Florence Nightingale died a hundred years ago, in August
1910. She survives in our imaginations as an inspired nurse, who cared
passionately for injured and dying soldiers during the Crimean war, and
then radically reformed professional nursing as a result of the horrors
she witnessed. But the "lady with the lamp" was also a pioneering and
passionate statistician. She understood the influential role of
statistics and used them to support her convictions. So to commemorate
her on the centenary of her death, we'll have a look at her life and
work as a statistician.
A privileged intellect
A young Florence Nightingale
Florence Nightingale was born in 1820 into a liberal-humanitarian
household. Her solidly upper-middle-class family were intellectually
adventurous free thinkers who endorsed women's education. Various
tutors taught Florence and her elder sister Parthenope arithmetic,
botany, French and geography, as well as drawing and piano. Their
father, William Edward Nightingale, a graduate of Trinity College,
Cambridge, gave them a university education at home, teaching them
mathematics, Latin and Greek. After Florence had finally begun this
rigorous education at the age of 12, she wrote that "I have the most
enormous desire of acquiring. For seven years of my life I thought of
little but cultivating my intellect." Nightingale's upbringing thus
nourished and stimulated her enthusiasm of mathematics. By the time she
was nine years old, she was already organising data from garden fruits
and vegetables in numerical tables.
Florence's early life was privileged not just in an intellectual
sense. After her father inherited an enormous fortune from his uncle, he
settled down to the life of a country gentleman. The family had a
14-bedroom house in Lee Hurst in Derbyshire (now the Derbyshire Royal
Infirmary) where they stayed in the summer and a Georgian mansion in
Embley Park in Hampshire (now the Hampshire Collegiate School) that came
with 100 acres, where they lived most of the year. They also had rooms
in Mayfair for the spring and autumn London seasons. The family toured
the continent attending operas in Italy and socialising in Paris.
In these exalted circles Nightingale met a number of Victorian literati, including the mathematician
Charles Babbage.
She was fascinated with numbers at an early age and at twenty wanted
further tuition in mathematics. She began receiving two-hour
instructions from a Cambridge-trained mathematician. Her mathematical
aptitude fuelled her predilection for statistics. In the mornings
Nightingale would study material on the statistics of public health and
hospitals, and eventually she accumulated a formidable array of
statistical information. Her enjoyment was so immense, she found the
sight of a long column of figures "perfectly reviving".
Victorian statistics
Nightingale was not alone in her passion for numbers, for the
Victorians were avid statisticians. The word "statistics" had been
introduced to the English language in 1798 by the Scottish landowner
Sir John Sinclair in his
Statistical Account of Scotland.
Initially, politicians were interested in matters of the state, such as
land ownership and the population, mainly to determine the numbers who
were liable for the military and to fix the rates of taxation. But by
the late 1820s and early 1830s, MPs embraced the newer fields of vital
and social statistics. With the aid of the newly developed steam
printing press and railway, colossal amounts of data could be collated
and disseminated by state agencies, organisations and individuals, and
used to study mass phenomena including poverty, disease and suicide.
This, in turn, led to a wide-spread dissemination of statistical
information by the middle-classes who provided lectures, health tracts
and medical advice in the popular press, self-help books and novels.
Journalists, social reformers and MPs used statistics to floor their
opponents.
Florence Nightingale in the 1850s
Many of the early Victorian statisticians regarded statistics as more
than the mere collection of social data or a set of techniques. For
them statistics was "the new study of man in society", which would
enable them to make predictions about the social conditions of the poor
and the labouring classes. The health reformers and vital
statisticians,
William Farr and
Edwin Chadwick,
undertook statistical analyses, which led to the creation of the Public
Health Acts to improve the deleterious circumstances of the poor,
especially in the industrialised cities where perilous living conditions
threatened the lives of so many Victorians.
