Note on Contagion and Infection.
There are no words in regard to which there is more misconception, or more nonsense talked and written, than the two words “contagion” and “infection;” and as the word “infectious” has been used in these Notes, it is necessary to say what it does mean, and what it does not mean. The word “contagion” appears to have been first used by certain classical writers to signify the spread of scab among sheep; and it would have been well for humanity if the word had been restricted to this very primitive bucolic signification. It was not till centuries after Virgil’s death that the common sense of men had descended so low as to introduce it into the Medical vocabulary. This took place at a period when, from the neglect of sanitary arrangements, pestilence attacked whole masses of people, and when no one appears to have considered that nature had any laws for her guidance whatever. It was not until human intelligence had descended to this depth that men seem to have bethought themselves of Virgil’s term as affording them an adequate explanation for pestilence, and sufficient reason for not exerting themselves to prevent its recurrence. So it has continued ever since. The little word used in all innocence by the poet for poetic purposes has become the ground-work of every manner of false observation, false reasoning, neglect of sanitary laws, lazarettos, quarantine, and continually-threatened interruption to the commercial intercourse of mankind. No single word has ever done so much harm to the human race, or given such a proof of what a mighty thing a word is!
One would have thought that, after the sanitary experience of the last fifteen years, the word “contagion” would have disappeared from our language; but, even in the last document issued by the expiring Board of Health, written by their Medical Officer, Mr. Simon, and based on erroneous statistical evidence (Papers relating to the Sanitary state of the People of England, 1858), it is stated that “a further—practically speaking, unavoidable—cause of premature death in every civilized country is the risk of its current contagions.” [The italics are not mine.] And this refers to small pox, hooping cough, measels, and scarlatina, the mortality from which we are to presume, is “unavoidable.”
If this be Board of Health doctrine, it is certainly not sanitary doctrine. It would have astonished the Health of Towns Commission, and the first Board of Health.
“Contagion,” as its etymology implies, means the communication of disease from person to person by contact. It is often confused with “infection;” but it has quite a different meaning. Contagion presupposes the existence of certain germs, like the sporules of fungi, which can be bottled up and conveyed any distance, attached to clothing, merchandize, especially to woollen stuffs, for which it is supposed to have a particular affection, and to feathers, which of all articles it especially loves, so much so that, according to Quarantine laws, a live goose may be safely introduced from a plague country; but, if it happens to be eaten on the voyage, its feathers cannot be introduced without danger to the entire community. The absurdities connected with the doctrine are numberless. Suffice it to say that in the ordinary sense of the term there is no such thing as “contagion.” There are two or three diseases in which there is a specific virus which can be seen, tasted, smelt, and analysed, and which, in certain constitutions, propagates the original disease by inoculation, such as small-pox, cow-pox, and syphilis, but these are not “contagions” in the sense supposed.
With regard to the mysterious, imponderable, indivisible nonentities, which make up our “current contagions,” they may safely be dismissed into the limbo of extinct superstitions.
The word “contagion” therefore is altogether objectionable.
The word “infection” expresses a fact, without involving a hypothesis.
It is most necessary, however, that the meaning should be guarded; for, just as there is no such thing as “contagion,” there is no such thing as inevitable “infection.” Infection acts through the air. Poison the air breathed by individuals and we have infection. Shut up 150 healthy people in a Black Hole of Calcutta, and in twenty-four hours you have an infection produced, so powerful that it will in that time have destroyed nearly the whole of the inmates. Sick people are more susceptible than healthy people; and if you shut up sick people together, without a sufficient space and sufficient fresh air, you will have not only fever, but erysipelas, pyæmia, and the usual tribe of Hospital-generated epidemic diseases produced.
Again, if we have a Fever Hospital with over-crowded badly-ventilated wards, or with the air stagnant in them, we are quite certain to have the air become so infected as to poison the blood not only of the sick, so as to augment their mortality, but also of the medical attendants and nurses, so that they shall also become subjects of fever.
It will be seen at a glance that, in every such case and in every such example, the infection is not inevitable, but the simple result of gross carelessness and ignorance. In certain Hospitals it has been the custom to set apart wards for what are called “infectious” diseases; but, in reality, there ought to be no diseases considered such. It follows from what has been stated that, with proper sanitary precautions, diseases reputed to be peculiarly “infectious” may be treated in wards among other sick without any danger; just in the same way as, with proper sanitary precautions, a number of healthy people may be congregated together without becoming subject to the horrors of the Black Hole of Calcutta.
