Chapter III: Part 3

That there has not been a single death from typhus, or any other form of
continued fever, among the adults in any of these buildings since
their establishment; and that during the two first visitations of
epidemic cholera, with the exception of two cases which occurred under
peculiar circumstances, there was no attack of cholera in any of these
buildings, while from four to six deaths from the pestilence occurred
in single houses in the immediate neighbourhood.

Such are the results of the first imperfect attempt at improvement; which, remarkable as they are, are not more striking than the results of neglect. Of the children born in the best part of a town one fifth die before they attain the fifth year of age; of the children born in the worst, one-half die before they attain their fifth year. The inhabitants of the worst localities attain little more than one half of the age of those who live in the best. Of 100,000 children born in Surrey, 75,423 attain the age of ten years; 52,000 live to the age of fifty; and 28,878 live to seventy. In Liverpool, out of 100,000 persons born, only 48,211 live ten years; 25,878 live fifty years; and 8373 live seventy years. The probable duration of life in Surrey is 53 years; in Liverpool it is 26 years. Were the whole of the metropolis as healthy as the Model Dwellings, there would be an annual saving in London of nearly 20,000 lives. But these lives are not saved; this number of persons is allowed to perish every year, and they are as truly and as needlessly sacrificed as if they were taken out on Bethnal-green and shot.

When we bear in mind the suffering which in every case accompanies this waste of life, and the suffering which must inevitably follow it, and remember that it is admitted that these dreadful evils are remediable and preventible, it is difficult to suppress the natural feelings of indignation and of sorrow, that in a country calling itself Christian the application of the known remedies should be so long delayed.

It is right however to acknowledge that something has been done, and is in progress, for the improvement of the sanitary condition of the people. The principle is admitted that it is the duty of the Legislature to deal with this matter, and the first systematic legislative effort to bring about a better state of things has been made.

The Public Health Act is in operation, and the general and proper application by local authorities of the powers it confers would place every part of every town in Great Britain in as good a sanitary condition, at least, as that of the Model Dwellings.

Up to the present time (1855) there are under this Act 196 towns, containing a population of upwards of 2¼ millions. In about 50 of these towns, however, nothing has yet been done.

Eleven towns, with a population of about half a million, have adopted the powers of the Act in subsequent local acts.

Works of drainage and water supply are completed, or are in an advanced state, in 70 towns.

Mortgages have been sanctioned—

For drainage works nearly 1¾
and water supply, millions
sterling;

────────────────────────────────────
For private works of about £45,000;
drainage and water
supply,
────────────────────────────────────
For paving, street about £200,000;
improvements, &c.,

Making a total of nearly two millions sterling devoted to sanitary improvement.[24]

Footnote 24:

This has been since greatly increased: see Appendix, p. 129. [ED.]

It is difficult at present to give the average cost of these combined and complete sanitary works; but the total expense for public and private works of drainage and water supply for houses of from £10 to £20 per annual rental, may be taken at 4d. per week per house.

The great obstacle to sanitary progress is the fear of rates, not so much on the part of the poor, who gladly pay for the improvements, but on the part of the owners of small tenements, by whom chiefly opposition is raised to the application of this Act.

In the town of Alnwick, public and private works of sewerage and drainage have been completed. There have been laid down about twenty miles of sewers and drains, and seventeen miles of apparatus for water supply, at a total cost, for the combined works, of 4d. per week per house for the term of thirty years; after the expiration of which period the cost of the works, both principal and interest, will have become liquidated, and the only expense thereafter will be for maintenance.

On inspecting these works, I saw in the tenements occupied by the lowest classes a high degree of cleanliness, wholesomeness, and comfort, and heard from the inhabitants an expression of the greatest satisfaction.

We have as yet no certain knowledge of the extent to which such works are capable of preventing sickness and lengthening life. But the most perfect drainage, combined with the most ample supply of water, will not alone secure for the public health all which it is practicable to accomplish. There must also be provision for the better construction of the houses of the poor; for the prevention of overcrowding; for street ventilation and cleansing, and for the exclusion from the neighbourhood of human dwellings of filth-creating animals and of noxious trades. When all this is done, as it might be done, and as it would be done were there a general perception of the crying evils it would remedy, Epidemics would disappear, the more formidable of them immediately, and all of them, I believe, in the end.

