Florence Nightingale and hospital design

Portrait of Florence Nightingale ca. 1900 [College Archives RBNA P279]The year 2010 saw a number of events commemorating the centenary of Florence Nightingale's death. An exhibition at King's College London, The Thinking Nurse, set us thinking about her impact upon the design of hospitals.

After her work in the Crimean War, Florence Nightingale became a highly influential figure in the management of hospital care in the UK. In the second half of the nineteenth century and well into the twentieth, not only were the best nurses trained in the Nightingale School at St Thomas's Hospital (known as 'Nightingale Nurses' - trained in her methods and ingrained with her values) but she even had a ward-type - the 'Nightingale Ward' - named after her.

For a very long time these wards became ubiquitous in any new hospital design. Even today, they are still discernible serving as integral parts of existing health-care facilities of long-standing hospitals still in use under the National Health Service, visible from maps or in satellite views. But although these wards came to carry her name, Florence Nightingale was promoting an idea already in evolution.

Here we feature a small clutch of items held in the Foyle Special Collections at King's, all of which are associated with the Victorian debate about the best design for British hospitals.

Florence Nightingale with a dying soldier at Scutari, from: Alexis Soyer. Soyer's culinary campaign : Being historical reminiscences of the late war. With the plain art of cookery for military and civil institutions, the army, navy, public, etc., etc Alexis Soyer ... London : G. Routledge & Co, 1857 [Early Science Collection UC720 SOY]The mid-Victorian debate was rooted in public knowledge about hospitals as foci of disease. Richer people were still largely cared for at home. Most better-off households had at least one servant - many had more - and could afford private nurses and medical staff to visit. One has only to look at the casebooks of Dr John Snow, who worked as a free-lance anaesthetist in London, to see that even surgical operations were done in a domestic setting for those that could afford to hire the necessary staff.

Hospitals were for those who could not afford such care, and conditions in them were largely below the radar of general public discussion until the 1850s. There was however, constant fund-raising for the 'voluntary' charitable hospitals which accepted poorer patients with acute and curable conditions; the lying-in hospitals for maternity, and the fever hospitals which endeavoured to contain and limit the spread of infectious diseases in the community.

Then, too, there were institutions funded by compulsory local Poor Rates: the Poor Law workhouses which housed the infirm elderly, chronically sick, mentally ill, incapacitated, disabled, unmarried mothers, and the orphaned and dying poor. Dying in the workhouse was an occupational hazard of growing old among the working population, as there were no pensions, and even large families were often so depleted by early deaths and emigration that for many old people there was literally nowhere else to go. Amongst the working population, the fear of dying ‘on the parish’ was endemic.

In all kinds of healthcare and human warehousing institutions, there were epidemics, and they often produced waves of fatalities. But the subject did not really break through into broader public discussion until the cholera epidemic at Drouet’s establishment in Tooting, in 1849, in which at least 200 poor children died. These were workhouse children from various London parishes, who had been sent away from their own parents and parishes to a boarding institution where, for a fee, they were fed and housed. The process was known as ‘farming’ or ‘farming out’ the poor. The later medical report on Drouet’s establishment, and inquests on some of the children subsequently ordered by the coroner Thomas Wakley of The Lancet, showed that poor diet, overcrowding and impure air had hastened the spread of the disease. The British Medical Journalcommented at the time: ‘The farming of pauper children at starvation prices, is a system so atrocious as to demand immediate suppression’, and thought it a disgrace to the national character.

A 'Nightingale ward' at St Thomas's Hospital ca. 1910-17 [College Archives StTs ward THpp3vol4107]. This photograph shows the architecture of the ward well: the beds well apart, interspersed by windows, and the specialist heaters mid-ward, which created up-currents of hot air to aid the removal of vitiated air, and the circulation of fresh air.Cholera is of course an anomaly as an epidemic disease, in that (we now know) its most effective mode of spread is in polluted drinking water. But at that time, no-one knew for certain how it was transmitted, and the overcrowding at Drouet’s implicated impure air.

