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QUARANTINE;
GENERAL PRINCIPLES AFFECTING ITS ORGANIZATION.
THE TRANSMISSIBILITY OF YELLOW FEVER AND
       CHOLERA IN THEIR RELA TION TO
                QUARANTINE.
(Read before the New York Academy of Medicine, and requested by The Medical
    Society of the State of New York for publication in its Transactions.)
S.  OAKLEY VA
EL, M. D.,
Health Officer of the Port of New York;  late President of the Medical Society
      of the State of New York; Honorary Fellow of the New
            York Academy of Medicine, etc., etc.
      ALBANY, N. Y. :
CHARLES VAN BENTHUYSEN & SONS,
         l874.
s^V1-^ 
 
I 
DIX   ISLAND   HOSPITAL
         STATKN ISLAND IN THK DISTANCE. 
PERSPECTIVE VIEW
    FROM THE

  SOUTH WEST
QCBTMNS
RESERVOIR
      CLOSETS
SANITARY BUILDINGS
OFFICERS SERVANTS QUARTERS ENGfNE HOUSE 10
■OAT LAHDIH6
HOFFMAN   ISLAND 
 
GENERAL PRINCIPLES
AFFECTING THE
ORGANIZATION OF QUARANTINE.
A PAPER READ BEFORE THE NEW YORK ACADEMY OF MEDICINE, IN
   DECEMBER, 1873, AND, BY RESOLUTION OF THE MEDICAL
     SOCIETY OF THE STATE OF NEW YORK, REQUESTED
       FOR PUBLICATION IN ITS TRANSACTIONS.
                BY


     S. OAKLEY VANDEKPOEL, M.D.,

HEALTH OFFICER OF THE PORT OF NEW YORK ; LATE PRESIDENT OF THE
  MEDICAL SOCIETY OF THE STATE OF NEW YORK ; HONORARY
    FELLOW OF THE NEW YORK ACADEMY OF MEDICINE, ETC.
           ALBANY:
CHARLES VAN BENTHUYSEN & SONS,
    PRINTERS, STEREOTYPERS AND BINDERS.
             1874. 
 
General Principles affecting the Organization of Quarantine; a paper read before
  the New York Academy of Medicine, in December, 1873, and, by resolution of
  the Medical Society of the State of New York, requested for publication in its
  Transactions.  By S. Oakley Vandekpoel, M.D., Health Officer of the Port of
  New York.
  The consideration of the subject of quarantine is based upon the
notion that there is  a class of blood-poisons which are transmissible.
It is, I  believe, admitted that there are those of a  strictly endemic
character, dependent upon local conditions, and, with the exception
of typhus fever, rarely extending beyond the influence of those con-
ditions.  With this single exception they are not contagious, or, to
use a more fashionable term, in the place of one which, since the
days of Frascator, has  done good  service, and explained succinctly
the idea intended to be conveyed,  they are not transmissible.
  There is, however, another  class, which may be termed exotic in
origin, and to prevent  the importation or  transmission of  which,
quarantine, in  one  form  or another, was  long since established.
Limited both  in  number, and in the extent of territory in which
they are indigenous, they assume a virulent  and specific character,
become transmissible to persons not exposed to the primary influ-
ence, and extend  over vast portions of the inhabitable globe, and,
after raging epidemically for a period, subside sometimes, it would
seem, from mere lack of material for further ravages,  or at another
as if the primary germ-power had become exhausted.  Coming as
they do from localities outside of European or North American centers
of population, their approach  is always regarded with grave appre-
hension ;  and  from the earliest periods we find each country, each
district, or it maybe each municipality,  devising restrictive measures
to prevent their  ingress.  The plague, yellow fever, and cholera,
are the three diseases included in the above description.   From the
first named this country has been wholly exempt; yet from the fact
that it has repeatedly  been a  fearful visitant over large portions of
Europe,'and that the restrictive measures adopted for its prevention,
running through centuries, were the bases of all later ordinances to
prevent the spread of yellow fever and cholera, I shall be compelled
to refer constantly to them in the discussion of the question.  For-
tunately, in the organization of measures at this port, the traditions, 
4
and oftentimes senseless regulations, which resulted from blind and
fanatical populations in Europe, were not all-powerful  to  control
their formation.   Still the traditions of the past can everywhere be
seen, sometimes affording valuable light to direct jjresent operations,
and sometimes, by an effort at blind  uniformity and  fixed  regula-
tions, presenting stumbling-blocks, which would be to the sanitarian
so many causes of offense, and obstructions to all real progress.
   I am  aware that the subject is one rarely brought to the atten-
tion of a medical audience ; yet if you recall for a moment that in
its consideration  are involved the  most delicate questions which
hygiene  presents, that  we  must study  the origin, progress,  and
methods of dissemination of contagious  diseases, in order that we
may intelligently limit  them, you will see that it is intimately ger-
mane to  all hygienic studies.
   The name of quarantine is  given to  the measures of isolation
imposed  on persons and cargoes, susceptible, on account of  their
passage or their  contact writh  persons or contaminated objects, of
transmitting an epidemic or contagious disease of exotic production.
Originally  the  word  indicated the  limit of time (forty days) that
individuals suspected  of exposure to pestilential  contagion  should
be placed under observation.   It no more expresses the duration of
this trial; and now, in ordinary parlance,  as well as special sanitary
expression, the word quarantine expresses principally isolation and
sequestration, without  reference to the duration of the application
of these measures—a  duration  which  has  varied so  frequently
according to  the  particular period,  which  varies still in different
places, and which varies especially according to the nature and the
different conditions of clanger recognized  in those exposed.   It com-
prises, then, more specially, the whole series of restrictive measures
destined to prevent the march of an epidemic or contagious affec-
tion.  There are other measures, not strictly included in the above,
which serve to complete this system, in acting not as barriers against
the threatened scourge,  but rather as modificators of the particular
district  threatened, in which are involved all  hygienic precautions.
For the march of  every affection transmissible by man is in reality
subordinate to two conditions, each  of which plays an  important
part:  1. The contagion, more  or less intense, no matter what may
be the vehicle.   2. Amount or degree of receptivity of the threat-
ened population, of whom the immunities  or morbid predispositions,
sometimes  inappreciable  in their  intimate cause,  are,  however,
usually referable to the  hygienic conditions of the population. 
5
  Since the end  of the last century, however, we see observers of
merit inveigh against the doctrine of contagion, and consequently
the practical consequences thence arising.   These would be the sup-
pression  of  quarantines,  the abolition of  all  impediments which
might obstruct commerce, and the free circulation of travelers and
merchandises.  This is not, then, a discussion purely scientific, which
amuses only cultivated intellects, having little practical results ; on
the contrary, an affirmative or negative solution would, on the one
hand, paralyze afl efforts, or, on  the  other, impress upon them  a
determinate  course.   For, if the origin of epidemics is to be ascribed
to cosmic, telluric, or individual causes, over which we cannot hope
to exercise any influence,  we must be resigned to them, and support
them with  the same patience as we do the summer heats or wintry
storms.   This  idea has  its practical application  in  the respective
measures taken by England and France with reference to the cattle-
plague.   Breaking out  as  it  did about  the same  time  in both
countries, the resultant effect  of  different  action is  readily noted.
The French veterinary officers, convinced of its contagious charac-
ter, took immediately the most vigorous measures to strike at the
root of the evil.  It was  necessary to  slaughter promptly about  a
hundred animals  to put a stop to the progress of the epidemic.  In
England, the anarchy of opinions, as well  as imperfect legislation,
allowed things to follow their natural course.  The result was, that
three hundred thousand animals died from the disease.
  It is, then, of the highest importance to have decided opinions
upon the subject: to wait  until  an epidemic is upon us, is to wait
for precautionary measures  after our building has been fired.  Indi-
vidual facts have  more than once shown  that the arrival of a single
sick person  in a locality, up to that  time  intact, has  developed  the
epidemic.  It is the  initial case in which lies the chief danger ; nor
can I recall a better illustration of this than the facts presented by
Dr. Peters  in his researches upon the cholera in Lexington, Ken-
tucky, during  the past summer.  Thirteen deaths occurecl, before
that of the  initial case, every one of which was traceable to causes
emanating from that case.   I may mention  here as at least a recog-
nized fact,  that all epidemics • follow the  routes, and with the same
celerity as  those who travel upon them.
  On these points it will at least be  found that clinical observation,
international hygiene, and direct experiment, are in full accord with
the teachings of traditional medicine. 
                                6