From the whole of these facts and observations we see—

1. That Epidemics are under our own control; we may promote their spread; we may prevent it. We may secure ourselves from them. We have done so. We have banished the most formidable. Those that remain are not so difficult to be conquered as those that have been vanquished. The causes of Typhus are more completely under our control than those of Intermittent. We have banished Intermittent. We may put an end to Typhus. We have actually done so. We have encompassed the Model Dwellings by a barrier which neither typhus, nor even cholera, nor any of the other causes of excessive sickness and premature mortality have been able to pass. To the residents within that barrier the chance of life has been almost doubled; to their children it has been doubled; and compared with some other children of their own class it has been increased fourfold.

2. We see that Epidemics are not made by a Divine law the necessary condition of man’s existence upon earth. The boon of life is not marred with this penalty. The great laws of nature, which are God’s ordinances in their regular course and appointed operation, do form and give off around us, products which are injurious to us; but He has given us senses to perceive them, and reason to devise the means of avoiding them, and epidemics arise and spread because we will not regard the one, nor use the other.

3. We see that there are circumstances which render it doubtful whether civilization has yet attained a point that places it beyond the danger of retrogression. States in some respects of higher civilization than our own have relapsed into barbarism. There is indeed one circumstance which may give us hope; there is one humanizing principle which is now at least recognized and in partial operation, of which there is no trace in any nation of antiquity. I mean the principle of kindness as a governing influence, distinguished from the principle of brute force.

That the whole human race is one family, that the people of every colour, clime, language, government, and faith, are one brotherhood, and that the same law of love which is the bond of the union, strength, and happiness of a single family, is equally binding on the universal family of mankind, are the fundamental and distinguishing principles of our religion; and in proportion to our conformity in our private and public life to the spirit of these divine principles, advancement in civilization is certain; relapse into barbarism is impossible. But as yet there is no such conformity. We neglect the education of the people, quarrelling about the mode, and postponing the thing. We devote to a life of absorbing labour the child and the youth ungrounded in the elements of knowledge, untrained to habits of self-restraint, thereby dooming the man to the blankness and turbulence of ignorance and intemperance. We equally neglect the sanitary condition of the people. We make no provision for securing to the humblest classes, and they can make none for themselves, the conditions that are essential to their physical health, the loss of which to them involves and includes every other. We thus neglect body and mind, and then the disorders and vices which necessarily follow we endeavour to repress by punishments that harden but never reform, neither trusting nor trying the influence of gentleness, which our religion teaches us is stronger than ignorance, stronger than crime, and can master both. It is this state of things that places in danger the ark of civilization.

Lastly, we see the first step that must be taken to elevate the people: nay, even to bring them within the pale of the civilization already attained. We must improve their sanitary condition. Until this is done, no civilizing influence can touch them. The schoolmaster will labour in vain; the minister of religion will labour in vain; neither can make any progress in the fulfilment of their mission in a den of filth. Moral purity is incompatible with bodily impurity. Moral degradation is indissolubly united with physical squalor. The depression and discomfort of the hovel produce and foster obtuseness of mind, hardness of heart, selfish and sensual indulgence, violence, and crime. It is the Home that makes the man; it is the home that educates the family. It is the distinction and the curse of Barbarism that it is without a home: it is the distinction and the blessing of Civilization that it prepares a home in which Christianity may abide, and guide, and govern.

[The foregoing is from the Edinburgh Lectures. See Introduction. ED.]

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QUARANTINE AND CONTAGION.

[From First and Second Reports on Quarantine. See Introduction. ED.]

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.

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.

“4. As this discriminative preference of the disease to attack certain
classes, living in certain localities, never obtains to the same
extent with diseases arising from a specific contagion, it is more
than probable that the causes engaged in the generation of the plague
are not constant, but variable and accidental; its initial cause, the
peculiar atmospheric constitution, having no power to develop the
disease, unassisted by season and local conditions.

“5. The transmissibility of plague from person to person out of the
noxious atmosphere in which it originated—the only certain test of
such a power—has not been proved by the four instances, during
thirty-eight years, in which it is alleged to have been communicated
to persons employed by the Quarantine Department of Malta, carbuncular
affections being endemic among the population of this island.

