QUARANTINE (Fr. quarantaine, a period of forty days) is, in the original sense of the term, a thing of the past in the United Kingdom and in several of the other states of Europe, as well as in America. Its interest is therefore largely historical, and a sketch of the history will be given at the end of this article. But, in common usage, the same word is applied to the modern substitutes for quarantine, although these are a complete departure in principle or theory from the indiscriminate system of detention of ships and men, unlading of cargo in lazarets, fumigation of susceptible articles, and the like, which used to be carried to great lengths on account of the plague and in connexion with the Levantine trade.

Substitute for Quarantine in the United Kingdom.—The modern practice is to detain or refuse " pratique" to no ship unless there be a communicable form of sickness on board, or there had been such during the voyage. It is the duty of the officers of customs to question the captain as to the existence of any catching disease among the passengers or ship's company; if there be any evidence or suspicion of communicable infection, the officers of cus-toms report the same to the port sanitary authorities, who have power to deal with the case under the Public Health Act, and according to an order of the Local Government Board first issued in 1873. The medical officer of health proceeds at once to make an inspection, detaining the ship and all on board only until such time as the inspection can be satisfactorily made, the sick removed to hospital, and disinfectants applied. This practice was adopted with success in the case of several arrivals from Baltic and North Sea ports with cholera on board in 1873, no exten-sion of the disease on shore ensuing, and again in 1884 in the case of a troopship arrived at Portsmouth direct from Bombay, and of at least two arrivals (at Liverpool and Cardiff) from Marseilles, with cholera on board. It is also adopted from, time to time on account of small-pox cases, and of other catching importations at the discretion of the port sanitary authority.

The last importation of yellow fever into the United Kingdom was at Swansea in September 1865, by a wooden vessel with copper ore from St Jago de Cuba. There had been cases of yellow fever on board during the voyage; but at Swansea (as in many other instances) the infection spread rather from the ship's hull and the unladed cargo than from the crew or their effects, and some fifteen deaths ensued. If such a case were to occur again, it would be dealt with, like any other communicable disease, by the port sanitary authority under the Public Health Act. The yellow-fever incident of 1865 at Swansea is the last oc-casion on which the sanction of the Quarantine Acts has been appealed to. The privy council merely directed the board of customs to warn the parties implicated of their liability to prosecution, although no prosecution would be instituted. The Quarantine Acts are still unrepealed, but they may be said to have become practically obsolete during the past twenty years.
Quarantine or its Substitutes in other European Countries. —The principle of inspection, and of isolation of the sick, as stated above for the United Kingdom, was accepted with small reservation by the sanitary conference of Vienna in 1874, and it is now more or less consistently acted upon by all the larger European maritime states except Spain and Portugal. In times of cholera panic, quarantine of the original kind has been imposed against all arrivals from an " infected country " by ports of the Levant and Black Sea, and by several Mediterranean states besides Spain. But it is only in the ports of the Iberian Peninsula that the old quarantine traditions remain in force from year to year; and it is only for them that any special account need be given.

The principal occupation of the quarantine establishment at Lisbon all the year round is with arrivals from Brazil, where yellow fever is endemic. The lazaretto of Lisbon, which is probably the largest and in ordinary times the busiest in the world, is situated on a hill opposite the Belem Tower, 4 miles below the city. The present establishment was erected by the Portuguese Government at a cost of over £200,000. It consists of seven perfectly distinct pavilions standing radially in a semicircle with the convexity to the river. It is managed by an inspector who is under the minister of the interior. Public tenders are invited every year, or every two years, for boarding and lodging the passengers according to their classes on board ship (1st, 2d, and 3d), the contract being given to the lowest bidder. The present prices for board and lodging per diem are about 5s. 6d. 1st class, 3s. 2nd class, and Is. 6d. steerage. The establishment is carried on at a loss to the Government. Quarantine is imposed, as a matter of fact, on all ships, passengers, luggage, and cargo coming from the Brazils. The term varies from five days to seven days, according as the Brazilian port is considered infected or suspected. A bill of health is issued to the captain by the Portugese consul at the port of sailing, which usually bears on it that so many deaths from yellow fever had occurred during the previous eight or ten days. If clean bills of health were issued, the quarantine would be raised; and this has happened for short periods at rare intervals. During the winter months (December, January, February), when the cold makes a development of the yellow fever virus at Lisbon improbable, if not impossible, the baggage and cargo only are subject to quarantine, the passengers being allowed to go ashore at once with their hand baggage. Throughout the rest of the year all passengers from the Brazils have to go to the lazaretto and stay there the alloted time, their effects being aired, fumigated, or disinfected. If Lisbon be the port of discharge, the cargo from an infected ship will be landed at the lazaret for purification if so directed. There is a schedule of " susceptible articles," which includes cotton, hair, hemp, letters, parcels, and other correspond-ence, hides, fresh meat, wool and linen, skin, feathers, and silk. These articles are fumigated with chlorine; the in-side of the ship is washed with chloride of lime or other disinfectant. In the case of a mail steamer on her way to England, the passengers and effects for Lisbon are landed at the quarantine grounds, and the vessel proceeds to her destination (Liverpool or Southampton) " in quaran-tine," which means nothing as regards the English ports.

