Hitting the Books: How Florence Nightingale Changed Medicine Using Statistics and ‘Rose Tables’
During the Crimean War, the hospitals of the time were not so much healing or recovery centers as places where wounded fighters would die a little more slowly. The Turkish hospital in Scutari is a notable example. Converted by the British Empire from army barracks, Scutari lacked every conceivable convenience, from basic sanitation to sufficient ventilation, this “hospital” served as a powerful incubator for a myriad of infectious diseases – until Florence Nightingale and her team of volunteer nurses arrived in 1854..
Diseases of the Empire by Jim Downs explores how many aspects of modern medicine are carried on the backs of mankind’s most loathsome impulses, though in the excerpt below Downs illustrates how a woman’s unwavering tenacity and outfit meticulous records have helped launch the field of preventive medicine.
Extract of DISEASES OF THE EMPIRE: HOW COLONIALISM, SLAVERY AND WAR TRANSFORMED MEDICINE by JIM DOWNS, published by The Belknap Press of Harvard University Press. Copyright © 2021 by the President and Fellows of Harvard College. Used with permission. All rights reserved.
While in Scutari, Nightingale developed a record keeping system that tracked a variety of factors at Barrack Hospital and the nearby General Hospital. She took notes on everything from cleanliness and quantity of supplies to diet and the location of latrines and cemeteries.
She also carefully examined the physical space. She carefully noted the size of the rooms, the condition of the roof, and the quality, size and location of the windows. In her book on the health of the British army, like Thomas Trotter and others who have written on the importance of fresh air, she highlighted the problem of poor ventilation and she devoted an entire section to the “Poor ventilation”. She quotes the report of the health commission which states “the defective state of the ventilation” of the hospital of the barracks. There were only “a few small openings here and there,” so there was no way for the “hot and stale” air to escape. A follower of the miasma theory, she believed that diseases spread through the air and advocated ventilation to release “stale air” from hospitals.
In addition to inadequate ventilation, Nightingale reported poor drainage and poorly designed sewers and plumbing. In her testimony to the royal commission, Nightingale reported on the vile conditions she found at Barrack Hospital upon arrival. “The condition of the latrine … for several months, over an inch deep in the dirt, is too horrible to describe.” She observed six dead dogs under one of the windows and a dead horse lay in the aqueduct for weeks. The drinking water was dirty; once she saw used hospital uniforms in the water tank. Rats and insects abounded, and “the walls and ceilings were saturated with organic matter.”
In the conclusion of her report on the health of the British army, she explained: her equal) of an army, having failed at the slightest ebb of disease and disasters due to the negligence committed, having recovered again to the highest state of health and efficiency thanks to the remedies applied.
“It’s the whole experience on a colossal scale.” She recalls that during the first seven months of the Crimean campaign, mortality exceeded that of the plague of 1665 as well as that of the recent cholera epidemics. But during the last six months of the war, after the health reforms, “we had … a mortality among our sick a little more than that among our healthy guards at home.
Using mortality data she had collected during the war, as well as domestic mortality statistics, Nightingale showed that between 1839 and 1853, mortality among soldiers was much higher than among civilian men: ” 10,000 soldiers [at the age of 20], 7,077 live to the age of 39, of which 135 die in the following year; while out of 10,000 civilians aged 20, 8,253 reach the age of 39, and among these 106 die in the following year. Almost all of the mortality among the soldiers was the result of illness; “The actual losses in combat are only a very small part of the calamities of a long war”. Nightingale classified the causes of death into “zymotic diseases” (which in the 19th century referred to infectious diseases such as fever, measles and cholera), “lung and tuberculosis diseases” and “all other diseases (including violent deaths) ”. Nightingale was critical of the military’s disease classification system. At the bottom of a table, she notes: “Bronchitis and influenza have no place in the army’s nomenclature. It is believed that the chronic catarrh of army returns is actually a consumption, in the vast majority of cases; acute catarrh includes both epidemic catarrh, or influenza and bronchitis.
Nightingale presented statistics using charts, tables and charts, which were just starting to appear in research reports, to make it easier for readers to see the comparison she was making. She developed a new type of chart, called a “pink chart,” also known as a comb chart or polar zone chart, to present Crimean War mortality data. Each graph, which is presented as a pie chart, shows data for a year, with the slices representing months. Each slice is divided into colored segments whose area is proportional to the number of deaths.
One segment is for injury-related deaths, a second for “preventable or mitigable zymotic disease” and a third for all other causes. A quick glance at the death tables from April 1854 to March 1855 and from April 1855 to March 1856 suffices to show that many more deaths were caused by disease than by fighting, and that overall mortality has decreased the second year.
To make the dangers of unsanitary hospitals even more visible, Nightingale gathered mortality data from matrons, nuns and nurses working in fifteen London hospitals who died of “zymotic diseases” of fever and cholera. She presented tables, which she notes that William Farr compiled for her, showing that the death rate of nurses was much higher than that of the female population in London; in addition, women working in hospitals were more likely to die from zymotic diseases than other women. She used these figures to argue for the “very great importance” of hygiene in hospitals. “The loss of a well-trained nurse by [sic] disease, ”she writes,“ is a greater loss than that of a good soldier of the same cause. Money is no substitute either, but a good nurse is harder to find than a good soldier.
In her book Notes on Hospitals, she told the story of the British prisoners of war who died in an overcrowded prison cell in India in 1756: “Shut up 150 people in a black hole in Calcutta, and in twenty-four hours an infection is produced so intense that it will have, in that time, destroyed almost all of the detainees. Nightingale’s reference to the case is proof of its status as a prototypical illustration of the need for ventilation. And the fact that it took place in India shows how British medical authorities used information from across the empire.
As a result of her work with a large number of patients during the Crimean War, Nightingale framed her analysis as an epidemiologist, in terms of populations. She focused on how the disease spreads within a group. She devoted her energies not to changing bedpans or healing wounds, but to studying the structure of hospitals, analyzing statistics and finding ways to increase ventilation.
The war gave him the opportunity to compare death rates in a variety of settings: overcrowded hospitals, dilapidated tents and wooden huts. It also underscored the importance of preventive measures, which are one of the major principles of modern epidemiology. By posting her observations, ideas, and guidelines for hospitals, she hoped to provide a set of rules and guidelines for doctors to follow to prevent the spread of the disease. While efforts to ensure good hygiene as a means of guarding against disease can be attributed to Mesopotamian civilization and the Sanskrit writings of 2000 BCE, Nightingale’s warnings, in particular, and health reform, more generally, triggered a critical turning point in the mid-19th century that gave birth to preventive medicine. This transformed military medicine from a business largely focused on treatment and surgery to one that began to address epidemiological issues and problems.
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