In her copy of Thomas à Kempis’ fifteenth century The Imitation of Christ is the inscription, in her own writing, “I only wish to be forgotten”. Although remaining a very private figure throughout her lifetime, this was not a desire that could ever be fulfilled. Since her death on 13 August 1910, at the age of 90, Florence Nightingale’s fame and the legend of the lady with the lamp has failed to dim. That her name has become a synonym for nursing is, however, misleading; and the public perception of her as a nurse does a great disservice to her life as a pioneering statistician.
The lady with the lamp
The legend of Florence Nightingale as the lady with the lamp was born in a filthy hospital in the midst of the Crimean war, which was fought between the Russians on the one side and a coalition of Ottomans, British, French and Sardinians on the other. Beginning in October 1853, it trundled on until March 1856 with, in the words of the historian Alexis Troubetzkoy, few other wars rivalling it in “greater confusion of purpose”. On 21 October 1854—after reports in newspapers of the terrible conditions in which the British wounded were being kept led to a public outcry—Florence was put in charge of a team of nurses, many coming from religious houses, and sent to Turkey, where she was to be responsible for the nursing at the military hospital of Scutari, a former army barracks that had been built over an enormous cesspit. The idea was revolutionary: the army establishment was vehemently opposed to the presence of female nurses in its hospitals. However, Nightingale had the support of Sydney Herbert, at the time secretary of state for war and a staunch ally of Florence until his death in 1861.
On 24 February 1855, the Illustrated London News published an engraving of Florence with her lamp, the only glow of light and hope in a gloomy room, filled with wounded men. In the same month, John MacDonald, in an article for the Times, wrote that “when all the medical officers have retired for the night and sickness and darkness have settled down upon the miles of prostrate sick, she may be observed alone, with a little lamp in her hand, making her solitary rounds”. And so the image stuck.
But despite this public perception of Florence, she did very little actual nursing while in the Crimea and, indeed, throughout her whole life. In fact, the words of her sister, Parthenope, apply as much now as they did then: “what Florence does and what she is, is most faintly conceived of in England […]. The public there generally imagine her by the soldier’s bedside, where doubtless she is often to be found, but as she herself said, how satisfactory, how easy if that were all. The quantity of writing, the quantity of talking is the weary work, the dealing with the selfish, the mean, the incompetent.” Much of her job involved the day-to-day running of the hospital, the management of the nurses (some of whom fell somewhere on the scale of hopelessness), the sweet-talking of the sometimes recalcitrant doctors and the constant battle against bureaucracy and obstructionism in the offices of the purveyor and holders of the purse-strings back in London.
The legend of Florence Nightingale was undoubtedly born in the misery of Crimea’s hospitals. But so too was her burning desire for social change, beginning with the medical treatment of Britain’s soldiers. To fight her battles, she turned to the relatively new science of statistics.
Florence Nightingale: before the legend
In an age when girls were rarely educated, Florence was lucky to have had a father, William Nightingale, who believed that everyone had a right to an education. Her early learning consisted of a wide range of subjects—chemistry, geography, physics, history, languages (classical and modern)—but only very basic mathematics. This changed when she managed to get hold of a copy of Euclid’s Elements, which once upon a time was virtually a prerequisite for serious mathematical study. It was her aunt Mai (a prominent character in the story of Florence’s life) who petitioned Fanny, Florence’s mother, to hire a mathematics tutor for her daughter. As with Mary Somerville, whose On the Connexion of the Physical Sciences led Florence to analyse the moon’s path in detail, this request met with a considerable amount of initial opposition, until a tutor was finally obtained. There is a possibility that one of Florence’s tutors was James Joseph Sylvester (1814–1897), who made significant contributions to the theory of matrices, among other things, but no documentary evidence of this exists.
The Nightingale parents’ approach to their daughters’ education was, however, one of education for education’s sake. A relatively wealthy family, there was no need for Parthenope and Florence to apply their education in any meaningful way, or for them to break away from the passive roles that were assigned to women by societal convention. For Florence, however, this was unacceptable; her desire for action is perhaps best reflected in her attitude to God: although highly religious, she believed that humanity had a duty to act to sort out its own problems, rather than relying on petitions to a supreme being—a belief perhaps influenced by an experiment she carried out at the age of six to determine whether or not God answered her prayers.
She found one of her first sources of inspiration in the work of Adolphe Quetelet (1796–1874), who had founded the Royal Observatory of Belgium but was more famous for developing his concept of l’homme moyen, the average man, whose behaviour could be characterised by the mathematical laws of probability. He carried out extensive surveys of mortality, suicide and crime rates: his 1835 book Sur l’homme et le d’éveloppement de ses facultés, ou Essai de physique sociale (translated into English in 1842 as Treatise on Man) challenged the conventional consensus that individuals had a freedom of choice, showing that societal factors like education predisposed people to certain actions. His work was a groundbreaking—and controversial—embodiment of the statistical revolution that was underway.
