would be very expedient that one or more houses should be kept in view
in each town or its neighbourhood, as places to which every case of
the disease, as soon as detected, might be removed, provided the
family of the afflicted person consent to such removal; and, in case
of refusal, a conspicuous mark, ‘SICK,’ should be placed in front of
the house, to warn persons that it is in quarantine; and even when
persons with the disease shall have been removed, and the house shall
have been purified, the word ‘CAUTION’ should be substituted, as
denoting suspicion of the disease; and the inhabitants of such house
should not be at liberty to move out or communicate with other persons
until, by the authority of the local board, the mark shall have been
removed.
“It is recommended that those who may fall victims to this most
formidable disease should be buried in a detached ground, in the
vicinity of the house that may have been selected for the reception of
cholera patients. By this regulation, it is intended to confine, as
much as possible, every source of infection to one spot: on the same
principle, all persons who may be employed in the removal of the sick
from their own houses, as well as all who may attend upon cholera
patients in the capacity of nurses, _should live apart_ from the rest
of the community.
“Whenever objections arise to the removal of the sick from the
healthy, or other causes exist to render such a step not advisable,
_the same_ PROSPECT OF SUCCESS IN EXTINGUISHING THE SEEDS OF THE
PESTILENCE cannot be expected. Much, however, may be done, even in
these difficult circumstances, by following the _same principles of
prudence_, and by avoiding all unnecessary communication with the
public out of doors: all articles of food or other necessaries
required by the family _should be placed in front of the house, and
received by one of the inhabitants of the house after the person
delivering them shall have retired_. Until the time during which the
contagion of cholera lies dormant in the human frame has been more
minutely ascertained, it will be _necessary_, for the sake _of perfect
security_, that convalescents from the disease, and _those who have
had any communication with them_, should be kept under observation for
a period of _not less than twenty days_.
“All intercourse with any infected town and the neighbouring country
must be prevented, by the best means within the power of the
magistrates, who will have to make regulations for the supply of
provisions.
“Other measures of a more coercive nature may be rendered expedient
for the common safety, if unfortunately so fatal a disease should ever
show itself in this country, in the terrific way in which it has
appeared in various parts of Europe; and it may become _necessary to
draw troops or a strong body of police around infected places, so as
utterly to exclude the inhabitants from all intercourse with the
country_: and we feel sure that what is demanded for the common safety
of the state, will always be acquiesced in with a willing submission
to the necessity which imposes it.”
This announcement by the English physicians of 1831 was published
throughout the land in the form of an Order of the King in Council.
But the strong good sense of the public averted many of the mischiefs
which these scientific advisers would have produced, had their
counsels been carried into execution. The preventive measures which
were eventually adopted by them consisted in prohibiting intercourse
between one town and another by sea, and permitting it by land; thus,
communication between London and Edinburgh by stage coach was
perfectly free and uninterrupted, while communication between those
capitals by sea was prohibited with such rigour that no interest,
however powerful, could procure an exemption. Francis Jeffrey—at this
time holding the high office of Lord Advocate of Scotland, and whose
influence, from his personal and official connections, was very
great—was unable to obtain permission for his faithful servant, in the
last stage of dropsy, to go from London to Leith by water, lest he
should carry with him to his native country, by that mode of
conveyance, not the dropsy, which he had—but the cholera, which he had
not.
“You will be sorry,” writes Jeffrey to Miss Cockburn, “to hear that
poor old Fergus is so ill that I fear he will die very soon. I have
made great efforts to get him shipped off to Scotland, where he most
wishes to go; _but the quarantine regulations are so absurdly severe,
that, in spite of all my influence with the Privy Council_, I have not
been able to get a passage for him, _and he is quite unable to travel
by land_; he has decided water in the chest, and swelling in all his
limbs. The doctors say he may die any day, and that it is scarcely
possible he can recover.”—_Cockburn’s Life of Jeffrey_, p. 247.
These examples are not adduced for the purpose of casting obloquy on
Sir Henry Halford, Dr Maton, and the other eminent physicians their
colleagues, who vainly attempted to reduce to practice in the
nineteenth century, the standard but obsolete doctrines taught, almost
universally, in the medical schools in the country; but solely for the
purpose of displaying the state of the science of Public Health in the
year 1831–2, as far as the physicians of highest reputation and
largest practice may be taken as its exponents.—_Origin and Progress
of Sanitary Reform, by T. Jones Howell._
The consideration of the common properties of pestilence, under whatever
form or name it may occur, has led to the general conclusion that the
true safeguards against pestilential diseases are not quarantine
regulations, but sanitary measures—that is to say, measures which tend
to prevent or remove certain conditions, without which pestilential
diseases appear to be incapable of existing.