   With this preliminary statement, I proceed to a more systematic
discussion of the subject.
   1. All restrictive  measures, isolation, quarantine, or, as practised
in parts of Europe, the "cordon  sanitaire," have  exclusively  as
their purpose,  often indeed at the expense  of  human liberty,  to
trammel the  propagation of the  morbid  cause.  Local hygienic
measures are intended to render a district, so  to speak, refractory to
the action of this cause, by not presenting the materials  favorable
to such propagation.  Unfortunately, these two  courses have been,
on the part  of some, considered as  two distinct methods, antagonis-
tic the one to the  other.   The  first, that is, restriction, has been
extolled beyond  measure by the contagionists, as sufficient.  They
only see, in every epidemic propagation, a series of morbid acts,
fatally imposed  on  many similar  organisms  by  the contact of a
specific germ.  The  second, the pure hygienist, is  the device of the
partisans of morbid  spontaneity, of  the  anti-contagionists, who, not
content to recognize the enormous  influence which the local condi-
tions possess upon  the  germ, forget that we often  see  epidemics
propagated  in most  salubrious localities, and consequently that wd
must oppose to transmissible affections other obstacles than those
ordinarily included  in mere hygienic principles, which alone can
never confer upon the masses of a population an immunity compar-
able to that of  lessening or rather  excluding  the cause.   Each sys-
tem errs in creating  an exclusivism, because first,  the method of
absolute  restrictions is contrary to the  dignity of man, by the fre-
quency and  the abuse of the sequestration which it  imposes.  It is
contrary also to the  well-being and health of a people, in neglecting
to guard  against the  dangers which arise  from  the collections  of
filth, the true local nests of every infection.   Yet to-day we see this
exemplified  in  all the Spanish, Italian,  and many  Eastern ports,
where it constitutes  the only safeguard in times of great epidemics.
We  know  full well  that,  in most  of these  countries,  the moral
wretchedness of the  people equals their physical, that above all else
they are blindly superstitious, and attach themselves to measures of
quarantine sequestration with the fanaticism of all their other beliefs,
and  are ready  at the  first  indication  to sustain  them  by the most
violent and  blinded acts.
   2. The method of local  prevention by rendering  healthy the
threatened locality, in ameliorating all  the social conditions of the
inhabitants,  is, in itself alone, more specially  adopted by a civilized
people.   It  has this  immense advantage, of inaugurating and estab- 
/
lishing  for a community an era of comfort  and prosperity.  You
are all  aware  how much  England owes  to her immense works,
undertaken, upon hygienic bases, within the past ten years. Thanks
to these labors—thanks, also, to her natural isolation from the Con-
tinental masses ; still more, thanks to certain climatic conditions—
Great Britain can,  with impunity,  maintain the free pratique of her
ports.   To attribute her immunity against different pestilential dis-
eases  to the happy effects of hygienic  measures, is to encourage
every nation or community with  whom the principles of hygiene
have not yet become  practical; but, in so doing, only one of the
reasons  of this immunity is recognized : the importance of climatic
and topographic influences upon the march  of epidemics is forgot-
ten.   In France, where public hygiene has made great progress—
in this country, which will soon surpass, in this respect, the civilized
world—owing  to the  special conditions of geography and climate,
it is necessary to  adopt, against the propagation of epidemics, a
more complete system of prevention.   They  must first obstruct, by
restrictive measures,  the propagation  of the morbid germ ;  and,
second by,  render,  as  far as possible, each  locality refractory to its
development.  In  both France and this country we have the daily
proof that the two methods, in place of mutual exclusion, should be
combined, in order to unite the double base of international  and
municipal prevention.  So  far  from  opposing each  other, these
methods mutually complete a system ;  and  now, at this  port, the
system  of quarantine  embraces the whole series of  prophylactic
measures opposed to the propagation of epidemic diseases, it mat-
ters not whether the measures have for object the opposing of the
transmission  of the  morbid  germ, or whether  only  to hinder  its
development by hygienic labors.  From this happy accord results a
sanitary regime more complete and more rational, and where we can,
according to circumstances,  apply the one  or  the other element.
Quarantine restrictions, so senseless and imperfect heretofore, have
drawn from prophylactic hygiene the fundamental principles of their
actual working.
  The truth  is, the question of quarantines is one of the most com-
plex of  hygiene and medicine.  If you bear in mind the obscurity
which still hangs over the conditions of the development of epidem-
ics ; if you recall  that, upon the  globe, there is not  a continent—
that, on such continent, there  is  not a country—which does not
present  different conditions of predisposition, or immunity,  with
reference to these scourges ; if, further, it is remembered that every 
8
quarantine system, while it  confers advantages upon  those it pro-
tects, involves grave prejudices for those it contravenes, you will
understand  how difficult it  is to express, in determinate adminis-
trative formulas, regulations applicable  to every place.  The  joint
responsibility so necessary among  localities, since the most rational
or the most absolute measures undertaken in one country can be
annulled in  their  results by the indifference of another, will,  for a
long  time, be difficult  to obtain.   To be scientific  and practical,
they should necessarily arrive at conclusions variable according to
the locality or port  to which  the regulations  are to  be applied ;
variable, also, according to the nature of the diseases they propose
to contravene.  These  regulations will  then,  by their diversity,
recall how varied are the dangers they should prevent, and also how
different is  the morbid  receptivity  of  the  different  populations
which they are to  protect.  It is not difficult, then, to  comprehend
how essential it is that the great question of sanitary measures should
become more and more the privilege of competent men—of men
who understand the mode  of propagation of-epidemics, the  local
and geographical  conditions of their development, and the special
prophylactic measures applicable to each.
  Rules  established by tradition and custom have, without doubt
thanks to their uniformity, great facility in  their practical  applica-
tion.  But always to impose the  same rules, in the most diverse
conditions of time and place, as well as the nature of the epidemic
designed to arrest,  would be to act contrary to all our scientific data.
Too long has this reform been retarded by the traditional errors
drawn from European regulations, and we have, in this country, the
opportunity  to  disembarrass ourselves  from a  host  of practices
inspired by secular prejudices common in Europe.
  While, then, true prudence should cause us to abstain from brino--
ing the same regulations to the prevention of all pestilential diseases
the forms  and  modes  of propagation  of which vary so  wholly
according to the places  in which they are observed,  we  are not so
embarrassed in determining the nature of the  establishment required.
Sanitary establishments have to-day their types, indicated by physi-
cians and hygienists—types which can be reproduced and,  as occa-
sion requires, perfected.  Not so, however, the  regulations.   You
cannot give to all  ports the same mode of application.  In one city
there may be topographical  or  social conditions which modify the
degree of morbid  susceptibility in the different classes of the popu- 
                               9               i

