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"twenty days having elapsed since the last death, and thirteen days since the last case [attack] of illness," she was admitted to free pratique;-that till the 3d of August she was being III. Foreign unloaded by labourers of St. Nazaire;-that many of these Epidemics and labourers were, on the 5th and 6th of August, attacked with Quarantine. yellow fever; that previously (on the 2nd, 3rd, and 4th of August respectively) the mate of the Anne Marie who had remained on board, a cooper who had been "employed to repair the cases," and a stone-cutter "who had been working on the quay near to the Anne Marie," had been attacked with illness which, in at least the first two, was believed to be yellow fever; —that, moreover, on August 1, the Chastan (which now was at Indret, but previously had been at St. Nazaire lying alongside the Anne Marie) had had a first attack of yellow fever, and that by August 5, all the five men who formed her crew had been attacked;-that when the place of the Chastan beside the Anne Marie was taken by the Dardanelles, a boy in charge of the Dardanelles (the only person on board her) contracted yellow fever-that the Cormoran, which had been taking cargo from the Chastan while alongside the Anne Marie, had, after some days, two cases of yellow fever on board;-that a steamer of the Lorient Company, having remained two days in harbour near the Anne Marie, had, on returning to Lorient, two of her crew attacked with yellow fever;-that two lighters from Indret, having also remained two days near the Anne Marie, had afterwards their crews, seven or eight in number, attacked with "a kind of half-yellow fever;"-finally, that an eighth vessel, the Arequipa, which had also remained for several days near the Anne Marie, and had on August 1 sailed for Cayenne, but been detained off the French coast by bad weather till August 5, had on August 5 a first attack of yellow fever, and had other attacks at intervals during the six or seven weeks following. It was alleged, morever, that while the above events were in progress, certain of the patients, being on shore at St. Nazaire and its neighbourhood, communicated yellow fever to two or three, and slighter illness of the same kind to some others, of the persons who were about them; but, without going here into any minute discussion of these cases, I may state, as the conclusion to which a careful study of the official papers led me, that, in my opinion, it was only in a very qualified sense, if at all, that communication of yellow fever by means of personal intercourse could be said to be proven by the cases.* The total mischief done by the out

"In one very important case (that of M. Chaillon) the sufferer is said not to have been near the ship, but to have contracted the infection from certain labourers who came infected from the ship, and whom he attended medically ['frictioned'] at their homes. In a second case, one of the ship labourers, who himself had yellow fever, is said to have carried the infection certainly to his wife, and perhaps to an old man in whose house he and his wife lodged; for these two had attacks of yellow fever, the old man fatally; and though it was not known as a certainty' by M. Mélier that the old man had not been near the ship, it seems agreed that the woman had not been there. [H.M. Consul, Sir A. Perrier, eventually found reason to believe that both these persons had been exposed to chances of direct infection from the ship.]

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break was set down at 44 cases of yellow fever, resulting in 26 deaths from the disease. It was stated that, at the time when the Anne Marie arrived in port, there was no other vestige of yellow fever at St. Nazaire, or in its neighbourhood; that neither III. Foreigu yellow fever nor anything like it had ever before existed in the Epidemics and district; and that no other yellow fever was seen in that summer on this side of the Atlantic. The description given of St. Nazaire was this: the town is partly built on the strand, and is tolerably healthy; its vicinity is marshy, and subject to intermittent fevers-perhaps more than usually so this year: nevertheless, nothing uncommon was observed in the state of public health." The weather is said to have been extremely hot-"more like that of a tropical than of an European climate."

