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The stringency with which they should be then administered depends on many conditions, mainly the lateness of the season. A balance is to be struck between the good to be gained and the hardship imposed.

HOUSE QUARANTINE OF NO AVAIL IF MANY CASES ARE CONCEALED.

And here let me also say that the measures above outlined for use prior to an epidemic are recommended where practicable—i. e., when the authority or influence of the health officer is sufficient to carry them out.* Should the condition be such, however, that the attempted enforcement of these restrictions leads to the successful concealment of cases they must be modified, as successful concealment of cases takes away all chance of suppressing fever.

Our reliance is then placed on preventing the infection of his environment by the patient and preventing ingress. Above all, the first is important and is to be depended on. The presence of the sanitary inspector and of the trained nurse necessary to carry this out are such boons to the patient that we may be sure that no cases will be concealed on account of these measures, if reasonable tact be used.

Indeed, the aim must be in all cases to make the household with the yellow fever a privileged one, so that it will be to its interest if there be a case among them to have it officially known.

To this end physicians and medicines, delicacies for the patient, and even subsistence for his family free, are wise sanitary measures as well as charities.

Remember, if cases are concealed to any considerable extent our chance of suppressing the fever is lost.

MEASURES NECESSARY WHEN THE FEVER CAN NOT BE SUPPRESSED.

The townspeople are always loth to recognize that this condition exists, but when we find cases arising of which we can not trace the source of infection, when we are unable to efficiently carry out the measures here outlined, or when cases are being successfully concealed we may know that the fever will not be suppressed until it has run its course or cold weather supervenes.

* Obviously it is implied that the state of feeling in the community is to be taken into consideration also. Measures which will be readily agreed to and carried out in good faith in one community will excite violent and unconquerable opposition in another.

The observation of the writer is that, in small towns at least, Americans of Eng. lish descent will willingly bear any reasonable amount of inconvenience and soine hardship if convinced that this is necessary to avert a greater calamity from the rest of the community, whether of their own town or neighboring towns, and if convinced of the reasonableness of the measures to be taken will assist in carrying them out. The case of Jesup, Ga., which closely guarded itself, well illustrates this, as does the “house quarantine" in Franklin, Perkinston, and several towns in north Mississippi. It is paralleled by the history of not a few English towns with the plague. The sense of duty to the community seems to be strong.

ILLICIT COMMUNICATION.

An infected town is a source of danger to its neighbors, no matter what means of quarantine are taken. This is because a certain amount of illicit communication from the town to clean territory will be kept up. no matter what rules and regulations are made. The danger is almost exclusively due to those who leave the town for infectible territory. It is in proportion to the number who thus leave directly and to the proportion of infection in the town, hence to their product. Thus, 100 persons leaving when there is 1 per cent of the town infected conveys the same risk as 10 people if 10 per cent of the town be infected. It is our aim, then, to reduce the number who leave directly for infect. ible territory to a minimum (and, if possible, have none to leave). But to take such risk of leaving as must be taken rather in the beginning of the fever, when there is little infection, than later, when there is much more, we first take measures to prevent these people leaving directly without sanitary supervision—i.e., establish quarantine, and,

second, arrange for their leaving under such conditions as will not convey infection to clean territory.

MAKE LEGITIMATE COMMUNICATION EASY, AS BEST PREVENTIVE of ILLICIT.

This allowing some means of egress from the infected town should go hand in hand with the prohibition of unsafe egress, not only on the ground of humanity to the townsfolk but because a legitimate means of egress being provided, the number of attempts to pass the lines in other ways—a certain proportion of such will succeed—is enormously lessened, and the providing of a legitimate means of egress, if safe, is an added safeguard, and an important one, against the infection of clean territory.

While it is scarcely necessary to cite instances of this, many can be given; it is self-evident, certainly to all who have had experience of epidemics and seen the imperfection of the best devised prohibitive measures. On the same principle this means of egress should not be made more difficult than is necessary for safety. We wish to encourage its use; to have it, rather than an “underground railroad” selected by those who would leave.

Depopulation, then, which has long been recommended as a valuable means of lessening the horrors of an epidemic in the interest of the

infected town, is not less valuable as a protective measure to the surrounding infectible territory.

EARLY DEPOPULATION SAFER THAN LATE DEPOPULATION,

Stress should be laid on early depopulation. There is then not much infection in town, and not only are people who leave escaping risk to themselves by leaving early and lessening the rapidity of the spread of the disease in the town, but the chance of infection of outside places from any mishap which may occur is less than if it should happen later.

CLASSES WHO MAY LEAVE.

All who have been certainly not exposed to infection, which we would be able to say of few later, should go without let or hindrance.

The others may go (1) directly to points incapable of receiving the infection of yellow fever, generally northern points—high altitudes— to remain there indefinitely, or for a time to cover their incubation; (2) to points capable of receiving such infection but through a camp of detention.

By a “camp of detention” is meant any place at which these persons stay unexposed to any infection a sufficient time to cover their period of incubation. No infected article going within.

PEOPLE LEAVING FOR NONINFECTIBLE TERRITORY-POINTS NORTH.

(1) How to get these people through infectible territory to their destination without infecting it is a problem of “traffic,” and will be there considered. Before these people are allowed to go north we must be assured that they will remain there to cover the period of incubation of yellow fever, say ten days, or indefinitely, i.e., after frost.

TREATMENT OF BAGGAGE.

