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almost unknown in the United States, certainly scarcely a death was reported. The result of a long-continued immunity from this disease is great laxity in regard to vaccination. Large numbers of children born during such periods are allowed to remain unvaccinated in every community. Hence, when small-pox appears after such intervals of immunity from the disease, it spreads with far greater virulence than when vaccination is enforced by the fear which the presence of small-pox creates. In 1879 there were a few deaths by that disease in New York (25) and in San Antonio, Texas, (125), but the country at large enjoyed a remarkable immunity from that affliction. The cases in 1879, in New York, occurred among unprotected foreigners, and those in San Antonio werc unprotected New Mexicans. But during 1879 small-pox began to be more than usually prevalent in European seaports and in Canada. Much uneasiness was felt by many of the most vigilant sanitary officers in different parts of the country lest the infection should be brought to this country, especially from the neighboring Province of Canada, particularly at Montreal. In several instances local outbreaks of the disease occurred along the Canada frontier, owing to the importation of the infection through immigrants. Towards the close of the year 1879 there were evidences of a wider distribution of small-pox than could be accounted for by importation from Canada. It appeared in New York, Philadelphia, Chicago, the District of Columbia, and other cities. During the year 1880 these outbreaks became more general and were most marked in the Western and Northwestern States, while in the larger Eastern cities it prevailed with a constantly increasing tendency to become epidemic. The present year, 1881, opened with a wide distribution of the disease, and frequent local epidemics of great severity.

The following table, though not complete, furnishes sufficient information to indicate the gradual rise of the epidemic and the present distribution of the disease. It gives the number of deaths from small-pox reported in 1879, 1880 and 1881, up to the week ending June 11:

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New Britain, Conn.
Waterbury, Conn.
New York...
Utica, N. Y..
New Haven....
Hudson County, N
Newark, N. J...
Camden. NJ...
District of Columb
Richmond, Va.....
New Orleans......

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From reliable sources it is known that small-pox prevails to an unusual extent in many of the large cities of the North and West, and that virulent and fatal epidemics of this disease are of frequent occurrence in small towns and in small communities of many States.

If, now, we inquire into the causes of this diffusion of small-pox throughout the country, we shall find that immigration is at least an important factor. First, it must be remembered that small-pox became epidemic or certainly unusually prevalent in foreign seaport towns and in Canada in 1878, 1879, and 1880, and is at present the prevailing epidemic disease in these towns. From the following figures it appears that the tide of immigration to this country from Europe began to rise in 1879, and in 1880 reached proportions hitherto unprecedented in the history of immigration to this country. And still the tide is rising, as appears from the following late reports of the Chief of the Bureau Statistics at Washington, viz: for nine months ended March 31, 1880, 214,596; for the same period in 1881, 357,396. The total increase in the number of immigrants during the last nine months is 142,800. From still later reports we learn that the arrival of immigrants at the principal ports of the United States is yet on the increase. Indeed, it is no unusual occurrence to witness the arrival of from 6,000 to 8,000 immigrants at the port of New York in a single day.

Second.-It must be noticed that the immigrants are largely from Germany, England, Wales, Ireland, Scotland, and the Dominion of Canada, countries in which small-pox has been, and still is, unusually prevalent. The number of immigrants arrived during the eleven months ended May 31, 1881, was as follows: From Germany 175,306; Dominion of Canada, 110,611; England and Wales, 57,861 ; Ireland, 61,796; Scotland, 12,628; China, 7,443; and from all other countries, 138,649. Total 564,294.

Third.—The number of cases of small-pox arriving on immigrant ships at the ports of the United States is unusually large, as reported by the health officers of the several ports of arrival. With rare exceptions the sick immigrant is not effectually isolated from the steerage passengers. The hospital quarters are amidships, with no adequate means of seclusion nor independent ventilation. As a consequence 1,000 to 1,500 persons are more or less directly exposed to the contagion and infection; nor is vaccination of the passengers practiced or even attempted at sea, so that when the ship reaches

its destination it may have on board many persons who are thoroughly inoculated with the contagion, though as yet apparently perfectly well.

Fourth.-Another important fact is the rapidity of ocean transit, which must be taken into consideration in estimating the influences of immigration on the importation and dissemination of small-pox. While the incubation period of small-pox is fourteen days, eight or twelve days is the average period of the voyage of the immigrant vessel arriving at New York, where the greater number of immigrants land. Now, it is a well ascertained fact that the emigrants reach the ports of embarkation commonly several days before the sailing of the ship. During this interval the emigrant families take quarters in the low lodging houses about the docks and wharves in which small-pox is now very prevalent. The result is that the unprotected emigrants become infected, and if they immediately embark they may not only reach the port of destination before the incubation period has passed, but may pass the quarantine in apparently perfect health. And, what is still more important, if such infected immigrants immediately on landing take passage on board the immigrant trains,as vast numbers do, they may reach the most distant settlements before the disease finally develops. It is quite plain that under these circumstances no amount of vigilance in merely searching for the sick can prevent the introduction and wide dissemination of small-pox in this country. And this conclusion has tenfold force when applied to the introduction of small-pox from the Dominion of Canada by means of immigrants.

