46 SECTION II Evolution of Nursing Theory: Essential Influences
punctuality and care in the administration of diet, of
each or of all of these.
—Florence Nightingale,Notes on Nursing
(1860/1969, p. 8)
The Medical Milieu
To gain a better understanding of Nightingale’s
ideas on nursing, one must enter the peculiar world
of nineteenth-century medicine and its views on
health and disease. Considerable new medical
knowledge had been gained by 1800. Gross
anatomy was well known; chemistry promised to
throw light on various body processes. Vaccination
against smallpox existed. There were some estab-
lished drugs in the pharmacopoeia: cinchona bark,
digitalis, and mercury. Certain major diseases, such
as leprosy and the bubonic plague had almost dis-
appeared. The crude death rate in western Europe
was falling, largely related to decreasing infant mor-
tality as a result of improvement in hygiene and
standard of living (Ackernecht, 1982; Shyrock,
1959).
Yet physicians at the turn of the century, in 1800,
still had only the vaguest notion of diagnosis.
Speculative philosophies continued to dominate
medical thought, although inroads and assaults
continued to be made that eventually gave way to a
new outlook on the nature of disease: from belief in
general states common to all illnesses to an under-
standing of disease-specificity resultant symptoma-
tology. It was this shift in thought—a paradigm
shift of the first order—that gave us the triumph of
twentieth-century medicine, with all its attendant
glories and concurrent sterility.
The eighteenth century was host to two major
traditions or paradigms in the healing arts: one
based on “empirics” or “experience,” trial and error,
with an emphasis on curative remedies; the other
based on Hippocratic notions and learning.
Evidence of both these trends persisted into
the nineteeth century and can be found in
Nightingale’s philosophy.
Consistent with the speculative and philosophi-
cal nature of her superior education (Barritt, 1973),
Nightingale, like many of the physicians of her
time, continued to emphatically disavow the reality
of specific states of disease. She insisted on a
view of sickness as an “adjective,” not a substantive
noun. Sickness was not an “entity” somehow sepa-
rable from the body. Consistent with her more ho-
listic view, sickness was an aspect or quality of
the body as a whole. Some physicians, as she
phrased it, taught that diseases were like cats and
dogs, distinct species necessarily descended from
other cats and dogs. She found such views mislead-
ing (Nightingale, 1860/1969).
At this point in time, in the mid-nineteenth cen-
tury, there were two competing theories regarding
the nature and origin of disease. One view was
known as “contagionism,” postulating that some
diseases were communicable, spread via commerce
and population migration. The strategic conse-
quences of this explanatory model was quarantine,
and its attendant bureaucracy aimed at shutting
down commerce and trade to keep disease away
from noninfected areas. To the new and rapidly
emerging merchant classes, quarantine represented
government interference and control (Ackernecht,
1982; Arnstein, 1988).
The second school of thought on the nature and
origin of disease, of which Nightingale was an ar-
dent champion, was known as “anticontagionism.”
It postulated that disease resulted from local envi-
ronmental sources and arose out of “miasmas”—
clouds of rotting filth and matter, activated by a
variety of things such as meteorologic conditions
(note the similarity to elements of water, fire, air,
and earth on humors); the filth must be eliminated
from localareas to prevent the spread of disease.
Commerce and “infected” individuals were left
alone (Rosenberg, 1979).
William Farr, another Nightingale associate and
avid anticontagionist, was Britain’s statistical super-
intendent of the General Register Office. Farr cate-
gorized epidemic and infectious diseases as
zygomatic,meaning pertaining to or caused by the
process of fermentation. The debate as to whether
fermentation was a chemical process or a “vitalis-
tic” one had been raging for some time (Swazey &
Reed, 1978). The familiarity of the process of fer-
mentation helps to explain its appeal. Anyone who
had seen bread rise could immediately grasp how a
minute amount of some contaminating substance
could in turn “pollute” the entire atmosphere, the
very air that was breathed. What was at issue was
the specificity of the contaminating substance.
Nightingale, and the anticontagionists, endorsed
the position that a “sufficiently intense level of at-
mospheric contamination could induce both en-
demic and epidemic ills in the crowded hospital