This rigorous routine is a concession to the popular recollection of the terrible epidemic of yellow fever in the hot summer of 1857, when there were 19,000 cases in and around Lisbon, with about 6000 deaths, a large proportion being among the well-to-do. The importation was traced to a tainted ship and cargo from Bio. For many years, no cases of yellow fever have developed among the suspected passengers landed ; and in only two or three instances have there been cases among the employes of the establishment who are occupied with the baggage and merchandise. The Lisbon chamber of commerce is now in favour of a modification of the quarantine law, and of regulations in conformity with the prominent facts of experience—namely, that the fever is not started on shore through personal contact, but solely by emanations from a ship's hull, ballast, cargo, or passengers' effects, and that high-class iron steamships are not, in the nature of things, under the same suspicion as old wooden sailing vessels.

The quarantine practices of Lisbon are copied faithfully at the Azores, Madeira, and the Cape Verd Islands.

For Spain there are two chief quarantine stations or "foul lazarets," one for the Atlantic seaboard at Vigo, and another for the Mediterranean coast at Port Mahon, Minorca. Vessels arriving at Spanish ports with foul bills of health (from Havana, &c, in ordinary times, and from various ports in cholera times) must proceed to one or other of these appointed stations to perform their quaran-tine. A " quarantine of observation," which is usually for six or three days, and is imposed on vessels with clean bills, may be performed at any port. It is a routine maxim of the Madrid board of health that any country, such as the United Kingdom, which does not practise quarantine, is ipso facto suspected when a foreign epidemic is in any part of Europe to which its vessels trade; and all arrivals from its ports may be subjected to a quaran-tine of observation. This abstract doctrine, which can hardly be approved by responsible medical authority, was acted on for a short time as recently as 1883 and 1884, when cholera was in Egypt and in Provence.

Next to Spain and Portugal, Turkey and Greece are the countries in Europe where the old quarantine traditions have most vitality, owing doubtless to their nearness to former seats of plague in the Levant. The lazarets at the Pirasus and in the Dardanelles are considerable establishments, mostly used now in times of cholera. Ships bound inwards for Turkish ports take health-guards on board in the Dardanelles. There are many other lazarets at Mediterranean, Adriatic, and Levantine ports, including Malta and Gibraltar, surviving from the days of the plague, whose machinery is furbished up from time to time when cholera breaks out. For the whole of northern Europe, including the Atlantic seaboard of France, quarantine is now practically obsolete; by Holland it was never seriously practised even for the plague, and by the states bordering on the Baltic it was given up about the same time as it fell into disuse in Great Britain.' In Norwegian ports subsequent to 1866 there were 3128 arrivals from countries infected with cholera, on board which 25 cases of cholera were found and 29 cases of cholerine; but the malady obtained no footing on shore although quarantine was not enforced. In 1873, when cholera was prevalent in several ports of the Baltic and North Seas, there were 550 arrivals at Norwegian ports from infected countries, among which were 12 cases of cholera; but importation of the epidemic to the shore was prevented simply by inspection and isolation of the sick. In Italian ports, again, 800 vessels were quaran-tined in 1872, in not one of which was any case of cholera found. The immunity of the United Kingdom in 1873 and 1884, notwithstanding the arrival of ships with cholera on board, and even (in 1873) the unobserved land-ing of cholera cases, has been mentioned already.

Land Quarantine.—A land quarantine on a frontier is still enforced on account of cholera from time to time in southern Europe, e.g., in 1884 by Italy against France at Ventimiglia and Modena and by Spain against France in the passes of the Pyrenees, and in 1885 by Portugal against Spain. The experiment occasionally succeeds. A "sanitary cordon " is the rigorous isolation (by troops) of a pestilence-stricken place from the country around. It is a survival from the times of the plague, and is of no use in cholera.

