Few books made a greater impression on Miss Nightingale than those of Adolphe Quetelet, the Belgian astronomer, meteorologist, and statistician; and she had few friends whom she valued more highly than Dr. William Farr, the leading statistician of her day in this country. From his meteorological studies, Quetelet deduced a law of the flowering of plants. One of his cases was the lilac. The common lilac flowers, according to Quetelet's law, when the sum of the squares of the mean daily temperatures, counted from the end of the frosts, equals 4264° centigrade. Miss Nightingale was greatly interested in such calculations, and the lilac had a special place in her year. Lady Verney's birthday was April 19, and a branch of flowering lilac was Florence's regular birthday present to her sister. Miss Nightingale used to talk of Quetelet's law with great delight, and commended it to gardening friends for verification in their Naturalist's Diaries. But this is a lighter example of Quetelet's researches. What fascinated Miss Nightingale most was his Essai de physique sociale (first published in 1835), in which he showed the possibility of applying the statistical method to social dynamics, and deduced from such method various conclusions with regard to the physical and intellectual qualities of man. In regard to sanitation, we have heard already of the reforms which Miss Nightingale was instrumental in carrying out in Army Medical Statistics. She turned next to the question of Hospital Statistics, where improvement seemed desirable both for the surer advance of medical knowledge and in the interests of good administration.
Miss Nightingale had been painfully impressed during the Crimean War with the statistical carelessness which prevailed in the military hospitals. Even the number of deaths was not accurately recorded. “At Scutari,” she said, “three separate registers were kept. First, the Adjutant's daily Head-roll of soldiers' burials, on which it may be presumed no one was entered who was not buried, although it is possible that some may have been buried who were not entered. Second, the Medical Officers' Return, in regard to which it is quite certain that hundreds of men were buried who never appeared upon it. Third, the return made in the Orderly Room, which is only remarkable as giving a totally different account of the deaths from either of the others.”[312] When Miss Nightingale came home, and began examining Hospital Statistics in London, she found, not indeed such glaring carelessness as this, but a complete lack of scientific co-ordination. The statistics of hospitals were kept on no uniform plan. Each hospital followed its own nomenclature and classification of diseases. There had been no reduction on any uniform model of the vast amount of observations which had been made. “So far as relates,” she said, “either to medical or to sanitary science, these observations in their present state bear exactly the same relation as an indefinite number of astronomical observations made without concert, and reduced to no common standard, would bear to the progress of astronomy.”[313]
Miss Nightingale set herself to remedy this defect. With assistance from friendly doctors on the medical side, and of Dr. Farr, of the Registrar-General's Office, on the statistical, she prepared (1) a standard list, under various Classes and Orders, of diseases, and (2) model Hospital Statistical Forms. The general adoption of her Forms would, as she wrote, “enable us to ascertain the relative mortality in different hospitals, as well as of different diseases and injuries at the same and at different ages, the relative frequency of different diseases and injuries among the classes which enter hospitals in different countries, and in different districts of the same countries.” Then, again, the relation of the duration of cases to the general utility of a hospital had never been shown. Miss Nightingale's proposed forms “would enable the mortality in hospitals, and also the mortality from particular diseases, injuries, and operations, to be ascertained with accuracy; and these facts, together with the duration of cases, would enable the value of particular methods of treatment and of special operations to be brought to statistical proof. The sanitary state of the hospital itself could likewise be ascertained.”[314] Having formed her plan, Miss Nightingale proceeded with her usual resourcefulness to action. She had her Model Forms printed (1859), and she persuaded some of the London hospitals to adopt them experimentally. Sir James Paget at St. Bartholomew's was particularly helpful; St. Mary's, St. Thomas's, and University College also agreed to use the Forms. She and Dr. Farr studied the results, which were sufficient to show how large a field for statistical analysis and inquiry would be opened by the general adoption of her Forms.
The case was now ready for a further move. Dr. Farr was one of the General Secretaries of the International Statistical Congress which was to meet in London in the summer of 1860. He and Miss Nightingale drew up the programme for the Second Section of the Congress (Sanitary Statistics), and her scheme for Uniform Hospital Statistics was the principal subject of discussion. Her Model Forms were printed, with an explanatory memorandum; the Section discussed and approved them, and a resolution was passed that her proposals should be communicated to all the Governments represented at the Congress. She took a keen interest in all the proceedings, and gave a series of breakfast-parties, presided over by her cousin Hilary, to the delegates, some of whom were afterwards admitted to the presence of their hostess upstairs. The foreign delegates much appreciated this courtesy, as their spokesman said at the closing meeting of the Congress; “all the world knows the name of Miss Nightingale,” and it was an honour to be received by “the illustrious invalid, the Providence of the English Army.” The written instructions sent by “the Providence” to her cousin for the entertainment of the guests show her care for little things and her knowledge of the weaknesses of great men: “Take care that the cream for breakfast is not turned.” “Put back Dr. X.'s big book where he can see it when drinking his tea.” Miss Nightingale also induced her friend Mrs. Herbert to invite the statisticians to an evening party. The feast of statistics acted upon her as a tonic. “She has been more than usually ill for the last four or five weeks,” wrote her cousin Hilary (July 12); “now I cannot help thinking that her strength is rallying a little; she is much interested in the Statistical Congress.” Congresses, like wars, are sometimes “muddled through” by our country, and Miss Nightingale was able here and there to smooth ruffled plumes. A distinguished friend of hers, though his name had been printed as one of the secretaries of a Section, had not received so much as an intimation of the place of meeting; he was disgusted at so unbusiness-like an omission, and was half inclined to sulk in his tents. Miss Nightingale's letter on the subject is characteristic:—
(Miss Nightingale to Dr. T. Graham Balfour.) 30 Old Burlington St., July 12 [1860]. You are quite right in what you say. We are all of us in the same boat. And, if it were not that England would not be the mercantile nation she is, if she had not business habits somewhere, I should wonder from my experience where they are. Certain of us, who were asked to do business for the Statistical Congress, had it all ready since December last—and were not able to get it out of the Registrar-General's Office till this week. Certain of us were asked to do business this morning, and to have it ready by to-night, which, if not done, would arrest the proceedings of the Congress, and, if done, must be the fruit of only five hours' consideration, when five months might just as well have been granted for it. I don't say that this is so bad as the treatment of you who are Secretary. But still it is provoking to see a great International business worked in this way.
