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Cormack, chief state sanitary inspector, who, with four assistants, is in control here, I visited the pesthouse and found 49 cases of variola and 23 suspects. There are also 400 suspects quarantined at their homes. The first case occurred in October, 1897, and was imported from Birmingham, Ala. The State Board of Health took charge of the epidemic on February 28, 1898, declaring the disease epidemic, and since that time there have been 169 cases and 2 deaths to this date, 34 of the cases being white and 135 negroes, one of the latter being a child one day old, the eruption appearing at the same time on mother and child. The population numbers about 4,200, and consists chiefly of the employes of the furnaces and a tannery, and miners, who live in the town and work in the adjoining mines. Nearly, if not quite, half the population are negroes. The town has been absolutely quarantined since February 28th, no one being allowed either to enter or leave it. Sixten guards, one day and one night, guard each of the eight roads leading to the town, and no tickets are allowed to be sold either to or from the town, and practically there is no travel. Since the Board of Health took charge 1,960 people have been vaccinated, and forcible vaccination is still progressing. The occasion for the request for an officer of the Marine-Hospital Service was as follows: Middlesboro was a “boom town," started some ten years ago, and several million dollars were invested here in various enterprises. In two or three years the "boom" collapsed and left the town stranded with a heavy debt. When this epidemic came it found the town without a dollar in the treasury. The place is practically owned by two or three companies, and everybody works on a salary. These companies paid up their taxes in advance, and all having been expended, there were no other funds for the city to draw on.

The county, which is also heavily in debt, has been haggling with the city in regard to an appropriation, but none has been made. The city scrip is worthless, and the grocer who has been furnishing the supplies refuses longer to accept it. The physicians and guards are practically getting no pay. Under these circumstances the State Board of Health threatened to withdraw all guards and physicians, and quarantine the entire county, unless the county provided funds to care for the epidemic. In the presence of this threat the mayor requested that an officer of the Service be sent to investigate, trusting that the government would come to their aid financially, if not otherwise. I am informed by Dr. McCormack, chief sanitary inspector, who is a son of the secretary of the State Board, and who is acting for him here, that the disease is under control, and that the State Board is entirely able to care for it, it being the determination of the Board to force the county to provide funds. To-day the patients are without food. A committee of citizens met and discussed the matter, and have wired the situation to the governor and the State Board, asking them to request the assistance of the government. Chief Inspector McCormack informs me that the Board will not make such a request, claiming that it is able to handle the situation itself. Under these circumstances I do not see that the Service can do anything further in the matter. There are a few cases of variola at Jellico, Ky., but Dr. McCormack informs me that they are under control and thoroughly isolated. Numerous little towns and in lages within a radius of twenty miles have instituted "shotgun” quaran. tines, and will allow no one to enter or leave them, though they have no small-pox in them. Among these places may be mentioned Pineville Ky.. Cumberland Gap, Morristown, Greeneville, Limestone Jonesha and Tazewell, all in Tennessee. Some of these places will not alllow

any one to get off the train. While en route to this place I had to delay several hours in Knoxville, and called on the city physician and met several of the prominent business men. I am informed that in Knoxville there have been sixteen cases of variola since December 14, 1897, and thirty suspects; that there are now five cases in the pestboat, which is anchored out on the river above the city. I am informed that the disease is under control of Knoxville, and no further danger is feared except from reinfection.

Respectfully yours,

C. P. WERTENBAKER,
Passed Assistant Surgeon, U. S. M. H. S., on Special Duty.
Surgeon-General Marine-Hospital Service.

At the request of the president and secretary of the State Board of Health of Kentucky, of the governor of the state, and of the member of Congress from the district including Middlesboro, for national aid in suppressing the epidemic of small-pox prevailing in Middlesboro and vicinity, P. A. Surg. C. P. Wertenbaker, who had been ordered on March 10th to investigate and report on the situation, was directed, on March 17th, to confer and co-operate with the state authorities by furnishing inspection, vaccination, and disinfection service.

