QUARANTINE vs. SANITATION. BY W. T. SEDGWICK, Ph.D., Massachusetts Institute of Technology, Boston. Reprinted from the Boston Medical and Surgical Journal of August 24, 1893- BOSTON: DAMRELL & UPHAM, PUBLISHERS, 283 Washington Street. 1893- QUARANTINE vs. SANITATION. BY W. T. SEDGWICK, PH.D., Massachusetts Institute of Technology, Boston. A memorandum of unusual interest has lately ap- peared defining the attitude of Great Britain towards quarantine. England has always held a leading po- sition in sanitary affairs, so that her steady refusal to adopt wholesale quarantine at her seaports has nat- urally excited frequent comment and inquiry. It has seemed very strange to many that the nation having the largest commerce, and therefore most exposed to cholera and other exotic diseases, should be so indif- ferent, and even opposed, to quarantine. Sanitary officials of the political kind, such as too often exist in this country, have naturally supposed that England's opposition to a mediaeval system was based upon merely mercenary motives - these always offering to minds of a certain order an ample explanation of un- usual action. Sanitarians, however, have long known that the key-note of the English system is local isola- tion and, especially, general sanitation, which shall make widespread outbreaks impossible even if ex- otic diseases like cholera should be imported. To ap- ply a saying of Pettenkofer, the English have re- garded unsanitary conditions as a kind of powder for which cholera is a spark: and they have held that it is wiser to keep no powder than to spend their ener- gies in frantic attempts at beating off a spark, which, if it got in, would be sure to blow them to pieces. Quarantine, and that, too, of a rigid kind, is employed in England ; but it emphasizes sporadic, internal and domestic, rather than peripheral or frentiftr, quaran- 2 tine and deals with individuals rather than masses, - a system now generally described by the term "isolation." The memorandum referred to was compiled at the request of the Foreign Office with a view to its circu- lation amongst British representatives abroad, and to its serving as an answer to a number of requests made by foreign countries as to the action taken in England for the prevention of the spread of infection. It was prepared by Dr. Thorne Thorne, medical officer to the Local Government Board, and himself a distinguished sanitary authority, in answer to a request of the Foreign Office to be supplied with a statement " set- ting forth the general nature of the standing precau- tionary measures adopted in the United Kingdom to prevent the introduction of contagious or infectious diseases." In reply, Dr. Thorne states that even in the case of cholera, the Public Health Department of Great Britain recognizes no system of quarantine. He adds:1 For nearly fifty years past it has been held that reliance on a quarantine system would be, to a large extent, impracticable, and that any attempt to carry it out would be injurious, both by reason of engendering a false sense of security and by afford- ing a pretext to sanitary authorities for avoiding expenditure of those local funds on which, in this country, we depend alike for effecting large schemes of sanitary improvement and for carry- ing out our current sanitary administration. Hence, our princi- pal trust has been in securing amendment in every way in the sanitary circumstances under which the population are living; and defence against cholera in this sense has been supplemented by the adoption of a series of cholera regulations which apply to our ports and coast line and which are aimed at preventing the introduction of cholera by means of shipping. . . . If, as the result of examination, the medical officer of health certifies a ship to be infected with cholera, the ship must be moored at a specified place, and every person on board is re- quired to submit to examination. Every person who, as the result of that examination, is not certified to be suffering either from cholera or from any illness which the medical officer of health suspects may prove to be cholera, is permitted to land immediately on satisfying the medical officer of health as to his 1 Lancet, July 1st and 22d, 1893. 3 name, place of destination, and address at such place. This in- formation is communicated to the sanitary authority at the place of each such person's intended arrival, and it is for that other authority to take measures (which commonly include a visit for some five consecutive days, on the newly-arrived per- son) such as may be expected to prevent extension of cholera should that disease appear in any one after arrival in their dis- trict. Any person on the ship who is certified to be infected with cholera is required to be removed to a hospital provided by the sanitary authority. Should the condition of the patient not permit of this, the ship is detained under the control of the medical officer of health. And any other person certified to be suffering from an illness which it is suspected may prove to be cholera, can similarly be detained for the purposes of diagnosis for a period not exceeding two days. The ship is required to be disinfected and other precautionary measures have to be adopted as regards drinking-water, bilge-water, infected articles, dead bodies, etc., after which she is at once released. The only instance in which any further measure of restriction can be applied is as to persons on board a ship which, though not infected with cholera, either carries passengers who are in a filthy or otherwise unwholesome condition or has come from a place infected with cholera. If, in any such case, the medical officer of health deems it necessary to intervene, with a view to checking the introduction or spread of cholera, he is required to give a certificate to that effect. When such certificate has been given no person is allowed to leave the ship unless he satisfy the medical officer of health as to his name, place of destination and address at such place, such information to be utilized