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made, so far as the conditions would admit. Of sixty-two cases now in the small-pox hospital, he said, fifty of the sufferers could not speak English. Patients arrived in Chicago from New York and Baltimore who had reached the eighth, ninth or tenth day of eruption. In one case, a woman, who came by the way of Baltimore, died in four hours after reaching the city. The trouble was that the disease was not sufficiently developed at the port of entry to enable the inspector there always to detect it.

Dr. De Wolf thought that the only remedy was for the authorities of the different European ports to insist on every intending passenger producing a certificate of recent vaccination. Any steamer bringing passengers without such certificate should be placed in quarantine.

Dr. Hewitt, of Minnesota, said that within the past year there had been eight outbreaks of small-pox in that State; but in every case the disease had been confined to its local center. He thought the chief reason for this was that vaccination had become much more general than in former times. The speaker did not feel at all clear about the practicability of inter-State quarantine, and doubted the power of the National Government to enforce it. The question of maritime quarantine was an entirely distinct one, and should be kept separate from the other. Dr. Hewitt believed that by vaccination and revaccination the people at home could be protected, and an imported case would then be simply a pathological curiosity. He thought something could be done in the way of maritime quarantine; did not believe in the possibility of an inter-State quarantine. The trouble was that small-pox did not have the politeness to break out just in time for the health inspector at any particular point to detect it.

Dr. Farquaharson, of Iowa, said that small-pox had been introduced into that State in twenty or thirty instances, during the previous spring. In many of these cases, particularly in the northeastern part of the State, the disease was directly traced to recentlyarrived immigrants. There were also cases imported from Southern Illinois and St. Louis. Isolation had been pursued with success in these cases.

Dr. Wight, of Milwaukee, said he had no knowledge of the importation of small-pox by immigrants into Milwaukee during the past three years. There had been cases of small-pox in the city, with regard to which the plan of isolation had been adopted, the buildings quarantined, and infected property destroyed. Wisconsin had a very stringent law with regard to the movements of persons known to be afflicted with contagious diseases. The speaker wanted the Conference to discuss scarlatina and diphtheria, as well as small-pox. He thought the best preventive of epidemic small-pox was to enforce vaccination in every community. The matter of concealment of cases could be reached in every city by a law similar to that of Wisconsin.

Dr. Reeve, of Wisconsin, said there had been four or five cases introduced into Wisconsin by immigrants.

Dr. Steuart, of Baltimore, agreed with Dr. Wight. Baltimore. had a compulsory vaccination law, enforced by a heavy fine against the parents of unvaccinated children. When small-pox occurred,

either the patient was removed to the small-pox hospital, or the house was quarantined and decorated with a yellow flag. This year there were only three cases among immigrants. In the speaker's opinion, the palladium of safety from small-pox was vaccination and revaccination. When communities were thus protected they need care very little about what small-pox might be brought in by immigrants. Disease thus brought in would have no meat on which to feed, and would soon die out.

Dr. De Wolf said that what was wanted was protection for immigrants, as well as for our own citizens. Immigrants form a large yearly addition to our population, and they must be rendered safe from carrying and disseminating contagion, or local measures will be unsatisfactory to a great extent.

Dr. Stevens, of Indiana, thought the discussion had taken a wide range, and that some form of resolution, or other tangible expression of opinion, should be presented to bring the question properly before the meeting.

Dr. Briggs thought some measure should be adopted to meet the existing emergency, while the Department of State was getting ready to begin to do something. It would take too much valuable time to await the adjustment of questions of international comity involved.

Dr. Howard, of Maryland, told of one case smuggled through Baltimore, which did not develop until the patient reached Chicago. Out of 20,000 immigrants arriving in Baltimore, there were only three cases of small-pox. The passage from Bremen to Baltimore occupied sixteen to eighteen days, and if the immigrants contracted the disease, or were exposed to infection in Germany, it seemed to him the symptoms would have been manifested before reaching port-the period of incubation never exceeding fourteen days. He wanted to hear from the representatives of New York and the Eastern and Canadian ports, and called attention to the fact that Philadelphia, with its limited arrivals of immigrants, officially recorded over 1,000 deaths from small-pox in the last year.

The speaker defended the inspection system in vogue at Baltimore, and wanted all immigrants to be vaccinated in Europe just before sailing. It was impossible to successfully handle them on arrival, if this precaution were neglected.

Dr. Baker reported that only two or three cases of small-pox had been detected at Port Huron, Mich., although over 10,000 immigrants passed through that place each month. Vaccination was duly attended to in Michigan, and there were few cases in the State.

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Dr. Stephen Smith spoke on behalf of New York and of the National Board of Health. He said that in 1878 and 1879 there was no small-pox in the United States, but that with the increase of immigration the disease had manifested itself to a considerable extent. He had no doubt that small-pox had been brought from Europe, and considered the system of quarantine on vessels in New York harbor to be utterly inadequate. Large numbers of persons, principally children, came in unvaccinated. Many of the immigrants thus unprotected were Poles, who entertained violent prejudices against vaccination. The speaker said there were not more

than fifteen to twenty deaths per week in New York from smallpox, and a thorough system of vaccination was carried out there by a trained corps of physicians. A "scare" had been gotten up by the health authorities of New York, which had led to immense numbers of citizens submitting themselves to vaccination or revaccination.

Dr. Smith held that steamship lines should be compelled to bring no persons who could not show evidence of vaccination or a proper certificate of protection. This could only be arranged by agreementwith foreign Governments, and there were many difficulties in the way. An imperative rule requiring the vaccination of each immigrant on arrival, might work, but it would be impossible to detain the parties for observation. A whole ship-load could be vaccinated in an hour at New York, and re-inspections might be made at interior points, provided the necessary power could be obtained.

Dr. H. A. Johnson, of Chicago, had no statistics on the subject but believed there was no doubt that small-pox was brought in by immigrants. The foreign population of Chicago, as ofother cities, showed much aversion to vaccination. The matter of legislation was a difficult one, and the creation of a healthy public sentiment should be sought. While it might not be practicable to enforce the vaccination of immigrants at Liverpool or Bremen, the Government could certainly place proper limitations upon the landing of persons not protected.

Dr. Steuart said the rivalry between ports of entry was so great that a strict quarantine enforced in one city and not in another would drive immigration away from the port where the regulation was honestly carried out. He offered the following:

Resolved. That it is the sense of this Sanitary Conference held in Chicago June 29, 1881, that notification should be sent to the various steamship lines, that unless certificates of vaccination be furnished with each immigrant arriving at the ports of the United States, the vessels carrying such immigrants would be quarantined for a sufficient time to insure the development of all undeveloped cases of small-pox, as well as the discovery, if possible, of concealed existing cases which have developed during the voyage.

The resolution was referred to a committee, consisting of one member from each organization represented, which committee was also instructed to prepare a set of resolutions to be submitted to the Conference for discussion and adoption.

Resolutions, calling upon the National Board of Health to secure the cooperation of foreign governments, were referred to the same committee, which subsequently submitted the following

REPORT.

The constantly recurring outbreaks of small-pox in various parts of the United States during the past few months, and the widespread and fatal prevalence of that disease in many localities, demand the most serious consideration of the health authorities of this country. In our opinion this Conference should use its utmost power to unite all the health authorities of the United States in a well-organized plan, not only of stamping out smallpox where it at present exists, but of preventing its further introduction into the United States and its spread from one State into another. For two or three years prior to 1879 small-pox was

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 were 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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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

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