Florence Nightingale: nursing by numbers

This article was first published in the August 2010 issue of BBC History Magazine 

“Were I a man of wealth I would see that Florence Nightingale was commemorated not only as the ‘lady of the lamp’ but by the activities of the ‘Passionate Statistician'”

This judgement was made by Florence’s friend Karl Pearson 
(1857–1936), himself a pioneer in the application of statistics to social problems as a professor at University College, London. His 
view was confirmed by Florence’s cousin Hilary Bonham-Carter, who wrote that: “However exhausted Florence might be, the sight of long columns of figures was perfectly reviving for her.” Florence herself wrote that statistics were “the cipher by which we may read the thoughts of God.” Her precocious interest in the subject, which she mostly taught herself, dismayed her father who considered the subject unfeminine. Florence first applied her mathematical skills when she trained as a nurse at Kaiserswerth in Germany, tracing relationships between illnesses and such factors as age, sex and poverty.

Throughout her life her gift for mathematics was often to be a source of frustration for her because of the ignorance of those whom she sought to influence. In 1891 she wrote that: “Though the great majority of cabinet ministers, of the army, of the executive, of both Houses of Parliament, have received a university education, what has that university education taught them of the practical application of statistics?” In despair at the innumeracy which she encountered she devised a ‘coxcomb’ diagram “to affect through the eyes what we may fail to convey through their word-proof ears”. It was an early and sophisticated pie chart.

When she reached Scutari, the base for casualties from the Crimea, Florence calculated that deaths from disease were seven times those arising in battle and used the information to campaign for better food, hygiene and clothing for the troops. She persuaded the government to commission Isambard Kingdom Brunel to design a prefabricated hospital to be shipped out to Scutari, though it arrived after hostilities had ceased.

Upon returning to England, Florence continued her work and calculated that, even in times of peace, mortality among supposedly healthy soldiers, aged 25–35 and living in barracks, was double that of the civilian population. She wrote to Sir John McNeill (who was conducting the enquiry into the mismanagement of the Crimean campaign): “It is as criminal to have a mortality of 17, 19 and 20 per thousand in the line, artillery and guards, when that in civil life is only 11 per thousand, as it would be to take 1,100 men out upon Salisbury Plain and shoot them.”

Florence’s most important ally in reducing mortality among Queen Victoria’s subjects, and particularly among her soldiers, was the queen herself. The welfare of her soldiers was 
a matter of great interest to Victoria who had written to Florence at Scutari, sending her a medal inscribed “Blessed are the merciful” and asking Florence both to send reports directly to her and to visit her at Balmoral immediately upon her return.

Florence’s visits to Balmoral made a strong impression upon the queen who wrote: “We have made Miss Nightingale’s acquaintance and are delighted and very much struck by her great gentleness and simplicity and wonderfully clear and comprehensive head. I wish we had her at the War Office”. After lengthy interviews with Victoria and Prince Albert, Florence wrote to her uncle that: “The queen wished me to remain to see Lord Panmure [minister of war] here rather than in London because she thinks it more likely that something might be done with him here, with her to back me”. To put Panmure in the ‘right’ frame of mind, Victoria wrote to him: “Lord Panmure will be much gratified and struck with Miss Nightingale.”

Florence made good and continuing use of this connection. When she was dissatisfied with the reaction she received from politicians and officials 
to her reports, statistics, charts and diagrams she wrote to Victoria or Albert and received replies such as the one that greeted her analysis of the demographic consequences of the plan to move St Thomas’s hospital from London Bridge to its new home on the Albert Embankment. Her report on the subject to Prince Albert received the assurance that the matter “has received the immediate attention any communication from you would be sure to command”.

Florence’s interview with Lord Panmure led to the creation of a royal commission on the health of the British army. She bombarded the commissioners with questions about the relationship between the death rates in barracks and such factors as the provision of water, sewerage, ventilation, accommodation and food, using a ‘coxcomb’ chart to press home her points. She used her contacts to ensure that her views received publicity in newspapers. The commission reported in 1863, accepting most of her recommendations and Florence then used her royal connections to ensure that they were put into effect. Death rates fell by 75 per cent.

Hospital statistics

In the meantime Florence had turned her attention to the welfare of the civilian population. In 1860 she attended the International Statistical Congress and read a paper in which 
she proposed a scheme for the collection of “uniform hospital statistics”, leading the delegates to decide that: “Miss Nightingale’s scheme should be conveyed to all governments represented.” She argued for the inclusion in the 1861 census of questions on “persons suffering from sickness or infirmity on census day” 
so that she could analyse the data and make a “connection between the health and the dwellings of the population”. The census commissioners refused her request on the grounds that the terms “sickness or infirmity” were too vague to elicit reliable information. In 1858 she became the first woman to be elected as a fellow of the (later Royal) Statistical Society. Fifteen years passed before another woman was elected: the almost equally formidable Baroness Angela Burdett-Coutts.

Florence’s campaigns continued to the end of her life. In 1891, as another census approached, she wrote a letter to the eugenicist Francis Galton. The letter was headed “A Scheme of Social Physics [ie. Social Science] and Teaching”. 
It proposed the collection of data on four subjects (the letters are hers):

“A. The effects of education: What proportion of children forget their whole education on leaving school?

B. Punishment: The deterrent or encouraging effect upon crime of 
being in gaol.

C. Workhouses: What is the 
proportion of names which from generation to generation appear in workhouse records?

D. India: Whether the population there are growing richer or poorer.”

In the same year, 1891, she corresponded with Francis Galton and Benjamin Jowett, master of Balliol College, Oxford, about her intention to bequeath £2,000 to Oxford University to endow a professorship of statistics which would have been the first in the world. She later revoked the decision because she was not convinced that 
the money would not end up “in endowing some bacillus or microbes [by which she meant something of 
no consequence]”.

She didn’t get everything right. 
Her analysis of the 19th‑century cholera epidemics convinced her that it was caused by foul air, not polluted water and her influence was such that she probably hampered the fight 
against the disease. But, despite such miscalculations, she was certainly 
a “passionate statistician”.

Dr Stephen Halliday is author of The Great Filth: The Waar Against Disease in Victorian England, (Sutton, 2007) 

Book: Florence Nightingale: The Woman 
and her Legend by Mark Bostridge (Penguin, 2009)

Place to visit: Explore Nightingale’s life and legacy at the Florence Nightingale Museum, London.