The service was discontinued December 31, 1882, and up to January 31, 1883, there had been, for seven months, no solitary introduction of small-pox into Illinois by an immigrant. In February, however, there were three such introductions, and in March and April one each. The immigration of 1883 proved to be very light, as compared with that of the previous year; the infection was dying out abroad; at the various seaports the methods inaugurated by the Service were again enforced on the approach of spring, and the resumption of immigrant travel; communities most exposed to this travel in the interior had either been efficiently protected by vacci nation and revaccination, or had lost their susceptibility to the infection through the operation of the disease itself; and to these various causes is attributable the absence of immigrant-introduction during the remainder of 1883.

Thus it will be seen that not only is the negative proposition proven, that States and muncipalities, acting independently, are unable to control small-pox during seasons of immigation-movement from infected countries; but a positive proposition is equally well-substantiated, to-wit: That the elimination of the factor of imported infection renders the control of small-pox in a given territory a very simple sanitary problem.

PROPOSITION III.-That a continuous sanitary surveillance of immigrant travel is necessary to supplement whatever other preventive measures can be secured before embarkation or during the voyage.

On this point I am compelled to admit that my opinions of a year ago have undergone a material modification. I then held that, if immigrant passengers could be inspected and vaccinated on embarkation or during the early part of the voyage, there would be little or no necessity for or inspection after landing. There is no existing authority, of course, to compel such pre-inspection and vaccination. But even if the most perfect international quarantine legislation could be secured to this end, my recent experience, which I have reason to believe accords with that of others under similar circumstances, conclusively proves that not even its bona fide enforcement would protect the interior from imported contagion.

For example: Given the existence of small-pox at the port of embarkation, the exposure of a greater or lesser number of unprotected immigrants during the period of rendezvous is certain. The inspection of such individuals at the time of embarking would reveal nothing beyond the fact that they required to be vaccinated. But, if the exposure ante-dated the vaccination three or four days, they might arrive at New York quarantine with vaccinia visibly progressing, but no evidence of small-pox; and thus be passed on, to arrive at Chicago in the eruptive stage of varioloid. If the vaccination should be deferred until during the voyage, the risk of such results would be proportionately increased. For this dilemma, which grows out of the character of the disease itself, there would be no remedy short of the detention and observation of all unprotected persons for the full period of incubation, say two weeks before embarkation. Such a course is obviously impracticable, and it is idle to expect legislation which would be so radical in its character and so onerous, vexatious and expensive in its enforcement.

In the foregoing illustration of the difficulties in the way of European inspection, a theoretical perfection of service is assumed which it would be folly to depend upon in practice. I am forced to the conclusion, by repeated instances which have come under my own observation, that the sense of responsibility, and consequent thoroughness of work, bear a direct relation to the distance between the inspector or vaccinator and the point of ultimate destination of the immigrant. Inspectors on duty at Liverpool, or Havre, or Bremen, or Hamburg, and surgeons on steamers from those ports, lack the stimulus that an inspector in Chicago feels from the knowledge that, if small-pox should break out among the immigrants passing through his hands, it could be readily traced home to him; not alone from the towns and prairies of his own State, but from the lumber camps and villages of Wisconsin, the wheatfields of Iowa and Minnesota, or from still more remote regions beyond the Mississippi. Such a stimulus is necessary in order to secure vigilance in inspection, thoroughness in vaccinating, and due care in the proper selection of virus-matters which were very generally ignored by the steamship surgeon prior to the establishment of the Inspection Service by the National Board of Health.

In conclusion, it may be well to anticipate the criticism that the foregoing argument ignores everything but the immigrant. It was so intended. Its sole object was to set forth the importance of this factor; to show that an uncontroled annual influx of hundreds of thousands of immigrants fron infected countries (455,884 arrived at the port of New York alone during the year 1882,) is sufficient to largely neutralize the efforts at protection of any community exposed to such influx.

It would not be just, however, to imply that, while doing this, no account is made of the necessity for vaccination and revaccination in each and every community. These, after all, are the real safeguards of any people against small-pox. But granted that these are scrupulously enforced: One general, and one local condition. obtain to demand the exclusion of the infection by every possible means. The general condition is that, no matter how faithfully vaccination and revaccination may be carried out, there will still remain a by no means inconsiderable number in whom susceptibility to small-pox cannot be entirely exhausted. It is obviously unjust to subject these to the risk of exposure to the infection if it can be prevented. The local The local condition, and that which obtains more largely and dangerously in the Western States than elsewhere, arises from the settling in these States of large numbers of unprotected or imperfectly protected immigrants.

Both for themselves and for us the maintenance of a system of sanitary surveillance of immigrant travel, during seasons of epidemic. small-pox, is of the utmost importance. Such a system was that carried on by the Immigrant Inspection Service of 1882, and which was then demonstrated to be in the interest

Of our own people, who were secured by it from imported contagion:

Of the immigrant-who was protected through it from the effects of his own neglect*, and to whom it brought better care and increased comfort in transit across the country:

And to the common carriers of these immigrants-who were relieved by it from the menace of local and State quarantines of exclusion, which would inevitably have been resorted to in the interior, had it not been for the inauguration and maintenance of the Immi grant-Inspection Service.

In the absence of international quarantine regulations and of uniformity in the administration of our maritime and boundary quarantines, the substitution of a simpler, less expensive and more useful system may be possible, but is not probable. Certainly nothing had heretofore been done in this direction which secured the same amount of benefit at the same cost. And this cost, it should be borne in mind, is equitably defrayed from the general treasury, instead of being saddled upon States and communities, which, prior to the inception of this Service, were compelled to protect themselves against evils for which they were not responsible, and whose attendant benefits they shared with others, or had no participation in whatever.