lation.  In fine,  no absolute,  no arbitrary rules can be  formed,
suitable for every latitude, every clime, or every people.
  There is still another class of influences, irrespective of locality
and  the different forms of the pestilential diseases.   They are the
particular features of the epidemic  itself, so variable at each explo-
siou.   When, for instance, we see one of these affections cover,  so to
speak, the entire world in its manifestations, or, at another time, as
a circumscribed  epidemic—when,  in  following out their history
through a course of centuries,  we see,  at one time,  the  plague, at
another, cholera, or, again,  yellow fever, play successively the prin-
cipal part in the scourges which decimate populations—we are cer-
tainly compelled to recognize  the variability of the  conditions of
development of  epidemic diseases, and  consequently the inequality
in the character of the protective measures.
  It seems to me, you will  best appreciate the different bearings of
this  subject by tracing, for  a few moments, the origin and  progress
of the  principle I have stated, and which  controls the administra-
tion of this branch of sanitary science.  The idea of the transmission
of diseases by contact is one which dates back to the farthest anti-
quity.  The minute prescriptions by which Moses sought to isolate,
even in the midst of his camp,  those attacked with leprosy, or  other
diseases which he supposed  contagious, would indicate that already,
with  the ancient Egyptians, this first notion  had been universally
accepted.
  Still, the  first  account we have of an epidemic propagated  from
contagion is  not  by a physician, but by the historian  Thucydides.
The plague at Athens is the first known of these formidable  affec-
tions which, coming from  without,  fall suddenly upon an  entire
population,  snatching  innumerable victims.  In the march of this
epidemic we find the  principal characters which at different  times
have  been   met  in  all  subsequent  incursions.  Overcrowding,
wretchedness, hunger, were shown among the  predisposing causes,
and which ever since have been known to favor the development of
these fearful  scourges.   The fact, too, was established, that its way
of entry was by the sea, the chief route for  epidemics  to enter a
country.
  It  was not, howeve*r, until the appearance of the plague in 1348-
'50,  that the regime of quarantine against pestilential affections was
fully inaugurated.   As for  ages previous leprosy had been the prin-
cipal disease in which isolation  was ordered, we see, in looking over
the regulations which  existed  in many of the places on  the shores 
10
of the Mediterranean, that they were those adopted with regard to
leprosy, save that the definitive isolation of the one was changed to
the temporary sequestration of the other.  About this period the
recurrence of grave pestilential epidemics inspired the public, rather
than physicians, with the notion of their  transmissibility by those
attacked.   As a consequence the  restrictions were marked  by the
brutal and superstitious spirit which  characterized  the age.   The
murdering of physicians, the bloody persecutions against the Jews,
self-imposed  tortures by individuals to propitiate  Divine mercy,
witness the superstition and barbarity of the epoch.
   Soon it  was noticed that vessels  and passengers coming from the
East, though not attacked themselves, brought with them the morbid
germ.  Venice, rising from her lagoons,  was then the most enterpris-
ing and chief commercial city of the world.   Covering  the Mediter-
ranean with  her vessels,  she made at the same time commerce and
war ;  consequently her port more than any other was subject not only
to the black plague, but especially the Egyptian, then so frequent in
its explosions.   Induced by their frequeut appearance, she proscribed
the sale and destroyed the effects of those who had died.  She created
three  protectors of the health, a health bureau, and finally a lazaretto,
which subsequently formed the model for all other ports.
   Her example was followed by all  the smaller places on the Adriatic
coasts, existing then as separate governments.  It is probable that the
terror inspired  by the repeated visitations of the pestilence gave rise
to that persistent hostility to strangers which still exists in many por-
tions of Southern  Italy.  From this time, too, dates the period of
fwty days as  necessary  for  the examination of suspected persons.
Another  fact of interest in  this connection is, that for  the first time
medical men, not only by the aid of scholastic arguments, but by the
study of  facts, interested themselves in the question, "how far conta-
gion was concerned in the transmission of the plague"—as the result
of these inquiries, running, it is true, through a long series of years,
for after  the disappearance of each scourge [precautionary measures
were  laid  aside, to reappear more  absolute at the approach of  new
danger.
   About the middle of  the sixteenth century,  the celebrated work of
Frascator appeared.  It is the first workjjwhich speaks of contagion as
now understood.   According to  him,  a specific virus rises by exhala-
tion from the body of the sick, extends but a  short distance, attaches
itself  to certain substances, which  thus  become  contaminated;  this
contamination remains,  and  may be transported  unknown distances, 
11
and infect entire communities.  He recognizes also that certain other
substances  would  not be  contaminated.   The public mind seized
eagerly upon this distinction of contamination and non-contamination,
the decision of which has been the source of so many discussions and
such  diversity of opinions.   Independent  of  his natural exaggera-
tions, his work wrought this  double advantage:  1.  To show certain
real  dangers not before suspected, and  recall to  rational  observation
many minds, misled by the belief in the influence of the  stars, or by
their faith  in the Galenist dogma of occult causes.   2.  To dispel, on
the other hand, that  which  was equally difficult, certain prejudices
which exaggerated the property of transmission of such diseases and
admitted that they could be communicated  by voice and expression
of the sick.   This opinion was still  more  fortified  by a subsequent
work by Masaria, who showed the immunity of persons who, during
an epidemic, had remained  shut up in their chateaux or in monasteries.
He limited  the lavages, in isolating  the sick outside the city.   The
success  which fblknved this advice made his work an article of faith,
and  it was  followed by the organization of  similar  establishments in
all Mediterranean ports.
  From the beginning of the seventeenth century, Europe found her-
self,  relative to the plague, in analogous conditions to those in which
we are  relative to cholera.   The disease had reached its maximum of
diffusion through the civilized world,  and  was especially terrible in
all  the  large capitals.   Sanitary  police  were established in all or
nearly all,  and the most  vigorous  measures were  adopted for the
sequestration of those stricken.   Both  local  and general authorities
acted in concord,  the one in defining the movements and restrictions
of the  inhabitants ; the other in surrounding the  pested  city with
troops,  to prevent ingress or egress except under definite regulations.
The spirit  of isolation was carried  to such extremes that without
doubt the scourge was intensified, by  compelling the inhabitants to
remain  in the infected districts, and  often by the inadequate supply
of food to those so subjected.   Fumigations were also liberally  prac-
tised in all suspected localities, and also by  physicians in making
professional visits,  but the articles  employed were  more marked
by the  pungency or specialty of odor than  by any  true disinfecting
property.
  The eighteenth  century  was marked  by the more decided use of
lazarettos.   The result was soon observed ; the disease declined  from
the interior portions of Europe, and  was chiefly confined to  the mari-
time ports.  The  regulations  assumed  a  more explicit and in some 
12
sense rational  form,' though the penalties  were very severe,  and
enforced with  intense  rigor.  Explicit directions were  given to all
vessels trading with  Egypt or the  Levant, not with  reference to
passengers only,  but  also  the cargo and  the vessel itself.  The
increasing commerce of France with the East gave the port of Mar-
seilles an especial prominence, and its lazaretto became the most cele-
brated in Europe, not only in the care manifested, but, as knowledge
existed, the best conducted.   It enjoyed, too, the confidence of the
citizens, by several times restraining the contagion from the city after
its entrance into the lazaretto.
  To one familiar with the history of the subject, it is interesting to
study the minute distinctions made not only with  reference to the
bill of health, but the measures of observation taken with reference
to passengers and merchandise—measures which, while they might
protect the community, lost sight entirely of the rights and privi-
leges of those suspected;  and which, were there the least trace of
fomites in the vessel or cargo, would be certain to communicate to
the poor  unfortunates, who  were compelled to undergo an almost
unlimited period  of observation.   During the latter  part of this cen-
tury, observations were more carefully and systematically instituted,
and the modes of propagation of the scourge more accurately noted.
Chief among these,  was the great  philanthropist, John Howard.   He
visited successively the hospitals and lazarettos of the Mediterranean,
where the  plague  prevailed ;  attacked energetically the defective
appointments, established the importance of the hygienic conditions
in these  establishments,   sustained  the  inutility  of  quarantines
imposed on merchandise, and really laid the foundation for the pres-
ent English legislation on the subject.  He dispelled the idea that
the corpse could  communicate the disease;  a point of great impor-
tance,  since  in many  epidemics  they Avere  allowed  to  accumulate
unburied, people flying from them in terror.   He combated, also,
the  foolish and  grotesque precautions  taken  by physicians  and
nurses to escape immediate contact w7ith the sick, and  dispelled the
illusion that the contagion could be conveyed by their breath.
  During the  early part  of the  present century,  the doctrine of
quarantine  was affirmed  with  renewed  energy, and the privileges
accorded  were, if possible, more  decided;  gradually, a more  exact
appreciation of facts induced a more eclectic tendency, preserving that
which was useful, and  rejecting that which  was exaggerated.   We
notice, too,  in European governments the first  steps  taken to stifle
pestilential  maladies in their  place of origin, which resulted  in  the 
13
international congress to consult upon the principles to be laid down
in order to prevent their wide-spread diffusion.
   An additional interest arises in their study, from the modification
of the list of diseases to which restrictive measures should be applied.
Up to the commencement of this century, no other disease than the
plague  had  occupied  the  attention of quarantines.   From  1821,
however, the  interest in this  disease  gradually snbsided,  to be
replaced, in a far  greater degree, by the questions of yellow fever
and cholera.   During the few years previous to this the anti-conta-
gionists  had inveighed severely against all restrictive measures  in
yellow fever, asserting that it could not be  imported, and that those
who thus affirmed were men without experience, obstinate, and of
limited  information.   Scarcely had these  positive  opinions been
enunciated, and even  obtained  some credence in public sentiment,
when the terrible scourge of yeflow fever, which invaded Barcelona
in 1821, appeared.  Its transmission by sea was undeniable ; reach-
ing the quarantine of Marseilles, it was excluded from that city.
   For the  cholera, a different order of circumstances presented.
The danger to be  apprehended  here was  not from the side of the
sea,  but from the  land.   For years  European governments had
watched the  progress of the Indian scourge, the terror inspired by
its ravages in Asia, and had hoped to arrest its  progress on the Rus-
sian frontier.   It was thought that, by creating  a " cordon sanitaire"
on the boundaries of each country, its  progress could  be  arrested.
Various  restrictions to intercourse were established, virtually estab-
lishing quarantines by land as well as by  sea.   We all know how
useless  were  these  efforts.   The rapid march of the first cholera
epidemic through Europe in 1831, and the fact that it did not appear
in certain countries where no restrictive measures were applied, showed
the utter uselessness of these cordons sanitaires in thickly settled dis-
tricts, and they were soon abandoned.   It had the effect to revive
the old discussions relative to its transmissibility from man to man,
many asserting that it  was wholly epidemic  in its character, an argu-
ment which had a specious force from  the rapidity and uncontrol-
lability of its progress.   Its contagion  was treated  by them  as a
chimerical belief; those  who opposed  the idea of contagion were
considered truly men of progress, since  they opposed  restrictions to
personal  liberty, and their views were applied,  not  only to cholera,
but typhus  and  other diseases.   These hesitations and differences
continue more or less  still among the different  portions of Europe.
Indeed, the  futility of the  effort  to establish a uniform  system of 
14
quarantine regulations for countries or seaports in different localities,
having: different relations with  countries from which malignant dis-
eases  are  brought, is acknowledged there—that which experience
had long ago taught in this country.
  Mattel's remained very much in this unsettled state, both as to the
principles which should govern the administration of quarantines,
and  the varied action  of different  governments, when, in 1850, a
convention, with reference to some uniformity of principle, was held
at Paris.
  It  consisted  of representatives  from  all principal  European
powers.   They  were medical men, and with  them were  associated
also the consuls of the respective  countries represented in France.
Discussions of a purely scientific character were ignored ; confining
themselves to facts generally  accepted, and  by the aid of mutual
concessions,  they arrived at a code of  international sanitary regula-