It is in the highest degree probable that we should never have heard of “infectious” wards, if the other wards of a Hospital had been supplied with sufficient space and air for the sick; and in too many cases it is to be feared that the presumed “infectious” cases are huddled away into small, ill-lighted, ill-ventilated rooms, a kind of Lazaretto, in fact, where, if they die, they have at least been kept from doing harm to the other sick in Hospital!
It is high time that common sense should deal with the question; for there does not seem to be much hope for a deliverance from these superstitions from any other quarter.
The “infectious” wards in Military Hospitals correspond, in some sense, to the “casualty” wards in Civil Hospitals, into which accidents, noisy, and erysipelatous cases are transferred, when necessary. The advantages of a separate set of wards for this class of cases have been already insisted upon in these Notes; not certainly because the cases are inevitably “infectious,” but because the segregation of such facilitates greatly administration and nursing, while it removes offensive and noisy patients out of the Hospital wards, whose inmates they would annoy. The question of infection or non-infection has nothing to do with the arrangement. No stronger condemnation of any Hospital or ward could be pronounced than the simple fact that any disease has attacked other patients than those first affected by it. “Infection” and incapable management, or bad construction, are, in Hospitals, convertible terms.
It may be useful to mention what the meaning is of the words “epidemic,” “endemic,” “sporadic,” and “zymotic.”
When a large number of people are attacked simultaneously with the same form of disease it is said to be epidemic. When a small number, as, e. g., the inhabitants of a single court or alley, are so attacked, it is said to be endemic. When scattered cases of the same disease happen, one here, one there, over a large surface, the disease is said to be sporadic. The term zymotic, which includes all diseases of the preceding categories and some others, implies the existence of certain changes in the constitution or in the blood, rendering persons so affected liable to the diseases in question.
It is a vulgar error to suppose that epidemics are occasioned by the spread of disease, from person to person, by infection or contagion; for it is an ascertained fact that, before any people is attacked epidemically, the disease attacks individuals in a milder form, one at a time, at distant intervals, for weeks or months before the epidemic appears. Before an epidemic of cholera, these cases consist generally of diarrhœa of more or less intensity, followed by a rapidly fatal case or two, very much resembling cholera. Even plague itself, as in the recent epidemic at Bengazi, begins with cases which cannot be distinguished from ordinary typhus-fever, the succeeding cases getting more and more intense, until the epidemic seizure takes place. Experience appears to show that without this antecedent preparatory stage, affecting more or less the entire population of a town or district, the occurrence of an epidemic is impossible—the epidemic being, in fact, the last or, so to speak, the retributive stage of a succession of antecedent phenomena extending over months or years, and all traceable to the culpable neglect of natural laws. It is simply worse than folly, after the penalty has been incurred, to cry out “contagion,” and call for the establishment of sanitary cordons and quarantine, instead of relying on measures of hygiène. Epidemics are lessons to be profited by: they teach, not that “current contagions” are “inevitable” but that, unless nature’s laws be studied and obeyed, she will infallibly step in and vindicate them, sooner or later.
In the words of the Registrar-General, which are as applicable to Armies as to States, “Sanitary measures and not quarantines are the real safe-guards of nations.”
Note.
I have just seen a paper by Sir John Hall, entitled “Observations on the Difficulties experienced by the Medical Department of the Army during the late War in Turkey.” In this somewhat singular document, which appears to be a defence of Sir John Hall’s own conduct, there are certain statements made about the female nursing establishment in the East which require a word of comment.
It will be observed that throughout the paper, the weapon which Sir John Hall uses against all civil interference in repairing the sufferings which proceeded from the defects of his own department is simply detraction.
As for Civil Commissions, they were useless, as for Civil Hospitals, they were costly, and their officers lived magnificently and were extravagantly paid. As for the nurses, they were benevolent, pious, well-intentioned persons, but what could they do? How could one woman nurse eighty sick? The medical men thought they could not.
Why had Miss Nightingale stores of port wine placed at her disposal, which she could give to the French Hospitals, while he, the principal Medical Officer of the Army, had no such stores at his disposal?