In my opinion, Congress could make few wiser or more useful appropriations, and none which would command a more general and emphatic approval, from the Northwest, at least, than one for the support of some such system.

*During the seven months of the inspection season ended December 31, 1882, an aggre gate of about 150.000 immigrants was permanently added to the population of the Northwest-of which number 115,057 passed through the hands of inspectors in the Western District. It is probable that no equal number of people in the same region are so wei protected against the risk of contracting or propagating small-pox as these. The repeated inspections and vaccinations have resulted in a vaccinal security which will con tinue during life, in a large majority of them. The work is thus seen to be permanent in its character.

IMMIGRANT-INSPECTION SERVICE

OF THE

NATIONAL BOARD OF HEALTH.

OPERATIONS IN THE WESTERN DISTRICT, COMPRISING THE STATES OF INDIANA, ILLINOIS AND MISSOURI, JUNE 1-DECEMBER 31, 1882.

THE preliminary steps which led to the establishment of the Immigrant-Inspection Service of the National Board of Health have already been detailed in the Fourth Annual Report of the ILLINOIS STATE BOARD (pages xxii and 117-130,) and in the report of the Quarterly Meeting of the BOARD, April, 1882, in this volume (pages xi-xiii.)

Early in April, 1882, the following letters were sent out, the first to members and officers of the various State Boards of Health and to other sanitary authorities; the other to the gentlemen whose names are appended:

MY DEAR DOCTOR:

SPRINGFIELD, ILL., April 3, 1882.

It evidently will not do to await the possibilities of national legislation on the subject of the prevention of further small-pox introduction into our midst by unprotected immigrants. Although the bills now before Congress will, if enacted, enable the National Board of Health to exert its authority without proving the actual infection of a foreign port, prompter relief is promised by the plan indicated in the annexed letter-a_plan which is, in effect, that proposed at the Small-pox Conference held in Chicago last June.

While this does not interfere with, or supersede, the proposed modification of the maritime quarantines, it will pave the way for such, and get work done at once which, in any event, should be done some time. Better now than six months hence-the earliest period, probably, in which any practical results could be obtained from new legislation. By that time the bulk of this year's enormous immigration will have been received.

As you are aware, the plan contemplates the thorough inspection (and such necessary action as is implied by the term.) of all immigrants at the ports of arrival in the United States, and their re-inspection at certain westward points until they reach the Mississippi river. By this means it is believed that vaccinal protection of the great majority of these persons can be secured before they scatter into the interior. While under our surveillance any cases of small-pox which may be detected will be promptly cared for, and the necessary precautionary measures at once enforced, without exposing communities along the line of travel, or saddling them with the expense or responsibility of their care. The inspectors, while clothed with the authority of the State and local organizations of their respective territories, would be salaried by the National Board of Health, and the other expenses incident to the service would be defrayed by the same body. To secure this it needs that we unite in a requisition upon the National Board for this purpose, and it is hoped no time will be lost in forwarding such requisition to Washington, in order that the work may begin promptly on the first proximo.

I beg to suggest the forthcoming meeting of the Sanitary Council of the Mississipp. Valley, at Cairo, Illinois, on the 19th April, as offering a suitable opportunity for a confer ence on this subject, and formal action as a basis for the movement of the National Boar! in the premises.

Trusting you will at once signify your approval of this measure, and your intention to be present at the time and place indicated, I am, Very truly yours.

Secretary:

JOHN H. RAUCH, M. D., (Illinois State Board of Healls, Sanitary Council, Miss. Valley.

ILLINOIS STATE BOARD OF HEALTH,
OFFICE OF THE SECRETARY,

DEAR SIR:

SPRINGFIELD, April, 188

With the co-operation and aid of the National Board of Health, the State BoardNew York, West Virginia, Kentucky, Indiana, Michigan. Wisconsin and Illinois, and the health authorities of Pittsburg, Cincinnati. St. Louis, Detroit and Chicago, contemplate an inspection of all immigrants in transit westward (and, if necessary, their vaccination or other treatment.) beginning on the first of May, prox. Suitable provision will be made. at convenient points, for the care of the sick and "suspects," if any such be found.

The almost daily introduction of small-pox into the interior, by immigrants after passing the maritime quarantines, makes the proposed action a sanitary necessity.

It will be the duty of the ILLINOIS STATE BOARD OF HEALTH to exercise this supervision over the trunk lines leading into Chicago, and the BOARD is anxious to discharge this duty with as little interference with the business of the roads, and obstruction to immigrant travel, as are compatible with the protection of the public health.

With your assured co-operation and assistance it is believed that this can be accomplished without exercising the quarantine power and authority vested by law in the BOARD-a power and authority which it is desired to exert only as the last resource. Awaiting your prompt response, I am, Sir, Very respectfully,

General Manager, Lake Shore and Michigan Southern Railway,
Cleveland, O.

Responses to the foregoing letters were prompt and favorable: the requisitions of the various State Boards of Health upon the National Board were at once granted*; and on the 1st of June, 1-82, the Immigrant-Inspection Service was inaugurated. The following abstracts of the monthly reports of the Supervising Inspector to the Secretary of the National Board, embrace the features of general interest in the Western District:

*See Report of Quarterly Meeting, ILLINOIS STATE BOARD OF HEALTH, April, 1882, nie page xii.