tions, which, though  since modified in  many particulars,  have
remained the basis of all subsequent quarantine legislation.  Among
them I find many of the provisions of the law now in force in this
state.  I cannot enter  into  an analysis of its  provisions, but  who-
ever reads it  carefully will see that it  is based upon a study of the
cause and progress of the diseases which it is intended to intercept,
and, almost  for the first time, places the administration of  these
establishments in the hands of medical men.  It is not inappropriate
to quote an  extract from  a paper  by the Minister of Agriculture
and  Commerce, written just before this  convention.  He writes :
" The question of quarantine is one  of those  questions  of public
hygiene which the government cannot decide,  and which can only
be resolved, either by the Academy of Medicine, or the Academy of
Sciences."
   The spirit  inspired by this convention  awakened  a  new interest
and  enthusiasm on the  subject, and was the initiation for the subse-
quent gathering at Constantinople  some  fifteen years later.   An
energetic impulse  was  given,  not only to the  study of restrictive
measures, but the still more  important  duty, the application of
public hygiene to the  prevention of epidemics, if possible, at the
source—to stifle them in their exotic cradles, or at home,  in  remov-
ing the causes by which they are propagated,  thus each diminishino-
the zones over which they can spread.
   In looking over quarantine legislation as enacted at different  times
in this State, we are first struck with the freedom from the trammels
and prejudices and formalities  which  so  long marked all European 
15
enactments.   Each  principle seemed to  spring  from  the practical
necessity of the occasion, and w7as generally the result of the experi-
ence afforded by some epidemic of fever just passed.
   The  first legislation was in  1784, and compares  most favorably
with contemporaneous European enactments.  Yellow fever was then
a frequent visitant of this port, appearing as an epidemic nearly every
year  during  the  latter  part of the last and  the  early years of the
present century.  Another principle, as the result of these repeated
epidemics, was  early established,  viz. :  that all vessels  from foreign
ports, and all coasting-vessels, coming from south of Cape May at
certain seasons of the year, should undergo  sanitary  inspection on
entering the port.  The futility of locking the door after  the article
is stolen was applied to  quarantine, in the  comparative  uselessness of
restrictive measures  after  an epidemic had gained  foothold in the
city.   The great mistake  was, that in  protecting  the community
they lost  sight wholly of the commercial interests involved.   True,
with  navigation at that  time wholly in sailing-vessels, lime was not
as important a factor as since the  introduction of  steam, and  vessels
and owners  submitted most patiently to the  restrictions.   It is evi-
dent,  however, that the natural history  of the disease (yellow fever)
was not fully understood, or we should have no such clause as this :
" Vessels to be  detained thirty days at  quarantine, and twenty days
after discharge of cargo.   Cargoes to be detained subject to the deci-
sion of the health-officer.   Crews  and passengers  to  be detained
twenty days after  the last case of yellow fever, or twenty days  after
sailing from an  infected port."  What would become of West India
trade if such  orders were  now enforced ?   Yet a provision, contain-
ing; almost similar regulations, stands  now in force upon the statute-
book.   The whole tenor, however, of legislation  has been to recog-
nize the  opinions and decisions of medical men  in  the  quarantine
enactments ; and, as a rule, they  reflect the current  opinions of the
mode of dissemination of the epidemics they were intended to con-
travene.  It is not necessary in this connection to recount the present
practice with  regard to pestilential diseases.  I need only say in pass-
ing that,  as now  constituted, the establishment is most complete in
all its appointments, and fully equal to  the sanitary requirements of
the times.   For the present there are still a few  general  considera-
tions connected with  the subject to notice before proceeding to the
study of the special diseases.
  We are now prepared, after a very hasty historical sketch  of the
origin and growth of the  systems of quarantine, to consider their 
16
prophylactic value.   I am  aware of the varied opinions which exist
on this  point, both in this country and in Europe, of part isans who
on the one hand deny all sanitary value to their  restrictions, and on
the other, who  claim for them  exaggerated benefits.  On  looking
closer at the  school which  opposes all  sequestration, I find, almost
invariably, that their opinions are formed and based by the surround-
ings and climate of  their particular localities—surroundings whore,
from the nature of their position  to neighboring countries, no restric-
tive measures, save those which could be effected by a cordon sanitaire
(a system found  totally inefficient in thickly-populated countries, and
only applicable in sparsely-settled  districts), could be applied ;  and, on
the other hand, countries situated in latitudes where  the  exotic pes-
tilences, all of which find their endemic  dwelling in the torrid zone,
can, with the exception of cholera, find but a short season when tem-
perature and hygrometric conditions would favor  their development.
   Such persons, studying alone  from their own stand-point,  attempt
to apply general principles  for all localities : a fallacy too absurd for
contradiction.   Quarantines are not essential to the higher regions of
the temperate zone, nor to  the localities in the  torrid, where climate
and temperature readily  make yellow  fever and cholera endemic.
Strange as it may seem, there are still partisans who have their objec-
tions, upon  the blind  belief that there is a  mysterious, intangible
principle in the propagation of  epidemics, and so deny the  benefits
of preventive measures.
   The question naturally arises,  in how far sequestration is advisable
against exotic contagious diseases.
   I. This sequestration is only advisable in localities where a general
supervision of the arrival of such diseases is easily made, and which
are separated, so to  speak,  by a  natural  zone of isolation from sus-
pected  districts.  Such are localities on islands or cities, where  the
entrance of  the disease would be almost wholly by sea.   In  such
places the necessary regime  is easy of application.   This is shown by
the almost total immunity  which this city enjoys from yellow fever,
for not a season passes, but numerous cases are  taken off of vessels
and detained in the quarantine hospital.   During the cholera of 1865,
many islands of the Mediterranean enjoyed an entire  immunity from
the disease.  On  the other  hand, where  topographical conditions are
less favorable, this isolation from contagious diseases is almost impos-
sible, and consequently it is illogical to  impose such conditions upon
them.
   Still another series of  conditions would modify the application of 
17
these measures.   Such are countries  situated in the endemic zone of
the  disease which  it is desired  to restrain.   Before deciding, then,
upon its apphcation for any given locality, we must determine whether
it does not  already exist there ;  it may be in complete evolution, or
as a localized germ.  To apply restrictive  measures without first
determining these  facts, is to establish useless barriers, and  renew
under another form  one of the principal abuses of the old system.
The limits of this zone of endemicity are often difficult to decide, still
a solution so far as yellow fever is concerned has been reached.   The
establishment of  quarantines along our southern seaboard has shown
that its endemicity scarcely reaches our shores : in other words, that,
with the exception of a small portion of our southern coast, the
disease is exotic.   Still another set of conditions neutralizes the benefit
of restrictive measures.   Certain countries are too distant from the
seats of pestilence, or enjoy climatic conditions so peculiar, that these
affections rarely find a lodgment.  Take, for example, England :
for the past  two centuries her ports,  relatively to the  other ports of
Europe, offer a  remarkable immunity, when we take into account
the extent of her commercial relations, against pestilential  diseases.
Shall we, then, say that the system of free pratique, which prevails in
England, should be  employed  on the Continent ?  Her immunity
from yellow fever is the natural condition of her climate : this,  while
severe on the coasts of Spain and Portugal,  is naturally mitigated
as we ascend the Atlantic coast, until in England it finds a tempera-
ture wholly unsuited  to  its development.   The same argument
applies to the cities farther north than this on this coast.   Again, yel-
low  fever seems  to require a certain density of population, seldom
appearing in places  where  the population  falls  much below five
thousand.   It is readily seen that few of these objections to the
establishment of quarantine  observations  apply to the  cities of the
Atlantic coast.   Situate in the  exotic zone, we  know how useful re-
strictive measures  have been during  this century, in suppressing
contagions  almost  entirely from  the centres of population.  True,
much of this has been done in disregard of all consideration for
the  persons, the cargoes,  or the vessels sequestrated, and been the
occasion of bitter  conflicts  between the  sanitary  and  commercial
interests ; but, since a better appreciation of the origin and progress
of pestilential disease has been determined, it seems  such  interests
are in no  manner  antagonistic, but, rather, that the prosperity of
commercial interests  is inseparably connected with a healthy  condi-
  [s. o. v.]              2 
18
tion of the  port, and  that  this can be maintained without  contra-
vening their interest or prosperity.
   Shall we, then, in the presence of such marked differences, aris-
ing from topographical conditions, proclaim the complete inutility
of quarantines, even in localities in which, at the moment of danger,
every avenue  cannot be guarded ?   The  transmission of epidemics
through channels of human communications, is too  capricious to
guard  every avenue and manner of contact.   All  know, however,
the special susceptibility of  seaports, the guarding  of  which should
be one of the principal pre-occupations of the  sanitary authorities
in time of epidemic.   If we cannot absolutely stop every  method
of penetration, we  diminish, to a great degree, the  chances, and
preserve intact our  commercial centre.
   The port of New York, regarded in this aspect, presents peculiari-
ties which require a moment's consideration,  not with reference to
her  position to the  yellow-fever zone, from which,  since  the use of
steam-transit,  the passage is  made within the period of incubation
of that disease, and where, without a supervising control, the infec-
tion is liable,  during certain months of the year, to be brought into
the city, but rather to the peculiar feature presented by the emigra-
tion to this port.  Nearly four hundred thousand persons, cabin and
steerage, enter annually, not from a single port, or the inhabitants
of a particular nationality, but from every country and every prin-
cipal seaport of  Europe.  It is thus, in an especial manner, liable to
the incursion  of epidemics  raging in any portion of Europe, and
experience has shown that  their  influence is carried hither even
easier  than to England.   A large emigration of Poles, Finns, and
Wallachians  is  taking  place, and,  as they come  from the direct
neighborhood where cholera  enters Europe, and where it has been
more or less epidemic for the past five years,  it imposes a constant
vigilance  upon the  sanitary condition  of  those  coming  from such
countries.  These emigrants are lacking,  too, in even  the ordinary
habits  of cleanliness which characterize those from the more  western
portions  of Europe ;  wearing whole suits of leather, it may be  for
months in succession, the clothing  becomes in  an  especial  manner
easily contaminated, and, when so, impossible to purify.  The limits
of a paper will not permit a recital of the practices which  govern
the inspection of these vessels, for it covers not only the prophy-
lactic measures involved in the principle of  quarantine, but also  the
general hygienic regulations which pertain to  the comfort and well-
being  of  the  steerage  passengers.   Indeed, the functions  of the 
19
department are now extended to every thing which pertains to their
hygienic condition ; so that while the community, on the one hand,
is protected, the passengers are maintained as cleanly as the crowded
quarters permit, and a system of aeration and a frequent sending on
deck is  enforced.
  It may be asked, "Are not the ports from which these emigrants
sail equally exposed  as  this port ? "  We  answer, decidedly not;
they seldom receive from sea any of the passengers which they send
to us under such crowded  conditions.   The emigrants reach those
ports in small  parties, by rail or otherwise, and  it is only when a
thousand to fifteen hundred are crowded in a limited space that the
germs of contagious disease spread with such fearful violence.  On
land a single case  may be promptly isolated ;  not so, however, on
shipboard.  Isolation and sequestration are almost impossible, while
all  concomitant  influences, such as confined air, filth, bilge-water
and dirty clothing  are so many fostering influences  for  the  germ.
  If the general principles we  have  expressed are correct, it will
not be difficult to make  the particular application, not only to  any
given locality,  but  also with reference to the particular disease it is
desired to contravene.  Such application must be founded upon the
natural history, the manner of transmission, and the period of incu-
bation of  the disease, and, in shaping  restrictive measures, all inci-
dental  circumstances must be borne in  mind.   Whenever  rational
hygienic measures  are faithfully pursued, not only at the source of
the infection, but also on vessels in  transit, it should be a powerful
modifying element in the restrictions  applied to passengers, cargo.
or vessel on their arrival in port.
  I have, however, so far transgressed your patience that  I leave
the subject, hoping, if agreeable to you, that I may, at some future
time, elucidate this branch of the study. 
 
