CHAPTER II.

THE EVIDENCE DRAWN FROM DISEASE ATTACKING THE RELATIVES, ATTENDANTS, AND VISITORS OF THE SICK, IN FAVOUR OF ATMOSPHERIC CONTAGION, CONSIDERED—FACTS EXPLAINED.

Few points have been held so conclusive of the existence of atmospheric contagion, as the circumstance of the attendants and visitors of the sick being attacked with the same distemper, during, or shortly after, their communication.

It is vain to deny, that where a person is ill of a disease, such as fever, that those about him, the members of his family, his attendants, and his visitors, are sometimes attacked with the same distemper.

Such is a common occurrence, but common as it is, it cannot prove that the efficient cause is atmospheric contagion.

Were it established that atmospheric contagion existed in that individual disease, and in that individual case, then it might be admitted that the circumstance did lend some countenance to the supposition, and should perhaps entitle the case to examination.

But it has never been shown that that principle positively exists. There is, as has already been observed, no proof, saving that drawn from the very circumstances for which it is called in to account.

Thus it is entitled to no exclusive respect.

Here is then an agency, of whose existence there is no evidence of a sufficient nature, and here there is reason to believe that the same circumstances are operating widely, and upon the relatives, the attendants, and visitors of the sick, which have already produced the disease in those visited.

These circumstances, in general, are ascertained to be acting upon these individuals, and where they cannot, from their obscure nature, be recognised, there is reason, from the very circumstance of the sick having been affected, to conclude that they are operating, though perhaps in an insidious way. Now, a question arises, whether it is wisest to attribute the prevalence of disease among those holding communication with the sick, to the operation of atmospheric contagion, or to those circumstances and agencies which caused the disease originally, and which there is room to believe are exerting their influence over them also.

It has been said in the preceding chapter, that, during the prevalence of widely spread or epidemic disease, there are generally found circumstances of an unwholesome tendency, favouring its career, and that the range of their action corresponds with that of pestilence. That being the case, as it undoubtedly is, it would be proper, before admitting the operation of atmospheric contagion, to shew that no such circumstances were in operation. An inquiry would be necessary; and their presence being proven, it would not be short of imbecility to attribute to that agency, effects such as are wont to follow their action. It would be to call in a principle whose existence has never been proven, and which, therefore, must be held as at least doubtful, to account for phenomena, the ordinary results of circumstances present, which would indeed be absurd.

Before the operation of atmospheric contagion could with propriety be entertained, it behoved to shew that those circumstances which induced disease in the visited, were not operating with those holding communication with them.

But in all those cases in which atmospheric contagion is held as acting, no attempt is made to prove such absence, and the belief in its presence is not the less strong because these circumstances can be proved to be present.

It is a self-evident truth that some agency or agencies, totally independent of atmospheric contagion must have been in operation, and acting as the cause of disease in the first case or cases that occurred. For this ample reason, that, for atmospheric contagion to exist at all, it is obviously necessary that disease pre-existed, since it is the product of disease, and of disease only.

Thus, then, it is proved, that some causes, totally independent of atmospheric contagion, produce the first cases of an epidemic, or widely spread disease. Now, there is no evidence that these same causes are not operating upon those who visit the sick, and in absence of any facts to the contrary, and of the operation of an equally active and undoubted agent, there is justice in thinking it probable that they are acting, more especially if the self-same results are manifested—and this may, with safety, be done, even when direct testimony cannot be obtained—which is very seldom entirely the case.

The causes of the disease being widely extended, and the visited patient being ill from the operation of forces shared in common with many, it is only fair to conclude that as relatives, attendants, and visitors are like the great mass of people thus operated upon—that they, _cæteris paribus_, are as likely to be affected with the prevalent disease, as those who are suffering were previous to its invasion.

They do suffer, but not in general in a greater proportion than other persons having no communication, and similarly situated in other respects.

It would be ample time to look for the operation of some other agency in addition to those commonly experienced, when the portion of the community, holding communication with the sick, is affected with disease in a greater proportion than that portion having none.

Now, with a few exceptions, it is the result of much patient investigation, not only into the experience of others, but of many epidemics we have had the most ample means of noting, that, in general, in respect to diseases held to be propagated by atmospheric contagion, those who have communication with the sick, do not suffer in a greater proportion than those who keep apart, but remain in the sphere in which the agencies and circumstances are operating, which produced the first cases.

