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CONTAGIOUS DISEASES.

Quarantine and the Cholera, with special reference to the present Epidemic in the Mediterranean. By GAVIN MILROY, M.D.

THE Association having taken so prominent a part in the investigation of quarantine, through the committee which was appointed at the Annual Meeting in Liverpool, in 1858, and which continued its labours till 1861, it seems but right that the attention of this Depart ment should be drawn to the subject at the present time, when its operation is being felt in all the countries bordering on the Mediterranean, and as this operation will be still more widely felt if the cholera extend to other countries.

It may be remembered that the circumstance which led to the institution of that committee was the then recent outbreak of a malignant fever, having many of the characters of the Oriental plague, at a point on the Eastern Barbary coast, not far from the town of Benghazi. The disease, it was afterwards found on inquiry, had been existing for a great many months, among the wretched and famishing Arab population of the district, without any special notice having been taken of it; and it was only when the dreaded name of the plague began to be given to the fever, which hitherto had been regarded as typhus, that all the complex machinery of the quarantine system was immediately set in action, not only throughout the entire extent of the Mediterranean, but in the oceanic ports of Spain and Portugal, and even as far as St. Petersburg, and other Russian ports in the Baltic. The system, in all its rigour, was kept up for many weeks and months. The disease never extended beyond the district where it first broke out, nor affected any persons there but those who were living in squalor and want. It was a purely local outbreak, and ceased when the people were moved out of their filthy dens, and were duly supplied with food. Not even a trace or suspicion of the distemper was ever seen either in Alexandria or any other place on the coast of Africa, or in the hundreds and thousands of vessels that were subjected to a more or less lengthened quarantine detention, throughout the entire extent of the Mediterranean sea-board.

On the present occasion, the danger against which quarantine has been, and is being, directed, is much more formidable, alike from the already wide spread of the cholera, and the extreme malignity of the disease wherever it has appeared. If quarantine can preserve a country from the invasion of such a scourge, it is clearly the duty of every enlightened government to enforce its vigorous adoption, whatever may be the cost incurred, or the inconvenience and loss inflicted on individuals or on commerce. Salus populi suprema lex will unquestionably hold good, in the judgment of wise men, in such matters; and as the subject is, unquestionably, one of the most

important with which State medicine has to deal, its consideration appears to me to be peculiarly suitable at such a meeting as the present; for it is eminently a social question, and pre-eminently an international one. Moreover, it is one of those mixed questions on which laymen may fairly judge of the value of the evidence on which the stem rests, nearly as well as medical men; and it is very certain that no satisfactory solution of many of the controverted points relating to it will ever be come to, until enlightened public opinion is brought to bear upon this investigation.

Fortunately, the subject has recently been attracting a good deal of attention in several foreign countries; and it is likely to attract still more throughout Europe, since the institution of those annual international gatherings, on the plan of this Association, in different leading cities on the Continent. At the meeting of the "Association Internationale pour le progres des Sciences Sociales," last year, beld in Amsterdam, it formed one of the questions set down for special consideration in the Public Health Department; and it was men. tioned at the séance, when the subject was discussed, that the Dutch Government has lately had it under their consideration.

I wish, in limine, to state that the object of the present paper is simply narrative and historical, viz., to record, from the imperfect means of information at command, what has hitherto taken place throughout the Mediterranean; and then briefly to compare some of the recent circumstances and results with what occurred in former epidemics of the pestilence-chiefly with the view of keeping public attention to the subject, and of inviting all, and specially medical men, to follow the devious course and progress which the present epidemic will yet in all probability pursue (it may be this year, or it may be next year) in countries yet unattacked; and to watch the results of the measures, adopted in each, to avert or exclude the scourge from their peoples. Hitherto, far too little profit has been gained from the experience of former visitations, in the way of guidance for the future. When the danger is past, all is forgotten; the next visitation is left to care for itself; and then the very same things are done, and the same efforts are made, and the same anxiety and panic incurred, with little or no regard all the while to the teachings of the past.