                    ON THE

             TRANSMISSIBILITY

                      OF

YELLOW FEVER  AND  CHOLERA
IN THEIR
RELATIONS TO QUARANTINE.
  By S. OAKLEY VANDERPOEL, M.D.,
HEALTH OFFICER OF THE FORT OF NEW YORK. 
 
On the transmissibility of Yellow Fever and Cholera in their relations to Quarantine.
   By S. Oakley Vanderpobl, M.D., Health Officer of the port of New York.
   After the pretty full  discussion of the principles which control
the organization of quarantines, we can now advance to the study
of the  two principal diseases whose inroads they are expected to
interrupt.   The study will, of course, be limited to their origin and
modes  of  transmission,  and not in  any way to their diagnosis,
pathology, and  treatment; the intent being that, by understanding
the material  features, an intelligent prophylactic  course can be
adopted.   In  the limited  time  allotted,  this  examination  will be
necessarily  brief and cursory,  and I  shall, therefore, only attempt
to present  the salient points in yellow fever and cholera.

                        Yellow Fever.
   Yellow fever  is a transmissible disease,  its place of origin  being,
probably, certain of  the West India islands,  and portions  of the
shores of the  Gulf of Mexico.    Its prominent characteristics are, a
"eeble condition, vomiting of  black  matters,  haemorrhages, and a
jellow  coloration of the skin,  more or less constant, but which is
usually most  marked after death.   The enumeration of symptoms
iidicates, at first sight, a general disease—an intoxication produced
bj a specific principle—which extends  its  action to  the whole
economy.   It does not always present the same intensity.   While
usially assuming the severe form, we may have  also merely outline
or typical cases, which, to  the sanitarian, are as much to be dreaded
as the more decided.   These half-sick often deceive  the  most rigid
scrrtiny ;  yet they possess the  same specific element as the graver
kind, and,  in  point of contagion, the  same danger.  Quite as much
as the lighter forms of scarlet  fever or small-pox convey the specific
germ, so do these outlined cases of yellow fever.
   It is not necessary, in this connection,  to enumerate the epidem-
ics of yellow  fever, even along  the  different  cities  of the Atlantic
coast  It has appeared  as far north as Boston, nearly two  hundred
years smce, followed by several  outbreaks during  the latter part of
the e^hteenth century; while, in New York, during the last  cen-
tury md the  early years of the present, it was  marked by several 
24
epidemic appearances.   It has become a yearly visitor at the port—
not a summer passing but from twenty to sixty cases are treated at
the quarantine hospitals.
   Yellow fever can, so far as the greater  part of the  shores of the
United States  are concerned, be termed  an exotic disease.  When
and where are the precise spots of its origin will probably never be
known.  It is never shown on our shores except by importation.
Once introduced, it may develop and propagate, but  never sponta-
neously.  Limited as seems originally to have  been  the extent of
territory from  which  it  could  claim  origin,  that  territory  has,
through human intercourse, been very greatly extended, and there
are now few places in the tropical and semi-tropical  coasts of the
Atlantic but what may be termed starting-points for the spread of
the pestilence.
   In this connection it should  be noted that, while the disease has
been known on the Atlantic coast for over two  centuries, it is  only
within the past thirty years, or thereabouts, that its appearance has
been established on the coast of the Pacific.  This, in  part, may be
accounted for by the  difficulty of transmitting it,  even in the  hold
of the  ship, around the  cold  ami wintry climate  of  Cape Horn ;
but also by another principle scarcely less  potent—the difference in
the telluric aspect of the two  coasts, the one  offering conditions
for a permanent nidus, the other wholly different.  Much  of the
tropical and semi-tropical ^3oast on the eastern  shore of the conti
nent is low, flat—through which  large  rivers pass  slowly and sinu-
ously—and is  eminently unhealthy.   The western slope,  forme!
through most of its extent  by the chain  of Cordilleras, presents a
far less favorable field for development.
   The special  sources from which  the fever emanates are those
marked by paludal conditions.   An alluvial soil, scooped or argil-
laceous, inundated,  periodically, by long rains ;  covered or  bor-
dered  by mangroves; channels  with  mixed  salt and  fresh water;
pools of brackish water,  or lagoons, formed at the mouth of the
tortuous, sluggish river ; these, and other paludal conditions—aich
as exuberance of  decaying vegetation, subsoil infiltration—mark the
immediate spots from which the fever may propagate.  Yet, even
here, let me recall a remark made when  speaking on the general
subject of malaria: that,  with its paludal origin, it is not necessary
to suppose that there is an identity of cause between  yellow fever
and the forms  of malarial disease.  The  two  diseases  have been
repeatedly shown to exist simultaneously.   The one is transmissible, 
25
the  other is not;  and, again, many countries, many localities exist
which generate a deadly paludal  but no yellow fever.   We may
say that the germ of yellow fever appears to be of an organic, mias-
matic nature—whether vegetable  or animal cannot be  affirmed—
coming  from endemic localities.   These localities are exclusively
found either on the borders of the sea or at the mouths of rivers,
often in common with paludal fevers proper, but still differing from
the  latter in power of transportation for great distances, and pre-
serving for  a long time, without alteration, its reproductive germ.
   Recognizing, then, the telluric influence in the origin of yellow
fever, there are certain local conditions which  favor its propagation
when  transplanted.   First, its ravages are chiefly confined to low
countries.   Dr. Tower, after a careful analysis of  all the localities
in which it  has prevailed in this country, finds none as high as five
hundred feet above tide-water. Again, density of population  is
another element; it seldom assuming an  epidemic form in localities
containing  less than five thousand inhabitants.  Humidity  of the
soil  also exercises an  influence.   Soil  saturated  with water will
preserve the disease-germ.  In this respect  it presents a  notable
analogy  to cholera.  As with cholera, too, the social  and hygienic
conditions of a people exercise  a notable influence in its propaga-
tion.   It  attains its   greatest malignity  among  the filthy  and
impoverished,  particularly if, as generally occurs, these reside in
the low and ill-drained localities of any city.
   A word should be said relative to the acclimation of individuals.
The general impression is, that the residents of tropical latitudes
are,  to  a  great  degree,  exempt,  its  ravages being confined to
strangers or those unacclimated.   This is, however, the case only
when  the disease is endemic.  Let it appear for  the first time in
any tropical regions, and natives are quite as liable  to fall its victims
as any other  class.  Acclimation,  therefore,  is only  to  those who
have passed a preceding  epidemic  period, without  having left the
country, and who must have been  more or less impregnated with
the yellow-fever germ.
   As  the germ of yellow fever is, of necessity, transported from
locality to locality chiefly by vessels, either  engaged  in  commerce
or war, it becomes, to the sanitarian, a question of  the first impor-
tance  to determine  whether  the  fever can develop spontaneously
upon the ship.   If its spontaneity is possible, then sanitary measures
and  precautions  should not  be restricted  to vessels  coming from
ports where the fever is known to exist, but to every vessel  in bad 
                               2li

