The real goods and the oversell

by Lynn McDonald

Significance, Volume: 17, Issue: 2, Pages: 18-21, First published: 20 March 2020, DOI: (10.1111/1740-9713.01374)

Abstract

To many, Florence Nightingale is a hero. But like all heroes, elements of her story have been exaggerated. Lynn McDonald, editor of Nightingale’s collected works, sorts fact from fiction.

Florence Nightingale (1820–1910), the first woman Fellow of the Royal Statistical Society, elected in 1858, and an honorary member of the American Statistical Association from 1874, deserves all the attention she is getting in 2020, the bicentenary of her birth. At one time it became fashionable for some historians to deprecate her work. But statisticians and quantitative researchers in general have continued to revere her. She was, after all, a pioneer of evidence‐based health care.1

Her contributions, however, have been exaggerated by such eminent statisticians as Edwin W. Kopf and I. Bernard Cohen, as well as by military and medical historians and other ordinary mortals. Kopf, for example, writing of Nightingale’s work as a nurse in military hospitals during the Crimean War (1854–6), stated correctly that “none of the statistical records were kept in uniform manner”, then added, incorrectly, that “she was able to introduce an orderly plan of recording the principal sickness and mortality data of the military hospital establishments which came within the sphere of her influence”.2 Nightingale did not introduce any plan for recording hospital data – but her analysis of the data, post‐Crimea, using official War Office statistics, covered all the hospitals, not just those under her jurisdiction.

These exaggerations, no matter how minor, serve to embellish Nightingale’s story while making a muddle of her legacy. On the 200th anniversary of her birth, it is important to understand what Nightingale did and did not do, so that we might put her real contributions into better perspective.

What Nightingale did not do

To many statisticians, Nightingale will be best known for her Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army and the striking diagrams within, such as Figure 1, showing the proportions of deaths from various causes during the Crimean War.3 But, contrary to belief, Nightingale never collected data on death rates in Crimean War hospitals, nor could she have. She had no mandate to do so, and no staff. This should be obvious, as the published data show death rates from April 1854 (when the British Army arrived in Turkey), while Nightingale and her nurses arrived only in November.

Nightingale’s famous polar area chart, “Diagram of the causes of mortality in the army in the East”. The chart appeared in Nightingale’s 1858 publication Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army,3 but the version above is from her 1859 publication A Contribution to the Sanitary History of the British Army during the late War with Russia.5

Also during the Crimean War, Nightingale did not save lives by bedside nursing or her famous walks with a lamp by night, much as they were appreciated by the soldiers. Nor did she ever claim to have. Bedside nursing, however dedicated, cannot overcome the faults of overcrowding, poor ventilation, polluted water and inadequate nutrition (many soldiers arrived with scurvy along with their bowel diseases, fever or wounds).

She also did not invent the chart type shown in Figure 1: often referred to as a polar area chart. But she and Dr William Farr, the leading medical statistician at the time, worked together to produce effective charts, better than any Farr had published before. These charts vividly showed how much “preventable deaths” were of the total, and then showed how the rates came down with the arrival of the British government’s Sanitary Commission in Crimea.

Nightingale probably did not do the mathematics or prepare charts such as these herself. Equations are included in her evidence to the Royal Commission on the Crimean War, and historians of statistics point out that she was instructed in mathematics by an expert, Joseph Sylvester. However, there is nothing in her own hand describing what she learned or how she used it, and the instruction lasted no more than 6 weeks, in April and May 1840. Letters sent to Farr following the Crimean War thank him and his staff for sending tables, and letters from Farr advise of material about to be sent.

It was through her work with Farr and others that Nightingale helped to save lives – if not in the way often supposed. She and her team (and she always worked with experts) arguably saved many more lives by what they learned from the Crimean War than what she and others did during the conflict.

Nightingale’s key contributions

Nightingale was an expert on asking the right questions, analysing data and writing it up persuasively. This was simple data analysis, columns and rows, well organised so that relevant comparisons could be made. For her studies of the Crimean War, she and her team paid attention to time, tracking hospital admissions and deaths month by month. At the time, standard statistical tests were not in use and regression analysis was still decades in the future, so the judgements they made were based on eyeball assessments.

