On the battlefields of the Crimean War and in the hills of Sheffield, Florence Nightingale's legacy lives on
How Nightingale used numbers to revolutionise medicine
By Professor Steven Julious
"However exhausted Florence might be, the sight of long columns of numbers was perfectly enlivening." This description of Florence Nightingale might come as a surprise to those who only have a glancing acquaintance with the heroic nurse more popularly associated with social reform than strings of numbers. But Nightingale's love affair with figures was to endure throughout her life, with the nurse once describing statistics as "More enlivening than a novel."
It's an aspect of Nightingale that tends to get overlooked, much like her connection to Sheffield. She was born into a Sheffield family — her grandfather William Shore was a wealthy banker who lived in Tapton Hall on Shore Lane. Her father, William Edward Shaw, changed his name in 1815 to Nightingale to acquire an inheritance from his maternal uncle, Peter Nightingale.
She was brought up in Lea Hurst in Derbyshire and maintained ties to Sheffield, being elected governor of Sheffield Royal Infirmary on 27th March, 1857. Since women at the time were not permitted to go to university, instead, she got the next best thing: a university level education led by her father. As part of her education she received specialist mathematical training from the age of 20 and she always enjoyed the challenge of statistics.
While debating a sugar duties bill in 1848, the Conservative politician and two-time Prime Minister Benjamin Disraeli said: “I always regard [statistics] with great suspicion, as I listen to them with great perplexity. I cannot yield my conviction, nor make my experience succumb to those anonymous manuscript statistics.”
On a first read, this quote is off putting — it suggests statistics are a bad thing. But in fact, Disraeli was saying we needed more and better statistics, to give us an improved knowledge of the subject. It gives a vivid sense of the context within which Florence Nightingale – a highly numerate person in the health sector – was working. It was a time when people were saying there was a need to better quantify things.
This was a call for change borne out by Nightingale's career. Between 1853 to 1856, a war was fought between Russia and the Ottoman Empire (which sprawled across Southeast Europe, Western Asia and Northern Africa) known as the Crimean War. The UK was an ally of the Empire and so fought alongside it and at the time, the war received plenty of press attention for the medical situation, which was considered scandalously poor. A report was published in The Times, in which the War Correspondent William Russell, wrote on the situation:
“The commonest accessories of a hospital are wanting; there is not the least attention paid to decency or clean linen; the stench is appalling; the fetid air can hardly struggle out to taint the atmosphere, save through the chinks in the walls and roofs; and for all I can observe, these men die without the least effort being made to save them.
There they lie, just as they were let gently down on the ground by the poor fellows, their comrades, who brought them on their backs from the camp with the greatest tenderness, but who are not allowed to remain with them. The sick appear to be tended by the sick, and the dying by the dying -”
Due to the controversy Sydney Herbert, Secretary of State for War, invited her to be “Superintendent of the female nursing establishment in the English General Military Hospitals in Turkey”. Herbert and Nightingale had first met in 1847 and became lifelong friends.
The invitation couldn't have come at a more pressing time: there was a cholera outbreak and many soldiers found their health deteriorated more within hospitals than it might have on the outside. Hospitals were dirty and plagued by rats. Surgeons would use the same equipment on subsequent patients after operating.
During her stint in the Crimea, fresh water was introduced and fresh fruit and vegetables purchased. Better hospital equipment and clean equipment was used. Crucially, an overflowing sewage system that was causing the cholera outbreak in the hospital was repaired.
“Orderlies were wanting, utensils were wanting, even water was wanting. I supplied all the utensils, including knives and forks, spoons, cans, towels, etc... and was able to send instant arrowroot in huge milk pails (two bottles of port wine in each) for 50 men... I am a kind of General Dealer in socks, shirts, knives and forks, wooden spoons, tin baths, tables and forms, cabbages and carrots, operating tables, towels and soap, small tooth combs, precipitates for destroying lice, bedpans and stump pillows”
- Florence Nightingale writing to Sydney Herbert
Nightingale had two advantages on her side in the fight for change. For a start, unlike virtually every other British woman and most British men, she had the direct ear of the Secretary of State for War and was able to update him on the situation and implement actions in real time. Secondly, she was a competent statistician.
