Known to many as "The Lady with the Lamp," and the founder of modern nursing, Florence Nightingale dedicated her life to caring for the sick, reforming the public health system and improving military medicine. A prolific writer and statistician, Nightingale accomplished her goals in spite of a lifelong illness that kept her bedridden for decades. The surprising diagnosis of that illness is the focus of this year's historic clinicopathologic conference (CPC) sponsored by the University of Maryland School of Medicine and the Veterans Affairs (VA) Maryland Health Care System in Baltimore.
"It is my opinion that Florence Nightingale suffered from bipolar disorder, a mental illness characterized by alternating highs and lows," says Kathy Wisner, M.D., M.S., professor of Psychiatry and OB/GYN at the University of Pittsburgh Medical Center. "Florence heard voices and experienced a number of severe depressive episodes in her teens and early 20's - symptoms consistent with the onset of bipolar disorder," says Dr. Wisner, an expert in mood disorders.
During a CPC, the case history of an unnamed patient is presented to an experienced clinician for discussion in an academic setting. "This method teaches medical students and residents how to properly diagnose difficult or challenging cases," says Philip A. Mackowiak, M.D., professor and vice chair of the Department of Medicine at the University of Maryland School of Medicine and director of medical care at the VA Maryland Health Care System.
Florence Nightingale earned her reputation by caring for sick and wounded British soldiers during the Crimean War. Leading a group of 38 nurses, Nightingale arrived in Turkey in the fall of 1854 to find abysmal conditions at the army hospital. Filthy, rat invested and rife with disease, the hospital lacked adequate food, water and bandages. Troops were dying by the thousands, suffering from battle wounds, cholera, dysentery, typhoid, and brucellosis, a fever-causing bacterial infection.
"In the mid-19th century, more soldiers suffered and died from disease and frostbite than battlefield wounds," says writer and Nightingale biographer Mark Bostridge from London, who will also speak at the conference. "There was little regard for the plight of the average soldier, but that changed when Nightingale arrived." While providing compassionate care, the Nightingale nurses worked night and day to improve hygiene and provide better food for the suffering soldiers. The death rate fell dramatically, and Nightingale became a national heroine. It was the poet Longfellow who first described Nightingale as the "Lady with a Lamp," symbolizing her unceasing commitment to nursing.
But before returning to England, Nightingale herself became ill. According to the CPC case study, she suffered from extreme fever and fatigue, "her condition fluctuated between satisfactory and critical. Her mind wandered and she was unable to concentrate. Over the next year, she complained of spinal pain, insomnia, anorexia, nervousness and depression." For most of the next 40 years, Nightingale confined herself to her room, reporting a wide range of ailments.
Nightingale's symptoms have most often been attributed to chronic brucellosis. "She may very well have contracted the infection in the Crimean War," says Dr. Wisner. "But that illness alone does not account for her severe mood swings, or the fact that she could be so incredibly productive and so sick at the same time."
Through meetings and correspondence, Nightingale campaigned tirelessly to improve health conditions in army and civilian hospitals. Despite being isolated in her room, she established the first modern nursing school, and wrote 200 reports and books, including the first nursing textbook. Nightingale was also an accomplished mathematician. She was among the first to apply statistics to the study of public health, and is credited with inventing the pie chart.
"The manic periods of bipolar disorder allow for extreme productivity, creativity and insight that go beyond what would normally be possible," says Dr. Wisner. But she says Nightingale also battled bouts of severe depression for most of her life. According to the case study, Nightingale "frequently expressed a sense of failure and worthlessness. When Nightingale 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."
Some have suggested that Nightingale's lifelong illness was psychosomatic. But biographer Bostridge says to focus on Nightingale's health or her selfless service as an army nurse is to miss the major accomplishment of her life. "Nightingale wielded extraordinary influence across the entire public health spectrum. She should be remembered for the far-sighted reforms that have influenced an entire profession," says Bostridge.
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