This work was not easy, for there were conflicting sources of death data. Nightingale discussed the problem of discrepancies, noting the troubling fact that the number of burials, collected by the Adjutant‐General, was higher than the number of deaths in three different sets of data collected by army doctors.

In 1858, she published her Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army,3 a comprehensive 853‐page report, while the Royal Commission published her much shorter evidence to it.4 In 1859, she published a very short paper, A Contribution to the Sanitary History of the British Army,5 which also contained the famous polar area charts. In the latter publication, she specified that certain tables were prepared by Farr and his office, working from “official documents” presented to Parliament – meaning the two‐volume Medical and Surgical History of the British Army, which was to become the official report of the Crimean War.6

But unlike this official report, Nightingale gets the story right about causal factors. The official report includes charts of deaths by barometric pressure and temperature, evidently considering them to be causes, and indeed death rates were higher in hotter months than in cooler ones. Nightingale’s polar area chart, by contrast, which shows the great decreases in death rates achieved, noted the arrival of the Sanitary Commission sent by the British government. This commission, and the Supply Commission that was also sent, were led by civilian experts who were given a mandate to act, not merely report. The leaders of the Sanitary Commission, Dr John Sutherland, a public health expert, and Robert Rawlinson, a civil engineer and water expert, acted vigorously. Their report included detailed amounts, measured variously by cartload or tonne, of “filth”, meaning faecal material, and dead horses removed from the water supply. No barometric pressures or temperatures were noted.

The official report gave no credit to either commission, both of which were sent out by the civilian government of Lord Palmerston, not the Army Medical Department or the War Office. Palmerston, who understood “sanitary science” – or “public health”, as it would later be called – was a neighbour of the Nightingale family in Hampshire, and would be an ally on post‐Crimea reforms.

Beyond Crimea

Nightingale’s great ally in the reforms made after Crimea was Sidney Herbert, the junior war minister at the outset of the war and the person who got her appointed to lead the nursing team (they were friends from meeting in Rome in 1848, when the Herberts were on honeymoon). He chaired the four sub‐commissions established to implement the major reforms recommended in the Royal Commission Report, and he and Nightingale worked together for five years after the war, until his death in 1861. Enormous changes were made in hospitals and barracks for the British Army, changes that brought down their death rates.

Nightingale’s compliment to her friend – his obituary, in effect – was a short paper published in 1863, titled Army Sanitary Administration, and Its Reform under the Late Lord Herbert.7 In it, she gave three bar charts that succinctly show Herbert’s success in saving lives (Figure 2). The first chart gives the baseline mortality of the English male population, followed by a chart each for army deaths for the years 1837–46 (before Herbert’s term in office) and 1859–61 (after his term), with dramatic decreases clearly visible.

Nightingale’s visual tribute to her great ally, Sidney Herbert: “Diagram representing the relative annual mortality from zymotic diseases, chest & tubercular diseases & other diseases in the English male population aged 15–45, and in the infantry of the line, serving at home, before & since Lord Herbert’s administration”. From Nightingale’s Army Sanitary Administration, and its Reform under the late Lord Herbert.7

After Crimea, Nightingale continued to apply her talents for asking questions and analysing data, including for a Royal Commission on India, reporting in 1863, and subsequently working with medical officers on their statistical reports to make them both more accurate and more useful.

In 1862 she wrote an unpublished “Note on the Supposed Protection Afforded against Venereal Disease, by Recognizing Prostitution and Putting It under Police Regulation”,8 which served as a refutation of police regulation of prostitution (compulsory inspection and treatment of women, never men) by showing that rates of venereal disease were no lower in army bases where such a system was in effect than in places where it was not.

For the 1863 publication Sanitary Statistics of Native Colonial Schools and Hospitals, Nightingale showed that death rates were roughly twice what they should be.9 She called for ongoing monitoring, which did not happen. (Incidentally, with this publication, Nightingale became the first person to reveal the defects of residential schools, which would become notorious later in Canada for their destruction of language and culture, and sexual and physical abuse.)

