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MEDICAL REMINISCENCES*

II. THE MEMORIAL SERVICES FOR FLORENCE

NIGHTINGALE BY VINCENT Y. BOWDITCH, M.D., BOSTON, MASS. In a preceding article I told of my visits in 1889 to Brehmer and Dettweiler in their sanatoria in Germany. I come now to another event which occurred twenty-one years later, of a very different nature, but equally vivid and inspiring,—the memorial services to Florence Nightingale at St. Paul's, in London, two days after her death, in gust, 1910.

The name of Florence Nightingale will go down to a grateful posterity as the synonym for heroic, unselfish devotion to the welfare of the human race. Inspired with the same spirit that filled Joan of Arc, confident from earliest years of her mission in the world, she persistently fought against the universal, deeprooted prejudice which at that time, and even up to the end of the nineteenth century frowned upon any attempt on the part of woman to broaden and enlarge her sphere of life. With a passionate desire and aptitude for nursing the sick, she finally succeeded, after many heart-breaking discouragements, in beginning work at a small "nursing home" in London. Soon afterwards came the outbreak of the Crimean War, and the great opportunity FLORENCE NIGHTINGALE AS A GIRL: of her life presented itself. The terrible tales

ABOUT 1845 of the suffering of soldiers during that great Reproduced from a plate facing p. 38, Vol. I of campaign in the Near East has long been

Cook's Life of Florence Nightingale. Original draw

ing by Miss Hilary Bonham Carter known to the world. Her decision to organize at once a corps of nurses and to offer her services to the Government; the subsequent his

power, never quenched for a moment, she laid tory of her marvellous grasp of the situation;

the foundation for all modern trained nursing her courage in facing and overcoming the

and became the projector and wise counsellor often furious opposition of the military

for many far-reaching schemes intended not authorities who scoffed at the idea of her at

only for the good of the soldiers, but for the tempting to usurp what they considered their betterment of many conditions affecting the prerogatives in such matters: all these facts

health of the British Empire. are matters of history graphically told in re

At her death the whole nation mourned, and cent years by Sir Edward Cook in his biog

throughout the civilized world came that sense raphy of this wonderful woman.

of personal loss which accompanies the deep A halo of romance rests upon her work

feeling of reverence for those who devote in that fearful campaign. Longfellow has im

their lives to the welfare of mankind. mortalized her in his poem “The Lady of the

From my earliest years I had learned to Lamp,” in which she is portrayed as the lov

associate the name of Florence Nightingale ing, tender woman stealing about the wards

with all that stands for noble womanhood,of the great hospital with a shaded lamp at

an impression that gathered strength in later night, soothing and cheering the suffering sol

years when I had learned through personal diers, idolized by them all. Such a picture,

experience the value of her great services to however true, gives little idea of her marvel

the sick and suffering. The news of her death lous strength of character; her powers of or

in London in the summer of 1910, when I ganization and accomplishment. The Crimean happened to be in Scotland, came to me with episode was but a small part of the tremen

peculiar force, and I determined then and dous work she afterwards accomplished, even

there that should any memorial service be held, when doomed to a life of invalidism for her

as I felt sure would be the case, I would make many remaining years. With her passionate

every effort to be present in order to give my and burning enthusiasm and indomitable will

tribute of respect to her memory. As I had

surmised, the newspapers almost immediately * This is the second of a series of Medical Rem- announced that a memorial service would be iniscences by Dr. Bowditch. The first, on “Visits

held in St. Paul's Church on the morning of to Brehmer's and Dettweiler's Sanatoria," appeared in the March number.—THE EDITOR.

August 20th.

[graphic]

FLORENCE NIGHTINGALE: ABOUT 1858 From a photograph by Goodman. Reproduced from plate facing p. 394 of Cook's Life of Florence