Fifth-- It is a noticeable fact that large numbers of immigrants are found, on inspection, to be unvaccinated. This might be inferred from the fact that such a large proportion of the total number are children. Of the 457,257 immigrants arriving in the year 1880, 87,154, or about one-fifth, were under 15 years of age. It is found also that an intense prejudice exists against vaccination on the part of several nationalities. In several instances compulsory measures have been resorted to at the port of New York to compel the vaccination of unprotected persons who have been exposed to the infection. These immigrants have been known to wash their vaccination wounds immediately after the operation, and in some instances they have been detected having another person, as the mother of a child, suck the wound to remove the virus.

The measures at present adopted and relied on to prevent the introduction and spread of small-pox in the United States by immigrants, are evidently inadequate to meet existing conditions. Our health officials are pursuing the methods of prevention in vogue before the era of steam, ocean and land travel. Thus far at the port of arrival the health officer takes cognizance only of vessels having well marked small-pox cases on board, either in transit or on arrival. In this case the vessel is subjected to cleansing and disinfection, and the passengers are vaccinated and allowed to depart, no further care being taken to insure successful disinfection of baggage, nor of the vaccination of the unprotected. The immigrant trains proceed to their destination, scattering their occupants along the way without further sanitary care or inspection. Wherever the immigrant stops he seeks the low lodging-house, and there the

disease that he has carried in his system from the port of embarkation may first develop itself, and establish a focus of infection which may, and often has of late, involved a whole town in disaster. The first knowledge the local health authorities have of the arrival of the pestilence, is its apparently sudden outbreak. It is evident, not only from our past experience, but from the nature of the case, as developed in the preceding recital of facts, that the methods we are now pursuing will not prevent the introduction of small-pox into the United States, nor control, in any proper sense, its spread. There is every indication that the amount of immigration will not be disminished, and that small-pox will become more and more prevalent abroad. To meet this emergency, it is the duty of this Conference to determine upon a practicable plan of concentrated operations adequate to accomplish the purpose in question. In this view, the following scheme is proposed for consideration :

It is evident we can no longer rely simply on quarantine rule, which secures vaccination only of those on board vessels having had small-pox cases during the voyage. The future rule must be that all immigrants shall give satisfactory evidence of being protected against small-pox before being allowed to land. There are two methods of accomplishing this object:

(1.) The restrictions of quarantine may be so applied as to make it obligatory upon steamship owners to cause a medical inspection of all emigrants when they embark, and vaccination of all persons found unprotected. If this plan were carried out in good faith scarcely an immigrant could reach our ports who would develop small-pox. He could only carry the infection in his baggage. But, if proper sanitary care of the baggage was required, that also could be relieved of infection on the voyage. It is doubtful, however, if these measures could be fully carried into effect without Congressional legislation, and it should be a part of the action of this Conference to secure the insertion of such provisions into the bill pending before Congress regulating immigration as will accomplish the results mentioned.

(2.) The second method is the establishment of medical inspections of all steerage passengers at the ports of arrival in the United States, with power to vaccinate all persons found unprotected. This method can be put into operation at once, by adding to the rules regulating quarantine one requiring the inspection and vaccination of all immigrants found unprotected. In localities or ports where local boards make the rules governing quarantine, this rule could be at once adopted. Where State legislation is necessary to make the rule, which cannot be attained, the National Board of Health could make the rule and render it effective. Or the National Board of Health could make the rule for the several great immigration ports, and the local officers could enforce it. From the following table it appears that the number of immigrant ports is very few, and can be readily brought under a system of efficient inspection:

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Through six ports, it appears that the class of immigrants requiring inspection pass into the United States, viz. : New York, Boston, Philadelphia, Baltimore, Detroit, Huron, and San Francisco. To these, perhaps, should be added Passamaquoddy Bay, Maine, and Minnesota. It is evident that a system of inspection and vaccination, such as here proposed, at the first arrival, must be attended with as little detention as possible. Detention of three days for observation of the results of vaccination, would result in the constant collection of from 20,000 to 30,000 persons in the quarantine of New York. Not only would such detention be unadvisable, owing to the hardship which it would create, but as a sanitary measure those vast hordes should be dispersed as rapidly as possible, and aided, rather than hindered, in their efforts to reach their future homes.

To meet the exigency, which requires future inspection of those vaccinated to verify the results, local inspection stations might be established at proper points along the great thoroughfares which the immigrant trains travel, where but a momentary detention would be required to re-inspect the vaccinated, and when necessary to revaccinate. This inspection would be facilitated if a system of ticketing was followed, which might be arranged as follows: Let the port inspector give to every person found to be protected, & white card, having on it his name, age, nationality, date of inspection, and destination; to every person requiring vaccination let him give a red card, indorsed like the other, but giving date of vaccina

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