Middlesboro, Ky., March 24, 1898. Sir: I have the honor to make the following report on the operations of the Service at this place:

Upon receipt of your telegram on the afternoon of March 17, 1898, directing me to assume control of the operations of the Service at this point, I held a consultation with the representative here of the State Board of Health (Dr. Robertson), and outlined a plan of action for the suppression of the epidemic of small-pox here. I em ployed five inspectors and started them at work making a thorough inspection of the city, vaccinating all persons that had not been successfully vaccinated. I also employed twenty-five guards. Not being able to secure the camp train, it became necessary to look around for some house capable of being used as a hospital. I was fortunate in securing one that was originally built for a boarding house, containing ten rooms up stairs and five large rooms on the first floor. It was occupied at the time as a boarding place, and I had to pay the proprietor $50 to move out; but as it was the only available place to be found it was considered best to do this. The house is located in the outskirts of the city, about a mile from the center; is isolated and well adapted for the purpose. It had to be completely fitted out, as it contained, after the boarding-house keeper moved out, only a cooking stove and twelve chairs, which I bought of the keeper. By hard labor we got the house fitted up, and moved into it ninety-one persons from the former pesthouse, which was located in a thickly settled part of the city and adjoined the detention camp, and there were no adequate means of keeping the patients and suspects apart. The Service was then organized under six divisions, as follows: Headquarters, inspectors, guards, disinfecting division, suspect camp and small-pox hospital.

SMALL-POX HOSPITAL. The small-pox hospital corps consists of Dr. W. C. Duke in charge, nurses, cooks, attendants, etc. An ambulance has been secured, and is kept near the hospital, and is sent in whenever needed for a patient.

SUSPECT CAMP. The suspect camp consists of a row of wooden houses, twelve in number, adjoining a row of four houses that were formerly used as a small-pox hospital. This camp is in charge of Dr. W. N. Shoemaker, and has the usual corps of attendants. At both the small-pox hospital and suspect camp the physicians in charge remain in each, respectively, and the physician of the small-pox hospital is quarantined and not allowed to leave the place. Both the camp and hospital are supplied with tents furnished by the State Board of Health, and are used as bathing and disinfecting tents. Patients discharged from the hospital are given a bath, followed by a bichloride of mercury bath (1-2000), and then a bath in fresh water. The clothes are washed in a solution of bichloride of mercury (1-800) and dried. The same precautions are taken with suspects admitted and discharged from the suspect camp. All suspects are vaccinated on admission. Suspects are detained sixteen days.

INSPECTOR'S DIVISION. Under the direction of Chief Inspector Dr. Samuel Blair, the city has been divided into five districts, and an inspector assigned to each. They report at headquarters at 9 a. m. and between 5 and 6 p. m. They make a house-to-house inspection, examining all persons, vaccinating all who have not been protected, and in the event of the refusal of any one to be vaccinated, the name of each person so refusing is sent in to headquarters, where they are turned over to the city authorities, where the option is given them of being vaccinated or being sent to jail, and in the latter event they are vaccinated as soon as they enter, under a law requiring all inmates of jails to be vaccinated. Any case of smallpox, or suspicious case of disease, is at once reported by telephone to headquarters, and the chief inspector is directed to visit and report on the case. Should the case prove to be small-pox the ambulance is sent at once to remove it to the hospital. Another ambulance, connected with the suspect camp, is kept to bring suspects and their bedclothing to the camp, this clothing being disinfected before being used.

GUARDS. The guard consists of a chief and assistant chief and twenty-five privates, guarding the small-pox hospital, the suspect camp, the depot and the four principal roads leading into the city, for at the present time the city is in quarantine, and no one is allowed to go in or out except upon a permit signed by myself and Dr. Robertson. The chiefs of guard are on duty for twelve hours each daily; the guards at the camp and hospital are relieved every eight hours, while those at the depot have a twelve-hour tour of duty. Those guarding the roads are on from 6 a. m. to 10 p. m. The chiefs are required to accompany each relief and put the men on duty, and also to inspect the post of each guard at least once during his tour of duty. As the guards are much scattered, the chief is furnished a horse. The guards are armed with Springfield rifles borrowed from the local military company, and the presence of a guard with a rifle on his shoulder is very effective in keeping order.

DISINFECTING DIVISION. This division is under the charce of Acting Assistant Surgeon Porter. Two autoclaves, with carboy of formalin, have been received from New Orleans for use in this division. Sulphur disinfecting outfit, con

sisting of pots, tubs, etc., have been purchased. Bichloride in barrels, with force pump and hose, has also been secured, and this division is at work. Two wagons are required to transport the outfits from house to house, and the work will be pressed as rapidly as possible. A map of the city, with each infected house marked on it with red ink, has been made, and as each new case appears the house is marked on the map, and is disinfected as soon as possible. There is much work for this division to do, as there are many infected houses. Those houses that can not be disinfected will be reported to the local authorities with the request that they be burned.

