She saved the lives of thousands of soldiers in the Crimea and was one of the founders of modern medical care. She was also a pioneer in the uses of social statistics and in their graphical representation
|regards to Constantinople, the Orthodox holy city; one of the proximate causes of the Crimean War was the Russian demand that it be given a protectorate over the Orthodox subjects of the Turkish sultan.) The allied forces scored a quick victory at the Battle of the Alma River on September 20, and then began a siege of the Russian naval base at Sevastopol. Public jubilation||in Britain soon turned to dismay when the Crimean correspondent of The Times, William Howard Russell, reported that sick and wounded British soldiers were being left to die without medical attention. Not only were there too few surgeons and “not even linen to make bandages” but also there was not a single qualified nurse in the British military hospital at Scutari|| (near Constantinople). The French, on the other
hand, had sent 50 Sisters of Mercy to the Crimea.
It was a golden opportunity for the ambitious Nightingale. She immediately wrote to a longtime friend, Sidney Herbert, the “Secretary at War,” to volun-
|FLORENCE NIGHTINGALE is pictured in a photograph taken in later life. Beginning soon after her return from the Crimea in 1856 until her death in 1910 at the age of 90, she lived as au invalid, large-||ly confined to her bedroom. Her illness may not have been organic, but it did not prevent her from excising her influence by receiving frequent visitors and by maintaining an extensive correspondence.|
|teer her services. As it happened, a letter
from Herbert was already on its way to her, asking her to recruit a corps
of trained nurses and lead them to Scutari. When Nightingale left for Turkey
on October 21, 1854, accompanied by 38 nurses, she had the official backing
of the government (although not of the army) and, perhaps more important,
the private financial support of a special fund raised by The Times. Besides
making her an international heroine, her work in the Crimea and the conditions
she saw there were to determine her mission for the rest of her life.
The conditions Nightingale and her party found when they arrived at Scutari on November 5, the day of the major Battle of Inkerman, were appalling. The hospital barracks was infested with fleas and rats. Under the buildings, as a commission of inquiry later reported, “were sewers.., loaded with filth... through which the wind blew sewer air up the pipes of numerous open privies into the corridors and wards where the sick were lying” on straw mats, in a state of overcrowding that got even worse after Inkerman. The canvas sheets, according to Nightingale, were “so coarse that the wounded men begged to be left in their blankets”; moreover, the laundry was done in cold water, with the result that many linens returned as clean were so "verminous” that they had to be destroyed. Essential surgical and medical supplies were lacking, or their distribution was blocked by military red tape.
These were the conditions that awaited patients arriving at Scutari after a slow sea voyage across the Black Sea and through the Bosporus, weak and emaciated, suffering from frostbite and dysentery as well as from their wounds. In fact, the resulting epidemics of cholera and typhus, and not the injuries themselves, caused the greatest loss of life at Scutari. In February, 1855, the mortality rate at the hospital was 42.7 percent of the cases treated.
In her efforts to establish an effective hospital in Turkey, Nightingale showed real skill as an administrator. At every step, however, she was hampered by the military authorities, who resisted any change that might seem to be a concession of their own errors or incompetence. The military men resented the fact that Nightingale’s authority was independent of the armed services, that she was a civilian and—far worse—that she was a woman. Hostility to her mission ran so high that at first her nurses were not allowed on the wards. Even after she had achieved greater acceptance she had to struggle against petty officials, such as a supply officer who refused to distribute badly needed shirts from his store until the entire shipment of 27,000 could be inspected by an official of the Board of Survey.
In the face of such impediments it
barracks and hospital, even in peacetime. It could be ended only by instituting throughout the Army Medical Service the same sanitary reforms that had saved so many lives at Scutari. This was the task Nightingale set herself.
How could she convince people of the need for reform? Nightingale saw that the most compelling argument would be statistical. The idea of using statistics for such a purpose to analyze social
conditions and the effectiveness of public policy is commonplace today, but at that time it was not. The science of social statistics was in its infancy, and in promoting the cause of medical reform Nightingale became a promoter of the new tool as well.
Seen simply as the collection of numerical data, statistics have a long history (going back at least to
the Book of Numbers of the Old Testament), but the analysis of such data is only as old as the scientific
|revolution of the 17th century. Early attempts to analyze data on social phenomena were hampered by inadequacies both in the data themselves and in the mathematical tools of analysis. According to the historian of statistics Helen M. Walker, the rise of modern statistics in the 19th century had three roots: the development of the mathematical theory of probability, the emer|
|LINE DIAGRAMS from the Royal Commission’s
report compare conditions in the army to those in civilian life. Mortality
in the peacetime army in Britain was nearly twice as high as it was among
civilians (top). In the Crimean War “zymotic” diseases were the main causes
of death and were far more prevalent than they were in England (bottom).
|the top diagram are percentages; those in the bottom one are per 1,000. The report led to the adoption of a sanitary code for the army and to a series of physical improvements in military buildings. Like other diagrams in report, these are examples of Nightingale’s innovative approach to representation of statistics.|
|gence of the modern state with its agencies for collecting
information on its citizens and their activities, and the theoretical interest
of political economists in finding causes for human social behaviors. These
“three movements,” Walker wrote, were pulled together in the career of
the mid-l9th-century Belgian astronomer-statistician Lambert-Adolphe-Jacques
Quételet, widely regarded as the founder of modern social statistics.
