THE NATIONAL GOVERNMENT SHOULD HAVE SUPREME CONTROL OF QUARANTINE AT ALL FRONTIERS. BY E. O. SHAKESPEARE, M.D., OF PHILADELPHIA, PA. FROM THE MEDICAL NEWS, September io, 1892. [Reprinted from The Medical News, September 10, 1892.] THE NATIONAL GOVERNMENT SHOULD HAVE SUPREME CONTROL OF QUARANTINE AT ALL FRONTIERS. E. O. SHAKESPEARE, M.D., OF PHILADELPHIA, PA. In discussing the importance of " What the State Can Do to Prevent Cholera," the recent Surgeon- General of India, J. N. Cunningham, M.D., very justly states that "the questions involved are questions of vast interest, not only to the people of India, but to the people of all countries. They in- volve the health and happiness of millions of homes in all parts of the world." We have only to recall the immense losses that have been entailed upon most of the civilized and uncivilized nations of the world through the in- vasions of this disease to appreciate the great prac- tical value which the solution of this question may have.1 In India, where cholera rages constantly from year to year, the Sanitary Reports of the Indian Government for the eleven years preceding and in- clusive of 1884 show that, during that period, the deaths from cholera in that country amounted to 1 Much of the facts and language in this connection have appeared elsewhere; in the main, in my " Report on Cholera in Europe and India,'' published by the Government Printing Office, 1890. 2 not less than three and a quarter millions, in round numbers. In referring to the ravages of the epidemics of cholera in Europe, it is not necessary to summarize the detailed losses that have occurred since the first visitation by cholera in 1831, but attention may be called in this connection to the extent of the damage done by the epidemic previous to the present one. In 1883, Egypt is said to have lost 60,000 lives from cholera, and it is estimated that in 1884 and 1885 Italy and France together lost in the neighborhood of 60,000 inhabitants from the dis- ease ; to these numbers should be added the loss that Italy suffered during the years 1886 and 1887 from the same cause. The loss of life in Austria- Hungary has also been considerable. Spain, how- ever, was the greatest sufferer from the ravages of cholera during that epidemic. Among a population of 16,000,000 there were, according to the official reports (which, no doubt, are short of the reality), 119,620 deaths from cholera. The records of the present epidemic, so far as we learn, show that the mortality in Russia, in Persia, and in India has been quite as severe as in the worst epidemics that these countries have previously suffered. For example, we are informed that the loss to Russia alone from this cause in the present year has already amounted to 150,000 lives, and yet there is very little indica- tion that the epidemic has passed its acme. Before the end of this season in that country, in all human probability,the deaths from cholera alone will mount to upward of 200,000. Judging from the history of previous epidemics in Russia, in all probability the 3 next year will witness a s acrifice of even more lives than have been destroyed during the present season there. When one undertakes to estimate the loss to a coun- try of the intrinsic value only of the lives destroyed, the amount, though great, must seem insignificant when compared with the loss of incalculable mil- lions of treasure due to the paralysis of industry and commerce. Political economists in Europe have variously estimated the value to the State of a human life. It may be said that the average estimate places this at one thousand dollars per capita. Calculating upon this factor, we see that a destruction of value in Europe, represented in human lives sacrificed dur- ing the epidemic previous to the present one, has amounted to two hundred and fifty millions of dol- lars. Estimating the value to the State of human life in India, which, let us say, is one-tenth of that amount-that is, one hundred dollars per capita- we find that India has suffered a loss from this source alone, during the eleven years mentioned, of three hundred and twenty-eight millions, five hun- dred and sixty thousand dollars. No doubt political economists in America would estimate the value to the State of the average human life as greater than the sum named per head, and if we regard the sta- tistics of death by cholera in former epidemics in the United States, we can readily perceive the enormous national loss that has been due to this cause. So that when Surgeon-General Cunningham, in dis- cussing the subject of what the State can do to pre- vent cholera, purely from the practical standpoint, and speaking of the theories at present entertained 4 or that have been entertained at various times by scientific bodies concerning the nature of the dis- ease, says, " Whether these theories are scientifically correct or not is a matter of very minor importance," he can scarcely expect that many familiar with the history of the ravages of cholera in parts of the world outside of Hindostan can agree with him. In view of the enormous interest the State (that is, the Nation) has in the prevention of the injuries that follow the uninterrupted spread of a wide and devastating epidemic of any kind, and particularly of cholera, I propose to discuss from this standpoint the question of national supremacy in the control of quarantine at all frontiers. In the first place, regarding the estimation of the loss by the State in the destruction of human life alone occasioned by cholera epidemics, it can be readily understood that the loss to the public occa- sioned