Statistics as the word of God
Perhaps surprisingly to a modern mind, Florence's own statistical
ideas were an integral part of her religious beliefs. As a child she
had a desire to nurse the sick and remembered that her daydreams were
all about hospitals; she thought these daydreams symbolised that "God
had called her to Him in that way". This calling meant, much to her
relief, that she would not have to be tied to a life of society and the
stifling constraints of a Victorian upper-middle class marriage. The
divine inspiration gave her the opportunity to develop her intellectual
pursuits. By the time she was in her twenties, she had rejected the
supernatural and miraculous underpinnings of Christianity, and awaited
the coming of a female Christ.
Embley Park, one of Nightingale's family homes. Image:
Dmartin.
Nightingale proposed a form of religion in which human beings
actively contributed to the realisation of God's law through their work.
Statistical laws, since they reveal patterns in the world around us,
had the power to reveal God's providential plan: "to understand God's
thoughts, we must study statistics for these are the measure of His
purpose". This ideology, which was rooted in the ideas of the
eighteenth-century clergyman and natural philosopher
William Derham,
turned the statistical study of natural phenomena into a moral
imperative and religious duty: it was the surest way of learning the
divine plan and then acting in accordance with it. Moreover, her
religious outlook turned the study of statistics from a slightly
questionable activity for a lady into a legitimate pursuit within a
religious Victorian culture.
The Crimean war
In October 1853 the conflict between Russia and an alliance of
European countries over the declining Ottoman empire turned into a
fully-fledged war, fought in the Turkish region of Crimea. Nightingale
volunteered her services and was eventually asked by her lifelong friend
and Secretary at War, Sidney Herbert, to be "Superintendent of the
female nursing establishment in the English General Military Hospitals
in Turkey" for the British troops fighting in the Crimean war. She took a
group of thirty-eight nurses with her.
Nightingale at the Scutari hospital, from an 1856 lithograph.
Once Nightingale arrived in the Crimea, she found herself amid utter
chaos in the hospital at Scutari: there were no blankets, beds,
furniture, food, or cooking utensils, and there were rats and fleas
everywhere. Nightingale was dismayed not only by the appalling lack of
sanitation, but also the statistical carelessness she found in the
military hospitals. The medical records were in a deplorable state, as
none had been maintained in a uniform manner. Moreover, there was a
complete lack of co-ordination among hospitals and no standardised or
consistent reporting. Each hospital had its own system of naming and
classifying diseases, which were then tabulated on different forms,
making comparisons impossible. Even the number of deaths was not
accurate; hundreds of men had been buried, but their deaths were not
recorded.
One of the first books Nightingale wrote,
Notes on Matters Affecting Health, Efficiency, and Hospital Administration of the British Army
(1858), provided statistical evidence that showed just how much of the
mortality was due to the conditions of the hospitals. Whilst her use of
the word "notes" might suggest that it is a small collection of her
thoughts, the book is, in fact, 850 pages long. She worked incessantly
on this book and "sometimes for twenty-four hours out of 24", finishing
it in a record-breaking two years. In it she compared the death rates
of the army in peacetime with the civilian rate and concluded that, "our
soldiers are enlisted to die in barracks".
The statistical data Nightingale collected during the first seven
months of the Crimean campaign were later analysed with the help of
William Farr, Britain's foremost statistician at the time. Farr had been
recruited to compile the statistical records of the General Register
Office, which records vital information such as births, deaths and
marriages, shortly after it was first set up in 1832. His legacy with
his colleague, the epidemiologist
Thomas Rowe Edmonds,
was "the creation of the modern discipline of vital statistics and
using these statistics to assess public health and welfare".
A statistical partnership
It was Nightingale's close collaboration with Farr that led to some
of her most important statistical work. When they met at a dinner party
at the home of Colonel Alexander Tulloch in the autumn of 1856, she had
just returned from the Crimea a national heroine and recognised that if
such suffering were never to happen again, the Army Medical Service, and
if necessary the army itself, must be reformed. She was about to begin
her campaign for reform in the Army Medical Department when they met.