Before closing my account of these two little outbreaks of yellowfever in exceptionally northern latitudes, I ought to state that, though nothing of quite the same sort had previously occurred either in England or in France, yet, in both countries, some slight and almost overlooked warnings, to the same general effect, had been given. Thus, in France, though apparently yellow fever had never touched the ordinary land-population or spread from ship to ship anywhere so far north as St. Nazaire, probably, on a few occasions, and in very small amount, the disease had been seen in the quarantine establishment of a still more northerly port-that of Brest, attacking now and then some official whose business had In some other cases, persons who apparently had not been near any affected ship, but had attended patients from the Chastan, were attacked, though but slightly, with symptoms very suggestive of yellow fever. M. Mélier's belief with regard to the several just-cited cases is, that they were cases of true contagion, using the word 'contagion' in the sense in which we call smallpox and typhus contagious. Without pretending to controvert this belief (which on other grounds may or may not be tenable) I would observe that it is not a necessary consequence of the facts recorded in the present papers. The facts, supposing no exception taken to them, would be to this effect :-that labourers who had spent time in the hold of the Anne Marie, and had caught yellow fever there, carried with them some power of infection; and that a like power, much feebler in degree, went also with the crew of the Chastan. But almost unquestionably, with regard to the Anne Marie, and not improbably with regard to the Chastan, it seems that the ship, irrespectively of sick persons in it, was a focus of yellow fever infection. And, on this showing, the alleged facts admit of more than one interpretation. Whether, namely, the men carried infection because they themselves had contracted yellow fever, or merely carried infection passively as they might have carried an odour from the ship; whether men who had laboured in the hold of the Anne Marie without themselves contracting yellow fever there might equally have carried infection to their homes whether they who carried infection might have been disinfected by soap and water and change of dress; whether, in short, the infective power belonged, not to the sick body, as such, and to its excretions and discharges, but to the mere washable surface and clothing which had been saturated with the atmosphere of the ship; this question remains unanswered by facts in the present record. And I draw attention to that openness of the question, because of its all-important bearing on the practical issue, whether it was necessary to adopt at St. Nazaire the system of personal quarantine which certain of M. Mélier's regulations enforced."-Extract from Office-Memorandum on the St. Nazaire outbreak. See also Appendix No. 17. The distinctions which I have drawn as to the mode in which yellow fever might have been (if it was) communicated by personal intercourse at St. Nazaire, and the doubts which I have intimated as to the provenness of true contagion there, are equally applicable to the discussion of the somewhat similar facts which are reported to have occurred thirteen or fourteen years ago at Southampton.

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been with a newly-arrived infected ship.* Dr. Buchanan's inquiry at Swansea elicited that probably on two or three occasions a solitary case of yellow fever had occurred there under like cirIII. Foreign cumstances. cumstances. At Southampton too, on one occasion, in 1852, it Epidemics and happened that an engineer of an infected ship was attacked with yellow fever on shore eight days after the ship's arrival in port.† And it is alleged that also at Southampton, in the years 1852-3, the landing of yellow fever patients from infected ships led on three occasions to ill-results, as follows:-that in one case, witnessed by Mr. Wiblin in December 1852, it was believed that a convalescent from yellow fever infected two members of his family, who afterwards infected three others, with illness much less severe than ordinary yellow fever, but having at least some affinity to it; that, in another case, witnessed by Mr. Dusautoy, in the summer of 1853, a woman died with symptoms of yellow fever shortly after having washed the clothes of a seaman who had been landed with that disease; that, in the remaining case, witnessed by Mr. Wiblin in July 1853, it was believed that a yellow fever patient taken to the Southampton poor-house communicated his disease, in a fatal form, to another inmate of the establishment. It is proper to add that, in some of the above cases, medical controversy was raised as to the nature of the disease. Of course no absolute judgment can now be given on questions of fact which so many years ago were in dispute; but, so far as the statements are accepted in proof of the communicability of yellow fever by personal intercourse, the acceptance must be qualified with the same considerations as I have expressed in regard of the corresponding statements at St. Nazaire. In the thirteen years which have elapsed since the occurrences in question, persons, more or less ill with yellow fever, have on numerous occasions been landed at Southampton from West Indian steamers; but in no case, so far as my information extends, has it even been suspected that their disease has spread to other persons. Nor did anything of this kind arise in connexion with the above-mentioned case of the engineer who ran the whole course of his disease in Southampton.

The various incidents to which the last preceding pages have been given possess in common one particular kind of interest. For when the public mind is troubled with facts or rumours of epidemic visitation, question always arises how far the mischief can be stopped or prevented by restrictions on the ordinary freedom of traffic, national or international. And since the present report records the coincidence of several cases wherein that

Particulars of one such occurrence (which took place in 1856) are given in the Bulletin de l'Académie de Médecine, vol. xxii.

† See the case, as reported by Mr. Wiblin, in the Lancet of 1853. I may note here that the ship was a wooden one, and that the engineer, though lodging on shore, had been spending much of his time in the ship. Also I may note that, in our present ignorance as to the incubation-time of yellow fever, we cannot absolutely say that the disease was not latent in the man when he first landed.

See Foot-note (*) at pp. 32, 33.

question was raised, it may be convenient that I here briefly state MEDICAL the principles on which such such cases have been considered.

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When phenomena of pestilence are under popular discussion, III. Foreign and most of all when quarantine is being spoken of, frequently Epidemics and language is used which seems to imply a belief that the medical profession is divided as it were into two camps, respectively of "contagionists" and "anti-contagionists." Now, so far as my knowledge extends, I will venture to say (speaking of course of the medical profession as represented by its acknowledged teachers) that no such duality of opinion exists. That many of our worst diseases acquire diffusion and local perpetuity by means of specific infective influences which the sick exercise on the healthy, is an elementary truth of medicine; and among persons who are competent to distinguish the certainties from the uncertainties of science, there is no more doubt, broadly, as to that truth than there is doubt as to the diurnal and annual movements of the earth. Ambiguities which fifty years ago existed in respect of some particular cases have since then been gradually cleared away; -sometimes through the ascertainment that seeming contradictions of fact were facts of different diseases confounded under a common name;† sometimes through the new and conclusive evidence of well recorded cases and experiments; sometimes through improved insight into the habits of a morbid poison; § and generally through that better grasp which time has given us of the subject as a whole. And more and more the once chaotic phenomenology of contagion is tending to become an intelligible. and consistent section in the great science of organic chemistry.