“6. Quarantine restrictions enforced by the penalties of _corporal
punishment_ and _death_, and seconded by the greatest dread of contact
with suspected persons or things, among the panic-struck populations
of Malta and Gozo, utterly failed to arrest the progress of plague; on
the contrary, where these restrictions were carried to their utmost
limits by an absolute power, there the disease persisted longest, and
the mortality was greatest.”

“All these circumstances,” says the French Dr Chervin, speaking of the
restrictions and cruelties of quarantine, “are calculated to fill with
horror the breast of every feeling and honest man; and we are really
obliged to offer violence to ourselves in not giving vent to our
indignation against the partisans of contagion, who yet desire to
continue to defend their erroneous opinions, and who, to this day,
have used all their efforts to make obscure and disfigure the subject,
to the great detriment of truth;—who have never ceased to deceive
governments, which think it their duty, with regard to this disease
[Yellow Fever], to surrender themselves to the judgment and knowledge
of medical men,—who have never ceased to describe it as contagious,
and have induced those authorities to adopt, with respect to it, the
most false and contrary measures, and to neglect the suitable,
prophylactic, and _preservative_ means, and others which might have
put an end to the disastrous epidemics of this disease;—thus it is
they have always acted contrary to truth, to the interest of
governments and of humanity.”

“I am of opinion,” says Dr Reece, of New York, “that the oppressive
features of our quarantine system should be reckoned among the relics
of barbarism which an enlightened Legislature should make haste to
abrogate for the sake of our character as a people. There is no
pretext for the perpetuation of a system founded in ignorance, and
fruitful only in public and private injustice, cruelty, and wrong.”

“Cholera,” says Professor Caldwell, of America, “though a fatal
scourge to the world, will, through the wise beneficent dispensation
under which we live, be productive of consequences favourable alike to
science and humanity. Besides being instrumental in throwing much
light on the practice of physic, it will prove highly influential in
extinguishing the belief in pestilential contagion, and bringing into
disrepute the quarantine establishments that have hitherto existed.”

If the great practical truth, taught by modern investigation and experience, be, that the only real security against any kind and degree of epidemic disease is an abundant and constant supply of pure air, the prevention of overcrowding, and the dispersion of the sick; and if, as is generally agreed, confinement in a foul atmosphere can convert common fever into pestilence, and ventilation and dispersion can dissipate any contagion, then quarantine must be not only useless but pernicious, since the invariable effect of quarantine as hitherto practised in all countries has been the congregation and confinement of the sick, and of those who, though not actually sick, are suspected to have in them the seeds of disease, requiring only a few days or hours for their development,—the congregation and confinement of such persons in a limited space, often in a filthy ship and an unhealthy locality, and always under circumstances calculated to excite apprehension and alarm—conditions in the highest degree favourable to the generation and spread of disease: it follows that quarantine, instead of guarding against and preventing disease, fosters and concentrates it, and places it under conditions the most favourable that can be devised for its general extension; and therefore must not only fail to accomplish its object, but tend to produce the very calamity which it endeavours to prevent.

* * * * *

The principal ground on which objection is made to the continuance of quarantine is that the fundamental principle on which it is based is fallacious, and that the only means of preventing the origin and spread of epidemic disease is the adoption of sanitary measures. Substitution of sanitary measures for quarantine restrictions would render the importation of any disease from one country into another in the highest degree improbable.