The whole machinery of quarantine is based on the assumption that by an
absolute interdiction of communication with the sick, either by the
person or by infected articles, it can prevent the introduction of
epidemic disease into an unaffected community.
But this assumption overlooks the essential condition on which epidemic
disease depends, namely,—the presence of an epidemic atmosphere, without
which it is now generally admitted that no contagion, whether imported
or native, can cause a disease to spread epidemically. Allowing,
therefore, to contagion all the influence which any one supposes it to
possess, and to quarantine all the control over it which it claims,
there remains the condition, the primary and essential condition, which
confessedly it cannot reach, namely, the epidemic atmosphere.
Experience affords evidence that the influence of an epidemic atmosphere
may exist over thousands of square miles, and yet affect only particular
localities. The cases of cholera which have occurred in numerous and
widely distant parts of England and Scotland mark the presence of the
epidemic influence; yet over this extended area cholera has fixed itself
and prevailed as an epidemic only in very few places. Why has it
localized itself in these particular places? Probably because it has
there found conditions of a specific kind, either local or personal, or
both. It follows that our true course is to make diligent search for all
localizing circumstances, and to remove them, so as to render the
locality untenantable for the epidemic. But quarantine makes no such
search, and leaves all localizing conditions untouched and unthought of.
Hence the signal failure of quarantine as a means of prevention, with
reference at least to the most prevalent epidemics, in all the nations
of Europe in which it has been tried in modern times; and hence the
general relaxation, and in some instances the total abandonment, of the
system of quarantine, with reference to several diseases against which
it was formerly rigidly enforced, and the growing distrust in the
supposition that measures of this kind really afford protection against
the introduction of any epidemic disease into any country.
The influence of great epidemics is not limited to human beings; it
extends to all classes of domestic animals.
It is stated by Dr Thomas Lesslie Gregson, who was at Alexandria during
the prevalence of the great plague of 1836, on duty there as
surgeon-in-chief to the Naval, Military, and Civil Hospital, that cattle
were attacked with decided symptoms of plague some time before the
disease broke out among the human species. “Before the disease broke
out,” he says, “a number of the Pacha’s oxen were seized with a malady,
of which above one hundred died in a few days. I was sent to investigate
and report on this epidemic. On examination I found gastroenterite in
the most intense degree; so much so, that I have found extensive
gangrene in oxen that have only been observed ill twelve hours. They had
also large buboes. This I reported plague, and caused them to be
interred deeply.”
Quarantine is based on the assumption that epidemic diseases depend upon
a specific contagion; but the question of contagion has no necessary
connection with that of quarantine. The real question is whether
quarantine can prevent the extension of epidemic diseases, whatever may
be their nature, whether contagious or not. If it can, it is valuable
beyond price; if it cannot, it is a barbarous encumbrance, interrupting
commerce, obstructing international intercourse, periling life, and
wasting, and worse than wasting, large sums of the public money.
But if the power of protecting the country from the introduction and
spread of disease, whether contagious or otherwise, claimed by
quarantine, be really possessed by it, this must be proved by other
considerations than those which establish the contagiousness of disease;
it is a mere matter of evidence and experience, and consequently the
disputed point of contagion should be placed entirely out of view in
this discussion, and the whole question should be argued on the broad
ground whether or not quarantine is a public security, or is capable of
affording practically any useful result.
There is indeed one point of view in which it may be proper, and even
necessary, to consider the question of contagion with relation to that
of quarantine. Assuming the existence of contagion, if it can be proved
that quarantine, instead of affording any protection against contagion,
absolutely fosters it, then the stronger the proof of contagion the more
decisive the argument presented by it against quarantine; and it will be
shown hereafter that this is the true and the only relation in which
contagion stands to this question.
There is no more reason why the controversy on contagion should
complicate the question of quarantine than why it should continue to
encumber the general subject of the removable causes of disease, from
which efforts have long been made to disentangle it.
The discussion whether epidemic diseases arise and spread from contagion
or from common or specific poisons generated in the localities in which
these pestilences first break out, has nothing whatever to do with
quarantine, the sole inquiry with reference to this question being
whether, however epidemic diseases arise, quarantine can prevent their
introduction into a country or arrest their progress when there.
Few will question that the progress of the opinion of observers in
Europe during the last half-century has been steadily towards a material
modification, if not an entire abandonment, of the doctrine of contagion
with reference to the majority of epidemic diseases, taking the word
contagion in its strict sense, that is, the communicability of disease
exclusively by contact: direct, that is, with the body or breath of an
infected person; or indirect, with something which an infected person
has touched.
