Extract from the Eighth Report of the Medical Officer of the Privy Council, 1865 (John Simon)

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Extract from the Eighth Report of the Medical Officer of the Privy Council, 1865

I have dwelt on the above qualifications in order that I may not be misunderstood in the remarks which I am about to make, doubtless in the contagionistic point of view, on the foreign diseases which came under consideration in 1865. Of these, for my present purpose, cholera is infinitely the most important. Cerebro-spinal meningitis, if diffusible by human intercourse, is not so in a high degree. Yellow fever (apart from other considerations concerning it, to which I shall hereafter advert) may at present be assumed to have little or no tendency to spread in this country. But with cholera the case is different. Not disregarding the qualifications which I began by setting forth: not asserting that the mere uniform influence of contagion would account for the several fitful spreadings of cholera from the East; not ignoring that the power of the cholera-contagium in our climate varies almost infinitely according to local circumstances, and specially according to those circumstances which regulate the distribution of typhoid fever: I yet, for public health purposes, deem it quite essential to insist on the evidence which is now accumulated in all the archives of European Medicine, attesting the contagiousness of cholera.

The doctrine on this subject which in my opinion deserves, in the present state of knowledge, to be accepted as practically certain—sufficiently certain, I mean, to be made the basis for precautionary measures, may be stated in the following propositions:—that, when cholera is epidemic in any place, persons who are suffering from the epidemic influence, though perhaps with only the slightest degree of diarrhoea, may, if they migrate, be the means of conveying to other places an infection of indefinite severity; that the quality of infectiveness belongs particularly, if not exclusively, to the matters which the patient discharges, by purging and vomiting, from his intestinal canal; that these matters are comparatively non-infective at the moment when they are discharged, but subsequently, while undergoing decomposition, acquire their maximum of infective power; that choleraic discharges, if cast away without previous disinfection, impart their own infective quality to the excremental matters with which they mingle, in drains or cesspools or wherever else  they flow or soak, and to the effluvia which those matters evolve; that if the cholera-contagium, by leakage or soakage from drains, or cesspools, or otherwise, gets access, even in small quantity, to wells or other sources of drinking-water, it infects in the most dangerous manner very large volumes of the fluid; that in the above-described ways even a single patient with slight choleraic diarrhoea may exert a powerful infective influence on masses of population among whom perhaps his presence is unsuspected; that things, such as bedding and clothing, which have been imbued with choleraic discharges, and not afterwards fully disinfected, may long retain their infectious properties, and be the means of exciting choleraic outbreaks wherever they are sent for washing or other purposes.

The precautions, generally, which may be taken against contagious diseases are of two kinds:—first, if possible, to prevent the entrance of the contagion;—secondly, if the contagion be present, to annihilate as far as possible the circumstances which favour its spread.[1] And thus, as regards cholera, a first and incalculably important question to be answered by those who have to care for the public health of a country, is the question `whether, by any measures of quarantine, they can provide that all contagion of the disease shall be kept outside the limits of their land.

Subject to one qualification which is not an important one for the present argument, it may, I think, be accepted as certain that quarantine, conducted with extreme rigour, and with the precision of a chemical experiment, will keep cholera out of any part of Europe in which the extremely difficult conditions can be absolutely fulfilled[2] and thus, if I speak to the dry question of medical practice, I have no hesitation in saying that England ought to resist cholera by quarantine. On the other hand, though I cannot pretend to discuss with any kind of authority the non-medical aspects of the question, it would be mere pedantry for me to ignore that facts which are of common notoriety, and considerations which are of common sense, conflict with that medical conclusion. A quarantine which is ineffective is a mere irrational derangement of commerce; and a quarantine, of the kind which ensures success, is more easily imagined than realised. Only in proportion as a community lives apart from the great highways and emporia of commerce, or is ready and able to treat its commerce as a subordinate political interest, only in such proportion can quarantine be made effectual for protecting it. In proportion as these circumstances are reversed, it becomes impossible to reduce to practice the paper plausibilities of quarantine. The conditions which have to be fulfilled are conditions of national seclusion; and the fulfilment of such conditions by England would involve fundamental changes in the most established habits of the country.