Nightingale

intense feeling in the matter, leaned confidentially down to me and said, “You might go round to the south door, sir; sometimes a party comes with a spare ticket, sir." Thanking him, I again worked my way through the crowd to the south gate, and, reaching the barred entrance, asked the same question of the policeman behind the iron gate, at the same time explaining the fact that I was an American physician. At first, the same answer; then, looking at me keenly, in rather a low tone he said, “If you don't mind waitin', sir, sometimes a spare ticket comes, sir"; and I gladly assented. It would be hard to describe the feeling of suppressed excitement and hope that surged through me during the next ten minutes as I watched the throngs pass through; still harder to say what went on within me as I saw a lady approach and speak to the policeman, and heard her say, “I have a spare ticket for someone here." My heart seemed to stand still and then bound, as the policeman turned to me and, in a low tone, said, "I have one for you, sir; step in, please sir," and I found myself, scarcely able to believe it true, in the yard of St. Paul's, profusely thanking the policeman in addition to giving him a comfortable fee, received with evident smiling satisfaction as he watched my face and I turned toward the church. I found myself at the back of the great chancel, where I was met by a young gentleman, who said most politely, “Where would you like to sit, sir?" and then laughed as I excitedly said, “Oh, anywhere, now that I am here!" He escorted me to the interior of the chancel and placed me in one of the "stalls” where I could command a view of nearly the whole of the vast edifice, near the pulpit and organ and above the level of the great congregation already collected there. The Coldstream Guards, the finest military band in England, was placed in the centre, under the dome; not far away sat representatives of the royal family; and soon afterwards, the Lord Mayor and his retinue filed in and took their places with the usual ceremonies, in the stalls directly oppo

Many trained nurses in their uniforms were seen scattered throughout the concourse of people. It is impossible to describe the feeling of elation that came to me as I realized my wonderfully good fortune not only in accomplishing what I had hoped and determined to do if possible, but that I was about to take part in a great and memorable occasion.

I had arrived just in time. A short pause, and the solemn, beautiful measures of Haendel's “Largo" in a magnificient body of sound from the great band filled the vast church with soul-stirring effect. I saw many weeping, and I must confess that I was shaking from head to foot with suppressed feeling and had the greatest difficulty in not giving way to my own emotions as I watched and listened.

A short reading of the Scriptures and then Florence Nightingale's favorite hymn,

[graphic]

site me.

Leaving Scotland, I traveled rapidly to London, arriving the night before the services. News was rapidly spreading through the newspapers and otherwise that three thousand tickets had been issued and that already seven thousand applications had been made, a rather hopeless outlook for me. Determined to succeed if possible, however, I took a taxi early the next morning and drove to the American Embassy, hoping thereby to find some stray ticket. Here I met my first rebuff from a self-sufficient attendant, who curtly informed me, "No business before eleven here," and, with a still more curt reply to my query as to whether I could possibly find a ticket there. Undaunted, however. I again took a taxi and, telling the man to drive quickly, we flew through the streets down to the immediate vicinity of St. Paul's, where crowds were already gathering. Leaving the taxi, I slowly worked my way through the throngs of people and approached a policeman near one of the gates. “I am an American physician and I want to pay my tribute to Florence Nightingale; can I possibly get in?" I asked. "Not without a ticket, sir; impossible, sir," was the reply, politely given from one of the ever-courteous London policemen. Still I pushed on to the second and third gates, asking the same question, receiving the same reply. The last one, however, evidently noticing my

“The Son of God Goes Forth to War," was
sung, the whole congregation joining in the
service. Again a short reading from the
Scriptures, and then silence. I sat expectant.
Suddenly came a sound that startled me-a
deep low rumble, and my first thought was,
"Can this be an earthquake?". In the next in-
stant, as it increased, I recognized the mili-
tary salute: the roll of the muffled drums. It
rapidly increased in a magnificent crescendo,
filling the ears with tremendous vibrations
which, mingled with the deep diapason of the
organ, reverberated like the roar of an oncom-
ing tempest through the great edifice, until it
seemed as if the walls must crack and crumble
with it's force—tremendous, awe-inspiring!
Then a gradual lessening of sound, until it
soon ceased, and a silence came over that
great concourse of people, a silence so deep
that it could be almost heard, broken only by
the dim roar, in the distance as it were, of the
great city of London, the heart of the world.
Never in my life, before or since, have I heard
anything, unless it be the roar of Niagara, to
equal the grandeur of that sound; intensely
dramatic, full of dignity, never-to-be-forgot-
ten.

And then the “Dead March” from "Saul” was given with fine effect by the great band. Later, selections from the Scriptures; exquisite singing by the Kieff male choir; another hymn sung by the whole congregation, standing; and the benediction. Thus ended, in an hour, the memorial service, one of the most beautiful, soul-inspiring experiences of a lifetime. As I stood and watched the quiet, reverent departure of the great concourse, my respect for Great Britain rose to the highest point, while I thought. “Thus it is that a great nation honors its great dead."