hygienic condition,  traversing  tropical  regions.  The  opinion  of
physicians of extended experience  is unanimous against the hypoth-
esis of spontaneous generation.  If it were possible, how is it  that
it  never appears in vessels from  China  or  India—vessels which,
from the length of the voyage, and  the long exposure to tropical
heats, would seem to be in external conditions to favor the develop-
ment ?
  While, therefore, the vessel may not create the specific cause, it
may become a powerful agent for  the concentration of the poison,
independent, indeed, of the crew  themselves.  This power resides
in the interior arrangements, in the stowage  of the  hold,  in the
material and character of the cargo.  We frequently see, on ship-
board, the disease re-appear if it has ceased, or become exasperated
if already present, should some  change be effected in the stowage,
no matter in what part of the ship this occurs.  This persistence  of
infectious causes  on shipboard  is  so remarkable, that sometimes,
after the unloading of  the cargo, even for mouths, if the vessel  is
not thoroughly purified, every one  entering  the vessel  is at once
taken sick.   While  practically this  cleansing on  board of vessels
engaged purely  in  commercial pursuits  is easily  and  promptly
effected, it  becomes a very serious problem upon vessels-of-war.
The more   intricate construction  of the  latter,  the  difficulty  of
reaching the innermost parts of the vessels, render thorough  purifi-
cation almost impossible.  Dr. Bell,  of Brooklyn,  for some years a
medical  officer in the Navy,  has  informed  me that some of our
vessels-of-war, once infected, could never enter a tropical region, no
matter whether the disease existed at the particular point or not,
but that the fever would re-appear  on the vessel; that, too, (although
the vessel  in  the mean  time had spent a year in cold  latitudes,
without showing the least suspicion that the fever-germs  lurked  on
board.  It is this tenacity of the poison to the ship, which induced
the hypothesis of spontaneous generation.   It would rather be a
powerful consideration that there  was a living, vital  germ,  of
remarkable  tenacity whenever  a favorite  nidus for  lodgment  was
presented.   It  becomes magazined  in the hold  and sides of the
vessels.
  While to  certain ports  on this  continent the question of trans-
mission of yellow fever might, with some  show of probability be
questioned, yet, when wTe have innumerable well-authenticated  and
observed instances of its transmission to European ports, and many
of the more northern on  this continent, it would seem  that point 
27
required no  extended discussion, and  it remains only for us to
determine the modes and manner of the transmission.
  Probably,  in the  literature of yellow fever,  the features of no
one epidemic have been more carefully studied, and the surround-
ing circumstances more carefully noted, than in that which occurred
in St.  Nazaire, France,  in 1861.   Situate  entirely beyond the
yellow-fever zone, in 40° of north latitude, there was no danger of
confounding  the disease, or mistaking  the modes  of transmission.
Every circumstance  was most carefully noted from the veiy incep-
tion  of the epidemic, by an expert commissioner, on the part of the
government.  In the statements now made,  therefore,  many will
be  drawn from  the  study of  that epidemic,  without necessary
allusion each time to the source.  I may state that experience at
this port, and all the other writings I have consulted, fully corrobo-
rate the statements advanced.
  We have seen that the  germ  of  yellow fever, having  its initial
point  on the borders of  the sea, or at the mouths of maritime
rivers, in a comparatively restricted part of the equatorial regions,
may leave these regions;  during transit it may be its presence is
manifested by the appearance of sickness among the crew ; then, on
the  arrival  of the  vessel,  we see, during and after its discharge, a
series  of accidents which,  starting from a common source, go on
to multiply, forming thus the starting point of the many epidemics
of yellow fever.  We must now examine closer into the mode of
this  transmission, to determine  whether the  vessel, the cargo, or
the crew and passengers are the agents.
  In the vessel the  preponderating influence belongs to the hold;
there is a confined atmosphere in which the morbific germ goes on
concentrating, and which, when the hatchways are open, allows the
disease to appear, destroying those who come within its influence,
even at distances of  several rods.  Those necessarily most exposed
are the stevedores, who work in the hold, unloading the cargo, and
the  coopers who repair the broken packages.  The water  of the
bilge is also a favorite lodgment for the germ.   If, in the  purifica-
tion  of a vessel, this is overlooked, the disease,  if once present, will
almost certainly re-appear.  Certain cargoes  or articles will trans-
mit the germ, but their influence is secondary to the hold of the ship
itself, and are usually harmless unless the hold is already surcharged,
so to speak, with poison.  It may also be transported in the clothing
of passengers and dunnage of sailors.  It is not, however, directly
contagious from  person to person.   In the five  years that Dix 
28
Island has been  used as a hospital  for this  disease, not a case has
ever appeared amoug the attendants or the residents of the  island.
Of course, precautionary means are taken, the details of which will
be given when we speak of prophylactic measures.  In this respect
it stands in striking contrast to cholera.   The one is transmitted by
influences entirely outside the individual himself, the other by influ-
ences arising directly from the person affected.   To apply botanical
terms, the one is  exogenous, the other endogenous.
   The pernicious influence is exerted not only upon those who are
immersed in the infected atmosphere, but the poison may be carried
by currents of air for greater or lesser distances, and, if the expos-
ure be sufficiently long, affects those thus subjected.  It can be dis-
tinctly traced for over a thousand feet.
   Some practical points remain  for us still to determine :  1.  The
incubation—upon the decision of this must  depend the length of
quarantine observation.  The result of many observations has fixed
the duration between two  and six days ; most ordinarily three  or
four days.
   Having considered the origin of yellow fever, the extent of ter-
ritory in which it has been acclimated, the manner of its propaga-
tion,  and the duration of incubation, we are  prepared to consider
the necessary prophylactic measures.
   1.  Measures to be taken at  the port at ivhich the epidemic  pre-
vails.—Directly, we have no control of measures to be applied there
—indirectly, our influence is felt, for the  facility afforded to those
who  employ proper precautions warrants them in following the
suggestions given.
   As filth is the  almost necessary nidus for this, as well as all con-
tagious germs, the utmost cleanliness on the  part of the vessel, and
the persons of the crew, should be enforced.   While the vessel is in
port  the bilge  should be pumped out  daily, and  often sea-water
pumped in until the water  pumped  out is clear.   After  the  men
have finished their  day's work, have  them take a bath and put on
clean flannels, and do not allow them to lie  upon the open deck ;
wherever there is a poop-cabin so much the  better.  If the bodies
are cleaned,  and  clean flannel used, all the animal effluvia and sweat
which remain on the surface are got  rid of; these are  found  to be
a nidus for the germ.  Still  one more measure experience has told
is beneficial.  It has been found that sailors, whose bowels are kept
 a little active while in port,  are less  liable to take the fever, and, if
they do, the attack is less  severe. 
29
   2.  Transit of the vessel to this port.—The hatches are to be kept
 open and the hold  freely ventilated  whenever the weather  will
 permit.   It  is in confined air that  the virulence of the poison is
 concentrated.  The bilge-water should be daily changed.   On arri-
 val at port, the duration of the traverse is first  noted.  If no sick-
 ness has occurred, and the passage has occupied more than six days,
 the crews, after thoroughly airing their dunnage, and submitting it
 to fumigation, are discharged.   It  may be  noted that the crews
 seldom take  any part in unloading the vessel.
   Careful inspection of the cleanliness, as far as can be, is made by
 the inspecting physician.   The hatches and all possible openings are
 kept open for twenty-four hours in the lower bay, so that the strong
 air which usually prevails  there shall permeate  every part; every-
 thing is then closed tight,  and fumigation, as thorough as can be, is
 made in all parts of the vessel.  Arrived  at the  lighterage-station,
 the discharge is  commenced at the earliest moment; there is abso-
 lutely no quarantine of detention ; for, if there be fomites on board,
 the longer it is allowed to remain in the hold and  bilge,  the more
 virulent it becomes :  a little leaven leavens the whole lump.   Here,
 so far as the cargo is  concerned, fresh air is wholly relied on.  The
 raising of the cargo on  deck in the open bay, passing it to the deck
 of an open  lighter, where it lies several  hours  for free  aeration,
 carrying it some miles across the  bay to a warehouse, so diffuse any
 fomites, that, in the two summers' experience I have had, not a case
 of sickness has arisen from this source, and that, too, on very many
 vessels bringing sickness into port.
   Fumigation is daily made upon the vessel during the unloading.
 This discharge of cargo is performed by stevedores, who remain at
 the lighterage station continuously,  no  one ever being allowed to
 go to the city for six  days after he has labored upon a vessel.  The
 same rule refers  also  to the  coopers, for you will remember it was
 stated that the great danger  consisted in going into the hold of  an
 infected vessel during the time of  her discharge.  When the cargo
 is entirely removed, the sides, and  every part  accessible, are sub-
jected to scrubbing  with  brooms and  water,  after which a more
 thorough disinfection and fumigation  follow, and  the vessel is at
 once furnished free pratique.  She is thus actually returned to com-
 merce sooner than if permitted to  go to dock  and be subject to the
 usual process of unloading.   There is, therefore, so far as yellow
 fever is concerned, no antagonism between commerce and quarantine.
  Should the vessel have sickness at the time of entering port,  or 
30
have had  sickness or death on the passage, the vessel  proper takes
the same  course :  the sick are at once taken off, and the crew or
passengers, instead of being  at  once discharged, subjected  to sur-
veillance until a period of five or six days from  the  last case shall
have transpired.
  The large use of steam transportation between this and yellow-
fever ports modifies in some respects the foregoing regulations.
  Peaching,  as  they readily can, this port within  the  period  of
incubation, I have established the rule that five  days must  elapse
from their departure before  any passengers or crew can leave ship.
As  this time is more patiently passed at sea than  lying in the lower
bay, the time of passage  is  usually made to  fill  the  entire period.
While five days  is not  the limit of incubation, I  must  depend
somewhat upon the doctrine  of  averages;  that is, if, in  a hundred
persons, passengers and crew, no case of fever is  developed during
that time, taking into account the possibility that with some it may
have been in  incubation at the time of their going on board, I con-
ceive there would not be  one chance  in five  hundred for it  to
develop on the sixth day. Passengers, if no sickness have occurred,
are at once  allowed entry to the city.   Should there  have been
sickness, the course already indicated would be followed out.  The
steamer is lightered and subjected to the same process of cleansing
as in a sailing vessel.   It  is readily understood that, with steamers,
time is a far more important factor than with sailing vessels.  With
an  average arrival of five or six weekly from yellow fever ports
during the past summer, not one lost her  sailing day.   Here  cer-
tainly was no antagonism to commerce.  That our visits  of inspec-
tion were  not fruitless,  sixty-two cases of  yellow fever were taken
from forty or more different ships during the past summer; that
the protective measures were efficient, is shown in that  not  a case
reached the city or came above the Narrows.
  I must now pass to the consideration of the remaining exotic dis-
ease, viz.,  cholera.  In its historical features it presents, taken in con-
nection with the frequency of its later irruptions, an unusual interest,
while various writers have attempted to show that cholera was recog-
nized in the writings of Hippocrates, quoting, indeed, the passage from
that writer wThich  attempts  to prove such recognition,  but which
points  unmistakably to cholera-morbus, or,  as termed by the French,
cholera-nostras.   True,  between the two  there  is a  symptomatic
analogy which  is  not manifested in  the clinical expression.  The
specific cause separates them both;  the same as between a  violent 
31
indigestion provoked by indiscretion in food, and the phenomena
determined by taking qertain poisonous substances.  There may be
an apparent similitude, though no identity of cause.
  If, however, we turn  to  the  most ancient of the Eastern  manu-
scripts, we have unmistakable descriptions of the terrible malady.
The intermittent  character of its virulence  can  also be recognized
from the time of  the first appearance of Europeans in that portion
of the world.  It was this intermittent  character which  caused so
many years  to elapse before its specific  recognition.  Following
down the lapse of years after its recognition, its  presence is, from
time to time, signalized.   Even  during these  three centuries, and
while communication with Europe was  constant,  it maintained
almost wholly  its endemic  character,  being limited to  the  south-
eastern portion of the Eastern Hemisphere.  Nor  was it until 1817
that it assumed its  migratory character.  From  this time  it pre-
sents the singular phenomenon of a disease  suddenly changing its
character, to emigrate from its birthplace and extend its ravages
throughout the world—to be carried from the borders of the Ganges
to the Elbe,  and  finally to reach the capitals of  Europe in 1831,
and this country in 1832.
  The terror it  has inspired,  the frightful  mortality following in
its  train,  the repetition  of its invasions, the almost well-grounded
fear that it may become acclimated, explain sufficiently the interest
which attaches to its study,  and  the  multiplicity of writings of
which it has been the subject.  By universal assent, and a conviction
derived from its non-recognition by earlier European writers, by its
description in the most  ancient of  those of the East,  by  the study
of  successive irruptions  during  the present century, its origin is
referred to the valleys of the Ganges and the Brahmapootra Rivers.
Nor is the locality  of its  endemicity probably very extended.  It
may  be   described  as  general  in the  province  of  Bengal,  and
especially the city of Calcutta; with less intensity in the stations
of  Cawnpore and Allahabad, and  their environs.   In other coun-
tries of India which, in this respect, may be termed near, and in
almost similar external  conditions, it  appears  as  epidemic, it may
be  yearly, as at Madras and places of Hindoo pilgrimage, or every
four or five years in the provinces of Northwestern Hindostan.  As
in  yellow fever,  so  in cholera, the exact nature of the particular
circumstances  which produce the  choleraic germ  has not been
determined, nor why it should be found particularly in that  valley.
All the peculiarities, both  from the formation of the river, and  the 
32
habits of the populations on its banks, have been mentioned, but
without receiving the accredit of dispassionate observers.   W e can
only say, with probability,  that  it,  too,  like yellow fever, has  a
paludal wrigin,  the mysterious germ of  which, once  introduced
into the human system, may go on  in  the  process  of propagation,
without any lessening of  its contagiousness or  virulence,  even
though it had traversed large portions of the earth's  area, and had
passed through millions of human beings.
  Like yellow fever, its power of transmission has also been denied,
and, when the epidemic ravages have spread over whole countries,
general influences have been invoked to explain the ravages. With
its more careful study, few, I think, will venture  to deny, not  only
that  it is transmissible, but also that it  is contagious.   In this,  bear
in mind  the broad  distinction between  cholera  and yellow fever.
The latter has been stated as not strictly contagious, but transmissible
through the media  of many substances, and  the confined  air and
bilge of vessels.   The former is, however,  directly contagious from
person to person, and  may be conveyed wherever there are routes
of human intercourse, whether by land or sea.   It is now,  and has
been for some time past,  a favorite  study to  trace out  the grand
routes of the various epidemics which have, within the past forty
years, so often scourged  Europe and portions  of this continent.
We need here only refer to the results of those studies which have
enunciated the principle of its transmission by the great routes of
human travel.  This, is, then, the central fact of the  study, that it
is transmissible and contagious from the sick to the  healthy, not by
contact  with the bodies  of the  sick,  but with  a  material  poison
thrown off from their  bodies, and capable of being  conveyed to  a
distance.  This recognized, we start from a presentable stand-point,
and feel an assurance in efforts to prevent  the spread of the pesti-
lence.
  The question has often been  raised, "  Why is cholera  only an
occasional visitant beyond the limits of its endemic house in certain
provinces of Bengal ? "  It has been supposed that some unknown
atmospheric conditions favor the  extension of the disease at certain
seasons, and not at  others.   True,  as a rule, it is favored by  high
temperature, and checked by cold.  Still  there  have been serious
local outbreaks, during the  winter  season, in India, Europe, and
this country.  Neither great moisture nor extreme dryness of air is
essential for the prevalence of the  disease, which has been widely
diffused, and very virulent under the opposite extremes of moisture
t 
33
and of dryness.  The disease has sometimes been known to break
out with sudden violence  after the occurrence of a mist-laden or a
dust-laden wind blowing  from a neighboring infected district, and
it has sometimes received a sudden check after the occurrence of a
violent storm.  Probably human occurrences explain, partially, this
remittent character rather than the influences of telluric or physical
agencies.  (In  studying the habits of the  people it is found the
outbreaks occur coincidently with certain great fairs and pilgrimages,
when immense multitudes are brought in close relation,  with all the
accompaniments of filth, and utter lack of all sanitary precautions.)
  The cholera shows  itself every year with more or less  intensity,
in an epidemic form,  in places where the  pilgrims gather.  Many
of these combine both fairs and  religious  ceremonies.   Among the
principal places where this  double purpose is carried out are Hurd-
war and Juggernaut  (and  Conjeveram).  Hurdwar is in the north
of Hindostan, on the  Ganges, just where the river breaks through
the mountains.  The  fair  is held  there every year just at the full
moon of April, and every  twelve years the pilgrimage is reputed
more efficacious than ordinarily, and consequently the affluence  there
at such times is enormous.   A million of persons from every direc-
tion are gathered there to make their ablutions in the sacred waters.
Passing the night upon the banks of  the  river, without any cover-
ing, they strive to  enter the water as nearly as  possible at the  same
time.   Scarcely do the ceremonies  commence than  the  disease
breaks out, and twenty thousand have been known to die in  eight
days.  Can we seek for a more  efficacious mode of distribution ?
These pilgrims are not alone confined to  Hindostan ; but, over all
countries where the  Hindoo worship  prevails, pilgrims come to
these sacred  shrines.   They disperse to  the northwest along the
great caravan routes, carrying the pestilence in  their train.  A simi-
lar  mode of distribution is recognized in  the immense pilgrimages
of Mohammedans  to the sacred shrine of  their  prophet.
  While, therefore, recognizing the original spot  and district from
which cholera  may radiate in an  epidemic form, as also the means
through which this distribution has been chiefly made, the question
naturally arises whether or no it may become temporarily endemic
or acclimated in any district.  The inquiry at this juncture becomes
the more pertinent, since thus far the  most diligent research has
failed to trace the epidemic of the past  season in the Mississippi
valley to importation, and the chief medical officers of Russia have
  fs.  o. v.]              3 
34
made a similar declaration with reference to the seven4 epidemic in
portions of that empire during the last summer.