In order to illustrate this view, the medical postulates of quarantine deserve to be considered in detail. Quarantine, purporting to be effectual, cannot rest satisfied with excluding from entry such persons as are obviously sick, but, indispensably for its purpose, must also refuse to admit the healthy, till they shall have passed in perfectly non-infectious circumstances, at least as many days of probation as the disease can have days of incubation or latency;—this condition often involving as its consequence that, if one case of disease arise among a number. of persons in quarantine, the whole number of apparently-healthy must recommence their period of probation, and this perhaps again and again. Now, setting aside, as not essential to quarantine, the cruelties which its mal-administration involves, and which in practice are almost identified with its exercise: criticising only the conditions which quarantine, if it is to be effective, must involve: and, for the moment, not even counting as an objection the cost of that gigantic establishment which has to be permanently maintained in order to meet occasional exigencies: I here insist only upon the restrictions.[3] Considering what they, when really carried into effect, must involve—what inconvenience to persons, what interruption to commerce, and on how vast a scale, and for what indefinite duration of time, no one can expect, in regard of great trading communities, that governments, if they go so far as to enact, will have much success in enforcing, quarantine. Against the efficiency of it, when enacted, there operate some of the strongest of all law-breaking influences; on the one hand, instincts of contempt for the narrow self-protectiveness which it represents, and, on the other, those eager commercial interests which now mainly govern the world. The latter, in proportion as they are affected, elude the restrictions which would embarrass them. Contraband of quarantine, like ordinary smuggling, is developed as soon as the inducements for it are considerable. And thus, practically speaking, where great commercial countries are concerned, it can scarcely be dreamt that quarantine-restrictions will be anything better than elaborate illustrations of leakiness.

In respect of England, moreover, there are other facts to be stated. In 1832-3, when some sort of quarantine against cholera was adopted here, the results gave no encouragement to a repetition. Then followed the erroneous belief (which subsequent better knowledge has corrected) that the spread of cholera is unaffected by human intercourse. Under these and other influences the thought of quarantine in England became more and more obsolete, and the possibility of enforcing it, if ever so much desired, fell more and more towards nothingness. Probably there was the practical conviction that, against any contagious disease current on the continent of Europe, quarantine, of the utmost strictness which England could hope to attain, would not give results worth the sacrifice. I daresay that quarantine in England was never otherwise than very lax. And at all events for many years past it has, in every medical sense, been abolished. Also with its virtual extinction, the establishment for giving it effect has declined. As successive governments advanced further and further in relinquishing what probably at its best was only a sham of quarantine, corresponding reductions of establishment were made. And the result of the entire process may be told in these very few words,—that, at the present moment England has not in readiness the means of properly quarantining even a single ship.[4] It is not for me to say that this state of things may be deemed final. But if reversal of the policy which it expresses were ever so much desired, it could not be effected off hand. Enormous first expenditure of money in creation of proper lazarets would be wanted, as well as subsequent very large annual outlays for maintaining the necessary establishments. And the time which would be required for bringing the organization into work forbids the supposition that this could ever be done on emergency.

So, for England, under present circumstances, quarantine against cholera, as existing in the countries which are nearest to us, is a precaution of which there can be no serious thought. Were the country ever so ready to endure those extreme restrictions without which the whole thing is fruitless and absurd, the means for imposing them do not exist.[5] To extemporise a cordon sanitaire is simply and totally impossible; and no partial quarantine can be relied on for national purposes. Not only as regards cholera, but generally as regards all contagious disease, the position, which now has to be recognized and dealt with, is—that contagions current on the continent of Europe must be deemed virtually current in England.

Having regard, however, to our entire unprotectedness by quarantine against any contagions which may threaten us from abroad, I feel it additionally incumbent on me to insist on the present very imperfect state of our sanitary law and administration. Especially in view of the present re-infection of Europe by Asiatic cholera the necessity for a better state of things seems to me of the most urgent kind.

On the one hand I would beg leave again to refer to the evidence which is summed up in my last report, and is corroborated by new instances in the present one, as to the very ex-tensive inoperativeness of the Nuisances Removal Acts in England.