Disinfection of baggage is not necessary for such people. If, however, they will return after a time to points South, their baggage must be disinfected on departure. Indeed, if there be any reasonable doubt of their not returning, the burden of proof being on them, disinfection of baggage must be done.

The methods by which the train inspector, on whom this work falls, assures himself (1) that a passenger intends and will stay North indefiinitely, and (2) that he will stay ten days and not double back, must be worked out for each particular epidemic, and to a certain extent to each particular road and case. A good man will err by over suspicion and

hard rulings.
TRAIN INSPECTIONS.

A person leaving New Orleans in 1897 took an affidavit—the stub of which was preserved by the train inspector—that he “would not return to any place quarantined against New Orleans” or that he would not return to quarantining place “for ten days.” In the latter case his baggage was disinfected and a certificate of disinfection given him giving the date of his departure from New Orleans, and of course the same date of disinfection and the number and kind of pieces disinfected. A label of thin paper was then pasted on each piece of baggage. The certificate of date of leaving New Orleans had a personal description, and the baggage label was made of thin paper so it could

Ilot well be detached and used over again. It had the name and date on it, and was signed. It seems best to disinfect all baggage going to remain at points like Atlanta, Charlotte, Nashville, etc., which are great distributing points for railroad travel south, and the only baggage ever sent to any such lolaces undisinfected in 1897 was that of some schoolgirls going to Nashville to a seminary the latter part of October. Indeed, Atlanta required this to save herself from quarantine by the coast cities. There seems no reason why baggage going north through these IPlaces should be disinfected, any more than Havana baggage going by the Ward Line to the same points. Indeed, there is good sanitary reasons for not doing so. Every obstruction, however slight, put in time way of people leaving an infected town to some extent prevents their leaving and to a disproportionate extent induces them to put off leaving if they do leave. We want them to leave early. Again, as before said, no quarantine is perfect, and in proportion as a safe and legitimate way of exit is obstructed the illegitimate ways are sought, which is (especially if sought after the town is well infected) dangerous in the extreme to the territory we seek to protect. Unless we have been in an epidemic on the inside we fail to realize what slight obstructions prevent people leaving an infected town by the ways provided and induce them, for the purpose of avoiding moderate inconvenience, to take sanitary risks for others which are simply appalling. The rule which should obtain, then, would be to “require everything which is necessary for safety and nothing which is not necessary,” throwing, of course, the doubt in favor of stringency. Arrangements should be made with sanitary inspectors at places to which most of these people go to return South again—Atlanta, Nashville, St. Louis, etc.—so that they can keep some supervision of them and see that they do not leave for the South until their ten days are past. It would not be difficult to arrange for a pretty fair supervision. It will require to be supplemented by a train inspection south from some of these places. This latter has always been put on. (2) Persons leaving for infectible territory through a detention camp. The method of conducting detention camps in detail will not be described. They require much pains and care in their management. I would again call attention to the sanitary protection they afford to the quarantining places as well as advantage to the infected town by letting its people escape. By providing a safe and allowed means by which people who can not go North can leave the infected town, the effort to evade quarantine restrictions is lessened and the seepage, so to speak, through the cordon is minimized. It is extremely difficult to prevent people evading quarantine who have friends willing to receive them outside, and these are the very people who will go through a camp. For the same reasons as given for not disinfecting through baggage,

the camp should be made as pleasant as possible, and impose no restric10918 23

tions which are not necessary to prevent the conveyance of infection. The writer holds that it should be known that it will not be held open indefinitely, but be closed after a limited time, so that those intending to avail themselves of it should not unduly put off coming to it. The earlier the people come to camp the less fever will develop among them; and while the development of fever at a camp is to be expected, yet it is to be averted as much as possible. It is surprising how little does develop.

WORK IN THE TOWN.

It is no part of this paper to describe the “relief measures” to be taken in the town for the care of the sick, relief of pecuniary distress, etc., only such as appertain to purely hygienic “quarantine” work. They have, consequently, not been considered. They are not the less important. A modification of the measures of disinfection and isolation heretofore outlined may be of use in lessening the rapidity of spread of the fever even when we no longer hope to suppress it, and I quote from the latter part of a paper read by title at the Mobile Conference, on “House quarantine.” House quarantine during an epidemic.—Here, it seems to me, no elaborate or specially restrictive measures are advisable. Certainly in large towns, and with the epidemic well under way, none are practica. ble. To attempt too much is to fail and do less than if less were attempted. The aim should be— (1) To prevent infection of sick premises and to keep the other inmates from developing fever from such infection as we fail to prevent. (2) To prevent unnecessary ingress of people in the sick room, or premises. (3) To prevent conveyance of infection from sick premises to outsiders. (4) To destroy, as far as possible, the focus (presumably) thus estab. lished. Of these, the first, second, and the fourth are now the most important. (1) The removal of unnecessary fabrics from the sick room, cleanli. ness, aeration and destruction or disinfection of the discharges are about all that can be done to prevent infection of premises. The isolation of the inmates from the sick room should be advised and the advantage of sleeping in the upper story remembered. (2) The means which will prevent ingress varies with the respect for the law and the good sense of the community. In some places, as at Montgomery, Ala., an official prohibition and placarding is sufficient, and when this is not it is doubted if the measures which would be are advisable. In general, simply designating the houses and prohibiting entrance is all that to me seems advisable. (3) Perfection here would be change of clothing, disinfection of hair,

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