Quarantine or its Substitutes in the Western Hemisphere. —Apart from the visitations of cholera now and then, the chief occasion of quarantine on the American continent and adjacent islands is the endemic existence of yellow fever in Brazilian and West Indian harbours, particularly Havana and Bio de Janeiro (and, since 1853, in Callao and other Beruvian ports). During the yellow-fever season from April to November, the ports of the United States are on the outlook, under the quarantine laws of each State, to de-tain vessels with yellow fever on board arriving from Gulf ports or from the West Indies and Brazil. In like manner the ports of the Biver Plate would protect themselves against foul arrivals from Brazil; and some of the Mexican Gulf and West Indian harbours will even practise quarantine against each other according as the fever happens to be epidemic here or there. The practice at New York, Boston, Philadelphia, Baltimore, and other United States ports is to detain only the sick, or those who are reasonably suspected, the lazaret (usually on an island in the harbour) being practically a hospital for sailors, immigrants, and other newly-arrived persons suffering from communicable disease. In some years the cases of yellow fever arriving at New York have been numerous, and an epidemic has now and again arisen among the residents near the lazaret. Experience has shown that the ship's hull, foul ballast, and the like have been the real sources of infection, cases occurring at New York every year among the labourers on infected ships. It is only occasionally that the unlading of the cargo of a yellow-fever ship into the quarantine barges has been insisted on. The classification of ships according as they carry clean or foul bills of health has been found to be practically unworkable in the United States, a foul bill being a rare thing. The severity of the quarantine is left, accordingly, very much to the discretion of the medical officer of the port. According to the de-finition of the National Board of Health, quarantine is " the administration employed to determine the presence or absence of the causes of contagious or infectious diseases, and to secure the removal or destruction of such causes and it does not imply detention for any specified time, nor for more time than is necessary for the above purposes. Notwithstanding the creation of a National Board of Health for the Federal Union, quarantine is still an affair of the States acting independently. The detection and isolation of small-pox cases is one of the chief occupations of the quarantine officers at United States ports.





As regards the introduction of cholera into the United States, Billings says :—" The present quarantine systems of the United States are now probably unable to prevent the introduction of this disease, as they have been heretofore. Unless the disease had actually occurred on board ship, very little precaution would be taken, and very few of our ports have the necessary facilities for properly dealing with a large passenger ship having cholera on board, in such a manner as to obtain a reasonable amount of security without causing unreasonable delay, involving unnecessary suffering and danger on the part of those not actually sick " (Trans. Internat. Med. Congress, London, 1881, iv. 416).

In several instances, when cholera has broken out among emigrants in a transatlantic steamship, the vessel has put into Halifax, N. S., where there are facilities for quarantining passengers ; and more than once the epidemic, although of the most threatening kind, has gone no farther. New Orleans has proved itself a more likely port of entry for cholera than any of the Atlantic ports.

In the ports of South America and the West Indies the quarantine practice is variable and empirical. Sometimes an absolute cordon has been established, as in the instance of Dominica against Guadeloupe in 1865-66 during the cholera. The smaller and healthier the community the more severe is the quarantine likely to be. In the West Indies, the Bermudas, etc., the very remarkable disease of dengue (probably a modern hybrid form) is considered to be an importable infection which quarantine can keep out.

Quarantine in the Red Sea and at Suez.—Cholera having come to Europe in 1865 by a new route, by the pilgrim traffic to Mecca, the conference of Constantinople in 1866 took into consideration the question of a quarantine at the Straits of Bab-el-Mandeb. Since that time such a quaran-tine has been instituted for pilgrim ships at the island of Xamaran on the Arabian side of the Red Sea, some 200 miles within the straits. Since the severe outbreak of cholera at Mecca in the end of 1881, the quarantine for pilgrim ships at Xamaran has become more stringent. The slight outbreak at Mecca in 1882 is said, without good reason, to have arisen owing to three English steamships with pilgrims having evaded that quarantine. All pilgrim ships whatsoever are required to stop at Xamaran, and the pilgrims from cholera-stricken countries in the East are disembarked and kept under observation in the lazarets on the island for ten or fifteen days.

On the dispersal of the hajj at Mecca, another quaran-tine is performed by the pilgrims returning by way of Suez, who are usually only a small fraction of the whole assemblage. They are disembarked either at Wejh on the Arabian coast half way between Jeddah and Suez, or at Tor on the Sinaitic side of the Gulf of Suez, sometimes even at both places. After the epidemic at Mecca from September to December 1881, it was not until the 19th February 1882 that the last company of pilgrims was allowed to re-embark at Wejh for Suez, by the authority of an inspecting sanitary commission from Egypt. If no suspicious cases occur, the detention is for fourteen days; but a single case subjects the whole group in which it had appeared to a further term of quarantine. Filgrims bound for Smyrna, Beyrout, or other ports in the Levant are subjected to another term of quarantine in the lazaret of the port of arrival. Those proceeding landwards to Damascus undergo a quarantine at Moses' Wells.

The usefulness of this control over the movements of the Mecca pilgrims has been much debated. Begarding the ad-vantages of the quarantine after the breaking up of the hajj there has been a good deal of positive evidence since 1865 ; but the detention at Xamaran is a much more questionable affair. In a great assemblage at Mecca, such as that of 1881, there are all the conditions for the fresh breeding of a choleraic form of sickness, which shall be communicable to others, just as there have often been (in the common-sense view) the elements of its de novo origin under pre-cisely similar circumstances among a multitude of Hindus at Hurdwar, or other religious places of resort in India; and the excessive pains taken to exclude hypothetical cases of the communicable disease coming from India, Java, or other endemic centre are disproportionate so long as there is no assurance that the soil of Mecca is not itself about to become a breeding-place of the poison de novo. On the other hand the dispersal from Mecca is obviously an occa-sion for sanitary precautions.