Then, when a midwifery programme and maternity ward at King’s College Hospital was closed on account of high death rates, Nightingale conducted a comprehensive analysis. Data collection was a great challenge, as there was then no routine recording of maternal deaths, and she was disappointed with what she managed to obtain from sympathetic doctors, including a workhouse doctor, and a small number of publications with comparative data from Europe. Still, her research in the report, Introductory Notes on Lying‐in Institutions, published in 1871, marks an enormous advance on the subject.10

Nightingale understood the importance of population data, but was unsuccessful in her attempt, in 1860, to get two new items added to the census form for 1861, on health status and housing – the latter being seen as a major cause of sickness (whether a person lived in a hovel, a stable or a mansion). She was turned down then, but housing questions were gradually brought into the census in later decades.

Late in life, Nightingale sought to obtain a university chair or readership in “social physics”, a term that originated from Belgian statistician Adolphe Quetelet in his major publications.11 Quetelet was Nightingale’s main source on statistics and social science research more broadly. She knew his work well, commented on it in detail (as an exercise) and met him when he was in London for the International Statistical Congress in 1860. She regretted that his work was not used in the UK as it could be, although his major books had been translated into English. She chose Oxford University as the venue for her desired chair, as it was the university that trained the most senior civil servants and politicians – that is, the people who should be, but were not, using social data. Indeed, she complained that while governments collected vast amounts of statistics, much of it was stuck in ministers’ pigeon‐holes, “which means not at their disposal”.1

Nightingale approached the eugenicist Francis Galton to be the intermediary with Oxford, but nothing came of it. The statistician Karl Pearson, in his Life, Letters and Labours of Francis Galton, judged that Galton had messed up and that Nightingale had had a very good idea. What she wanted was data to assess public policy – what works and what does not. Her examples were: the effects of the Education Act that established (compulsory) state schools, including its effect on crime (increasing or decreasing); results from secondary schools, night schools and workhouse schools; general effects of workhouses (children of workhouse inmates becoming inmates themselves); and, in India, the effect of British administration in making the people richer or poorer, their trade and handicrafts flourishing or perishing. This was a call for no less than evidence‐based public policy on a great range of concerns. But her call was not to be answered.

Conclusion

Nightingale’s research was geared towards saving lives, especially of soldiers, the sick poor, famine victims, indigenous peoples, birthing mothers and nurses – people who were not, by and large, priorities in public policy at the time. She not only worked relentlessly herself, but also developed a team of committed experts to pursue these issues. In the course of her work, she and they saw to improvements in the routine collection of data, its analysis and presentation.

Making results accessible – and persuasive – was always part of her mission. She failed in many of her particular endeavours, not because her ideas were poor, but because she was too far ahead of her time. What she did accomplish was formidable. Queen Victoria wished that Nightingale could run the War Office. I would have liked to see her in charge of climate change.

Endnotes

1. McDonald, L. (2001) Florence Nightingale and the early origins of evidence-based nursing. Evidence-Based Nursing, 4(3), 68–69.

2. Kopf, E. (1916) Florence Nightingale as statistician. Publications of the American Statistical Association, 15(116), 388–404.

3. Nightingale, F. (1858) Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army. London: Harrison.

4. McDonald, L. (ed.) (2010) Florence Nightingale: The Crimean War. Waterloo, ON: Wilfrid Laurier University Press.

5. Nightingale, F. (1859) A Contribution to the Sanitary History of the British Army. London: John W. Parker and Son.

6. Great Britain, Army Medical Department (1858) Medical and Surgical History of the British Army which Served in Turkey and the Crimea during the War against Russia in the Years 1854-55-56. London: Harrison and Sons.

7. Nightingale, F. (1863) Army Sanitary Administration and its Reform under the late Lord Herbert. London: McCorquodale.

8. McDonald, L. (ed.) (2005) Florence Nightingale on Women, Medicine, Midwifery and Prostitution. Waterloo, ON: Wilfrid Laurier University Press.

9. Nightingale, F. (1863) Sanitary Statistics of Native Colonial Schools and Hospitals. London.

10. Nightingale, F. (1871) Introductory Notes on Lying-in Institutions. London: Longmans, Green, and Co.

11. Quetelet, L. A. J. (1869) Physique sociale, ou essai sur le développement des facultés de l’homme. Brussels: Muquardt.