Sir John Hall must have already discovered that this old weapon is no longer of use in defending his position.
It would have been more to the purpose had he produced his requisitions for food, clothing, comforts, &c., and shown how they were refused or not complied with. At the very time I gave over part of our own private stores of port wine, &c., to the French Hospitals (for part only of what was given were Government stores at all), Sir John Hall might have obtained, out of the large wine store at Balaklava, any amount of wine he required, by merely asking for it. The simple statement of this fact would have been a better answer to M. Baudens[20] than assuming that I could obtain from Government stores and wine for the French Hospitals which he could not obtain for his own.
As to his statement about the Nurses, it simply shows ignorance of the whole matter. Nobody ever contemplated giving to a Nurse the entire charge of a number of sick in a Military General Hospital. It is no part of good Hospital nursing to do so. With proper Orderlies, a Nurse can very well attend to sixty or seventy sick. We were prevented, indeed, by the authorities, and by circumstances, from organizing a proper system of nursing, and were obliged to do all the good possible in the best possible way. But Sir John Hall’s method of estimating the efficiency of nursing, by dividing the number of sick by the number of Nurses, is simply absurd.
Footnotes:
[2] As little reference as possible, no reference at all, if it can be avoided, should be made, on our part, to the Confidential Report, which, in 1855, was presented against the War-Nurses. The less scandal about women is reverted to the better—a truth all slanderers have always appreciated: “Calomniez, calomniez toujours: il en reste toujours quelque chose.” It would be far preferable if Nurses could enter the Army Hospitals quietly, and let by-gones be by-gones (the useful experience always excepted, which has been gained).
[3] The work was done under many difficulties, some inevitable, some which should have been spared. Things happened among us deeply to be regretted. Rebellion among some ladies and some nuns, and drunkenness among some nurses unhappily disgraced our body; minor faults justified pro tanto the common opinion that the vanity, the gossip, and the insubordination (which none more despise than those who trade upon them) of women make them unfit for, and mischievous in the Service, however materially useful they may be in it. Of all this, the material consequences might have been spared by some such “General Order” as the above, which, at least, prevents others from taking advantage and making capital of such faults.
[4] The Extra Diet Kitchens must, it is necessary to state, be under a separate roof from the General Kitchens, as long as the present system (or no-system) of cooking exists. But the sooner it is altered the better. There should be one kitchen only. But the Nurse should always superintend the administering of the Diets. She is unquestionably the proper person, also, to administer the medicines, &c. The Orderlies, to be of any use, must act under the direction of the Head-Nurse and not independently. It would seem hardly necessary to enunciate such a self-evident proposition.
[5] To all references which may here be made to Civil Hospitals I should wish to say, by way of preface:— 1. That I have always believed and I believe it more and more every day I live, that what is wrong in hospitals is to be patiently, laboriously, and, above all, quietly mended by efforts made from within them, if it pleases God to grant that blessing upon them without which all human efforts are vain, and not by accusations, investigations, and noise from without. 2. Also I have always believed, since I knew Hospitals at all, and I believe it more and more every day I live, that, with all their faults and shortcomings, which are easily learnt and more easily declaimed against, our great English hospitals are places in which more is done for the relief and cure of human misery, or, rather, of that large branch of it arising from disease, than in any other places in the world. Also that their faults are not essential to them, but that they may, by God’s blessing on the patient endeavours of many years, be very much modified.
[6] In their regulation dress they should always appear, except when they go on holidays. But let the Queen pay for the transport of one box and one bag only, for each Nurse on duty; and if she takes more let her pay for it herself.
[7] I would allow each Nurse 1½ pint of porter or ale per diem, or, instead of the half-pint of porter, 1 oz. of brandy or a wineglass-full of wine, as she likes best. Most Nurses crave, and rightly, for a luncheon about 9 or 10 A.M., and drink some beer then. I would let them take their own time as to when they drink their day’s allowance. But, while trying to suit each Nurse’s varying tastes (and in Hospital duty the taste does vary) each Nurse must keep to one thing, say for a week or month.
[8] Better than a closet is a moveable dresser, only table-height, under which cleaning can be carried on. There should be no projections in a ward or recess, which are only lodgments for flue and dust. The walls of a ward should be even, polished, impervious.
