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156 QUARANTINE 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 Port 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. 1 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 Avere 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 chiefly to be discussed, the epidemic! ogical prin- ciples being somewhat different in the two cases. But one or two remarks have to be made about the theory of preventing the intro- duction 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. As 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 1 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. 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. Tin: 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 tliu stationary men-of-war to an almost incredible extent. On the main- land, 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 be deduced. It is not a passenger steamship arriving at Nc,w 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