1847.] Distinction between Infection and Contagion. 457 also in a sporadic form. The attribute of epidemicity might thus seem to' be not necessary to the existence of a pestilence; but Dr. C. guards himself against this objection, by stating that it is to "the irruptions of these maladies, to their rapid extension, and to their great fatality, the generic term pestilence may be justly applied." Why Dr. C. should have deviated from the ordinary view of the question, and also have limited the term to three diseases, viz., Epidemic Cholera, Yellow Fever, and the Plague, or, as he calls them, the Choleric Pestilence, the Hæmagastric Pestilence, and the Septic or Glandular Pestilence, is not very apparent; unless, indeed, he considers that this triad is possessed of certain characteristic features in common, peculiar to themselves, and distinguishing them from all other maladies to which the appellation of "pestilential" has usually been applied. Whether he has acted wisely in so doing, we shall not now wait to enquire. That this arrangement has had its effect in leading Dr. Copland to adopt some very peculiar views, as to the origin and diffusion of the diseases in question, will appear when we come to examine the details which he has adduced upon these very important subjects. He loses no time, we may remark, in announcing, at the very threshold of the enquiry, his strong and decided opinion, not only that the three pestilences named are essentially infectious, but also that this property of infectiousness has always operated as the most influential cause in their dissemination. The reader is thus at once prepared for what awaits him in the perusal of the sequel: we need scarcely say that our author displays his accustomed industry and erudition in endeavouring to substantiate the views which he has adopted. It is to a patient and candid examination of the proofs and arguments which he adduces, that we now invite the attention of our professional brethren. As it is most necessary, in scientific discussions, that the exact signification of the technical terms or phrases employed should be clearly understood by all parties, we have to observe, that whenever the words infectious, infection, &c., are used, we wish to denote that property of certain diseases being communicable from one individual to another, in consequence of certain effluvia or morbific miasms emanating from the body of the sick, and acting, through the medium of the respired air, upon that of a person in health. Scarlatina, Measles, and Hooping-cough, are uni versally admitted to be infectious diseases, in this acceptation of the word. The epithet contagious, on the other hand, ought assuredly to be restricted to such diseases as are communicable only by contact, and not by any vitiation of the atmosphere with morbific effluvia, in the manner we have just alluded to. We would suggest the term contagio-infectious, to denote those that are capable of being communicated in both ways. To this latter class belong Small-Pox, Hospital Gangrene, and perhaps also Glanders and Puerperal Fever. The importance of attending to these distinctions will be perceived in the course of our enquiries, more especially when we come to notice (once more) the last of the three Pestilences on Dr. Copland's list. But, before concluding these prefatory remarks, we must not fail to allude to a circumstance of the very highest interest in the general history of Infection, and one which requires to be most assiduously kept in mind whenever an attempt is made to determine whether this property belongs to certain diseases or not. The point to which we refer is thus very accurately set forth by Dr. Copland in the following passages, from the article "Infection," in his elaborate work: "It may be stated as an axiom, that the foul air generated by the crowding of many persons, or animals, even in health, but more especially in disease, into a confined space, as in the wards of hospitals, &c., or by few persons only in the same apartment, if their diseases be attended by copious discharges, will infect those who breathe it in a state of predisposition, with low fever, dysentery, &c.; and that the persons thus infected will communicate the malady to others similarly predisposed." Again, we thus read in another passage: "Diseases may take place sporadically, or from local causes; and, owing to various circumstances acting either in close succession or coetaneously, the circulating and secreted fluids, and even the soft solids, may be so changed during its course as to emit an effluvium contaminating the surrounding air, and thereby infecting many of those who breathe this air in a sufficiently contaminated state; and thus it will be propagated to several, and from these to others-especially under favourable circumstances of temperature, humidity, electrical conditions, and stillness of the air, and of predisposition on the part of those who come within the focus of infection, Thus diseases may become infectious and epidemic, aided by the constitution of the air and other circumstances; and, after a time, cease and entirely disappear with the circumstances which combined to propagate it." This very lucid description of what is usually meant by the expression "contingent" or "conditional infection," deserves especial notice, as bearing, in no indirect manner, on the history of Epidemic Diseases in general.