HEADQUARTERS. I have secured comfortable offices, centrally located, for administrative work. I have had a telephone put in, which enables us to communicate with the small-pox hospital, the inspectors, and other parts of the city. The work now being systematized, and the raw material being gradually worked into shape, we are moving along easily and effectively. The disease has been so widespread, and the methods used so ineffectual, that it is hard to predict when the epidemic will be under control. Confidence has been restored among the people, who are now looking forward hopefully to an early termination of their trouble.

Respectfully yours,

C. P. WERTENBAKER,
Passed Assistant Surgeon, U. S. M. H. S., Commanding. -
Surgeon-General Marine-Hospital Service.

Middlesboro, Ky., March 28, 1898. Sir: I have the honor to report that the situation here is rapidly improving, and that the epidemic is under control. Only two cases have developed since March 22, and for the past six days no case has developed. Isolation of cases and suspects and disinfection of houses and clothing have been prompt.

The disinfecting division is now at work disinfecting houses that are suspicious, houses in which cases of small-pox had occurred previous to the arrival of the Service, and which have been unoccupied since.

The inspection service has been thorough, and for the past five days has been directed particularly to the infected district, which is occupied chiefly by negroes, but no case of small-pox has been found.

There are thirty-two cases in the small-pox hospital this morning, a good many of which will be discharged within the next few days. There are twenty-three suspects in the detention camp this morning; a majority of them will have covered their period of detention this week.

I think that the quarantine of the city, which was put on by the State Board of Health on February 28, 1898, can be raised by Monday, April 4, 1898, and all guards, except those for the small-pox hospital and detention camp, be discharged. *

* * *
Respectfully yours,

C. P. WERTENBAKER,

Passed Assistant Surgeon, U. S. M. H. S.
Surgeon-General Marine-Hospital Service.

Middlesboro, Ky., April 7, 1898. Sir: I have the honor to make the following report on the smallpox situation in this city:

In the small-pox hospital there remain 19 cases; in the detention camp, 14. Since the last report (March 28, ultimo) 5 new cases of smallpox have developed, 2 of which were in the detention camp. The last case occurred yesterday.

It was thought best to continue the quarantine of the city until another thorough house-to-house inspection could be made, and until the work of disinfection of all known infected houses could be completed. The 300 tubes of virus telegraphed for upon my arrival April 4 came yesterday, and another inspection of the city was begun. This will be finished this week, as will also the work of disinfection.

In my opinion, quarantine may be safely raised on Monday, April 11, and I have communicated with the State Board of Health, through its representative here, to that effect. By that time the detention camp can be abandoned, the quarantine guards dismissed, and our force reduced to those necessary for the care of the three or four patients remaining in the small-pox hospital. Unless other cases develop these few can be transferred to the county pesthouse, if orders to that effect are received from the Bureau, and the Service affairs here can be brought to a close on the 12th or 13th instant.

Very respectfully,

HILL HASTINGS,

Assistant Surgeon, U. S. M. H. S. Surgeon-General Marine-Hospital Service.

Middlesboro; Ky., April 15, 1898. Sir: I have the honor to respectfully submit the following report of the work of the Service in suppressing the epidemic of small-pox in this city:

A brief resume of the course of the epidemic before the Service took charge may not be inappropriate. The first case of small-pox in this city developed in the latter part of November. No accurate knowledge can be obtained as to the date of occurrence or whence it came. It is thought to have come from Birmingham, Ala. From this the disease spread among the negroes and lower class of white people. Owing to its mildness and the doubts that existed as to its being small-pox, no active steps to prevent the spread of the disease were taken at first. Many cases would recover without medical attention. After small-pox had become epidemic the city and county health officials undertook to stamp out the disease. As there was no pesthouse established, the cases, with those who had been exposed, were gathered together in a row of vacant houses, vaccination of the inhabitants, estimated at 3,000, was begun, and quarantine of the city was declared by the State Board of Health. When the resources of the city and county were exhausted, the State Board of Health was applied to for relief. Vaccination inspectors were sent and the vaccination of the inhabitants was thoroughly done as long as the inspectors remained. But the state authorities refused to bear the expense of the epidemic. An appeal was then made to the Surgeon-General of the Marine-Hospital Service. P. A. Surg. C. P. Wertenbaker was directed by telegraphic orders, dated March 10,

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