Cholera may be taken as an example of the diseases of the epidemic
class. When cholera first invaded Europe in 1831,[26] the belief in its
contagious nature was almost universal, and in this country in
particular there was scarcely a medical man who did not entertain this
conviction; but as in India, where this disease is known, the belief in
its contagious nature is universally abandoned, so in Europe it
gradually diminished in proportion as opportunities of observing the
disease increased; and now in Russia, Poland, Prussia, France, Belgium,
and England, the contrary view, with few exceptions, is maintained.
Footnote 26:
See note p. 61.
There has been much confusion of terms in respect to the use of the
words contagion and non-contagion. Professional men have avowed their
belief of the contagiousness of typhus, and stated that they had
experienced it in their own persons. When asked for the evidence on
which the belief was founded, they have usually related some
circumstances showing, not the contagiousness, but the infectiousness of
the disease. Contagion is a term applicable to a different set of
circumstances. According to the hypothesis of contagion, no matter how
pure the air, no matter what the condition of the fever ward, if the
physician only feels the pulse of the patient, or touches him with the
sleeve of his coat, though he may not catch the disease himself, he may
communicate it by a shake of the hand to the next friend he meets; or
that friend, without catching it himself, may give it to another; or if
the physician wash and fumigate his hand, but neglect the cuff of his
coat, he may still convey the deadly poison to every patient whose pulse
he feels during the day. If this were so, the track of a general
practitioner who attended one patient labouring under a specific
epidemic disease would be marked by the seizure of the rest of his
patients; if it were true of cholera and typhus, the members of the
General Board of Health must have fallen by these diseases, who from
morning until night received inspectors that came from places where
these epidemics were rife; and if any disease of common occurrence
really possessed such powers of communication and diffusion, it is
difficult to conceive how it is that the human race has not been long
since extinguished.[27] To assume the method of propagation by touch,
whether by the person or of infected articles, and to overlook that by
the corruption of the air, is at once to increase the real danger, from
exposure to noxious effluvia, and to divert attention from the true
means of remedy and prevention. It is not in human power to take from
any disease the property of contagion, if this property really belongs
to it; but it is in our power to guard against and prevent the effects
of any contagion, however intense; and it is equally in our power to
avoid communicating to common disease an infectious character, and
aggravating it into pestilence.
Footnote 27:
In January, 1866, the members of the Aberdeenshire Cattle Plague
Association being much interested in the question as to how the
disease could possibly have reached Pitmillan, Fovernan, no suspicious
communication by beast or otherwise having taken place with the farm
for weeks, Mr Hay, veterinary surgeon, inspector for the county, gave
the following explanation of the matter in a letter to Mr Barclay, the
hon. secretary:—“I am happy to be able to satisfy the public mind as
to how the disease was brought to Pitmillan. About Christmas Mr Fraser
got from Mr Duncan, flesher, Aberdeen, a quantity of beef rolled up in
packsheet, which had apparently paid several visits to London round
carcases, and doubtless mingled there with many of its kind from
various places of the kingdom. After being removed from the beef at
Pitmillan, this packsheet was thrown aside for some time, when one of
the servant girls took and used it (unwashed) as an apron for a
considerable period before the first cow got bad, and was carrying the
kail in it to the cow after she was taken ill. You see by this that we
are liable to get the disease at any time. Tons of packsheet return
weekly by railway, and no surer agent could be employed to bring
rinderpest to the country.” The secretary having some doubt about the
guilt of the packsheet (which however, was gravely accused in both
Houses of Parliament), reported his opinion that the contagion was
conveyed by the wind! [ED.]
If indeed the emanations thrown off from the living body formed
permanent and powerful poisons, like miasms connected with the products
of decomposition, and if they were, like such products, capable of being
conveyed unchanged to great distances, we should be able to live only in
solitude; we could never meet in society, for we should poison each
other; the first symptom of illness would be the signal for the
abandonment of the sick, and we should be compelled by a due regard to
self-preservation to withhold from persons afflicted with disease every
kind and degree of assistance that required personal attendance.
Happily, we are not so constituted, and the evidence that has been
adduced of the narrowness of the sphere even of the most virulent
contagion, shows the groundlessness of the alarm sometimes entertained
respecting this dreaded agent, while it points to the certain means of
destroying it. The London Fever Hospital is separated from the Small-Pox
Hospital only by the space of between thirty and forty feet, and the
windows of the wards of both establishments are immediately opposite
each other: yet there is no instance of the communication of small-pox
to the typhus patients, nor of typhus to the small-pox patients; nor of
either disease to the convalescent, or to the official inmates of the
adjoining establishment. There does not appear to be a single instance
on record, in any country, of the extension of infection beyond the
walls of an hospital, or even of a lazar-house, so as to injure in any
manner the nearest inhabitants.
But though it appears that modern experience and research have shed
considerable light on the origin and progress of epidemic diseases, yet
there are still some circumstances connected with their propagation
which the present state of our knowledge does not enable us to
understand, and which therefore appear to us as difficulties.