For the general traffic from the East a quarantine of observation of twenty-four hours is imposed on arrivals at Suez from time to time when cholera is formally declared to be epidemic in Bombay or other Eastern port. Under such circumstances, ships pass through the canal in quarantine, having their canal pilots either on board the .ship " in quarantine," or, under an older and more cum-brous arrangement, navigating the vessel from a steam-launch. In like manner, the coaling at Bort Said is done in quarantine, and the mails and passengers landed at Brindisi under the same restrictions and formalities. The question of a more searching quarantine at Suez for the general Eastern traffic has been much discussed in the French Academy of Medicine, and has been taken up more recently at Berlin; but the weight of opinion (led by M. de Lesseps) is against any such inter-ference with the quick despatch of vessels, as at once futile and impracticable. During all the years that the canal has been open, cholera has become epidemic in Europe only once owing to direct importation from the East, namely in 1884, when the vehicle was a transport returned from Saigon ; and the circumstances in that case were such that a quarantine at Suez, unless it had included the ship's hull and the personal effects on board, would have made no real difference. On the other hand, transports with recognized cholera on board have on two or three pre-vious occasions been passed through the canal with all despatch, and no harm done on shore either in the isthmus of Suez or at the port of arrival (Portsmouth, Toulon).

PRINCIPLES OF QUARANTINE. —Plague, yellow fever, and Asiatic cholera are the three great spreading diseases which have been successively the subject of quarantine restrictions. Plague For many years plague has ceased to have any practical interest in this connexion ; the last occasion of alarm in the Mediterranean ports was the outbreak of 1859, at Benghazi, in Tripoli; and at the present date the sole concern is about the land quarantine along the Turko-Persian and Russo-Persian frontiers. It is for yellow fever and Asiatic cholera, therefore, that the principles of quarantine have chielly to be discussed, the epidemiological prin-ciples being somewhat different in the two cases. But one or two remarks have to be made about the theory of preventing the introduction of other communicable diseases.

In the draft of an international bill of health which was adopted by the international sanitary congress at Washington in 1881 small-pox and typhus are scheduled along with plague, yellow Small- fever, and cholera. Although there are few countries where small-pox, pox has not obtained a footing, yet every seaport finds it advisable to prevent the free entrance of fresh cases. Thus Denmark, in 1884, took precautions against the importation of small-pox from the Thames. It is mostly in Australia, New Zealand, the Cape, and other colonies that quarantine against small-pox is rigorously carried out. Except for a limited outbreak in Sydney in 1884, that disease has been absolutely excluded from the Australasian colonies, thanks to their admirable quarantine establishments. The case is very different at the Cape, owing to the existence of a virulent native centre of variolous disease at no great distance in the interior. Typhus. A.s regards typhus, the principles of prevention are entirely different from those that apply to small-pox. When the Irish emigration by sailing ships was brisk forty years ago, typhus often came with the new arrivals to New York, Boston, Philadelphia, Quebec, and Montreal; and a similar state of things now goes on in connexion with the Italian and other European emigration to Brazil and the River Plate. Filth, overcrowding, and want are the causes of such outbreaks ; and it is only where those conditions obtain on shore that the imported disease spreads. A period of detention amidst clean and wholesome surroundings after landing has much to recommend it, the best argument for such general precaution being the fact that the disease in some instances had not occurred during the voyage, but only after the emigrants had landed in the new country. Another illustration of the need of quite special rules for typhus, and of the need of freedom from dogmatic bias about pre-existing disease germs, is the remarkable outbreak at Liverpool in 1859. The epidemic was clearly traced to an Egyptian frigate with four hundred souls on board, many of them convicts in chains. The vessel arrived in the Mersey from Alexandria in an indescrib-able state of filth ; about one hundred of the crew and others were on the sick list from diarrhoea, dysentery, and the like ; but none of the cases were typhus, nor was there a single case of that disease among the ship's company from first to last. The typhus occurred in the pilot and others who went on board in the river, among the attendants at a bath to which the filthy crew were sent to be washed, and among the patients of the Southern Hospital, into which some of the Arabs and Nubians were admitted for common complaints. To make quarantine effective against typhus, it is necessary to keep in mind that the specific fever may be vicarious to a common condition of filth and general misery. It is a modified form of the same principle of vicarious infection that, in the his-torical retrospect, gives us the key to the much more important problem of yellow fever, a disease which is to be regarded as a special form of typhus.

