The 9th Historical Clinicopathological Conference

Florence Nightingale

Presentation of Case

The patient’s illness began at age 35 years. She was in Scutari, Turkey at the time, working twenty or more hours a day as an army nurse and hospital administrator under extraordinarily squalid and mentally and physically exhausting conditions. At one point, she and a mere 38 nurses under her supervision had direct responsibility for the care of some 4,000 troops suffering with everything from battle wounds to cholera, diarrhea, dysentery, typhoid, typhus, brucellosis, frostbite and gangrene. Rodents and vermin (especially lice) were rampant. Housing was primitive. Drinking water was foul. Washing and laundry facilities and sewage disposal were lacking, as was proper nutrition. A typical meal consisted of “goat’s flesh, and something they called mutton – black, blue and green in color; coarse bread, rancid butter, milkless tea.” Within three months of her arrival, she witnessed the deaths of over 3,000 of her patients, many of whom she had ministered to personally with total disregard for the contagion which carried off the vast majority.

Her illness began suddenly with tremendous fatigue and fever. She had arrived in the Crimea seven days earlier after a three-day journey by ship from her home base in eastern Turkey. For two weeks “her condition fluctuated between satisfactory and critical, with relapses in the morning, followed by recovery, and then another relapse in the evening.” During this time, “her mind wandered and she was unable to concentrate.” Her physician rated her illness “as bad an attack of fever as I have seen.” After two weeks, the crisis was over. However, the patient continued to be extremely weak for several more weeks and was unable to speak above a whisper or to feed herself. After two months, she returned to her home base emaciated, weak and pale and looking much older than her age. Bed rest had been her principal treatment.

Five months after the onset of her acute illness, the patient was again hospitalized, this time for sever sciatica, accompanied shortly thereafter by bouts of dysentery, earache, laryngitis and insomnia. She also exhibited an obsessive fear of failure. During the ensuing year she complained of persistent insomnia, anorexia, nausea at the sight of food, irritability, nervousness and depression (sometimes severe), all of which were to plague her for the next 32 years.
At age 37 years, she collapsed while experiencing a severe bout of palpitations. She was treated with bed rest and hydrotherapy. A month later, she had what appears to have been a relapse of her original febrile illness and declared herself an invalid. For most of the next three decades, because of her chronic fatigue and other assorted symptoms, she confined herself to an invalid chair, bed or couch and, although in much demand and highly productive professionally, limited herself to one visitor at a time and no more than three to four visitors per day. During this period, she feared, as did her family, that her condition was terminal. She continued hydrotherapy and other forms of alternative medical therapy.

Her forty-first year was plagued by three attacks similar to her original illness, in addition to a new symptom, “nervous tremors.” At one point she developed spinal pain so severe that she was barely able to move. Her physician, a noted neurologist, diagnosed her condition as “congestion of the spine.” Because of this complaint and continued weakness, she spent the next six years virtually confined to her bed. The precise location of her pain is uncertain. However, at one point, she implied that it was most severe in her “left fore quarter.”

From age 43 to 46 she had arthralgias (especially of her right elbow), “recurrent spasms of the heart” and dyspnea due to chest pain. Her pain was so severe and constant she couldn’t bear her own weight and had to be carried from room to room. During particularly difficult periods, she could not tolerate having her position changed for 48 hours at a time. She obtained only partial relief from subcutaneous injections of opium. Sleep continued to elude her and she was convinced her end was near. Nevertheless, she continued to work feverishly and productively.
Between the ages of 50 and 68 years, she complained bitterly of headaches and insomnia. She was depressed and frequently expressed a sense of failure and worthlessness. There were also additional bouts of spinal pain. When she was 60, her mother died, leaving her in a state of “nervous collapse”. She was too ill with palpitations, insomnia, headaches and depression to attend the funeral. Bromide and spirit chloroform brought her little relief.

The patient was born in Florence, Italy to British parents belonging to the privileged “upper ten thousand” class of the United Kingdom. She had been sickly as a child, with hands so weak that she did not write cursive script until age 10 and weakness of the ankles so pronounced that she had to wear steel-lined boots for support. She had recurrent respiratory infections as a child and measles at age 33. She had one sibling, a sister 1 year older, who died at age 71 after suffering for many years with rheumatoid arthritis. Her sister had a “nervous breakdown” at age 33. Her father had enjoyed excellent health until age 80 when he died as a result of head trauma sustained during a fall. Her mother died at age 91 after suffering for many years with senile dementia.

The patient was remarkably independent by nature, even at an early age. She was deeply religious and at age 16 experienced a “mystic’s calling to lift the load of suffering from the helpless and the miserable” – – a calling she continued to answer for the rest of her life. She never married, although she had at least two proposals of marriage. She had no children nor, for that matter, any known sexual relationships. She did not smoke. She was a nurse, health care administrator, health policy consultant and an expert in public health, time management, hospital design, infection control and statistical analysis. She was a social activist. As a young woman she had a pet owl, later, a dog and cats.

When the patient reached the age of 68, her symptoms of chronic illness finally began to abate; her depression lifted, and gradually she began to venture from her room to visit with family and associates. Whereas in middle-age she had been “cold, obsessed and tyrannical”, late in life she was able to resume something like normal relationships with relatives and friends. By age 75, she began to complain of failing memory and eyesight, although visitors found her lively, factual and witty. By age 81 she was blind and by age 82 so demented as to require round the clock nursing care. She died in her sleep at age 90, according to her death certificate of “old age and heart failure.”