Florence Nightingale died one hundred years ago, in August 1910. She lives on in our imaginations as an inspired nurse who passionately cared for wounded and dying soldiers during the Crimean War and then radically reshaped professional nursing as a result of the horrors she witnessed. . But the "lady with the lamp" was also a pioneering and passionate statistic. She understood the influential role of statistics and used them to support her convictions. So, to commemorate her on the centenary of her death, let's take a look at her life and her work as a statistician.
a privileged intellect
A young Florence Nightingale
Florence Nightingale was born in 1820 into a liberal-humanitarian family. Her solid upper-middle-class family were intellectually adventurous freethinkers who supported women's education. Various tutors taught Florence and her older sister, Parthenope, arithmetic, botany, French, and geography, as well as drawing and piano. Her father, William Edward Nightingale, a graduate of Trinity College, Cambridge, gave them a college education at home, teaching them mathematics, Latin, and Greek. After Florence finally began this rigorous education at age 12, she wrote that "I have the greatest desire to acquire. For seven years of my life I have thought of little more than cultivating my intellect." Nightingale's education nurtured and stimulated her enthusiasm for mathematics. At the age of nine, she already organized the data of the fruits and vegetables in the garden in numerical tables.
The early years of Florence were not only privileged in an intellectual sense. After his father inherited a large fortune from his uncle, he settled into the life of a country gentleman. The family has a 14-bedroom house in Lee Hurst in Derbyshire (now Derbyshire Royal Infirmary) where they will not see and a Georgian mansion in Embley Park in Hampshire (now Hampshire Collegiate School) that comes with 100 acres, where they live for the most part of the year. They also had rooms in Mayfair for the spring and autumn seasons in London. The family traveled the continent attending operas in Italy and socializing in Paris.
In these hot-headed circles, Nightingale met a number of Victorian literati, including the mathematicianCharles Babbage🇧🇷 I was fascinated by numbers from an early age and by the time I was twenty I wanted more math lessons. She began receiving two-hour instructions from a Cambridge-trained mathematician. Her mathematical aptitude fueled her predilection for statistics. In the mornings Nightingale studied material on public health and hospital statistics and eventually amassed a formidable body of statistical information. Her pleasure was so immense that she found the sight of a long column of figures "perfectly invigorating."
Nightingale was not alone in her passion for numbers, as the Victorians were avid statisticians. The word "statistics" was introduced into the English language in 1798 by the Scottish landownerMr John Sinclairdon't giveScottish Statistical Account🇧🇷 Initially, politicians were interested in state issues, such as land ownership and population, mainly to determine the number of military responsibilities and set tax rates. But in the late 1820s and early 1830s, parliamentarians embraced the new fields of vital and social statistics. With the help of the newly developed steam printing press and railroad, state agencies, organizations, and individuals could collect and disseminate colossal amounts of data, and use it to study mass phenomena such as poverty, disease, and suicide. This, in turn, led to the wide dissemination of statistical information by the middle classes, who provided lectures, health pamphlets, and medical advice in the popular press, self-help books, and novels. Journalists, social reformers, and parliamentarians used the statistics to bring down their opponents.
Florence Nightingale in the 1850s
Many of the early Victorian statisticians saw statistics as more than just collecting social data or a set of techniques. For them, statistics was "the new study of man in society", which would allow them to make predictions about the social conditions of the poor and working classes. health reformers and vital statisticians,Guillermo FarrmiEdwin Chadwick, carried out statistical analyses, which led to the creation of the Public Health Acts to improve the harmful conditions of the poor, especially in industrialized cities, where dangerous 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 care for the sick and remembered that her dreams were about hospitals; she thought that these dreams symbolized that "God called Him that way". This vocation meant, to her relief, that she would not have to be bound by society and the stifling restrictions of an upper-middle-class Victorian marriage. Divine inspiration gave him the opportunity to develop her intellectual activities. When she was twenty years old, she rejected the supernatural and miraculous foundations of Christianity and longed for the coming of a female Christ.
Nightingale proposed a form of religion in which human beings actively contributed to the realization of God's law through their work. Statistical laws, by revealing patterns in the world around us, had the power to reveal God's providential design: "To understand God's thoughts, we must study statistics, for they are the measure of his purpose." This ideology, which had its roots in the ideas of the 18th century clergyman and natural philosopher.Guillermo Derham, made the statistical study of natural phenomena a moral imperative and a religious duty: it was the surest means of knowing the divine plan and then acting in accordance with it. Furthermore, his religious perspective transformed the study of statistics from a slightly questionable pursuit for a lady into a legitimate pursuit within Victorian religious culture.