Principles of Quarantine against Yellow Fever.—The first Yellow requirement in the quarantine doctrine of yellow fever is to know fever, where the disease is endemic, that is to say, where its poison exists in such a form that it may rise in exhalations from the harbour mud, alluvial foreshores, or wharves and shipping quarters in general, or may enter the bilges of ships with the water. There is a natural reluctance on the part of seafaring communities in the western hemisphere to admit that they harbour the seeds of yellow fever; but some of the endemic foci of the disease are beyond dispute. The principal are Havana and Rio de Janeiro. But if we take the whole historical period of yellow fever into our view, from 1640 onwards, we shall find that there is hardly a single great slave port in the New World that has not been at one time or another a native seat and source of the miasmatic virus of yellow fever. Some of these have long since got rid of the poisonous exhalations, such as Philadelphia and Baltimore ; others, such as Norfolk, Charleston, and Savannah, have in all probability seen the worst days of the fever, and are now practically free from the taint in their harbours and their soil; but there are other United States ports, such as New Orleans, for which the like assurance cannot as yet be given. In the West Indies the ports of the Spanish An-tilles are the worst primary breeding-places of the poison at the present day ; although in the 17th and 18th centuries Bridgetown (Barbados), English Harbour (Antigua), Fort Royal (Martinique), and Basse Terre (Guadeloupe) were poisonous to the crews of the stationary men-of-war to an almost incredible extent. On the main-laud, Georgetown, Demerara, is in the same rank ; and the Brazilian ports (particularly Rio) have been so since 1849. Besides these harbours, all of them among the principal slave-ports at one time or another, there are others, such as Vera Cruz, Tampico, Chagres, and Porto Bello, which would seem to have lurking in their soil or shore-mud the specifically noxious thing that produces yellow fever ; but it is a question whether these have not got the virus at second-hand from other centres in the Gulf. Again, it is probable that the occasional outbreaks at Monte Video had been caused by material quantities of the specifically noxious filth carried thither in trading bottoms. The great epidemics in the ports of Spain in the first quarter of this century were certainly due either to reship-ment of the virus from the West Indies in the bilges of merchant-men, or to an original deposition of it from contraband slave-ships making the return voyage to Europe with cargoes of produce (see an article by the writer in the North American Review, Oct. 1884). The rare outbreaks in Europe within the last fifty years have been due to foul arrivals from slave-ports like Havana and Rio.