Statistics in the nineteenth century
Statistics was a relatively new science at the turn of the century, its increased use triggered by William Playfair’s (1759–1823) invention of graphical methods of representing data. States and ruling bodies had long collected information about the people who lived within their jurisdiction—the Domesday Book of 1086 was England’s first formal, surviving census—but its popularity grew throughout the course of the nineteenth century and its use evolved from that of determining taxation to describing the welfare of society. Decennial censuses were introduced in 1801, with the first four being supervised by John Rickman, a high-ranking clerk in the House of Commons and a friend of the Nightingale family. In 1841, the census was expanded and took a form similar to the one used today: a record of all individuals present in a household on a certain night. Throughout government, various offices and departments began collecting statistics; and in 1837, the civil registration of deaths, births and marriages became mandatory.
The wealth of new data that was becoming available and the opportunities it opened up is perhaps comparable to the current excitement generated by the promise of big data. It was now possible to apply the science of statistics to the fields of economy, politics, social problems, the condition of the poor and, of course, medicine.
Florence Nightingale, statistician
Hospitals for much of the nineteenth century did not play much of a role in healthcare. The rich were tended to at home, the poor by their family, while the so-called ‘undeserving’ poor (those who were condemned as being too lazy to work) were sent to workhouses where they were forced to carry out menial labour. When they fell sick, they were treated in the workhouse infirmary, where conditions were more conducive to dying than recovering. Any hospitals that did exist were mainly for the ‘deserving’ poor—who had to present themselves with a letter of recommendation—and did not treat fever, serious conditions such as tuberculosis, cancer or smallpox, and did not deliver babies. Nurses themselves were largely religious sisters or domestic servants filling time between private posts. Either way, no training or experience was required; tales of drunkenness and sexual shenanigans between the hospital bedsheets were rife. However, this was beginning to change: industrialisation was leading to an influx of people in major cities and towns from more rural areas, increasing the pressure on the workhouses and hospitals.
It was against this background that Florence Nightingale began her battle for an improvement in the provision of medical care. By the time of her death, government was well on the way along the path of reform that would eventually lead to the National Health Service (NHS) Act of 1946 and the establishment of the NHS in 1948. Her immediate legacy, however, was the creation of the first school for nurses to be connected directly to a hospital, St Thomas’.
In her fight, Nightingale was ably assisted by the statistician William Farr (1807–1883), an authority on epidemiology, who had set up a system for recording causes of death. It was he who encouraged Florence to analyse the mortality rates of soldiers following the Crimean campaign, which led her to the finding that the death rate of soldiers, even in peacetime, was twice that of the civilian population and, even more shockingly, that the mortality of all British troops in the Crimea was two thirds that of those who remained at home. The dilemma turned to how best to present this information.
The Nightingale rose diagram
Florence Nightingale understood the need to present her findings in a way that the public could instantly understand or, in her own words, to “affect thro’ the eyes what we may fail to convey to the brains of the public through their word-proof ears”. This led her to the creation of the Nightingale rose diagram, a collection of which was termed the coxcomb. Perhaps inspired by Farr’s use of circular diagrams in his work on deaths caused by cholera in London, the Nightingale rose diagram is an example of a polar-area graph, invented by the French statistician André-Michel Guerry (1802–1886) in 1829, which differs from Playfair’s pie chart in that sectors all have the same angle but differ in their radius, which varies according to the data.
The coxcomb appeared in the report of the Royal Commission on the Health of the Army (1857), whose chairman was Florence’s ally Sydney Herbert and which reported on the medical fiasco of the Crimean war and made recommendations for future reform. On Florence’s insistence, one of these recommendations was that a proper method of statistical accounting be introduced; a desire that was achieved with the appointment of a sub-commission in April 1861 tasked with the establishment of a statistics branch of the Army Medical Department.
Florence’s wish for a wholesale reform of the War Office, however, didn’t come to fruition, despite her near-constant pressure on the various people who filled the post of secretary of state for war during her lifetime. She published numerous pamphlets that included her diagrams depicting the needless death of soldiers from insanitary conditions and neglect. This included helping Harriet Martineau in the writing of her book, England and her Soldiers, which was published in 1859 and contained her coxcombs, bringing them to a public audience for the first time.
Her work to improve the conditions of the army led Florence to turn her attention to its health in India, where the death rate was particularly high. Her concern, however, then expanded to include the sanitary condition of the people and she applied her rigorous statistical approach to link it with the mortality rates of both Indians and British soldiers. Her lobbying led to the establishment of a Royal Commission on the Sanitary State of the Army in India, whose report (which again included some of Nightingale’s findings) was published in 1864.
The lady with the lamp, again
Florence Nightingale wasn’t forgotten. She stands on a plinth in Pall Mall next to her good friend Sydney Herbert and in front of the Guards Crimean war memorial: three Guardsmen overlooked by Honour, arms outstretched, cast in bronze from cannons captured at Sevastopol. Queen Victoria, on opening the new St Thomas’ hospital on 21 June 1871, referred to Florence as “the lady whose name will always remain associated with the care of the wounded and sick”. Prophetic words.
But perhaps we should review the legend of the lady with the lamp: in the misery of Scutari, it may have been her lamp, immortalised in her statue, that provided hope for the wounded; but for most of her work, it was statistics that was the lamp that lit the way to effective reform. It was her groundbreaking use of statistics, as well as her desire to present it in an accessible form, that should form a fundamental part of her lasting legacy.
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