What I want now is to put a good face upon it before the foreigners. Let them not see our short-comings and disunions. Many countries, far behind us in political business, are far before us in organization-power. If any one has ever been behind the scenes, living in the interior, of the Maison Mère of the “Sisters of Charity” at Paris, as I have—and seen their Counting House and Office, all worked by women,—an Office which has twelve thousand Officials (all women) scattered all over the known world—an office to compare with which, in business habits, I have never seen any, either Government or private, in England—they will think, like me, that it is this mere business-power which keeps these enormous religious “orders” going.
I hope that you will try to impress these foreign Delegates, then, with a sense of our “enormous business-power” (in which I don't believe one bit), and to keep the Congress going. Many thanks for all your papers. I trust you will settle some sectional business with the Delegates here to-morrow morning. And I trust I shall be able to see you, if not to-morrow morning, soon.
Mind, I don't mean anything against your Office by this tirade. On the contrary, I believe it is one of the few efficient ones now in existence.
Having received the imprimatur of an International Congress, Miss Nightingale circulated her paper on Hospital Statistics widely among medical men and hospital officials. Thereby she produced immediate effect. She printed large quantities of her Model Forms, and supplied them, on request, to hospitals in various parts of the country. Through the good offices of M. Mohl, she also worked upon public opinion in France. “Some months ago,” she wrote to Dr. Farr (Oct. 20, 1860), “I got inserted into the leading medical journals of Paris an article on the proposed Hospital Registers; and you see they are at work.” The London Hospitals took the matter up. Guy's printed a statistical analysis of its cases from 1854 to 1861; St. Thomas's, of its from 1857 to 1860; St. Bartholomew's, a table of its cases for 1860. With regard to the future, a meeting was held at Guy's Hospital on June 21, 1861, and it was unanimously agreed—by delegates from Guy's, St. Bartholomew's, St. Thomas's, the London, St. George's, King's College, the Middlesex, and St. Mary's—that the Metropolitan Hospitals should adopt one uniform system of Registration of Patients; that each hospital should publish its Statistics annually, and that Miss Nightingale's Model Forms should as far as possible be adopted. She called further attention to her scheme in a paper sent to the Social Science Congress at Dublin in August 1861,[315] and incorporated it in a later edition of her Notes on Hospitals. The statistics of the various hospitals which had accepted her Forms were published in the Journal of the Statistical Society for September 1862, but I do not find that the experiment has been continued. So far from there being any uniform hospital statistics, of the kind contemplated by Miss Nightingale, even in London some of the hospitals do not keep, or at any rate do not publish, any at all. The laboriousness, and therefore the costliness, of the work of compilation, the difficulty of securing actual, as well as apparent, uniformity, and a consequent doubt as to the value of conclusions deduced from the figures are presumably among the causes which have defeated Miss Nightingale's scheme. Some limited portion of her object is perhaps attained by the statistical data which the administration of King's Hospital Fund demands, but even here there are possibilities of misleading comparison. There is probably no department of human inquiry in which the art of cooking statistics is unknown, and there are sceptics who have substituted “statistics” for “expert witnesses” in the well-known saying about classes of false statements. Miss Nightingale's scheme for Uniform Hospital Statistics seems to require for its realization a more diffused passion for statistics and a greater delicacy of statistical conscience than a voluntary and competitive system of hospitals is likely to create.
At the time she was full of hope, and, having obtained a start with medical statistics, she next pursued the subject in relation to surgical operations. Sir James Paget had been in communication with her on this point. “We want,” he had written (Feb. 18, 1861), “a much more exact account and a more particular record of each case. Thus in some returns we have about 40 per cent of the deaths ascribed to ‘exhaustion,’ in others, referring to the same [kind of] operations, about 3 per cent or less; the truth being that in nearly all cases of ‘exhaustion’ there was some cause of death which more accurate inquiry would have ascertained.” Miss Nightingale (May 1, 1861) congratulated him on “St. Bartholomew's having the credit of the first Statistical Report worth having,” but the table of operations was still, she thought, most unsatisfactory. “It would be most desirable that an uniform Table should be adopted in all Hospitals, including all the elements of age, sex, accident, habit of body, nature of operation, after-accidents, etc., etc. Could you come in to-morrow between 2 and 4, and bring your list of the causes of death after operations? It would be invaluable, coming from such an authority, for constructing a Form.” She consulted other surgeons, civil and military, and wrote a paper, with Model Forms, for the International Statistical Congress held at Berlin in September 1863. These also were included in a revised edition of Notes on Hospitals. The Royal College of Surgeons referred the subject to a Committee, which, however, reported adversely upon Miss Nightingale's Forms.