Wherever the line be drawn between endemic and non-endemic , ports of yellow fever, it is only the latter that can in reason seek to impose quarantine against the disease. Of such are now the ports on the Atlantic seaboard of the United States, the ports of the River Plate, and the whole European seaboard; for these the history is full of instances of true importations traceable to particular vessels, and from such instances the principles of an efficacious quarantine may he deduced. It is not a passenger steamship arriving at New York or Lisbon with a case or cases of yellow fever on board that calls for quarantine (as distinguished from isolation and care of the sick); no real epidemic can be shown to have ever arisen from purely personal importation of that kind. The great epidemics in Spain and Portugal, and the more recent and smaller outbreaks in New York and in some ports of northern Europe, have been traced to other sources than the persons of the sick. Even a ship with a fever-stricken crew is dangerous, not so much because of the fever among the crew, but on account of those lurking causes of yellow fever in the ship through which the crew themselves were infected. There is an overwhelming mass of testimony that the real risk of importing the yellow-fever virus is always in the foul bilges of wooden ships, which had been lying in one of the endemic yellow-fever harbours. The poison is sucked in through the ship's seams ; it ferments or multiplies in her bilges, rises as miasmata to infect the hold or 'tween decks, sometimes clinging to cargo, and perhaps making no sign until the cargo is all out. Again, in temperate latitudes, the virus may be imported and do no harm, unless it meet with a tract of exceptionally hot 'weather, such as happened at Swansea in 1865. According to this principle, all iron ships, which have little or no bilge-water, and all clean ships whatsoever, are practically free from the risk of importing an epidemic of yellow fever, even although one or more of their passengers or crew may have developed the malady on the voyage, having come on board in the stage of its incubation. The only question of practical consequence in the case of iron steam-ships arises in connexion with the modern practice of carrying water-ballast in tanks or compartments of the ship's bottom. On the other hand a wooden ship from a yellow-fever port, especially if she have open seams and had lain long in the harbour or " careenage," is not above suspicion on arriving during hot weather, even if no cases of yellow fever had occurred on board during the voyage. Such vessels have often carried the yellow-fever poison in their bilges ; in some cases they had not been suspected until it was too late, and in other cases of mysterious outbreaks they have never been suspected at all because they had no actual cases on board. The grand lesson of experience in yellow fever is that the ship's hull is infinitely more dangerous than the persons of yellow-fever patients ; and a ship's hull is dangerous only because there is a material quantity of specifically poisonous filth fermenting in the recesses of the hold. All high-class iron ships, and clean ships in general, are, for common-sense purposes, above suspicion. The persons of the sick are little likely to introduce the fever ; but foul linen, bedding, and clothes are a source of danger, especially if they have been in a box or bundle for some time (witness the slight outbreak at Madrid in 1878 on the unpacking of soldiers' baggage brought via Santander from Cuba). Cholera. Principles of Quarantine against Cholera. —The peculiar dangers of cholera diffusion arise from the vomited and purged matters which are characteristic of. the common type of the malady. Under certain circumstances the discharges of the sick are infective ; they are probably not infective as they come from the body; but even minute quantities of the choleraic matters, if they have fermented in the ground, or in boxes and bundles of foul linen, bedding, or clothes, may exhale a virus which is often suddenly prostrating in its action. Thus every person with cholera, or even with choleraic diarrhoea in times of epidemic, is a source whence many more may be poisoned. When the choleraic matters percolate into wells or reservoirs the poisoning may be on a great scale. Cholera with such infective properties is an exotic to the soil of Europe and probably of all countries except south-eastern Asia; and, if the in-fective discharges of cholera patients from the East were kept out of Western soil, no choleraic disease would he likely to become epidemic on the latter. Such exclusion has been more or less the endeavour of all Western states from the time of the first invasion through Central Asia in 1831. The only question is whether, by attempting too much, they have not lost the opportunity of con-trolling the spread of the disease by less drastic means. The instances where cholera has been kept out by a rigid cordon, or the strictest form of quarantine, are few: it is probable that Spain owed her immunity in 1849, when all the rest of Europe suffered, to her policy of exclusion; there was a strikingly successful instance of the same in the case of Dominica in 1865, during a frightful cholera mortality in Guadeloupe, only 22 miles distant; and it has happened more than once for Portugal to keep out the epidemic and for Sicily to protect herself for a time against the mainland of Italy. But in the great majority of instances the quarantines against cholera have been "elaborate illustrations of leakiness." Island communities have the best chances of succeeding; hut in the case of the British Islands the attempt has been abandoned as impracticable. The British policy of attempting a good deal less was justified by success in 1873, when the Baltic and North Sea trade went on uninterruptedly, notwithstanding the presence of cholera at various ports across the water. In 1874 the inter-national sanitary conference of Vienna adopted an abstract resolution by a large majority approximately in favour of the British practice, though the conference of Rome in 1885 was slightly reactionary. According to this practice a case of cholera is received into the country with much the same sort of assurance as a case of typhoid fever would be. There is much reason to believe that in both cases the agency of the soil or other tertium quid is needed to give potency to the poison, and that the diffusion of both diseases can be limited by disposing of the discharges of the sick in such a way that they shall neither taint the soil or the water, nor ferment on unwashed linen or bedding. Wherever a filth-sodden soil receives the choleraic matters, poisonous miasmata will rise from it; and such miasmata will also arise even in houses or on board ship, or from bundles and boxes of effects, if cleanliness be thoroughly overpowered by the stress of events. In India such cholera-soils exist from year to year, or are capable of being made on occasion, as at great religious fairs ; and in that respect some Indian soils are to cholera what certain of the harbours and fore-shores of the western hemisphere are to yellow fever. Both diseases in their native seats are primarily caused by specific miasmata from the tainted soil. But in Europe the spreading power of cholera is infinitely greater than that of yellow fever because the choleraic-matters are more copious, and more likely to ferment under all circumstances of climate, locality (coast and interior), states of weather, and differences of race. But there is still a reasonable prospect of finding a good substitute for quarantine against cholera, in the fact that its power of spreading is certainly made subject to conditions. The maxim for cholera is—Take care of the conditions, and the disease will take care of itself. Cholera is what Pettenkofer calls an " exogenous " infection: the infective matter acquires its virulence, not in or upon the body, as in a case of small-pox, but outside the body, amidst filth or other sanitary neglect. The reason why cholera is more difficult to manage than typhoid fever is that it is peculiarly a disease of the poor; poverty has always been the true quartermaster of cholera. The virus is transported (in the WTest at least) from place to place largely by emigrants, religious pilgrims (as in Russia), fugitives, tramps, or others hard pressed by circumstances ; one of the most remarkable instances of that kind is its alleged transmission, in 1833, from Kansas across the Rocky Mountains to the Pacific by parties of Indians successively infected. The danger from the wandering poor is all the greater that they would be naturally unwilling under any circumstances to sacrifice their small belongings of clothes, bedding, and the like, which are often the real media of infection. It is not to be denied that the old-fashioned detention for a week or more in a lazaret has still something to recommend it for such poor classes of travellers ; but the detention will be more likely to give vitality to any lurk-ing virus of the disease than to extinguish it, unless the lazaret be particularly well found in all the conveniences of living.

HISTORY OF QUARANTINE. —The first lazarets in Europe were con-structed for the plague ; and that disease was the only one for which quarantine was practised (not to mention the earlier isolation of lepers, and the attempts to check the invasion of syphilis in northern Europe about 1490) down to the advent of yellow fever in Spain at the beginning of the 19th century, and the arrival ot Asiatic cholera in 1831. Venice took the lead in measures to check the spread of plague, having appointed three guardians of the public health in the first years of the Black Death (1348). The next record of preventive measures comes from Beggio in Modena in 1374. The first lazaret was founded by Venice in 1403, on a small island adjoining the city; in 1467 Genoa followed the example of Venice ; and in 1476 the old leper hospital of Marseilles was converted into a plague hospital, the great lazaret of that city, perhaps the most complete of its kind, having been founded in 1526 on the island of Pomegue.

The practice at all the Mediterranean lazarets was not different from the English procedure in the Levantine and North-African trade, to which the rest of this sketch will be confined. On the approach of cholera in 1831 some new lazarets were set up at Western ports, notably a very extensive establishment near Bordeaux, afterwards turned to another use.