These exceptions are—

_1st_, The relations and inmates of the same house inhabited by one sick of fever.

_2d_, Those receiving disease from actual contact with the palpable contagious matter, or by contactual contagion.

_3d_, Those persons, through the operation of fear, and from depression of mind, affected with disease, as fever, cholera, &c.

_4th_, The attendants in fever institutions, &c.

These exceptions will meet with a little consideration, in order to shew in what manner, and wherefore, those persons are seized in greater proportion, and to prove that it is not in consequence of atmospheric contagion.

This statement is important, and is made cautiously, and only after the most detailed examination, and unprejudiced weighing of evidence.

The facts which have led to that conclusion might be detailed, but, as they would occupy much room, and perhaps prove uninteresting to the general reader, they will be withheld, however, to be produced, if any sufficient objections be made.

That statement is contrary to common belief, which attributes disease in a much greater proportion to those communicating with the sick, than to those keeping apart; but that is not of much consequence, since implicit reliance is not to be placed upon the opinions on that subject, held either by the public or the medical profession.

On the whole, disease does affect, in a greater ratio, those who communicate with the sick, than those who do not, the instances which we excepted being included. But the difference, on the whole, is very trifling, at least much less than is usually supposed.

One of the reasons that the difference is thought to be much more than is actually the case, is, that every case of a visitor or attendant being affected with disease, after or during communication, is bruited about, and becomes the subject of much gossip; while that of hundreds, equally exposed, who escape, is treated very judiciously with silence. There is no impartial hearing of evidence. All that is heard is taken in favour of one side, and instead of an opinion being formed from the whole bearings of the case, one is got up on partial statements, which, however, as it agrees with preconceived notions, answers very well.

But that is not the way in which a case so important should be treated. Be it hoped that medical men, at least, will take more enlarged views, when their own reputation and the public weal are at stake.

The partial statements remind us strongly of the self-deception of which many persons are the dupes, in respect to fortune-telling and the solving of dreams. Every instance of the divination of the fortune-teller, or the solution of a dream, having any, the most far-fetched, correspondence with the future history of the individual, is stored up in the memory, and adduced as undeniable evidence of the truth of those dark arts, however much a thousand facts may cry out against them as vile impositions. The prognostications must, of necessity, be right sometimes, in much the same manner as Louis the 14th declared those astrologers must at some time be correct, who were constantly foretelling his death.

We now proceed to inquire into the circumstances which cause disease to attack those having communication with the sick, in a greater proportion than is observed to hold with those apart from them, yet living in the sphere of the epidemic causes, that is, generally speaking, in the same locality.

_Exception 1st_, The greater proportion in which relatives and others inhabiting the same house with one sick of disease, are attacked, we would explain in this manner:—

_1st_, The relatives, if inhabiting the same locality, are, like others, liable to the disease.

They are suffering in general under depression from apprehension of losing a dear friend.

They are, perhaps, under an apprehension that they themselves may be affected with the same distemper. They may have a dread of atmospheric contagion, or, as is often the case, may have a presentiment of fatal sickness.

They are irregular in the time of taking diet—have often no appetite—are deprived of their night’s rest—maintain long and anxious watchings—and are in general in that feverish state of mind that precludes the possibility of taking due rest.

They are deprived of their wonted exercise in the open air, and of that elasticity of mind and body which it imparts.

They respire an atmosphere, though not contagious, often, and especially in the houses of the poor, deprived of its oxygen or more important principle, and tainted with the admixture of adventitious vapours or gases arising from the excretions, and perhaps the fermenting of impurities often found collected on the skin.

It would be wonderful, where there is a widely-spread disposition to disease, say to fever, if members of the same family, inhabiting the same house, in which one of them lay ill of that distemper, did not take ill, seeing how much they are exposed to it.

Nor is it to be thought extraordinary that relatives living in the same locality, but in different houses, or even in different villages, should take the disease also after visiting the house of a sick friend. What has been stated will sufficiently explain that occurrence.

Here it will perhaps be permitted to make a slight digression to mention a fact which has given much credit to the doctrine of atmospheric contagion,—the simultaneous invasion of fever among relatives, living together, in different houses, in different villages, and in very different parts of the country. We are aware of several extraordinary instances, where from ten to twenty of the same family were ill, at the same time, of fever, several of whom were living far apart.