[9] With regard to children we might look forward to a time when a school might be formed for the children, if any, of such of Her Majesty’s Nurses as are widows. This would be an additional bond to the Service for the mothers. The children, of course, are not to be admitted into Hospital; and strict rules must be made (and kept to) as to when the mother should visit them. I do not anticipate that it would be possible ever to have married women in the Service. And it is hardly necessary to add, that no women but of unblemished character can ever be admitted.
[10] Should a woman, however, out of the higher orders, be found as efficient as one of the middle classes, as Matron, this should be no reason for excluding her.
[11] If it be desired to include some War-Nurses after 40 it would be better for the Superintendent-General, with the sanction of the Secretary of State, to take, at first starting, a few past the age, than, on their account, to alter the age. It stands to reason that, on the formation of the Staff, approved Nurses of the War-Service should be included in it, for the sake of the Service.
[12] It is better to omit the Belief. Singularly enough it is the one thing objected to by Dissenters and Roman Catholics.
[13] If the Surgeons are for the men doing it, I would not overpress this point. But, in the case of weak patients, it requires extra care, and it would be much better to leave it as the duty of the Nurse. At all events it will not answer to leave the enema and its administrator unspecified. The Medical Staff Regulations assign it to the Ward-Masters. It is a simple thing enough, but one by the careless or ignorant administration of which many a man (and woman) has been injured for life; and either the Ward-Master, the Assistant Ward-Master, or the Nurse should be responsible for it. I should prefer, as above stated, charging the Nurse with it; but if objected to by the Surgeons, I should at once let them assign it to whichever Non-commissioned Officer they chose.
[14] One Nurse might possibly be able to serve the whole Pavilion. The highest estimate is here taken.
[15] The floors are of deal; the length and breadth of the boards depending on circumstances. Wood skirtings run round the walls, following the recesses of the window and doors, 2½ in. in height and 1½ in. in thickness. The skirtings should have no indents in them, which form convenient lodgments for dust and take time to clean. A little rim must run round the top of the skirting, edging the wall. The skirting should thence descend, unindented, upon the floor. The boards are coloured and prepared, as follows: A new floor is rubbed over two or three times, with warm linseed-oil varnish, having some fine yellow-ochre, powdered, in it; then a coat of “laque-lustre,” a species of French polish, is laid over it, the result being a reddish-yellow colour, in which the grain and veining of the wood is shown. If, after being used some time, it begins to look worn, it is rubbed over with oil and a new coat of polish laid on it; but, as this takes a long time to dry, it is usual to fill up the worst parts with thin oil-colour, and then to take the yellow polish and lay it on, in two successive coats, leaving it to dry, if possible, for twenty-four hours, as it wears the better the firmer and drier it is. For old boards, that have been much used, considerably more laque-lustre is required than for new ones. After laying on the laque-lustre it is desirable that the floor should not be trodden upon for six weeks, and it is also well occasionally, say about once a week, to polish it, which conduces much to make it serviceable.
[16] And this should be adhered to, the rare though extant cases of efficiency for Hospital nursing, past this age, notwithstanding.
[17] Great caution must be used in acting upon this. The Superintendent-General, or the Superintendents who are responsible to her, order the service of each Nurse. How far is it just to consider extra dangerous duties or stations meritorious in the Nurse who does or suffers from them? Others might have done the same, if so ordered. Others might have wished for such an order. Or a strong efficient Nurse who, in other respects, gives anxiety, may render extra useful service on an emergency, and suffer for it in health: and yet, during her whole service, have given more anxiety and less satisfaction than others who did not, perhaps had not the opportunity to, distinguish themselves by any extra useful service.
[18] The “Superintendent” and “Matron” are here used throughout as synonymous terms; because “Matron” is the shorter and more familiar name; although, for reasons before given, “Superintendent” would be the better word for Military Hospitals.
[19] If it be said that the Workhouse sick are ill-nursed, it is in proportion as this rule is broken, not as it is kept, that they are so.
[20] To M. Baudens, whose recent death is so much to be lamented, I cannot here but add a tribute of admiration for his wise and enlightened sanitary views, during the year of his superintendence over the Medical Department of the French army in the East, and of gratitude for his ready and magnanimous acceptance of our stores, when the French sick were really in want of them, after these had been refused by other French authorities.
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