Farr was sympathetic to her ideas. They began a correspondence that
would continue for twenty years, writing some four hundred letters
between them.
William Farr in 1870.
Queen Victoria summoned Florence Nightingale to Balmoral the week
after she returned from the Crimea. She was keen to meet The Queen and
Prince Albert, an emphatic supporter and patron of science and
statistics, and she successfully procured their support for a Royal
Commission on the health of the army. On her recommendation Farr was
appointed a member, as was the army doctor and statistician, Thomas
Graham Balfour, FRS.
Nightingale relied on Farr for the analysis of the army reform
returns of death and disease (though she did eventually become competent
at undertaking statistical analyses on her own), and for some of his
tactics of using mortality statistics as argumentative tools. Farr
benefited from Nightingale's knowledge of nursing practices in major
hospitals and her politically influential connections — her maternal
grandfather sat in the House of Commons for nearly 50 years as an
abolitionist, and her family's neighbour at Embley Park, Lord
Palmerston, became Prime Minister during the Crimean War. Their twinned
desires to see reforms in the Army Medical Department led to a
fulfilling and productive professional relationship. They collaborated
in the preparation of hospital statistics for her books
Notes on Hospitals (1859) and
Introductory Notes on Lying-in Institutions (1871).
Dying in the barracks
The statistical evidence from Nightingale's mortality rates in
civilian and military hospitals showed that unsanitary living
conditions leading to endemic diseases such as typhus, typhoid and
cholera were indeed the principal reason for such high mortality rates.
Moreover, the Crimean data revealed that during the war more troops
died from these diseases and unsanitary living conditions than in London
during the plague of 1655. Nightingale and Farr discovered there was an
annual mortality rate of 60% for these soldiers. Between the ages of
25 and 35, the mortality rate in military hospitals was double that in
civilian life.
Later on, Nightingale and Farr demonstrated that three times as many
soldiers died at home and abroad during peacetime than when they were at
war because of overcrowding and filth in the industrialised cities.
Nightingale wrote a report based on the army medical statistics and
sent it as a confidential communication to the War Office and Army
Medical Department. Eventually, the army adopted Farr's classification
of disease, with modification. One of the main outcomes of the
statistical aspect of the Royal Commission was the creation of a
department of Army Medical Statistics. The Surgeon-General and President
of the Statistical Society of London (from 1888 to 1890), Thomas Graham
Balfour, undertook statistical analyses of material relating to the
Army Sanitary Commission of 1857 and its report of 1858. A year later he
was appointed to work in the new Army Medical Statistics Department
that Nightingale and Farr established. In this capacity, he compiled the
first four volumes of
Statistics of the British Army.
The polar area graph
Farr was one of the first statisticians to make extensive use of
circular diagrams and other pictorial aids. Like Nightingale, Farr
understood that the use of visual aids and graphs should be aimed at
those who were not accustomed to looking at statistical data or life
tables. Nightingale developed a flair for devising graphic methods,
including her well-known
polar area graph, which was similar to the pie chart created by the Scottish economist
William Playfair
in 1801. This polar area graph is equivalent to a modern circular
histogram, used for illustrating grouped cyclic data. It was cut into
twelve equal angles, where each slice represented one month of the year,
which, as you can see, revealed changes over time. (The graph is often
mistakenly referred to as
the coxcomb, although Nightingale herself used the term for specially printed copies of her booklet,
Mortality of the British Army, which contained the graph.)
Nightingale's most famous polar area diagrams:
Diagram of the causes of mortality in the army in the east.
If we look at the polar area graph, we can see that the area of each
coloured wedge, measured from the centre, is in proportion to the
statistic it represents. The blue outer wedges represent the deaths from
contagious diseases, such as cholera and typhus. The central red wedges
show the deaths from wounds. The black wedges in between represent
deaths from all other causes. If this rate had continued, and troops had
not been replaced frequently, then disease alone would have killed the
entire British Army in the Crimea. Nightingale's graph not only
dramatised the extent of the needless deaths among the soldiers during
the Crimean War, but it was used as a tool to persuade the government
and medical profession that deaths were preventable if sanitation
reforms were implemented in military and civilian hospitals.