It is in vain to think of atmospheric contagion being the cause. Possibly that notion might be entertained in reference to those living together, and having communication,—but cannot possibly apply to those in remote and different parts of the country. We know of instances where a family has been seized with fever in our village, and members of the same, living at great distances, forty and sixty miles, have suffered the same distemper at or nearly at the same time, without any communication having subsisted, either by person, by packets, or by letter.

These extraordinary circumstances speak of something more than atmospheric contagion. That could not possibly have extended to those relatives who had no communication; and it is remarkable that, in those instances, disease did not go as with the other members of the community, attacking at leisure, now this, now that one, but almost on the same day, many different members of the same family.

We have sometimes thought, from the consideration of such circumstances, that there is something like a community of disposition causing members of the same family to be similarly affected by like agents, more than subsists between men who are unconnected:—something like an idiosyncrasy, which goes to make them suffer after the same fashion.

There are such things as family characters, family idiosyncracies, family dispositions, family peculiarities of bodily conformation, and family temperaments; and may there not exist some family disposition, to be similarly affected by like circumstances?

The case appears well worthy of philosophical inquiry, something beyond the untenable puerilities of Mesmerians.

_2d Exception._—Visitors and attendants are liable to increase their ordinary chance of taking the prevalent distemper, by touching the body or clothes of the sick, when he labours under a disease marked by a palpable contagious poison. Though the poison cannot be diffused through the air, it may, and sometimes does, act by contact, which we call contactual or immediate contagion. That, of course, can operate in those diseases only in which a palpable poison is eliminated. Those diseases are in this country chiefly small-pox, chicken-pox; the plague, if it can now be said to be a disease of this country; the itch; and, as is commonly believed, measles, scarlet fever, &c. &c.

Though the propagation of these diseases may take place from contact with their peculiar contagious matters, we are disposed to think, that, at least with most of them, especially the latter, the cases which occur in that way are very few.

It is sometimes difficult to produce disease, even when the skin is cut, and the matter is then introduced. That step sometimes fails in respect to cow-pox matter, even when fresh; and small-pox matter we have known to be in contact with the tips of the finger for a minute or so, in innumerable cases, as in feeling the pulse, and no disease has followed. Women affected with small-pox bear healthy children.

Almost the only diseases which we are disposed to think are propagated by contact with the person or clothes of the sick, are small-pox, chicken-pox, scabies, plague, &c. They all possess palpable matters in abundance.

Many instances are known to us, where children have got small-pox, and of grown-up people who have got itch, from sleeping with those sick of these distempers, and thus coming in contact with them closely, and for some time; and where they have not been seized with them, when only breathing the same atmosphere used by those sick.

Thus visitors and attendants may get disease by contact with palpable contagious matter, that is, by contactual contagion, and by touching clothes impregnated with the same, that is, by fomitic contagion, which they would not have taken, had they merely been respiring the air used by the patients.

_3d Exception._—The visitors, and those in general holding communication with the sick, are also liable to be affected more with disease than others who remain free of it, on account of the sorrow usually felt on all occasions of public calamities, and particularly of very mortal pestilence, and more especially experienced in all its acuteness, in the silent sick-room of a friend.

Among the scenes our professional duties call us to witness, there is, perhaps, none so touching as the sorrow-striken countenances of friends, directed to the sick, nay, perhaps the deathbed of one they love; and we have noted the unspeakable sorrow then felt, the deep anguish then experienced, and the silence more touching than eloquence that reigns throughout the sick-room, as an awful contemplation, truly indicative of a depression that is calculated to throw its sufferers into the same situation which they so much deplore in others.

That sorrow attendant on such calamities, and that was so well marked, when cholera lately assailed the nations of the earth, throws into the shade almost every other form, sinks deep into the soul, and enervates every principle of life. It gives a pall to every taste, a disregard to all enjoyment, deprives the unhappy victim of that serenity and composure so favourable to health, and, on the contrary, imparts a restlessness to body and mind, until at length his system becomes a very nidus of disease.

None who have attentively watched the course of widely-spread disease, can doubt that that sorrow, so generally experienced on those occasions, is an active instrument, and a strong abettor of the original epidemic influences. It must be obvious to them, that those strong and deeply-felt emotions, with which man contemplates his relatives, his neighbours, aye, his very race, falling around him,—feeling, too, that he is in the midst of danger, and can do nothing for his security,—must produce a withering influence on the most vital functions of the body, and prove the immediate cause of disease.