On the other hand, not even the merest tyro in medicine supposes that contagion (as a morbific power acting from each sick centre) operates equally on all persons, or equally under all varying circumstances of place and time. Differences are obvious even to superficial observation, and such differences become still better appreciated as the general doctrine of contagion gets to be better understood.

First, as regards personal differences of susceptibility;-they are seen, on a small scale, when we observe with what different degrees of severity different persons and different families, in

* In my sixth annual report, when discussing the subject of the spread of communicable diseases in hospitals, I stated with some detail, and need not now again state, the very different conditions under which different diseases are communicated. See Report for 1863, p. 53.

Well, for instance, might there be difference of opinion about the communicability of "continued fever," while under that name typhus, typhoid, and relapsing fevers were all spoken of as one disease. So, too, in regard of syphilis, the old uncertainty as to the laws of the contagion depended in great part on confusion between two kinds of chancre.

Such for instance as those by which the contagiousness of typhoid fever and of cholera has been established.

§ As, for instance, in the knowledge which has been got as to the great development of contagious property in choleraic discharges some two or three days after their discharge from the body; or the knowledge of the different effect which one kind of syphilitic inoculation exercises on those who have, and those who have not, previously suffered from a like inoculation.

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similar external circumstances, and with similar exposures to contagion, suffer the diseases which they thus contract;—and, on a much larger scale, the same thing is seen in that permanent and complete insusceptibility which most persons acquire in relation to certain contagia which have once affected them: to small-pox, typhus, and measles, for instance: so that millions of persons who have acquired that kind of immunity are being daily exposed to chances of contagion, but, whatever the quantity of the contagium, and whatever the external circumstances, do not suffer second attacks of the disease which they have once undergone.

Secondly, as the local circumstances vary in which a contagiously-diseased person is placed, so, pari passu, the power of contagion may show an almost infinite range of differences. Typhus and typhoid fevers, for instance, which, amid overcrowding and non-ventilation and refuse-odours and foul water-supply, would develop themselves to be the most spreading of pestilences, will, in thoroughly clean atmospheres and with thoroughly clean watersupply, be so restricted in their infectiveness, that typhoid will scarcely be recognized as contagious, nor even typhus extend beyond limits which admit of being narrowly defined. Again there are certain geological conditions which make the greatest difference (though probably only in an indirect way) to the spread of the diarrhoeal infections.* And, even apart from such influences as the above, it seems doubtful whether all contagious diseases are equally capable of pandemic extension:-it is said, for instance, that hitherto neither scarlatina nor typhus has shown much disposition to spread either in Asia or in Africa.

Thirdly, the very important qualification has to be stated, without which no one can bring into an intelligible whole the epidemiology of different lands and different ages of the world, that, in the category of time, far out of human reach, there are circumstances which greatly influence contagion. Any one who will reflect on that most curious branch of natural history which treats of the various plagues which in different times have fallen, sometimes on man, sometimes on his fellow-creatures of the animal or vegetable world, will be convinced that not fixed local conditions, and not mere more or less of international traffic can, either singly or conjointly, explain the wonderful fluctuations of effect. When the ordinary distribution of human disease on the surface of the globe is studied, it is easy to distinguish certain spaces, of larger or

*This, in relation to cholera, has been more or less definitely observed throughout all the fifty years that the disease has been studied; first abundantly in India, and afterwards in Europe. See Hirsch's Hist. Geogr. Pathologie, Vol. I., pp. 134-146. In 1848-9, when I first had to do with the disease, though but in one city, the fact forced itself strongly on my attention. See reports on sanitary condition of city of London. pp. 95-100 and 223-5. The subject has much prominence given to it, and is admirably treated in Professor Pettenkofer's contributions to the report of the Royal Bavarian Commission on the cholera-epidemic of 1854. See also foot-note, (†) p. 38. The bearing of the geological influence, however, is apparently none but this-that where populations are living in certain geological conditions, there, unless engineering science have supplied artificial drainage and water-supply, the local atmosphere and drinking-water will almost certainly be much polluted by those fæcal impurities amid which the diarrhoeal contagia are peculiarly apt to multiply.