by a single widespread epidemic of cholera, or even of yellow fever or smallpox, is far greater than would be the cost of the proper maintenance for many years of a perfect quarantine establish- ment at all our ports. In the case of Asiatic cholera especially, but also in that of scarlet fever or smallpox in a lesser degree only, the relation of the enormous emigration from Europe into this country, as bearing upon the introduction of epi- demic diseases here and their rapid dissemination throughout the land, should be closely consid- ered. It cannot be denied that the entrance of the thousands of emigrants who annually reach our country after starting from or passing through locali- ties infected with contagious diseases, frequently in 5 their persons and in their pestiferous clothing carry with them often as far as their ultimate destination, and let loose there the active germs of these diseases; and the herding of these emigrants into the miser- ably ventilated and frightfully unsanitary quarters usually provided for steerage passengers on the trans- Atlantic steamships, the modern rapidity of ocean and land travel, and the great facility with which these swarms of people are so soon distributed all over our country, combine to multiply the danger to the public health, with which, in the laxity of our laws and the unsatisfactory administration of them, these incessant influxes constantly menace the country. In their enormous numbers, their poverty and their squalor, and in their mode of transportation of all sorts of infections and contagions, these emigrants can be likened only to the Oriental pil- grims, in whose track pestilence has so frequently followed. It is, indeed, with the extremest rarity that smallpox or cholera has, in modern times, been introduced into North America by any travellers other than the immigrant class. To take the proper means to guard the ports of entrance against the infected persons and baggage of cholera emigrants would probably keep cholera from our midst; to do the same with smallpox emigrants, with the addi- tion of compulsory vaccination and disinfection of personal effects, as an invariable condition prece- dent to the privilege of landing, would go far toward banishing that scourge from the land ; and the importation of scarlet fever, diphtheria, and like diseases might likewise be prevented by similar adequate measures. The past history of cholera 6 and a study of the mode of its spread during the present epidemic (in which its movement from east to west has been unprecedentedly rapid) shows that the main conveyors of the infection have been, this year, as in all previous times, the persons and per- sonal effects of emigrants, pilgrims, or large masses of soldiers. In 1887, when cholera reached the quarantine station at New York, it was brought there by emi- grants direct from the port of Naples, where cholera was then raging. The introduction into South America, in 1886, of the seeds of cholera, and the widespread epidemic in Argentina, in Chile, and in neighboring countries, was due to the convey- ance of the infection by an emigrant ship that sailed from Genoa at a time when cholera was present in that locality. Although examples of the convey- ance of cholera in this manner might be multiplied almost indefinitely, it is unnecessary to more fully emphasize the well-known and indisputable fact that it is by the unrestricted movements of such people during the prevalence of an epidemic of Asiatic cholera that the disease has been conveyed from one country to another. The establishment of quarantine has heretofore been the main means relied upon to prevent the introduction into any country threatened by the in- vasion of the seeds of this disease-and with varying results, according to the favorable situation of the given country with regard to the course of these infecting streams, and according to the hygienic condition of the threatened populations. Because of the inadequate quarantine establishments, often- 7 times combined with exceedingly faulty administra- tion, in the past, these methods of preventing an introduction have often necessarily failed, and the failure has (irrationally, to my mind) been ascribed, almost universally, to an impossibility of warding off cholera in this manner. In fact, the history of past epidemics is prolific in examples of complete protection of localities and of whole countries, when absolute non-intercourse has been adopted. In modern times, however, the serious damage done to trade by the adoption of such a sweeping policy has brought about an almost entire repudiation of absolute non-intercourse as a means of prevention. To my mind, in the case of the United States, so far distant from the source of cholera, and so remote from European shores, we need only to fear, during the prevalence of a widespread epidemic of cholera in the northern portion of Europe, the introduction of the disease here through the numerous hordes of emigrants constantly arriving from Europe. It is a fact beyond dispute, that cholera preys upon and breeds among those living in squalor and filth, and closely follows their movement. It is exceptional, even in Bengal, the home of cholera, that the Englishmen there are attacked by the disease. It is true, also, in filthy and frightfully unsanitary localities in Southern and Eastern Europe, that the intelligent and well-to-do classes suf- fer to no great extent during the period of a cholera epidemic. There is but little danger of the class of people who constitute the cabin passengers of the trans-Atlantic steamers bringing with them, either on