superior, opposed them.
Nightingale preferred cautious doctors and urged caution, which is discussed in Chapter 2 in the section “Heroic Medicine,” “Bad Medicine.”
Nightingale’s “restorative” approach entailed a firm rejection of the prevailing “humors” theory of Galen and other ancients
a first Scientific Skeptic.
Did you know… the College of Nursing, USask has an historical nursing artifact (medicine chest) that once belonged to Florence Nightingale?
The Nightingale medicine chest has been in many locations over the years, but the five-foot display case is currently located in the Health Sciences Building E-Wing 4th floor.