QUAKANTINE 155 chief occasion of quarantine on the American continent and adjacent islands is the endemic existence of yellow fever in Brazilian and West Indian harbours, particularly Havana and Rio de Janeiro (and, since 1853, in Callao and other Peruvian ports). During the yellow-fever season from April to November, the ports of the United States are on the outlook, under the quarantine laws of each State, to de- tain vessels with yellow fever on board arriving from Gulf ports or from the West Indies and Brazil. In like manner the ports of the River Plate would protect themselves against foul arrivals from Brazil ; and some of the Mexican Gulf and West Indian harbours Avill even practise quaran- tine against each other according as the fever happens to be epidemic here or there. The practice at New York, Boston, Philadelphia, Baltimore, and other United States ports is to detain only the sick, or those who are reasonably suspected, the lazaret (usually on an island in the harbour) being practically a hospital for sailors, immigrants, and other newly-arrived persons suffering from communicable disease. In some years the cases of yellow fever arriving at New York have been numerous, and an epidemic has now and again arisen among the residents near the lazaret. Experience has shown that the ship's hull, foul ballast, and the like have been the real sources of infection, cases occurring at New York every year among the labourers on infected ships. It is only occasionally that the unlading of the cargo of a yellow-fever ship into the quarantine barges has been insisted on. The classification of ships according as they carry clean or foul bills of health has been found to be practically unworkable in the United States, a foul bill being a rare thing. The severity of the quarantine is left, accordingly, very much to the discretion of the medical officer of the port. According to the de- finition of the National Board of Health, quarantine is " the administration employed to determine the presence or absence of the causes of contagious or infectious diseases, and to secure the removal or destruction of such causes ;" and it does not imply detention for any specified time, nor for more time than is necessary for the above purposes. Notwithstanding the creation of a National Board of Health for the Federal Union, quarantine is still an affair of the States acting independently. The detection and isolation of small-pox cases is one of the chief occupations of the quarantine officers at United States ports. As regards the introduction of cholera into the United States, Billings says : " The present quarantine systems of the United States are now probably unable to prevent the introduction of this disease, as they have been heretofore. Unless the disease had actually occurred on board ship, very little precaution would be taken, and very few of our ports have the necessary facilities for properly dealing with a large passenger ship having cholera on board, in such a manner as to obtain a reasonable amount of security without causing unreasonable delay, involving unnecessary suffering and danger on the part of those not actually sick " (Trans. Internal. Med. Congress, London, 1881, iv. 416). In several instances, when cholera has broken out among emigrants in a transatlantic steamship, the vessel has put into Halifax, N. S., where there are facilities for quarantining passengers ; and more than once the epidemic, although of the most threatening kind, has gone no farther. New Orleans has proved itself a more likely port of entry for cholera than any of the Atlantic ports. In the ports of South America and the West Indies the quarantine practice is variable and empirical. Sometimes an absolute cordon has been established, as in the instance of Dominica against Guadeloupe in 1865-66 during the cholera. The smaller and healthier the community the more severe is the quarantine likely to be. In the West Indies, the Bermudas, (fee., the very remarkable disease of dengue (probably a modern hybrid form) is considered to be an importable infection which quarantine can keep out. Quarantine in the Red Sea and at Suez. Cholera having come to Europe in 1865 by a new route, by the pilgrim traffic to Mecca, the conference of Constantinople in 1866 took into consideration the question of a quarantine at the Straits of Bab-el-Mandeb. Since that time such a quaran- tine has been instituted for pilgrim ships at the island of Xamaran on the Arabian side of the Red Sea, some 200 miles within the straits. Since the severe outbreak of cholera at Mecca in the end of 1881, the quarantine for pilgrim ships at Xamaran has become more stringent. The slight outbreak at Mecca in 1882 is said, without good reason, to have arisen owing to three English steam- ships with pilgrims having evaded that quarantine. All pilgrim ships whatsoever are required to stop at Xamaran, 1 and the pilgrims from cholera-stricken countries in the East are disembarked and kept under observation in the lazarets on the island for ten or fifteen days. 2 On the dispersal of the hajj at Mecca, another quaran- tine is performed by the pilgrims returning by way of Suez, who are usually only a small fraction of the whole assemblage. They are disembarked either at Wejh on the Arabian coast half way between Jeddah and Suez, or at Tor on the Sinaitic side of the Gulf of Suez, sometimes even at both places. After the epidemic at Mecca from September to December 1881, it was not until the 19th February 1882 that the last company of pilgrims was allowed to re-embark at Wejh for Suez, by the authority of an inspecting sanitary commission from Egypt. If no suspicious cases occur, the detention is for fourteen days; but a single case subjects the whole group in which it had appeared to a further term of quarantine. Pilgrims bound for Smyrna, Beyrout, or other ports in the Levant are subjected to another term of quarantine in the lazaret of the port of arrival. Those proceeding landwards to Damascus undergo a quarantine at Moses' Wells. The usefulness of this control over the movements of the Mecca pilgrims has been much debated. Regarding the ad- vantages of the quarantine after the breaking up of the hajj there has been a good deal of positive evidence since 1865 ; but the detention at Xamaran is a much more questionable affair. In a great assemblage at Mecca, such as that of 1881, there are all the conditions for the fresh breeding of a choleraic form of sickness, which shall be communicable to others, just as there have often been (in the common- 1 The working of the quarantine at Xamaran will be best understood from a particular instance. The steamship " Hesperia " sailed in July 1882 from Bombay for Jeddah with 498 pilgrims, who had been inspected xmder the Native Passengers Act. She arrived on the 26th July at Aden, where she was quarantined for ten days owing to the death of one of the firemen from cholera. Xamaran was reached on the 8th of August, and the pilgrims landed for a ten days' quarantine. Deaths having occurred among the pilgrims on shore, a second quaran- tine of ten days was imposed ; and towards the expiry of that time the health officer again placed the ship in quarantine for ten days owing to more deaths on shore. On September 8, when the vessel was still in quarantine, it became necessary to proceed to Aden for coals, steam having been kept up continually owing to the dangerous nature of the quarantine moorings. In leaving Xamaran the ship broke her quaran- tine, and only escaped the threatened fire of the Turkish gunboat by her speed. She returned from Aden on the 19th September, and re- embarked her passengers for Jeddah on the 23d, two of them dying in the boats during the embarkation. The drinking-water of the quaran- tine camp at Xamaran was credibly stated to be in a fetid condition, causing vomiting and purging, and the food insufficient and inferior. Each pilgrim had to pay 10 rupees, and the ship 12,000 piastres of sani- tary dues. After landing her passengers at Jeddah, the " Hesperia" proceeded on her voyage to Liverpool, undergoing a twenty-four hours' quarantine of observation at Suez. Brit. Med. Journ., 1882, ii. 952. 2 The international sanitary conference of Rome (1885) has pro- posed a relaxation of the rule : each ship with more than thirty pilgrims to carry a doctor, and no ship to be detained more than 24 hours, nor the pilgrims disembarked, unless there be or has been cholera on board.