These cases are sometimes termed exceptional; but they are only
apparent, not real, exceptions; as in all other departments of human
research, they are merely indications of the imperfection of our
knowledge, and advancing science will unquestionably one day so
elucidate these very exceptions, as to render them additional
confirmations of the true conditions.
In the present state of popular opinion it has been deemed requisite to
enter into this detailed consideration of the general subject of
contagion, because it appears that in proportion as undue weight is
attached to this dreaded agent the effect is mischievous; since, “it
diverts attention from the true source of danger, and the real means of
protection, and fixes it on those which are imaginary; creates panic;
leads to the neglect and abandonment of the sick; occasions great
expense for what is worse than useless; and withdraws attention from
that brief but important interval between the commencement and the
development of disease, during which remedial measures are most
effective in its cure.”
It is also necessary to examine the questions of contagion and
quarantine apart from each other, because there are points of obscurity,
and therefore grounds for controversy, which, in the present state of
our knowledge, may be reasonably considered as belonging to the former,
that do not attach to the latter. The inquiry with reference to
quarantine, indeed, is simple, and lies in a narrow compass. The sole
question to be determined is, whether or not it accomplishes, or is
capable of accomplishing, its professed object, and this is a mere
question of evidence and experience.
The object of quarantine is to prevent the introduction of epidemic
diseases from one country into another, and the agency which it employs
for this purpose is the isolation of the sick; the detention of, and the
placing under inspection for a given period, persons who come from an
infected country or district, though they may not be actually sick; and
the purification of articles of commerce presumed to be capable of
imbibing and conveying pestilential virus, before such articles are
landed and dispersed.
It appears that facts and observations place beyond all reasonable doubt
the utter inutility of this system.
If there be any truth in the preceding representation, that epidemic
diseases are universally and inseparably connected with an epidemic
atmosphere, the question is at once decided. Quarantine can exercise no
more control over this epidemic atmosphere than over the electricity and
temperature of the common atmosphere, and the direction and force of the
wind.
If it be true that epidemic diseases, such, for example, as influenza
and cholera, traverse the globe in determinate courses or zones, and
often spread from country to country, and through the vast populations
of their great cities, in single weeks, and even days, it must be futile
to array such a machinery as that of quarantine, that is to say, a
vessel placed at the entrance of one or two seaport towns, a line of
soldiers guarding a few miles of the frontier, of a particular country
against morbific agents, which pursue their course like the blight that
destroys the vegetation of a country in a night, and which extend their
influence over the greater part of the habitable globe.
If it be true that the epidemic influence precedes the actual outbreak
of epidemic disease—that that epidemic influence is present in a
country, creating a predisposition or susceptibility to disease before
the epidemic appears in its true and recognized form,—quarantine must be
futile, because, before it takes its precautions or erects its barriers,
such as they are, the epidemic is already in the country busy in action,
vitiating the blood of the most susceptible of the population, and
preparing the way for its general attack.
If it be true, as ancient and modern authorities are agreed, that,
without the essential preliminary of an epidemic atmosphere on the spot,
foreign contagion is inert, and that, unless both concur, no pestilence
ensues, quarantine under any circumstances must be useless; for in the
absence of an epidemic atmosphere it must be useless, because then no
disease will spread beyond the individual affected; and with the
presence of an epidemic atmosphere it must be useless, because then the
disease will spread wherever the infected atmosphere goes and finds
favouring conditions.
If the preceding principle be true, it must be futile to place vessels
coming from infected countries in quarantine, unless those vessels are
capable of bringing with them an epidemic atmosphere, and unless
quarantine can control such an atmosphere when imported; and the
uselessness of this procedure will be placed in a still stronger light
when recent experience as to the comparative insusceptibility of
Europeans, though resident on the spot, to plague itself is
considered.[28]
Footnote 28:
Dr W. H. Burrell, Deputy Inspector-general of Hospitals, who was three
years Principal Medical Officer at Malta, presented, in 1852, to the
General Board of Health, an elaborate examination on the plague which
had formerly raged in that island. The following are the conclusions
to which he had arrived:—
“1. There is no evidence to prove, or even to render it probable, that
the plague was introduced either into Malta in 1813 or into Gozo in
1814 by importation.
“2. There is every reason to believe that the plague existed in Malta
at the time of the arrival of the ship supposed to have introduced the
disease; and that in Gozo the first case (a stranger) contracted the
disease from local causes, which enhanced by quarantine, produced it
in others.
“3. The lower orders, and those occupying the lowest, most crowded,
and worst ventilated dwellings, furnished the great majority of cases;
which decreased in proportion with improvement in these respects.