* Other passages, inculcating the same views, might be quoted from the Dictionary of Practical Medicine; but these now given will amply suffice. * In a recently-published pamphlet we expressed the same doctrine, in the following terms : "Whenever a number of human beings, even in a state of health, are cooped together in a narrow, ill-ventilated space, the air gradually becomes so contaminated by the effluvia given off from their bodies, that, in the course of a more or less limited space of time, Fever will almost inevitably make its appearance among them; and this fever, so generated, will often be found to exhibit infectious properties, if the sick are not removed to a more airy and wholesome locality. Something of this sort was observed in the case of most of the 23 survivors of that dreadful night when upwards of 140 human beings were shut up in the Black Hole at Calcutta. We have daily illustrations of the same fact in what takes place on board troop and slave ships, in jails, crowded penitentiaries, and so forth. "If such, then, be the case with persons in health, can we wonder that the effluvia from the bodies of the sick must be still more poisonous and contaminating? If any one has a doubt upon this score, let him walk from the open air into the ward of a hospital, when all the windows have been closed for a time; a sense of nausea and oppression, accompanied not unfrequently with actual shivering, are often immediately experienced. "Now, it is in the way we have just mentioned that various maladies, which are certainly not primarily or essentially infectious, are apt to become so in impure and badly-ventilated situations, more especially when many sick are crowded together. The infectiousness is not a necessary quality of the disease; it is an 1847.] Doctrine of Contingent Infection. 459 Now, if the doctrine of Contingent Infection be admitted-and where is the enlightened reader who will dispute its truth?—it is obvious that, to talk of medical men being of a necessity either "infectionists," or "noninfectionists," in reference to certain diseases as if they must positively make up their minds either to admit or to reject in toto the communicability of these diseases under all circumstances is not dealing quite fairly with the question. To call those who hold the doctrine just mentioned "non-infectionists," is clearly to mislead the unpractised reader, by leaving an erroneous impression upon his mind. Let us take an example. If the broad and general question, " Is Erysipelas or is Dysentery infectious?" were put to a physician, he might with perfect truth and propriety answer it in the affirmative; and yet all that he meant by such a response might be the simple declaration of his opinion that these diseases are occasionally or conditionally communicable from one person to another, although such an occurrence does not happen once in a thousand times, and only under very peculiar circumstances. It would be wrong, however, to assert, without any qualification, that the physician in question was either an infectionist or a non-infectionist. Now, as it is with Erysipelas and Dysentery, so it may be with malignant cholera. To adduce a few instances wherein there has seemed to be a transmission of the disease from one individual to another-and this, too, be it remembered, not in sporadic cases, but when an acknowledged epidemic is prevailing at the time cannot satisfy any dispassionate enquirer that the disorder should be placed in the same category with Scarlatina or Measles. But the mere determination of the question, whether a disease like Pestilential Cholera is ever infectious, is far from being either the most difficult or most important point in our enquiries. We have to ascertain whether this property of infectiousness is primary, essential, and permanent, or only contingent, conditional, and occasional; whether the attacks of the pestilence can, with any show of probability, be attributed to personal infection from one individual to another; whether its dissemination from one district to another, and from one country or continent to another, can be fairly traced to this agency; and whether there be any rational grounds for hope that its progress may be arrested, or its invasion prevented, by any of those means of restraint or precautionary regulations, comprised under the general term of Quarantine. These are the really momentous problems in the enquiry to be discussed; and not the very minor one, whether the disease has, upon any occasion, manifested infectious properties. Medical men have too often allowed themselves to be altogether occupied with the history of insulated facts, and have neglected to view the question in its accessory or contingent attribute. Various forms of low or typhoid Fever, Erysipelas, Dysentery, Angina, &c., may be mentioned as affording not unfrequent examples of the phenomenon in question. The consideration of this subject teaches us two important lessons. In the first place it inculcates the imperious necessity of thorough cleanliness and free ventilation, wherever a multitude of sick persons are congregated together; and in the second, it exposes the absurdity of the disputes which have so often taken place about the infectiousness or non-infectiousness of several diseases."-Quarantine and the Plague, 8vo. pp. 71, Highley, 1846. broad and more general bearings. They seem to have been examining the eddies by the shore, and to have forgot all the while to watch the great current of the ocean stream. With the view of keeping our readers' attention steadily directed to the topic most worthy of consideration, we shall occasionally in the sequel employ the terms "importationist" and "non-importationist," in place of those of "infectionist" and "non-infectionist," in more common use. Having cleared our way of any difficulties arising from the ambiguity of certain technical expressions, we should now at once proceed to examine the arguments adduced by Dr. Copland to show that pestilential cholera is not only essentially and primarily communicable from one person to another, but also that its wide diffusion and extension have been chiefly attributable to this property of infection. But, before we can do this with any advantage, we must first investigate a point in the history of the disease on which our author dwells with great emphasis, and the right determination of which is very intimately connected with our ulterior enquiries. Dr. Copland divides Cholera into three species; 1, the bilious; 2, the flatulent; and 3, the spasmodic, or mort de chien of