Thanks to this background, she decided to review and collate the medical records. There was just one obstacle standing in her way: they were not well maintained, and there was no coordination or consistent reporting across hospitals. Undeterred by this, she organised both the data and the record keeping, then used these data to calculate mortality statistics. The data led to an estimate that turned the stomach. Namely, that a person was seven times more likely to die from disease in hospital than on the front. However, the same data showed that the measures brought in successfully reduced the disease mortality rate from 60% to 2%.
“Statistics is the most important science in the whole world: for upon it depends the practical application of every other science and of every art: the one science essential to all political and social administration, all education, all organization based on experience, for it only gives results of our experience.” — Florence Nightingale
When she came back from the Crimea, she must have stepped under a lucky star: she got to know the statistician William Farr who she met at a dinner party in the autumn of 1856. They struck up a powerful alliance: she had the connections and he was a statistician who could put them to good use. After meeting Queen Victoria, Nightingale secured her support for a Royal Commission to be established on the health of the army. On Nightingale's recommendation, none other than Farr was appointed as a member.
All of this wrangling might seem silly to modern readers: why did Nightingale need a man to represent her concerns? But this was crucial. She worked together with Farr to collate evidence showing another shocking statistic: unsanitary conditions meant that military hospitals had double the death rate of their civilian counterparts. As a woman, Nightingale was not permitted to present in person. It's hard to imagine how frustrating this must have been — to have had sufficient influence to get the commission in place and to recommend appointments, but to be barred by her gender from making her own presentations.
But statistics won out again. One of the recommendations from the commission was to establish an army medical statistics department, which would collate data and provide reports on health status of soldiers to inform policy makers.
Although Florence Nightingale had a passion for tables and columns of numbers, she understood that other people's hearts did not necessarily leap with joy at the sight of rows and rows of numbers. As such, she tried to present the data she collected in clear and innovative ways. To assist in the interpretation of the mortality data she is credited as inventing a radial plot to illustrate trends.
The radial plot used data to slice up a circle into 12 equal sections that correspond to the months of the year. Then the areas with each section are deaths attributed to death from: disease (grey); other causes (brown) and battle (orange). With deaths from the disease being the biggest cause the figure was used to provide persuasive evidence that most deaths were preventable.
This statistical wizardry was used to effect massive change. What seems most impressive to me about Nightingale's life was how her mission wasn't about a single hospital, a single war. She was working at a sufficiently high level to influence policy that would shape countless hospitals and wars. It was the empirical evidence that she curated that was used to inform the decisions to change military hospital practice.
One of the few things Florence Nightingale did not manage to achieve in her lifetime was get statistics on the curriculum taught at universities. She understood the importance of the teaching of statistics but in this instance, her lobbying failed. However, in 1911 the statistician Karl Pearson established the Department of Applied Statistics at University College London to commemorate her — which feels like a fitting tribute to her talents.
Nightingale has left a lasting statistical legacy. She in effect invented clinical audit and proposed evidence-based medicine long before the term was widely understood. Both of these concepts are routinely used today to improve patient care. She also understood the importance of good quality data to provide evidence and was advocating standards for the coding of disease years ahead of her time.
Another mission she pursued was on ensuring the UK coordinated better data collection. This might sound deadly dry, but coheres with the general rule that the more boring something sounds, the more important it often is (this is why celebrity gossip is incredibly sexy but rots your brain). She knew the importance of obtaining good quality data. However, there was no coordination in how data was collected which undermined comparisons across hospitals. In her bid to make data better in this country, she attended an international statistical congress and got the congress to endorse her proposed coding forms which were then applied in five hospitals in London. Almost 200 years ago, in 1860 she was proposing that all hospitals code events in the same way to facilitate comparisons between hospitals. This is a lesson we are still learning today.
It would be nice to think she also left a legacy in Sheffield, the city of her paternal family. The University of Sheffield was established in 1905, in part funded by a voluntary subscription from the working people of the city in penny donations. It incorporated the teaching hospital of which Florence Nightingale was life governor. The university had a founding aim to be "a centre where the treatments of accidents and diseases will be studied". And who has shaped that sector more than her?