Embley Park, one of the Nightingale family homes. Image:Dmartin.
the crimean war
In October 1853, the conflict between Russia and an alliance of European countries over the decline of the Ottoman Empire escalated into a full-blown war, fought in the Turkish region of Crimea. Nightingale offered her services and was eventually asked by her old friend and Secretary of War, Sidney Herbert, to be "Superintendent of the Women's Nursing Establishment at the English General Military Hospitals in Turkey" for British troops fighting in the Crimean War. . She brought with her a group of thirty-eight nurses.
As soon as Nightingale arrived in the Crimea, she found herself in utter chaos in the Scutari hospital: there were no blankets, beds, furniture, food, or kitchen utensils, and rats and fleas were everywhere. Nightingale was appalled not only by the appalling lack of sanitation, but also by the statistical neglect she found in military hospitals. The records were in a deplorable state, as none of them had been consistently maintained. Furthermore, there was a complete lack of coordination between the hospitals and no standardized or consistent reporting. Each hospital had its own system of nomenclature and classification of diseases, which were later tabulated in different files, making comparisons impossible. Even the death toll was not exact; hundreds of men were buried, but their deaths were not recorded.
One of the first books Nightingale wrote,Notes on issues affecting the health, efficiency and hospital administration of the British Army(1858), provided statistical evidence showing how much of the mortality was due to conditions in hospitals. Although the use of the word "notes" might suggest that it is a small collection of his thoughts, the book is actually 850 pages long. He worked endlessly on this book and "sometimes for twenty-four hours out of twenty-four", finishing it in a record two years. In it, he compared peacetime army death rates with the civilian rate and concluded that "our soldiers are ready to die in barracks."
The statistical data collected by Nightingale during the first seven months of the Crimean campaign was later analyzed with the help of William Farr, Britain's leading statistician at the time. Farr was hired to compile the statistical records for the General Record Office, which records vital information such as births, deaths, and marriages, shortly after its creation in 1832. Farr bequeathed with his colleague, the epidemiologistThomas Rowe Edmonds, was "the creation of the modern discipline of vital statistics and the use of these statistics to assess public health and well-being".
a statistical association
It was Nightingale's close collaboration with Farr that led to some of his most important statistical work. When they met at a dinner at the home of Colonel Alexander Tulloch in the fall of 1856, she had just returned from the Crimea as a national hero and recognized that if such suffering never occurred again, the Army Medical Service and, if necessary, the army itself. It must be reformed. She was about to start her campaign for reform in the Army Medical Department when they met. Farr was sympathetic to her ideas. They began a correspondence that would last twenty years, writing some four hundred letters between them.
Nightingale at the Scutari Hospital, from a lithograph of 1856.
Queen Victoria summoned Florence Nightingale to Balmoral a week after her return from the Crimea. She was eager to meet the Queen and Prince Albert, an emphatic supporter and patron of science and statistics, and she successfully won her support for a Royal Commission on army health. On her recommendation, Farr became a member of it, as did Army physician and statistician Thomas Graham Balfour, FRS.
Nightingale relied on Farr for analysis of army reform death and sick pay (although he became proficient in statistical analysis on his own) and for some of his tactics of using mortality statistics as argumentative tools. Farr benefited from Nightingale's knowledge of nursing practices in large 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 neighbor in Embley Park, Lord Palmerston, became Prime Minister during the Crimea. War. His twin desires to see reform in the Army Medical Department led to a rewarding and productive professional relationship. They collaborated in the elaboration of hospital statistics for their booksNotes on hospitals(1859) miIntroductory Notes on Detention Institutions(1871).
die in the barracks
Statistical evidence of Nightingale death rates in civilian and military hospitals showed that unsanitary living conditions leading to endemic diseases such as typhus, typhoid, and cholera were, in fact, the main reason for the death rates. so high. Furthermore, data from the Crimea revealed that during the war more soldiers died from these diseases and unsanitary living conditions than in London during the plague of 1665. Nightingale and Farr found that there was a 60% annual mortality rate for these soldiers. . Between the ages of 25 and 35, the death rate in military hospitals was twice that of civilian life. Later, Nightingale and Farr showed that three times as many soldiers died at home and abroad in peacetime than in war because of overcrowding and filth in industrialized cities.