Under such circumstances, when disease manifests itself, it certainly cannot be wise to disregard the part they must enact in the production of the effect observed, and to attribute the whole, or nearly the whole, to the operation of atmospheric contagion, which has already been shewn to be without sufficient evidence of its existence, in any one case, or in any one disease.

The visitors, also, are exposed to the action of an atmosphere, which, as it is sometimes impure, is liable to be hurtful.

_4th Exception._—That of the attendants in Fever Institutions. It has often been remarked, that in some fever institutions the nurses and medical clerks resident in the house, are attacked with fever in a much greater ratio than holds with the population around. The difference has been seen on some occasions to be very great, and from information collected on the subject, we are disposed to think, on some occasions, and in reference to some institutions at least, that the statement is correct. That fact has been attributed to atmospheric contagion; and we shall proceed to inquire if it is not more likely that it is dependent on other circumstances which are operating, and that are known to be adequate for the effect observed.

The history of the Royal Infirmary of Edinburgh, and of Queensberry House, an institution for the reception of fever patients, shews that on some occasions almost all the clerks and nurses waiting upon those affected with fever, have been seized with it also.

And it would appear to be owing to some agency peculiar to fever patients or their wards; for in regard to the first-mentioned institution, it is ascertained that it is with those attendants only, who wait upon those patients, that the greater amount of sickness is experienced. Those attendants exclusively occupied in the surgical wards being attacked in no greater proportion than those unconnected with the institution.

This is certainly an important fact, and one on which the advocates of atmospheric contagion are wont to place no small weight. Did that principle exist, there is perhaps no fact in the whole history of medicine, on which we would place more reliance in proving its operation, for it is self-evident that nothing relating to the general unwholesomeness of the institution can be entitled to much activity in this case, for any insalubrious tendency of its situation, of the soil on which it stands, or emanations therefrom, and of the general economy and discipline, cannot be confined in their operation to one apartment or ward, cannot possibly be experienced in the fever wards only.

But an occurrence of this kind is apt to be too readily received and made the ground of many inferences. In itself it certainly is a strong, a cogent fact, and such as naturally leads the mind to believe, that, as some very potent agency is at work, it may be that of atmospheric contagion, which in alleged activity is surpassed by none.

Before proceeding to explain the occurrence, on principles very different from atmospheric contagion, it is right to say that it is such as does not occur in connection with all such institutions; and that, if the case which has been stated, proves it is likely such a principle as contagion is present in these institutions, that others of a directly opposite nature, and as much to the purpose, can be produced to shew, granting the possibility, that it is not present in other institutions, much larger.

By physicians of the first eminence, such occurrences as that referred to in connection with the Royal Infirmary of Edinburgh, are held as decisive proof of the operation of contagious atmosphere.

Dr Alexander Tweedie, a physician of London, and one justly eminent, after mentioning the self-same cause, goes on to say, in a sufficiently assured tone,—“No statement more conclusive, as to the contagious nature of fever, need be adduced: and if such facts will not lead to conviction, the mind of such a sceptic must be strangely constructed indeed.”

The case had been made much stronger, and would have stood inquiry much better, had Dr Tweedie shewn, that the occurrence he treats of was not solitary or uncommon, but was such as is wont to be observed in all like institutions.

He should have known, that it is not from extraordinary, nor even from unique cases alone, that knowledge is to be obtained, nor laws deduced, of the ordinary characters, and action of disease. It is dangerous to deduce inferences, and construct laws, from the knowledge of one circumstance, and where, too, many can be obtained bearing on the case.

Let us see if this occurrence holds with other establishments. We will find that it by no means always holds.

Dr Bateman, who saw much of fever, and gave it much of his active consideration, in his excellent Treatise on Contagious Fever, says,—“During the fourteen years, in the course of which I have almost daily been in contact with persons labouring under contagious fever, not only myself, but all the nurses have been preserved from infection, with one exception, down to the period of the present epidemic” (in the London House of Recovery).[3]

Footnote 3:

Bateman on Contagious Fever, p. 154. 1818.

Similar cases of exemption might be given, but it seems unnecessary to say more here.

But though Dr Bateman’s evidence in a manner meets the case recorded, connected with the Royal Infirmary of Edinburgh, yet it does not disprove its correctness; and we proceed to explain what has been held as only to be explained by the presence of atmospheric contagion.

But though the case could not at present be explained, we deny that one such circumstantial piece of evidence should outweigh the many facts, and the results of reasoning, that have been laid before the reader, and that are yet to follow.