There has been and continues to be a popular impression of the importation or the contagiousness of disease, created by the frequent occurrence of epidemic diseases amongst itinerant classes of the population. Seeing the occurrence of such diseases amongst those who travel, it is an easy and apparently a natural inference that the diseases are carried by them. Thus, the low tramps’ lodging-houses in our towns were in the Sanitary Report shown to be throughout the country the worst of fever-nests in each place; but they were also shown at the same time to be the places where there was the most overcrowding and the greatest filth. With a stationary population, with the same overcrowding and filth, it may be confidently pronounced that the disease would be worse. When by bad weather the tramps are detained and kept stationary, it is worse. The tramping about from town to town and in the open air—the movement which to superficial observation imports the disease—in reality mitigates it. From what we have already said, it is consistent with this general statement that tramps infected with fever in one place may carry it with them and spread infection in another place amongst classes of persons predisposed by the like habits and conditions, as was exemplified in the spreading of the Pali plague. Of late times the poor Irish emigrants are said to have imported fever into this country; they are represented, for example, to have imported fever into Liverpool; but the description of the places where the fever burst out, and the overcrowding in them, displayed fever-nests sufficient to have produced fatal results on the most robust of the stationary populations. “In one small cellar with no window,” a gentleman, who ministered to the wants of the poor people who had crept for shelter into damp uninhabited houses, and who, it was stated, fell a victim to the contagious nature of the fever, found “eighteen persons in fever, lying on wet dirty straw. In one house he counted eighty-one, in another sixty-one, in every stage of fever, on straw in the corners.” It would be surprising if the poor Irish had not imported fever into the lower districts of towns, when, as in Glasgow, they have added 10,000 annually to the already overcrowded and wretched population of that city; just as the miserable refugees from the infected villages of Ragpootana carried the pestilence into the close, filthy, and already overcrowded huts of the neighbouring villages. But the conditions in which the Irish emigrants have arrived, and have been crowded together in the towns as well as on shipboard, are just the conditions in which fevers arise amidst stationary populations; and, we may confidently state, would have been worse had the particular class of migrants been stationary.

The like delusion as to the _importation_ of disease is created by the appearance of fever amongst the migrants at sea. It is important that the universal effects of overcrowding, filth, and atmospheric impurity should be known and discriminated in all cases. It will be seen that they produce their effects at sea as well as elsewhere. It appears to be most important also to display the facts as to the common existence of the conditions of fever in ships themselves as at present regulated; and that, if properly regulated, instead of being fever-nests or “the means of importation” of the disease, a voyage in the open sea would become a sure means of arresting any such disease. Epidemic disease is often more severe in ships when stationary in port than when sailing, and with them the passage in fair weather when overcrowding is avoided is a means of mitigation.

The sanitary regulation of the ships themselves—a measure of the utmost importance to the seafaring classes of the community—would accomplish far more than could be hoped for or pretended to be accomplished by any known system of quarantine, and would have, moreover, a beneficial effect upon popular opinion by removing the fallacious appearances which favour the belief in imported disease, while they divert attention from the true causes of disease, the removable and preventible causes that exist on the spot.

The basis of sanitary legislation is the evidence that has been accumulated in relation to the whole of the epidemic, endemic, and contagious diseases, and the latest opinions of medical authorities with reference to them. It having been shown by indubitable evidence that the prevalence and mortality of typhus, scarlatina, cholera, and every other epidemic disease, are uniformly in proportion to the low sanitary condition of the population, the Legislature has decided on attempting to check the prevalence of these diseases by laying the foundation of sanitary improvement.[29] It appears that the measures adopted by the Legislature with this view should be consistently carried out and applied to the dwellings of all classes of the population whether on land or at sea. In the larger vessels in which well-directed care has been exercised, the general ill-health has been reduced below the average ill-health of populations of the like ages on shore; but from the evidence which has been brought from witnesses at the ports, medical men well acquainted from long practice in the mercantile marine, it appears that the _general_ condition of merchant-vessels, and of the forecastle in which common seamen are, for the most part, lodged, renders them in effect cellar-dwellings, just as dark, foul, and unventilated, as the filthy, unaired, and dismal cellars on shore with which the Legislature has endeavoured to deal. It appears also that typhus and other epidemic diseases do break out at sea in these movable cellars, just as they do in the cellars of the dirtiest courts on shore; and were it not that seamen work in a purer external atmosphere, that they are below decks comparatively for short intervals only, and that in general they are men at the most robust periods of life, it is probable that epidemic disease would be still more frequent among them; an inference supported by the fact that whenever passengers, emigrants, and others are, owing to stormy weather, much confined to the berths below, some form of malignant disease is almost sure to break out.

Footnote 29:

See pp. 57, 129, works executed after this was written. [ED.]

* * * * *

There are not wanting instances in which the energetic adoption of such measures as were available, particularly the enforcement of all practicable means of cleansing, and the resolute removal of nuisances, warded off Cholera to a very great extent, even under circumstances in which a formidable attack appeared inevitable; and perhaps it may serve for encouragement and guidance to direct attention to one or two of such examples.[30]

Footnote 30:

The two following examples are taken from “Results of Sanitary
Improvement,” by Dr Southwood Smith, 1854. [ED.]