And on the other hand I would refer to the observations, which conclude my letter (Appendix No. 9.) addressed to the Lord President in April last, on the powerlessness of local authorities in regard of certain dangers of contagion. The footing on which the country now stands in relation to foreign contagions is, I apprehend, this:—that they have to be dealt with like our ordinary home-bred contagions; that, for preventive purposes, no action, or at least no’ effectual action, can be taken by the general executive of the country; that, so far as any good is to be got out of proceedings directly against contagion, this, like the good of indirect proceedings, has to be sought in the vigour of local authorities. It therefore becomes quite essential that the position of local authorities generally, in regard of contagion, should be reviewed. As to contagions already current in the country, practically any diseased person scatters his infection broadcast almost where he will—typhus or scarlatina, typhoid or smallpox, or diphtheria; and, under present circumstances, it cholera were in a district, the patient with choleraic diarrhoea would form no exception to the general licence. I cannot say that the exceptional case of the foreign infection seems to me of more importance than the every-day case of our native diseases; but I would venture to submit that, with regard to both classes indifferently, the present unlimited licence seems urgently to demand restriction. As in the case of typhus or typhoid, so also in the case of cholera: or, to use one general description, in the case of any dangerous contagious disease: the local authority, I submit, ought to have the power of requiring from the diseased person that, in regard of residence and otherwise, he shall so conduct himself as not unnecessarily to multiply the chances of extending his infection to others. Subject to the condition that proper hospital-accommodation can be offered, the authority ought to be able to enforce, in regard of any dangerous contagious disease, that the sufferer should not be in circumstances which promote the spread of disease to the general population. This power, exercised in seaport towns in relation to the poorer classes who might arrive infected from abroad, would in effect work thus:—such persons would be debarred from resorting to the common lodging-houses and crowded tenement-houses of the town, and would (as much to their own advantage as to that of others) be constrained to go to the local hospital, there to remain till cured. How far such a power for local authorities would be delegable to them under the Quarantine Act, or would require special legislation, is perhaps not a question of any ultimate importance, and is one which I am not competent to discuss. It deserves notice, however, that if the power in question were vigilantly used by local authorities, and in conjunction with other sanitary powers, its exercise would not of necessity be only of local effect, but might under some circumstances contribute, even importantly, to those national purposes which quarantine is intended to accomplish.[6]

[1] To the above-mentioned two kinds of precautions may be added, with regard to many important cases, a third, as follows:—So far as practicable, not to bring into personal relation with the sick, as attendants or otherwise, any persons who have not before acquired, or probably acquired, an insusceptibility to the existing disease. In typhus-epidemics, for instance, economies of valuable life may often be made by preferring for employment as nurses, doctors, inspectors, and so forth, persons who have already once had typhus. The same principle applies to many other contagions fevers; but I have no evidence that it in any degree applies to cholera. If I mention yellow fever in this note it is not with any intention of classing it as a contagious fever in the sense in which typhus is contagions; but, as the same principle of conduct is involved in both cases, this may be a convenient place for observing, that when yellow fever is epidemic in districts, persons to be sent into those districts ought, as far as possible, to be only persons who have already had that disease.

[2] The qualification with which the above opinion is guarded relates to the uncertainty how far the mysterious influence which starts, and perhaps accompanies, each pandemic extension of cholera, is an influence which creates new centres of “spontaneous generation” for the disease. As regards Europe, there seem to be strong presumptions against the likelihood that any such new centres are created. But this negative cannot be deemed absolutely certain; and of course the qualification becomes more and more important, in proportion as the country to which the question applies is near to those countries where cholera first had its beginning.