When evidence is contradictory, it is well to ascertain on which side it preponderates; and even when it is nicely balanced, which is not the case here, it should be tested by a reference to general principles. That was done in the first part of this work, and the reader cannot have forgotten the result.

We are disposed to think, that the great prevalence of fever among the nurses and resident medical attendants of fever institutions, and fever wards in general hospitals, which does occasionally occur, is, in no small degree, owing to the particularly great contamination of the atmosphere, which is liable to take place from the peculiarly strong tendency there is in the body of those labouring under fever, especially of the low or typhoid character, to run to putrescence.

The body, it is ascertained, so afflicted, is particularly prone to putrefaction, as is sufficiently attested by the presence of black spots upon the surface, sordes upon the teeth and gums, and the general appearance of corruption, often sufficiently manifest.

The secretions and excretions are marked at first by a putrid character, and in a short time they are in an active state of putrefaction. In that state, chemical changes take place, gases are evolved, such as nitrogen, hydrogen, carbureted hydrogen, phosphureted hydrogen, singly and combined, forming for instance ammonia, which is a combination of hydrogen and nitrogen: they become mingled with the atmosphere, and impart to it pestiferous qualities.

In fever, the body is much more prone to run into the state of putrefaction, than when in health, or even when affected with merely local disease. The whole system is then affected, the whole functions are deranged, the decayed parts of the blood and solids are not removed, nor are they corrected by admixture with new and purer elements obtained from the products of digestion. The correcting influence of exercise is lost, and likewise the assistance it gives to the due performance of the various secretions; and it need not cause surprise that a body so situated, for days and weeks, becomes at length prone to putrefaction.

It will perhaps be argued, that the same corruption or contamination of the air is as likely to take place in the surgical wards, where patients are kept having sores, &c. But in those wards, in general, there is not the same amount of tendency to putrefaction. Their health is often excellent, their functions are often not at all deranged, and their bodies, in general, are not more prone to putrefaction than those in health.

There are, to be sure, a multitude of sores and the like, but, as long as they are healthy, and the matter is good, there is no risk of their injuring the air, provided they are kept tolerably clean.

Healthy matter is a bland and innocent fluid, not more prone to putrefaction than healthy blood. When healthy, matter may be present in an apartment or ward in abundance, without the least injury being felt by those respiring the atmosphere in the room in which it is contained, as the history of surgical hospitals amply proves.

But as soon as matter, by any means, becomes of a bad character, acrid, fretting, unkind, and prone to putrefaction, then it sends forth gases, and perhaps, compound agents, produced by their combination, which mingle with the atmosphere, impart to it most virulent properties, and thus produce havoc among the various patients, as great, as well marked, and as dreadful as those sometimes observed among the attendants of fever patients, from the supposed operation of what has been considered atmospheric contagion.

Wounds are much connected with the state of the general health. Where that, by any means, is affected in a serious manner, the wound takes on an unhealthy aspect, and the matter, which before was bland, becomes acrid and irritating. If the body is affected with a putrid taint, then the matter takes on the same, and from the emanations spoken of, disease spreads around the ward.

That dreadful disease, called hospital gangrene, was some years ago a common affection in military hospitals, from effluvia, and inattention to ventilation; and it was common to observe healthy wounds taking on a sphacelating character, from such causes. Sir John Pringle says, “I have seen instances of it (hospital fever), beginning in a ward, where there was no other cause, but one of the men having a mortified leg.”[4]

Footnote 4:

Sir John Pringle on Diseases of the Army, p. 288.

There are other circumstances of a hurtful character, operating in general upon the young gentlemen who fill the offices of clerks, and upon the nurses, in these establishments, which we doubt not co-operate with the other circumstances mentioned, in producing the extraordinary amount of disease sometimes observed among them. But of these which will readily suggest themselves to all, it is unnecessary to say much in this place.

It is in the fever wards principally that contagious atmosphere is apprehended.

The young gentlemen officiating as clerks are generally arrived at the most important part of their course of study. They are in preparation for their examination before the colleges, and are often in consequence in a very feeble state of health—which, if not always marked with actual sickness, is often sufficiently indicated by worn out and emaciated systems, and by complexions of a very sallow or sickly colour. They are thus predisposed to fever. The nurses waiting upon fever patients are subject to more fatigue and more interruptions to their rest, on account of the great attention which those under their care require, than the same class of persons are exposed to, who belong to the surgical wards.