That afternoon, in strict accordance with her expressed wish, simple funeral services were held over her body in the little church of her native Wiltshire village. Through a pouring rain, the little procession of relatives and village friends passed into the church. Close by the coffin, sat silently an old blind Crimean soldier who thus wished to express his last tribute of love and gratitude to the one who many years before had brought him back to life.

And so ended a day that will be memorable in history.

SANTA FILOMENA

(Florence Nightingale)

Whene'er a noble deed is wrought,

Lo! in that house of misery
Whene'er is spoken a noble thought,

A lady with a lamp I see
Our hearts, in glad surprise,

Pass through the glimmering gloom,
To higher levels rise.

And fit from room to room. The tidal wave of deeper souls

And slow, as in a dream of bliss,
Into our inmost being rolls,

The speechless sufferer turns to kiss
And lifts us unawares

Her shadow, as it falls
Out of all mcaner cares.

Upon the darkening walls.
Honor to those whose words or deeds As if a door in heaven should be
Thus help us in our daily needs,

Opened and then closed suddenly,
And by their overflow

The vision came and went,
Raise us from what is low!

The light shone and was spent.
Thus thought I, as by night I read

On England's annals, th igh the long Of the great army of the dead,

Hercafter of her speech and song,
The trenches cold and damp,

That light its rays shall cast
The starved and frozen camp,

From portals of the past.
The wounded from the battle-plain,

A Lady with a Lamp shall stand
In dreary hospitals of pain,

In the great history of the land,
The cheerless corridors,

A noble type of good,
The cold and stony floors.

Heroic womanhood.
Nor even shall be wanting here
The palm, the lily, and the spear,

The symbols that of yore
Saint Filomena bore.

HENRY WADSWORTH LONGFEL’OW.

EDITORIAL NOTE In the June, 1918, number of the JOURNAL OF THE OUTDOOR LIFE Dr. Krause first took up in his series of essays the difficult and complicated subject of infection. Each succeeding number of the JourNAL since that time has taken up some phase of the subject of infection. In the July number he discussed the sources of infection, with particular emphasis on Cornet's theory of dust infection. In the August number he took up Fluegge's theory of droplet or inhalation infection. In September, October and November he discussed infection by ingestion, taking up in the last number the problem of bovine and human tuberculosis. In January of the current year he took up the question of mouth infection, and for February and March has discussed childhood infection, dealing especially in the latter number with the manifestation of apparent childhood infection in adult life.

In this number of the JOURNAL Dr. Krause summarizes the various discussions of infection, prefatory to entering upon a more extended presentation of the problems relating to adult infection and reinfection.

Dr. Krause's series of essays began with the January, 1918, number. A limited number of copies of the JOURNAL OF THE Outdoor Life for the year 1918 are available and may be purchased for 15c. each.

ESSAYS ON TUBERCULOSIS

XV. A REVIEW OF THE MATTER OF PRIMARY INFECTION

BY ALLEN K. KRAUSE, M.D.

more striking elements and factors that must be concerned in the tuberculous infection of man.

*

We have arrived at a point in our inquiry that no longer invites us to search out the most probable sources of infection among those that are possible ones, or to explore the most likely portals of entry and modes of invasion of the tubercle bacillus. For the time being we have addressed ourselves to a matter of which we must have some comprehension before we can pretend to understand tuberculous infection as it makes itself felt in man and animals. This is the docrtine that, after childhood, manifest tuberculosis of man is the fruition of a seed that most commonly has struck root in the individual's long-forgotten past. We have seen* that such a conception presupposes, or at least implies, that adult man ordinarily does not acquire tuberculous infection; and it remains for us to look into the reasons that have fathered this idea and developed it.

An examination of this kind necessitates a considerable digression from our main theme; and before making this detour it may not be unprofitable to pick up some of the many threads that we have woven into our story during the past year and pass in review the

+ See March, 1919, number.

are

We have found that, theoretically at least, all things in nature that are contaminated with tubercle bacilli and that can establish contact with human beings are immediate sources of infection. Yet, because the tubercle bacillus cannot maintain and propagate itself indefinitely apart from the animal body, the original sources of infection must be man or animals. The materials that constitute the immediate sources of infection are, therefore, all bacilli-containing substances that eliminated by tuberculous individuals, whether these be the sputum, milk, feces, urine, pus and mouth spray of human beings, or the milk and flesh, or the products of these, of diseased animals. In addition, any article that is dirtied by such substances also becomes a possibie immediate source of infection.