East Indian writers; while what has been generally termed the Epidemic or Pestilential disease is declared by him to be not Cholera at all, but a distemper that is sui generis, essentially and fundamentally distinct not only from the various species of Cholera now enumerated, but also from all other diseases, and which he proposes to designate by the appellation of "Asphyxia pestilenta." He employs indeed the term of "Choleric Pestilence; but only for the sake of convenience. Now the main question comes to be, how are we to distinguish between the malignant or aggravated form of endemic Asiatic Cholera, so well known to, and so well described by, many E. Indian writers during the latter part of last century and the beginning of the present one, and this pestilential disease, which Dr. Copland considers to be of very recent origin and of an essentially different nature. Let us see what he says upon the subject; and, first of all, we shall look at the definitions which he has given of these two fundamentally-distinct disorders. "Spasmodic Cholera" is defined thus: vomiting and purging of watery malters, without any appearance of bile; spasms violent and extending generally through the frame; (it is subsequently said, "spasms of a violent, painful, and tonic character, attacking the muscles of the abdomen, thighs, legs, thorax, and lastly the arms and hands;") speedily followed by sinking of the powers of life. This disease is endemic in some inter-tropical countries. Sometimes, Dr. C. says, it has prevailed epidemically; and then he admits that it "nearly approaches" the pestilential disease; viz., the Asphyxia pestilenta. He does not consider it to be infectious. Let the reader particularly mark this point. On the other hand, the definition of the "Pestilential Disease" stands thus:"Anxiety and oppression in the chest, epigastrium and præcordia; disturbance of the bowels, with nausea, faintness, giddiness, and depression of vital power; frequent ejections of an offensive fluid, resembling rice-water, from the bowels and stomach, followed by spasms, tremours, distress; a cold, clammy, purplish, and shrivelled state of the surface; coldness and rawness of the expired air; a sense of painful or burning heat at the epigastrium, with 1847.] Difference (?) between Spasmodic & Pestilent. Cholera. 461 urgent thirst, and rapid disappearance of the pulse ;-the distemper being often preceded by indigestion and diarrhea, and frequently followed by febrile reaction, affecting chiefly the brain and abdominal organs." The one definition is certainly considerably fuller than the other; but where, it will be asked by many, is the material difference between them? In the latter, the general appearance of the patient, the state of the surface of the body, and the rapid sinking of the pulse are made prominent characteristics; but then, if we turn to Dr. Copland's own description of the bad cases of the Spasmodic Cholera, what do we read? * "In the course of a few hours," says he, "the features shrink, the hands and feet become cold and clammy, the exacerbation of the spasms force out a cold clammy sweat on the face and breast, the pulse is extremely small and weak, or nearly disappears ;-in a case which came before me in Africa in 1816, the pulse could scarcely be felt four hours from the attack. The powers of life fail very rapidly; the eyes sink and are surrounded with a livid circle the countenance assumes a remarkably anxious cast, or is pale, wan and shrunk; and the spasms extend to the very fingers. The breathing now becomes extremely laborious; the patient is restless, and at last is carried off, sometimes in the space of ten or twelve hours." The accuracy of Dr. Copland's description is well shown by comparing it with the accounts left us by Curtis, Girdleston, Duffin, and other medical men who wrote upwards of seventy years ago. Take that of Curtis, a naval surgeon, writing of the mort de chien, or the malignant endemic cholera, at Trincomalee in 1782 : * * * * * * * "In all of the cases, the disease began with a watery purging, attended with some tenesmus, but with little or no griping. This always came on some time in the night, or early towards morning, and continued some hours before any spasms were felt. The purging soon brought on great weakness, coldness of the extremities, and a remarkable paleness, sinking and lividity of the whole countenance. Some at this period had some nausea and retching to vomit, but brought up nothing bilious. In a short time, the spasms began to affect the muscles of the thighs, abdomen and thorax, and lastly they passed to those of the arms, hands and fingers. * * The hands now began to put on a striking and peculiar appearance. The nails of the fingers became livid and bent inwards; the skin of the palms became white, blanched, and wrinkled up into folds, as if long soaked in cold water. All this while the purging continued frequent, and exhibited nothing but a thin watery matter or mucus. In many, the stomach became at last so irritable that nothing could be got to rest upon it; but every thing that was drank was spouted out immediately, without straining or retching. The countenance and extremities became livid; the pulsations of the heart more quick, frequent and feeble; the breathing began to become more laborious and panting; and, in fine, the whole powers of life fell under such a great and speedy collapse, as to be soon beyond the power of recovery." * * * * * Girdleston has described with equal accuracy the disease as observed by him in the naval hospital at Madras, in the course of the same year, 1782. One passage in his description is remarkable. "The hands and feet generally become sodden with cold sweat; the nails livid, the pulse more feeble and frequent, and the breath so condensed as to be both seen and felt, issuing in a cold stream, at a considerable distance. The thirst was insatiable, the tongue whitish but never dry; vomitings became almost incessant; the No. 108 30 |