[3] It may be convenient to consider the restrictions in some detail, and with cholera to illustrate their bearing. The incubation-time of cholera, in the strict medical sense of the words—i.e. the time which elapses between the moment of infection and the moment when critical inquiry may first discover an altered (though perhaps but very slightly altered) action of the bowels, may be not more than two or three days; but practically the incubation-time of the disPnco must be regarded as of much longer duration—as continuing, namely, till the symptoms are so far developed that the sufferer cannot overlook or disguise them; and this point in the progress of the disease may not be reached till the first slight looseness of bowels’ (which many persons would overlook or deny) has continued for many days, or, it is said, even for weeks. If for the purposes of the argument we assume that an allowance of ten days will cover the time during which infection can be latent or designedly concealed: which, however, is less than the time on which quarantining governments insist, and I believe, only half the time of an average quarantine in Greece: and if we translate into practical language what this would mean, if England had quarantine against the continent: it would be, that ten days would be the minimum time in which any person, sick or healthy, could enter England from the continent—that, for instance, our present 90 minutes between Calais pier and the Dover railway-station would become an affair of at least ten days, and that no national advantage from quarantine could be promised, if this rule were in any single case relaxed or evaded.

[4] It may be proper to mention that the ceremonies to which, under the name of quarantine, certain trans-atlantic ships are subjected, on their arrival in this country, have not, properly speaking, any medical significance in relation to this country, but are part of an international obligation contracted for commercial reasons.

[5] When cholera last year broke out so vehemently at Alexandria, and was hitherto not in Europe, it would have been, comparatively speaking, a trifle to quarantine arrivals from that one port; not only because of their being few, in comparison with the innumerable arrivals from the ports of continental Europe, but also because, with the long voyage, the object of quarantine would generally have accomplished itself before arrival. And medically, of course, such a precaution was to be desired. But while my Lords still had it under consideration, whether to establish this amount of quarantine, and to provide the means of conducting it, cholera had already almost ceased at Alexandria, and had shown itself in other various ports. Before proper quarantine arrangements against Alexandria could have been organised, no quarantine would have been self-consistent which bad not been a quarantine against France, Turkey, Spain, Italy, and Germany, as well as against our own possessions of Malta and Gibraltar; and doubtless the contagium of cholera was in Southampton long before any effective arrangements could have been called into existence for excluding it.

[6] For obvious reasons it is only to a small extent that legal restrictions can avail to prevent the spread of such contagions as are once current in the country. They can only apply to conduct by which the public health is manifestly and directly endangered, and not to all kinds of such conduct. But in proportion as the physiology of contagion gets to be better understood by the public, the influence of legal restrictions will be increased by the appeals which well-informed persons will be able to make, and to which the example of such persons ought to give force, against all reckless conduct in such matters. Conditions of lodgment, as discussed in the text, are not all that require consideration. Complaints are often made of the freedom with which persons imperfectly convalescent from contagious fevers (as, very notably, from smallpox) expose themselves in places of common resort, and a careless sending of sick children to school often does much to spread diphtheria, scarlatina, and other contagious diseases; the careless transmission of infected things to common laundries, and of course the traffic in infected rags, imply dangers of the same sort; and against all such sorts of action the public ought to have some ready means of protecting itself. So, too, as regards the use of public carriages by persons contagiously diseased : no doubt a proper organisation for the conveyance of sick persons ought to form, part of the medical relief arrangements of every large town, and the use of the common public carriages ought then to be forbidden but if, as often happens in our present circumstances, persons who have smallpox and other dangerous contagious diseases cannot be taken to hospital except in common street cabs, surely the subsequent disinfection of every such carriage might be insisted on. Other dangers are for personal, rather than municipal, precaution. For instance, the modes by which puerperal fever is spread, and the extreme and fatal sensibility of puerperal women to the contagion of scarlatina, are matters which require, both generally from the public, and specially from persons who visit from one sick room to another, far more thought than is yet given to them. See App. No. 7., and Sixth Report, p. 59. Here also, I may observe, for the consideration of those whom it concerns, that our new institution of Turkish baths, used in common by swarms of persons—by some more or less for health, but by numbers also for mere enjoyment or curiosity, involves (inter alia) some awkward chances of syphilitic contagion : indeed Turkish baths are now among recognized means of treatment for persons with constitutional syphilis, who, in some cases, have local symptoms by which the disease can be communicated : and the question whether such patients take the general run of public baths, and are among the numbers who nakedly occupy the seats and couches of common sweating-rooms, is one which may greatly concern other frequenters of such establishments.