Soon after the Tooting scandal, the very high levels of mortality from infection (over 40% in some reports) at the barrack hospital in Scutari became a source of great shock when it became known. The illusion had always been that fit fighting men from the British army died gallantly in battle, but here was news of the sheer wastage of human life. The contribution of buildings to human survival was implicated when the contrast became evident between survival rates at insanitary Scutari, with its defective accommodation and polluted water, and in the prefabricated hospital pavilions at Renkioi, sent out from England to the design of Isambard Kingdom Brunel.

The 1850s was a key decade for these humanitarian and architectural concerns. In parallel, understanding was growing gradually about the mechanisms of disease-spread. A number of important pointers were beginning to indicate that what we call germs were real, material, entities. Yet there was also a great deal of scepticism and doubt about how infection or contagion actually spread. Nowadays we are aware of airborne, waterborne and foodborne diseases, germs, viruses, slow viruses and diseases carried by vectors, like mosquitoes. In the 1850s, none of this was understood… and arguments raged.

Gradually, research work undertaken by individuals in Europe and America began to confirm - from a number of different scientific angles - the age-old belief that infection was spread in air, on objects (fomites) and in breath… but even with Tyndall’s work on dust and the sterilization of air, Pasteur’s work on fermentation, Quekett’s work on microscopic objects, Hassall on food and water pollution, Lister on chemical sterilization, Koch on bacteria, and long after Gordon, Wendell Holmes and Semmelweiss had shown the infectivity of puerperal fever – there was still active debate about whether diseases were generated from within or without the body, or the soil, or somewhere else.

Despite the success of smallpox immunization, there was also no real grasp of the notion of immunity until the mid-twentieth century. The enormous variety of disease organisms was simply not understood. We should not blame the Victorians for this, the problem was – and still is – extremely complex. Even today, we are still trying to understand possible routes of infectivity for cancer, and especially for new diseases, like slow viruses CJD, BSE, and mystery post-viral illnesses like ME.

The best antidote for all these difficulties, for the mid-Victorian architect and the professional nurse, was fresh air. The ward plan with which Miss Nightingale’s name became so firmly associated was designed as a long narrow block, of limited height, with tall windows interspersed at regular intervals along both sides to allow cross-ventilation, and with space between each window for a single bed. These long ward blocks could be laid out in a variety of ground-plans, the best being regarded as oriented east/west, and placed far enough apart to allow fresh air to circulate between the blocks, vitiated air to escape, and sunlight to shine in.

The ideas which underlay their design did not spring like Athena from the head of Zeus. Their roots evolved over time, largely predating both the Tooting disaster at Drouet’s and the Crimean War, and can be traced to the work of little-known doctors and engineers who had been working on the ventilation of ships, schools, sewers and railways carriages, and to the planning of several older hospitals – especially in Paris, in Belgium, and in the United States, but also in the UK.

Miss Nightingale’s ringing endorsement of them in her famous Notes on hospitals established her association with the design. Several important pages in that work were taken from the architectural journal The Builder, whose Editor, George Godwin, was an architect with a strong interest in the role of architecture in the improvement of the public health. In 1856, while Miss Nightingale was still in the Crimea, Godwin published a series of editorials on the subject of good hospital design apropos the design of a new government hospital at Netley, near Southampton.

Some later commentators took this material to have been Miss Nightingale’s own work, because unsigned. But all editorials in The Builder were unsigned, and the voice is that of Godwin. Moreover, the architectural historian Anthony King has shown conclusively that Godwin had gained his inspiration from the work of a Manchester doctor, John Roberton, whose ideas had been formulated over many years, after very wide reading, deep concern for patients, and years of practical work in obstetrics in Manchester. Roberton had published an important paper in 1856 from a lecture he had given that year at the Manchester Statistical Society, entitled On the defects, with regard to the plan of construction and ventilation of most of our hospitals for the reception of the sick and wounded.

It is evident from what has been said, that a great many individuals from disparate disciplines were directing their thoughts to the design of hospitals in the mid-nineteenth century. The coalescence of humanitarian debate around flaws in the design of Netley, and the return of Miss Nightingale from Scutari, was a tipping-point which propelled a real change in attitudes towards healthful buildings for the care of the sick, and resulted in the wide adoption of the Nightingale plan ward as the standard.

Dr Ruth Richardson
November 2010

PLEASE NOTE: This exhibition was created for the web and is only available to view online.

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