                 The  Acclimation of  Disease.
  The  solution  of this  question  becomes of the highest interest,
when we consider the important bearing  it has with reference to the
origin and portability of several cholera epidemics.
  The first  point of observation  is, that neither yellow fever  nor
cholera becomes acclimated in eveiy point, where, for a season, they
may  prevail  epidemically.   Yet,  wherever  they  occur  in a zone
where the meteorological  conditions and  physical  formation  of  the
soil resemble their original starting-point, it is not improbable  the
germs may remain for periods latent, to re-appear in  activity under
some special  conditions, the  precise nature of which we are not, as
yet, cognizant of.  The facts illustrative of this, derived from yellow
fever, are numerous and well established ; those of cholera bearing
upon it  are  now undergoing lively discussion by epidemologists,
both in Europe  and this  country. It is generally conceded that
the starting-point, the nidus of country, so  to  speak, from  which
both  diseases sprang, is comparatively limited ; and yet we  notice
in the case of yellow fever that it is permanently endemic, in a large
portion of the tropical and sub-tropical regions of the Atlantic coast.
  It is a strange fact that yellow fever is older at all  the northern
ports of this coast  than at  New Orleans.   Its  first appearance
in that city was in  1796, since which  it has prevailed  epidemic-
ally there thirty-five times, while  not a season passes in which it is
not more or less  endemic.   It appeared in Boston a hundred years
previous to that date, nearly the same in New York and Philadel-
phia, and in  Charleston  ten times before its appearance in New
Orleans.   This  seems the more remarkable, that, while  it was so
frequently epidemic  upon all the chief cities of the  Atlantic  sea-
board, New Orleans was  more  closely connected in  geographical
position, commercial  intercourse,  language, and  government with
both  insular  and  Central  America, where  yellow  fever had pre-
vailed for centuries.   Several other places in that  zone could be
specified, where similar conditions are shown to exist: so much so,
that  we cannot always locate the precise point from which an epi-
demic may spread.  It is difficult  to assert the same with reference
to cholera.  Its  appearance is relatively far more recent; its birth-
place so restricted, its usual course through the medium of pil-
grims  so  apparent, that epidemologists  have become accustomed 
35
to that source, and that alone, for the  origin of every epidemic;
and  yet within the  past year epidemics  quite wide-spread  have
appeared, both in Russia and in  this country, where the most dili-
gent inquiry thus  far has failed to trace the direct importation of
the disease ;  and how would it be strange or strained if the analogy
of yellow  fever were applied to  cholera ?   Both  diseases have  a
paludal origin, both are transported by  what we must term, in our
present state of knowledge, a germ, for  the transmissible  principle
in both shows so  many of the properties of animal and vegetable
germs,  we can relate it in no other connection.  Now, all analogous
forms  of life readily  propagate  themselves whenever a  suitable
nidus is presented, even far from their primitive  origin, flourish
for a  season, pass into  a period of quiescence, to re-appear again
after a season in all their first activity.   The period of this dormant
vitality is not known, and is it difficult to conceive of  cholera  what
is now fully recognized of yellow fever ?   In  the  late cholera epi-
demic in Russia there was an interval  of two years,  1867 to 1869,
when it would seem to have been latent, and to have re-appeared
without the  importation of any new germ ;  and  Dr. Blikan, as
Director of the Medical Department of the Russian Government,
says of the epidemic of the last season, that,  " the infected  localities
being separated from each other by an immense space, entirely free
from cholera, the idea  of any genetic  connection  between  the epi-
demics  which visited these  localities, falls of itself to the ground."
   You  are all aware of the wide-spread epidemic which  has pre-
vailed during the  past summer in  the Mississippi Valley.   Starting
in April in New Orleans, it pursued its usual course of propagation
to all the principal towns along that river,  vaiying in intensity in
almost  every instance  with the cleanliness  of the  place,  and the
vigor of the local hygienic measures adopted to suppress it.   Now,
the most diligent, painstaking research has  so far failed to trace it
to importation.   The  heretofore  recognized necessity for such an
introduction left no  stone unturned to establish it in this  instance.
The local sanitary authorities of that city, early impressed with the
necessity of deciding the inquiry,  have failed to find even  the  most
distant trace of importation.  The chairman of the State Board of
Health  of Louisiana gave  the  subject  his  earnest and prolonged
research ; the physician to the lazaretto at New Orleans affirms
that he  examined every vessel bringing  passengers from European
ports  during the  months of January, February, and March, that
not a  death occurred  upon the passage,  and not a case of diarrhoea 
36
was  noticed.  So far  the universal  negative  testimony,  of those
whose duty would  be to know, is entirely opposed to importation,
and we are compelled to accept their report until a positive relation
can be established.  I might add, incidentally, that many  of the
telluric and  meteorological  conditions  of the  lower Mississippi
resemble  the  Ganges, and  that  it would be  difficult at least  to
suppose that the same dormant  condition of  the germ  known to
exist  at the  Ganges may occur at the  delta of the Mississippi.   If
cholera be propagated by a  germ, would  there be a radical differ-
ence  betweeu  that  and all other  germs ?   And yet, who  has ever
supposed  that the germ, infection, or whatever  it is called,  of small-
pox, became any the less  active,  much less  lost its vitality, because
it did not always prevail in an epidemic form ;  or, again,  avIio ever
failed to see the characteristic pustule of the vaccine, even though
it had passed  through  hundreds since its renewal ?  You readily
see, gentlemen, the solution  of this question has an important prac-
tical bearing.   If the doctrine of even yizase-acclimation be accepted,
we must look even  more closely  than we  have done heretofore to
the fulfillment of all local hygienic measures.
  Do not misapprehend me ; this is no effort to  show that cholera
may spring  de novo, wherever the external conditions of fomites
and filth are favorable to  its development; it  recognizes the vital,
living germ—the germ, which, when  active, produces cholera and
nothing else;  still a germ which, when it has found its appropriate
nidus, may remain for a  season quiescent, until seasons and condi-
tions  conspire  to  have it display its full power as an epidemic.
  Perhaps it may be suggested here that the acclimation of yellow
fever is admitted,  but not  so with regard  to cholera,  since the
germ  of  each is transmissible  in different ways.  The  germ  of
yellow fever not being generated in the  human system, nor trans-
mitted  from person to person in any way, but  generated outside,
and taken up  after the manner  of marsh-malaria, easily finds its
acclimation in the many articles  in which  it is transported, but that
cholera-germ,  generated  in  the individual, could only be transmis-
sible  by the actual  presence of  those suffering  from it.   This, it
seems to me, is the strongest point of the  argument against accli-
mation.   Yet who  will decide the  length of time during which the
cholera-germ may retain vitality when in a favorable nidus /  Who
will determine the length  of time that  the trichina; or  the tape-
worm may continue in the cestoid state unless favorable  influences
for their development  occur ?  The little  animalcules which swarm 
37
each mud-pool are, as the pool dries up carried off with the7 floating
wind, to  re-appear in full  activity at the  next summer's shower.
The epidemic in Russia has  shown that the germ remained vitalized
for two years at least;  how long would this continue  under the
more favorable influence of  a tropical clime ?
   Dr. Macnamara states that if fresh cholera dejecta are  dried on
clothes and furniture, or in the soil, they retain their activity for
years, if access of moisture be  prevented.   He had  some of  the
dejecta which, when fresh, were mixed with sand and dried seven
years before.  Now, when  mixed with water,  and exposed  to  the
sun, they could not be distinguished from a fresh cholera-stool.
   Having established that cholera can be transmitted, it remains to
show how this occurs, what are the  agents of transmission,  how it
is influenced by the different modes of locomotion, the crowding of
persons, what are the  attributes  of the generating  principle,  the
means by which  it enters   the  organism.   In  the  limited time re-
maining,  these can be treated only in the most general manner :
   I. This contagion always  follows the routes of travel, and  never
progresses faster than it can be transported by an individual himself.
In this is, of course, included all  that pertains to his progress; his
baggage,  merchandise, the vessel which  carries him, everything
indeed which accompanies him.
   LI. The poison  of cholera is cast  off with the characteristic  dis-
charges of the alimentary canal, and communicated to others in the
following principal ways:
   1. By the soiled hands of the attendants who are  not careful to
wash before taking their food.
   2. By means of bed and body linen, carpets and other articles
soiled by the choleraic discharges.
   III. The discharges  finding their way into  the sewers and into
the soil may spread the disease in various ways : 1. By percolating
through the soil into wells  and other  reservoirs of drinking  water.
2. By rising with watery vapor into the air.   3. By becoming dried,
and then dispersed with the  atmosphere in form of  an impalpable
dust;  or, in the words of Mr. Sirnon, Registrar-General of England,
" it cannot be too distinctly understood that the person  who con-
tracts  cholera in  this  country is,  ipse facto, demonstrated with
almost absolute certainty to have  been exposed to excremental  pol-
lution, excrement-sodden earth, excrement-reeking air, excrement-
tainted water."
   Nor is it essential for this contamination that the infected  person 
38
should be laboring under the full access of cholera-symptoms.  The
affection is just as  certainly transmitted, and  probably more fre-
quently by persons  suffering from  mere  choleraic diarrhtea.  The
essential germ is the same in both, and  the  choleraic diarrhcra of
one will develop into the malignant form  in another.   Whenever it
passes by a sudden leap  from an affected  locality to one not as yet
poisoned,  it is probably by some such transportation.   Persons so
affected are moving about—it may be traveling in cars or on  river
steamboats.   Each  dejection,  miles separate, may disseminate the
poison in the particular locality.  Numerous  authenticated  cases
are on record of propagation  in this manner, and, during  the epi-
demic of the past summer  in  the  Mississippi Valley, its capricious
meanderings were many times traced by this mode of transmission.
Its importation to this country is, of necessity, by ships, and, as by
far the greater portion of people enter this port, the  danger  from
this  source is relatively greater  here than in any other.   To show
the activity it acquires, after being  retained for a time on board, let
me recite the following  fact: The steamship England arrived off
Halifax a few years since with cholera on board.  A pilot, with an
assistant and his son, went off to the ship in an open boat.   Hearing
that there was sickness on board, the men remained  in  the boat,
which was towed at a considerable distance astern by a ten-fathom
line.  In this way the ship, with the boat in tow,  was conducted to
her  place of anchor.  The pilots  then  went  on shore, and were
never on board the  infected ship.  In the course of the  next two
days both men were seized with  cholera,  and  one died.  Both men
communicated the  disease to their familes.   In the  family of one
there were three cases, but no death ; in  that of the other, besides
the  father, who  died, there were four cases and two deaths.   The
only other cases of cholera in Halifax at  that time occurred in the
family of a man, whose two children were seized, after playing with
soiled bedding which had floated on shore from the infected steamer ;