One of the most remarkable of these occurred at Baltimore, during the prevalence of epidemic cholera in America, in 1849.

The population of that city was about 149,000 souls. The site of the town is naturally salubrious, and parts of it are well built; but the districts near the river occupied by the poorer classes are low and damp, and liable to remittent and intermittent fevers, and, therefore, predisposed to cholera.

In the spring of 1849, the pestilence, which had attacked with great violence several neighbouring towns, appeared to be close upon the city. A general conviction prevailed, both among the authorities and the citizens, that uncleanliness had much to do with the development and spread of the disease; they therefore spared neither money nor labour to purify the city, and they gave the execution of the cleansing operations to experienced and energetic officers, who performed the work so vigorously, that it was generally admitted that never before had the town been in so clean a state, or so thoroughly purified, as during the summer months of the year 1849.

About the middle of June, while cholera was prevailing at New York, Cincinnati, and other places, north and west of Baltimore, diarrhœa broke out, and became general over the whole city, accompanied by another symptom which was universal, affecting even those who had no positive attack of diarrhœa; namely, an indefinable sense of oppression over the whole region of the abdomen, seldom amounting to pain, but constantly calling attention to that part of the body.

“At that time,” says the medical officer of the city, “I felt assured that the poison which produced cholera pervaded the city; that it was brooding over us; that we were already under its influence, and I anticipated momentarily an outbreak of the epidemic. In about two weeks, however, from the commencement of this diarrhœa, and the prevalence of the uneasy sensation which accompanied it, these symptoms began to subside, and in a short time they wholly disappeared. Simultaneously with their disappearance, cholera broke out at Richmond, and other towns south of Baltimore. I then felt assured that the fuel necessary to co-operate with this poison did not exist in our city: that the cloud had passed over us and left us unharmed.”

No case of cholera was reported to the Board of Health or other authorities of the town as having occurred during this time; but on close examination, it was ascertained that four deaths had taken place from the disease in its most virulent form.

That the cholera poison had really pervaded the city, was appallingly evinced by an event which occurred in its immediate vicinity.

The Baltimore almshouse is situated about two miles from the city, on sloping ground, remarkable for its beauty and salubrity, in immediate contiguity with the country-seats of several of the wealthy families of the town. It is surrounded by a farm of upwards of 200 acres, belonging to the establishment, for the most part under cultivation. The building is capable of accommodating between 600 and 700 inmates. An enclosure of about five acres, surrounded by a wall, adjoins the main building upon its north side. In the rear of this north wall is a ravine, which at one point approaches the wall to within about nine feet. This ravine is the outlet for all the filth of the establishment. It is dry in summer, but retentive of wet after rain. The space between the wall and the bed of the ravine is not under tillage, but is overgrown with a rank, weedy vegetation, common in rich waste soils. The physician of the establishment, under the same apprehension of an outbreak of cholera as had prevailed in Baltimore, had taken the same precautions against the disease, and had placed the establishment itself in a state of scrupulous cleanliness.

On the first of July cholera attacked one of the inmates. On the seventh a second attack occurred. This was followed in rapid succession by other seizures, and within the space of one month 99 inmates of the establishment had perished by cholera.

Within the building and grounds the most diligent search failed to discover anything that could account for this outbreak; but on examining the premises outside the northern wall, there was found a vast mass of filth, consisting of the overflowings of cesspools, the drainage from pigsties, and the general refuse of the establishment. “In short,” says the medical officer, “the whole space included between the ravine and the wall, upon its north side, was one putrid and pestilential mass, capable of generating, under the ardent rays of a Midsummer sun, the most poisonous and deadly exhalations.”

During the greater part of the time that this outbreak continued, a slight breeze set in pretty steadily from the north, conveying the poisonous exhalations from behind the north wall directly over the house.

The first persons attacked were those who happened to be particularly exposed to the air blowing from the north side of the building.

On the male side of the house there was no protection from the ravine. The female side was partially protected by three rows of trees. The residents on the women’s side were more numerous than on the men’s, but the attacks were considerably less.

Among the paupers, those who slept in apartments exposed to the north were attacked, those not so exposed generally escaped.

In the basement story of a building, opening directly to the north, and close to a spot which received the contents of one of the cesspools, 17 lunatics were lodged, all of whom were attacked, and all died.