their persons or in their clothing, the infection 8 of cholera. It is for this reason that I hold most confidently that the chief and, I may say, the only source of danger of cholera finding a foothold, when inspection is properly performed at quarantine, lies in its introduction by the emigrant classes. The establishment of a policy of non-intercourse, so far as emigration is concerned, during the times when Europe is suffering from a cholera epidemic, would, in my opinion, constitute the best, and per- haps the only means of safeguarding the general public from the ravages of this disease. I have re- peatedly had occasion, in several publications and in communications to the medical and lay press upon this subject from time to time, to point out the dangerous state of imperfection, to my personal knowledge known to exist, in several of the Atlantic quarantine stations. The ports of Boston, Phila- delphia, and Baltimore would certainly, in their establishments and in their limited corps of admin- istration, be unable to cope successfully, for any long period, with an invasion through the emigrant classes who are allowed to come incessantly during periods of prevalence of cholera in Europe to our shores. Even the quarantine station at New York- which is the best, most completely equipped and best administered of all our quarantine stations--with the frequent arrival of trans-Atlantic steamers carry- ing infected emigrants, would quickly reach the safety-point of defence and be overwhelmed, unless we adopt the policy of long detention of travellers, ships, and cargoes-a policy which would involve a tremendous loss to those engaged in maritime trade or in any manner associated in a business way, 9 directly or indirectly, with maritime commerce. The capacity of the New York quarantine station will be reached for purposes of safe defence with the landing of, say, one thousand infected emigrants. It can be readily seen how soon, with an uninterrupted stream of emigrants from infected localities, the capacity of this, our best quarantine station, would be taxed to the utmost. In my opinion, the action of the President in attempting to suspend immigration, even in the indirect manner of enforcing quarantine of twenty days, is a wise procedure, and perhaps the only one that could be adopted under the present circum- stances which would reasonably insure this coun- try against an invasion of cholera. The placing of an embargo on immigration only would un- doubtedly be the most direct means of accomplish- ing this desirable result, and would not be coupled with any harassing impediments to the course of trade, involved in the long detention of ships and cargoes, or harassing restrictions upon the move- ments of travellers who are but little likely to intro- duce the infection. It is needless to point out that with the ship's inhabitants limited to the crew and the cabin passengers, certainly the quarantine station of New York, in its present preparation, could be safely relied upon to guard the country against the introduction of cholera through that port. The present arrangements that have been adopted and placed in operation at the quarantine stations of Boston, Philadelphia, and Baltimore-imperfect as these are in establishment-would also be in no dan- ger of being overwhelmed by the exigencies of the * 10 occasion. I regret to learn by the public press, however, that, while the authorities at the three latter quarantine stations have willingly acquiesced in the determination of the President, as expressed by the proclamation of a twenty days' quarantine against all vessels carrying European emigrants, the quarantine physician in control of the port of New York has allowed himself to be prompted by a spirit of defiance, in claiming his right, under the laws of the State of New York, to entire independence of any national control, thereby assuming to nullify the efforts of the General Government to protect the general welfare. It is unfortunate for the country that the quarantine officer at the port of our metropolis, through which the vast majority of European emigrants pass, to spread widely through the whole of our country, should so lightly regard the duties and relations of a frontier quarantine officer to the safeguard of the United States and the welfare of the sixty-five millions of her inhabitants. This example in itself affords sufficient reason for the establishment, by national legislation, under Congressional laws, of the supremacy of the nation in control of quarantine at all our frontiers for the safeguarding of the national welfare. The ridiculously antiquated, obsolete, and inade- quate permanent establishments at most of our maritime quarantine stations, and the apparent im- possibility, except perhaps when confronted with emergencies such as the present, of obtaining ap- propriations from local authorities of sufficient sums of money for the erection of extensive and com- 11 plete quarantine establishments in accordance with modern science and accurate knowledge of the nature, mode of spread and means of prevention of cholera, are further and, to my mind, incontro- vertible reasons why the general public cannot rely upon independent local quarantines for the defence of the whole country against the introduction of the common epidemic diseases, much less of epi- demics of cholera. In this connection the question may be very pertinently asked : Why, then, should the direc- tion, expense, and responsibility of a system of common defence against the inroads of foreign dis- eases, any more than against invasions of foreign foes, be assumed