one  child died,  the other  recovered.  The mother also took the
disease  and died.   Surely  if disease was ever communicated by
infection,  it was  so in the case of these three families, the  different
members of which were, in various ways, brought into contact with
the infecting material imported by  the steamer.
   An indirect proof of the contagiousness of cholera is afforded by
the fact that the disease has never reached certain countries which,
being separated from India by a wide expanse of ocean, and having
little communication with that country, have escaped the infection. 
39
Among the countries are Australia, New Zealand, and the other
Pacific islands ; the Cape of Good Hope, and the  southern  part of
the west coast of Africa ; the Azores, Bermuda, Iceland, the Faroe,
Orkney and  Shetland islands,  and the western  coast of South
America.
  Of the agents for the immediate transmission of cholera,  impure
water plays an important part.   Whoever has kept  pace with the
many writings on cholera, will  see the  importance which  of late
years has been attributed to impure water as an excitant of cholera,
not only on the general  principle that water, rendered impure by
the presence of large quantities of organic matter, favors the spread
of an epidemic, but also from water contaminated directly by cholera
excretion.  Now  that public  attention is fully awakened  to this
matter, and  also the fact that, almost  for  the first  time  in  this
country, the  epidemic of the  past summer was  carefully noted in
many  places,  w7e have many  interesting proofs establishing this
source of poisoning.  In the first case which occurred in Lexington,
Kentucky, the dejections were thrown out, so that by percolation
they reached a well situate near  by ; twelve subsequent cases were
clearly traced to this water contamination.   In this  connection, I
can as advantageously notice  as elsewhere, that out of a  certain
number of persons who are exposed to cholera contagion, whether
by impure water, contact with excretions in  any form, but a mod-
erate percentage  really suffer from such  exposure:  thus  out of
nineteen persons  known to  have drank  inadvertently of water, in
which cholera excretion had  been thrown, but five suffered from
the  disease.   Observations show  that in a  crowded  community,
apparently equally exposed to the same influences, the above figures
are not far from  the average, of those who will show actively the
contamination.  It happens, then,  that a large majority of persons
exposed  to cholera-poison  escape completely,  or incompletely,
though of the latter there are far more than of complete immunity.
Of this category are the great number of choleraic diarrhoeas known
to prevail at the time of  an epidemic.  This immunity may extend
to entire communities, for, after  the recent presence of an epidemic,
there is an indisposition for another,  even  though there may have
been an entirely new importation ; a condition somewhat similar to
what we  noticed in yellow fever—the community is  for the time
acclimated.
   Let me return, however.  Another fruitful mode of contamina-
tion is from soiled clothing.   Again and again has it been  carried 
40
 into perfectly healthy districts by sending into such localities cloth-
 ing which had  been  soiled by  those suffering  from  the  disease.
 Those, too, who wash such clothing are peculiarly exposed ;  indeed,
 it should be  an established axiom that no contaminated clothing be
 washed until it has first been thoroughly immersed  in some disin-
 fecting fluid.  Here, too, I  may notice a clinical fact which is of
 practical  value.   There is  good reason  to believe that the fresh
 cholera-stools are nearly if not quite harmless ; that their greatest
 infecting power coincides with the stage of commencing decomposi-
 tion, and  that in a more advanced stage of decomposition they again
 become harmless.   The practical deduction is obvious : that attend-
 ants may, almost  with impunity, wait upon those affected  if the
 dejections are immediately thrown in some disinfecting composition,
 and care is taken to wash the  hands and promptly remove soiled
 clothing.   In addition to these direct modes of communication, the
 virus  may be diffused  through  the air, and thus enter the  system
 by the  lungs.  Its rapid dissemination in  a locality attacked, the
 simultaneousness of a  great number of cases in a given agglomera-
 tion of persons where contact  has  not been possible, the fact that
 persons may  be attacked at a short distance from the suffering case,
 favor the proposition,  and attest to the volatility  of the  cholera-
 germ.   The  distance to which  the  principle  can be, in this wray,
 transported,  is probably limited,  but still must be  recognized in
 studying the  active modes of propagation.
   Pettenkofer, who has  given  to  the  subject  long  and patient
 study,  insists that soil-saturation performs also an important part in
 this propagation;  i. e., that  a porous soil,  easily permeable  to air
 and water, coinciding  with an  elevated water-level from  subter-
 ranean springs, and especially coinciding with changes in the level
 of these waters, becomes an  active agent in disengaging the poison
 once brought to it.
   We  have  now no  difficulty in understanding  that  cholera is a
 disease capable  of being  rapidly communicated from the sick to
 the healthy over an extensive population, and  yet that, with ordi-
 nary precautions, the  immediate personal  attendants  on the sick
 incur scarcely airy risk  of  infection.  In this respect, there is  a
very close resemblance  between  cholera and typhoid or enteric
fever.   The alimentary canal is in both diseases the chief if not the
sole outlet for the poison.  The  bowel-discharges  are the means for
the infection, and. whereas,  the fresh secretions are comparatively
 innocuous, the subsequent fermentation  of the discharges from  a 
41
single patient may infect the drains of an entire district.   Hence,
it  follows  that  the inhabitants of  a house with untrapped drains,
half a mile  or more  away,  may incur three  times  more risk  of
infection than the sick man's nurse or doctor.
   Having  established the  proposition that  cholera  can be trans-
ported, and pointed out some of the principal modes by which it is
transmitted, it remains, in order to  complete the picture, to fix the
duration of the incubation, for cholera, like all  contagious  diseases,
requires  a certain time after its  introduction  into the system  to
develop its specific character.   The  congress of  1865  at Constan-
tinople discussed  this point long and fully ; for the fact that the
period of incubation may be from a  few hours to (as many asserted)
several days, necessarily called forth the most varied opinions.   It
is probable some of this diversity would be  reconciled if the chole-
raic diarrhoea, which so  often precedes the more intense symptoms,
could be more rigidly determined.   In the  practical operations  of
the quarantine, we cannot, from its  greater facility of transmission,
take the average  incubation, as in  yellow fever, but rather extend
it beyond the extreme period, say ten days.
   It now remains to  deduce the  preventive  measures, based  upon
these views of its history and modes  of transmission.   Our remarks
will apply only to those applicable to its ingress by way of the sea.
First, then, no  arbitrary rules  can   be  laid  down which  shall be
applicable to all vessels.  Every arrival of  a  vessel wTith cholera
must, having  in view all the general laws Ave have  laid down, be
judged by the  particular  features Avhich   belong  to  that  case.
While, as a rule, every vessel, its  passengers and crew having had
cholera upon its passage, or at the time of its entry, should be sub-
jected at least to a quarantine of observation,  still  this  rule is not
Avithout exceptions.   For instance, two steamers entered the harbor
last fall,  having had deaths from  cholera, and  another Avith one
well marked, and  several of choleraic diarrhoea on board, neither
one of Avhich Avas  detained more  than twenty-four hours ; and yet
I felt quite secure in allowing them  to proceed to the city.   Why
Avas this ?  In the first, the  case was a cabin-passenger.  The nature
of  the  disease was almost immediately  detected by the  surgeon.
At once absolute isolation Avas enforced, passengers from neighbor-
ing  state-rooms  were  removed,  dejections  disinfected, and  care
taken Avith reference to soiled linen.   Seven days had elapsed since
the death ; when  the vessel  entered, the  state-r6om  had been scru-
pulously cleaned and  disinfected  daily.   Here, then, every intelli-
   [s. o. v.]              4 
42
gent preventive measure had been employed ; the  time of  incuba-
tion, when any passenger having contracted the disease before enter-
ing the vessel, Avas past, and,  in view of the measures employed, I
had only to consider the possibility of contamination from the par-
ticular case.   It had been limited to one ;  the average time of incu-
bation was more than past since  his death, without another  case,
and I therefore decided to let the vessel go  up.   Now, had a cast-
iron rigidity been followed, without reference to the measures which
the surgeon employed,  all  the passengers  should have  been taken
from  the ship, subjected for  eight or  ten days to  a quarantine ot
observation,  the vessel itself thoroughly  cleaned, and  every part
aired and daily fumigated.   While such a course Avould have been
warranted  by  law, and sanctioned,  too, by  sanitarians, I felt that
the precautionary measures adopted were  sufficient, and would en-
courage medical officers and the shipping  interest to attack the dis-
ease at its source, rather than passively allow it to  gain full headAvay,
under the  conviction that no efforts they might apply Avould  be
recognized by the sanitary authorities of the port.
   The other death Avas in the steerage, so  sudden that the surgeon
was not  informed until actual collapse.   On inquiry, no dejection
had  taken  place except at  the  Avater-closet into  the  sea  ;  none
occurred after the collapse ; the clothing was, at the time, examined
to see whether any stain Avas upon it; the  body Avas at once thrown
overboard, all the effects disinfected,  and ten days had elapsed since
the death, on their arrival.   Wherein Avould a quarantine of obser-
vation have helped me in this matter ?
   In the case of cholera Avhich entered the  port, every precautionary
measure had been adopted ;  the most rigid examination  and  inquiry
could not  detect other cases  of choleraic  diarrhoea  than  those
referred to.  The  period  of incubation,  from  acquiring it  before
entering the ship, had  passed, and, Avith no evidence of contamina-
tion to others, the vessel Avas allowed pratique.
   In acting in this manner in the above three  instances, I  but fol-
loAved, on a limited scale, Avhat is universally recognized by all the
 European governments, and to which all their later efforts have prin-
cipally tended, viz., to suppress the disease as far as possible at its
 source.  They feel that the great field for pecautionary measures is
 in the home of the disease, and the local  governments are, as far as
 possible, discouraging the great pilgrimages, with the large agglom-
 erations of people, and their subsequent religious rites, with  already
 an appreciable  diminution in the  routes of transmission. 
43
  A vessel arriving, however, with several cases on board would be
compelled  to undergo  the  full ordeal of precautionary measures.
The passengers would be removed from the vessel, subjected to a
quarantine of observation;  any sick  appearing to  be  promptly re-
moved to the hospital located on another island, a mile distant from
the island Avhere the quarantine of observation was  enforced.   In
the meantime all  clothing Avould be thoroughly washed, aired,  and
disinfected, and, when  eight days had  elapsed without the appear-
ance of a new case, they would be allowed to leave.  In the mean-
time the vessel,  after  being subjected to thorough cleansing and  dis-
infection, would be allowed pratique.
  I think you will agree with me, gentlemen, that in the restrictive
measures there  is no  blind formalism, nor any mysterious proceed-
ings.   All are deducible from the accepted  notions of the history,
nature,  and modes of transmission of the disease.   If this principle
is faithfully carried  out, there  will be, I am  sure, no antagonism
between sanitary and commercial interests, but most of the measures
adopted in behalf of the one will indirectly promote the prosperity
of the other. 
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