The plague had disappeared from England, never to return, for more than thirty years before the practice of quarantine against it was definitely established by an Act of Parliament of Queen Anne's reign (1710). The first Act was called for, owing to an alarm lest plague should be imported from Poland and the Baltic; the second Act of 1721 was due to the disastrous prevalence of plague at Marseilles and other places in Provence; it was renewed in 1733 owing to a fresh outbreak of the malady on the Continent, and again in 1743 owing to the disastrous epidemic at Messina. In 1752 a rigorous quarantine clause was introduced into an Act regulating the Levantine trade ; and various arbitrary orders were issued during the next twenty years to meet the supposed danger of infection from the Baltic. Although no plague cases ever came to England all those years, the restrictions on traffic became more and more stringent (following the movements of medical dogma), and in 1788 a very oppressive Quarantine Act was passed, with provisions affecting cargoes in particular. The first year of this century marks the turning point in quarantine legislation ; a parliamentary committee sat on the practice, and a more reasonable Act arose on their report. In 1805 there was another new Act, and in 1823-24 again an elaborate inquiry followed by an Act mak-ing the quarantine only at discretion of the privy council, and at the same time recognizing yellow fever " or other highly infectious disorder" as calling for quarantine measures along with plague. The steady approach of cholera in 1831 was the last occasion in England of a thorough-going resort to quarantine restrictions. The pestilence invaded every country of Europe despite all efforts to keep it out. In England the experiment of hermetically sealing the ports was not seriously tried when cholera returned in 1849, 1853, and 1865-66. In 1847 the Privy Council ordered all arrivals with clean bills from the Black Sea and the Levant to be admitted to free pratique, provided there had been no case of plague during the voyage ; and therewith the last remnant of the once formidable quarantine practice against plague may be said to have disappeared. The quarantine establishment fell gradually into disuse, and is now represented by a hulk at the Motherbank (Portsmouth), which is kept up solely for formal reasons.

For a number of years after the passing of the first Quarantine Act (1710) the protective practices were of the most haphazard and arbitrary kind. In 1721 two vessels laden with cotton goods, &c., from Cyprus, then a seat of plague, were ordered to be burned with their cargoes, the owners receiving £23,935 as indemnity. By the clause in the Levant Trade Act of 1752 vessels for the United Kingdom with a foul bill (i. e., coming from a country where plague existed) had to repair to the lazaretto of Malta, Venice, Messina, Leghorn, Genoa, or Marseilles, to perform their quarantine or to have their cargoes " sufficiently opened and aired." Since 1741 Stangate Creek (on the Medway) had been made the quarantine station at home; but it would appear from the above clause that it was available only for vessels with clean bills. In 1755 lazarets in the form of floating hulks were established in England for the first time, the cleansing of cargo (particularly by exposure to dews) having been done previously on the ship's deck. There was no medical inspection employed, but the whole routine left to the officers of customs and quarantine. In 1780, when plague was in Poland, even vessels with grain from the Baltic had to lie forty days in quarantine, and unpack and air the sacks; but owing to remonstrances, which came chiefly from Edinburgh and Leith, grain was from that date declared to be a " non-susceptible article." About 1788 an order of council required every ship liable to quar-antine, in case of meeting any vessel at sea, or within four leagues of the coast of Great Britain or Ireland, to hoist a yellow flag in the day time and show a light at the maintopmast head at night, under a penalty of £200. After 1800 ships from plague-countries (or with foul bills) were enabled to perform their quarantine on arrival in the Medway instead of taking a Mediterranean port on the way for that purpose ; and about the same time an extensive lazaret was built on Chetuey Hill near Chatham at an expense of £170,000, which was almost at once condemned owing to its marshy foundations, and the materials sold for £15,000. The use of float-ing hulks as lazarets continued as before. In 1800 two ships with hides from Mogador (Morocco) were ordered to be sunk with their cargoes at the Nore, the owners receiving £15,000. About this period it was merchandise that was chiefly suspeeted: there was a long schedule of "susceptible articles," and these were first exposed on the ship's deck for twenty-one days or less (six days for each instalment of the cargo), and then transported to the lazaret, where they were opened and aired forty days more. The whole detention of the vessel was from sixty to sixty-five days, including the time for reshipment of her cargo. Pilots had to pass fifteen days on board a "convalescent ship." The expenses may be esti-mated from one or two examples. In 1820 the "Asia," 763 tons, arrived in the Medway with a foul bill from Alexandria, laden with linseed ; her freight was £1475 and her quarantine dues £610. The same year the "Pilato," 495 tons, making the same voyage, paid £200 quarantine dues on a freight of £1060. In 1823 the "William Parker" from Alexandria paid £188, or 5£ per cent, on the value of her cargo. In 1823 the expenses of the quarantine service (at various ports) were £26,090, and the dues paid by shipping (nearly all with clean bills) £22,000 ; in 1824 the figures were respectively £23,704 and £14,419. A parliamentary return moved for by Mr Forster showed the expenses of the quaran-tine establishments at Rochester, Portsmouth, Bristol, Milford, Liverpool, and Bo'ness for the year ending 6th January 1846 to be £15,590. A return for the United Kingdom and colonies moved for by Mr Joseph Hume in 1849 showed, among other details, that the expenses of the lazaret at Malta for ten years from 1839 to 1848 had been £53,553. Under the direction of Sir W. Pym, the superintendent-general of quarantine, the home establishments were gradually reduced from 1846 onwards ; and the reports of the Board of Health (signed by Chadwick, South-wood Smith, and others) in 1849 and 1852, which argued against quarantine, although not always on sound epidemiological prin-ciples, gave a further impetus in the same direction. The most recent appeal to the quarantine law (at Swansea in 1865) has been referred to above.

