RECOMMENDATIONS AND CONCLUSIONS.

These have largely been set forth in my preliminary statement submitted immediately after my investigation. The sanitary condition of the school, with the exception of the faulty sewer, is such that the presence of typhoid fever must be purely an accidental occurrence.

As the premises around the school have been disinfected and made sanitary, it would appear that a remodelling of the sewer plant, the primary source of the trouble, would be next in order.

The energy displayed by the management of the place, Mr. and Mrs. Pennington, and by Dr. Winsey, the attending physician, is highly commendable.

Dr. Frederick V. Beitler,

Acting Secretary, State Board of Health,

Baltimore, Md.

Dear Dr. Beitler: I have the honor to report upon the investigation of the typhoid fever outbreak in Towson, Baltimore County, made pursuant to your instructions on Wednesday, the 18th of September, 1912. I was accompanied by Dr. R. C. Massenburg, health officer of the district. For some time typhoid fever had prevailed to an alarming extent in this community. The location of Towson on the Baltimore City watershed also added to the seriousness of the situation. Altogether there were 56 cases of the disease.

COMPARATIVE FIGURES.

A few cases of typhoid fever have occurred in Towson every year, especially in the late summer and early autumn months. In this respect the disease has conformed closely to the wellestablished rule that typhoid is essentially an autumnal malady.

The following table, giving the three-year incidence of the disease by months, will indicate at a glance the high-tide of the affection, being in the month of August, in the year 1909; in the month of October, in the year 1910: in the months of August and September, in the year 1911.

In the first six months of 1912, there were four cases of sickness, with one death, distributed as follows: two cases of sickness in February and two in June; the one death which. resulted occurred in March.

PRESENT OUTBREAK.

That typhoid fever was unduly prevalent in Towson, was brought to the knowledge of the State Department of Health in the latter part of August. On the 4th day of September a preliminary investigation was made, which revealed the fact that the sanitary conditions of the town, especially as regards sewerage and drainage, were exceptionally bad; and that the seeds of a deadly contagion when once introduced, could scarcely help but cause a serious and widespread epidemic.

At this date (September 4th) it was also found that the town of Towson was literally dotted with surface toilets and cesspools, most of which were but poorly kept and dangerous to the public health. Many of these insanitary nuisances were located in close proximity to the surface wells, which source furnishes a large part of the water used by the people of Towson for drinking and culinary purposes. In these and many other respects, the urgent need of a sewerage system for Towson was urgently demonstrated.

STATUS OF TOWSON.

The town of Towson, county seat of Baltimore County, one of the largest and most opulent counties of Maryland, is located at the headwaters of the Lake Roland watershed, about six

miles from the City of Baltimore. It has a population of 2,500.

Compared with the cities and towns of Maryland, there is much that should be done in Towson, from the standpoint of public health. It is wholly a residential town, there being not a single live industry located in it. It is also the seat of the court-house and other public buildings, a feature which attracts to it many persons throughout the county. This lends an additional reason for the safeguarding of public health matters in Towson.

CLINICAL HISTORIES.

In regard to the sex and color of the 56 typhoid fever patients in Towson, 26 were males and 30 were females; 49 were white and 7 were colored. Their ages range from 2 years to 53 years, the greatest number of cases 5 in each instance, occurring at the age of 12 years, 17 years, and 22 years. But ten of the cases occurred in persons beyond 25 years of age.

The family incidence is not a marked one, showing that the element of direct contagion had been pretty well guarded against. In no instance were there more than two cases in a single family, but this occurred in at least seven households.

CHRONOLOGY OF CASES.

The Towson typhoid epidemic of 1912 prevailed most extensively in the months of August and September. It really began in July, and continued until the middle of October. monthly distribution of the cases is, as follows:

The

The cases are scattered, there being no "infected area." In seven or eight instances more than one case occurred in a household.

RATE OF MORTALITY.

One of the patients, a white female aged 40 years, a schoolteacher by occupation died of the disease at her home in Towson, after an illness of three weeks. Several others died in the hospitals of Baltimore; and for this reason I have no accurate account of the total number of deaths which occurred, but my impression is that there were four altogether. A majority of the cases were mild, and hence the low death rate, 1 to 14, the usual proportion in rural Maryland being as 1 to 10.