in the same way as in the case of a ship certified to be infected with cholera. But beyond this there is no right of in- terference either with the vessel or with those on board. The English cholera regulations do not profess to be so framed as to prevent all chance of the importation of cholera into the country. They aim at detection and arrest of all actual or sus- pected cholera at our ports and at giving the earliest possible warning to inland authorities as regards particular persons about to arrive in their respective districts. If, in spite of these measures, the disease should be imported, every sanitary authority has the responsibility for the maintenance of condi- tions which should enable them to deal with imported cholera in such a way as to prevent its extension. In a lecture delivered at St. Bartholomew's Hospi- tal, Dr. Thorne spoke more informally about the Eng- lish system substantially as follows : Up to a recent date the Continental Powers had relied essen- tially upon a rigid quarantine system. Quarantine, as applied 4 to the Thames, for example, would mean the detention of all vessels coming from infected ports for a period varying from ten to five days according as the conclusions of the Constanti- nople Conference or of the Rome Conference were accepted. Dur- ing that period healthy and sick alike would be prohibited from having any communication with the shore. If, during the quar- antine detention a case of cholera occurred on board, the whole of the crew and passengers, together with the ship, would have to go through a second period of detention and so long as any fresh attacks occurred. In the meantime shipping would be accumulating and the result for us would become a mere ab- surdity. And not only so, but half-a-crown would any night secure a boatman's service for lauding on the river banks. In short, the system would only have to be applied to ensure its immediate breakdown. England decided against quarantine for another reason. If the people in this country were told that a line had been drawn round England to keep out cholera, a death blow to our sanitary administration would at once be dealt. Since they have been told that cholera cannot, with certainty, be kept out of the country, and that they themselves must be prepared to deal with it if it is imported by maintaining their districts in such a sanitary condition that the disease shall not spread if it should make its way into them, eight millions sterling have been spent in sanitary works every year and hundreds of thousands of lives have been saved from typhoid fever and other epi- demic diseases. The general mortality has also largely de- creased and a Frenchman - an old fellow-student of his - who is now at the head of the public health service in France, has calculated that, according to the estimate of human life by Dr. Farr and other English authorities, taking all the millions we have spent and all the lives that have been saved (I forget the exact sum), we have just got our money back. It might almost seem as if we had done it on purpose. No greater calamity could happen to this country than to apply the system of quar- antine. . . . At Dover alone, in one week in August, 5,800 people arrived at the port. What would Dover have done had she been obliged to quarantine them ? They could not have them in the harbor at night, for they could easily have escaped; they could not have them on land for a similar reason. If they had put them to sea they would probably have been sunk by the first tempestuous wind. The attempt would be perfectly ridiculous and could be attended by nothing but disaster. . . . Quarantine was also a cruel process. That was best exem- plified by reference to land quarantine, as, for example, during the Egyptian outbreak of 1883, when villages and communities were surrounded by troops with loaded rifles and bayonets. Any person taking food within the prohibited line would be subject to the same quarantine as the villagers, and it is be- 5 lieved that land quarantine has often destroyed more lives by starvation and misery than would have been sacrificed by cholera. But land quarantine, too, is essentially inefficacious, the line being broken without difficulty, whether in Egypt or elsewhere, by all who can afford to pay their tribute of bak- sheesh. ... The following is especially interesting and sugges- tive : For England the abandonment of quarantine has been an al- most unmixed good. The knowledge that no pretence would be made to keep out all chance of cholera in this country, has done more perhaps than anything else to induce our sanitary authorities to spend their money on great works of sanitation and on such improved sanitary administration as is likely to prevent the spread of any imported disease of the type of cholera. Millions have been spent to this end; but, on the other band, hundreds of thousands of lives have been saved. Even if cholera should once more succeed in passing the barrier of our ports and diffusing itself inland and cause a heavy mor- tality, we should still be enormously the gainers in point of human life by the system which we have so deliberately adopted ; but there is no doubt that our system is rather calcu- lated to prevent than to lead to such a contingency. No one can successfully deny that these principles embody sound sense as well as a rational application of the best results of modern science to sanitation. In our own country at present there is still altogether too much of leaning upon federal and frontier quar- antine. This has its place ; but our great cities ought to understand that their first and principal business is to set their own houses in order ; to see that their own sanitary affairs are in expert and watchful hands, and, especially, that their public food supplies, such as milk, ice and water are free from all taint of sewage. Effi- cient local sanitation and isolation-not so much wholesale, by quarantine, as for each particular case - these are the plain teachings of common-sense as well as of modern science.