In 1841 Quételet organized Belgium’s central statistical bureau,
which became a model for similar agencies in other countries, and his international
leadership in statistical research continued until his death in 1874.
scholars trying to make a science out of the study of human behavior faced
a dilemma: the model science of those days was classical physics, with
its deterministic laws describing natural phenomena, but human behavior
seemed individual and indeterminate. Quételet’s resolution of the
problem bypassed the question of the individual with the concept of an
“average man.” He showed that whereas there are no laws determining individual
behavior, there are regularities in the attributes and behavior of groups,
and that these regularities could be characterized mathematically by the
laws of probability. Quételet was convinced that even menial and
moral traits, if only they could be measured accurately, would also follow
regular laws of statistical distribution.
|those “addled heads” who would use the yearly average
temperature in the Crimea “as a reason for clothing a soldier in nankeens
[silks] on a night when he would be frozen to death in fur.” Dickens disliked
the statistical view because he thought it was dehumanizing, and in Hard
Times he portrayed the regularities found by statisticians in the rate
of insanity, crime, suicide and prostitution as a “deadly statistical clock.”
Nightingale, on the other hand, was an ardent admirer of Quételet’s work, and she early displayed a predilection for collecting and analyzing data. At Scutari, apart from the all-important sanitary reforms she instituted, she also systematized the chaotic reord-keeping practices; until then even the number of deaths was not known with accuracy. When she returned to England in 1856, she met William Farr, a physician and professional statistician. Under Farr’s guidance Nightingale soon recognized the potential of the statistics she had gathered at Scutari, and of medical statistics in general, as a tool for improving medical care in military and civilian hospitals.
Throughout ut military history until
the 20th century the main cause of death in war was disease rather than
wounds sustained in battle, and the Crimean War was no exception. Nightingale’s
numbers still speak eloquently. During the first months of the Crimean
campaign there was “a mortality among the troops at the rate of 60 percent
per annum from disease alone,” a rate exceeding that of the Great Plague
of 1665 in London and higher also “than the mortality in cholera to the
attacks” (that is, the mortality among those who had contracted the disease).
In January, 1855, the mortality in all British hospitals in Turkey and
the Crimea, measured in relation to the entire army in the Crimea but not
including men killed in action, peaked at an annual rate of 1,174 per 1,000.
Of this number 1,023 deaths per 1,000 were attributable to “zymotic” disease
(a category introduced by Farr including epidemic, endemic and contagious
disease). This means that if mortality had persisted for a full year at
the rate that applied in January, and if the dead soldiers had not been
replaced, disease alone would have wiped out the entire British army in
| death rate among sick British soldiers in Turkey
was “not much more” than it was among healthy soldiers in England; even
more remarkable, the mortality among all British troops in the Crimea was
“two-thirds only of what it [was] among our troops at home.”
The comparison suggested that the soldiers at home were living in their barracks under unhealthy conditions. After Farr had made Nightingale aware of the significance of mortality tables, she at once thought of comparing the mortality among civilians to that among soldiers. She found that in peacetime soldiers in England between the ages of 20 and 35 had a mortality rate nearly twice that of civilians. It is just as criminal, she wrote in 1857, “to have a mortality of 17, 19, and 20 per thousand in the Line, Artillery and Guards in England, when that of Civil life is only 11 per 1,000, as it would be to take 1,100 men per annum out upon Salisbury Plain and shoot them.” (The 1,100 represented 20 per 1,000 of an enlisted force of 55,000.) Clearly the need for sanitary improvements in the military was not limited to hospitals in the field. By pressing her case with these statistics Nightingale eventually gained the attention of Queen Victoria and Prince Albert, as well as of the prime minister, Lord Palmerston. In spite of the passive resistance of the War Office, Nightingale’s wish for a formal investigation of military health care was granted in May, 1857, with the establishment of a Royal Commission on the Health of the Army.
It would not have been possible at that time for a woman to serve on such a board. Nightingale nonetheless strongly influenced the commission’s work, both because some of its members were her friends (including Sidney Herbert, the minister who sent her to the Crimea) and because she provided it with much of its information. As a statement of her own views she wrote and had privately printed an 800-page book titled Notes on Matters Affecting the Health, Efficiency and Hospital Administration of the British Army, which included a section of statistics accompanied by diagrams. Farr called it “the best [thing] that ever was written” either on statistical “Diagrams or on the Army.”
