Hospitals with no beds or blankets. Emaciated, weak and dying soldiers. Rats and fleas everywhere. When Florence Nightingale arrived with her 38-strong nursing team in the Crimea in November 1854, this was the appalling scene that greeted them.
Two years later, she had developed pioneering statistical methods to convince other people that widespread reform was vital.
The Crimean war
The Crimean War (1853–6) was the first high-technology conflict of the modern age—an age of railways, telegraph wires, photography and high-explosive shells.
And it was a war of shocking statistics, with tens of thousands of soldiers dying.
Florence Nightingale and her team came to run hospitals for wounded soldiers evacuated from Crimea. Her work in the Scutari barracks has gone down in history and legend for its effects on modern medical care.
The scandal she uncovered was that more soldiers were killed by preventable diseases caused by unsanitary healthcare than as a result of battlefield wounds.
What were conditions like in Crimea?
Florence Nightingale and her nurses saw soldiers suffering from frostbite, dysentery, cholera and typhus living in ‘utterly chaotic, unsanitary and inhumane living conditions’.
‘There were no blankets, beds, furniture, food, or cooking utensils, but there were rats and fleas everywhere’, historian Eileen Magnello has recounted.
On top of that, the nurses found inadequate medical records. There was no systematic recording or reporting, hundreds of soldiers were buried without a record being made of their deaths, and a bureaucratic inertia prevented nurses and administrators from spotting obvious flaws in the system.
An analytical approach to medical care
Florence Nightingale studied mathematics from an early age as her parents had strongly endorsed women’s education.
Years before she began her formal mathematical training at the age of twelve, she had developed skills in collecting, organising and presenting data.
Her devotion to mathematical practice and the study of statistics drove her throughout her subsequent career in nursing and medical reform.
Nightingale set about collecting statistics in Crimea. She treated this activity—counting the number of soldiers killed, injured or diseased—in the same way biologists collected specimens of butterflies and fossils on field trips.
Like many collectors, she employed other people to collect statistics on her behalf, running a team of data-gatherers at the Crimea.
Nightingale's polar area diagram
When Nightingale returned from the Crimea to London in 1856 she set about publicising her statistical findings as well as her proposed medical reforms. But she was aware of the limited effect one person could have on practices within the armed forces and the nursing profession.
Her mission was to reach the people who could put her reforms into practice: MPs, government officials and army officers, few of whom had statistical or scientific training.
One of Nightingale’s most significant innovations was a diagram which showed the causes of soldiers’ deaths over two successive years in the Crimea.
The first year (shown on the right of the diagram) was 1854–5, following her arrival in the region. The second (on the left) was 1855–6, after she had implemented a series of reforms to the hospital and nursing practices.
In her diagram, each wedge represented a month, and the area of the wedge showed the number of soldiers who had died that month. The blue area showed deaths from preventable diseases picked up in the terrible conditions at the Crimea. Red sections showed deaths from battlefield wounds. Black areas were deaths from other causes.
Readers could see two things. The first was that the reforms Nightingale implemented and campaigned for had made a huge positive difference to mortality. The second, and more shocking result, was that more soldiers died from preventable diseases during the war than from injuries.
Why was Nightingale's diagram revolutionary?
By 1856, Florence Nightingale had transformed hospital care in the Crimean War—her next step was to use statistics to convince the British army and government of the need for widespread reform.
Today, we are used to seeing statistics presented in graphical form. Infographics are common in newspapers, magazines and online. However, in 1850s Britain, the approach was revolutionary.
While most statisticians provided data in tables of numbers, Nightingale was one of a small group of mathematicians who seized on the power of graphics to describe statistical findings to a non-specialist readership.
With her mortality diagram, Nightingale wanted MPs and army officials to get a quick visual understanding of the scale of the problem, counteracting their entrenched belief that soldiers died from wounds rather than unsanitary hospitals.
Using data to advocate for change
Nightingale needed exposure to get her message out. In 1856, she began collaborating with the radical writer, journalist and sociologist Harriet Martineau.
Alongside fictional work, Martineau was noted for her early work on economics and taxation.
She was also leader-writer for the left-wing Daily News, publishing on social issues such as women’s rights, education, poor-law and the abolition of slavery.
In 1859, Martineau agreed to write a popular book revealing Nightingale’s findings to the public.
It included the now-famous polar-area diagram of soldier fatalities in a fold-out page at the front of the book.
One of the most remarkable political or social productions ever seen.
Harriet Martineau, on reading Nightingale’s reports (1858)
Nightingale was concerned that her work would be censored by the British army for the effect it would have on troop morale. She advised Martineau that her reform proposals would need to be disguised in the book’s narrative.
In spite of this, the message imparted in ‘England And Her Soldiers’ was hard-hitting. In her preface, Martineau wrote, ‘we sustained a fearful misfortune in the last war’, describing the ‘mismanagement, helplessness, and doomed condition’ of soldiers there.
The book was, she said, ‘a grave work’ and, following its publication in 1859, it was deemed unsuitable for distribution to the libraries at army barracks. Nightingale's concerns over censorship had been well founded.
Nightingale and Martineau's legacy
Harriet Martineau’s book ‘England And Her Soldiers’, with Florence Nightingale’s pioneering statistical diagrams, was widely read outside the army rank-and-file. It undoubtedly advanced Nightingale’s cause. The two reformers worked together for many years on other projects.
In the decades that followed, statistical graphics became common as a means to share complex data with non-mathematicians.
Nightingale was elected the first female member of the Statistical Society (now the Royal Statistical Society) in 1858, just two years after returning from the Crimea.
Her influence on nursing and the presentation of statistics was profound.
Header image: Florence Nightingale receiving wounded soldiers at Scutari Hospital. Colour lithograph after J. Barrett © Wellcome Library, London (CC-BY 4.0)