and borne by those municipalities or States that happen to have a maritime location? Why should the vast majority located inland be allowed to shift their responsibilities and obliga- tions or be denied a voice in the direction of affairs which so closely concern them? The protection of the public health by maritime quarantine is a matter that interests not merely a narrow belt of sea-coast; it seriously concerns the whole of the vast territory between our shores. In view of the foregoing considerations I would therefore uphold the following propositions: A. The present methods of independent quarantine provided and regulated by sea-board States or cities are essentially defective and insufficient for the exclu- sion from the United States of the diseases against which quarantine is directed. The truth embodied in this statement is abun- dantly established by the report of the committee 12 of the College of Physicians of Philadelphia, 1888, in regard to the three ports it inspected, New York, Philadelphia, and Baltimore, during the time of prevalence of cholera at'the quarantine station of New York in the autumn of 1887. (Since the pub- lication of this report, the quarantine station of the port of New York has been improved in one or two particulars-for example, a crematory has been put into active operation for the destruction of infective corpses; the large interiors of the two observation buildings on Hoffman Island have been divided into compartments for the better isolation of small groups of immigrants from infected steamers. This truth is fully borne out in regard to the other quarantine stations between the St. Lawrence River and the Rio Grande by the elaborate official report Dr. John H. Rauch, Secretary of the Illinois State Board of Health, made to that body in 1886, and the latest information shows that but little, if any, perma- nent improvements have been introduced in them. The defects of local quarantine stations arrange themselves into two principal groups: (1) Inade- quacy of establishment. (2) Faults of administra- tion. 1. With regard to the establishment-which term is here used to include the accommodations for the temporary housing and care of immigrants and travellers not sick, adequate hospital accommodations for the sick, appliances for disinfection, and the necessary medical, nurse, police, and other atten- dants for the care of both of these groups of indi- viduals-only four of the many stations upon the Atlantic and Gulf coast may lay claim to anything 13 like adequate provision. These are Grosse Isle quarantine station on the St. Lawrence River below Quebec, the Boston quarantine station on Galop's Island, that in New York Harbor, and those in the Mississippi River below New Orleans. Of these four it may be said : first, that the former excellent establishment at Grosse Isle is now dilapi- dated and practically useless as a safeguard against the importation of the disease, in view of the fact stated in the report of Dr. Rauch, that during the quarantine season up to October 9, 1885, only 32 vessels out of a total of 420 arrivals had stopped at this station for examination ; second, that at the quarantine stations at Boston, Philadelphia, Balti- more, and I believe also New Orleans, no perma- nent provision for the housing and care of travel- lers and immigrants not sick exists ; third, that in the last-named particular, as well as in several other respects, the quarantine station at New York, hith- erto regarded as fully adequate to the requirements of that great port of entry, still shows defects. According to the official description by Dr. Joseph Holt, president of the State Board of Health of Louisiana, it would appear that the quarantine sta- tion at the mouth of the Mississippi is, in respect of means of disinfection, fully up to the requirements of modern science. Of the intervening stations it is scarcely necessary to speak. Certainly, as regards the prevention of cholera, and to a less extent also of yellow fever, the greater number of them consti- tute quarantine stations simply in name. 2. When we come to consider faults of admin- istration, it is obvious that it is impossible to dis- 14 cover their nature or extent during times of quar- antine inactivity-that is to say, during those fortu- nately more or less prolonged periods in which the absence of disease upon incoming ships narrows the duties of the quarantine officials down to the simple inspection necessary to establish that fact at such times; we have therefore at present no criterion by which to judge of the efficiency of the quarantine administration at the greater number of the stations. The fact already mentioned with reference to the quarantine station at Grosse Isle, that during the quarantine season of r885, up to October 9th, only 32 vessels out of the total 420 were examined, indi- cates defects in administration at that station so glaring as to require no further comment. Faults of administration equally serious, although of a different kind, were shown by the above cited report of the committee already mentioned to have recently (1887) existed at the quarantine station in the lower bay of New York harbor at a time when cholera actually existed in the hospital, and was from day to day finding new victims among more than five hundred Italian immigrants detained at the quarantine of observation on Hoffman Island. It is only necessary to emphasize this statement by calling attention to the following facts brought to light by the investigations of that committee : First, the absence of resident medical officers both at the hospital on