Not all substances can take equal rank even as merely theoretical sources of infection. By far the greater numbers of tubercle bacilli are cast out upon the world in human sputum. Judged by bulk alone, therefore, human

sputum must constitute the prime source of infection. All other human sources fade into insignificance as compared with sputum. Of animal sources only one is conceivably important, and this is cow's milk. The number of things throughout the world that the habits of man make it possible to be contaminated with sputum makes the immediate possible sources of infection theoretically almost innumerable.

Just as the sources of infection may be extremely diversified, so too the paths by which tubercle bacilli may gain entrance to the body and thence proceed to exert their specific effect are, theoretically speaking, more varied than obtain in any other infection. Animal experimentation has taught us with certainty that no matter how the germ enters the body it can under the proper conditions arouse the production of tubercle somewhere in the individual. It can be effective whether swallowed or merely taken into the mouth, or inhaled, or deposited on uninjured skin or mucous membranes, or inoculated.

And so far as the mere development of tubercle is concerned, when inoculated it makes no difference whether this is made into the skin, or underneath the skin, or into the abdominal or pleural cavities, or into the spinal canal, or into the blood vessels. No matter how we put tubercle bacilli into the body, tubercle will develop.

We start therefore with the two great primary facts: that tubercle bacilli must be in very many places around us, and that it is possible for us to get tubercle in a variety of ways. And now begins the really practical business of trying to determine how the generality of us actually do get tubercle; for if this were once known we should very soon discover whether or not it were possible for us to prevent infection without disturbing our social organization and habits to the point of an absurdity.

Out of the well-nigh countless observations, experiments and speculations on tuberculous infection that would attempt to harmonize what we know about sources of infection with what we know about portals of entry and the later manifestations of tubercle, have emerged two ideas of infection that have gained the widest popular acceptance. These are, first, that the infection is inhaled and, second, that it is ingested.

The inhalation idea postulates always that whatever of an infectious nature is breathed in goes to the lower parts of the respiratory tract—the lungs—that infection first takes root here, and that it is from this place that it spreads later.

The ingestion idea always assumes that the infectious material enters by the mouth, is swallowed, and passed on to the lower parts of the digestive tract—the intestines—that the bacilli enter the body at this point, that they may or may not set up lesion nearby, and that entering by way of the intestines the

bacilli may be carried from there to more remote parts of the body.

In support of the inhalation idea two scientific hypotheses have been framed that have exercised the most profound effect on our ideas of tuberculous infection. These are Cornet's theory of dust infection and Flügge's theory of droplet infection. At bottom both are in agreement in that human sputum is almost the sole original source of infection. But from this point they diverge widely and even radically.

The Cornet theory has it that infection by the germs in sputum is indirect and brought about by an intermediary which is dust, that is stirred up by indoor and outdoor traffic and blown about by air currents. It has several weak points, one or two of which are almost vital. It is based on a great number of experiments, it is true, but, with a very few exceptions, none of these are inhalation experiments. For sputum to attain an inhalable condition, it presupposes a drying and a pulverization and a prolonged residence outside the body, all of which would combine to operate unfavorably on the viability and virulence of the bacillus, and thus tend to raise doubt as to the plausibility of the theory. The strongest argument for this theory is the easily demonstrable circumstance that atmospheric dust is continually being inhaled to the furthest recesses of the lungs by every human being. The main criticism against it is that, in the conversion of sputum into dust capable of being inhaled, but relatively few tubercle bacilli would survive with virulence undiminished. For this reason many believe that even though infection does take place in the manner that Cornet contends, this method is at work in relatively few instances and under exceptional conditions.

The Flügge theory would make infection a matter of direct contact between man and man in which the bacilli are forcibly propelled from donor to recipient through the medium of droplets of spray that are emitted by a tuberculous individual. This theory is founded on far more experimental data than any other hypothesis of infection. Nevertheless the data are mainly collateral and subsidiary, and direct or crucial experiments that aim to satisfy all the conditions of the theory are far from satisfying. The germ of the theory lay in the well-known fact that animals placed in atmospheres that were surcharged with sprays that contained tubercle bacilli very uniformly became tuberculous, while those that were subjected to clouds of artificially-made sputum dust remained free from tubercle more frequently than they became infected. Flügge and his associates proved that consumptives do emit a spray that carries bacilli; and from this discovery and the circumstance that has just been mentioned above elaborated the theory of droplet infection as being the naturai method ior human beings. His own exhaustive studies, however, would seem to limit seriously the universal operation of this

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