Literature.—The most considerable treatise on quarantine is the article (pp. 106) by Leon Colin in the Dict. Encyl. des Sc. Med., 3d section, vol. i., Paris, 1874 {with a bibliography). There is also a general article by Reincke in Eulenburg's Handbuch des Gesundheitswesen. A quarantine committee of the Social Science Association collected, in 1800-61, valuable consular returns on the practice of quarantine in all parts of the world; these were edited by Milroy and ordered to be printed (with the report and summary) as three parliamentarv papers com-municated to the board of trade. The third paper (6th August 1861, No. 544) contains, in an appendix, an Historical Sketch of Quarantine Legislation and Practice in Great Britain, by Dr Milroy, from which the above historical notes have been largely taken. See also Sherston Baker, Law of Quarantine, Lond., 1873. Russell's Treatise of the Plague (4to, London, 1791) contains "remarks on quarantines, lazarettoes, &c," and an account of the mode of "shutting up" practised by households in Aleppo on the outbreak of plague in the town. On plague-quarantines, see also Hirsch, in the Vierteljahrsschrift Oeffentl. Gesundheitspflege, 1880, xii. 6. The inexpediency of quarantine hi the United Kingdom is discussed by John Simon in the eighth Report of the Medical Officer of the Privy Council for 1865, p. 35. The fifth Report (new series), 1875, contains an abstract by Seaton of Proceedings of the International Sanitary Conference at Vienna, 1874. (C. C.)



Footnotes

Sir William Pym, the superintendent-general of quarantine, who visited most of them officially in 1844, narrates a ease at Messina which illustrates the abuses that these establishments might be put to : " it is only very lately that the board of health at Messina placed a vessel (the 'Rapid') from England under quarantine, because a report had appeared in the papers of a fever having prevailed at Glasgow, and subjected her to a charge of about 3 per cent, upon the value of her cargo for quarantine fees " (Correspondence respecting the Quarantine Laws, Pari. Paper, 1846, p. 16).
The lazaret for all the Baltic states was on the Swedish island of Kanso at the entrance of the C'attegat opposite Gothenburg.

The working of the quarantine at Xamaran will be best understood from a particular instance. The steamship " Hesperia" sailed in July 1882 from Bombay for Jeddah with 498 pilgrims, who had been inspected under the Native Passengers Act. She arrived on the 26th July at Aden, where she was quarantined for ten days owing to the death of one of the firemen from cholera. Xamaran was reached on the 8th of August, and the pilgrims landed for a ten days' quarantine. Deaths having occurred among the pilgrims on shore, a second quaran-tine of ten days was imposed ; and towards the expiry of that time the health officer again placed the ship in quarantine for ten days owing to more deaths on shore. On September 8, when the vessel was still in quarantine, it became necessary to proceed to Aden for coals, steam having been kept up continually owing to the dangerous nature of the quarantine moorings. In leaving Xamaran tile ship broke her quaran-tine, and only escaped the threatened fire of the Turkish gunboat by her speed. She returned from Aden on the 19th September, and re-embarked her passengers for Jeddah on the 23d, two of them dying in the boats during the embarkation. The drinking-water of the quaran-tine camp at Xamaran was credibly stated to be in a fetid condition, causing vomiting and purging, and the food insufficient anil inferior. Each pilgrim had to pay 10 rupees, and the ship 12,000 piastres of sani-tary dues. After landing her passengers at Jeddah, the "Hesperia" proceeded on her voyage to Liverpool, undergoing a twenty-four hours' quarantine of observation at Suez.—Brit. Med. Journ., 1882, ii. 952.

The international sanitary conference of Rome (1885) has pro-posed a relaxation of the rule: each ship with more than thirty pilgrims to carry a doctor, and no ship to be detained more than 24 hours, nor the pilgrims disembarked, unless there be or has been cholera on board.

A large majority of the medical delegates to the conference of Rome (1885) voted in favour of detaining at Suez for at least five days such vessels as might be judged by an officer of the International Sanitary Commission to be suspect,—the passengers to be disembarked and isolated in groups.



The above article was written by: Charles Creighton, M.D.