Nightingale wrote a report based on army medical statistics and sent it as a confidential communication to the War Office and the Army Medical Department. Eventually, the Army adopted Farr's disease classification, with modifications. One of the main results of the statistical aspect of the Royal Commission was the creation of an Army Medical Statistics department. The Surgeon General and President of the Statistical Society of London (1888-1890), Thomas Graham Balfour, carried out statistical analyzes of material relating to the Army Sanitary Commission of 1857 and its 1858 report at the new Medical Statistics Office of the Army that Nightingale and Farr established. In this capacity he compiled the first four volumes ofBritish Army Statistics.
The polar area chart
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 graphics should be directed at those who were not accustomed to looking at statistics or life tables. Nightingale developed a talent for creating graphic methods, including his well-knownpolar area chart, which was similar to the pie chart created by the Scottish economistGuillermo Playfairin 1801. This polar area chart is the equivalent of a modern pie histogram, used to illustrate grouped cyclical data. It was cut into twelve equal angles, each slice representing a month of the year, which, as you can see, revealed changes over time. (The graph is often mistakenly referred to asthe petimetre, although Nightingale herself used the term for the specially printed copies of her pamphlet,British Army Mortality, which contained the graph.)
Nightingale's most famous polar area diagram:Diagram of causes of death in the eastern army..
Looking at the polar area plot, we can see that the area of each colored slice, measured from the center, is proportional to the statistic it represents. The blue outer wedges represent deaths from contagious diseases such as cholera and typhus. The central red wedges show deaths from wounds. The black wedges in the middle represent deaths from all other causes. Had this pace continued and troops not been frequently replaced, the disease alone would have killed the entire British army in the Crimea. Nightingale's painting not only dramatized the extent of needless deaths among soldiers during the Crimean War, but was also used as a tool to persuade the government and medical establishment that the deaths could be prevented if health reforms were implemented. health in military and civilian hospitals.
hospitals at home
Nightingale's spirit of reform was not limited to military hospitals. His investigation of London hospital statistics in 1858 confirmed that record-keeping needed to be reviewed. He found that, beyond the simple sloppiness in the collection of statistical information, there was a complete lack of scientific coordination. For example, hospital statistics provided very little useful information on the average duration of hospital treatment or the proportion of patients who recovered compared to those who died.
As Superintendent of Statistics at the General Record Office, Farr was deeply concerned that there were so many inconsistencies in the reporting of deaths in English hospitals, which did not use a standard system for classifying diseases. A Committee of the Statistical Society was created for the campaign to maintain hospital statistics in a uniform framework that would allow comparative studies to be carried out. 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, he convinced London and some Parisian hospitals to comply with his forms. In 1861, the results of these hospital reports were published in theJournal of the Statistical Society of Londonin 1862.
Nightingale's skills in reporting and illustrating statistical data for health reform in military and civilian hospitals led William Farr to appoint her as the first woman elected to the Statistical Society of London in October 1858. In the same year, she also she was elected to the Statistical Congress, and was made an honorary foreign member of the American Statistical Association in 1874.
By the end of the Victorian era, politicians could no longer ignore the overwhelmingly important role of statistics in government, especially since many of them were inconsistent and needed to be standardized. However, this did not happen on a large scale until 1918, after the Great War, due to the work that Karl Pearson and his colleagues and students carried out during the war. Another of Nightingale's ideas, to create a department of statistics at Oxford University, was partially realized shortly after his death, when a Department of Applied Statistics was created at University College London in 1911. More than a century would pass before that Oxford University A renamed its Department of Biomathematics the Department of Applied Statistics in 1988.
While Florence Nightingale is duly recognized and highly revered for her role in reforming nursing in the mid-19th century, she clearly deserves more credit than she received for revolutionizing nursing through the use of statistics. Her statistical research work led to a decline in the many preventable deaths that occurred throughout the 19th century in English civilian and military hospitals. Her pioneering use of evidence-based medicine has become a powerful guide to garnering support from the medical community and government.
Nightingale's innovations and statistical achievements are as important in the 21st century as they were in the mid-19th century. Certainly making statistical data accessible through diagrams and graphs is imperative for the medical sciences. Additionally, the development of randomized controlled trials in the mid-20th century and the growing reliance on evidence-based medicine in the 21st century require an understanding of contemporary statistical methods, which will enable nurses to make informed decisions about medical research. current and their patients. .
About this article
This is a modified version of an article that first appeared onradical 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 statistical innovations and the life of the late Victorian mathematician.Karl Pearson🇧🇷 Her longstanding interest in the role of Victorian vital statistics in the promulgation of public health in the 19th century 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. His most recent book isPresentation of statistics: a graphical guide, reviewedaboutThe majority, and is currently writing a book on the life and statistical work of Florence Nightingale.