Hospitals at home
Nightingale's reformatory spirit did not restrict itself to military
hospitals. Her investigation of London's hospital statistics in 1858
confirmed that the record-keeping needed to be revised. She found that
in addition to just simple carelessness in the collation of statistical
information, there was a complete lack of scientific coordination. For
example, hospital statistics gave very little useful information on the
average duration of hospital treatment or on the proportion of patients
who recovered compared with those who died.
As Statistical Superintendent to the General Registrar Office, Farr
had found it deeply troubling that there were so many inconsistencies in
the reporting of deaths in English hospitals, which did not use a
standard system to classify disease. A Statistical Society Committee was
set up for the campaign to keep hospital statistics in a uniform scheme
that would permit comparative studies. Nightingale proposed that the
same medical forms be used in all hospitals. After the International
Statistical Congress, held in London in 1860, endorsed Nightingale's
plans she convinced London and a few Parisian hospitals to comply with
her forms. In 1861 the results of these hospital reports were published
in the
Journal of the Statistical Society of London in 1862.
Nightingale's skills in reporting and illustrating statistical data
for sanitary reform in military and civilian hospitals led William Farr
to nominate her as the first woman to be elected a Fellow of the
Statistical Society of London in October 1858. In the same year she was
also elected to the Statistical Congress, and she was made an honorary
foreign member of the American Statistical Association in 1874.
Nightingale's legacy
By the end of the Victorian era politicians could no longer afford to
ignore the overwhelming importance of the role of statistics in
government, especially as much of which was inconsistent and needed to
be standardised. However, this did not happen on a large scale until
1918, in the aftermath of the Great War, owing to the work Karl
Pearson, his colleagues and students undertook during the war. Another
of Nightingale's ideas, to set up a department of statistics at the
University of Oxford, found partial fruition just after her death, when a
Department of Applied Statistics was set up at University College
London in 1911. More than a century would pass before Oxford
University renamed their Department of Biomathematics the Department of
Applied Statistics in 1988.
Although Florence Nightingale is rightly acknowledged and highly
venerated for her role in reforming nursing in the mid-nineteenth
century, she clearly deserves more recognition than she has received for
revolutionising nursing through her use of statistics. Her
investigative statistical work led to a decline in the many preventable
deaths that occurred throughout the nineteenth century in English
military and civilian hospitals. Her pioneering use of evidence-based
medicine became a powerful directive in garnering support from the
medical community and the government.
Nightingale's statistical innovations and achievements are as
important in the twenty-first century as they were in the mid-nineteenth
century. Certainly, making statistical data accessible by using
diagrams and charts is imperative for the medical sciences. Moreover,
the development of randomised clinical trials in the mid-twentieth
century and the growing reliance on evidence-based medicine in the
twenty-first century demand an understanding of contemporary statistical
methods, which will enable nurses to make informed decisions about
current medical research and their patients.
About this article
This is a modified version of an article which first appeared in
Radical Statistics, 102 (2010) pp 17-32.
Eileen Magnello trained and worked as a statistician before doing her
PhD in the history of science at St Antony's College, Oxford
University. She has published extensively on the statistical innovations
and the life of the late-Victorian mathematician
Karl Pearson.
Her long-standing interest on the role of Victorian vital statistics in
the promulgation of public health in the nineteen century has led to
her interest in Florence Nightingale's use of statistics in her
development of the nursing profession. Magnello is a Research Fellow in
the Department of Science and Technology Studies at University College
London. Her most recent book is
Introducing statistics: A graphic guide, reviewed on
Plus, and she is currently writing a book on the statistical life and work of Florence Nightingale.