One other prefatory remark. Let the true and real nature of quarantine, or, in other words, its interpretation in practice be steadily borne in mind, whenever the subject is spoken of; for much, very much, of the error and controversy about it, even in the writings of medical men, is owing to the want of a clear definition c what is meant by the term. It is not, as we shall presently see, the mere detention of sick persons, or of sickly ships, arriving in a port hitherto exempt from the apprehended disease, and the segregatiza and purification, during an allotted time, of such sick persons or

* I had the honour of being requested by the Council of the Association to read a paper on the subject; it is printed in the "Annales de l'Association." &c.,1865.

ships. But it is the detention and segregation of all persons, and of all vessels, coming from an infected place, whether or not any sickness whatever has occurred on board during the voyage, or exists on board at the time of arrival; the theory being, that the persons or ships, although remaining healthy themselves, may yet hold and bring with them, in some way or other, the disease, in a latent or undeveloped state. I would again state, that it forms no part of my present paper, nor comes within its scope, to enter into any discussion of this or any other theoretical topic of the subject. All who may be interested in the inquiry, I would beg leave to refer to my former papers in the Transactions of this Association, and to the report of the committee already mentioned.

The earliest acknowledged cases of the epidemic in Alexandria occurred in the second week of June; but whether these were really the first instances which had been seen, and whether there had been any peculiarity in the antecedent state of the public health indicating the advent of the disease, we have at present no means of accurately determining. That the cholera had been previously prevailing at Mecca, and at other points of the Arabian peninsula on the Red Sea, is known; but, beyond this single fact, more cannot be affirmed. Considering the season of the year-about Midsummer-a season, too, remarkable almost everywhere for excessive heat, it is more than probable that the development of the cholera on the present occasion, as in former epidemic visitations, was not a sudden or unheralded event, but had been preceded, for some time, by the prevalence of diarrhoeal and other intestinal affections among the lower classes in Alexandria, and the other towns and villages in the delta of the Nile which were first attacked. The pestilence seems to have appeared almost simultaneously at several widely-distant points of the country, in that malarious region. Rosetta, Tanta, Damietta, &c., were affected about the same time as Alexandria. The panic soon became so great in the latter city that thousands of the population took to flight, scattering themselves in all directions, and spreading alarm, if not the disease, wherever they went. All the Mediteranean ports had of course resorted, on the earliest intelligence, to the adoption of quarantine restrictions, of greater or less rigour and duration, upon arrivals by sea from Alexandria. The Austrian government was among the first to establish a quarantine upon all arrivals therefrom at Trieste passengers to be detained seven days in the lazaret, the ship to be fumigated, and goods and letters on board to be subjected to the customary purification of being smoked or passed through water. At Malta, too, similar measures were put in force about the same time; so that the Peninsular and Oriental Company's steamers ceased to have any direct communication with the island on their homeward or return voyage, to the no small inconvenience of a multitude of passengers, as well as to the interruption of considerable commerce. Such persons as were landed-although in health at the time-were confined in the lazaret for seven days, if no sickness had occurred on board during the voyage, and for twelve days if other

wise. Notwithstanding these precautions, cases of the disease began to manifest themselves in Valetta, in the second and third week in July; few and sporadic at first, and gradually becoming more numerous and widely-diffused, until the epidemic reached its acme about the end of August. Malta, having frequent and rapid communication by steam, as well as by sailing vessels with very many places in the Mediterranean, was treated with extreme rigour by the neighbouring states. In Sicily, an embargo was placed upon all intercourse; so that the commerce between the two islands was all but suspended, to the very serious suffering of the small traders, boatmen, and others, dependent for their means of subsistence on the traffic between them. Such was the alarm on the part of the authorities and others in Sicily, that not only were vessels arriving from Malta, and other infected ports, refused admission into the harbours, although everyone on board was in health and not a case of sickness had occurred on the voyage, but they were warned off the coast, under the threat that they might be fired into, if any attempt was made to land. Many vessels bound for Sicilian ports, in conse quence, had to proceed on to Naples, and there remain in quarantine, for five or six days, at the small island of Nisida in the bay.

