Part 6

The object of quarantine is to prevent the introduction of epidemic diseases from one country into another, and its regulations are based on the assumption of the contagiousness of the diseases with which it deals; it being supposed that such diseases are propagated by contact, direct or indirect, of the unaffected with the affected. In accordance with this view the preventive means adopted by quarantine consist of the isolation of the sick or suspected, with whom it interdicts all communication, whether by person or by articles deemed capable of transmitting contagion.

When quarantine was first established, the spread of epidemic diseases exclusively or chiefly by contagion was a doctrine universally received;[25] but during the last century a change has gradually taken place in professional opinion in almost every country in Europe, particularly in France, Russia, and Austria, as well as in America, with respect at least to several of these diseases, chiefly by medical officers, who, having had the charge of the health of fleets and armies in different quarters of the globe, have been under the necessity of studying the circumstances connected with the outbreak and spread of formidable epidemics; and also by those who, having had the care of hospitals and dispensaries in large cities, have been obliged to visit the localities and abodes of the poorer classes, where these diseases are always the most prevalent.

Footnote 25:

The wide difference between the qualifications of the accomplished popular physician and the scientific investigator into the causes of epidemic sickness was strikingly exhibited in the first outbreak of Asiatic cholera in 1831, when the emergency required not merely a knowledge of the practice of medicine, but the power also of applying the philosophy of public health to the exigencies of the moment. How were these exigencies provided for?

A board, comprising all the most eminent and skilful physicians of the day, was assembled in the College of Physicians, under the presidency of Sir Henry Halford; and, after declaring, in opposition to the unanimous opinion of the physicians of Bengal, “that no measures of external precaution for preventing the introduction of the cholera morbus by a rigorous quarantine have hitherto been found effectual,” they issued the following official notification:—

“To carry into effect the separation of the sick from the healthy, it 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.