Nightingale was a true pioneer in the graphical re presentation of statistics: she invented polar-area charts, in which the statistic being represented is proportional to the area of a wedge in a circular diagram. Nightingale used these diagrams, which she called her “coxcombs” because of their vivid colors, to dramatize the extent to which deaths in the Crimea campaign had been preventable. Farr was impressed with Notes, and much of Nightingale’s work found its way into the statistical charts and diagrams he prepared for the final report of
NOTES ON NURSING: WHAT IT IS,
|the Royal Commission. As part of her “flank march” against
the forces of resistance to medical reform, Nightingale had the statistical
section of the report printed as a pamphlet and distributed widely in Parliament,
the government and the army. She even had a few copies of the diagrams
framed for presentation to officials in the War Office and in the Army
Nightingale’s efforts were not in vain. Four subcommissions were established to carry out the reforms recommended in the report of the Royal Commission. The first presided over physical alterations to military barracks and hospitals: improvements in ventilation, heating, sewage disposal, water supply and kitchens. Other subcommissions drafted a sanitary code for the army, established a military medical school and reorganized the army’s procedures for gathering medical statistics.
Nightingale next turned her attention
to the health of soldiers in India. She and Farr began to study the sickness
and mortality records of the India Office, and she sent inquiry forms to
the various British stations in India for information on sanitary conditions
there. In 1858 and 1859 she lobbied successfully for the establishment
of another Royal Commission to look into the Indian question. Two years
later she submitted to the commission a report, based on the inquiries
sent to the stations in India, on the conditions that were causing among
the troops in India a death rate six times higher than the rate among civilians
in England: defective sewage systems, overcrowding in the barracks, lack
of exercise and inadequate hospitals, among other things. The commission
completed its own study in 1863. After 10 years of sanitary reform, in
1873 Nightingale reported that mortality among the soldiers in India had
declined from 69 to 18 per 1,000.
|at the beginning and end of a year and the number of
patients admitted during the year, the number of patients who had recovered
or who had been either discharged as incurable or dismissed at their request,
the number of patients who had died and the mean duration of hospital stays.
Yet although the ideal of gathering uniform hospital statistics was clearly
a good one, and far ahead of its time, the new scheme was never put into
general practice. The proposed form itself was overly complex, and it included
an idiosyncratic system for the classification of diseases devised by Farr
with which many pathologists strongly disagreed. In medical science, unfortunately,
Nightingale did not display the same understanding that led her to recognize
the value of medical statistics; for instance, she showed no interest in
the new germ theory of disease and its implications for the treatment of
Nightingale’s commitment to statistics transcended her interest in health-care reform, and it was closely tied to her religious convictions. To her, laws governing social phenomena, “the laws of our moral progress,” were God’s laws, to be revealed by statistics. Quételet’s science, she taught, was “essential to all Political & Social Administration,” yet political leaders were for the most part completely untrained in the interpretation of statistics. The result of such ignorance, in Nightingale’s view, was legislation that was “not progressive but see-saw-y,” written by officials who “legislate without knowing what [they] are doing.” That is why she experimented with graphical representations, which everyone could understand, and why she struggled to get the study of statistics introduced into higher education, although her dream of a university chair in statistics did not become a reality until after her death. Even today society has not come around fully to Nightingale’s point of view, as is clear from the fact that statistics has yet to become a mandatory part of public education.
Something of the religious fervor Nightingale felt for statistics is evident from her annotation of her copy of Quételet’s book Physique Sociale. On the title page she incorporated the title into a statement of her own creed:
The sense of infinite power
To Nightingale, Quételet was the founder of “the most important science in the whole world,” because “upon it
|depends the practical application
of every other [science].” Judging from their correspondence, the respect
seems to have been mutual.
Although statistics were important
to Nightingale, during her later years of being “an influential” she by
her own account yearned to return to nursing, her chosen profession, her
first “call from God.” She could not, however, because she lived a good
part of her life after her return from the Crimea as an invalid, practically
LOSS OF MANPOWER in the British army due to excess
mortality and invaliding is illustrated by diagrams from the report of
the Royal Commission. Both graphs assume that 10,000 20-year-old recruits
are added to the force annually and that a healthy soldier’s career lasts
for 20 years. Each small rectangle represents 1,000 men. Under the existing
unhealthy conditions (bottom) death (brown) and invaliding
(yellow) reduce the strength of the army (beige) to 141,764
from its maximum size of 200,000, a loss of 29 percent. If mortality were
as low as it was in the civilian population and the relation between mortality
and the invaliding rate stayed the same, the report concluded, the strength
of the army would increase significantly, to 166,910 (top).