Swinburne Island and at the quarantine of detention on Hoffman Island (this has been in the present emergency temporarily remedied); second, the absence of anything like an adequate sanitary police force on the latter 15 island ; third, the lack of any proper daily syste- matic inspection, such as would enable the authori- ties promptly to discover and isolate new cases of cholera-I mean the lack of direct subordinates of the quarantine officer constantly on board all de- tained vessels for the detection of looseness of the bowels-an exceedingly important matter in the case of cholera. B. It is impossible adequately to protect the public health of the country against the importation of epi- demic diseases by independent local maritime quaran- tine establishments. Rival political and commercial interests are inim- ical to the perfect protection of the general public of the whole United States by independent and local quarantines. One of the most serious dangers to which the general public is exposed through local maritime quarantine organizations is the possibility of bodies of immigrants with infected baggage being transferred directly from the quarantine station to distant inland com- munities by rapid railroad journeys, without any prolonged sojourn or without any adequate inspec- tion at, or precautions being taken by the authorities of the seaboard cities through which they pass. In point of fact, this danger was realized in regard to cholera in 1873, when epidemic outbreaks of that disease occurred in Ohio, Minnesota, and Dakota, which were " caused by cholera poison packed up in the household effects of emigrants from Holland, Sweden, and Russia, respectively. These emigrants sailed from healthy ports in healthy vessels, and were subjected to the usual sanitary requirements of the 16 period. They passed through New York and the inter- mediate territory without injury to the public health ; but when their infected goods were unpacked in the interior of the continent they liberated the poison which gave rise to the local outbreaks." (Report of Dr. Rauch.) It is but natural that municipal organizations should, in looking after their own interests, pay little regard to the welfare of distant communities. In this connection may be noted the indisposition and failure on the part of local quarantine officers to notify the authorities interested, of the arrival of emigrants from infected localities. Notwithstand- ing the frequent paramount interest of inland com- munities in the efficiency of the establishment and administration of quarantine at the seaboard, the local authorities of the latter frequently evince an unreasonable jealousy of any sort of investigation or suggestion looking to the general welfare. In the absence of any general regulation or su- pervision, local quarantine measures must in the nature of things be exercised with varying degrees of efficiency; the most complete establishment and perfect administration at a few ports might, there- fore, fail to protect the country if defective or in- adequate measures of quarantine were practised elsewhere. C.-National supremacy of maritime quarantine is necessary. 1. It is only in this way that the necessary protection against the importation of epidemic dis- eases in all our ports can be continuously secured. 2. It is the only practical mode by which uni- formity of establishment and administration, regard being had to the modifications made necessary by difference of latitude and other circumstances, can be assured. Such necessary uniformity can be obtained by no other arrangement, for the reason that the National Government is alone able to defray the expense of complete quarantine estab- lishments at every port, according to the require- ments of each and without regard to the revenue derived from the shipping of any. 3. The benefits of quarantine inure to the wel- fare of the whole country; therefore, it is just that money should be as freely expended when necessary at one port as at another, without respect to their relative commercial importance or to the amount of revenue collected in the shape of boarding and inspection fees, etc. It is manifestly unfair that the seaboard cities and States should, as at present, be obliged to bear the entire expense of quaran- tine establishments whose most important function should be the protection of the inhabitants of every region of the vast territory of the United States. 4. A national quarantine, properly administered and conducted by trained officials, accustomed to deal with contagious and infectious diseases, would tend to prevent panic, to allay undue anxiety, and to favor a reasonable sense of security. 5. Experience has shown that much needless alarm, as well as preventable danger, arises upon the appearance of an unfamiliar epidemic disease at quarantine stations, as when cholera has shown itself at New Orleans or New York, or yellow fever at Philadelphia or Boston. A national quarantine 17 18 would very greatly lessen the necessity for vex- atious temporary interstate quarantines, which so seriously disturb inland trade. 6. A national quarantine system, directed in such a manner as to fully meet the requirements of existing sanitary knowledge, would not adversely disturb any commercial interest. It would, on the contrary, do away with many of the embarrass- ments incident to maladministration of existing local regulations, and the enforcement of measures which are unnecessary and are prompted by a state of panic due to ignorance of the best and most re- liable methods of prevention. 