The state of matters in Malta at the present moment is altogether very strange. Since the subsidence of the disease at Alexandria, the Egyptian authorities have imposed a quarantine of seven days upon arrivals from Malta; and, on the other hand, Malta, although still having the cholera in her midst, imposes a quarantine of ten days upon arrivals from Marseilles, and one of twenty days upon arrivals from Constantinople or Ancona. Most people will be puzzled to understand the meaning of such proceedings. They cannot surely be believed to afford any real protection to health; while they inevitably cause serious detriment to the trade of the island, and a vast amount of vexatious interference with intercourse. The Peninsular and Oriental steamers refuse to land any goods either from Alexandria or from Marseilles; they stop at Malta only to coal. Passengers, if they wish to be landed, must go into the lazaret for the specified number of days.

What quarantine measures had been adopted at Ancona, prior to the severe outbreak there, and what were the circumstances under which the earliest cases took place in that seaport town on the Adriatic, I am unable to say. A great many places on and near to the coast of Italy, from Ancona southwards to Brindisi, have, it is well known, suffered severely; but whether from alleged intercommunication with places previously infected, or quite independently of any traceable communication, there is no evidence as yet to show.

It is worthy of remark, that the epidemic has not spread to the north of Ancona, as it has done to the south, although the cir cumstances, as to intercourse, have apparently been quite similar. Sporadic cases only have, it is reported, occurred in Modena and its neighbourhood; also in Acqui, and one or two other places in Piedmont; but there has been nothing like an epidemic prevalence in

these districts. Moreover, the disease has not hitherto manifested itself at any point along the western or Tyrrhene coast of the Italian peninsula, from Genoa to the Straits of Messina. At Naples, besides the comparatively mild quarantine by sea-mild as compared with that enforced throughout Sicily, and with that formerly practised under the Bourbon dynasty-a sort of sanitary cordon has been established round the city, as a defence against persons coming from the Adriatic coast: but, in truth, the disease seems not yet to have crossed the Apennines.* Travellers, too, arriving from Rome, and other uninfected places to the north, are said to be subjected to fumigation at the railroad stations outside the city, before they are permitted to enter; but such a proceeding must be rather to humour the prejudices of the populace, than for any expected useful purpose. The present government of Italy are disposed, we believe, to relax much of the rigorous restrictions hitherto imposed; but the ignorant fears of the masses stand in the way. An important fact, worthy of notice, is that in the between 200 and 300 vessels which have, each, been detained for from five to seven days at Nisida, having an aggregate of between 13,000 and 14,000 persons on board, not a single case of cholera is said to have occurred, either on board the vessels, or in the lazaret on shore.

At Rome, the impression appears to be that the baggage of the travellers by land is more liable to convey the poison of the disease than the travellers themselves; for there has been an edict for some time past in force, that "Every traveller arriving at Rome, who cannot prove by authentic documents that he has dwelt for at least fifteen days in a place free from suspicion of the cholera, shall have his baggage transported for purification to the Casino di Papa Giulio, about two miles distant from the gates." This regulation has been adopted, it is said, for the benefit of travellers who, wishing to avoid the quarantine of seven days at Civita Vecchia, prefer to land at Leghorn or Naples, and thence proceed by road to Rome.

Now, leaving Italy, let us follow the epidemic westward, and see what measures have been adopted, and with what results, in Spain and France. And first, of our own important colony, the "Rock," guarding the entrance on the one shore of the great inland sea. At Gibraltar, quarantine was established on all arrivals from Alexandria about the same time as at Malta; and there, too, it has proved unsuccessful as a defence against invasion. The cases which occurred first were solitary, and at considerable intervals; then, as the disease exhibited no tendency to spread, hopes were at one time entertained that it had entirely disappeared, and the town and fort were, in consequence, officially declared to be free from all infection, to the great relief of the bulk of the civil population, whose subsistence mainly depends on the constant traffic with Spain on the one

* Within a week or ten days of the reading of this paper, the epidemic began to manifest its presence in and around Naples, viz., about the middle of October.