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scheme is practicable. I intended to elaborate it at the conference of port medical officers of health held
at the Ministry in April last to discuss the draft of the proposed new port sanitary regulations but time
was too limited and moreover I knew that, though the Ministry took a more sympathetic view of the
suggestions than they did six years ago, they felt that difficulties might arise because the scheme involved
a wide departure from accepted international practice. Nevertheless I am taking this opportunity of
submitting the scheme for consideration and criticism. In the two ports with which I am really familiar,
viz., Liverpool and London, I believe it could be worked, but it may be that in some other ports it would
be quite impracticable.
Defects of the Present System.—First of all may I submit what seem to me to be the disadvantages of
the present system under which all ships arriving from infected ports are medically inspected even if they
report " all well and no sickness during the voyage."
In the first place there is the difficulty of keeping the infected port list up to date and of acquainting
pilots, customs officers, shipping companies and agents promptly of changes in the list. This difficulty
has led in the ports of London and Liverpool to scheduling whole coast-lines rather than individual ports
as infected. Other port sanitary authorities take the weekly record issued by the Ministry of Health as the
basis of their infected port list. Consequently there is a lack of uniformity in the ports of the British Isles
and the master of an incoming ship never knows whether his ship is going to be medically inspected or not.
Sometimes he has his crew mustered and his papers ready only to find that he is not to be inspected ; much
more frequently he has gambled on not being inspected and has nothing ready.
Secondly there is a tendency amongst masters to think that port sanitary authorities are only interested
in ships from infected ports and that we are not concerned with sickness on ships which have not touched
at any such port. I have myself had this excuse offered to me by the master of a ship on which there was
an undiagnosed case of typhoid fever which was only reported by the customs officer after the vessel had
docked.
Thirdly, let us consider the position of the medical officer who boards a healthy ship from an infected
port. Frequently he will meet with considerable passive resistance to the mustering of all persons on
board, particularly where passengers are concerned. If the medical officer is thoroughly conscientious he
will insist on seeing everybody himself however unpopular he is in consequence. But I wonder whether
all medical officers are both conscientious and determined enough to carry out a detailed inspection in
every case ? Even the most conscientious medical officer is not infrequently faced with the situation that
a detailed inspection means the ship losing her tide. Is he going to insist on mustering everybody then
and be involved in correspondence and perhaps personal interview with the shipowner who points out that
he has been put to very heavy expense by the delay to his ship ? I doubt it ! So that quite apart from
differences in the practice of port sanitary authorities there are differences in the practice of the boarding
medical officers even in the same port. Little wonder then that the masters of ships are confused as to
what English port sanitary requirements really are and complain that they never know what is expected of
them.
Let us consider what results we have to show for this system which leads to so much confusion and
which frequently places even the best boarding medical officer in a most difficult position. I should be
interested to know in how many cases the routine boarding of ships from infected ports has led to the
discovery of cases of the more serious infectious diseases when no indication was given by the master that
illness requiring the attention of the port medical officer had occurred or was present on board. I have
myself discovered a missed case of small-pox but only in an instance when the master had declared a primary
case landed abroad. On the other hand, I have known at least one case of small-pox which escaped detection
because the ship was not from an infected port and the master had not suspected the illness to be of an
infectious nature, and I have known several cases of typhoid fever to be brought into dock under similar
circumstances. I admit that if a single instance can be cited where small-pox or plague was discovered
under the present system which would be missed if the scheme I am about to suggest had been in force, then
my proposals go by the board ; but it appears to me that we have at present a confused system and that
even so we are frequently obliged to accept the word of the master or of the surgeon that all is well on board
a ship arriving from an infected port.
Proposed Alternative Scheme.—It is obviously impossible that in every port in the British Isles every
person on board every ship should be medically inspected on arrival ; some system of selection must be
adopted. At present we select for inspection those ships which are most likely to have infectious disease
on board and leave the rest unless the master reports infectious sickness either by wireless or to a customs
officer. If the master fails to report it is difficult to prosecute him because he can always claim that, not
being a doctor, he could not be expected to diagnose the disease in question. If we are agreed that the
present system is unsatisfactory, what is the alternative ? I would suggest the following :—
First of all I would provide by law that immediately before arriving in a port in the British Isles, the
master should acquaint himself as to the state of health of every person on board his ship and then should
answer " yes " or " no " to the following questions :—
(1) Have you during the present voyage had on board any case of infectious sickness or of illness
which you suspect to be of an infectious nature ?
(2) Have you had on board any case of illness as to the nature of which you are in doubt.
(3) Have you had any death from sickness during the voyage.
(4) Have you on board at the time of arrival any case of sickness of any sort whatever; injuries
excepted ?