7. A national quarantine would not necessarily supersede any existing arrangements regarded as expedient by local authorities. It should consti- tute an outer line of defence under exclusive con- trol of the National Government, and it should be conducted wholly without extra cost to shipping, and would thus work no additional pecuniary hard- ship, even if the present fees were to be still exacted by the local authorities. 8. The ability of the National Government by an existing Act of Congress to come to the aid of local quarantine authorities in answer to the appeal of the Executive of any State in time of grave dan- ger implies a function of very narrow scope and uncertain application. Appeals of this kind are likely to be deferred until the emergency is extreme, and the aid obtained from the Government is there- fore likely to be rendered too late to accomplish its most important purpose, namely, the prevention of an invasion. 19 D. A national organization would secure advan- tages not attainable by independent local quarantine establishments, however complete. Among many other advantages the following may be enumerated : 1. Suitably arranged and commodious buildings provided with necessary furniture and appliances at all ports. 2. An efficient corps of trained officials and assistants always on duty. 3. The practicability of the concentration of force, money, and attention at any threatened port without loss of time. 4. Officials under the control of the National Government and free from local political and com- mercial influence. 5. The objects of quarantine would be furthered by full and reliable consular reports and sanitary inspection of emigrants at ports of embarkation, functions properly belonging to officials of the General Government. The organization of a supreme national maritime quarantine system in the United States should re- quire : 1. That the whole matter should be placed under an appropriate department of the General Govern- ment. 2. A central bureau of control established at Washington. 3. A sufficient corps of medical officers and as- sistants, with nurses, sanitary police, laundrymen, engineers, and officers and crews for boarding tugs, organized at every station. Among the requirements for the medical service should be a speaking knowledge of at least two modern European languages besides English. In view of the constant and systematic attempts to falsify the ship's log for the purpose of concealing the existence of infectious disease dur- ing the voyage, the health officers should be able when necessary to go among the passengers and themselves closely question them, without the mediation of an interpreter. The establishment of a school and laboratories for sanitary instruction and research in connection with this service would be an advantage. In addition to the men on duty at the respective stations, there should be a sufficient number of medical and other officials fully trained in quarantine duties and familiar with contagious diseases, unattached and available for immediate auxiliary service at any threatened port. 4. The erection of necessary hospital and other buildings, wharves, disinfecting apparatus, wash- houses, latrines, etc., in suitable localities, when pos- sible upon islands at or near the entrances to harbors, and at some distance from the main channel. 5. These stations must be organized and fully equipped at every port of entry of the coast in such a way as to meet the requirements of each port in the measure of its commerce and immigration and the especial diseases to which it is most exposed. 6. The cost of the establishment and maintenance of the national maritime quarantine should be pro- vided for by appropriation from the National Treas- ury, and not from fees exacted from vessels. The danger from immigrants would not be en- tirely banished, however, though the quarantine of 20 21 the coast of the United States were perfect, for the way through the British Provinces would still be open to these travellers. In the absence of efficient quarantine inspection in the St. Lawrence River and in Nova Scotia, the attempt thoroughly to pro- tect ourselves from importations of epidemics would necessitate the doubtful and difficult expedient of a land quarantine along our northern frontier. The more efficient plan would be to have the same pre- cautions taken at the ports in the British provinces as should be practised at those in the United States ; but this course could only be assured through treaty or international agreement, which our local authori- ties are not competent to make. It appears that our Canadian neighbors have already evinced their desire for uniform quarantine laws for the two Governments. The Provincial Board of Health of Montreal, recognizing a com- munity of interest in the question of maritime quar- antine, deemed the presence of the Canadian Fish Commissioners in Washington opportune for the adoption of resolutions requesting the Commis- sioners to urge upon the American authorities "the necessity of establishing uniform quarantine regu- lations for both countries." In connection with an efficient system of national quarantine a harmony in the provisions of law in the United States and in Canada seems indispensable for the full protection of our extensive northern frontier, and our National Government should be strongly urged to respond actively to the expressed wishes of the Canadian authorities relating to such an important matter of common interest. The Medical News. Established in 1843. A WEEKLY MEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHLY MEDICAL MAGAZINE. 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