ORIGIN OF THE DISEASE.

The crigin of the disease was traced to one man's milk route, whose wife had had an attack of typhoid fever two years previously. The stool and urine of this woman were examined bacteriologically, and typhoid bacilli were demonstrated therein. She had been employed about the dairy, and had dispensed milk to customers. Of a total of 56 cases of typhoid fever which occurred in the Towson milk outbreak, five-sixths, or between 45 and 50, developed in persons who had used milk obtained from this dairy.

METHOD OF SUPPRESSION.

The infected dairy was ordered closed on the 28th of September; and in ten days the epidemic was practically at an end. Rigid steps were taken to prevent the occurrence of secondary cases of the disease. These consisted in a thorough examination of the water from all surface wells used for drinking purposes, the disinfection by means of chloride of lime of those found polluted, and a thorough cleaning up and liming of all surface toilets and cess-pools within the limits of the town of Towson.

CONCLUDING REMARKS.

The Towson epidemic is a good example of a milk-borne infection of typhoid. As is usually the case in such outbreaks, the incubation period was short, those attacked were largely young persons, and the cases were relatively mild in character.

The water supply, as well as the raw food supply used by the people of Towson, is quite variable; and it was determined that neither of these had any primary bearing on the typhoid fever outbreak.

Moreover, upon investigation the water supply of the people of Towson was found to be pretty generally bad. It is herewith recommended, that the town of Towson make an effort to obtain a water supply of undoubted purity, that an adequate system of drainage be provided, and that the milk dairies be kept sanitary.

Respectfully submitted,

C. W. G. ROHRER,

Acting Chief, Bureau of Communicable Diseases.

Cases Examined for Diagnosis.

CASE NO. 1.

Date Reported: January 22, 1912. Date Examined: January 22, 1912. Examiner: Dr. Rohrer. Disease Suspected: Smallpox. Name: Oscar Robinson. Address: Halethorpe. Baltimore County. Age: 24 years. Color: Colored. Sex: Male. Married. Date of Onset: January 15. Date of Eruption: January 16.

Previous History: Occupation, farmer. Patient was vaccinated seventeen (17) years ago. Has a faint, large scar on left arm. He has had usual diseases of childhood, but states that he has had no other eruption.

Present History: Patient felt badly on Monday, 15th. No vomiting or lumbar pains. Heavy feeling-burning and soreness-in stomach. Had been constipated for three (3) days. Headache and feverish on Tuesday; eruption appeared Tuesday night.

Clinical Examination: Visicular eruption-some contain a little pusappearing in crops. Was first noticed on face, which is now nearly well. One lesion on edge of left upper eye-lid; one on back of right hand; none on palate or buccal mucosa. Eruption most profuse on back and on chest. Arms and thighs also involved. Very few lesions on forearms and hands, legs and feet. None on the palms of the hands or soles of the feet. Vesicles unilocular; lesions begin as vesicles; occur in successive crops. Some are whitish, and contain a little pus.

Diagnosis: Varicella, or chickenpox.

CASE NO. 2.

Date Reported: February 14, 1912. Date Examined: February 16. 1912. Examiner: Dr. Rohrer. Disease Suspected: Scarlet Fever. Name: Frances Shank. Address: Smithsburg, Washington County. Age: 5 years. Color: White. Sex: Female. Single. Date of Onset: February 11. Date of Eruption: February 12.

Previous History: Parents state that child has had no previous exanthematous disease.

Present History: Disease began with vomiting and rise of temperature, on last Sunday night. Vomitus of a yellowish color; temperature. 105°.

Clinical Examination: "Strawberry" tongue beautifully shown. For five (5) days-Sunday. Monday, Tuesday. Wednesday and Thursdaypatient had sore throat. Cervical glands considerably swollen. both sides, Entire body covered with a scarlet-red eruption, which is now beginning to clear up a little. Cheeks are beginning to show a fine desquamation.

Diagnosis: Scarlet fever.
List of Contacts :

1. Mr. B. F. Shank.

2. Mrs. Alice Shank.